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Assisted Reproductive Techniques

IUI (intrauterine insemination) AIH (artificial insemination by husband) AID (artificial insemination by donor) GIFT (gamet intrafallopian transfer).

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Assisted Reproductive Techniques

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  1. IUI (intrauterine insemination)AIH (artificial insemination by husband)AID (artificial insemination by donor) GIFT(gamet intrafallopian transfer) IVF (in vitro fertilization)ZIFT (zygote intrafallopian transfer)PROST (pronuclear stage intrafallopian transfer)IVF-ET (in vitro fertilization and embryo transfer)ICSI (intracytoplasmic sperm injection) Assisted Reproductive Techniques

  2. Indications to IUI • Cervical factor • Chronic anovulation (COH-PCOS) • Male factor • Immunologic disorders • Endometriosis • Idiopatic infertility

  3. CONCLUSION: unjustified more than 4 correct IUI IUI • Proceeding - Ovulation stimulation - Sperm preparation (>1-4·106/ml) - Artificial insemination • Efficacy (depended on indications and stimulation protocol) • 10 – 30% pregnancies per cycle • 40 – 60% accumulated no improvement after 4 cycles

  4. Sperm preparation (IUI, IVF)gradient Sperm liquefaction Prepare the „gradient” Stratification on gradient Centrifugation Again centrifugation in EBSS ART 3 2 1 semen 40% Silica 80% Silica semen

  5. Ovulation stimulation for IUI • Clomiphene citrate • 50 – 250 mg p.o., day 5-9 • Clomiphene citrate + hMG (FSH) • 50 – 250 mg p.o., day 5-9 • 75 IU from day 9 • hMG (FSH) • 75 – 150 IU from day (3) 5 • Aim • growth 1-3 follicles to 18mm. When E2 250–300 pg/ml/follicle 10.000IU hCG is administered to cause ovulation

  6. Basic indications to IVF • Partial or complete tubal obliteration • Chronic anovulation (COH-PCOS) • Male factor • Immunologic disorders • Endometriosis • Idiopatic infertility

  7. Indications to ICSI • Indications to ICSI with sperm from ejaculateO, A, T, OAT <1-4·106/ml after preparation <5% normalforms failure of classic IVF(no fertilization) • Indications to MESAazoospermia(obstruction of ejaculatory ducts- obstructive azoospermia) • Indications to TESEazoospermia(patency of ejaculatory ducts- nonobstructive azoospermia)

  8. IVF-ET(classic) • Ovulation stimulation • Sperm preparation • Collecting the oocytes (under ultrasound control) • Oocytes maturity assessment • Oocytes insemination • Fertilization assessment (16-24h) • Embryo culture to 4 (48h) - 8 (72h) blastomers stageor to blastocyst stage(120h) • Embryo transfer (ET) • Embryo cryopreservation

  9. ICSI • Ovulation stimulation • Sperm preparation • Collecting the oocytes (under ultrasound control) • Oocytes maturity assessment • Intracytoplasmic sperm injection • Fertilization assessment (16-24h) • Embryo culture to 4 (48h) - 8 (72h) blastomers stageor to blastocyst stage(120h) • Embryo transfer (ET) • Embryo cryopreservation

  10. Ovulation stimulation for IVF (COH – controlled ovarian hyperstimulation) • Short protocoł aGnRH from day 1hMG (FSH) 150–300IU from day 3 • Long protocoł aGnRH from day 20 previous cyclehMG (FSH) 150–300 IU from day 3 • Aimgrowth some follicles. When dominant follicle is >18mm and 2 other at least 16 mm and E2 >1000pg/ml but <5000pg/ml (OHSS risk), 10.000IU hCG is administered to cause oocytes maturity)

  11. IVF - ICSI (skuteczność)

  12. Effectiveness of 1 mikrosurgery is equal with cumulative efficacy of 5 IVF trials IVF - ICSI (effectiveness) • Implantation percentage when 1 embryo is transferred in stage 4 – 8 blastomers is 12,5 – 17,5% • About 60% of embryos goes to stage of 4 blastomers (and far?) • Pregnancies percentage per cycle (patients < 40) • Less than 7 oocytes - 13% • More than 7 oocytes - 29%

  13. Cryopreservation • Freezing and storage • Embryos • Stage 2 pronucleus • Stage 2-4 blastomers • Stage blastocyst • Oocytes and ovarian tissue • Benefits • Low cost, no OHSS, possibility of more „aggresive” ovulation stimulation in first cycle • Effectiveness - 10 – 20% pregnancies per cycle

  14. Preparation to cryo-ET • Natural cycle (indication is growth the ovarian follicle) alternatively supplement therapy with estrogens and progestagens • Controlled cycle aGnRH with supplement estrogens and progestagens therapy

  15. Complications and potential risk of ART • Complications • OHSS • Rare cardio- pulmonary failure, renal failure, DIC ... • Multiple pregnancy (5 – 40% !) • Prematurity and preterm labours (to 98%), PIH (25%), bleeding (35%), anemia (15%), isthmocervical insufficiency (15%) Strategies: Transferof 1-2 embryos; multiembryo transfer and consecutive embrioreduction or leaving this problem for obstetricians and neonatologists

  16. Complications and potential risk of ART • Potential risk • Ovarian cancer • Increased risk of serous carcinomas, low malignancy (high grade) • More frequent after Clomiphene citrate • No confirmation in large randomised clinical trials !!! • Theoretical risk of hormonosensitive neoplasm (breast, endometrium) • Genetic defects transfer • Male infertility (AZF, delY...) • Besides no risk of malformations was confirmed (but too short observations) – 2,2–2,7%

  17. IVM & IVC • IVM (in vitro maturation) • OHSS prevention • In vitro culture of ovarian follicles from antral to developed follicle– IVF – IVC – ET • Multiple pregnancy prevention- IVC (in vitro culture) • In vitro culture of embryos to blastocyst stage (the best one for implantation) – 40-60% of pregnancies (blastocyst –sequential media) when compare to 12,5 – 17,5% (embryo in the stage of 2-4-8 blastomers) • Culture the embryos to this stage make some problems. About 35-60% of embryos in vitro goes to blastocyst stage. • IVC gives the possibility of reliable evaluation the embryos quality.

  18. Preimplantation diagnostic • Indications • Age > 35 (?) • Previous child with chromosome abnormalities • Carrier of genetic defects • Aneploidies (e.g. Down syndrome) • Monogenic disorders (np. fibrocystic disease) • X-linked inheritance (hemophilia) (important child sex) • Sampling • Blastomers biopsy • Methods • PCR (polymerase chain reaction) • FISH (fluorescent in-situ hybridization)

  19. IUI Woman Vaginal bacteriological examination Man 3-7 days of sexual abstinence IVF Woman Vaginal bacteriological examination hormonal profile Cervical canal explore with a probe (?) Hysteroscopy (?) Man 3-7 days of sexual abstinence Sperm bacteriological examination prophylactic antibiotic therapy(?) Conditions to start ART

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