Fertility Diagnosis & Treatment Options

Published on January 2017 | Categories: Documents | Downloads: 35 | Comments: 0 | Views: 249
of 76
Download PDF   Embed   Report

Comments

Content

Fertility Diagnosis & Treatment Options
Arlene J. Morales, MD, FACOG Fertility Specialists Medical Group

AJM 4/2011

Diagnosis of Infertility
 “unprotected coitus of 1 year

duration”  “active” versus no contraception exposure  Age:
  

< 35 years 35-39 years > 40 years
AJM 4/2011

1 year 6 months 3 months

Time Required for Conception: An Inefficient Process
Time of Exposure 1 month 3 months 6 months 1 year 2 years % Pregnant 22% 57% 72% 85% 93%

100 80 60 40 20 20 5 0 1 36 9 2 13 3 6 12 50 75 85

93

24

Cumulative Pregnancy Rates (<35 yrs) 40 yrs

AJM 4/2011

Fertility Decreases with Age
100 90 80 70 60 50 40 30 20 10 0

25

35
30 85 22 15 35

Age (Years)
25 % Pregnant at 1 year Monthly pregnancy rate 85 22 40 45

45
5

1

AJM 4/2011

AJM 4/2011

Etiologies of Infertility

Tubal Factors:30-40%

Male Factors: 30-40%

Anovulation: 10-15%

Uterine Factors: 20%

Cervical Factor:5-10%
AJM 4/2011

Uterine Diagnostic Studies

Sonohysterogram (SHG or SIS)
AJM 4/2011

Hysterosalpingogram (HSG)

The forgotten uterus

AJM 4/2011

Examples of Pelvic Disease

AJM 4/2011

Uterine Cavity Abnormalities

Normal

Polyp

Myoma

AJM 4/2011

Scarring

Congenital

Uterine Fibroids: Submucosal

AJM 4/2011

AJM 4/2011

Severe Tubal Factor

AJM 4/2011

Other Conditions

AJM 4/2011

Hormones
 Aging
 

Cycle Day 3 FSH, Estradiol x 2 cycles AMH – Anti-Mullerian Hormone TSH, Prolactin PCOS (FSH, LH, Fasting Insulin/Glucose)
• Androgens (testosterone, 17OHP, DHEAS)

 Hormonal Mileu
 

AJM 4/2011

Reproductive Aging
AGE=Quality ; AMH,AF,D3=Quantity
600 500 400 300 200 100 0 20-24 25-29 30-34 35-39 40-44 45-49
AJM 4/2011

Hutterites Burgeoisie 17th Burgeoisie 16th French Village Iranian Village USA 1955 USA 1981



Leading cause is varicocele

Etiologies of Male Infertility

AJM 4/2011

A.R.T. Laboratory Andrology
 Basic Semen Parameters (W.H.O.

Standards)
   

Days Abstinence Sperm Count Sperm Motility Sperm Morphology Sperm Volume



2-5 days  20 M/ml  50%  30% (W.H.O.)  14 % (Strict: Krueger’s) 2-5 ml

AJM 4/2011

Indications for Genetic Diagnosis
ICSI  Severe Oligospermia



Sperm concentration < 5 mil/cc

Chromosomal testing  Cystic fibrosis testing

AJM 4/2011

MESA Electroejaculation

TESA
AJM 4/2011

Sterilization
 Tubal Ligation Reversal


Pro’s & Con’s

 Vasectomy Reversal


Pro’s & Con’s

AJM 4/2011

Recurrent Pregnancy Loss
 Definition  1st

& 2nd Trimester

 Prognosis  Workup

AJM 4/2011

Traditional Algorithm
Detailed History and Physical Exam Ovulation Cavity and Tubal Status Ovulation Induction Timing of Intercourse Ovulation Induction Intrauterine Insemination IVF
IVF Directly

Semen Analysis

AJM 4/2011

Traditional Therapy


Ovulation Induction (OI)


Clomiphene Citrate (1-3-5 eggs)
• 2 to 3 visits over 2 weeks



Gonadotropins (5-8-10 eggs)
• 5 to 7 visits over 2 weeks



Intrauterine Insemination (IUI)

AJM 4/2011

Intrauterine Inseminations 10 to 14 days

http://www.fertilityplus.org/faq/tomcat.jpg

http://www.universityfertilityassociates.com/images/art_08.jpg

http://www.follistim.com/Authfiles/Images/349_91850.gif

AJM 4/2011

Efficacy of Clomid/IUI
CLOMID - 3 trials cross-over placebo trials
 

UK: 118 patients with Unexplained (100 mg)


Cumulative preg rate was 22.3% vs 14.6% (3 cycles) Monthly fecundity of 9.5% (148 cycles) vs 3.3% (150 cycles) Cumulative preg rates was 13.2% vs 5.6%
AJM 4/2011

USA: 67 patients with Unexplained (50 mg)




Canada: 148 couples with Unexplained (100 mg)


Efficacy of Gonadotropin and IUI for Infertility

 Guzick and National Cooperative
Reproductive Medicine Network N Engl J Med 1999;340:177-83




Couples: no identifiable etiology & motile sperm 4 cycles of treatment
IUI alone n=234/717 18 % 5%
AJM 4/2011

COH & IUI n=231/618
Cummulative 33 % Per Cycle

COH & ICI n=234/637

ICI alone n=233/706

15 %

19 % 4%

10 % 2%

IVF
Completed Check-list
Including Sonohysterogram and Mock-Transfer

Medication Protocol
Prep “stuff” 2-4 weeks

Medication Class

Treatment 4 to 5 weeks

Your Stimulation Cycle Retrieval (2 to 4 weeks)

Embryo Transfer (3 to 6 days later)

Pregnancy Test (7 to 10 days later) Prenatal care
AJM 4/2011

Follow-up

Egg Collection Area

AJM 4/2011

Transvaginal Aspiration Oocytes

AJM 4/2011

Oocyte Aspiration

AJM 4/2011

Embryo Culture Area

AJM 4/2011

Embryologist at Work

AJM 4/2011

AJM 4/2011

Oocytes
MATURE

IMMATURE STRIPPED
AJM 4/2011

AJM 4/2011

Insemination Methods
 Conventional Insemination
   

10-30,000 motile sperm 1-4 eggs in a 50 l drop of media Incubate overnight Check for fertilization

AJM 4/2011

Fertilized Egg From IVF

AJM 4/2011

AJM 4/2011

ART Lab Techniques: ICSI

AJM 4/2011

ICSI (cont)

AJM 4/2011

Embryo Development (D2-D4)

AJM 4/2011

Blastocyst Development

AJM 4/2011

Holding pipette

AJM 4/2011

Hatching pipette

Assisted Hatching

AJM 4/2011

Preimplantation Genetic Diagnosis (PGD)






Consists of taking a single cell (biopsy) from each embryo, followed by genetic analysis to determine the normalcy of the embryo. Subsequent replacement to the patient of those embryos classified by genetic diagnosis as normal. Three PGD methods of analysis
  

FISH (Fluorescent In Situ Hybridization) PCR (Polymerase Chain Recation) Whole Genomic

AJM 4/2011

Preimplantation Genetic Diagnosis
 Fluorescent In Situ Hybridization (FISH)


Detects chromosomal abnormalities
• Chromosomal Aneuploidy (Missing Chromosomes)  13, 16,18, 21, 22, X, Y • Chromosome Translocation



. Polymerase


Chain Reaction

Detects single gene defects  Tay-Sachs Disease, Sickle-Cell Anemia

AJM 4/2011

Preimplantation Genetic Diagnosis

AJM 4/2011

Preimplantation Genetic Diagnosis
Advanced maternal aged
• Increasing maternal age is associated with increased aneuploid embryos






Family history of translocations Recurrent Pregnancy Loss (RPL)
AJM 4/2011

Extra chromosome 13 in an embryo
AJM 4/2011

Inefficient Process
 

High incidence of failed conception in-vivo and in-vitro A lot attributed to differential embryo viability

15% of embryos arrest by day-3 ? Aneuploidy
AJM 4/2011

< 50% reach the blast stage

Catheter Placement

AJM 4/2011

We’ve come along way
 In 1978, Louise Brown born through IVF  Since then, techniques have improved to

break the barriers of infertility

AJM 4/2011

Single Intrauterine Pregnancy

AJM 4/2011

Embryo Transfer and Multiple Gestation
 Multifetal pregnancies constitute an

iatrogenic complication of assisted reproduction
80 70 60 50 40 30 20 10 0 World Collaborative Report ASRM
AJM 4/2011

singletons twins triplets quadruplets

AJM 4/2011

Multiple Gestation; How do we avoid?


Judicious use of ovulation induction

   

Limiting the number of embryos transferred


How many is too many ?

Improving cryopreservation & thawing techniques Improving the quality selection criteria of the embryos Improving the culture systems
AJM 4/2011

Multiple Gestation; How do we avoid?

Day 3 embryo

Day 5 or 6 embryo “ hatching blastocyst”

•Allow for screening of potential aneuploidy •May improve the implantation rate •Reduce the number of transferred embryos
AJM 4/2011

Inefficient Process

AJM 4/2011

ASRM Guidelines
VS <35 years old

35-37 yrs old

38-40 years old

Over 40 years

AJM 4/2011

Other Methods of Reproduction
 Donor Oocytes  Gestational Carriers  Gestational Surrogate  Donor Gametes (both oocytes and sperm)  Frozen Embryo Transfer of donated embryos

AJM 4/2011

Reproductive Aging
60 50 40 30 20 10 0 27 31 35 39 43 47
Own Eggs Donor Eggs

AJM 4/2011

What is a good ART program?
High Quality Laboratory Comprehensive Services Excellent Documentation Professional management Psychological Support High Quality Clinical Care Patient Choice Research Cost-effective care Ethical Care

AJM 4/2011

Preconception Readiness


Genetic Risk
 

Cystic Fibrosis (ACOG Recommendation) African-American
• Sickle Cell Anemia



Ashkanazi Jewish
• 9 disease screen



Mediterrean/Asian
• Thalassemia



Immunity
 

Varicella Rubella

 

Blood Type Prenatal Vitamins (Folic Acid) AJM 4/2011

Advances in Assisted Reproduction
ICSI IUI

Ovulation Induction

IVF

AJM 4/2011

Luteal Phase Support

AJM 4/2011

AJM 4/2011

Pronuclei

AJM 4/2011

AJM 4/2011

AJM 4/2011

Day 2 (post retrieval)

Cells or blastomeres

AJM 4/2011

Day 3 (post retrieval)

AJM 4/2011

Day 4 (post retrieval)

Morula

AJM 4/2011

Day 5-6 (post retrieval)

AJM 4/2011

Blastocysts

AJM 4/2011

Day 5-6 (post retrieval)
Hatched blastocyst

Zona pellucida

Inner cell mass (fetus)
AJM 4/2011

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close