IVF NECESSARY ELEMENT IN

GYNAECOLOGY

What is in it for me?

There are novel concepts in Infertility that we need to know. They will make a

difference in your clinical practice

IntroductionThe inability to create a desired pregnancy that culminates in the birth of a child is likely to create a life crisis for women and their partners. Women seeking fertility treatment look to nurses for care, counsel and health teaching.

Introduction (Continued)

• Primary infertility: The inability to conceive after 1 year of unprotected intercourse for a woman younger than 35, or after 6 months of unprotected intercourse for a woman 35 or older (Speroff

& Fritz, 2005).• Secondary infertility: The inability of a

woman to conceive who previously was able to do so (Speroff & Fritz, 2005).

Introduction (Continued)

Infertility is more common in older women. However, increased age reduces the efficacy of treatment.

Infertility affects 15 % of couples, and 50-70 % of male infertility is potentially correctable so it name As: Subfertility …….

DECREASING SPERM QUALITY & QUANTITY: A

GLOBAL PROBLEM?

Evaluation of decreasing sperm count

Environmental Health Perspectives 108 (10) (Oct. 10, 2000); E. Carlsen et al.British Medical Journal 305 (Sept. 12, 1992).

Reduction in sperm density

Reduction in sperm density

Journal of Andrology, Vol. 28, No. 2, March/April 2007

Reduction in sperm morphology quality

Journal of Andrology, Vol. 30, No. 5, September/October 2009

Semen analysis• New reference values by WHO

Semen Parameter WHO 1999

WHO 20101

Volume (mL) ≥2.0 1.5

Count (x106/mL) ≥20 15

Total sperm number per ejaculate

≥40 39

Motility (%) ≥50 (a+b) 32 (a+b)

Vitality (%) ≥75 58

Morphology (%)2 (14) 4

Leukocytes (x106/mL) <1.0 <1.01Lower Limit (5% percentile); Recent fathersGrade a = rapid progressive motilityGrade b = slow/sluggish progressive motility 2Strict criteria

New WHO references valuesHow they were obtained

1,953 semen samples of recent fathers

Time to pregnancy (TTP) ≤ 12 mo 5 studies in 7 countries on 3

continents Laboratories with QC only Morphology by strict criterion

(Kruger) Progressive and non-progressive

motility Lower reference limits (5th centile)13

Impact of the New WHO Guidelines on Diagnosis and Practice of Male

Infertility 1

1. The Open Reproductive Science Journal, 2011, 3, 7-15

15

New WHO references valuesCritical Appraisal

USA(Columbia, NYC, Minneapolis, LA)

AUSTRALIA (Melbourne)

NORWAY(Oslo)

FINLAND(Turku)

DENMARK (Copenhagen)

FRANCE(Paris)

UK(Edinburgh)

??

??? ?

Prevalence and Overview of Treatments

• The overall incidence of infertility has remained relatively unchanged for the past 30 years (Speroff & Fritz, 2005).

• In 2002, about 2 percent of women of reproductive age had an infertility-related medical appointment within the previous year, and 10 percent had an infertility-related medical visit at some point in the past (Chandra et al., 2005).

Prevalence and Overview of Treatments (Continued)

Approximately half of all women who receive fertility care achieve conception leading to a live birth (Speroff & Fritz, 2005).

Scope of the ProblemTypes of ART cycles: United States, 2004 (Speroff & Fritz, 2005)

Incidence of infertility

Previous

Incidence of infertility

Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, et al. (2012) National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med 9(12): e1001356. doi:10.1371/journal.pmed.1001356http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001356

Present: Prevalence of primary infertility among women who seek a child, in 2010.

Present: Prevalence of secondary infertility among women who have had a live birth and seek another, in 2010.

Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, et al. (2012) National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med 9(12): e1001356. doi:10.1371/journal.pmed.1001356http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001356

Incidence of infertility

Medication: when and how to use antioxidants

Fertile Infertile0

1

2

Seminal Reactive Oxygen Species (ROS) (Log ROS + 1;

cpm)

Pasqualotto et al., Fertil Steril 2000

Need for fast conception

Success rate:

Need for fast conception

Reasons : Increase use of contraception

Semen analysis• New reference values by WHO

Semen Parameter WHO 1999

WHO 20101

Volume (mL) ≥2.0 1.5

Count (x106/mL) ≥20 15

Total sperm number per ejaculate

≥40 39

Motility (%) ≥50 (a+b) 32 (a+b)

Vitality (%) ≥75 58

Morphology (%)2 (14) 4

Leukocytes (x106/mL) <1.0 <1.01Lower Limit (5% percentile); Recent fathersGrade a = rapid progressive motilityGrade b = slow/sluggish progressive motility 2Strict criteria

New WHO references valuesHow they were obtained

1,953 semen samples of recent fathers

Time to pregnancy (TTP) ≤ 12 mo 5 studies in 7 countries on 3

continents Laboratories with QC only Morphology by strict criterion

(Kruger) Progressive and non-progressive

motility Lower reference limits (5th centile)

What is IVF

In vitro fertilisation

What is IVF

In vitro fertilisation In variable fertilisation (100% sure)

Indications

Previous: tubal factor only Fallopian Tube Damage/Tubal Factor

Bilateral blocked Fallopian tubes Failed reversal of Tubectomy

The only options for treating significant tubal damage are surgical repair or bypassing the tubes with IVF. This decision must be carefully individualized in each situation.

Indications

Present: Male Factor Infertility

Failed reversal of Vasectomy/ Tubectomy Obstructive azoospermia

Endometriosis Severe endometriosis

Age Related Infertility Premature Menopause Anovulation

Unexplained Infertility Preimplantation Genetic Testing (PGT

Acceptance by people

Previous: myths – Myth: IVF is only the last option  Myth: IVF is only for affluent people Myth: IVF is limited to a younger population

only Myth: IVF is successful in all cases Myth: IVF requires admission in the hospital Myth: IVF always result in multiple pregnancies

like twins or triplets Myth: IVF babies have a significantly high risk

of birth defects and malformations Myth: IVF is covered by insurance Myth: IVF is dangerous

Acceptance by people

Present : reality- Who Does it Help? In-Vitro Fertilization and the Hermeneutic of

the Gift Woman’s uncensored journey Maternal Age and Blastocyst Development Frozen Blastocyst Cycles The Future

Acceptance by people

Present : reality- The Future

Why it was not accepted by drs as routine?

DARR LACK OF CONFIDENCE LACK OF SENIORS SUPPORT LACK OF KNOWLEDGE FROM WHERE TO

LEARN HOW TO ESTABLISH LAB etc…..

IVF Without Surgery - Transvaginal Oocyte Retrieval

Success rate !!!

Technology

Previous & Present: -Ease of getting equipment & loans -support of companies -disposables& media -hormones( refine technology) -ovum pick up -embryo transfer( role of USG) -endocrinology & lab support -availability of embryologyst - knowledge & skill - ICSI ,IMSCI, PICSI,PGS, PGD,ERRAY , LAH,

STEMCELL etc…..

Technology

Assisted reproductive technology INTRACYTOPLASMIC SPERM INJECTION

(ICSI) GAMETE INTRAFALLOPIAN TRANSFER

(GIFT) ZYGOTE INTRAFALLOPIAN TRANSFER

(ZIFT)

Service at door step

By companies By doctors By laboratories

Medicine updates

Previous: Clomiphene citrate

Present: Various options

GnRH Agonists GnRH Antagonists Gonadotropins  hCG Progesterone Medrol  Doxycycline

Complications

Previous: None reported

Present: Ovarian Hyperstimulation Syndrome (OHSS) Ovarian cancer Uterine cancer Cervical Cancer Breast cancer Ectopic pregnancy Heterotopic pregnancy Miscarriage

Benefits

Fast conception Early identification of factor Demand & supply Dhiraj & dhakka Multiple pregnancy LSCS Both party happiness Remote centre franchise for drs

Physicians

Previous: Not aware

Present : Many physician refer patient to IVF clinic

To whom you should refer?

?????

Why IVF as routine?

Past tense: trial & error fertilisation

Present tense: in vitro & in variable fertilisation

1. Nowadays, the use of surgically-retrieved sperm and ICSI has become an established procedure for couples wishing to obtain a biological offspring in whom the male Subfertility.

2. So far, the post-natal outcomes of babies born from such fathers are reassuring.

Conclusion Understand the reproductive potential of

couple undergoing IVF

Success of ICSI (Very sucessfull data)

Male Factors Infertility IVF

~40% live birth ratesFemale Factors Infertility IVF

Higher results than other infertility causes~25% live birth rates

MICRO-TESE

Key MessagesAntioxidants helpful to decrease oxidative

stress.Interventions impact on semen quality 60 days

later.

WHO lowered semen analysis reference values.

IVF is beneficial for patient subgroups.

IVF and reproductive potential is dependent on the type of infertility

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