Dr Manuela Toledo - Procedures in ART -

Transcription

1 Dr Manuela Toledo - Procedures in ART - Fertility Specialist MBBS FRANZCOG MMed CREI Specialities: IVF & infertility Fertility preservation Consulting Locations East Melbourne

2 Planning a pregnancy - Folic Acid (500μg) at least 3 months prior - Women s & Men s multivitamin - Healthy BMI - Lifestyle - Visit GP for pre-pregnancy check-up

3 Natural conception Your fertile window is the best time during your menstrual cycle to conceive

4 Ovulation cycle tracking Determine your fertile window Ovulation triggered by surge of luteinising hormone Simple ultrasound and urine tests to detect hormone surge

5 Determine ovulation Symptoms Mittelschmerz Temperature charting Cervical mucus Saliva Ferning pattern Urine tests

6 Your chance of success What is infertility? Infertility is the inability of a couple to conceive over a 12 month period

7 Why aren t we pregnant? Major causes of female infertility Poor egg quality Ovulation problems Polycystic ovary syndrome Tubal blockage/ damage Endometriosis Uterine abnormalities

8 Egg quality

9 Anti-mullerian hormone AMH 8 This model shows that: At any particular age 34% of variation in AMH AMH peaks at age 24.5 years there is a neonatal peak and a pre-pubertal peak Kelsey et al. 2011

10 Why aren t we pregnant? Major causes of male infertility Sperm Problems Sexual Difficulties / Impotence Presence of Sperm Antibodies Lifestyle Unexplained

11 What affects fertility? Pre-existing medical conditions Weight Management Exercise

12 Medical conditions Irregular periods Painful periods Previous surgical procedures (eg ruptured ectopic pregnancy) Recurrent miscarriage Male factors

13 Weight management BMI >30kg/m 2 Decreased egg quality Decreased follicular development Decreased pregnancy rates RANZCOG Guideline Recommends treatment for fertility begin when BMI < 35 Diet and exercise

14 Weight management Pregnancy : Diabetes High Blood Pressure Preterm Birth of baby Baby Too big or too small Long Term: Diabetes and Heart Disease

15 Exercise in pregnancy

16 Exercise Before and during pregnancy Aerobic and strength training Aim to achieve just shy of peak fitness level Minimise risk of trauma or loss of balance No increase in abnormalities to baby Start pelvic floor exercises before pregnancy

17 Why a fertility specialist? What we do Advice Fertility Assessment Treatment Options Investigations

18 What treatment will I have? The results of investigations arranged by your fertility specialist, combined with your age, will determine the best treatment option for you. Maternal age will guide type of treatment <36 years = 12 mths >36 years = 6 mths

19 Other reasons Single Women Same sex couples Fertility preservation

20 Fertility surgery Laparoscopy Tubal Endometriosis Fibroids Hysteroscopy

21 Ovulation Induction The stimulation of ovulation by medication Clomiphene tablets & FSH injections Low cost Least invasive

22 Intrauterine Insemination Ovulation monitoring plus the insertion of washed sperm (partner or donor sperm) into the uterus by catheter With or without ovulation induction

23 IVF Sperm fertilises the eggs in the laboratory (rather than fallopian tube) The fertilised embryos grow in the laboratory over two to five days before being transferred back into the woman s uterus

24 IVF: medication & monitoring scans Aim to stimulate growth of more than one mature egg in ovary during menstrual cycle All stimulated IVF cycles require administration of FSH injections

25 Why stimulate the ovaries?

26 IVF Egg collection Usually hours after trigger injection under sedation Sperm collection Masturbation Surgical retrieval Donor

27 IVF: egg collection

28 IVF: sperm & egg preparation

29 ICSI Metaphase II oocyte

30 IVF & IVF with ICSI Conventional IVF (>100,000 motile sperm) Micromanipulation (ICSI) (1-20 sperm)

31 IVF & IVF with ICSI (video)

32 Pronuclear stage hrs 2PN 24 hrs later, ET 8 hrs later

33 IVF: embryo growth

34 Improving IVF success Advanced embryo screening Genetic screening to test embryos for aneuploidy e.g. Down syndrome

35 Embryo transfer & freezing Transfer best quality embryo back to uterus between two and five days after egg collection Freeze excess embryos for use via frozen embryo transfer

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37 Embryo transfer - preparation Appropriate timing Full bladder with anteverted uterus

38 OPU and Embryo transfer complications Infection Bleeding Pelvic organ damage OHSS (non-pregnant) OHSS (pregnant) Miscarriage Ectopic pregnancy

39 Congenital abnormality after ART RR 1.3 Background 2% After ART 4% No difference between IVF and ICSI

40 Twins Increased preterm birth, LBW, perinatal mortality, cerebral palsy Absolute risk much greater than singleton

41 Genetic abnormalities after ART Karyotypic abnormalities Y chromosome deletions Imprinting disorders

42 Genetic abnormalities after ART Imprinting disorders 1:14,000 1:60,000 pregnancies spontaneously conceived have imprinting disorders which predispose to brain abnormalities, tumours e.g. Prader Willi, Beckwith Wiedemann, Angelman syndomes 5-10 fold increase with ART

43 July Louise Brown First IVF baby Born to Lesley Brown - bilateral tubal blockage Natural cycle, single egg fertilization

44 Melbourne IVF Responsible for the first IVF baby in VIC 1980, NSW 1983, QLD 1984 (Virtus Health Group). Conceived 50,000+ babies over past 35 years - half Australia s IVF conceived population. Achieved world s first baby born from ovarian tissue grafted in anterior abdominal wall of a Melbourne woman in First to introduce Karyomapping in Australia, to help couples avoid the transmission of serious genetic conditions.

45 hank you! uestions? Dr Manuela Toledo Melbourne IVF FRANZCOG MMed CREI