INDICATIONS OF IVF/ICSI

Transcription

1 PROCESS OF IVF/ICSI

2 INDICATIONS OF IVF/ICSI IVF is most clearly indicated when infertility results from one or more causes having no other effective treatment; Tubal disease. In women with blocked fallopian tubes, IVF has largely replaced surgery as the treatment of choice. Endometriosis. Patients with endometriosis, often have tubal involvement and ovarian cysts (endometrioma). Ovulatory dysfunction. In patients with polycystic ovarian disease (PCOS) and other ovulatory problems. Age Related Infertility. In normal reproductive life, a woman's ovarian function is diminished with age. In many cases, this reduced function can be overcome through the use of IVF Male Factor Infertility. Azoospermia, oligozoospermia, asthenozoospermia, anti-sperm antibody etc. Preimplantation Genetic Testing (PGT). Genetic testing on pre-implantation embryos may be indicated for patients who are at risk for genetic disorders such as Cystic fibrosis and Thalassemia

3 STEP 1: DAY 2 OR 3 OF PERIOD Blood test for FSH, LH, Estradiol, Progesterone, AMH ± Transvaginal Ultrasound

4 STEP 2: OVARIAN STIMULATION AND MONITORING Day 2,3 FSH hormone injection: Puregon, Gonal F, Menopur, Follitrope, Pergoveris

5 STEP 2: OVARIAN STIMULATION AND MONITORING Day 5 Blood tests for Estradiol evaluate response, adjust dose of FSH ±Transvaginal ultrasound

6 STEP 2: OVARIAN STIMULATION AND MONITORING day Day 7 start second medication: GnRH antagonist

7 STEP 2: OVARIAN STIMULATION AND MONITORING day Transvaginal ultrasound check egg sizes, egg number, endometrial thickness

8 STEP 2: OVARIAN STIMULATION AND MONITORING day Average duration of medication: days

9 STEP 2: OVARIAN STIMULATION AND MONITORING day Ovulation trigger with Diphereline ± HCG When leading eggs are 18 mm or more at least 50% of the group

10 STEP 2: OVARIAN STIMULATION AND MONITORING day Check urine test for hcg, blood test for LH

11 STEP 2: OVARIAN STIMULATION AND MONITORING day Egg pick up under general anesthesia

12 Minor procedure, under general anesthesia Perform under ultrasound guided The eggs are aspirated by needle attached to a pump unit Egg collection process is usually completed in minutes Some patient might experience cramp-like pains and swelling on the day of OPU or after that but the symptoms will subside in a few days STEP 3: EGG PICK UP

13 STEP 4: EGG COLLECTION The number of the egg vary from 4-15 oocytes, old age will get less than young age The eggs are prepared and transferred to an incubator to await fertilization by the sperms 2-3 hours later after OPU

14 EGG COLLECTION AND DENUDATION The eggs are prepared and stripped from the surrounding cells. After the eggs are retrieved, they are examined in the laboratory for maturity and quality. The collected eggs will be examined under microscopy and classified as mature and immature eggs(80%maturation rate is normal) Mature eggs are placed in an IVF culture medium and transferred to an incubator to await fertilization by the sperms Only mature eggs(metaphase II) can be used for fertilization by IVF, ICSI, IMSI

15 STEP 5: SPERM COLLECTION BY EJACULATION OR SURGICAL SPERM RETRIEVAL Shortly before or after the oocyte collection the male partner will be asked to give a sperm sample Sexual abstinence of 3-4 days should b exercised Collected about minutes prior to fertilization Sperm preparation to wash dead cell and retrieve only good motile sperm

16 SSR(SURGICAL SPERM RETRIEVAL) Procedure is done under general anesthesia Minor procedure Indicated in case of azoospermia, severe male factor PESA TESA TESE

17 STEP 6: FERTILIZATION PROCESS(IVF/ICSI/IMSI) A few hours later, eggs will be fertilized with sperm Normal sperm quality, we can use standard IVF Put about 50,000 sperm around each egg to allow fertilization

18 STEP 6: FERTILIZATION PROCESS(IVF/ICSI/IMSI) Low sperm quality, case of PGS, PGD: During the process of ICSI, an embryologist isolates a sperm cell, draws it up into a microscopic needle and injects it inside an oocyte using a high power microscope.

19 IMSI IMSI is an advanced IVF technology developed to improve pregnancy outcome in severe low sperm quality. With higher magnification at least 6000 times compared with conventional method at times Choose the right sperm under higher view

20 STEP 7: FERTILIZATION CHECK On the following day after fertilization, visualization of two pronuclei (male and female nucleus) confirm the fertilization in the egg Occasionally, fertilization does not occur at all, even if ICSI was used but the incidence is low The percentage of fertilization will vary from 50-80% depending on egg and sperm quality

21 STEP 8: EMBRYO CULTURE AND DEVELOPMENT The fertilized eggs will be cultured in incubator for at least 5-6 days Normal human development is two cells on day2, eight cells on day3, more than 16 cells on day 4 and blastocyst on day 5-6 Blastocyst formation rate depends on the egg and sperm quality and age of women

22 BLASTOCYST FORMATION RATE THAI LANGUAGE TEACHING SLIDE, VERSION 1, 1/1/

23 STEP 9: PREIMPLANTATION GENETIC TESTS(PGS, PGD) The processes composed of blastocyst biopsy to remove a few cells from the trophectoderm component. The removed cells are tested for the chromosome abnormality(pgs) or a specific gene defect(pgd)

24 HUMAN CHROMOSOME AND DNA

25 HUMAN CHROMOSOME Chromosomes are the structures in our bodies that carry our genetic information or DNA There are 46 chromosomes arranged into 23 pairs numbered The final pair are the sex chromosomes (X and Y) The sex chromosomes determine if a baby is male or female Females usually have two X chromosomes and males usually have an X and a Y One copy of each chromosome is inherited from the mother s egg cell, and the other copy is from the father s sperm cell

26 CONVENTIONAL IVF/ICSI PROVIDES LIMITED OF SUCCESS It is believed that chromosomal abnormalities (aneuploidy) are a major cause of infertility and IVF failure The aneuploid embryo may not implant or is likely to miscarry early due to its inability to develop properly Nearly half of all IVF embryos are aneuploid, even in first-time IVF patients It is also estimated that at least 50% of first trimester miscarriages are associated with aneuploidy A few aneuploidies are compatible with life; however, most of these are associated with disease

27 ANEUPLOIDY INCIDENCE INCREASE WITH AGE Aneuploidy results in an abnormal amount of genetic material, which impacts the development of the pregnancy and can result in miscarriage Aneuploidy can occur in women of all ages; however, the chances are greater with increasing maternal age. As a result, infertility rates may increase The rate of aneuploidy in embryos increases with maternal age from approximately 30% at a maternal age under 35 to approximately 85% at a maternal age over 42 Most chromosome abnormalities are not likely to implant or result in a live birth Most chromosomal abnormalities are not compatible with life; however, some can result in a live birth, for example, Down syndrome (trisomy 21)

28 PREIMPLANTATION GENETIC SCREENING PGS is a procedure used to determine the chromosomal status of an IVF embryo by screening all 23 chromosomes pairs PGS is used to screen embryos so that only those with a normal number of chromosomes (euploid) are considered for transfer PGS helps to improve IVF success rates, as euploid embryos are more likely to implant and result in a live birth PGS may result in: Improved implantation rates Reduced spontaneous abortion and miscarriage Increased rate of ongoing pregnancy and number of live births Ongoing pregnancy rates: 69.1% with PGS* vs. 41.7% without PGS

29 STEP 10: EMBRYO FREEZING The technology used in freezing embryos significantly increases the likelihood of pregnancy per IVF cycle, making IVF by far the most successful and efficient form of ART Survival rates of good quality embryos are high at nearly 95%

30 WHY FREEZE ALL PROTOCOL Poor embryo environment after ovarian stimulation and egg pick up: poor fresh transfer pregnancy outcome There are proven advantages to delaying IVF embryo transfer for a month or more to take advantage of a frozen embryo transfer Freeze all IVF refers to the embryos that we collect after ovarian stimulation, egg retrieval, fertilization, embryo culture, ±embryo biopsy for genetic tests then freeze all Survival rate after thawing is excellent at 95% combined with good uterine lining(endometrium): Improving implantation rate twice compared with fresh transfer

31 BENEFITS OF FREEZE ALL IVF Improve the chance of pregnancy Have to options to freeze extra embryos for future IVF Medical purpose after surviving from cancer therapy Fertility preservation for couples who wish to delay a family

32 PREPARING FOR EMBRYO TRANSFER AFTER FREEZE ALL IVF Day 2, 3: Check hormone profile: FSH, Estradiol, Progesterone Start oral medication: Progynova (Estradiol) 1 tab 4 times a day ± Transdermal estradiol (Climara) for 14 days at least Check transvaginal ultrasound for measuring endometrial thickness, blood for progesterone level(should be less than 1.5 ng/ml)

33 PREPARING FOR EMBRYO TRANSFER AFTER FREEZE ALL IVF Endometrial thickness more than 8 mm is acceptable Blood for progesterone less than 1.5 ng/ml is acceptable Start progesterone vaginal suppository combined with oral progesterone for 5 days before blastocyst transfer Discuss with the doctor about the number for transfer: one or two or

34 EMBRYO TRANSFER Embryo transfer may be performed on day 2, 3 or 5 post fertilization. One or more embryos suspended in a drop of culture medium are drawn into a transfer catheter, a long, thin sterile tube with a syringe on one end. The physician gently guides the tip of the transfer catheter through the cervix and places the fluid containing the embryos into the uterine cavity

35 EMBRYO TRANSFER Blastocyst is the best stage for transfer One or two blastocysts can be transfer but one blastocyst can decrease multiple pregnancy rate while the success is still good The blastocyst formation rate depends on the egg and sperm quality Younger women have higher good quality blastocysts than older women

36 BLASTOCYST TRANSFER You will be asked to arrive with a partially full bladder on the day of the embryo transfer. Ultrasound guided procedure You will then be assisted into the correct position. A normal speculum will be use to view the opening of the cervix. A special media/wash is used to clean the vaginal canal and cervix. The abdominal ultrasound is used align the uterus and outer transfer catheter guide The physician will place the catheter loaded with embryos through the introducer and into the uterus under ultrasound. The embryo(s) will be transferred into the uterus

37 IN CASE OF FRESH EMBRYO TRANSFER After egg pick up procedure patient will take progesterone suppository to prepare endometrium and wait for process of embryo transfer Progesterone level on day of ovulation trigger must be less than 1.5 ng/ml for getting a good chance of pregnancy

38 AFTER TRANSFER Continue the same medications the same as before embryo transfer until the day of pregnancy test Activity will not impact on the outcome of the pregnancy so there is no "medical" reason to restrict your activity Following the completion of the procedure you will be able to get dressed and conduct your normal activities for the remainder of the day Blood tests for hcg on day days after transfer

39 OUR SUCCESS RATES

40 OUR SUCCESS RATES

41 OUR SUCCESS RATES

42 OUR SUCCESS RATES

43 OUR SUCCESS RATES