Dr. Shahin Ghadir A Primary Care Approach to Diagnosing and Treating Infertility St. Charles Bend Grand Rounds November 30, 2018 I have no conflicts of interest to disclose. + About SCRC State-of-the-art embryology lab On-site surgery center Most advanced technologies Andrology laboratory Endocrine laboratory Full-service fertility center Over 25 years experience Fertility 101 18% 16% 14% 12% 8% 6% 4% 2% Definition of Infertility Patients <35 yo trying to conceive for 1 year Patients >35 yo trying to conceive for 6 months The percentages represent the probability of a woman becoming pregnant during her next cycle, based on her age and the number of months she s been TTC. 3 6 9 12 24 36
Causes of Infertility Unexplained, 17% *Other, 9% Tubal, 22% Male, 25% *Endocrine, Immunologic, Uterine abnormalities Per Month Chance of Conception 25% 15% 5% The Age Factor AGE AND FEMALE FERTILITY 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 AGE Egg Age Infertility Evaluation 6 5 4 3 % of Genetically Normal Eggs by Age Infertility Evaluation Medical History Review Physical Examinations Diagnostic Testing <35 35-37 38-40 41-42 43-44 >44 Woman s Age
Ovaries Ovarian Reserve: AMH Ultrasound Female Testing Anti Mullerian Hormone (AMH) Female Testing Ovaries Ovarian Reserve Testing NORMAL Uterus Uterine Evaluation Saline Sonogram (HSS) Vaginal ultrasound (follicle count) ABNORMAL Female Testing Tubes Male Testing Tubal Evaluation Hysterosalpingogram (HSG) Semen Analysis : Volume (>2.0 ml) Concentration (> 20 million / ml) Motility (>5) Morphology (>4) Studies indicate that 3 of infertility is related to male factor problems
Treatment Hysteroscopy Treatment Uterine cavity evaluation Hysteroscopy (HSC) Normal Cavity Uterine Polyp Fertility Treatment Options Ovulation Induction Pregnancy Rates per Treatment Cycle in Women With unexplained Infertility Ultrasound Take medication for 5 days Trigger injection for release of egg 7 6 0.6 5 4 3 0.01 Natural Cycle 0.04 Natural Cycle with insemination 0.12 Clomiphene with Insemination 0.19 Gonadotropins with In vitro Fertilization insemination IUI Intrauterine Insemination
IUI Intrauterine Insemination Live Birth Rates Stratified by Diagnosis 18% 16% 14% 12% IUI success rates at best -15% In-vitro Fertilization 8% 6% VS. 4% 2% Unexplained Tubal Factor Endometriosis Male Factor DOR Ovulatory Dysfunction Other IVF success rates at 65%-75% Personalized Ovarian Stimulation Protocol Basics of IVF Cycle Egg Retrieval ICSI: Intracytoplasmic sperm injection Embryo development in culture Preimplantation Genetic Screening (PGS) IVF success rates at 65%-75% with genetically normal embryo
Preimplantation Genetic Testing (PGS/PGD) Indication for preimplantation genetic screening (PGS) and/or genetic diagnosis (PGD) Increased Implantation Rate Aneuploidy: such as Down and Turner Syndrome Decrease miscarriage rates Single Gene Disorders: such as Tay Sachs disease, cystic fibrosis, muscular dystrophy, Thalassemia, Sickle cell disease Chromosomal Translocation Gender selection Decrease time to pregnancy in older patients Implantation Rate 8 7 6 5 4 3 IVF success with chromosomally normal embryos PGS / NGS NO PGS Our PGS/D Avg. All Ages Our Frozen No PGS/D Avg. All Ages <35 35-37 38-40 41-42 Maternal Age Fertility Preservation Fertility Preservation Hope For The Future Sperm Freezing (Traveling, Medical Reasons, Age) Embryo Freezing Egg Freezing (Prior to cancer treatments, extensive pelvic surgery, aggressive treatment for autoimmune disorder, or electively)
Fertility Preservation Fertility Preservation Donor Eggs vs Nondonor Eggs Egg Freezing 10 9 8 7 25% Percentage of Fertility Preservation that is Elective Distribution of Elective FP cycles 6 5 Ovarian Surgery 1.6 4 3 15% Age 94.11% Other 5.89% Low Ovarian Reserve 1.7 Others 0.5 <24 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 >48 Age 5% Endometriosis 2. Donor Eggs Nondonor Eggs 2007 2008 2009 2010 2011 2012 2013 2014 2015 9 8 7 6 5 4 3 Oocyte Cryopreservation How many eggs do I need? Cumulative Live Birth Rates 5 8 9 10 15 CLBR <35 CLBR >36 Third Party Reproduction
Third Party Reproduction Egg donation What is Third Party Reproduction? Ovarian failure/menopause Poor egg quality Same sex male couples Increases chances of pregnancy Sperm Donation Third Party Reproduction Why use a Gestational Surrogate? Male factor: no sperm Single females Same sex female couples Absence of uterus or uterine pathology Medical contraindication to pregnancy Single male or same sex male couple.
ART Laboratory ART Laboratory What Sets Our Lab Apart Experienced and certified director Double witnessing verification Blastocyst culture Vitrification (flash freezing) Blastocyst biopsy PGS/PGD 24 chromosome genetic testing Sex selection Time-lapse video analysis - Embryoscope Embryo Biopsy for PGS/PGD