ASSISTED REPRODUCTIVE

TECHNOLOGY (ART)

BY
PROF. BABAGANA BAKO
 ART

All treatments or procedures that

include the handling of human
oocytes and sperms or embryos
for the purpose of achieving or
establishing a pregnancy
• 6.1% of married women, or approximately 1 million
women were infertile.

• The rate of infertility in null gravida women is correlated

with age:

• 15–29 years 7.3%, 30–34 years 9.1%, 35–39 years 25% &
40–44 years 30%

• 25,000 follicles by 37-38 years

• The rate of infertility is impacted on by parity

• The overall rate of infertility has decreased over time

 Historical perspectives of IVF

NHA on the 8th of March 2007

 INDICATIONS
• Female factor infertility
- tubal
- adhesions
- endometriosis
- anovulation (PCOS)
• Severe oligospermia
• Prolonged unexplained infertility
• Combined mild/mod M & F factors
• Failure of conventional Rx
 Types of ART
• Intrauterine insemination (IUI).
• GIFT
• ZIFT
• IVF + ET ( patient or Donor)
• ICSI/IMSI
• Embryo freezing
• Embryo donation
• Surrogate motherhood.
 Evaluation of infertile couple
• Detailed history –previous obstetric/gynae
• Fertility test/ treatment
• Infection screen, HBV,HCV,HIV, VDRL
• Seminal fluid analysis
• Ovarian reserve testing
• Other tests as indicated
• Comprehensive medical evaluation as needed
 Ovarian reserve Test:
Provides an indirect assessment of the woman’s
remaining follicular pool
Anti Mullerian hormone (AMH) = ↓0.5-1.26ng/ml
Antral follicle counts (AFC) = normal range (8-12)
Day 2-5: FSH level = ↑25IU/L or more
Basal oestradiol level = <20 or >80pg/ml
Inhibin B = ↓<45pg/ml
Clomiphene Citrate challenge test (CCCT) = 100mg of
CC and take FSH on day 3 & 10. ↑level (>10IU/ml)
Ovarian volume = ↓volume (Average value of 7ml)
 Intrauterine Insemination : IUI
IUI is a process in which processed
and concentrated motile sperms are
placed directly into the uterine
cavity.
The sperm could be from the
partner or a donor
 The main aims of IUI are to:
By pass the cervical mucus barrier.
Increase the numbers of motile
spermatozoa with a high proportion
of normal forms to be deposited as
close as possible to the Oocytes
Natural Conception
 INDICATIONS
Unexplained subfertility
Cervical factors
Mild male factors
Minimal endometriosis
Discordancy for STIs such as HIV
Severe sexual dysfunction (premature
ejaculation & Impotence)
Failure of timed intercourse
 Severe hypospadiasis, retrograde ejaculation
 CONTRA INDICATIONS

Bilateral tubal block

Severe male factor
Active cervical, intrauterine or
pelvic infection
 STEPS IN IUI
Patient assessment
Stimulation
Sperm preparation
Insemination procedure
Luteal support
Pregnancy test & scan
 Patient assessment
History & examination
Early follicular phase gonadotropin assay,
AMH assay, other assays (Thyroid etc).
Pelvic USS (TVS)
Aquascan/Hycosy/HSG
Hysteroscopy
Laparoscopy
SFA
COUNSELLING
 Stimulation protocol

Aim to generate 1 to 5 follicles

Natural cycle IUI
Ovulation monitoring (TVS,
urinary LH kit)
Standard Protocol For Ovulation In IUI
Tab Clomiphene Citrate 50-100mg Or
Letrozole 2.5-5mg from 2nd or 3rd day.
HMG from 6th day onwards till follicle
maturity usually 3-4days.
Once a mature size follicle of 18-22mm
and a >7mm trilamina endometrium is
obtained ,inject hcg 5 -10,000 I.U in the
evening.
IUI is timed 36-40hours from LH surge
TVS
 SPERM PROCESSING
Washing of the sperm is necessary to
remove
Prostaglandins
Infectious agents
Non –motile spermatozoa
Leucocytes
Immature germ cells
Antigenic proteins.
 Cont
The prostaglandin rich prostatic and seminal
fluid which causes cramping & rarely
anaphylaxis.
Maximizes quantity of motile sperm
Methods used (i) “SWIM UP” (ii) “DENSITY
GRADIENT CENTRIFUGATION”
Post wash motile count of > 5 million is
desirable
Swim up method
Density gradient method
 TIMING OF INSEMINATION

24- 36 hours after urinary LH

peak
30 – 40 hours after hCG trigger
Sperm prep and Insemination
 IUI PROCEDURE

Lithotomy position
Loading of processed sperm (0.5-
1ml) in IUI catheter
Injection processed sperm
Patient rests for 5- 10 minutes
before getting up
 LUTEAL SUPPORT AND
PREGNANCY OUTCOME
Questionable except in cases of
luteal deficiency
Progestogens used( Cyclogest)
Pregnancy test is conducted 14 to 16
days after insemination
Pregnancy rate 10 – 25% per cycle,
declines after the 3rd cycle
 Risk of IUI
Slight risk of infection
Spotting
Multiple pregnancy because of the OI.
Failure
 STEPS IN IVF
• Patient assessment
• Controlled ovarian hyper-stimulation
• Oocyte & sperm retrieval
• In-vitro Fertilization & Embryo culture
• Embryo transfer
• Pregnancy test & scan
 Patient assessment

• History & examination

• Early follicular phase FSH, LH, Estradiol, AMH

• Pelvic USS (TV)

• Hysteroscopy

• SFA
 Controlled ovarian hyperstimulation
• Aim to generate 6 – 15 follicles
• 3 group of drugs used
- GnRH-agonist/antagonist
- hMG
- hCG
• Various protocols
- Standard/long protocol
- Stop protocol
- Short or Flare protocol
 Long protocol
• Pituitary desensitization wt GnRH-a (started btw day
19 & 22 of menses) till hCG administration
- endo thickness <5mm
- absence of follicle/cyst > 10mm
- estradiol <150 pmol/L
• hMG in variable doses
• TV scan day 8 and subsequently
• hCG (5- 10,000 iu) when 2 or more follicles >18mm
(17-20mm)
 Protocols cont
• Stop protocol- GnRH-a is stopped on start of
hMG
• Short/Flare protocol
- GnRH-a starts on day 2
- hMG starts on day 3
- used >40yrs, high FSH, failure wt long
protocol
 Oocyte retrieval (OCR)
• Done 36 hours after
hCG
• TV scan guidance
with 17 G needle
• Light sedation &
analgesia
• Dark room
 Fertilisation /Embryo culture

• The sperm (50,000) and the egg are incubated

together in the culture media for about 18
hours.

• The fertilised egg is then cultured until the egg

consists of six to eight cells.

• Transfer may be done on day 2, 3 or 5

 In Vitro Embryo Development

Oocyte & Sperm Pronuclate Embryo Cleaved Embryo

 Embryo transfer (ET)
• 3 – 5 days after OCR
• 2 – 3 embryos to be transferred
• Conventionally trans-cervical
• A gentle procedure

• TUBAL EMBRYO TRANSFER(TET)

in severe cervical stenosis
Embryo Transfer
 Pregnancy test/scan
• Luteal support wt progesterone pessaries

• PT 14 days after ET

• TV scan 21 days after a +ve PT

• ANC
 Success rates
This is variable
• Average 25-30%
• Depends on several factors
 Maternal age
 Duration of infertility
 Basal FSH
AMH
 Number of oocytes,
• All reflecting ovarian function
 Other factors affecting success rates
• Tobacco smoking
• Body mass index
• Salpingectomy before IVF treatment increases
chances for women with hydrosalpinges
• Previous pregnancy/live birth
• Alcohol/caffeine intake
• Level of DNA fragmentation
• Semen quality
 Complications
• High failure rate
• Multifetal gestation
• Ovarian hyperstimulation syndrome (OHSS)
• Ectopic pregnancy
• Heterotrophic pregnancy
• Most recent studies show that the previously
suggested long term risk of epithelial ovarian
CA, breast CA and premature menopause are
unfounded
 GIFT
• Developed in 1984 for women with unexplained
infertility.
• Indicated in religious and ethnic communities in
which fertilization outside the body is not
acceptable
• Patient undergoes a controlled ovarian
hyperstimulation.
• The oocytes are retrieved transvaginally under
ultrasonographic guidance
• 3-4 oocytes are placed via laparoscopy into one
of the fallopian tubes along with sperms
 ZIFT
• Oocytes are retrieved and fertilized in vitro in
the laboratory as in IVF.
• At 2 cell stage, 3-4 embryos are transferred via
laparoscopy into one of the fallopian tubes.
• Beneficial in women who are thought to have
compromised embryo quality due to embryo
in vitro culture.
• Risk of ectopic pregnancy is high
 Male factor infertility
• Couples with severe male factor infertility are
not so amenable to conventional IVF
• Several procedures have been tried in an
attempt to circumvent zona pellucida,
perivitelline space and oolema
• 1992 Parlemo described ICSI
• 2002 Benjamin Bartoov described IMSI
 MICROMANIPULATION TECHNIQUES
• Partial Zona Dissection (PZD); mechanical distruption
of Zona to grant assess to sperms.
• Subzonal Insemination (SUZI); several sperm cells are
delivered to perivitelline space.
• Intracytoplasmic Sperm Injection (ICSI) ;single motile
spermatozoon is injected directly into the ooplasm
(200-400X).
• IMSI ; Intracytoplasmic morphologically selected
sperm injection which involves injecting a
morphologically selected sperm is directly injected
into the ooplasm(6000-10000X).
Microinjection
Intracytoplasmic sperm injection (ICSI)
• ICSI is used in more than half of all IVF cycles.

• ICSI is used in cases of severe male factor(<5 million)

or in cases when a prior standard IVF resulted in <30%
egg fertilized.

• Fertilization rates after this procedure are between 60%

and 70%.

• PGD
 IMSI
• Latest advances in micromanipulative IVF
• Involves a method of unstained, real-time, high
magnification evaluation of spermatozoa
(MSOME: motile sperm organelle morphology
examination).
• Sperms are examined under high magnification
microscopy (6,000 - 10,000)
• Most “normal” sperms are identified for
microinjection (morphologically/Organelles)
 Cont
• Indicated in severe male factor infertility
• Recurrent implantation failure
• Recurrent miscarriage
• Testicular sperm is superior to ejaculated.
• Freshly ejaculated sperm is superior to stored
sperm
Normal sperm cell
 Advantages of IMSI
• Increases pregnancy rates by 50% over ICSI
• Reduces miscarriage rates by 75% over ICSI
• Shown to identify viable sperms in men who
were considered azospermic under normal
magnification(cryptozoospermia)
• Treatment of choice in surgically obtained
sperms
 Other method
• Hyaluronic acid mediated sperm selection also
known as Physiologic ICSI.
• Annexin V binding is a newer method of
detecting sperm apoptosis or damaged
membranes occasioned by the release of
phosphatidyl serine.
 Third party ART
 Production of an offspring through the
gametes /uterus of an individual who will
not be involved in parenting
 sperm donation
 Oocyte donation
 Embryo donation
 Surrogate (Traditional or gestational)
 Conclusion

• Infertility is a treatable medical condition.

• Infertility has become a complex medical problem with

legal, moral, ethical, and financial implications.

• Efforts should be geared towards researches that will

preventing infertility and reducing the cost of

treatment.