ASSISTED REPRODUCTION

DR Cypress MBAH M.D / D.E.S:OBGYN

Department of Gynecology and Obstertrics
Faculty of Health Sciences
University of Bamenda
Introduction
• All the scientific technics used to facillited natural
conception
• The first sucessful intra insermation was realised in
1785 in London by a surgeon
• The first sucessful IVF in 1978 in London by a
gynecologist
• In Cameroon the first sucessful IVF in 1994 In Douala
• This is a sub specialty in obs/Gyns
• It is a multidisciplinary discipline
• Ethical considerations and legislation are needed to
put limits to what can be donne and to what extend
Some common abriviations

• IVF : In vitro fertilization

• IUI : Intrauterine insemination
• ICSI : Intra-cytoplasmic sperm injection
• PGD: Pre-implantation genetic diagnosis
• TESE: Testicular sperm extraction
• GIFT : Gamete intrafallopian transfer
• FSH: Follicle stimulating Homone
• AMH: Anti Mullerian Homone
Investigations prior to assisted conception: Female

• FSH To evaluate ovarian reserve

• AMH To evaluate ovarian reserve
• Prolactine
• Thyroid function
• Testosterone
• Sex binding homones
• Infectious work –up (Hepatitis Band C, HIV, )
Pelvic ultrasound

• Performed by the endo vaginal probe

• Ovarian morphology (polycysti ovaries are
prone to hyperstimulation syndrom)
• Diagnosis and characteristic of any ovarian
cyst
• Ovarian volume and antral follicle count
(calcuate the initial dose of FSH)
• Location of the ovaries (Transvaginal oocyte
retrieval)
• Role out any abnormalities of the uterus
• Role out any associated pelvic abnomalities
UTERINE CAVITY AND TUBAL PATENCY
• Analyse the uterine cavity
• Tubal patency
• Dictation of existing hydrosalpinx
(Responsible for pour results in IVF)
• This can be done by :
 Hysterosalpingography
 Ultrasonography
 Hystero contrast sonography
 Laparoscopy and hysteroscopy
Investigations prior to assisted conception:
Male
• Spermcount and spermculture
• The abnormalities dictated will
determine the assisted technic to be
use
• If parameters are good : IVF, and if
severe abnormal parameters: ICSI
• Dosage of Anti sperm antibodies
Important coexistent pathologies
• These coexistent pathologies need to be treated
before any form of assistad repruduction technic
• Thier presence signicantly reduces the sucess rate
• These are:
 Hydrosalpinx (bilateral or unilateral)
 Polycystic ovaries
 Endometrial polypes
 Submucosal fibroids
 Obesity(female)
 Cigarette smooking (both male and female)
Technics of assisted reproduction

• Brief description of the technic

• Indications
• Estimated sucess rate
• Avantages/Disadvantages
• Complications
Intrauterine insemination
• The oldest technic that is still being practice in
mordern medicine
• This is when prepare samples of sperm (usually
obtained by masturbation) is inserminated into
the uterine cavity at the appropriate time of the
patient’s menstral cycle
• Can de done with natural or stimulated cycle
• Monitoring and councilation of cycle at risk
• Stimulation by Clomifen or FSH
• Success rate per cycle of 5% with natural cycle,
8to 10% with Clomid and 12to18% with FSH
Intrauterine insemination
• Complications
 Higher order multiple pregnancy
 Ovarian Hyperstimulation syndrome with FSH
• Avantages
 Simple and cost effective
 Can be done in less advanced setting
 Acepted by most religious groups
• Disadvantages
 Low sucess rate
 Risk of higher multile gestation if monitoring is
sub-optimal
Intrauterine insemination
• Indications
 Unexplained infertility
 Mild maleFactor
 Ejaculatory problems
 Cervical problems
 Ovulatory disorders
 Mild endometriosis
 To optimize the use of donor sperm
In vitro fertilization IVF
• Two types of IVF:
 Classial IVF
 IVF by ICSI
• Involves ovarian stimulation and surgical
retrieval of the oocytes from the ovaries
• Two protocols of ovarian stimulation
• GnRH agonist long protocol and the Antagonist
short protocol
• The goal is to induced plurifollicular proliferation
• Ultrasound monitoring is mandatory (OHSS)
Indications of IVF

• Severe tubal disease – tubal blockages

• Severe endometriosis
• Moderate male factor
• Anovulatry cycles
• Unexplained infertility
• Unsuccessful IUI
Indications of IVF/ICSI
• Severe male factor including
azoospermia and subsequent surgical
sperm retrieval, either by MESA, TESE,
PESA
• Severe oligo-asthenoterato-zoospermia.
• Poor or total non-fertilization from
previous IVF cycles.
• Preimplantation Genetic diagnosis
cycles
Indications of IVF/Procedure
• Good selection of patients after preliminary work-
up
• Ovarian stimulation with FSH using the long or
short protocol
• Preparation of sperms
• Oocyte retrieval under LA or GA ultrasound guide
• Fertilization in the Laboratory
• Embryo transfer (2 or 3)
• Conservation of surplus embryos for the next
cycle
• Luteal phase support
• Pregnancy test after 12 days
Complications of IVF
• Multiple pregnacy
• Ovarian hyperstimulation syndrom (OHSS)
 Can be life threatening
 Occur in about 2% of Cases
 Polycystic ovarian dystrophy in young women is a high
risk group
• Ectopic gestation risk is higher in assisted
reproduction than in the normal population
• Transmision of rare genitic disease and fetal
malformation(ICSI)
• Complications during oocyte retreival(Infections,
bowel damage, abces , peritonitis)
IVF:sucess rate/ advantages/ disadvantages
• In advanced centers sucess pregnancy rate
ranges from 25% to 36% with live birth rate
ranging from 20%to30%
• Millions of infertile couples arround the
world have benefited from these technic
• Conflict with some religious beliefs and
doctrins
• Unresolve ethical problems
• At what moment should we stop and say
some couple will naturally not have
offsprings?
Other procedures in assisted reproduction
• Frozen embryo replacement cycles
 Surplus embryos of good quality are frozen in liquid
nitrogen in highly monitored tanks
 Replaced in natural or supressed cycles
• Egg donation
 Ovarian failure – either premature or physiological.
 Patients with very poor ovarian function where previous
IVF has repeatedly failed.
 Patients over the age of 45 and with severe male factor
 disease necessitating ICSI.
 Patients with hereditary genetic disease where using the
patients own gametes is not advisable.
Other procedures in assisted reproduction
• Surrogacy
 Uterus is absent or cannot carry a fetus
 Oocyte retreived as in normal IVF and fertilize
by the partner’s sperm
 Embryos replaced in a surrogate uterus in
another woman
• Egg freezing
 Sucess rate as low as 2% , frozen eggs do not
survive the thawing process
 Fertility preservation for a patient undergoing
chemotherapy with no partner yet
Other procedures in assisted reproduction
• Preimplantation genetic diagnosis
 One or two cells removed from the embyros and
tested for a particular genetic anormaly
 Usually a single gene anormaly example Cystic
fibrosis,Sexlinked haemophilia, sickle cell anemia etc
• Preimplantation genetic screening
 Screening for aneuplodies such as Trisomies 13,18,21 .
Sex genes X and Y
 Recurrent miscarriages
 Recurrent IVF failures
 Patients over the age of 37 undergoing IVF
 Previous aneuploid pregnancy
Other procedures in assisted reproduction
• Surgical sperm retrieval
 Secretory azoospermia
 Sperm cells are surgically retrieved from the
testes or epidydymus
• Donor sperm
 Azoospermia
 Carriers of Severe Genetic Disease
 Lesbian/single women