Recent advances in ART

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RECENT ADVANCES IN ART Dr. Kamini A. Rao DGO, DCh, MCh, FRCOG, FNAMS, FICOG,PGDMLE (Law) Medical Director Bangalore Assisted Conception Centre Bangalore , Karnataka India

ART : 

ART Evolving field at a rapid phase Advances in ART are running parallel to advances in Molecular biology, Genetics, Embryology, Pharmacology, Ultrasound & Endoscopy Hardly a day passes without public recognition of recent events related to this field

CHANGING PATIENT PROFILE : 

CHANGING PATIENT PROFILE Changing lifestyle Voluntary delay in conception – Decreased fertility potential Single parents Exposure to gametogenic toxins - environmental, drugs, nicotine etc… Voluntary gamete preservation

Endocrinology : 

Endocrinology Inhibin B Secreted by Granulosa cells of the developing follicle Lower levels are associated with fewer oocytes, higher cancellation rates, and lower pregnancy rates Questionable benefit as an independent marker Day 3 levels >45 pg/ml – Good predictor

Endocrinology : 

Endocrinology 2) Anti Mullerian Hormone (AMH) Glycoprotein hormone – Transforming Growth Factor Beta super family Expressed in Pre and Early Follicles Secretion reflects Pre and Early Follicular activity Decreases with increasing ovarian ageing Good predictor of ovarian response and IVF success

Oxidative Stress in Male Infertility : 

Oxidative Stress in Male Infertility Multi-factorial Varicocele Idiopathic Infection Immunologic Obstruction Developmental Lifestyle Genetic Endocrine Oxidative stress is due to the elaboration of ROS (reactive oxygen species)

Role of Antioxidants : 

Role of Antioxidants Protect normal sperm from ROS-producing sperm Protect normal sperm from WBC-derived ROS Suppress premature sperm maturation

Etiology of Oxidative Stress: ROS Production or Antioxidant Deficiency? : 

Etiology of Oxidative Stress: ROS Production or Antioxidant Deficiency? Production Degradation

Reactive Oxygen Species (ROS) : 

Reactive Oxygen Species (ROS) 25% infertile men have high semen ROS levels Semen ROS levels correlate negatively with sperm motility Mechanism of ROS-induced sperm dysfunction: Peroxidation of sperm membrane lipids (accumulation of lipid peroxides) ATP depletion Oxidation of proteins/SH-groups DNA oxidation/fragmentation

Effective Anti Oxidants : 

Effective Anti Oxidants Vitamin E Vitamin C Lycopene

Sperm Chromatin Structure Assay(SCSA) : 

Sperm Chromatin Structure Assay(SCSA) Assessment of DNA fragmentation by flow cytometry Increased fragmentation correlated with poor IVF success Useful in unexplained infertility & repeated IVF failures Can be treated with anti oxidants If fragmentation index remains high, testicular sperm may be used

Microdissection TESE : 

Microdissection TESE Removal of tiny (2-3 mm) volumes of testicular tissue with improved sperm yield Operating microscope with 15X – 25X magnification Advantages Improved yield of spermatozoa Less tissue removal Minimzes vascular injury Makes embbryologists job very easy

Spermatid Injection : 

Spermatid Injection Chances of getting spermatids in NOA ~ 70% Pregnancy rate after spermatid injection ~ 40% Types of spermatids – Round & Elongated ROund Spermatid Injection – ROSI ELongated Spermatid Injectio –ELSI ELSI gives better results Spermatid injection is the last option for men with NOA

Genetic Analysis : 

Genetic Analysis Y Chromosome Microdeletion Assay PCR based blood test – AZF regions on the Yq These area contains genes for spermatogenesis AZF c – Good Prognosis –May get sperm in TESE AZF a, AZF b and AZF b+c – Poor prognosis

Pharmacology : 

Pharmacology Recombinant LH Structurally & functionally similar to natural hormone Appropriate high doses can be used Single administration is enough Adequate final maturation of oocytes, corpus luteum formation and more viable pregnancy rate Will not cause OHSS Can also be used for OI in WHO group I anovulation

Pharmacology- Antagonist Protocols : 

Pharmacology- Antagonist Protocols 0 1 2 3 4 5 6 7 8 9 10 11 Fixed Day Regimen Multiple doses Single dose CETRORELIX CETRORELIX/GANIRELIX r FSH/hMG r FSH/hMG hCG hCG Cycle Day

Pharmacology- Antagonist Protocols : 

Pharmacology- Antagonist Protocols 0 1 2 3 4 5 6 7 8 9 10 11 Flexible Regimen Single dose CETRORELIX CETRORELIX/GANIRELIX r FSH/hMG r FSH/hMG hCG hCG Cycle Day Multiple doses The antagonist is administered when the lead follicle is 14 mm and / or E2 reaches 600 pg/ml

Embryology- Invitro Maturation of Oocytes (IVM) : 

Embryology- Invitro Maturation of Oocytes (IVM) Avoid using Gn, their side effects & cost Immature oocytes are retrieved from antral follicles before emergence of dominant follicle The critical chain of events leading from germinal vesicle break down to the expulsion of first polar body take place invitro & generation of metaphase II oocytes

IVM - Protocol : 

IVM - Protocol Progesterone withdrawal Retrieval on D8-D13, so long as all coexisting follicles are uniformly small(<8mm) Vacuum- 50 to 80 mm of Hg 17 G single lumen needle, more rigid, Shorter bevel Culture media –TCM 199 supplemented with fetal cord serum or fetal bovine serum, EGF, hCG, FSH and pyruvate for energy Fertilization with ICSI

IVM - Problems : 

IVM - Problems Decreased fertilization rate & pregnancy Increased chromosomal & spindle abnormality – High miscarriage rate Technically demanding

Blastocyst Transfer : 

Blastocyst Transfer Conventional Transfer – D2 or D3 : 4 – 8 Cell Availability of more physiological culture media made extended culture possible Sequential Media – Used here Phase I Sequence –Mimics the nutrients found in the Fallopian tube Phase II Sequence – Mimics the nutrients found in the receptive uterine cavity

Blastocyst Transfer - Advantages : 

Blastocyst Transfer - Advantages Embryo selection with highest developmental potential Synchronisation with endometrium Minimize the embryo exposure to the hyperstimulated uterine environemnt Reduced embryo expulsion Assessment of true viability after complete genomic activation Higher implantation – Reduced need of multiple embryo transfer Increased ability to undergo cryopreservation Ability to undertake cleavage stage embryo biopsy Increased overall efficiency of IVF

Asssisted Hatching : 

Asssisted Hatching A microsurgical procedure on pre embryos before ET Making a small hole in the zona or outer shell of pre embryo Excessive cytoplasmic fragments can be removed simultaneously during the procedure

Asssisted Hatching-Indications : 

Asssisted Hatching-Indications Maternal age > 37 years ZP thickness >17 mm Other ZP Abnormalities – Bilayering, Odd shapes >20% Cytoplasmic fragmentationa > Failed IVF attempts Poor embryo growth/morphology (<6 cell on D3)

PGD : 

PGD Used in Sex determination Diagnosis of Aneuploidies Diagnosis of Balanced translocations Single gene defects

PGD : 

PGD Cell Biopsy Polar body biopsy Blastomere biopsy Blastocyst or Trophectodermal biopsy

PGD : 

PGD Analysis FISH – For chromosomal analysis PCR – For detection of single gene defects Comparative Genomic Hybridization (CGH)- For identification of whole chomomosome aberrations

Cryopreservation : 

Cryopreservation Ovarian tissue cryopreservation One ovary is removed laparoscopically and ovarian cortex is isolated Cortex is cut into strips – 10 mm long, 5 mm wide and 1 mm thickness They are incubated incryoprotectants and frozen using a programmable freezer Best protocol – Sloe freeze, rapid thaw protocol EG or DMSO are the best cryoprotectants 7% of follicles are lost during freezing & thawing

Cryopreservation : 

Cryopreservation Oocyte cryopreservation Less effective – Mature oocyte extremely fragile Reasons-Large size, water content & Chromosomal arrangements Vitrification – Cryopreservation using high concentrations of cryoprotectants to solidify the cell in a glass state without formation of ice Vitrification is superior for oocyte preservation Live birth rate /frozen oocyte ~ 3-4%

Stem Cell : 

Stem Cell Totipotent cells Pleuripotent cells Multipotent cells

Stem Cell Research : 

Stem Cell Research Totipotent Cells From fertilized egg Can create 216 different cell types Can make human body

Stem Cell Research : 

Stem Cell Research Pluripotent Stem Cells Derived from inner cell mass of blastocyst Can make most cell lines Cannot make all cell lines, so cannot make an individual Called embryonic stem cells

Stem Cell Research : 

Stem Cell Research Multipotent Stem Cells Specialised cells -differentiated, only active function maintained Some adult tissues contain partially differentiated cells eg. Bone marrow These stem cells can form limited number of specialised cells Called adult stem cells

“Advancement comes only with habitually doing more than what you are asked for” Gary Ryan Blair : 

“Advancement comes only with habitually doing more than what you are asked for” Gary Ryan Blair

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