Assisted

reproductive
technologies
(ART)
By

Doaa Hegab

Range of techniques for

manipulating oocytes and
sperms to overcome
.infertility

:Major groups
Artificial

insemination husband (AIH).

FASIAR (Follicle aspiration, sperm
injection & assisted rupture).
In vitro fertilization (IVF) & embryo
transfer (ET).
GIFT & ZIFT
Gametes micromanipulation (ICSI &
IMSI).

:Encompasses also
Ex utero and in utero fetal surgery.
Cryopreservation & screening sperm and

embryos.
Micromanipulating and cloning embryos.

Artificial insemination husband

(AIH)
Process by which sperms are placed into

the reproductive tract of a female for the

purpose of impregnating her by using
means other than sexual intercourse.

:Indications
Mechanical infertility.
Defective seminal parameters:

-low count, motility or

abnormal forms.
-low or high volume, high viscosity
or abnormal liquefaction.
Immune infertility.
Idiopathic infertility.

:Preparation
Ovulation induction & monitoring.
Semen processing:

* Semen wash with sperm culture

media & centrifugation.
* Selection of motile sperms.
* Stimulation of motile spers.

:Techniques
Intracervical insemination (ICI).
Unwashed' or raw semen may be used.
Easy,semen is injected high into the cervix with a needle-less syringe.
Intrauterine insemination (IUI).
Washed sperm' can be injected directly into a woman's uterus
Intratubal insemination (ITI).
No beneficial effect compared with IUI.
ITI however, should not be confused with gamete intrafallopian transfer,
where both eggs and sperm are mixed outside the woman's body and then
immediately inserted into the Fallopian tube where fertilization takes place.
Intraperitoneal insemination (IPI). Prepared semen is
injected into Douglas pouch.

FASIAR
A transvaginal ultrasound-guided needle is used to puncture follicles in

the ovary.
The follicular fluid is aspirated with oocyte into a syringe that also holds
the semen. This mixture is then immediately injected back into the
follicle.
Because the total injected volume is much greater than the volume of
the original follicle, the fluid was noted to flow out of the follicle and into
the peritoneal cavity.
Differs from GIFT in that it depends on the tubal fimbriae to pick up the
oocytes.
FASIAR may reduce the risk of multiple births and is less expensive than
other procedures.

IVF & ET
A process by which oocyte is fertilised by prepared

sperms outside the body (in vitro).

IVF is a major treatment in infertility when other methods

of assisted reproductive technology have failed.

The process involves hormonally controlling the

ovulatory process, removing ova from the woman's

ovaries and letting sperm fertilise them in a fluid culture
medium.

 Ovarian stimulation

Treatment cycles are typically started on the third

day of menstruation and consist of a regimen of
fertility medications to stimulate the of multiple
follicles of the ovaries. In most patients injectable
gonadotropins (usually FSH analogues) are used
under close monitoring. Such monitoring frequently
checks the estradiol level and, by means of
gynecologic ultrasonography, follicular growth.
Typically approximately 10 days of injections will be
necessary. Spontaneous ovulation during the cycle
is typically prevented by the use of GnRH agonists
or GnRH antagonists, which block the natural surge
of luteinising hormone (LH).

 Egg retrieval
Transvaginal oocyte retrieval
When follicular maturation is judged to be
adequate, human chorionic gonadotropin (hCG) is
given. This agent, which acts as an analogue of
luteinising hormone, would cause ovulation about
42 hours after injection, but a retrieval procedure
takes place just prior to that, in order to recover the
egg cells from the ovary. The eggs are retrieved
from the patient using a transvaginal technique
involving an ultrasound-guided needle piercing the
vaginal wall to reach the ovaries. Through this
needle follicles can be aspirated, and the follicular
fluid is handed to the IVF laboratory to identify ova.
It is common to remove between ten and thirty
eggs. The retrieval procedure takes about 20
minutes and is usually done under
conscious sedation or general anesthesia.

Fertilisation

In the laboratory, the identified eggs are stripped of

surrounding cells and prepared for fertilisation. In
the meantime, semen is prepared for fertilisation by
removing inactive cells and seminal fluid. If semen
is being provided by a sperm donor, it will usually
have been prepared for treatment before being
frozen and quarantined, and it will be thawed ready
for use. The sperm and the egg are incubated
together at a ratio of about 75,000:1 in the
culture media for about 18 hours. In most cases,
the egg will be fertilised by that time and the
fertilised egg will show two pronuclei.
The fertilised egg is passed to a special growth
medium and left for about 48 hours until the egg
consists of six to eight cells.

Selection
Laboratories have developed grading methods to
judge oocyte and embryo quality. Typically,
embryos that have reached the 6-8 cell stage are
transferred three days after retrieval, however
sometimes embryos are placed into an extended
culture system with a transfer done at the
blastocyst stage at around five days after retrieval,
especially if many good-quality embryos are still
available on day 3. Blastocyst stage transfers have
been shown to result in higher pregnancy rates.

 Embryo transfer
Embryos are graded by the embryologist based on
the number of cells, evenness of growth and degree
of fragmentation. The number to be transferred
depends on the number available, the age of the
woman and other health and diagnostic factors.
The embryos judged to be the "best" are transferred
to the patient's uterus through a thin, plastic catheter
, which goes through her vagina and cervix. Several
embryos may be passed into the uterus to improve
chances of implantation and pregnancy.

 The sperm and the egg are incubated together at a

ratio of about 75,000:1 in the culture media for about

18 hours. In most cases, the egg will be fertilised by
that time and the fertilised egg will show two
pronuclei. The fertilised egg is passed to a special
growth medium and left for about 48 hours until the
egg consists of six to eight cells.
The fertilised egg (zygote) is then transferred to the

patient's uterus with the intent to establish a

successful pregnancy (ET).

Indications (as AIH)

Mechanical infertility.
Defective seminal parameters:

-low count, motility or

abnormal forms.
-low or high volume, high viscosity
or abnormal liquefaction.
Immune infertility.
Idiopathic infertility.
Irreversible tubal obstruction.

Complications
The major complication of IVF is the risk of multiple births. With

increased risk of pregnancy loss, obstetrical complications, prematurity,

and neonatal morbidity.

However recent evidence suggest that singleton offspring after IVF is at

higher risk for lower birth weight for unknown reasons

Another risk of ovarian stimulation is the development of

ovarian hyperstimulation syndrome.

If the underlying infertility is related to abnormalities in spermatogenesis,

it the male offspring is at higher risk for sperm abnormalities.

Birth defects:
certain birth defects could be significantly more common in infants
conceived with IVF, notably septal heart defects, cleft lip with or without
cleft palate, esophageal atresia, and anorectal atresia; the mechanism of
causality is unclear

Gamete intrafallopian transfer

(GIFT)
The oocytes will be harvested after ovarian

stimulation, mixed with the prepared sperms

suspension, and placed back into the woman's
Fallopian tubes during a single laparoscopy.
More simple, physiological & cheap than IVF.
Results not better than IVF.

Zygote intrafallopian
transfer (ZIFT)
The oocytes will be harvested after ovarian

stimulation by transvaginal ultrasound-guided ovum

retrieval. Co- incubation with prepared semen & after
fertilization in the laboratory the resulting early
embryos or zygotes are placed into the fallopian
tubes using a laparoscope.

However, the need for two interventions and the fact

that IVF results are equal or better leaves few if any

indications for this intervention.

ICS
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