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
• 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