An overview of IVF/ICSI

DR.RENUKADEVI SENIOR EMBRYOLOGIST

ARC International Fertility & Research Centre

INFERTILITY?

OVERVIEW OF INFERTILITY

• Definition: 1 year of well-timed, unprotected intercourse without a pregnancy

• 10-15% of population is infertile

• 15-20 % of couples have unexplained infertility (work-up is negative)

CAUSES OF INFERTILITY

Assisted Reproductive Techniques (ART)

Any treatment that deals with “means of conception other than vaginal intercourse” is termed as ART. NICE guideline 2013

IUI – Intra Uterine Insemination (Husband / Donor)

IVF + ET – In Vitro Fertilization + Embryo transfer

ICSI – Intra Cytoplasmic Sperm Injection

IUI • Injection of washed prepared sperms into the uterine cavity through a fine catheter during pre-ovulatory phase in a natural or stimulated cycle.

• Although pregnancy may not occur as quickly, a policy of initial treatment by IUI will probably save 20% of couples from moving onto IVF

• After 3-4 cycles of failed IUI treatment, patients should be encouraged to opt for IVF

Indications for Intra Uterine Insemination (IUI)

- At least one Fallopian tube must be normal and patent - Mild male infertility - Unexplained infertility - Ovulatory dysfunction, PCOS - Mild endometriosis - Cervical factors - Coital problems - Immunological factors - HIV, HBs Ag infection - Donor Sperm

SPERM PREPARATION

Intrauterine Insemination (IUI)

Goal is to Maximize the Chance of Fertilization• Increase Number of Eggs• Position Sperm Closer to Eggs

I.V.F.

In VitroFertilization

“Test tube babies”

Indication for IVFI. IVF as first line infertility treatment

- Tubal pathology (severe, non-repairable)- Donor Oocyte- Genetic Surrogacy- PGD (Possibility of genetically transmitted disease) - Fertility preservation in cancer patients- Where ICSI is indicated (Azoospermia)

II. IVF following failed cycles of IUI- Usually up to six cycles of IUI with controlled ovarian

stimulation are recommended, but there are situations where couples should move to IVF earlier.

IVF and ET• In Vitro Fertilization (IVF) and Embryo Transfer (ET) are the basic ART

for all related technology. These include:

- Intra Cytoplasmic Sperm Injection (ICSI)

- Assisted hatching

- Pre-implantation Genetic Diagnosis (PGD)

- Cryopreservation

- Donor oocyte IVF programs

- Donor embryo (genetic surrogacy)

- Intracytoplasmic Morphologically selected

Sperm Injection (IMSI)

- And many more

Various steps of an IVF treatment cycle

Pre IVF work-up Ovarian stimulation Monitoring

Preparation of sperms Oocyte retrieval

Embryo transfer Luteal Support

Ovulation induction

In Vitro Fertilization

EGG RETRIEVAL

SPERM PREPARATION

CONVENTIONAL -I.V.F.

• Simply put IVF is adding a man's sperm to his female partners eggs in the laboratory to produce embryos. In vitro fertilization is an option for many couples who cannot conceive through conventional therapies. These embryos are put back into the female partner's uterus (womb) after 3 to 5 days of being in the incubator.

CONVENTIONAL -I.V.F.

IN VITRO EMBRYO DEVELOPMENT

COC at the time of retrieval

M II oocyte with a PB (Mature)

2 PN embryo

4 cell embryo 8 cell embryo Fully grown blastocyst

Intra cytoplasmic Sperm Injection (ICSI)

• Unprecedented successful development of ART which has revolutionized the management of severe male infertility.

• The procedure involves the direct injection of a single sperm into the egg cytoplasm

INDICATIONS FOR ICSI• Sperm completely absent from the ejaculate

(azoospermia)• Sperm present in low concentrations (oligospermia).• Poor sperm motility (asthenospermia)• Poor sperm morphology (teratospermia)• Sperm retrieved by surgical techniques (for example

TESA, TESE)• If pre-implantation genetic diagnosis (PGD) is being used

to screen embryos for a specific genetic disorder• History of fertilization failure in conventional IVF

attempts

ICSI

IN VITRO EMBRYO DEVELOPMENT

COC at the time of retrieval

M II oocyte with a PB (Mature)

2 PN embryo

4 cell embryo 8 cell embryo Fully grown blastocyst

EMBRYO TRANSFER

HOW MANY EMBRYOS ARE TRANSFERRED?

• Related to age and embryo quality– <35 = 2– 35-37 = 2-3– 38-40 = 3-4– >40 = up to 5

– For patients with 2 or more failed IVF cycles, or a poor prognosis, can add more based on clinical judgment

EMBRYO TRANSFER

EMBRYONIC DEVELOPMENT