ivf - hyderabad conference

8/14/2019 IVF - Hyderabad Conference

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Egg plus sperm = baby


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Traditional approach

Infertility is a common problem

Important and urgent for the patient

However, most doctors take a wait

approach

Often , patients get fed up andfrustr

drop out oftreatment

This is a shame !


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Need to change !

Patients are getting married at an ol

Time is running out as the biological

ticks on

We now have effective technology to

them !


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IVF cycle

4 basic steps

1. Superovulation

2. Egg collection

3.In vitro fertilisation

4. Embryo transfer


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IVF cycle

1. Superovulation

1.With HMG ( gonadotropins)

Natural hormones

Newer recombinant preparations muc

expensive, but no better

2. Downregulation with Buserelin ( Gn

3. GnRH antagonists to prevent LH surg

4. Low cost clomiphene plus HMG


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IVF cycle

Superovulation

Monitor follicular growth ( ovarian r

Vaginal ultrasound scans

Day 3, 10, 12, 14

Rarely need to measure blood estrad

levels !


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IVF cycle

2. Egg collection

Vaginal ultrasound guida

Non-surgical


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IVF cycle

3.Insemination

Sperm added to egg in the incubato

Kept in vitro in conditions which mim

conditions

The incubator is the heart ofthe IVF


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IVF cycle

4. Embryo transfer

Non-surgical

Number ofembryos ?

When to transfer ? Day 2 or 3 or 5


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IVF cycle

No needfor bed rest you cannotthe embryo out !

Still a matter ofluck !

Not the patients fault ifshe doeconceive

She cannot reject the embryo !


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Risks ofIVF

1. No pregnancy

2. Multiple pregnancy

3.

Ectopic pregnancy4. OHSS ovarian hyperstimula

syndrome. Managed conserv


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Limitations ofIVF

Few medical risks

Major risks are

FinancialEmotional


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Advancedfertilisation tech

Intracytoplasmic Sperm Injection

Assisted Hatching

Blastocyst transfer

Preimplantation Genetic Diagno


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ICSI

Microinjection ( Intracytoplasmic spe

injection)

One egg + one sperm = one embryo

Can use testicular sperm evenfrom

testicular failure ( with high FSH leve

small testes)


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Blastocyst transfer

The high implantation rate is becaus

1. improved selection ofviable embr

2. better synchronization between e

and the endometrium at the time of


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Freezing - cryopreservat


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Vitrification

Can store and preserve

Sperm

Embryos

Eggs

Ovarian tissue


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The promise of ART

We can help any couple to hababy, no matter what their mproblem !

Third party reproduction

Embryo adoption

Donor eggs

Surrogate uterus


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PGD the newest ART

PGD marries genetic technology and

technology

The newest patient is the embryo !


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Procedure for preimplanta

genetic diagnosis

1.IVF cycle

2. 8-cell embryo at Day 3

3. Biopsy embryo ( micromanipulato

4. Fix blastomere

5. Study genetic composition ofblas

using genetic probes ( FISH)

6. Transfer selected embryos into ute


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Signal interpretation

Evaluate slides with a fluorescence m

Locate nucleus using DAPI filter

Interpret signals

Probe will bind to specific chromosom

Pink = Y ( Spectrum Orange)

Green = X ( Spectrum Green)


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Normal blastomere


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Trisomy 21


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Comparative Genomic Hybrid


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PCR


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Indications for preimplanta

genetic diagnosis

1. Sex linked genetic disorders

Hemophilia

Duchenne muscular dystrop

2.Chromosomal disordersDowns syndrome ( Trisomy


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Indications for preimplanta

genetic diagnosis

3. Single gene diseases ( using PCR)

Thalassemia

4. Older womendoing IVF

Screen embryos for aneuplo

5.Recurrent pregnancy loss because

chromosomal anomalies


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Future advances

Cloning

Reproductive cloning

Therapeutic cloning


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Embryonic stem cells

Can change the face ofmedicine

Very promising future

Lots ofresearch still needs to be Indian can be a leading center in

Collaboration betweenIVF clinic

basic research labs


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Weve come a long way, b


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ART is a medical success s

However, advances inIVF havwith government guidelines a

The purpose ofthese guidelinensure that these technologiused safely and responsibly

It is time to ask how well thes

guidelines work and what puthey really serve.


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Regulating, Reporting Validating ART are guide

rules and laws ofany us


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Human Fertilisation and Embry

Authority (HFEA) Act

Laiddown to protect the welfare of

Theory - It should be the parent(s) o

who should be empowered to make

decisions for their child

Practice - An impersonal governmen

without a heart or a soul makes thes

decisions, claiming that they are act

interests ofthe child.


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Global picture

What is remarkable about the

regulations which governART in

country is that they vary so wide

Guidelines are arbitrary and ofte

designed to fulfill prevailing polit

pressures, rather than being bas

scientific principles.


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Global picture

Rules vary from country to country

They also vary in an individual count

time to time.

Thus, the UK HFEAnow allows paren

select embryos ( using PGD for tissu

so that the baby created can becom

donor to an ill sibling ( saviour siblin

something which they had banned i


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UK v/s US

Interestingly, the US has nfound it necessary to pass federal law to regulate IVF

And they are doing fine tyou very much !


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Doctors v/s politician

Is it better to allow doctorsmake medical decisions ( adone in the USA) ?

Or to have legal hurdles, aspractice in many Europeancountries ?

Who can we trust ?


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Law ofunintended consequ

In Spain, it is legal to put embryos instorage, but it is illegal to destroy emto donate them to research

There are currently 50

,000

embryos unused infrozen storage in Spain- sbeyond the five-year storage limit.

What a sad mockery it is, when the lwas designed to protect embryos onends up destroying them in practice


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IVF laws anddoctors

By forcing doctors to practmedicine as laiddown in amindless statue drafted bybureaucrats, rather than bapplying their own judgmeare ending up harming ourpatients.


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Playing God ?

Whendoes life begin? and what are

ofan embryo?

Can human embryos be usedfor har

embryonic stem cell lines ?

Should cloning be allowed ?


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Two views

Playing God ! This technologycouples to manipulate Natureproduce children

v/s

This technology is a triumph ingenuity which can be used

overcome Nature's constraint


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Who decides ?

This decision shouldnot be lemoralists, or philosophers or government, or the doctors.

Instead, the decision is best leach individual couple, who pthe reproductive apparatus to

the baby.


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Should embryo research

banned ?

Banning research ends up stopp

scientific progress

We are not mad scientists trying

God

We are doctors trying

to do the best for our patients


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Doctors are trusted profess

Our freedom to do what is beour patients will be curtailedbureaucrats , activists and po

Ifdoctors can be trusted to manddeath decisions in the ICwhy cant we be trusted to mdecisions about IVF responsib


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Useful regulation

Most doctors would agree that thereto regulate the practice ofIVF, so thaclinics meet certain basic standards.

Need to protect infertile patients, wemotionally vulnerable, and can geteasily by unscrupulous doctors


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Theory v/s practise


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Surrogacy

One ofthe thorniest issues !

Who has the rights ?

What happens when something goe

Will India become the surrogacy out

capital ofthe world ?

Are we exploiting poor women by h

wombs ?


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How many embryos to tran

Ideal would be one. However, the te

is still not perfect

The law is blind limit of2for every

Why ? Makes sense for the NHS !

Does this make sense for a 43 year o

doing her 5th IVF cycle ?

Let the couple decide for themselvesthe pros and cons


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3 principles ofmedical et

Autonomy

Beneficence

Non-maleficence


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The very fact that rules vary so muchcountry to country means that thereno right answers.

In such circumstances, is it a good id

impose rules on infertile couples ? Might it not be better to allow docto

couples to decide what is best for th

Rather than apply rules blindly, isnt

to allow doctors the freedom to selebest for their patients ?


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Solution ?

Let patients decide for themselves its their life and their baby !

Ademocracy empowers people to m

own choices and they should be aluse the technology to fulfill their perreproductive desires, as long as theyharm anyone else !

Its unethical to interfere in their perfamily-building plans !


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Simplifying IVF to make it affo

Low cost IVF

Young couples ( get married y

Cannot afford expensive trea Mistake have copied the W

blindly so far

Need to adapt IVF for India !


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Low cost innovations

Minimal stimulationIVF

( gentle IVF)

Transport IVF eggs and stransported to central IVF

Satellite IVF


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Intravaginal Culture

Use the patients vagina as an incuba

No needfor expensive incubator or

supply

Stepped care IVF can be made ava

government hospitals indistrict tow

Should be part ofeach teaching hos

India


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What society cando

Infertility treatment should be a part

Family Planning and Family Welfare

Should be covered by medical insura

because infertility is a disease andnmedical treatment


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ivf - hyderabad conference

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