Medically Assisted Reproduction

Luisa Annamaria Merola

MEdically assisted reproduction (MAR)

ART

Equipment and personnel

Preparation

Index

Ovarian stimulation

Techniques

Risks and complications

Assisted reproductive technologies

Infertility

Infertility is clinically defined as the inability to conceive after 12 months of unprotected intercourse. It can result from female factors (e.g., ovulatory issues, fallopian tube obstructions, endometriosis), male factors, or both. Proper follicle development and ovulation rely on the interplay of FSH and LH.

Assisted reproductive technologies:

• ART includes any fertility treatments involving the manipulation of eggs or embryos.
• The first successful in vitro fertilization (IVF) was performed in 1978 in England.
• The use of MAR is increasing globally due to genetic factors, health conditions, delayed childbearing, and age-related fertility loss.

Equipment and personnel

Equipment

Personnel

• Medical director
• Physician licensed in reproductive endocrinology and infertility
• Physician with expertise in male reproduction
• Nurses trained in reproductive medicine and ART
• Embryology laboratory director
• Andrologist experienced in laboratory procedures
• Laboratory personnel for hormone assays
• Individual experienced in gynecologic ultrasound (physician, technician, or nurse)
• Mental health professional with fertility counseling experience
• Genetic counselor

• Incubator
• Microscope for handling and micromanipulation of oocytes and embryos
• pH and temperature monitoring devices
• Warming blocks
• Laser for embryo biopsy
• Cryopreservation equipment (liquid nitrogen tanks)
• Laboratory centrifuge
• Laminar flow hood
• Culture media
• Refrigerator
• Air filtration system

prEparation

Preparation for ART procedures

• Comprehensive History: Assessment of menstrual and pregnancy history, infertility duration, past treatments, medical and surgical history, family history, and environmental exposures/habits.
• Physical Examination: Checking vital signs, body mass index, thyroid function, signs of excess androgen, and conducting a pelvic examination.
• Hormonal Assessment: Measuring levels of hormones like FSH, E2, AMH, TSH, and testosterone to determine causes of anovulation.
• Ultrasound Evaluation: A baseline transvaginal ultrasound to detect any uterine factors or malformations affecting fertility and pregnancy maintenance.
• Male Infertility Workup: Performing a semen analysis to assess male fertility.
• Infectious Disease Screening: Conducting tests for syphilis, hepatitis, and HIV for both partners.

ovarian Stimulation

Controlled Ovarian Stimulation

Injection of exogenous gonadotropins, like follicle-stimulating hormone (FSH) and luteinizing hormone (LH), is frequently used for controlled stimulation. It maximizes the number of developing follicles during a single cycle. Transvaginal ultrasound monitoring is utilized to track the number and growth of follicles. Once ovarian follicles are mature, final maturation is artificially triggered.

Techniques

Intrauterine Insemination

Ovulation Induction

• First level MAR treatment
• Procedure: moderate pharmaceutical stimulation, gamete collection and insertion into utherine cavity via catheter
• Indicated in patiens with issues with sperm penetrating cervical mucus or alterations in seminal fluid

• Cause: anovulation
• Treatment: drugs to induce ovulation
• Advanced and efficient for personalised therapy

In Vitro Maturation

In Vitro Fertilization

• Second level MAR treatment
• Procedure: ovarian stimulation, gamete retravial, in vitro insemination, embryo culture and transfer
• Embryos are trasferred on day 3 (clevage stage) or day 5 (blastocyst stage), which have higher success rates.

• Alternative to traditional IVF for patients with risk of ovarian hyperstimulation syndrome

• Procedure: collection of immature follicles with minimal or no hormonal stimulation, maturation in vitro and transfer

Blastocyst Stage Culture

Introcytoplasmatic Sperm Injection

• Consists of embryo culture until day 5 or 6 (blastocyst stage), followed by transfer
• Has higher success rates for pregnancy

• Second level IVF technique for severe seminal fluid alterations
• Procedure: similar to IVF but involves direct injection of a single sperm into the oocyte usind micro-needle and micromanipulator under a microscope.

Heterologous Fertilization

PESA and TESA

• Consists in using gametes (sperm, oocytes ot both) from an external donor.
• In cases of irreversible infertility or sterility
• Types: egg donation, sperm donation or both (double heterologous)

• Sperm retrieval techniques: Percutaneous Epididymal Sperm Aspiration and Testicular Sperm Aspiration
• Indicated in patients with azoospermia due to obstruction of the seminal duct

Preimplantation Gentic Testing

Vitrification

• Preservation of gametes and embryos by immersion in liquid nitrogen at -196°C
• Prevents formation of intracellular ice crystals, with a survival rate of 97%

• PGT-A: assessment of embryo health for chromosomal aneuploidies
• PGT-M: genetic testing for monogenic anomalies
• PGT-SR: testing for structural chromosome abnormalities

Risks and complications

Embryo manipulation

Can lead to abnormal placental development and attachment

Ovarian Hyperstimulation Syndrome

Excessive follicolar growth causing fluids shifts and ascites or edemas

Psychological stess

It is a stressfull procedure and various outcomes are to be handled

THANK YOU !

sources

• National Library of Medicine
• Better Health Channel
• Endocrine Society
• Reproductive Medicine and Assisted Reproduction Centre
• European Foundation for the care of newborn infants
• British Broadcasting Corporation