| OVERVIEW OF INFERTILITY AT GIH
GIH Fertility Cenetre 2002 - IVF In the 21st Century
I. Definition/Incidence of Infertility
A. Infertility - no pregnancy despite unprotected intercourse x12 months (6 months if >37 years old).
B. IVF - Fertilization of an ova in the Embryology Laboratory (i.e., outside the body).
C. Infertility affects 1 out of 6 couples, approximately 15 million Americans.
D. In the United States, in 1998, 81,000 IVF cycles were performed at 360 Fertility Centers with 28,500 infants born.
II. History of Infertility/In Vitro Fertilization
A. Repeated references in the Bible regarding Infertility.
B. Artificial Inseminations - used in the United States for over 90 years.
C. First Test Tube Baby in England 1979.
D. Scripps Clinic - first San Diego delivery of IVF baby, 1984.
III. In Vitro Fertilization - Only When All Else Fails, or . Primary Treatment
A. During most of the 1980's and 90's - traditional treatments were performed first, (e.g., ovulation medications, Laser Laparoscopy, Tuboplasty) then IVF performed when all other treatments failed.
B. By the start of the 21st Century - most Fertility Centers now recommend a basic work-up, (semen analysis, HSG x-ray, Day 3 FSH & Estradiol levels), 3 cycles of Ovulation Induction (Clomid, etc) & Sperm Wash/Insemination and then proceed next to IVF.
IV. Best Candidates for In Vitro Fertilization
A. Women <35 years old with normal day 3 FSH & Estradiol levels and normal uterine cavity and men with normal semen analysis (and <55 years old)
B. Almost all causes of infertility can be treated with IVF, e.g., if the wife has endometriosis, PCO, or blocked tubes and/or husbands with low sperm count - via ICSI - IVF.
V. The "Standard" IVF Protocol - Overview
A. Medications to prevent early ovulation.
B. Medications to stimulate multiple egg recruitment and development.
C. Egg Retrieval.
D. Fertilization - Sperm and egg combined in IVF laboratory.
E. Transfer of embryos into the uterus 2-5 days later.
VI. ICSI (Intra Cytoplasmic Sperm Injection)
A. Injection of one sperm into the egg.
B. Indications when:
1. Low sperm count and/or low motility.
2. Testicular sperm aspiration or testicular biopsy are required to obtain sperm.
3. Standard IVF has failed.
4. Women >39 years old
VII. Blastocyst Transfer
A. By the 5th day of development the embryo is termed a Blastocyst (approximately 140-cell stage).
B. In selected cases (> 4 excellent "grade I" - 8 cell embryos at day 3) we observe embryos which are able to grow from day 3 to day 5. This allows the transfer of stronger embryos with a better chance of implantation. With equally good pregnancy rates, fewer embryos are transferred and less multiple births occur.
VIII. Gestational Surrogacy
A. Indicated for women with no uterus or an abnormal uterus, or other health problems which would make pregnancy and labor/delivery very dangerous or impossible.
B. Sperm is obtained from the male partner and eggs are retrieved from the female partner, but their resulting embryos are transferred into the uterus of another woman who agrees to carry an In Vitro Fertilized Embryo for the couple.
IX. Effect of Age
A. As women get older, pregnancy success rates decrease. Rates noticeably decline after age 34 and even more rapidly decline after 37 years old. Greatest effect of age is on ovarian reserve (egg quality and quantity).
B. Increased age = Decreased Pregnancy Rates + Increased Miscarriage Rates.
C. A similar pattern holds true for men, but approximately 30 years later than women.
X. Donor Egg IVF
A. Through the IVF process, the husband's sperm is used to fertilize eggs donated by a woman <30 years old. The resulting embryo is then transferred into the wife's uterus.
B. Indicated for women with Advanced Maternal Age, Premature Ovarian Failure (early menopause), D3 FSH >20mIU/ml, genetic abnormalities, or previous unsuccessful IVF.
IVF Success Rates (pregnancy per retrieval rate)
C. U.S.A. National Registry 1998Females < 35 years old approximately 35%/cycleDonor Egg approximately 40-50%/cycle
D. Scripps Clinic 2001Females < 35 years old approximately 50%/cycleDonor Egg approximately 60%/cycle
XI. U.S.A. 1998 Registry - Multiple/Infant Live Birth Rate
o Singletons 62%
o Twins 32%
o Triplets or > 6%
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The integra machine,
one of the technologies used for ICSI in our lab. 