Post on 19-Dec-2014
description
Assisted Reproductive TechnologyA.R.T.
Adam Nancekivell, BSc
Embryologist
Journey to a Baby
For some people the journey is short…•Think about starting a family•Successful pregnancy
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Journey to a Baby
For others the journey is longer…•Think about starting a family•Is there a fertility issue to overcome?•What can be done?•What does it cost?•What is treatment like?•Successful pregnancy
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Is there a fertility issue to overcome?
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1 Year is key timeframe
Failure to become pregnant after 1 year of unprotected intercourse is a key indicator
of infertility
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Is there a fertility issue?
Causes of Infertility
• Male 40%
• Female 40%
• Combined/unknown 20%
Is there a fertility issue?
Causes of Infertility - Female
• Failure to ovulate
• Tubal damage
• Endometriosis
• Age
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Is there a fertility issue?
Causes of Infertility – Male
• Genetic
• Developmental
• High body temperature
• Physical injury
• Chemicals / hormones
• Medical
• Lifestyle factors
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Is there a fertility issue?
What can be done?
• Optimize lifestyle factors
• See a fertility specialist regarding A.R.T.
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What can be done?
Optimise lifestyle factors
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What can be done?
Don’t smoke...What can be done?
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Smoking is bad for fertility and the health of future children
Women• By-products detectable
in fluid around eggs• Menopause occurs 1 to
4 years earlier• Zona pellucida (‘egg
shell’) thicker
Men• Sperm production,
motility, morphology and increases DNA damage
• Child born to a father who smokes has 4 X risk of childhood cancer
What can be done?
Smoking is also bad for treatment outcomes
• Male smoking significantly reduces success rates
• Female smoking halves pregnancy rates & doubles risk of early pregnancy loss
• …and there is no public funding for female smokers
What can be done?
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Be a healthy weight...
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What can be done?
Homan, G.F. et al. Hum Reprod Update 2007 13:209-223; doi:10.1093/humupd/dml056
Public funding cut off
Human Reproduction Update
Impact of BMI on female fertilityWhat can be done?
Impact of BMI on male fertility• Overweight men (BMI over 28) have sperm counts 22% lower
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What can be done?
0
5
10
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25
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35
40
45
20 - 24.9 25 - 29.9 30 - 34.9
%
Paternal BMI range
Pregnancy and live birth outcomes according to paternal BMI
Pregnancy loss
Live birth/OPU
0
5
10
15
20
25
30
35
40
45
20 - 24.9 25 - 29.9 30 - 34.9
%
Paternal BMI range
Pregnancy and live birth outcomes according to paternal BMI
Pregnancy loss
Live birth/OPU
Bakos et al., 2011, Paternal Obesity and ART Pregnancy
Cut out or cut right back on alcohol and coffee
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What can be done?
See a fertility specialist for a first consultation
What can be done?
The First Consultation
• History from both partners• Blood test on woman to check hormones• Ultrasound exam on woman• Sperm test arranged for man
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What can be done?
What does it cost?
The First ConsultationWhat does it cost?
Publicly-funded Consultation• Need GP referral• Must meet criteria
•Both NZ residents•18+ months infertility if woman <35 yrs OR•12+ months infertility if woman >35 yrs + OR•Known severe cause of infertility
•Additional criteria in Akld and Northland
•Woman under 40 yrs•Woman’s BMI =< 32•Woman non-smoker
• $0 • 1-2 months wait for appt
Interesting to note that mencan be old, overweight, smokers!
The First ConsultationWhat does it cost?
Publicly-funded Consultation• Need GP referral• Must meet criteria
•Both NZ residents•18+ months infertility if woman <35 yrs OR•12+ months infertility if woman >35 yrs + OR•Known severe cause of infertility
•Additional criteria in Akld and Northland
•Woman under 40 yrs•Woman’s BMI =< 32•Woman non-smoker
• $0 • 1-2 months wait for appt
Privately-funded Consultation•No referral•No criteria •$190 - $260• immediate – 2 week wait for appt
Fertility Treatmentusing A.R.T.
Treatment
Used mainly to assist…
• Heterosexual couples with infertility issues
• Lesbian couples who need a sperm donor
• Single women who need a sperm donor
• Families with history of genetically-inherited disease
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Treatment
Five Core ART Treatments
• Clomiphene / Ovulation Induction (OI)
• Intrauterine Insemination (IUI) / Donor Insemination (DI)
• In Vitro Fertilisation (IVF)
• Intracytoplasmic Sperm Injection (ICSI)
• Embryo Biopsy
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Treatment
The Basics = Sperm + EggTreatment
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Clomiphene / Ovulation Induction (OI)Treatment
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• Tablet taken between day 2 and 6 of woman’s cycle• Increases the level of follicle stimulating hormone (FSH)
to stimulate egg production• Involves some blood tests and scans to time intercourse• Mainly used where there is a problem with ovulation
DAYS OF WOMAN’S CYCLE
Intrauterine Insemination (IUI) and Donor Insemination (DI)
Treatment
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20,000,000 for Intercourse
1,000,000 for IUI
NUMBER OF SPERM TO FERTILISE EGG
• Sperm is washed• At ovulation, sperm is placed into uterus using a catheter• Mainly used for:
o Heterosexual couples where there is a mild male infertility or the female has mild endometriosis
o Lesbian coupleso Single women
In Vitro Fertilisation (IVF)• Conception takes place outside the body• Drugs stimulate and mature eggs• Eggs are aspirated using a fine needle• Sperm is washed and approx 50,000 are introduced to egg in a petri dish• After 3-5 days embryo is transferred into uterus• Mainly used with more serious female infertility issues
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Treatment
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Intracytoplasmic Sperm Injection (ICSI)• Conception also takes place outside the body as per IVF• 1 sperm is injected into each mature egg• Used when there is a serious sperm issue (quality and/or quantity)
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Treatment
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Embryo development (I)
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Treatment
Fertilised egg – 18hrs after adding sperm
8 cell embryo – day 3
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Embryo development (II)Treatment
Blastocyst – day 5-6 Hatching blastocyst – day 5-6
Embryo Biopsy
• To test for genetically-inherited diseases• One cell is removed from embryo and tested• If all OK embryo is placed in uterus
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Treatment
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Fertility treatment success rates improving
0%
5%
10%
15%
20%
25%
30%
Year
DI implantation rate in women < 37
0%
5%
10%
15%
20%
25%
30%
Year
DI implantation rate in women < 37
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Year
IVF/ICSI implantation rate in women < 37
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Year
IVF/ICSI implantation rate in women < 37
Treatment
But woman’s age is still key factor
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Treatment
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
<30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45+
Woman's age
Birth rate from a single IVF egg collectionincluding use of any frozen embryos within 6 months
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
<30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45+
Woman's age
Birth rate from a single IVF egg collectionincluding use of any frozen embryos within 6 months
What does it cost?
Fertility Treatment using ARTWhat does it cost?
Publicly-funded Treatment• Must meet criteria
•Both NZ residents•Woman under 40 yrs•Woman’s BMI =< 32•Woman non-smoker•Limit on 2 kids under 12 at home
• Must have CPAC* score 65+• $0 • 1 month wait (IUI) – 12 rounds• 1.5 year wait (IVF + ICSI) – 2 rounds
* Clinical Priority Assessment Criteria
Fertility Treatment using ARTWhat does it cost?
Publicly-funded Treatment• Must meet criteria
•Both NZ residents•Woman under 40 yrs•Woman’s BMI =< 32•Woman non-smoker•Limit on 2 kids under 12 at home
• Must have CPAC* score 65+• $0 • 1 month wait (IUI) – 12 rounds• 1.5 year wait (IVF + ICSI) – 2 rounds
Privately-funded Treatment• approx $ 1,900 (IUI)• approx $ 11,000 (IVF)• approx $13,000 (ICSI)• approx 1 month wait• unlimited rounds
* Clinical Priority Assessment Criteria
Legal Matters
• HART Act 2004– Human Assisted Reproductive Technologies
– Governs use of ART in New Zealand
• ACART– Advisory Committee on Assisted Reproductive Technologies
– Formulates policies and advice specific to New Zealand
• ECART– Ethics Committee on Assisted Reproductive Technologies
– Consider and determine applications for those ART procedures that are not deemed to be ‘established’ in the HART Act
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Treatment
ART Guiding Principals
• The health and well-being of children born should be an important consideration in all decisions ART.
• The human health, safety, and dignity of present and future generations should be preserved and promoted.
• The health and well-being of women must be protected in the use of these procedures.
• Individuals must make an informed choice and give informed consent.
• Donor offspring should be made aware of their genetic origins and be able to access information about origins.
• The needs, values, and beliefs of Māori should be considered and treated with respect.
• The different ethical, spiritual, and cultural perspectives in society should be considered and treated with respect.
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Treatment
Emotional Matters• Going through ART can be an emotional
rollercoaster• Coping with
– Infertility– Financial stress– Ethical dilemmas– Waiting for outcome of ECART applications– Different levels of motivation for treatment– Hormonal effects of fertility drugs– Medical interventions– Unsuccessful treatment– Comments from family and friends
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Treatment
Counseling Service
• Emotional health is as important as physical health!• Counselling is also compulsory for some
procedures using ART– Surrogacy– Embryo donation– Sperm or egg donation
• Free for publicly-funded treatment• $140 / hour for privately-funded treatment
Treatment