New Developments in Assisted Reproduction

Cork Fertility CentreDr John Waterstone

Ovarian Reserve

• Women are very different to men with regard to reproductive ageing.

• A woman’s entire lifetime’s supply of eggs is present at birth.

• Decreasing ovarian reserve is inevitable with increasing age, resulting in complete infertility by age 40-50.

• Decreasing ovarian reserve has a significant negative effect on a couple’s reproductive prospects from age 37 onwards but earlier for some women.

• Ovarian reserve is a measure of how well the ovaries are still functioning at a certain point in time.

Measures of Ovarian Reserve

FSH (Follicle Stimulating Hormone) - lower is better (Normal <10 iu/L)

– test cycle day 2-4– fluctuates between cycles when

ovarian reserve poor

AMH (Anti Mullerian Hormone)– higher is better (normal>5pmol/L)– less fluctuation between cycles

Measures of Ovarian Reserve

Antral Follicle Count (AFC)– higher is better – 5-10 AF’s per ovary –normal reserve– <3 AF’s per ovary –poor reserve– >10-15 AF’s per ovary – ‘polycystic’

Menstrual cycle length – shortening cycles indicate

deteriorating ovarian reserve

Polycystic Ovaries & PCOSMost women with polycystic ovaries do not have polycystic ovary syndrome

PCOS = PCOD = Stein Levinthal SyndromePCOS = Polycystic Ovaries + Oligo or Amenorrhoea

Variable abnormalities in PCOS –Raised LH–Raised Androgens–Hirsutism–Obesity–Impaired Glucose Tolerance

Management of PCOS• Good ovarian reserve but may be difficult to

manage.

• May succeed on first cycle of OII with Clomid

• May undergo OII, IUI, Ovarian drilling, IVF

• IVF also difficult because of risk of Ovarian Hyperstimulation Syndrome (OHSS)

• Metformin –no longer recommended for OII nor as an adjunct to IVF; may help patients lose weight.

Tests of Tubal Function• Laparoscopy - Gold standard test

- Carried out at Bon Secours Hospital- Detects adhesions /endometriosis

• Hystero Salpingography (HSG)- Less invasive

- Carried out Bon Secours Hospital- Does not detect adhesions/endometriosis

• Hystero Contrast Salpingography (HyCoSy)- Poor diagnostic test

- No longer used at Cork Fertility Centre

Pre-IVF Surgery for Hydrosalpinges

Communicating hydrosalpinges must be removed or blocked proximally prior to IVF

Tertiary Care – AR Options

• Ovulation Induction (Clomid or low dose FSH)

• IUI (low dose FSH)

• IVF / ICSI (LHRH analogue, high dose FSH injections, egg collection, embryo transfer)

Embryo Transfer

Intracytoplasmic sperm injection (ICSI)

~ 40% of IVF cycles involve insemination by ICSI

TESE

ICSI/TESE appropriate for primary azoospermia and post vasectomy

Day 2 - Day 3 Embryo Development

Day 5 Embryo development

•

•

Day 5 Embryo Transfer

Advantages

• Embryo Selection

• Reduction in number of embryos for ET resulting in reduction in multiple gestations

Egg Donation • For patients with poor ovarian reserve

• Alternative to adoption or childlessness

• Success Rate ~ 50% per cycle

• Known v Anonymous Donors

• Remuneration of Donors (Europe v USA)

• Reproductive Tourism

Egg Donation at Cork Fertility Centre

• Egg Donation available since 2006

• Donors almost all known to recipient couple

• Live Birth Rate (per embryo transfer) for 2006 – 2010: 61%

Cryopreservation of Gametes & Embryos

Cryopreservation of semen – successful & robust

Cryopreservation of viable embryos – technically easy

Cryopreservation of unfertilised eggs technically difficult but useful for:

– creating donor egg banks– preserving fertility in young cancer survivors– preserving fertility in women deferring reproduction

CFC IVF/ICSI Success Rates 2010

Live birth rates per Embryo Transfer

Patient Age <35 35-37 38-40 41-42 >42

Cork Fertility Centre 2010

49% 46% 35% 22% 8.5%

Success Rates” which quote “pregnancies” or “pregnancy rates” are misleading as a significant proportion of early pregnancies miscarry