WHAT IS NEW IN IVF

Dr.M.Gouri Devi. M.D.

Director, Gouri Hospital Ltd,

Director Ridge IVF group,

Vice President , Indian Fertility Society,

Member excecutive- AOGD, NARCHI, DGES

Not Very Long Ago

07/78 Louise Brownwas born

Birth after reimplantation of a human embryo

Steptoe P.C. / Edwards R.G.Lancet 2 (1978): 366

Introduction

Advances in assisted reproductive technology for infertile couples were among the great medical successes of the last century.

ART has made huge strides and fast progress towards finding suitable treatment options for each infertile couple

Milestones in reproductive medicine

1960 - ovarian stimulation with clomifene and gonadotrophins- radioimmunoassay

1970 - secretion, synthesis, mechanism of GnRH a. gonadotrophins

- in vitro fertilisation 1980 - GnRH-agonists and gonadotrophins

- cryopreservation 1990 - recombinant gonadotrophins

- preimplantation genetic diagnosis- intracytoplasmatic sperm injection (ICSI)

- GnRH-antagonists 2000 - in vitro maturation of oocytes

- embryonic stemcells- SET (single embryo transfer)

- vitrification

History of ovarian stimulation

1970 ClomifenhMG

1980 GnRH-agonist / hMG

1990 recFSHGnRH-antagonist / hMG or recFSH

2000 long acting FSH

long acting FSH

1 2 3 4 5 6 7 8 9 10 11 12 13 14 ….

FSH-CTP

10000 IE hCG

follicle aspirationafter 36h

GnRH-Antagonist

LF 10 mm LF 14 mm LF 17mm

Kisspeptins

The First IVF baby born by Kisspeptins 2013 at

Hammer smith hospital, U.K

What are Kisspeptins?

Naturally occuring hormones which is an important regulator of reproductive axis , and it is safer as the chance OHSS is reduced.

Instead of HCG, Kisspeptin is used as the trigger

Dosage is still under trial ( 0.6-1.2 nmol)

Mild stimulation Protocols The "mild" stimulation approach for IVF treatment is aimed

to develop more patient-friendly protocols in which the risks are minimized and the results are still acceptable .

A "mild" IVF cycle is defined (ISMAAR association) either as (a) a stimulation regimen in which gonadotropins are administered at a lower-than-usual dose and/or for a shorter duration throughout a cycle in which GnRH antagonist is given as co-treatment.

(b) a stimulation in which oral compounds (e.g. anti-estrogens) are used either alone or in combination with gonadotropins and GnRH-antagonists.

( Nargund .G et al Hum.Reprod :2011)

Male Infertility Per Cutaneous Epidydimo aspiration.

(PESA) Testicular epidydimo sperm aspiration.(TESA) Microsurgical epidydimo sperm aspiration

(MESA) Harvesting sperm from testicular tissue+ICSI:- Even in patients with sertoli cell only syndrome scattered pockets of sperms exist .Even with FSH> 3times ,sperms are found in30%of cases ( Kim et al: 2012)

Exciting new development in male infertility

In non –Obstructive azoospermia:

Though these men may have no sperm in their semen, we can now find sperm between the cells of

the testicles in almost half of these cases.

By using an operating microscope and doing micro dissection TESE, pregnancies have been acheived in one third of those men in whom sperm can be found within the testicle

ICSI-Micro TESE 179 cycles of Non- Obstructive azoospermia

22 cycles done

Fertilisation rate : 33.2%

6 Cycles chemical pregnancy

3 cycles :Normal pregnancies with 3 healthy babies.

(Ragaa.T Mansour et al:2013).

Fertilisation rate :48.3%

Pregnancy rate :28.9% ( Sousa. M.:Hum. Repro. 2012)

Advanced Sperm Preparation methods

Newer strategies of sperm preparation . 1. Morphological assessment by means of ‘motile sperm organelle morphological examination (MSOME)' :-

2. Electrical charge: This from the seminal plasma membrane –zeta potential-allows them to adhere to the surface of a positively charged tube. The resulting population has better quality, with normal DNA and chromatin condensation

3. Molecular binding characteristics of the sperm cell: The two methods currently used are sperm binding to

AnnexinV and Hyaluronan(PICSI)

4. Raman microspectrometry and Polarisation microscopy are in the offing

( Henkel R : Asian j.of Andrology:2012)

Motile sperm organelle morphological examination (MSOME). With MSOME, the morphological status of the acrosome,

post-acrosomal lamina, neck, mitochondria, flagellum and the sperm nucleus is examined. For the latter, the shape, as well as the presence and size of vacuoles, is observed.

The combination of MSOME and ICSI has been named intracytoplasmic morphologically selected sperm injection (IMSI).

IMSI has beenshown to increase fertilisation rate, blasocyst formation rate,implantation and pregnancy rates.

( Setti et al :Repro.bio.med.online:2013)

Can we select the best embryo?

Attempts have been made to do so

The best available method for embryo selection is morphological evaluation.

(Ebner et al., 2003; Gerris, 2005).

However implantation rates in general do not exceed 35%, although varying results have been reported,

(Centers for Disease Control and Prevention et al., 2010). Hence a strong drive for finding alternative

selection methods

Preimplantation genetic screening (PGS).

The biopsy at Day 3 of embryo development of a single cell and analysis of this cell by fluorescence in-situ hybridization (FISH) for aneuploidies, for a limited number of chromosomes.

Selection of best embryo by CGH array Pre-implantation genetic diagnosis with

testing of all 23 pairs of chromosomes by a microarray technique, which allows us to differentiate chromosomally normal from abnormal embryos

Replace only the normal ones on day five, discarding the abnormal embryos

Selection of single blastocysts for fresh transfer with array CGH and standard morphology alone for good prognosis IVF patients.

Clinical preg. Rate -70.9%vs 45.8% Ongoing preg.rate -69.1%vs 41.7% Twin - nil Aneuploidy rate -44.9% among biopsied blastocysts

Yang Z et al (Mol Cytogenet.2012 May)

PGD

Pre-implantation genetic diagnosis can also be utilised for translocations and single gene defects, eg. BRCA1 and BRCA2 and cystic fibrosis

Non Invasive methods –”Omics”

High-tech, non-invasive methods to select the best embryo includes metabolomic profiling, amino acid profiling, respiration-rate measurement and birefringence imaging.

(Nagy, 2008).

Metabolomic profiling: spectrophotometric tests are used to measure metabolomic changes in the culture medium of embryos.

Proteomic profiling: proteins produced by the embryo and released into the culture medium are identified.

Amino acid profiling: amino acid depletion and production by the embryo is assessed using the culture medium

Respiration-rate measurement: the respiration rate of embryos is assessed.

Birefringence imaging:polarization light microscopy is used to assess the meiotic spindle or the zona pellucida .

( Negy ZP: Reprod.Biomed.Online 2008)

Embryoscope

The novel monitoring system for continuous observation of early embryo development around the hour (EmbryoScope®) was introduced by Unisense Fertilitech, USA.

In December, the world’s first twins born by use of the new Embryo Scpe® at Cleveland Reproductive Center, Ohio, USA.

(2011)

Time Lapse Imaging Now the incubator is hooked upto a video

system capturing thousands of images of embryo upto blastocyst.

A normal embryo forms a blastocyst 6hrs earlier than an abnormal one.

The embryos need not be disturbed as in the conventional IVF. Better success orates are claimed. Still waiting for a randomised controlled trial.

( Reprod.bio med:2013, Alison Campbell:2013)

Primo Vision evo.wmv

The recent increased sensitivity of these techniques has allowed for the development of new protocols that are capable of not only profiling the proteome of individual human oocytes and embryos, but also the proteins produced by the embryo into the surrounding medium (the secretome)

( Katz Zaffe M g et al: Reprod.Bio med .on Line :2013)

Human Cloning The first succeessful human cloning

(Cell 2013:Shoukrat Mitalipov et al).

Cloning of human embryos for therapeutic purposes was made legal ( Amendment to the human embryology act :2001.)

Cloning human for reproductive purposes remain illegal.

Fertility Preservation in female cancer patients Oocyte freezing. Embryo Freezing Ovarian tissue cryopreservation Ovarian transplantation

Clinical: 2000 onwards First successful ovarian tissue transplant

after

frozen storage ( Kutluk Oktay et al:New Eng.J.of med:2000).

Pregnancy after transplantation of ovarian cortex retransplants ( Meirow et al:2005)

Ovarian transplant between 2 identical twin sisters.

( Sherman Silber :2005)

Ovarian transplantation

Ovarian Transplants

Review of 60 cases . 24 live births reported till date. ( Donnez .J.Et al: Fert.Ster.:2013).

Future: Better Freezing techniques

Enhance the vascular bed before

transplantation

Uterine transplantation Transplant done from a donar. Hysterectomy done 99days

after due to acute vascular thrombosis. (Saudi Arabia )

(Faqweeh.W.et al:Intl.J.Obst andGyn:2002). Patient conceived with IVF , miscarried at 8weeks.(Turkey)

(Erman Akar .M.et al :Fert.Ster:2013) Nine successful Transplants (Sweden) (Brannstorm .M et al :2013) Live birth after uterine transplant remains challenging ( Fert.Ster.: 2013)

Sperm/egg from embryonic stem cell In 2008, a flurry of announcements revealed further

developments with human same-sex reproduction, with a patent application filed by an American researcher.(Gregory Aharonian) specifically on methods for creating human female sperm using artificial or natural Y chromosomes and testicular transplantation.[( Human same sex reproduction project)

A UK-based group, in an interview, predicted they would be able to create human female sperm within five years.[ McRay,Fiona:2008)

Another group at the Butantan Institute in Brazil is working on creating male eggs from embryonic stem cells, and if successful, from adult skin cells, though their current experiments are on mice

Artificial uterus and pregnancy outside the body

To Conclude

The field of Reproductive medicine is fast progressing.

Aim of infertility treatment is to be simple, safe, successful and cheap.

In donar programmes, surrogacy,same sex reproduction etc there is a lot of political,legal and ethical issues involved.

Future looks like a well-lit tunnel

Thanks