1. Artificial / Assisted Reproductive Techniques (ART)
Dr Sohani Verma
Sr. Consultant Obstetrics & Gynaecology
Infertility & ART Specialist
Clinical & Academic Coordinator
Indraprastha Apollo Hospitals, New Delhi
Chairperson North Zone AICC RCOG
President Elect Indian Fertility Society

2. Introduction
A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner.
Offer an earlier referral for specialist consultation to discuss the options for attempting conception, further assessment and appropriate treatment where –
- the woman is aged 36 years or over
- there is a known clinical cause of infertility or a history of predisposing factors for infertility
NICE Guidelines 2013

3. Main Causes of Infertility
Multiple relatively minor abnormalities, either with 1 partner or both, account for 30% of all causes

4. Assisted Reproductive Techniques (ART)
Any treatment that deals with “means of conception other than vaginal intercourse” is termed as ART.
NICE guideline 2013
IUI – Intra Uterine Insemination (Husband / Donor)
IVF + ET – In Vitro Fertilization + Embryo transfer
ICSI – Intra Cytoplasmic Sperm Injection

5. IUI Injection of washed prepared sperms into
the uterine cavity through a fine catheter
during peri-ovulatory phase in a natural
or stimulated cycle.
Although pregnancy may not occur as quickly, a policy of initial treatment by IUI will probably save 20% of couples from moving onto IVF
After 3-4 cycles of failed IUI treatment, patients should be encouraged to opt for IVF

6. IUI
The procedure may help in increasing the chances of pregnancy in following ways –
Allowing sperm-ovum contact close to the date and time of ovulation
By bringing the sperm very close to the site of fertilization and by passing the cervical factors
Sperm preparation increases the sperm density and removes all antigens on the surface of sperm and in seminal plasma
IUI is the simplest and the least expensive method of ART
IUI alone (natural cycle) does not improve pregnancy chances, hence mild ovarian stimulation is usually recommended.

7. Indications for Intra Uterine Insemination (IUI)
- At least one Fallopian tube must be normal and patent Mild male infertility Unexplained infertility Ovulatory dysfunction, PCOS Mild endometriosis Cervical factors Coital problems Immunological factors HIV, HBs Ag infection Donor Sperm

8. Indications for Donor Sperm IUI
Azoospermia (where ICSI is not an option)
Severely subnormal semen parameters (ICSI not an option)
Persistent failure of ICSI
Rh Isoimmunization
Hereditary disease in the male partners

9. Indication for ART – IUI or IVF
The indications for IUI are often not dissimilar to those for IVF (or even for ICSI for moderate male factor) and often interchangeable with overlapping.

10. Common Indications for IUI Indications for IVF
Unexplained infertility - Unexplained infertility
Endometriosis (mild) - Endometriosis (moderate to severe)
Male factor infertility (mild) Male factor infertility (moderate to severe)
Ovulatory disorders Ovulatory disorders
Inability to have vaginal intercourse
People with conditions that require Tubal pathology
specific consideration (such as man HIV - Donor Oocyte
positive) Genetic Surrogacy
- People in same-sex relationship PGD (Possibility of genetically
- Donor Sperm transmitted disease) Fertility preservation in cancer patients
- Where ICSI is indicated (Azoospermia)

11. Meta-Analysis of IUI in Male Factor
Pregnancy Rate
Timed intercourse in natural cycle 2.4%
Timed intercourse in COH cycle 5.0%
IUI in natural cycle %
IUI in COH cycles %
Cohlen BJ et al Cochrane database Syst Rev 2003

12. Basic requirements for IUI success
Patient selection
Age of female partner < 35 years
Duration of infertility < 5 years
Cause of infertility (at least one functional normal
fallopian tube and no uterine factors)
Adequate ovarian reserve (based on Serum AMH, antral
follicle count, Day 2 FSH, LH, E2 levels)
Semen parameters Post wash TMSC >5 million/ml
Best pregnancy rates with >10 million/ml
< 1 or 2 million/ml – do not waste time in IUI. Advice IVF / ICSI straight away

13. Basic requirements for IUI success contd…
Choice of ovarian stimulation used
Number of dominant follicles – 1 to 3 follicles
Use of “transvaginal ultrasound follicle monitoring”
Timing of IUI
Between day 12 to 16 of the cycle usually highest pregnancy rates
Interval from hCG injection Hours usually recommended (range hours)
Single IUI 36 hours after hCG is usually the preferred option.

14. Basic requirements for IUI success contd…
Semen preparation technique – Quality and expertize of lab personnel
Procedure of IUI & type of catheter used
Luteal support is recommended
How many IUI cycles- 3-6 cycles usually recommended

15. INTRAUTERINE INSEMINATION – ESHRE Guidelines
There is general agreement in the literature that chances of success are better after mild ovarian stimulation and the maturation of a maximum of two or three follicles.
However, the cycle must be monitored by ultrasound and hormonal analysis; if there are more than three mature follicles, the attempt should be cancelled.
While the concurrent use of ovarian stimulation may increase pregnancy rates, it may be at the expense of a high chance of multiple pregnancy.
The majority of pregnancies occur during the first six cycles. In any case, the number of attempts should not exceed nine cycles.
When assessing the duration of an IUI programme, the age of the woman must be taken into account, to ensure timely transfer to more complex treatments if indicated.

16. The world's first "test-tube baby", Louise Brown, has spoken of her joy at giving birth to her first child.
Baby Cameron was born on 20 December’06 in Bristol, where his 28-year-old mother lives with husband Wesley Mullinder.
Well over two million "test-tube" babies have been born globally since Louise's 1978 birth after IVF

17. IVF and ET
In Vitro Fertilization (IVF) and Embryo Transfer (ET) are the basic ART for all related technology. These include:
- Intra Cytoplasmic Sperm Injection (ICSI)
- Assisted hatching
- Pre-implantation Genetic Diagnosis (PGD)
- Cryopreservation
- Donor oocyte IVF programs
- Donor embryo (genetic surrogacy)
- Intracytoplasmic Morphologically selected
Sperm Injection (IMSI)
- And many more

18. Various steps of an IVF treatment cycle
Pre IVF work-up
Ovarian stimulation
Monitoring
Ovulation induction
Preparation of sperms
Oocyte retrieval
In Vitro Fertilization
Embryo transfer
Luteal Support

19. IVF & ET Procedure
Picture

20. In vitro embryo development
COC at the time of retrieval
M II oocyte with a PB (Mature)
2 PN embryo
4 cell embryo
8 cell embryo
Fully grown blastocyst

21. Indication for IVF I. IVF as first line infertility treatment
Tubal pathology (severe, non-repairable)
Donor Oocyte
Genetic Surrogacy
PGD (Possibility of genetically transmitted disease)
Fertility preservation in cancer patients
Where ICSI is indicated (Azoospermia)
II. IVF following failed cycles of IUI
Usually up to six cycles of IUI with controlled ovarian stimulation are recommended, but there are situations where couples should move to IVF earlier.

22. Indicators for early referral
I. Female age - The biological clock is the major adversary to human reproduction

23. Woman’s age is the initial predictor of her overall chance of success
Live birth rates per Embryo transfer by age (HFEA post-October 2007 data)
NICE Guideline 2013

24. II. Diminished Ovarian Reserve at any age
- AMH- anti-Mullerian hormone of less than or equal to pmol/l
Antral Follicle Count (AFC) – Less than or equal to 4
Day 2/3 FSH >8.9 IU/L
Endometriosis
Moderate (more than slightly abnormal) degree of semen quality abnormalities.
V. Tubal Compromise
NICE Guideline 2013

25. ICSI
Unprecedented successful development of ART which has revolutionized the management of severe male infertility (Van Steirte-ghen 1992)
The procedure involves the direct injection of a single sperm into the egg cytoplasm

26. Indications for ICSI Severe alterations of semen characteristics
History of fertilization failure in conventional IVF attempts
Testicular or epidydimal sperm
Other relative indications

27. Success rates following IVF / ICSI
24.7 percent clinical pregnancies of all women who undergo IVF treatment (HFEA 2011).
50% of all embryos cultured in vitro reach blastocysts stage by day 6.
About 15% of transferred embryos will develop into a baby

28. Basics requirements for IVF/ICSI success
Pre – IVF work up of the infertile couple
Clinical history
Examination
Investigations
Counseling
Why necessary?
To identify the cause of infertility and thereby prognosis
To identify and correct associated adverse factors before treating
primary disorder
To decide most appropriate treatment protocol Type of drug starting dosage expected response and problems
To assess reproductive ageing and plan early access / resort to ART treatments

29. Basic requirements for IVF/ICSI success contd…
2. To get adequate number of good quality oocytes
Predictors of COHS response Normal responders Hyper responders Hypo- responders Age, AMH, AFC
- Response to earlier COHS
- Basal FSH, LH, E2
- BMI, Smoking, Alcohol Previous Ovarian Surgery B. Selection of COHS protocol Agonist versus Antagonist protocols Mild stimulation protocols

30. Basic requirements for IVF/ICSI success contd…
C. Ultrasound monitoring with power and colour
Doppler
D. Biochemical Monitoring
Ovulation induction hCG - urinary / recombinant GnRh agonist
Technique of Oocyte retrieval
Embryology lab quality and expertize
IVF or ICSI
Selecting best embryo (s) for transfer
Number of embryos transferred
Embryo transfer technique
Luteal Support

31. Luteal Support

32. Luteal Support
The transformation of mature follicle into corpus Luteum (CL) after the release of ovum is triggered by an optimal LH surge.
The function of CL is dependent upon continued LH stimulation in luteal phase.
CL is an essential source of pro-fertility hormones ie Progesterone (P), Estrogen (E) and other vasoactive and growth factors.

33. Luteal Support
It is well established that the ovarian stimulation regimens used in assisted reproduction cycles alter the luteal phase.
Edwards et al 1980, Kolibianakis et al 2003
Ovarian stimulation causes
an inadequate development of the endometrium
an asynchrony between the endometrium and the transferred embryo and
adverse effects on endometrial receptivity
Macklon & Fraser 2000, Devroey et al 2004

34. Luteal Support contd…
The luteal phase defect in IVF is present whether GnRH agonist or antagonist is used (Friedlers et al 2006).
The possible mechanism responsible may be –
Continuation of pituitary down regulation effect
Duration of luteal phase is shortened
Formation of multiple CL leading to inhibition of pulsatile LH release
Loss of granulosa cells during oocyte retrieval

35. Luteal Phase Support
Endometrial support – complements production by CL
Progesterone preparation
Estrogen preparation
Agents which support CL
hCG
GnRH-analogue LH
Newer agents which promote angiogenesis and
vascular supply

36. Progesterone preparations available
Micronized
Oral / vaginal mg BD
Vaginal Gel (8%) mg daily
Vaginal Pessary mg daily
Intramuscular (oil based) mg daily
(iii) Subcutaneous (aqueous preparation) mg daily
(iv) Synthetic – Dydrogesterone mg BD or TDS

37. Estrogen as an adjuvant to LPS
Estradiol valerate. Hemihydrate
Oral (intravaginal)
2-6 mg/day
Micronized Estradiol
Oral or intravaginal
Transdermal Estradiol
Patches (2 per week)
ugm/day

38. GnRH agonist as an adjuvent to LPS
Luteal Phase Support for assisted reproduction cycles (Cochrane Review 2011)
Tesarik J et al 2006 published their result on 600 women randomly assigned to receive a single injection of GnRH agonist (0.1 mg of triptorelin) or placebo on Day 6 after ICSI. The results showed improvement of implantation and live birth rates.
Van der Linder et al investigated progesterone versus prog + GnRHagonist
Six studies (1646 women)
There were significant results showing a benefit from addition to GnRH agonist to progesterone for the outcomes of live birth, clinical pregnancy and ongoing pregnancy.

39. Luteal Phase Support for ART Cycles
Authors' conclusions
Cochrane review 2011 showed a significant effect in favour of progesterone for luteal phase support, favouring synthetic progesterone over micronized progesterone. Overall, the addition of other substances such as estrogen or hCG did not seem to improve outcomes.
They found no evidence favouring a specific route or duration of administration of progesterone.
It was found that hCG, or hCG plus progesterone, was associated with a higher risk of OHSS.
The use of hCG should therefore be avoided.
There were significant results showing a benefit from addition of GnRH agonist to progesterone for the outcomes of live birth, clinical pregnancy and on-going pregnancy.
For now, progesterone seems to be the best option as luteal phase support, with better pregnancy results when synthetic progesterone is used.
Cochrane Review 2011

40. Nutritional Supplements and ART outcome
No definite conclusive evidence
Anti-oxidants – Vit C, E, selenium, zinc, taurine, carotene, lycopene
Vitamins – Folate, Vit B 12
Myoinositol and D-chiro-inositol (vit B complex)
L – Arginine
DHEA

41. Dehydroepiandrosterone (DHEA) supplementation
Cason and associates (2000) were first to suggest therapeutic benefits from the supplementation of DHEA in women with diminished ovarian reserve and suggested it may improve oocyte yields via IGF-1.
It was left to a 43 year old infertility patient in US (advised donor oocytes) to discover their paper and self administer DHEA while undergoing subsequent IVF cycles.
The patient underwent nine consecutive IVF cycles and increased oocytes and embryo yields from cycle to cycle, starting with one egg and embryo, respectively, and ending up with 17 oocytes and 16 embryos in her ninth cycle.
(Gleicher et al 2009)

42. Dehydroepiandrosterone (DHEA) supplementation
While all other pharmacological agents affect follicle maturation only during the final stage – gonadotropin – sensitive last 2 weeks, DHEA in contrast appears to affect folliculogenesis at much earlier stages of in-vivo follicle maturation (Gleicher N etal 2011)
DHEA has been shown to increase the number of primary, preantral and antral follicles.
DHEA supplementation is reported to improve ovarian response, IVF parameters and pregnancy chances. Younger patients with POA appears to have a slight pregnancy advantage.

43. Cumulative pregnancy rates in women with DOR with and without DHEA supplementation. POA patients appear to have a slight pregnancy advantage, Barad et al 2007

44. DHEA supplementation is also shown to significantly (50-80%) reduce the miscarriage risks in patients with poor ovarian reserve (Gleicher etal 2007)
Age-stratified miscarriage rates in DHEA supplemented DOR patient in comparison to national U.S. IVF pregnancies. Gleicher et al 2009

45. Treatment protocols, side effects and complications
Micronized DHEA at a dosage of 25mg TID
Effects occur relatively quickly (6-8 weeks) but peak only after 5-6 months of supplementation.
Side effects are small and rare and primarily relate to androgen effects – oily skin, acne vulgaris and hair loss.
Even long-term therapy of DHEA in suggested dosages have been demonstrated safe (Panjari M etal 2009).
However, before declaring DHEA as a wonder drug, larger RCTs are urgently needed to confirm the benefits.

46. Thank You
Sohani Verma