1. Anovulation- the most frequent cause of female infertility. It can be connected with: Irregular menstruation Irregular menstruation Oligomenorrhea Oligomenorrhea Amenorrhea Amenorrhea Regular menstruations can also occur Regular menstruations can also occur

2. Anovulation- the reasons: Hyperprolactinemia Hyperprolactinemia Hypothalamic- pituitary dysfunction Hypothalamic- pituitary dysfunction Ovarian failure Ovarian failure PCO PCO Diagnostic methods: PRL/MCP, FSH, LH, E 2 serum concentrations between 3 - 6 day of cycle. PRL/MCP, FSH, LH, E 2 serum concentrations between 3 - 6 day of cycle. P test and ultrasound ovarian assessment. P test and ultrasound ovarian assessment.

3. Hyperprolactinemia: PRL > 20 ng/ml, MCP > 300% PRL > 20 ng/ml, MCP > 300% Causes: stress, hypothalamic failure, PCO, psychotropic drugs (e.g. trnquilizers), rare - adenoma Causes: stress, hypothalamic failure, PCO, psychotropic drugs (e.g. trnquilizers), rare - adenoma When PRL>27.8 ng/ml determine TRH - hypothyreosis? When PRL>27.8 ng/ml determine TRH - hypothyreosis? Syndroms: Oligomenorrhea or amenorrhea, infertility- anovulation, deficient activity of the corpus luteum, galactorrhea in 33%. Syndroms: Oligomenorrhea or amenorrhea, infertility- anovulation, deficient activity of the corpus luteum, galactorrhea in 33%. Treatment: Bromocriptine Treatment: Bromocriptine

4. Hypothalamic- Pituitary dysfunction P test - negative, FSH, LH <5 mj/ml or normal, E2<40 pg/ml P test - negative, FSH, LH <5 mj/ml or normal, E2<40 pg/ml Causes: the most frequent congenital hypothalamic- pituitary insufficiency, stress, excessive exercise, weight loss, malnutrition. Causes: the most frequent congenital hypothalamic- pituitary insufficiency, stress, excessive exercise, weight loss, malnutrition. Management: Management: –Elimination risk factors –GnRH –hMH, FSH

5. Ovarian failure FSH >20mj/ml FSH >20mj/ml Possible in each age: Possible in each age: In younger women (age 30) frequently genetic causes- karyotype evaluation. In younger women (age 30) frequently genetic causes- karyotype evaluation. In woman at reproductive age it can be transient or permanent. In woman at reproductive age it can be transient or permanent. Causes: idiopathic, autoimmunological- thyroid inflammation, myasthenia, thrombocytopenia, rheuamtoid disease, adrenal failure, vitiligo, hemolytic anemia. past surgeries, chemio- or radiotherapy, inflammations, 17- hydroxylase hypoactivity, hormonal ovarian resistance. Causes: idiopathic, autoimmunological- thyroid inflammation, myasthenia, thrombocytopenia, rheuamtoid disease, adrenal failure, vitiligo, hemolytic anemia. past surgeries, chemio- or radiotherapy, inflammations, 17- hydroxylase hypoactivity, hormonal ovarian resistance.

6. Ovarian failure- treatment E/P, in women at the beginning of ovarian failure ovulation can be restored in about 20% of women. E/P, in women at the beginning of ovarian failure ovulation can be restored in about 20% of women. hMG treatment is ineffectiveness and autoimmunologic process can intensify hMG treatment is ineffectiveness and autoimmunologic process can intensify

7. Variety of syndroms in PCO according to Balen et al. Obesity 38 - 50% Obesity 38 - 50% Dysmenorrhea Dysmenorrhea Infertility in 75% Infertility in 75% Hyperandrogenism in 48% Hyperandrogenism in 48% Without syndroms 20% Without syndroms 20% Hormonal diagnostics: T, A T, A LH LH LH:FSH LH:FSH Insulin level in fasting state Insulin level in fasting state PRL PRL SHBG SHBG

8. Body weight reduction Body weight reduction Decreasing the E1 and LH concentrations Decreasing the E1 and LH concentrations Decreasing the P 450C activity and free Testosterone concentration Decreasing the P 450C activity and free Testosterone concentration

9. Metformin Decrease the insulin level and restore correct steroidogenesis Decrease the insulin level and restore correct steroidogenesis (take place the proper cytochrome P 450 C 17 alfa phosphorylation)

10. INFERTILITY DIAGNOSIS INFERTILITY DIAGNOSIS

11. Hysterosalpingography (HSG) Hysterosalpingogram- x-ray imaging of the uterus and fallopian tubes after instillation of a contrast liquid Hysterosalpingogram- x-ray imaging of the uterus and fallopian tubes after instillation of a contrast liquid Routine infertility evaluation (basic test) Routine infertility evaluation (basic test) Assess morphology of endocervical canal, uterine cavity, tubes. Assess morphology of endocervical canal, uterine cavity, tubes. Rule out tubal occlusion, synechiae, uterine anomalies. Rule out tubal occlusion, synechiae, uterine anomalies.

12. Contraindications to HSG: 1. active PID with abdominal tenderness or palpable mass 2. recent uterine/tubal surgery 3. active uterine bleeding 4. pregnancy (schedule exam before ovulation to avoid early pregnancy)

13. Normal hysterosalpingogram. A smooth triangular uterine cavity and spill from the ends of both tubes.

14. HSG showing a normal uterus and blocked tubes No "spill" of dye is seen at the ends of the tubes

15. Hysterosalpingogram showing a uterus with a myoma that is pushing in to the cavity.

16. A hysterosalpingogram indicate intrauterine adhesions (synechia) intrauterine adhesions (synechia)intrauterine adhesions (synechia)

17. Tubal Recannulization and Selective Salpingography

18. Selective hysterosapingography, or proximal tubal cannulization may open the tubes avoiding surgery.

19. LAPAROSCOPY

20. The camera and instruments are inserted into the abdomen or chest through small skin cuts allowing the surgeon to explore the whole cavity without the need of making large standard openings dividing skin and muscle.

21. After the cut is made in the umbilical area a special ( Veress) needle is inserted to start insufflation. A pressure regulator CO2 insufflator is connected to the needle. The pressure obtained should not be beyond 15 mmHg.

22. After satisfactory insuflation the needle is removed and a 10 mm trocar is inserted through the previous umbilical wound.

23. Laparoscopic view of a normal pelvis. Uterus in midline. Tubes and ovaries (white structures) also visible.

24. Contraindications to laparoscopy: Circulatory and respiratory insufficiency Circulatory and respiratory insufficiency Hypovolemic shock Hypovolemic shock Ileus Ileus Peritonitis Peritonitis Abdominal or diaphragmic hernia Abdominal or diaphragmic hernia Tumors in abdominal cavity Tumors in abdominal cavity

25. Pelvic laparoscopy is also not recommended for patients with: – severe obesity – existing severe pelvic adhesions from previous surgeries

26. Pelvic Laparoscopy: Risks Risks for any anesthesia are: Risks for any anesthesia are: reactions to medicationsreactions to medications problems breathingproblems breathing Risks for any surgery are: Risks for any surgery are: bleedingbleeding infectioninfection damage to adjacent organsdamage to adjacent organs

27. HYSTEROSCOPY HYSTEROSCOPY Assess the endocervical canal, uterine cavity and uterine openings of the oviducts. Assess the endocervical canal, uterine cavity and uterine openings of the oviducts. Enables to make the intrauterine operations. Enables to make the intrauterine operations.

28. Hysteroscopic view of a uterine septum. A septum can cause recurrent miscarriage.

29. A large polyp at the top of the uterine cavity

30. Contraindications to hysteroscopy: Infections of reproductive organs Infections of reproductive organs Massive bleeding from uterus Massive bleeding from uterus Pregnacy Pregnacy Cervical cancer Cervical cancer

31. Hysteroscopy. Risks. Uterine perforation Uterine perforation Bleeding Bleeding Infection Infection Pulmonary embolism (rare) Pulmonary embolism (rare)

32. Polycystic ovarian syndrome (PCOS) occur in 5- 10% of reproductive-aged women PCOS  ovulatory dysfunction or absent ovulation  infertility  infrequent or irregular menstrual cycles  infrequent or irregular menstrual cycles absence of ovulation  no progesterone production in the second half of the menstrual cycle  the risk for an abnormal buildup of the lining of the uterus (endometrial hyperplasia) or cancer.

33. Another feature to PCOS is clinical or laboratory hyperandrogenism  increased circulating amounts of or increased responsiveness to "male" hormones like testosterone or DHEAS Symptoms: oily skin or acne and excess hair on the face, between the breasts, or on the lower abdomen.

34. Changes in the ovaries in ultrasound Ultrasound findings: poly (many), cystic (small collections of fluid). The eggs in the ovaries do not develop to maturity  many small "follicles" (small fluid-filled sacs containing immature eggs) seen on ultrasound. The ovaries of women PCOS are often enlarged as well.

35. Another common feature of PCOS is increased body weight and trouble in losing weight. Mechanism: insulin resistance (the cells of women with PCOS do not respond as well to their bodies' own insulin)  women with PCOS are at higher risk for developing diabetes during pregnancy or later in life.

36. Treatment Strategies The aim: to help regulate menstrual cyclicity and prevent endometrial hyperplasia. Oral contraceptives (birth control pills- BCPs). BCPs also help reduce acne and facial hair in most patients with PCOS. Oral contraceptives (birth control pills- BCPs). BCPs also help reduce acne and facial hair in most patients with PCOS. In women who do not require oral contraception, progesterone given for 10-12 days every 30- 60 days will induce a reliable menses. For women with PCOS who desire pregnancy, ovulation induction (COH) is often necessary. Drugs that increase insulin sensitivity in PCOS- Metformin  help induce ovulation  help women to lose weight  help women to lose weight

37. In women who cannot tolerate oral medications or have failed several different regimens of medication, surgical induction of ovulation can also be attempted (laser or electrosurgical techniques to place small holes in the ovaries in an effort to normalize the hormonal environment and allow ovulation to occur)

38. ANDROLOGY Dr hab. Rafał Kurzawa CLINIC of REPRODUCTION and GYNECOLOGY POMERANIAN ACADEMY of MEDICINE

39. Infertility- epidemiology

40. Symptomatology of male infertility TYPE I – erection problems (0,3-7%) TYPE I – erection problems (0,3-7%) TYPE II – azoospermia (0,9%-16%) TYPE II – azoospermia (0,9%-16%) TYPE III – immunological infertility (3,4%-25%) TYPE III – immunological infertility (3,4%-25%) TYPE IV – abnormal seminal quality (23%-48%) TYPE IV – abnormal seminal quality (23%-48%) TYPE V – idiopathic sperm dysfunction (0-25%) TYPE V – idiopathic sperm dysfunction (0-25%)

41. Diagnosis General examination General examination Semen analysis Semen analysis Other diagnostic tests: Other diagnostic tests: –USG –Hormonal diagnostic –Diagnostic tests for Assisted Reproductive Technology

42. TYPE I – erection problems (0,3-7%) Normal ejaculation Normal ejaculation –Hypospermia (semen volume < 2,0 ml) – chronic prostatitis –Impotence Retrograde ejaculation Retrograde ejaculation –Neurogenic– DM, SM –Anatomical –Jatrogenic – drugs, operations disejaculation disejaculation –Functional – anorgazmia –Neurogenic – spinal injury –Jatrogenic – drugs, chemiotherapy, radiotherapy, operations

44. TYPE II – azoospermia (0,9%- 16%) Pre-testicular causes Pre-testicular causes –Hypothalamic or pituitary disorder – LH, FSH deficiency, Kallman syndrome, trauma, tumors, inflammation, meningitis Testicular causes Testicular causes –Primary testicular failure –Congenital – 47XXY, del Y, AZF –Acquired- mumps, testicular torsion, castration –Jatrogenic – radiotherapy, chemiotherapy Post-testicular causes Post-testicular causes –Congenital – CBAVD, CF –Acquired – inflammations (gonorrhea) –Jatrogenic – vasectomy, hernia operation

45. Diagnostic tests for Assisted Reproductive Technology - ICSI FSH FSH –If < 12IU – sperm biopsy is effective in 80-90% Blocked ejaculatory duct (Micro-Epidydymal Sperm Aspiration –MESE) Blocked ejaculatory duct (Micro-Epidydymal Sperm Aspiration –MESE) Other (Testicular Sperm Extirpation- TESE, Testicular Sperm Aspiration- TESA) Other (Testicular Sperm Extirpation- TESE, Testicular Sperm Aspiration- TESA)

46. TYPE III – immunological infertility (3,4%-25%) antisperm antibodies – the immune system may produce antibodies that attack and weaken or disable sperm antisperm antibodies – the immune system may produce antibodies that attack and weaken or disable sperm –Auto-immunological diseases –Concequences of testicular trauma

47. Congenital Congenital –Undescended testicles Sexually transmitted disease (gonorrhoea) or testicular infection (mumps) Sexually transmitted disease (gonorrhoea) or testicular infection (mumps) Vascular Vascular –Testicular torsion –Varicocoeles Diseases: Diseases: –Thyroid faiure; Addison disease, hepar diseases; DM, auto-immunological diseases; Environmental factors Environmental factors –Drugs (sulfasalazine, T, chemiotherapy) –Temperature –Other factors (X-rays, lead, cigarette smoke, alcohol; marijuana, frequently wearing tight-fitting pants and underwear) Immunological Immunological –Testitis Genetic Genetic –del Y, aberrations (count and structure of chromosomes) Idiopathic [46%] Idiopathic [46%] TYPE IV – abnormal sperm quality (23%-48%)

48. Morphologic images

49. Treatment Risk factor elimination Risk factor elimination Give up smoking Give up smoking Testicular temperatue decrease Testicular temperatue decrease Regular sexual intercourses (2-3 per week) Regular sexual intercourses (2-3 per week) Antioxydants Antioxydants –Vitamin E, C, Zinc Tetracicline Tetracicline –Chlamydia Trachomatis infection

50. Treatment (pharmacotherapy) Risk factor elimination Risk factor elimination Hormonal treatment Hormonal treatment –Testosterone –hCG –FSH –C.C, tamoxyphen

51. Varicose veins in the spermatic cord Physical examination Physical examination –I Valsalva test examination ( or during cough) –II large veins during palpation –IIIvisible varicouse veins Other diagnostic test Other diagnostic test –Semen analysis (SA) –USG Treatment Treatment –Operation –ART.: IUI, IVF, ICSI

52. Diagnostic and therapeutic algorithm (male) Diagnostic and therapeutic algorithm (male) Sperm analysis O, A, T, OA, OT, TA, OAT grave O, A, T, OA, OT, TA, OAT azoospermiaTesticular cells? TESE, MESA Treatment: operation, CC, hMG (FSH) ICSI IUI

53. Sperm analysis- recommendation by WHO –General male infertility diagnostic test- SA –sterility –sample should be delivered to laboratory in 60 min. after ejaculation –abstinence min. 48 hours max. 7 days –the next semen analysis between 7 days and 3 months

54. Seminal quality, cytology and sperm quantitation –liquefaction –viscosity –volume –color –pH –smell –Sperm count –Sperm motion analysis –WBC count (pyospermia) –Spermatozoa count –Antisperm antibodies –Sperm morphology –Microbiology

55. Semen analysis Semen analysis –Microscope –Makler counting chamber –Immunobead test (IgG, IgA or IgM) –CASA (computer-assisted sperm analysis)

56. Sperm motion analysis 1- immotile 2- weak movement with no forward progression 3- forward progression 4- rapid forward progression; vigorous tail movement

58. Seminal quality- ranges –Liquefaction < 60 minutes –Volume > 2 ml –Color- gray to white opalescent fluid –pH 7,2 – 8,0

59. IMMUNOBEAD TEST Microscopic polyacrylamide spheres, ranging in size from 2 to 10 um, coated with anti-human immunoglobins against human IgG, IgA or IgM Microscopic polyacrylamide spheres, ranging in size from 2 to 10 um, coated with anti-human immunoglobins against human IgG, IgA or IgM

60. Normal sperm range Motility >50% 3 or 2 ; or >25% 3 Motility >50% 3 or 2 ; or >25% 3 Sperm count >20·10 6 /ml Sperm count >20·10 6 /ml WBC count <10 6 /ml WBC count <10 6 /ml Spermatogonia <5·10 6 /ml Spermatogonia <5·10 6 /ml Autoagglutinating <10% Autoagglutinating <10% Immunebead test<10% Immunebead test<10% Sperm morphology >30% normal forms (WHO); 5-14% strict criteria (Kruger) Sperm morphology >30% normal forms (WHO); 5-14% strict criteria (Kruger)

61. Definitions of „abnormal” counts Definitions of „abnormal” counts Normozoospermia Normozoospermia Oligozoospermia < 20·10 6 /ml Oligozoospermia < 20·10 6 /ml Astenozoospermia<50% 3 or 2 ; or <25% 3 Astenozoospermia<50% 3 or 2 ; or <25% 3 Teratozoospermia<30% Teratozoospermia<30% Azoospermia no sperm Azoospermia no sperm

62. Assisted Reproductive Techniques IUI (intrauterine insemination) AIH (artificial insemination by husband) AID (artificial insemination by donor) IUI (intrauterine insemination) AIH (artificial insemination by husband) AID (artificial insemination by donor) GIFT (gamet intrafallopian transfer) GIFT (gamet intrafallopian transfer) IVF (in vitro fertilization) ZIFT (zygote intrafallopian transfer) PROST (pronuclear stage intrafallopian transfer) IVF-ET (in vitro fertilization and embryo transfer) ICSI (intracytoplasmic sperm injection) IVF (in vitro fertilization) ZIFT (zygote intrafallopian transfer) PROST (pronuclear stage intrafallopian transfer) IVF-ET (in vitro fertilization and embryo transfer) ICSI (intracytoplasmic sperm injection)

63. Indications to IUI Cervical factor Cervical factor Chronic anovulation (COH-PCOS) Chronic anovulation (COH-PCOS) Male factor Male factor Immunologic disorders Immunologic disorders Endometriosis Endometriosis Idiopatic infertility Idiopatic infertility

64. IUI Proceeding Proceeding - Ovulation stimulation - Sperm preparation (>1-4·10 6 /ml) - Artificial insemination Efficacy (depended on indications and stimulation protocol) Efficacy (depended on indications and stimulation protocol) –10 – 30% pregnancies per cycle –40 – 60% accumulated no improvement after 4 cycles CONCLUSION: unjustified more than 4 correct IUI

65. Sperm preparation (IUI, IVF) gradient Sperm liquefaction Prepare the „gradient” Stratification on gradient Centrifugation Again centrifugation in EBSS ART semen 1 2 3 40% Silica 80% Silica

66. Ovulation stimulation for IUI Clomiphene citrate Clomiphene citrate –50 – 250 mg p.o., day 5-9 Clomiphene citrate + hMG (FSH) Clomiphene citrate + hMG (FSH) –50 – 250 mg p.o., day 5-9 –75 IU from day 9 hMG (FSH) hMG (FSH) –75 – 150 IU from day (3) 5 Aim Aim –growth 1-3 follicles to 18mm. When E 2 250–300 pg/ml/follicle 10.000IU hCG is administered to cause ovulation

67. Basic indications to IVF Partial or complete tubal obliteration Partial or complete tubal obliteration Chronic anovulation (COH-PCOS) Chronic anovulation (COH-PCOS) Male factor Male factor Immunologic disorders Immunologic disorders Endometriosis Endometriosis Idiopatic infertility Idiopatic infertility

68. Indications to ICSI Indications to ICSI with sperm from ejaculate O, A, T, OAT <1-4·10 6 /ml after preparation <5% normal forms failure of classic IVF (no fertilization) Indications to ICSI with sperm from ejaculate O, A, T, OAT <1-4·10 6 /ml after preparation <5% normal forms failure of classic IVF (no fertilization) Indications to MESA azoospermia (obstruction of ejaculatory ducts- obstructive azoospermia) Indications to MESA azoospermia (obstruction of ejaculatory ducts- obstructive azoospermia) Indications to TESE azoospermia (patency of ejaculatory ducts- nonobstructive azoospermia) Indications to TESE azoospermia (patency of ejaculatory ducts- nonobstructive azoospermia)

69. IVF-ET (classic) Ovulation stimulation Ovulation stimulation Sperm preparation Sperm preparation Collecting the oocytes (under ultrasound control) Collecting the oocytes (under ultrasound control) Oocytes maturity assessment Oocytes maturity assessment Oocytes insemination Oocytes insemination Fertilization assessment (16-24h) Fertilization assessment (16-24h) Embryo culture to 4 (48h) - 8 (72h) Embryo culture to 4 (48h) - 8 (72h) blastomers stage or to blastocyst stage (120h) Embryo transfer (ET) Embryo transfer (ET) Embryo cryopreservation Embryo cryopreservation

70. ICSI Ovulation stimulation Ovulation stimulation Sperm preparation Sperm preparation Collecting the oocytes (under ultrasound control) Collecting the oocytes (under ultrasound control) Oocytes maturity assessment Oocytes maturity assessment Intracytoplasmic sperm injection Intracytoplasmic sperm injection Fertilization assessment (16-24h) Fertilization assessment (16-24h) Embryo culture to 4 (48h) - 8 (72h) blastomers stage or to blastocyst stage (120h) Embryo culture to 4 (48h) - 8 (72h) blastomers stage or to blastocyst stage (120h) Embryo transfer (ET) Embryo transfer (ET) Embryo cryopreservation Embryo cryopreservation

71. Ovulation stimulation for IVF (COH – controlled ovarian hyperstimulation) Short protocoł aGnRH from day 1 hMG (FSH) 150–300IU from day 3 Short protocoł aGnRH from day 1 hMG (FSH) 150–300IU from day 3 Long protocoł aGnRH from day 20 previous cycle hMG (FSH) 150–300 IU from day 3 Long protocoł aGnRH from day 20 previous cycle hMG (FSH) 150–300 IU from day 3 Aim growth some follicles. When dominant follicle is >18mm and 2 other at least 16 mm and E2 >1000pg/ml but 18mm and 2 other at least 16 mm and E2 >1000pg/ml but <5000pg/ml (OHSS risk), 10.000IU hCG is administered to cause oocytes maturity)

72. IVF - ICSI (skuteczność) IVFICSI ICSI MESA ICSI TESE Fertilizations50%65%60%55% Cells divisions 90%95% Pregnancies per cycle 15-25%25-35%35-45%25-35%

73. IVF - ICSI (e) IVF - ICSI (e ffectiveness ) Implantation percentage when 1 embryo is transferred in stage 4 – 8 blastomers is 12,5 – 17,5% Implantation percentage when 1 embryo is transferred in stage 4 – 8 blastomers is 12,5 – 17,5% About 60% of embryos goes to stage of 4 blastomers (and far?) About 60% of embryos goes to stage of 4 blastomers (and far?) Pregnancies percentage per cycle (patients < 40) Pregnancies percentage per cycle (patients < 40) –Less than 7 oocytes - 13% –More than 7 oocytes - 29% Effectiveness of 1 mikrosurgery is equal with cumulative efficacy of 5 IVF trials

74. Cryopreservation Freezing and storage Freezing and storage –Embryos Stage 2 pronucleus Stage 2 pronucleus Stage 2-4 blastomers Stage 2-4 blastomers Stage blastocyst Stage blastocyst –Oocytes and ovarian tissue Benefits Benefits –Low cost, no OHSS, possibility of more „aggresive” ovulation stimulation in first cycle Effectiveness - 10 – 20% pregnancies per cycle

75. Preparation to cryo-ET Natural cycle (indication is growth the ovarian follicle) alternatively supplement therapy with estrogens and progestagens Natural cycle (indication is growth the ovarian follicle) alternatively supplement therapy with estrogens and progestagens Controlled cycle aGnRH with supplement estrogens and progestagens therapy Controlled cycle aGnRH with supplement estrogens and progestagens therapy

76. Complications and potential risk of ART Complications Complications –OHSS Rare cardio- pulmonary failure, renal failure, DIC... Rare cardio- pulmonary failure, renal failure, DIC... –Multiple pregnancy (5 – 40% !) Prematurity and preterm labours (to 98%), PIH (25%), bleeding (35%), anemia (15%), isthmocervical insufficiency (15%) Prematurity and preterm labours (to 98%), PIH (25%), bleeding (35%), anemia (15%), isthmocervical insufficiency (15%) Strategies: Transfer of 1-2 embryos; multiembryo transfer and consecutive embrioreduction or leaving this problem for obstetricians and neonatologists

77. Complications and potential risk of ART Potential risk Potential risk –Ovarian cancer Increased risk of serous carcinomas, low malignancy (high grade) Increased risk of serous carcinomas, low malignancy (high grade) More frequent after Clomiphene citrate More frequent after Clomiphene citrate No confirmation in large randomised clinical trials !!! No confirmation in large randomised clinical trials !!! –Theoretical risk of hormonosensitive neoplasm (breast, endometrium) –Genetic defects transfer Male infertility (AZF, delY...) Male infertility (AZF, delY...) Besides no risk of malformations was confirmed (but too short observations) – 2,2–2,7% Besides no risk of malformations was confirmed (but too short observations) – 2,2–2,7%

78. IVM & IVC IVM (in vitro maturation) IVM (in vitro maturation) –OHSS prevention –In vitro culture of ovarian follicles from antral to developed follicle– IVF – IVC – ET Multiple pregnancy prevention- IVC (in vitro culture) Multiple pregnancy prevention- IVC (in vitro culture) –In vitro culture of embryos to blastocyst stage (the best one for implantation) – 40-60% of pregnancies (blastocyst –sequential media) when compare to 12,5 – 17,5% (embryo in the stage of 2- 4-8 blastomers) –Culture the embryos to this stage make some problems. About 35- 60% of embryos in vitro goes to blastocyst stage. –IVC gives the possibility of reliable evaluation the embryos quality.

79. Preimplantation diagnostic Indications Indications Age > 35 (?) Age > 35 (?) Previous child with chromosome abnormalities Previous child with chromosome abnormalities Carrier of genetic defects Carrier of genetic defects –Aneploidies (e.g. Down syndrome) –Monogenic disorders (np. fibrocystic disease) –X-linked inheritance (hemophilia) (important child sex) Sampling Sampling –Blastomers biopsy Methods Methods –PCR (polymerase chain reaction) –FISH (fluorescent in-situ hybridization)

80. Conditions to start ART IUI IUI –Woman Vaginal bacteriological examination Vaginal bacteriological examination –Man 3-7 days of sexual abstinence 3-7 days of sexual abstinence IVF IVF –Woman Vaginal bacteriological examination hormonal profile Cervical canal explore with a probe (?) Hysteroscopy (?) –Man 3-7 days of sexual abstinence Sperm bacteriological examination prophylactic antibiotic therapy (?)