1. Methods of assisted reproduction MUDr.Jitka Řezáčová ÚPMD, Praha 4, Podolí

2. When we talk about methods of assisted reproduction ► All therapeutic procedures and techniques in which is manipulated with gametes (oocytes and sperm).

3. History of assisted reproduction - IVF ► 1978 Louise Brown - the first child after IVF- ET (R. Edwards, P. Steptoe, UK) ► 1982 the first child after GIFT from us (L.Pilka, Brno) ► 1983 the first child after KET ► 1995 first child after KET in the Czech Republic (T.Mardešič, ÚPMD, Prague) ► 1993 first baby after ICSI (AC van Steirteghem)

5. Indications for treatment of infertility by in vitro fertilization ► Tubal factor ► Male subfertility ► Endometriosis ► Ovarian factor ► Immunological factor ► Idiopathic infertility

6. Distribution methods of assisted reproduction ► IVF-ET - in vitro fertilization and embryo transfer ► ICSI - intracytoplasmic sperm injection ► PICSI - positive selection of sperm ► AH - assisted hatching ► KET-cryoembryotransfer ► MESA - microsurgical epididymal sperm aspiration ► TESE - testicular sperm extraction

7. Recruitment IVF-ET health insurance companies in the Czech Republic ► A maximum of 4 cycles (first two cycles with single embryotransfer) ► From 21 to 39 years (absolute tubal factor from 18 years) old women ► Health insurance companies in the Czech Republic does not pay: ICSI, PICSI, assisted hatching, prolonged cultivation, cryopreservation gamet and embryos, KET, MESA,TESE

8. IVF-ET involves ► Hormonal preparation and monitoring cycle (controlled ovarian hyperstimulation - KOH) ► Collection of oocytes ► In vitro fertilization and embryo culture ► Embryotransfer ► Luteal support

9. Hormonal preparation ► Choice of stimulation protocol ► Select the type of gonadotropins and define the benefits

10. Monitoring cycles ► Monitoring of follicular growth and endometrial thickness (triple line) vaginal ultrasound probe ► Monitoring blood levels of E2

11. Timing of ovulation ► Applications hCG (Ovitrelle, Pregnyl)

12. Collection of oocytes ► 34-36 h after administration of hCG transvaginal collection of oocytes under the US control conscious sedation or general anesthesia for short term.

13. Cultivation of oocytes ► The first 2 hours after egg collection to the culture box in a 5% CO2 in air at 37C ► Assessment of oocyte maturation and detect the presence of polar bodies ► Selected for ICSI oocytes with the first pole element (metaphase II) ► Other retained 4-6 hours to mature

14. Preparation of spermatozoa for in vitro fertilization ► Remove seminal plasma centrifugation and swim up ► Capacitation in the culture medium usually 6 h

15. Fertilization of oocytes ► Adding sperm to media oocytes after about 6 hours after aspiration ► Check for fertilization after 17-22 h detecting the presence of pronucleus

16. ICSI

19. PICSI (before ICSI) ► ► It uses a simple chemical reaction. Normal sperm have the ability to bind to hyaluronic acid. ► ► Hyaluronic acid is a substance that surrounds the egg and is involved in sperm-egg binding ► ► This link show only mature sperm, which have significantly lower incidence of chromosomal anomalies.

20. Recommendation for PICSI ► ► Low fertilization oocytes after ICSI ► ► Poor quality embryos, respectively arrest their development ► ► Recurrent spontaneous abortions

21. Embryotransfer Usually within 48 h after oocyte aspiration Percentage transfer depends on: 1. Quality of transferred embryos 2. The number of transferred embryos 3. Technic of transfer 4. Status of endometrium at the time of transfer

22. Prolonged cultivation ► To the stage of blastocyst-up to 120 h

23. C ryoembryotransfer - KET ► All embryos good quality can be frozen. ► KET is thawed embryo transfer into the uterus either in native cycle or hormonal endometrial preparation.

24. KRYOKONZERVACE

25. Risks of Assisted Reproduction ► Multiple pregnancy ► Ovarian hyperstimulation syndrome ► Infection ► Adnexal torsion ► Hemorrhage

26. New trends in assisted reproduction ► Stimulation with low doses of gonadotropic hormone, GnRH antagonists (prevention of the development of a higher degree of OHSS) ► Simple application of drugs, patients can apply them at home (r- ​​ hFSH pen) ► Embryo transfer 1-2 embryos (reducing the number of multiple pregnancies)

27. Preimplantation genetic diagnosis (PGD) ► Genetic testing embryo before its introduction into the uterus ► Techniques for PGD: FISH, PCR, PCR + DNA -Microarray

28. PGD Indications:  Hereditary diseases pair  Birth of a child with a genetic defect  Recurrent miscarriages  Repeated failure of IVF  Women over the age of 35 years, men 45 years

29. PGD

30. MESA

31. TESE

33. Maintaining the reproduction of cancer patients ► Pharmacological protection of the gonads ► Freezing sperm, oocytes, embryos, ovarian and testicular tissue prior to treatment for cancer patients

34. Thank you for your attention