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Fertility Diagnosis and Therapy 2008. Gad Lavy, M.D. New England Fertility Institute Lifeline Cryogenics. The New Technology and the Aging Ovary. Improvement in diagnosis and therapy Aging and its impact on fertility The Approach to the “older infertile couple”

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Fertility diagnosis and therapy 2008 l.jpg

Fertility Diagnosis and Therapy 2008

Gad Lavy, M.D.

New England Fertility Institute

Lifeline Cryogenics


The new technology and the aging ovary l.jpg
The New Technology and the Aging Ovary

  • Improvement in diagnosis and therapy

  • Aging and its impact on fertility

  • The Approach to the “older infertile couple”

    • More aggressive diagnostic and therapeutic approach

    • ART

      • IVF

      • PGD

      • Egg donation

      • Freezing of embryos, eggs and ovarian tissue

  • Team approach to fertility therapy


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Infertility Dx and Rx

  • Success in Diagnosis

  • Success in Therapy


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Improved Success

  • Better Diagnostics: fewer cases of unexplained infertility.

    • PCOS

    • Ovulatory dysfunction

    • Imaging

    • Endometrial function

  • Better Therapy: Higher overall success.

    • Surgery

    • Ovulation induction

    • IVF and related procedures


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Aging Population

  • Age at marriage

  • Age at first pregnancy



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Age and IVF Success

IVF success: Effect of age and number of eggs


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The aging Ovary (and testicle)

  • Decreased Ovarian Reserve (DOR)

    • Lower conception rates

    • Higher rates of pregnancy loss

    • Higher incidence of Congenital defects


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The Aging Ovary

Menopausal ovary

Normal ovary

Fewer eggs

Decreased egg quality


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A Practical Approach to the aging ovary

  • Aggressive Diagnosis and therapy

  • Expand Treatment options


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Diagnosis: The evaluation cycle

  • Baseline hormones

  • Ovulation profile

  • Imaging: HSG, Sono-HSG, MRI

  • Semen Analysis

  • Other: Genetic studies, immune workup etc


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Therapy-The aging ovaries

  • IVF

  • Pre-implantation Genetics (PGD)

  • Egg Donation

  • Egg Freezing/Ovarian tissue freezing



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IVF

  • Intra-cytoplasmic Sperm injection (ICSI)

  • Assisted zona Hatching (AZH)

  • Day 4-5 transfer and improved culture media

  • Cryopreservation of embryos


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ICSI

  • Poor sperm quality

  • Zona Pellucida hardening

  • Poor egg-sperm interaction


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Assisted Zona Hatching (AZH)

Zona Hardening

Improved Implantation



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PGD

  • Micromanipulation: remove a single blastomere from an 8-cell embryo without damaging the embryo

  • Genetic testing

    • FISH

    • PCR



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PGD- Indications

  • Chromosomal disorders

  • Single gene defects (CF, Thalassemia, Sickle cell disease)

  • Recurrent pregnancy loss

  • Repeat IVF failures

  • Severe male factor


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How is PGD performed?

Ovarian Stimulation

IVF

Blastomere Biopsy on Day 3

Transfer of

Unaffected Embryo

Genetic Analysis

Outcome

Chromosomally Normal Baby


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PDG- Clinical outcomes

  • Identify normal embryos

    • Fewer embryos to transfer

    • Know when not to transfer

    • Reduce pregnancy loss and anomalies


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Third Party Reproduction

  • Egg donation

  • Embryo donation

  • Gestational surrogacy


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Ovarian Failure.

Poor egg quality.

Recurrent IVF failure.

Recurrent pregnancy loss

Genetic defects precluding normal pregnancy.

Egg Donation: Indications


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The Egg Donation Process

  • The process involves IVF.

  • The resulting offspring will carry genetic material of the donor and the male partner.


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The Egg Donation Process

  • Donor and recipient cycles are synchronized.

  • Eggs taken from the donor after ovarian stimulation.

  • Eggs are fertilized with recipient partner’s sperm.

  • Embryos transferred to the uterus of a hormonally primed recipient.


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Donor

Synchronize cycle with recipient

Ovarian stimulation

Egg retrieval

Recipient

Synchronize cycle with donor

Preparation of the uterus

Fertilization

Embryo transfer

Egg Donation: The Process


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Egg Donation: The donors

  • Donor recruitment: Who are the donors?

  • Donor Screening: How are they tested?

  • Donor matching: How do I pick a donor?


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Egg Donation: The recipient couple

  • Medical Screening

    • The Mock cycle

  • Psychological issues

  • Legal Issues

  • Ethical concerns: Disclosure



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Advantages:

Well established method.

High success.

Disadvantages:

More difficult for unmarried women.

Limited number of embryos

Delay in cancer therapy due to the IVF process.

Contraindication to ovarian stimulation in Estrogen sensitive tumors.

IVF and Cryopreservation of Embryos


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Egg Freezing-Applications

  • Ovarian malignancies

  • Ovarian surgery

  • Aging

  • Egg banks


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Advantages

No need for ovarian stimulation

No need for fertilization

Enables preservation of eggs prior to surgery chemo or aging

Disadvantages

Lower survival

Possible damage to mitotic spindle

Still experimental

Egg Freezing


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Egg Freezing At NEFI

  • Technique: New Advancements in cryopreservation.

  • Candidates

    • Cancer and chemo

    • Egg bank

    • Preservation of reproductive potential

      • Age <38

      • FSH <12

  • Good Survival/fertilization and embryo development

  • Ready to launch


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Summary

  • Technology is developing rapidly

  • Ovarian aging is a major factor

  • ART is limited but can offer help for the aging ovary.


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However

  • Don’t Delay.

  • Discuss all options early.

  • Consult or refer if needed.


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CT State Mandate for Fertility Therapy

  • Benefits

    • Diagnostics

    • Ovulation therapy/inseminations X3

    • IVFx1

  • Limitation

    • Age <40

    • Look Back:

    • Time with current carrier: at least one year

    • Excludes self insurers, religious organizations etc.


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Return to referring MDDelay in referral


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Return to referring MDLength of clomid therapy by PMD


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A Team Approach

  • The primary caregiver

  • The infertility specialist

    • Physician

    • Nurse/midwife/NP

    • Laboratory

    • Emotional counseling and support


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We would like to thank our sponsor:

  • Organon


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Thank you for coming.

Gad Lavy, M.D. F.A.C.O.G.

New England Fertility Institute

Lifeline Cryogenics


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