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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


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    1. Fertility Diagnosis and Therapy 2008 Gad Lavy, M.D. New England Fertility Institute Lifeline Cryogenics

    2. 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

    3. Infertility Dx and Rx • Success in Diagnosis • Success in Therapy

    4. 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

    5. Aging Population • Age at marriage • Age at first pregnancy

    6. Age and Fertility

    7. Age and IVF Success IVF success: Effect of age and number of eggs

    8. The aging Ovary (and testicle) • Decreased Ovarian Reserve (DOR) • Lower conception rates • Higher rates of pregnancy loss • Higher incidence of Congenital defects

    9. The Aging Ovary Menopausal ovary Normal ovary Fewer eggs Decreased egg quality

    10. A Practical Approach to the aging ovary • Aggressive Diagnosis and therapy • Expand Treatment options

    11. Diagnosis: The evaluation cycle • Baseline hormones • Ovulation profile • Imaging: HSG, Sono-HSG, MRI • Semen Analysis • Other: Genetic studies, immune workup etc

    12. Therapy-The aging ovaries • IVF • Pre-implantation Genetics (PGD) • Egg Donation • Egg Freezing/Ovarian tissue freezing

    13. In Vitro Fertilization and Embryo Transfer (IVF-ET)

    14. IVF • Intra-cytoplasmic Sperm injection (ICSI) • Assisted zona Hatching (AZH) • Day 4-5 transfer and improved culture media • Cryopreservation of embryos

    15. ICSI • Poor sperm quality • Zona Pellucida hardening • Poor egg-sperm interaction

    16. Assisted Zona Hatching (AZH) Zona Hardening Improved Implantation

    17. Improvements in culture conditions- Blastocyst transfer

    18. PGD • Micromanipulation: remove a single blastomere from an 8-cell embryo without damaging the embryo • Genetic testing • FISH • PCR

    19. PGD: Fluorescent In Situ Hybridization (FISH)

    20. PGD- Indications • Chromosomal disorders • Single gene defects (CF, Thalassemia, Sickle cell disease) • Recurrent pregnancy loss • Repeat IVF failures • Severe male factor

    21. How is PGD performed? Ovarian Stimulation IVF Blastomere Biopsy on Day 3 Transfer of Unaffected Embryo Genetic Analysis Outcome Chromosomally Normal Baby

    22. PDG- Clinical outcomes • Identify normal embryos • Fewer embryos to transfer • Know when not to transfer • Reduce pregnancy loss and anomalies

    23. Third Party Reproduction • Egg donation • Embryo donation • Gestational surrogacy

    24. Ovarian Failure. Poor egg quality. Recurrent IVF failure. Recurrent pregnancy loss Genetic defects precluding normal pregnancy. Egg Donation: Indications

    25. The Egg Donation Process • The process involves IVF. • The resulting offspring will carry genetic material of the donor and the male partner.

    26. 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.

    27. 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

    28. Egg Donation: The donors • Donor recruitment: Who are the donors? • Donor Screening: How are they tested? • Donor matching: How do I pick a donor?

    29. Egg Donation: The recipient couple • Medical Screening • The Mock cycle • Psychological issues • Legal Issues • Ethical concerns: Disclosure

    30. Cryopreservation of embryos, eggs and ovarian tissue

    31. 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

    32. Egg Freezing-Applications • Ovarian malignancies • Ovarian surgery • Aging • Egg banks

    33. 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

    34. 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

    35. Summary • Technology is developing rapidly • Ovarian aging is a major factor • ART is limited but can offer help for the aging ovary.

    36. However • Don’t Delay. • Discuss all options early. • Consult or refer if needed.

    37. 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.

    38. Return to referring MDDelay in referral

    39. Return to referring MDLength of clomid therapy by PMD

    40. A Team Approach • The primary caregiver • The infertility specialist • Physician • Nurse/midwife/NP • Laboratory • Emotional counseling and support

    41. We would like to thank our sponsor: • Organon

    42. Thank you for coming. Gad Lavy, M.D. F.A.C.O.G. New England Fertility Institute Lifeline Cryogenics