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”
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” • More aggressive diagnostic and therapeutic approach • ART • IVF • PGD • Egg donation • Freezing of embryos, eggs and ovarian tissue • Team approach to fertility therapy
Infertility Dx and Rx • Success in Diagnosis • Success in Therapy
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
Aging Population • Age at marriage • Age at first pregnancy
Age and IVF Success IVF success: Effect of age and number of eggs
The aging Ovary (and testicle) • Decreased Ovarian Reserve (DOR) • Lower conception rates • Higher rates of pregnancy loss • Higher incidence of Congenital defects
The Aging Ovary Menopausal ovary Normal ovary Fewer eggs Decreased egg quality
A Practical Approach to the aging ovary • Aggressive Diagnosis and therapy • Expand Treatment options
Diagnosis: The evaluation cycle • Baseline hormones • Ovulation profile • Imaging: HSG, Sono-HSG, MRI • Semen Analysis • Other: Genetic studies, immune workup etc
Therapy-The aging ovaries • IVF • Pre-implantation Genetics (PGD) • Egg Donation • Egg Freezing/Ovarian tissue freezing
IVF • Intra-cytoplasmic Sperm injection (ICSI) • Assisted zona Hatching (AZH) • Day 4-5 transfer and improved culture media • Cryopreservation of embryos
ICSI • Poor sperm quality • Zona Pellucida hardening • Poor egg-sperm interaction
Assisted Zona Hatching (AZH) Zona Hardening Improved Implantation
PGD • Micromanipulation: remove a single blastomere from an 8-cell embryo without damaging the embryo • Genetic testing • FISH • PCR
PGD- Indications • Chromosomal disorders • Single gene defects (CF, Thalassemia, Sickle cell disease) • Recurrent pregnancy loss • Repeat IVF failures • Severe male factor
How is PGD performed? Ovarian Stimulation IVF Blastomere Biopsy on Day 3 Transfer of Unaffected Embryo Genetic Analysis Outcome Chromosomally Normal Baby
PDG- Clinical outcomes • Identify normal embryos • Fewer embryos to transfer • Know when not to transfer • Reduce pregnancy loss and anomalies
Third Party Reproduction • Egg donation • Embryo donation • Gestational surrogacy
Ovarian Failure. Poor egg quality. Recurrent IVF failure. Recurrent pregnancy loss Genetic defects precluding normal pregnancy. Egg Donation: Indications
The Egg Donation Process • The process involves IVF. • The resulting offspring will carry genetic material of the donor and the male partner.
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.
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
Egg Donation: The donors • Donor recruitment: Who are the donors? • Donor Screening: How are they tested? • Donor matching: How do I pick a donor?
Egg Donation: The recipient couple • Medical Screening • The Mock cycle • Psychological issues • Legal Issues • Ethical concerns: Disclosure
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
Egg Freezing-Applications • Ovarian malignancies • Ovarian surgery • Aging • Egg banks
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
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
Summary • Technology is developing rapidly • Ovarian aging is a major factor • ART is limited but can offer help for the aging ovary.
However • Don’t Delay. • Discuss all options early. • Consult or refer if needed.
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.
A Team Approach • The primary caregiver • The infertility specialist • Physician • Nurse/midwife/NP • Laboratory • Emotional counseling and support
We would like to thank our sponsor: • Organon
Thank you for coming. Gad Lavy, M.D. F.A.C.O.G. New England Fertility Institute Lifeline Cryogenics