The basics of In Vitro Fertilization. Presented by Molina Dayal, MD of the Sher Institute for Reproductive Medicine

1. In Vitro Fertilization:
the basics….
Molina B. Dayal, MD
Medical Director
Sher Institute for Reproductive Medicine, St. Louis

2. All Couples
1 in 8 Couples
Age 30-34
1 in 6 Couples
Age 35-39
1 in 4 Couples
Age 40-44
1 in 2 Couples

3.  Inability to conceive after one year’s worth
of regular unprotected intercourse:
Can this be applied to everyone?
Age.
Ovulatory status.
Known tubal or male issues.

4. Infertility --- Basic Statistics
 20-25% couples conceive/month in 1st
year
 85% of couples will have conceived in one year
 Those 15% who did not conceive will have a monthly
chance of conception of 2-3%/month
 2-3%/month is achieved after just 6 months if the
woman is 35 years old or older

5. Causes of infertility
• Ovulatory Factor
• Egg Factor
• Tubal Factor
• Uterine Factor
Sperm Quality
50%
10%
40%
Unknown
Immunologic

6.  Assessment of ovulation
 Ovarian reserve screening
 Assessment of pelvic anatomy
(Hysterosalpingogram (HSG))
 Semen Analysis
 Immunologic

7. What should be done with the
information?

8. Cause of
Infertility
• Ovulatory Factor
• Decreased Ovarian Reserve
• Tubal Blockage
Or Abnormality
Treatment
• Ovulation Induction
• Clomid, etc
• IVF
• ?Egg donor
• IVF
• Surgery very unlikely to be
successful

9. Cause of
Infertility
• Mild Male Factor
• Moderate to
Severe Male Factor
• Uterine Factor
Treatment
• Fertility Meds +
IUI
• IVF (ICSI)
• Surgery

10. Cause of
Infertility
• Unexplained
• Immunologic
Treatment
•Fertility Meds + IUI
•IVF

11. A few words about
Intrauterine Insemination (IUI)

12. Overall IUI Success Rates
15% for women under the age of 30,
12% for women ages 30 to 35,
7% to 8% for women ages 35 to 39
< 2% for women over the age of 40.

13. Clomid with IUI
 Success rate dependent on age of female and
sperm quality of male
 <35 years old ---- 10%
 35-40 years old ---- 5%
 >40 years old ---- <2%
 Unfortunately, Clomid can have a negative impact
on uterine lining (therefore approx ½ chance of
success compared to overall chance with IUI)

14. Unexplained Infertility: Intrauterine
Insemination
Study Likelihood of Pregnancy
per Month
IUI vs. No treatment 4% vs. 3%
Clomid alone vs. No treatment 3% vs. 3%
Clomid + IUI vs. No treatment 8% vs. 3%
FSH inj + IUI vs No treatment 12% vs. 3%

15. Intrauterine Insemination (IUI)

16. IVF is oftentimes thought of as a ‘last resort’
but it shouldn’t be….

17. IVF should be considered as the
FIRST line treatment if….
Male factor (abnormal semen analysis)
Tubal factor (blocked or diseased fallopian
tubes)
Advanced maternal age
Pre-implantation genetic diagnosis/cGH
testing

18. IVF should be considered as the
FIRST line treatment if….
Pre-implantation genetic diagnosis (single
gene disorders/disease carrier states)
Protracted infertility
Immunologic Implantation Dysfunction
Need for gestational carrier
Fertility Preservation

19. What is IVF?
 It is the fertilization of eggs with
sperm/generation of embryos outside the body
 Multi-step process
 Medications (“protocols”) for patients are
individualized to optimize outcome

20. IVF: Manipulation of Normal
Physiology
FSH
E2

21. Deprogramming
 Birth control pill
 Lupron
 Ganirelix
 De-programs hypothalamic/pituitary axis.
 Prevents ovulatory/LH surge.

22. Stimulation of Follicles
Using FSH (follicle stimulating hormone) to stimulate follicles

23. Ultrasound Guided Oocyte
Retrieval

24. The Fertilization Procedure
Intracytoplasmic Sperm Injection
(ICSI)

25. Fertilization Check

26. Embryos at the Blastocyst Stage

27. Embryo transfer

28. Solving the Embryo Selection Dilemma
Blastocyst transfer
cGH testing

29. Embryo Selection Dilemma
Issues related to the transfer of early cleavage stage (day 3)
embryos
- Which is normal?
Morphology scoring:
Cleavage rate.
Blastomere symmetry.
Degree of fragmentation.

30. Embryo Aneuploidy
≥40/normal appearance 67%
≥40/abnormal appearance 70%
Munne et al, Fertil Steril. 1995.
Chromosomal abnormality rates in embryos increase with maternal age
even if the embryos appear normal
Age/Embryo Type (on day 3):
Rate of Chromosome
Abnormalities:

31. Why a blastocyst transfer?
 Depending on maternal age, the majority of
blastocysts are chromosomally normal.
 More efficient (less risk of high order multiple
pregnancies).
 More physiologic.

32. Why cGH?
 While the majority of blastocysts are normal in
younger women, this does not hold entirely true
in older women.
 Able to screen embryos, with high accuracy, for
chromosomal abnormalities (Down Syndrome,
etc) before an embryo transfer is performed.

33. Testing for Aneuploidy/Single Gene
Disorders:The Embryo Biopsy

34. Following Embryo Biopsy
Report generated indicating findings from genetic
analysis.
Patient and physician decide how many and which
embryos to transfer.
Normal embryos are transferred/stored for later
use while abnormal ones are disposed.

35. Additional Advantages of IVF
Assessment of ovarian reserve.
Assessment of fertilization.
Control number of embryos placed in
uterus.
Ability to freeze/store embryos for later
use.

36. Take Away Points
 Seek evaluation from a fertility specialist after one year of
infertility (or sooner if the woman >35 years old, has
irregular cycles or there is a known male factor)
 Consider fertility medications + IUI in cases of unexplained
infertility, limiting treatment to no more than 3 attempts
 Consider IVF as first line treatment when ovarian reserve
is of concern, tubal disease/blockage and male factor are
present, multiple IUI’s have failed, if an immunologic
implantation issue is discovered, or you are interested in
cGH testing.

37. Thank you!