Assisted Reproductive Technology

00:00 Let's now talk about intrauterine insemination. I talked about some of the options. We can actually put sperm in a catheter and place it directly into the uterus. This is a sort of giving the sperm an elevator ride closer to the tubes so they have less distance to swim. I mentioned IVF or in vitro fertilization. Here, you see one ultrasound of a normal ovary. You can see the vessel is right below the ovary in this picture. What we do is we give patients ovulation induction agents specifically gonadotropins that cause them to superovulate. This causes their ovary to enlarge and they make more follicles than they normally would. You see the other image shows a very stimulated ovary. I'd like to go over the process of an IVF retrieval. This is something we do in the outpatient setting with local sedation. Usually in our operating room where we performed this, we have a suction pump, is connected to a collection tube and a needle aspirates the fluid containing the oocyte and that goes into the collection tube and this is then passed to the lab for them to look for oocytes. This is what a retrieved oocyte looks like. This is a metaphase II oocyte and it's surrounded by a beautiful display of the corona radiata. These are specialized granulosa cells that are actually attached to a mature oocyte. This is typically what will be ovulated at the time of ovulation. If a patient has a partner who has a decreased motility found upon his semen analysis, then sometimes intracytoplasmic sperm injection is another way to cause fertilization. Patients who've had repeated IVF failures can also utilize this method of insemination.

01:57 This is in contrast to traditional IVF where we add 1 egg to 50,000 sperm per mL. Usually, 1 sperm will inseminate an egg if they're motile. If they cannot move, they cannot swim to the egg and therefore intracytoplasmic sperm injection is an alternative. Again, you can see here we take 1 sperm, we immobilize it, and we inject it into the egg being careful to stay away from the mitotic spindle of the oocyte. Once fertilization occurs either with IVF or ICSI, you actually make an embryo or a zygote. This is a 2PN stage embryo. It has 1 pronucleus from the mom and 1 pronucleus from the father. Fertilization is usually confirmed with extrusion of the second polar body. Let's look at embryo development. We start out as a 2-stage embryo. When then progressed to an 8-cell stage. We then become a blastocyst. A blastocyst is what invades the endometrial lining. You can see here that this blastocyst has a tightly compacted ball of cells called the inner cell mass which will become the fetus proper. The cells surrounding the blastocyst will become the placenta. They are called the trophectoderm. When a blastocyst hatches from the zona pellucida, this is what it looks like. We all hatch, even humans. Once we've made an embryo via IVF or ICSI, then we transfer it back to the intended mother. In the past, we did this based on age and prognosis. However, there are newer guidelines that we should only transfer a single embryo that is euploid. Euploidy is established through a process called preimplantation genetic screening.

03:54 I'll talk about that later. There are certain drawbacks to IVF. One of which is ovarian hyperstimulation syndrome. This occurs in 1 to 2% of the population. Ovarian hyperstimulation syndrome can lead to PE, DVT, and pleural effusions and ascites. It can be very worrisome for the patient and potentially can get worse with the pregnancy until the placenta takes over at about 7 weeks.

04:25 There is also an increased risk of surgery due to damage that's caused by IVF. It's only a 1 in 1000 risk but it's not zero. Higher order multiples are another complication of IVF. You can have twins, triplets, quads, or even more. In those cases, patients are at risk for preterm rupture of membranes, preterm labor, and preterm delivery. That has an effect on the child, the parents, and society. Let's now talk about gamete donation. About 10% of all IVF cycles in the US use a donor egg. In the past, we used fresh egg donation. That is a young woman will be reimbursed for donating her eggs. We would take the fresh eggs, inseminate them with the male partner sperm or donor sperm and then transfer them to the intended mother or gestational carrier.

05:27 However, we now have egg banks where young women can donate their eggs and be reimbursed and those eggs are then cryopreserved. We'll talk about that later on in the presentation as well.

05:39 You can also obtain donor sperm from sperm banks. Let's talk about gestational carriers and surrogates. In some countries just as an egg donation, this is outlawed but in the US it is permitted. A gestational carrier essentially just carries the baby for 9 months and then gives the child back to the intended parents. They are not genetically related to the fetus and they are reimbursed about $30,000 to 40,000 per pregnancy. They usually have had to have 1 natural delivery on their own already. A little contract will exist between intended parents and the carrier. I briefly mentioned PGD or PGS earlier in the lecture. This can refer to preimplantation genetic testing such as the case of inherited disorders such as sickle cell or cystic fibrosis or screening. Screening means we look at the karyotype of the individual embryo before we transfer it back. We have to do this on a blastocyst so that we can obtain enough cellular tissue to actually perform an analysis. Here you'll see a normal blastocyst. In the next window, you'll see a trophectoderm cell being sucked in to a suction pipette that will then be put in lysis buffer and process to do PGD or PGS. Also, at mini IVF centers, we offer oocyte cryopreservation. This occurs after an oocyte retrieval. You can see here there are 3 oocytes. One is very immature and is a germinal vesicle. That's typically what we see in the ovary before it's recruited. In the middle, we have a metaphase I oocyte. That's an immature oocyte. Both the GV and the M1 cannot be used and they are discarded or used for research. Here, the 3rd panel shows a metaphase II or M2 oocyte with a polar body. This is a mature oocyte that is ready for fertilization. We typically freeze an M2 oocyte in women who are about to undergo chemotherapy for cancer or women who just wish to preserve their fertility although there are some controversy about whether this is actually effective in an older woman. This used to be experimental but is no longer since ASRM came out with a guideline that says that we can offer patients this. Thank you for listening and good luck on your exam.