This document provides an overview of recent advancements in infertility management. It begins with definitions of infertility and its types. It then discusses various causes of female infertility including age, smoking, STIs, weight, chemotherapy, genetic factors, and issues with the fallopian tubes, uterus, cervix, and vagina. Tests for infertility and treatment options like laparoscopy, medication, and assisted reproductive technologies are also outlined. Specific ART procedures described in detail include IUI, IVF, GIFT, ZIFT, ICSI, and ovary transplants.

1. Topic presentation ON :-RECENT ADVANCEMENT IN
INFERTILITY MANAGEMENT
• PRESENTED BY
• Lalita Sharma
• MSC (N) FIRST YEAR

2. RECENT ADVANCEMENT IN
INFERTILITY MANAGEMENT

3. introduction
• The definition also includes
women who are unable to carry
pregnancy to live birth. There
are two general types of
infertility.
• Primary
• Secondary

4. INFERTILITY
• DEFINITION: Infertility is
medically define as the
inability to conceive
following one year regular
sexual intercourse without
contraception or after six
month if the women is
over age 35.

5. DEFINITION
• “Failure to achieve a clinical pregnancy after 12 months
or more of regular unprotected sexual intercourse.”…
(WHO)
• “Failure to achieve a successful pregnancy after 12
months or more of appropriate timed unprotected
intercourse or therapeutic donor insemination and after
6 months for women over 35 years of age”….ASRM
(American Society for Reproductive Medicine )

6. IT IS TWO TYPES
• It is define as difficulty
conceiving for a couple who
has never before had a child.
Primary
infertility:-
• Describe a couple who is
having difficulty conceiving
when at least one of the
partners has previously had a
baby.
Secondary
infertility:-

7. Incidence
• Generally worldwide it is estimated that one in
seven couples have problems in conceiving.
• In India most of these cases women is the
factor.
• Fertility problems affect one in seven couples
in United Kingdom

8. types
• In primary infertility,
pregnancy has never
occurred.
• In secondary infertility,
one or both members
of the couple have
previously conceived,
but are unable to
conceive again after a
full year of time.

9. CAUSES OF
FEMALE
INFERTITY:-

10. Acquired
According to the American Society for Reproductive
Medicine (ASRM),
•Age
• Smoking,
• Sexually Transmitted Infections, and
• Being Overweight or Underweight
can all affect fertility.

11. CONTI…..
In broad sense, acquired factors practically include
any factor that is not based on a genetic mutation,
including any intrauterine exposure to toxins during
fetal development, which may present as infertility
many years later as an adult

12. AGE
• A woman's fertility is affected by her age.
• The average age of a girl's first period (menarche) is
12-13 but, in postmenarchal girls, about 80% of the
cycles are anovulatory in the first year after menarche,
50% in the third and 10% in the sixth year.
• A woman's fertility peaks in the early and mid 20s,
after which it starts to decline, with this decline being
accelerated after age 35.

13. •Tobacco smoking:-
• Tobacco smoking is harmful to the ovaries.
•Nicotine and other harmful chemicals in cigarettes interfere
with the body’s ability to create estrogen.
• Also, cigarette smoking interferes with
folliculogenesis,
embryo transport,
 endometrial receptivity,
endometrial angiogenesis,
 uterine blood flow and
the uterine myometrium.

14. •Sexually transmitted infections
•Sexually transmitted infections are a
leading cause of infertility.
• They often display few, if any visible
symptoms, with the risk of failing to seek
proper treatment in time to prevent
decreased fertility.

15. Body weight and eating disorders
•12% of all infertility cases are a result of a woman either
being underweight or overweight.
• Fat cells produce estrogen, in addition to the primary sex organs.
•Too much body fat causes production of too much estrogen
•And the body begins to react as if it is on birth control, limiting the
odds of getting pregnant.

16. Chemotherapy:-
•Chemotherapy poses a high risk of infertility.
•Chemotherapies with high risk of infertility include
procarbazine and other alkylating drugs such as
cyclophosphamide, ifosfamide, busulfan, melphalan,
chlorambucil and chlormethine.
•Drugs with medium risk include doxorubicin and
platinum analogs such as cisplatin and carboplatin.
•Female infertility by chemotherapy appears to be
secondary to premature ovarian failure by loss
of primordial follicles.

17. Other acquired factors:-
Diabetes mellitus
Coeliac disease
Significant liver or kidney disease
Thrombophilia
Cannabis Smoking, such as of marijuana causes disturbances in
the endocannabinoid system, potentially causing infertility.
Radiation, such as in radiation therapy.

18. Genetic factors:-
There are many genes wherein mutation causes female
infertility .Also, there are additional conditions
involving female infertility which are believed to be
genetic but where no single gene has been found to be
responsible, notably Mayer-Rokitansky-Küstner-
Hauser Syndrome (MRKH).
Hypothalamic-pituitary factors
•Hypothalamic dysfunction
•Hyperprolactinemia

19. •Premature menopause
•Menopause
•Luteal dysfunction
•Gonadal dysgenesis (Turner
syndrome)
•Ovarian cancer

20. Tubal (ectopic)/peritoneal factors:-
•Endometriosis
•Pelvic adhesions
•Pelvic inflammatory disease (PID, usually due
to chlamydia)
•Tubal occlusion
•Tubal dysfunction
•Previous ectopic pregnancy.

21. Uterine factors:-
•Uterine malformations
•Uterine fibroids
•Asherman's Syndrome
•Implantation failure without any known
primary cause. It results in negative
pregnancy test despite having performed
e.g. embryo transfer.

22. Cervical factors:-
•Cervical stenosis
•Antisperm antibodies
•Non-receptive cervical mucus
Vaginal factors
•Vaginismus
•Vaginal obstruction

23. CAUSES OF FEMALE
INFERTILITY
There are a number of things that may be keeping
away a women from getting pregnant
•Damage to fallopian tubes
•Hormonal problems
•Cervical issues
•Uterine trouble
•"Unexplained" infertility

24. Tests for Infertility:-
• It includes a blood test to check hormone
levels and an endometrial biopsy to examine
the lining of your uterus.
• Hysterosalpingography (HSG)
• Laparoscopy:-

25. Infertility Treatment:-
•Laparoscopy.:- If patient been diagnosed with tubal or
pelvic disease, one option is to get surgery to reconstruct
her reproductive organs. Doctor puts a laparoscope
through a cut near her belly button to get rid of scar tissue,
treat endometriosis, open blocked tubes, or
remove ovarian cysts, which are fluid-filled sacs that can
form in the ovaries.
•Hysteroscopy :-. In this procedure, the doctor places a
hysteroscope into her uterus through her cervix. It's used
to remove polyps and fibroid tumors, divide scar tissue,
and open up blocked tubes.

26. Medication:-
If client have ovulation problems, doctors may be prescribed
drugs such
•Clomiphene citrate (Clomid, Serophene)
•Gonadotropins (such as Gonal-f,
Follistim, Humegon and Pregnyl),
•or letrozole.
•Metformin (Glucophage

27. ART PROCEDURE:-
• Intrauterine insemination
• In vitro fertilization
• Gamete intra-fallopian
transfer
• Zygote intra-fallopian transfer
• Intracytoplasmic sperm
injection
• Cryopreservation
• Sub zonal insemination
• Microsurgical epididymal
sperm- testicular aspiration
and biopsy
• Ovum donation
• Surrogacy and post humas
reproduction

28. DEFINITION
• ART includes all fertility treatments in which both eggs
and sperm are handled.
• In general, ART procedures involve surgically removing
eggs from a woman’s ovaries, combining them with sperm
in the laboratory, and returning them to the woman’s
body or donating them to another woman.
• They do not include treatments in which only sperm are
handled (i.e., intrauterine—or artificial—insemination) or
procedures in which a woman takes medicine only to
stimulate egg production without the intention of having
eggs retrieved.

29. 1.Intrauterine insemination:
• Intrauterine
insemination (IUI)
involves a laboratory
procedure to separate
fast moving sperm from
more sluggish or non-
moving sperm.

30. INDICATION:-
• there is unexplained
infertility
• there are ovulation
problems
• the male partner
experiences impotence or
premature ejaculation
• Women do not have any
known fertility problems
but may not have a male
partner and are trying for a
baby using donated sperm.

31. CONTI:-
• The procedure
• For women
• for men

32. PROCEDURE:-
• If women use fertility drugs to stimulate ovulation,
vaginal ultrasound scans are used to track the
development of eggs.
• As soon as an egg is mature, given a hormone
injection to stimulate its release.
• The sperm will be inserted 36–40 hours later. The
doctor will first insert a speculum into vagina, as in a
smear test, to keep vaginal walls apart.
• A small catheter (a soft, flexible tube) will then be
threaded into womb via cervix. The best-quality
sperm will be selected and inserted through the
catheter.

33. CONTI:-
• The whole process only takes a few minutes
and is usually painless. Some women may
experience a temporary, menstrual-like
cramping.
• Women may want to rest for a short time
before going home.

34. For men:
• Men will be asked to produce a sperm sample on
the day the treatment takes place.
• The sperm will be washed to remove the fluid
surrounding them and the rapidly moving sperm
will be separated out from the slower sperm.
• The rapidly moving sperm will be placed in a
small catheter to be inserted into the womb.
• If men are using donated or frozen sperm, it will
be removed from frozen storage, thawed and
prepared in the same way.

35. 2.IN VITRO FERTILIZATION
• Definition:-
• Retrieval of eggs from
ovaries
• Addition of sperm in lab
dish to make
fertilization.
• Transformation to
mother uterus.

36. Indications of invitrofertilization
Idiopathic causes:-
• Female causes-
• Problem of fallopian tubes
obstruction, or
salpingectomy due to
ectopic pregnancy, or
hydrosalpinx.
• Endometriosis
• Ovulation problem
• Antibodies that effects
both eggs and sperms

37. MALE CAUSES
• Defects in sperm
quantity and or quality.
• In-ability of the sperm
to penetrate the
cervical mucus.
• No sperm seen in the
semen fluid.

38. procedure:-
• Genetics diagnosis:-
Pre-implantation genetics
diagnosis to rule out
genetic disorders

39. Steps
First step
• Ovarian follicle
• Transvaginal US
• Blood test
• Seminal fluid
• Fallopian tube
• US scan uterus
• US scan- ovaries

40. Second step:- ovulation induction
• Producing many good follicles
to be fertilized.
• Short or long protocols: is
done daily injection of
gonadotropins.
• Regular monitoring by
ultrasound scan is done.
• Following the follicular
development and adjust the
dose of the injection
accordingly.
• After reaching certain size,
the final maturation of those
follicles is done by giving HCG.

41. Third Step: Egg Retrieval (oocytes)

42. PROCEDURE
• Egg retrieval is done 34 to 37 hours post HCG injection.
• This procedure is considered as minor surgery.
• It is done under the general anesthesia, using
ultrasound guide.
• It takes 15 to 20 minutes. Not more than two hours are
required for the patient to recover.
• Then , the patient can leave the hospital. A needle is
used to aspirate all follicles.
• The fluid is passed over to the embryologist, who
identifies and separates the eggs

43. Fourth step: spermand egg donation
• The eggs are prepared and stripped from the surrounding
cells.
• At the same time. Sperm preparation is done using a
special media.
• We need from 10,000- 100,000 motile sperm to be put
beside each in a special dish, this is called traditional I.V.F.
• It is different from intracytoplasmic sperm injection (ICSI),
in which we need only one sperm to be injected in the
cytoplasm of the egg).
• Which is indicated in case where sperm is present in the
testes but the semen fluid does not contain sperm.

44. Conti:-
Fifth steps :- fertilization
• After preparing the sperm, and the eggs are
put in the same dish, in cases of failed
fertilization we use ICSI procedure.

45. Conti:-
• Six step: Blastocyst day 5 embryo
• After 18 hours after the eggs. Called zygotes.
Are fertilized.
• They are cultured in special incubators to
support division and development.
• In this step. If the couple has a history of certain
genetics disease and the gene that is causing
that problem is identified, we may do pre-
implantation genetic diagnosis.
• Grading of the embryos is done using specific
criteria.

46. CONTI:-
Sevensteps:- embryotransfer
• The embryos are transferred into the uterus after 2 to 5
days from the date of pickup.
• Depending on the quality and quantity of the embryos.
• Using a special embryo transfer catheter.
• The patient is given drugs to help support the
implantation procedure
• There is no need for a lengthy hospital stay after the
embryo transfer procedure ( usually one hour is
sufficient).
• Residents of other countries can travel the next day if they
wish.

47. .GAMETE INTRA FALLOPIAN
TRANSFER
• Gamete intrafallopian
transfer (GIFT), GIFT is
an assisted reproductive
procedure which
involves removing a
woman’s eggs, mixing
them with sperm, and
immediately placing
them into a
fallopian tube.

48. INDICATION:-
• Couples with
unexplainable infertility
• Couples who have not had
success with IVF
• Couples who have a
religious or moral
reluctance to use IVF
• Women who have at least
one healthy fallopian tube
• Couples in which the
husband has a low sperm
count or other problems
with his sperm

49. 4.ZYGOTE INTRAFALLOPIAN
TRANSFER:-
• ZIFT is an assisted
reproductive procedure
similar to in vitro
fertilization and embryo
transfer, the difference
being that the fertilized
embryo is transferred
into the fallopian tube
instead of the uterus.

50. Indication:-
• Tubal blockage
• Significant tubal
damage
• An anatomic problem
with the uterus, such as
severe intrauterine
adhesions
• Sperm that are not able
to penetrate an egg

51. PROCEDURE
• Consents are signed by all parties.
• The woman is stimulated with medications to
develop multiple egg development.
• When the woman's follicles are mature, an aspiration
procedure is performed to remove the eggs from her
ovaries. The eggs are then fertilized in the laboratory
with her partner's sperm.
• The embryos are cultured in the laboratory for 1 day
for ZIFT and 2 days with TET. At that time, a tubal
transfer procedure (surgery with laparoscopy) is done
which places the embryos in the woman's fallopian
tubes.

52. Intracytoplasmic sperm
injection (ICSI) -
• The ICSI procedure
involves a single sperm
carefully injected into the
center of an egg using a
microneedle, Then the
embryo is transferred to
the uterus or Fallopian
tube. This method is also
sometimes employed
when donor sperm is
used.

53. Indications for ICSI:
• sperm cell agglutinates
availability
• azoospermia (in this case
sperm cells are taken
during testicular biopsy)
• unsatisfactory (absent)
fertilization of oocytes
during previous IVF (in
vitro fertilization)
attempts

54. ICSI methodology includes the
following stages:
• ICSI methodology
includes the following
stages:
• oocytes preparation
• sperm cells preparation
• sperm cell introduction
into oocyte cytoplasm
using a glass micro-
needle
• ICSI is performed only
with matured oocytes

55. 2.OVARY TRANSPLANTS
• The procedure involves
the removal of an ovary
which is frozen and
placed in storage until
required at a later date.
This ovary is then
thawed out slowly and
transplanted back into
the body.

56. Reasons for an ovary transplant
• Early menopause
• Cancer treatment
• Organ transplants

57. Ovary transplant procedure
• The ovary is removed via keyhole surgery which reduces
recovery time. The ovary is then frozen until further
notice.
• The ovary to be transplanted is thawed out slowly
beforehand. The transplant procedure is performed as
open surgery this time and involves reconnecting tiny
blood vessels to the ovary. This enables a steady blood
flow to the ovary which is vital for it to function.
• It will take a few months following surgery for the ovary
to be fully functional but evidence suggests that normal
hormone production occurs within 5 months or so.

58. CONTI:
• Another option is to transplant sections of
ovarian tissue rather than the complete ovary.
Some women have undergone surgery in which
strips of ovarian tissue have been transplanted
onto their defective ovary which then enables it
work again. And this has resulted in successful
pregnancies.
• During the surgery, the patient receives a graft
of ovarian tissue from the donor that is
transplanted to the same area where the ovaries
are.

59. 3. TESTICULAR SPERM
ASPIRATION/EXTRACTION (TESA/E)
• The testicular sperm aspiration/extraction
(TESA/E) involves the direct removal of
sperm from the testicles, which can then be
used in conjunction with Intracytoplasmic
sperm injection (ICSI).

60. 4.CRYOPRESERVATION
• This is a method of embryos, eggs, and sperm
preservation by freezing in liquid nitrogen.
• Cryopreservation can be performed as oocyte
cryopreservation before fertilization, or
as embryo cryopreservation after fertilization.

61. CONTI:-
• Embryo cryopreservation conditions:
• embryos are frozen only at zygote stage of 2,
4, and 8 cells and blastocysts
• Sperm receiving, freezing and preservation
stages:
• Cryopreservation and eggs preservation

62. 5.INTRODUCTION OF LONG ACTING
HORMONE
• The other recent
advances include the
introduction of long
acting hormone injections
which is effective for a
week as opposed to the
need for having daily
hormone injections
administered which has
very much simplified the
IVF process.

63. CONTI:-
• Gonadotropin Releasing Hormone (GnRH)
• GnRH stands for Gonadotropin Releasing
Hormone, which is a peptide ( a molecule
which consists of a chain of amino acids)
released by the hypothalamus. GnRH causes
the pituitary gland to release the
gonadotropin hormones, FSH ( follicle
stimulating hormone) and LH ( luteinising
hormone) .

64. Administration
• GnRH antagonists are administered by
either intramuscular injection (abarelix)
or subcutaneous injection (cetrorelix,
degarelix and ganirelix).

65. CONTI:-
• Human Chorionic Gonadotropin (HCG)
• When the ovarian follicles have reached a
certain degree of development, induction of
final oocyte maturation is performed,
generally by an injection of human chorionic
gonadotropin (HCG).

66. Assisted reproductive technology:-

67. DEFINITION
• Although various definitions have been used for ART, the
definition used by Centers for Disease Control and
Prevention CDC is based on the 1992 Fertility Clinic Success Rate
and Certification Act that requires CDC to publish the annual ART
Success Rates Report. According to this definition, ART includes all
fertility treatments in which both eggs and sperm are handled. In
general, ART procedures involve surgically removing eggs from a
woman’s ovaries, combining them with sperm in the laboratory,
and returning them to the woman’s body or donating them to
another woman. They do NOT include treatments in which only
sperm are handled (i.e., intrauterine—or artificial—insemination)
or procedures in which a woman takes medicine only to stimulate
egg production without the intention of having eggs retrieved.

68. 5.SUBZONAL INSEMINATION (SUZI),
• An older technique of m
icromanipulation used i
n cases of male factor in
fertility. Spermatozoa ar
e inserted into the periv
itelline space afterbreak
hing of the zona pelluci
da by mechanical or che
mical means. Also calle
d subzonal injection.

69. 6. MICROSURGICAL EPIDIDYMAL
SPERM- TESTICULAR ASPIRATION AND
BIOPSY :--
• MESA is a procedure to
harvest sperm from the
epididymis.

70. indication
• * Congenital Bilateral
Absence of the Vas
Deferens (CBAVD)
• *No vasa can be felt on
scrotal exam

71. Procedure:-
• Procedure:-
• After open up a little
tubule, aspirate the fluid
and will place it into a
special tube to send to
the IVF group for
processing and freezing
into multiple vials.
Usually, this is the only
procedure the male
partner ever needs
•

72. 7.Egg donation
• is the process by which a
woman donates eggs for
purposes of assisted
reproduction or biomedical
research. For assisted
reproduction purposes, egg
donation typically involves in
vitro fertilization technology,
with the eggs being fertilized
in laboratory; more rarely,
unfertilized eggs may be
frozen and stored for later use.
Egg donation is a third party
reproduction as part
of assisted reproductive
technology (ART).

73. Indication:-
• Congenital absence of
eggs
– Turner syndrome
– Gonadal dysgenesis
• Acquired reduced egg
quantity
– Oophorectomy
– Premature menopause
– Chemotherapy
– Radiation therapy
– Autoimmunity
– Advanced maternal age
– Compromised ovarian
reserve
• Other
– Diseases of X-Sex linkage
– Repetitive fertilization or
pregnancy failure
– Ovaries inaccessible
for egg retrieval

74. Process:-
• The process involves IVF. The resulting offspring will
carry genetic material of the donor and the male
partner
• Egg donation process fisrt:-
• 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.

75. Conti:-
• Egg donation process second:-
• Donor
• Synchronize cycle with recipient
• Ovarian stimulation
• Egg retrieval
• Recipient
• Synchronize cycle with donor
• Preparation of the uterus
• Fertilization
• Embryo transfer

76. Conti:-
• THE DONAR:-
• Donor recruitment: Who are the donors?
• Donor Screening: How are they tested?
• Donor matching: How do I pick a donor?
• SCREENING:-
• Donors
• Consultation
– MD/RN interview
• Psychological testing
– Interview
– Formal testing
• Blood tests
– Infectious disease
– Fertility potential: FSH follicle count

77. Procedure:-
• Egg donors are first recruited, screened, and give consent prior to
participation in the IVF process.
• Once the egg donor is recruited, she undergoes IVF stimulation
therapy, followed by the egg retrieval procedure.
• After retrieval, the ova are fertilized by the sperm of the male
partner (or sperm donor) in the laboratory, and, after several days,
the best resulting embryo(s) is/are placed in the uterus of the
recipient, whose uterine lining has been appropriately prepared
for embryo transfer before hand.
• The recipient is usually, but not always, the person who requested
the service and then will carry and deliver the pregnancy and keep
the baby.

78. 8.SURROGACY AND POSTHUMAS
REPRODUCTION:-
• A surrogacy arrangeme
nt or surrogacy
agreement is the
carrying of
a pregnancy for
intended parents.

79. Ethical issues
• ETHICAL ISSUES
• There are several ethical issues associated with infertility
and its treatment.
• High-cost treatments are out of financial reach for some
couples.
• Debate over whether health insurance companies (e.g. in
the US) should be required to cover infertility treatment.
• Allocation of medical resources that could be used
elsewhere
• The legal status of embryos fertilized in vitro and not
transferred in vivo.
• Pro-life opposition to the destruction of embryos not
transferred in vivo.

80. Conti:-
• IVF and other fertility treatments have resulted in an
increase in multiple births, provoking ethical analysis
because of the link between multiple
pregnancies, premature birth, and a host of health
problems.
• Religious leaders' opinions on fertility treatments.
• Infertility caused by DNA defects on the Y chromosome is
passed on from father to son. If natural selection is the
primary error correction mechanism that prevents
random mutations on the Y chromosome, then fertility
treatments for men with abnormal sperm (in
particular ICSI) only defer the underlying problem to the
next male generation.

81. LEGAL ASPECTS OF ASSISTED
REPRODUCTIVE TECHNOLOGY(ART)

82. Conti:-
• The Indian scenario in this field is quite
bleak. Delhi artificial insemination (Human)
Act 1995 is the only statutory act prevailing in
India . There is no internal regulatory body like
VLA in U.K, moreover Indian Infertility
specialist have rather opposed the steps
towards regulation of practice in this field.

83. Conti:-
1. Litigation against doctors
• a. Not taking proper informed consent
• b. Following the birth of a defective child
2. Legitimacy
3. Inheritance of property
4. Consummation of marriage