Preparation for IVF.ppt

1、Preparation for IVF,Ian Cooke Emeritus Professor University of Sheffield Director of Education International Federation of Fertility Societies,Precongress seminars XI International conference of RAHR “Reproductive technologies today and tomorrow” September, 10-12, 2009 Irkutsk, Siberia,Preparation f

2、or IVF, Of the patients Of staff and facilities Of organisation Review of U.K. infertility Guideline algorithm (2004, but valid) Emphasis on process leading to IVF,U.K. National Guideline developed by a multidisciplinary group: Stages 1. Process published 2. Draft formulated 3. Professional consulta

3、tion with interested bodies 4.Modification 5. Final publication,Background,The Guideline was produced for the NHS because of the wide variation in and limited access to NHS treatment. It covered a new review of the research evidence. The National Institute for Clinical Excellence (NICE) Guideline wa

4、s “to offer best practice advice on the care of people in the reproductive age group who perceive that they have problems in conceiving” (Feb.2004) Based on the Management of Infertility (RCOG,1998-2000) : initial (primary) investigation and management, management in secondary care and management in

5、 tertiary care. The full Guideline (CG11, 500pp. with refs) “Fertility assessment and treatment for people with fertility problems” is available (as a 1.21Mb file) at: .uk/guidance/index.jsp?action=download no thyroid function tests unless symptoms of thyroid deficiency No endometr

6、ial biopsy,Irregular ovulation,WHO Group I - gonadotrophins with LH activity - pulsatile LH WHO Group II - mainly PCOS Clomiphene - if anovulatory on clomiphene, hMG or uFSH or rFSH with ultrasound monitoring Hyperprolactinaemia -bromocriptine,Tests for tubal occlusion,Semen analysis and ovulation d

7、ata should be known Screen for Chlamydia trachomatis before uterine examination or prophylactic antibiotics HSG or Hysterosalpingo-contrast-ultrasonography if no history of endometriosis or pelvic inflammatory disease or ectopic Laparoscopy and dye if history of co-morbidity,Female,Consider: If occl

8、usion, - IVF - tubal surgery if mild disease - tubal catheterisation or cannulation if proximal occlusion If minimal/mild endometriosis - Surgical ablation or resection and adhesiolysis at laparoscopy - If no pregnancy - Stimulated IUI for 6 cycles with ultrasound monitoring with risk of OHSS and mu

9、ltiple pregnancy If moderate/severe endometriosis - surgery Endometriomas - laparoscopic surgery,Unexplained infertility,If normal: Unexplained infertility (normal semen analysis, no ovulation disorders, no tubal occlusion) clomiphene citrate unstimulated intrauterine insemination (IUI) Fallopian tu

10、be sperm perfusion,Factors affecting outcome of IVF,Salpingectomy before IVF for women with hydrosalpinges Optimal age 23-39 years Increased success with previous pregnancy and/or live birth Ideal Body Mass Index is 19-30 Increased success with low alcohol/caffeine intake Increased success in non-sm

11、okers Consistent outcome for first 3 cycles of treatment, effectiveness after 3 cycles is uncertain,IVF,If no pregnancy with oligozoospermia, bilateral tubal occlusion or 3 years infertility and the woman is aged 23-39 years: offer up to 3 cycles of IVF Additional principles of care: Access to evide

12、nce-based information (verbal and written) on risks/implications of assisted conception, including health of resulting children; genetic counselling; consideration of welfare of the child,Procedures in IVF treatment - 1,Offer screening - HIV, hepatitis B, C, specialist referral if positive Ovulatory

13、 stimulation - No natural cycle - GnRH agonist down regulation or agonist with gonadotrophins to reduce cost - No antagonists, no Growth hormone - Monitor follicular development with ultrasound: have a protocol to manage OHSS - Oocyte maturation with hCG - Oocyte retrieval: offer conscious sedation

14、- No follicle flushing, no assisted hatching,Procedures in IVF treatment - 2,Embryo transfer - Not 2 transferred in any one cycle - Offer cryostorage if 2 embryos - Frozen embryos to be transferred before further stimulated cycle - Ultrasound guided embryo transfer on day 2 or 3, or day 5 or 6 Lutea

15、l support - progesterone,Management options with IVF or other forms of ART - 1,ICSI - Severe semen defects, azoospermia - Poor IVF treatment response - Screen by karyotype Donor insemination - Azoospermia - Genetic disease in male partner - Severe rhesus isoimmunisation - Severe semen defects For fe

16、male: - Confirm ovulation, HSG if no pregnancy after 3 cycles,Management options with IVF or other forms of ART - 2,Oocyte donation - Premature ovarian failure - Gonadal dysgenesis including Turner syndrome - Bilateral oophorectomy - Ovarian failure following chemo- or radio-therapy - Some cases of

17、IVF treatment failure - Gene disorder transmission to offspring - Screen donors - Risks of ovarian stimulation and egg collection Egg sharing - counselling,Assessing tubal occlusion and uterine abnormalities,Screen for Chlamydia before uterine instrumentation B (A key priority) If positive, treat an

18、d refer the sexual partner for screening C Consider prophylactic antibiotics before uterine instrumentation if not screened GPP If no co-morbidities (pelvic inflammatory disease, previous ectopic, endometriosis) offer HSG (hysterosalpingogram or hysterosalpingo-contrast-sonography A) to screen for t

19、ubal occlusion B (A key priority) If co-morbidities, offer laparoscopy B Hysteroscopy should be clinically indicated and not used routinely. Treatment of uterine anomalies is not clearly linked to fertility B Do not use routine post-coital testing of cervical mucus as it has no predictive value for

20、pregnancy rate A,Key priorities in infertility management (3/6) before IVF,Intrauterine insemination,Mild male factor, unexplained infertility and mild to moderate endometriosis should have 6 cycles of IUI A (A key priority) It should be unstimulated IUI in male factor and unexplained infertility A Use stimulated IUI for mild to moderate endometriosis A Use single insemination (A) and Fallopian tube perfusion A,Standards of Care (BFS/RCOG),BFS/RCOG Standards of Care Summary,And so on through secondary and tertiary care; als