Adobe Systems Tvarožek S., Meixnerová I. Infertility 2020 Department of Gynecology and Obstetrics Brno University Hospital and Masaryk University, Faculty of Medicine head: doc. MUDr. Vít Weinberger, Ph.D Obstetrics and Gynecology - lectures Adobe Systems Infertility Infertility •Fertility – biological ability to conceive within 6–9 months • •Infertility – disability to concieve after 12 months of unprotected sex •15–20 % couples, rapidly growing incidence in last decades • •evaluation should begin after 6 months of trying unsuccessfully to conceive Adobe Systems Infertility Fertility – physiology •Ovulation •Oocyte migration •Sperm penetration •Fertilization •Embryo migration •Implantation in uterine cavity • Adobe Systems Infertility Infertility causes Male factor (40%) •Abnormal sperm production or function •undescent testicles, genetic defect, DM, infection, mumps •Sperm delivery problems •premature ejaculation, cystic fibrosis, blockage of testicles, damage/injury •Damage related to cancer treatment •radiation, chemotherapy •Immunological • an autoimmunity to own sperm • Adobe Systems Infertility Infertility causes Female factor (40%) •Uterine: polyps, shape abnormalities (septum...), fibroids •Tubal: blocking or damage (inflammation, endometriosis, adhesion) •Ovulatory: ovulation disorders, PCO, insufficiency,chemotherapy, hyperprolactinemia •Cervical: polyps, occlusion •Immunological: immunity to sperm, zona pellucida, ovary... Endometriosis: affect function of ovaries, uterus, fallopian tubes •Unexplained: not diagnoses by any known medical procedure Adobe Systems Infertility Age and fertility •Female fertility after 35 years of age decreases 3 times in comparison to women under 25 years of age • •Causes: ovarian dysfunction, endocrinologic factors, hypothalamic – pituitary factors, environmental changes Adobe Systems Infertility Diagnosis •Always both partners •Pacient/family history •Sexual habits (intercourse frequency) •Laboratory tests (hormones) •Genetic testing •Semen analysis •Ovulation testing (LH, P, prolactin) • Adobe Systems Infertility Diagnosis Adobe Systems Infertility Sperm analysis •Approximate concentration of total sperm cells: •1940 …………… 110 mil/ml •1990 …………… 60 mil/ml Adobe Systems t-267 Sperm Adobe Systems Infertility Semen deficiencies - nomenclature Normozoospermia normal result Oligozoospermia reduced concentration Asthenozoospermia reduced sperm motility Teratozoospermia abnormal morphology Azoospermie absence of spermatozoa (motile sperm cell) Aspermia complete lack of semen Adobe Systems Jméno předkládajícího proděkana s tituly Chromopertubation Adobe Systems normovar Normal ovary Adobe Systems listovar 1 Streak ovary (Turner sy.) Adobe Systems hypochemo Ovary after chemotherapy Adobe Systems ovar 2 Ovary after ovarian cyst removal Adobe Systems sacto Sactosalpinx Adobe Systems SONO HSG Adobe Systems SONO HSG - fimbriae Adobe Systems Infertility Assisted reproduction •medical procedures used primarily to address infertility •any procedure that involves the handling of eggs, sperm, or both, outside the human body •includes artificial insemination, intrauterine insemination, in vitro fertilization, and ovarian stimulation • Adobe Systems Infertility Assisted reproduction methods •Ovulation induction (stimulation) •Artificial insemination (IUI) – introduction of sperm into uterus •In-vitro fertilisation (IVF) •Preimplantation genetic diagnosis (PGD) •Donor conception •Surrogacy • Adobe Systems Infertility In vitro fertilisation •A process of fertilisation outside the body (in vitro/glass) •Monitoring and stimulating a woman‘s ovulatory process •Retrieving oocytes from ovaries •Sperm and oocytes placed in a liquid culture to fertilise •Embryo culture – embryo is growing in an artificial medium •Embryo transfer/frozen embryo transfer (to a uterus) Adobe Systems Infertility Ovulation induction (stimulation) •Woman is not ovulating or not ovulating regularly •Taking a hormone medication to stimulate ovulation •Response to hormones is monitored with US •Timing of intercourse •At the beginning of every IVF cycle •Th: clomifen citrate, FSH, hCG..... •monitored by US folliculometry folikulometrie Adobe Systems Infertility Oocyte retrieval/egg collection •transvaginal oocyte retrieval •removing oocytes from the ovary in order to enable fertilisation or to egg freezing (cryopreservation) punkce Adobe Systems Infertility Sperm retrieval techniques Microsurgical method of sperm extraction MESA, TESE Obstructive azoospermia •microsurgical epididymal sperm aspiration – MESA Non obstructive azoospermia •testicular sperm extraction – TESE • Adobe Systems Infertility Microsurgical epididymal sperm aspiration – MESA •in case of oclusion between epididymis and urethra •via 3 cm long scrotal incision, under general anesthesia •liquid is aspired from the ducts by pipette Adobe Systems MESA OBR4 OBR5 Adobe Systems Infertility Testicular sperm extraction – TESE •in case of no sperm was retrieved from MESA technique •It allows for extracting sperm cells (if they are present) from the ducts of the germinal epithelium •follows the previous MESA procedure •small incisions are made in the testicular sheets •a little of the testicular tissue is retrieved Adobe Systems MESA/TESE Adobe Systems Infertility In vitro fertilisation – advanced techniques •Intracytoplasmic sperm injection (ICSI) •direct injection of a single sperm into each oocyte •Preselected Intracytoplasmic sperm injection (PICSI) •transferring specially selected sperm •Sperm exhibits positive binding to hyaluronan gel •Hyaluronan is an important component of oocyt layer • Adobe Systems Infertility In vitro fertilisation – advanced techniques •Magnetic activated cell sorting (MACS) •selecting damaged spermatozoas with higher number of fragmented DNA •Assisted Hatching (AH) •Embryo is surrounded by a hard layer of cell – zona pellucida •Creating small crack in the zona pelludica •AH help an embryo implant in the uterus Adobe Systems Zygote 8-cell embryo after 72-hour-long cultivation Adobe Systems Blastocyst ICSI BLASTOC2 icsi Adobe Systems Micromanipulation pipettes ICSI Adobe Systems Sperm selection – hyaluronan acid binding for PICSI PICSIuprav Obr2 Adobe Systems Assisted hatching (AH) asisthatch Adobe Systems Pre-implantation diagnosis (PGD) pgd1 •the genetic profiling of embryos prior to implantation •sampling on single cell taken from developing embryo •usually takes place on the 5th day of the embryo’s development Adobe Systems Cryoconservation (cryopreservation) •process of freezing and storing embryos •providing an additional chance for pregnancy •saving embryos before certain treatments KRYO Adobe Systems Donor conception •the eggs, sperm or embryos or both (double donation) from donors are used in order to conceive •can be used in IUI or IVF •donation is voluntary and anonymous •some donor characteristics may be known (skin hair and eye color) – try to find the best match Adobe Systems Surrogacy •arrangement, whereby a woman (the surrogate mother) agrees to bear a child for another person or person •indications: abnormal uterus, post hysterecromy, congenital malformation of uterus, history of multiple miscarriages, (same sex couple) • Adobe Systems Infertility Endometriosis •The presence of endometrial tissue in an abnormal anatomical location (out of uterus) •Endometrial tissue respond to menstrual cycle hormones, and bleed during the menstrual cycle •between 6 and 10 percent of women of reproductive age worldwide •Lot of theories of etiology (metaplastic, Sampson‘s retrograde menstruation theory, and many others) Adobe Systems Infertility Localisation of endometriosis Sacrouterine ligg. 63 % Ovary 56 % C.Douglasi 25 % Vesica ur. 20 % Samps. Cyst 20 % Broad ligament 8 % Intestine 6 % 1UPRAV Adobe Systems Infertility Risk factors •White race •Early menarche •Late menopause •Nulliparity •Obesity •Short menstrual cycle •Family history Adobe Systems Infertility Symptoms •20-25% of women are asymptomatic •Pelvic pain/chronic pelvic pain •Dysmenorrhea •Dyspareunia •Dysuria •Mittelschmerz – associated with ovulation •Infertility •diarrhoea/constipation •Irregular/heavy period..... • Adobe Systems Infertility Diagnosis •Ultrasound examination / expert US examination •DGL •MRI •Biopsy/histopathology • • • Adobe Systems Infertility Therapy •depends on: symptoms, age, fertility, stage, former therapy •Hormonal therapy: COC, Progesterone, GnRH modulators •NSAID •Surgery – excision/resection endometrial endometriomas • • Adobe Systems Infertility Thank you for your attention Adobe Systems Pelvic infection and STDs Questions 1.Normal sperm cell concentration is? A)20 mil./ml B)40 mil./ml C)15 mil./ml. D)35 mil./ml. E) 2.Ashenozoospermia means? A)reduced concentration B)reduced sperm motility C)abnormal morphology D)absence of spermatozoa (motile sperm) E)complete lack of semen Adobe Systems Pelvic infection and STDs Questions 1.Normal sperm cell concentration is? A)20 mil./ml B)40 mil./ml C)15 mil./ml. D)35 mil./ml. E) 2.Ashenozoospermia means? A)reduced concentration B)reduced sperm motility C)abnormal morphology D)absence of spermatozoa (motile sperm) E)complete lack of semen Adobe Systems Pelvic infection and STDs Questions 1.Normal sperm cell concentration is? A)20 mil./ml B)40 mil./ml C)15 mil./ml. D)35 mil./ml. E) 2.Ashenozoospermia means? A)reduced concentration (Oligozoospermia) B)reduced sperm motility C)abnormal morphology (Teratozoospermia) D)absence of spermatozoa (motile sperm) (Azoospermia) E)complete lack of semen (Aspermia) Adobe Systems Pelvic infection and STDs Questions 3.Which of the following does not belong to assisted reproduction methods? A)Ovulation stimulation B)In-vitro fertilisation C)Surrogacy D)Vasectomy 4.Infertility is ? A)Failure to achieve a pregnancy after two years of regular unprotected intercourse B)Failure to achieve a pregnancy after 6 months of regular unprotected intercourse C)Failure to achieve a pregnancy after 9 months unprotected intercourse D)Failure to achieve a pregnancy after one year of regular unprotected intercourse E) Adobe Systems Pelvic infection and STDs Questions 3.Which of the following does not belong to assisted reproduction methods? A)Ovulation stimulation B)In-vitro fertilisation C)Surrogacy D)Vasectomy 4.Infertility is ? A)Failure to achieve a pregnancy after two years of regular unprotected intercourse B)Failure to achieve a pregnancy after 6 months of regular unprotected intercourse C)Failure to achieve a pregnancy after 9 months unprotected intercourse D)Failure to achieve a pregnancy after one year of regular unprotected intercourse E) Adobe Systems Pelvic infection and STDs Questions 3.Which of the following does not belong to assisted reproduction methods? A)Ovulation stimulation B)In-vitro fertilisation C)Surrogacy D)Vasectomy 4.Infertility is ? A)Failure to achieve a pregnancy after two years of regular unprotected intercourse B)Failure to achieve a pregnancy after 6 months of regular unprotected intercourse C)Failure to achieve a pregnancy after 9 months unprotected intercourse D)Failure to achieve a pregnancy after one year of regular unprotected intercourse E) Adobe Systems Pelvic infection and STDs Questions 5.Which of the following does not belong to infertility diagnostic methods? A)Anti-Műllerian Hormon (AMH) B)SONO-Hysterosalpingography C)Curettage D)Diagnostic laparoscopy 6.MESA is indicated for sperm retrieval in case of? A)failure of TESA method B)occlusion between epididymis and urethra C)oligospermia D)Occlusion between ovarium and uterus E) Adobe Systems Pelvic infection and STDs Questions 5.Which of the following does not belong to infertility diagnostic methods? A)Anti-Műllerian Hormon (AMH) B)SONO-Hysterosalpingography C)Curettage D)Diagnostic laparoscopy 6.MESA is indicated for sperm retrieval in case of? A)failure of TESA method B)occlusion between epididymis and urethra C)oligospermia D)Occlusion between ovarium and uterus E) Adobe Systems Pelvic infection and STDs Questions 5.Which of the following does not belong to infertility diagnostic methods? A)Anti-Műllerian Hormon (AMH) B)SONO-Hysterosalpingography C)Curettage D)Diagnostic laparoscopy 6.MESA is indicated for sperm retrieval in case of? A)failure of TESA method B)occlusion between epididymis and urethra C)oligospermia D)Occlusion between ovarium and uterus E) Adobe Systems Pelvic infection and STDs Questions 7.Which is the most common symptom of endometriosis? A)missed periods B)rapid weight loss C)chronic pelvic pain D)vomiting 8.Which of the following is not a risk factor for Endometriosis? A)long menstrual cycle B)nulliparity C)late menopause D)early menarche E) Adobe Systems Pelvic infection and STDs Questions 7.Which is the most common symptom of endometriosis? A)missed periods B)rapid weight loss C)chronic pelvic pain D)vomiting 8.Which of the following is not a risk factor for Endometriosis? A)long menstrual cycle B)nulliparity C)late menopause D)early menarche E) Adobe Systems Pelvic infection and STDs Questions 7.Which is the most common symptom of endometriosis? A)missed periods B)rapid weight loss C)chronic pelvic pain D)vomiting 8.Which of the following is not a risk factor for Endometriosis? A)long menstrual cycle B)nulliparity C)late menopause D)early menarche E)