Assisted Reproductive TechnologyA.R.T.

Adam Nancekivell, BSc

Embryologist

Journey to a Baby

For some people the journey is short…•Think about starting a family•Successful pregnancy

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Journey to a Baby

For others the journey is longer…•Think about starting a family•Is there a fertility issue to overcome?•What can be done?•What does it cost?•What is treatment like?•Successful pregnancy

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Is there a fertility issue to overcome?

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1 Year is key timeframe

Failure to become pregnant after 1 year of unprotected intercourse is a key indicator

of infertility

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Is there a fertility issue?

Causes of Infertility

• Male 40%

• Female 40%

• Combined/unknown 20%

Is there a fertility issue?

Causes of Infertility - Female

• Failure to ovulate

• Tubal damage

• Endometriosis

• Age

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Is there a fertility issue?

Causes of Infertility – Male

• Genetic

• Developmental

• High body temperature

• Physical injury

• Chemicals / hormones

• Medical

• Lifestyle factors

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Is there a fertility issue?

What can be done?

• Optimize lifestyle factors

• See a fertility specialist regarding A.R.T.

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What can be done?

Optimise lifestyle factors

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What can be done?

Don’t smoke...What can be done?

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Smoking is bad for fertility and the health of future children

Women• By-products detectable

in fluid around eggs• Menopause occurs 1 to

4 years earlier• Zona pellucida (‘egg

shell’) thicker

Men• Sperm production,

motility, morphology and increases DNA damage

• Child born to a father who smokes has 4 X risk of childhood cancer

What can be done?

Smoking is also bad for treatment outcomes

• Male smoking significantly reduces success rates

• Female smoking halves pregnancy rates & doubles risk of early pregnancy loss

• …and there is no public funding for female smokers

What can be done?

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Be a healthy weight...

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What can be done?

Homan, G.F. et al. Hum Reprod Update 2007 13:209-223; doi:10.1093/humupd/dml056

Public funding cut off

Human Reproduction Update

Impact of BMI on female fertilityWhat can be done?

Impact of BMI on male fertility• Overweight men (BMI over 28) have sperm counts 22% lower

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What can be done?

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Paternal BMI range

Pregnancy and live birth outcomes according to paternal BMI

Pregnancy loss

Live birth/OPU

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Paternal BMI range

Pregnancy and live birth outcomes according to paternal BMI

Pregnancy loss

Live birth/OPU

Bakos et al., 2011, Paternal Obesity and ART Pregnancy

Cut out or cut right back on alcohol and coffee

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What can be done?

See a fertility specialist for a first consultation

What can be done?

The First Consultation

• History from both partners• Blood test on woman to check hormones• Ultrasound exam on woman• Sperm test arranged for man

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What can be done?

What does it cost?

The First ConsultationWhat does it cost?

Publicly-funded Consultation• Need GP referral• Must meet criteria

•Both NZ residents•18+ months infertility if woman <35 yrs OR•12+ months infertility if woman >35 yrs + OR•Known severe cause of infertility

•Additional criteria in Akld and Northland

•Woman under 40 yrs•Woman’s BMI =< 32•Woman non-smoker

• $0 • 1-2 months wait for appt

Interesting to note that mencan be old, overweight, smokers!

The First ConsultationWhat does it cost?

Publicly-funded Consultation• Need GP referral• Must meet criteria

•Both NZ residents•18+ months infertility if woman <35 yrs OR•12+ months infertility if woman >35 yrs + OR•Known severe cause of infertility

•Additional criteria in Akld and Northland

•Woman under 40 yrs•Woman’s BMI =< 32•Woman non-smoker

• $0 • 1-2 months wait for appt

Privately-funded Consultation•No referral•No criteria •$190 - $260• immediate – 2 week wait for appt

Fertility Treatmentusing A.R.T.

Treatment

Used mainly to assist…

• Heterosexual couples with infertility issues

• Lesbian couples who need a sperm donor

• Single women who need a sperm donor

• Families with history of genetically-inherited disease

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Treatment

Five Core ART Treatments

• Clomiphene / Ovulation Induction (OI)

• Intrauterine Insemination (IUI) / Donor Insemination (DI)

• In Vitro Fertilisation (IVF)

• Intracytoplasmic Sperm Injection (ICSI)

• Embryo Biopsy

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Treatment

The Basics = Sperm + EggTreatment

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Clomiphene / Ovulation Induction (OI)Treatment

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• Tablet taken between day 2 and 6 of woman’s cycle• Increases the level of follicle stimulating hormone (FSH)

to stimulate egg production• Involves some blood tests and scans to time intercourse• Mainly used where there is a problem with ovulation

DAYS OF WOMAN’S CYCLE

Intrauterine Insemination (IUI) and Donor Insemination (DI)

Treatment

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20,000,000 for Intercourse

1,000,000 for IUI

NUMBER OF SPERM TO FERTILISE EGG

• Sperm is washed• At ovulation, sperm is placed into uterus using a catheter• Mainly used for:

o Heterosexual couples where there is a mild male infertility or the female has mild endometriosis

o Lesbian coupleso Single women

In Vitro Fertilisation (IVF)• Conception takes place outside the body• Drugs stimulate and mature eggs• Eggs are aspirated using a fine needle• Sperm is washed and approx 50,000 are introduced to egg in a petri dish• After 3-5 days embryo is transferred into uterus• Mainly used with more serious female infertility issues

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Treatment

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Intracytoplasmic Sperm Injection (ICSI)• Conception also takes place outside the body as per IVF• 1 sperm is injected into each mature egg• Used when there is a serious sperm issue (quality and/or quantity)

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Treatment

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Embryo development (I)

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Treatment

Fertilised egg – 18hrs after adding sperm

8 cell embryo – day 3

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Embryo development (II)Treatment

Blastocyst – day 5-6 Hatching blastocyst – day 5-6

Embryo Biopsy

• To test for genetically-inherited diseases• One cell is removed from embryo and tested• If all OK embryo is placed in uterus

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Treatment

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Fertility treatment success rates improving

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DI implantation rate in women < 37

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DI implantation rate in women < 37

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IVF/ICSI implantation rate in women < 37

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IVF/ICSI implantation rate in women < 37

Treatment

But woman’s age is still key factor

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Treatment

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<30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45+

Woman's age

Birth rate from a single IVF egg collectionincluding use of any frozen embryos within 6 months

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<30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45+

Woman's age

Birth rate from a single IVF egg collectionincluding use of any frozen embryos within 6 months

What does it cost?

Fertility Treatment using ARTWhat does it cost?

Publicly-funded Treatment• Must meet criteria

•Both NZ residents•Woman under 40 yrs•Woman’s BMI =< 32•Woman non-smoker•Limit on 2 kids under 12 at home

• Must have CPAC* score 65+• $0 • 1 month wait (IUI) – 12 rounds• 1.5 year wait (IVF + ICSI) – 2 rounds

* Clinical Priority Assessment Criteria

Fertility Treatment using ARTWhat does it cost?

Publicly-funded Treatment• Must meet criteria

•Both NZ residents•Woman under 40 yrs•Woman’s BMI =< 32•Woman non-smoker•Limit on 2 kids under 12 at home

• Must have CPAC* score 65+• $0 • 1 month wait (IUI) – 12 rounds• 1.5 year wait (IVF + ICSI) – 2 rounds

Privately-funded Treatment• approx $ 1,900 (IUI)• approx $ 11,000 (IVF)• approx $13,000 (ICSI)• approx 1 month wait• unlimited rounds

* Clinical Priority Assessment Criteria

Legal Matters

• HART Act 2004– Human Assisted Reproductive Technologies

– Governs use of ART in New Zealand

• ACART– Advisory Committee on Assisted Reproductive Technologies

– Formulates policies and advice specific to New Zealand

• ECART– Ethics Committee on Assisted Reproductive Technologies

– Consider and determine applications for those ART procedures that are not deemed to be ‘established’ in the HART Act

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Treatment

ART Guiding Principals

• The health and well-being of children born should be an important consideration in all decisions ART.

• The human health, safety, and dignity of present and future generations should be preserved and promoted.

• The health and well-being of women must be protected in the use of these procedures.

• Individuals must make an informed choice and give informed consent.

• Donor offspring should be made aware of their genetic origins and be able to access information about origins.

• The needs, values, and beliefs of Māori should be considered and treated with respect.

• The different ethical, spiritual, and cultural perspectives in society should be considered and treated with respect.

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Treatment

Emotional Matters• Going through ART can be an emotional

rollercoaster• Coping with

– Infertility– Financial stress– Ethical dilemmas– Waiting for outcome of ECART applications– Different levels of motivation for treatment– Hormonal effects of fertility drugs– Medical interventions– Unsuccessful treatment– Comments from family and friends

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Treatment

Counseling Service

• Emotional health is as important as physical health!• Counselling is also compulsory for some

procedures using ART– Surrogacy– Embryo donation– Sperm or egg donation

• Free for publicly-funded treatment• $140 / hour for privately-funded treatment

Treatment