Abstract
What are the indications of artificial reproductive techniques (ART)?
Acknowledgments The author would like to thank Dr. Ülkü Özmen who contributed to this chapter.
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What are the indications of artificial reproductive techniques (ART)?
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Tubal factor
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Severe male factor
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Severe endometriosis
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Unexplained infertility
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Age >35 years
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No pregnancy after 1 year of conventional ovulation induction treatment
What are the aims of the ART?
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Achievement of oocyte from ovary with an artificial method.
What are the methods of the ART?
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In vitro fertilization: Oocytes achieved from ovary and these oocytes and sperm put same media. After fertilization, embryo transfer is achieved.
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Gamet intrafallopian transfer (GIFT): Oocyte and sperm are placed in the fallopian tube.
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Zygote intrafallopian transfer (ZIFT): Zygote is placed in the fallopian tube.
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Tubal embryo transfer.
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Peritoneal oocyte and sperm transfer.
Which artificial reproductive techniques are used in male infertility?
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Techniques of sperm achievement
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Injection of one sperm to oocyte—Intracytoplasmic sperm injection (ICSI)
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Testicular sperm extraction (TESE)
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Microsurgical epididymal sperm aspiration (MESA)
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Sperm aspiration from testis
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Which screening tests are made before ART?
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Hormone profile
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HSG
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Sperm test
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Ultrasonography
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HIV1 and HIV2
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Hepatitis B and hepatitis C
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Chlamydia, syphilis, gonorrhea, CMV, and rubella
What are the treatment alternatives of artificial reproductive techniques?
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Spontaneous cycles (6% success)
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GnRH analogues
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GnRH antagonists
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Human menopausal gonadotropin (HMG)
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FSH
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Clomiphene citrate
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Metformin
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Aromatase inhibitors—letrozole, anastrozole
How to determine treatment options of patients requiring ART?
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Treatment is determined according to women age, and ovarian reserve.
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GnRH analogues + FSH are preferred in young women.
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Low-dose GnRH analogues + high-dose FSH ± combined oral contraceptives are preferred in advanced ages.
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GnRH analogues + FSH (or HMG) + letrozole preferred in patients with poor ovarian reserve.
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GnRH antagonist + low-dose FSH are used in PCOS.
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GnRH analogues + FSH (Luteal long protocols) are preferred in endometriosis.
How would you follow up a patient when ART is applied?
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Aim is controlled hyperstimulation.
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For each follicle (>14 mm), estradiol level of at least 200 pg/mL is preferred.
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Endometrial thickness in ultrasonography should be 7–12 mm; endometrial lining in ultrasonography should be triple line.
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Oocyte pick-up (OPU) is made 34–39 h after hCG injection.
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Embryo transfer is made 3–5 days later.
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Generally progesterone is given after embryo transfer.
What is the basic technique of oocyte pick-up (OPU)?
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Mild anesthesia and sedation is preferred.
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Optimal monitoring is made.
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Generally pick-up needle is inserted into an ovary once and oocytes are aspirated.
Describe the process of oocyte culture.
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Oocytes are examined under a microscope.
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Separated from the sheath (cumulus) around the oocyte after the egg collection.
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After 4–6 h, the sperm is injected into the egg or leave to fertilization.
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Sperm is separated by swim-up method (If IVF is done, 50,000–100,000 sperms are left per oocyte).
Describe the fertilization process.
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Matured oocytes are fertilized at 65–80%.
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Roughly 6% polyspermia-type 3 pronucleus cells are consisted.
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If fertilization problem is present or if sperm count is too low, ICSI should be referred.
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Surplus embryos are frozen.
Describe the embryo transfer process:
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Generally 8-cell embryos after 72–80 h are transferred.
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Or, if the quality embryo is high, embryo is transferred to the blastocyst stage after 5 days.
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Depending on the age of the woman, the number of embryos may increase. Normally good quality 1–2 embryos are given.
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Luteal phase support is needed.
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After the transfer, hCG is measured on day 10–11.
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Five weeks after last menstrual period, fetal heart activity is expected.
What are the pregnancy associated results of ART?
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Abortion rate 20%.
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It is stated that there may be minimal increase in congenital malformation because of increased multiple pregnancy.
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Ectopic pregnancy is seen 3%.
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Risk of multiple pregnancy 35%.
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After three unsuccessful cycles, success rate is significantly decreased.
Describe male factor in fertility in artificial reproductive techniques.
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Fertilization rate is low.
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ICSI is recommended treatment.
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All kinds of immature, immobile sperm can be used.
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Morphological selection of sperm is recommended.
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Describe genetic problems in male factor infertility
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Infertile men have chromosomal anomaly in 5–7%.
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There are high deletions in the Y chromosome in the presence of azoospermia.
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7–10% Y deletion in oligospermia.
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10% of sperms carry extra chromosomes.
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There is 0.84% sex chromosomal anomaly in ICSI pregnancies due to male infertility.
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Genetic screening should be made to azoospermic men.
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Klinefelter syndrome
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LH β subunit mutation
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There may be congenital absence of vas deferens. It is seen 1–2% in infertile men.
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There may be cystic fibrosis mutation.
Describe oocyte donation.
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Forbidden in some countries. Oocyte donation is the process in which a fertile woman’s several oocytes are aspirated, usually following ovarian stimulation, in order to be used in another patient (mostly infertile due to ovarian failure; Premature ovarian failure, Turner syndrome, Ovarian failure following chemotherapy or radiotherapy, IVF failure, genetic disorders).
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It may be used in patients with premature ovarian failure.
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Donor age 22–24 is preferred.
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Success rate is approximately 50%.
In which patients, preimplantation genetic diagnosis (PGD) is preferred?
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Cystic fibrosis
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Duchenne muscular dystrophy
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Sickle cell anemia
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Hemophilia
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Tay–Sachs disease
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Lesch–Nyhan syndrome
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Trisomy
Suggested Reading
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Fritz MA, Speroff L. Assisted reproductive technologies. In: Fritz MA, Speroff L, editors. Clinical gynecologic endocrinology and infertility. 8th ed. Philadelphia: Lippincott, Williams & Wilkins; 2011. p. 1331–83.
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Sel, G. (2020). Artificial Reproductive Techniques (ART). In: Practical Guide to Oral Exams in Obstetrics and Gynecology . Springer, Cham. https://doi.org/10.1007/978-3-030-29669-8_43
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