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Assisted Reproductive Technology (ART)
Rajeev Sharma, Randhir Puri, Narendra Malhotra, Jaideep Malhotra
CHAPTER 1:
Overview of ART
CHAPTER 2:
Infertility—Scope of Problem
CHAPTER 3:
Reproductive Anatomy and Physiology of a Couple
MALE REPRODUCTIVE SYSTEM
Testis
HORMONAL CONTROL OF TESTICULAR FUNCTION
Epididymis
Vas Deferens
Urethra
Prostate
PRODUCTION OF SPERMATOZOA (FIG. 3.8)
ERECTION AND EJACULATION
COMPOSITION OF SEMEN
Female Reproductive System
Vulva Constitutes the External Sex Organ (Fig. 3.5)
Internal Sex Organs Consist (Fig. 3.6)
Structure of an Oocyte (Figs 3.7A and B)
Ovarian Cycle
HORMONAL CONTROL OF OVARIAN CYCLE
CHAPTER 4:
Natural Menstrual Cycle
INTRODUCTION
CHAPTER 5:
Male Infertility—Causes and Investigations
DEFINITION
MALE ANATOMY AND FUNCTIONS
CAUSES OF MALE INFERTILITY
Anatomical Factor
Genetic Factor
Endocrine Factor
Infective Factor
Ejaculatory Factor
Other Factor
Idiopathic
DRUGS CAUSING IMPOTENCY AND EJACULATORY DYSFUNCTION
Sedative and Antidepressant
Phenelzine Sulphate
Antihypertensive
Drugs of Abuse
Others
MALE INFERTILITY WORK-UP
MEDICAL HISTORY
PHYSICAL EXAMINATION
Examine Penis
Examine Testes
Examine Epididymis
Normal Epididymis
Look for
Examine Prostate Gland
Inguinal Exam
LABORATORY EVALUATION
SEMEN ANALYSIS
Semen Collection
NORMAL
DEFINITIONS: SEMEN ANALYSIS
SEMEN ABNORMALITIES
SPERM AGGLUTINATION ASSAY
STD SCREENING
PROSTATIC FLUID DETERMINATION
POST-ORGASM URINE
HORMONE DETERMINANTS
Additional Tests
Fructose Test
CHAPTER 6:
Female Infertility—Causes and Investigations
INVESTIGATIONS
Clinical History
Physical Examination
Routine Investigations
Other Hormone Tests
Progesterone Test
Spinnbarkeit
Ferning
Tubal Patency Tests
Interpreting Results of Investigations of Female Partners
Test Result Interpretation
Midluteal
CHAPTER 7:
The Infertility Clinic and IVF Lab Set Up
SHOULD BE SEPARATE FROM ROUTINE OPD
INFERTILITY SPECIALIST
BASIC REQUIREMENTS
Lab Layouts (Appendix) (ICMR) Guidelines
ICSI Lab
Ovum Retrieval OT (Fig. 7.3)
Embryo Transfer Room
Interlock Room
Wash Room/Change Room
Genetic Lab
Sperm Bank
Cryo Freezers
CONSENT FORMS
QUALITY CONTROL
Record Keeping
Laboratory Personnel
Procedure
Quality Control of Equipment
Quality Control of Disposable Material and Media
CULTURE MEDIA
1. Bicarbonate
2. Phosphoric Acid Buffer
3.HEPES (N2 Hydroxy Ethylpiperazine N'2-Ethanesulfonic Acid)
4.MOPS (3-N- Morpholino Propane Sulphonic Acid)
HSA (Human Serum Albumin)
Different Commercial Medias used in ART Procedure (Figs 7.23 to 7.27)
CHAPTER 8:
Ovarian Stimulation
AIMS OF STIMULATION
Gonadotropins
Gonadotropin Preparations
Differences between Urinary and Recombinant Gonadotropin
Dose of Gonadotropins
Monitoring of Gonadotropin Therapy
Ovarian Stimulation Protocols
Protocols Choice Depends on
Ovarian Stimulation Protocols Using GnRH Agonists
NOTE
Softer or Mild Stimulation
Disadvantages of Luteal Long Protocol
Soft Protocols: Poor Responders
Poor Responders
Newer Methods of Drug Delivery of FSH
Long Acting rec-FSH
Orally Long Acting LH Agonists
Avoiding OHSS in ART
Management of OHSS
Mild
Moderate
Severe
CHAPTER 9:
Transvaginal Sonography in Infertility
TRANSVAGINAL SONOGRAPHY IN INFERTILITY
Vaginal and Cervical Factor Infertility Evaluation
Uterine Factor Assessment and Evaluation (Fig. 9.6)
Endometriosis
Fibroids
Congenital Anomalies
Sonohysterography
Endometriosis of the Uterus (Adenomyosis)
Evaluation of Endometrial Growth
Smith's Grading
Endometrial Thickness and Menstrual Cycle
Zones
Applebaum's USSR Scoring System (UBP)
Ultrasound and the UBP
Ultrasound and the UBP
Tubal Evaluation
OVARIAN EVALUATION BY ULTRASOUND
Ovarian Study
Follicular Development
Prediction of Ovulation
Confirming Ovulation
Ovary in Anovulatory Cycles
Endometrium
ROLE OF TRANSVAGINAL COLOR DOPPLER IN INFERTILITY
Study of Menstrual Cycle by Color Doppler
The Phases are as follows
Luteal Phase Changes in Ovarian Vascularity
Secretory Changes in the Endometrium
CHAPTER 10:
Ovulation Monitoring
OVARIAN STUDY (FIGS 10.5 TO 10.10)
FOLLICULAR DEVELOPMENT (FIGS 10.11 TO 10.14)
Antral Follicle
PREDICTION OF OVULATION (FIGS 10.15 AND 10.16)
CONFIRMING OVULATION
OVARY IN ANOVULATORY CYCLES
CORPUS LUTEUM (FIGS 10.17 TO 10.19)
POLYCYSTIC OVARIES
PREDICTING OVARIAN RESERVE
CHAPTER 11:
Intrauterine Insemination
CHAPTER 12:
Procedures
OVUM PICK-UP (OOCYTE RETRIEVAL) (See Video Courtesy Cook)
DISH PREPARATION
Four Well Dish (Insemination)
Single Well
ICSI or Injecting Dish
Enzymatic Solution
Denuding Dish
Culture Dish
Semen Collection
SURGICAL SPERM RETRIEVAL
Indications of Surgical Sperm Retrieval
Methods of Surgical Sperm Retrieval
STRATEGIES OF SURGICAL SPERM RETRIEVAL
MICRO EPIDIDYMAL SPERM ASPIRATION (MESA)
Limitations
Complications
PERCUTANEOUS EPIDIDYMAL SPERM ASPIRATION (PESA)
VAS DEFERENS SPERM ASPIRATION
TESTICULAR SPERM ASPIRATION (TESA)
TESTICULAR SPERM EXTRACTION (TESE)
Semen Preparation
Direct Layering Technique
Swim up Technique
Mini Swim up Technique
ICSI
TESA
OOCYTE PREPARATION FOR ICSI
Denudation of Oocyte
Micromanipulator Preparation
Preparation of Pipettes and Sperm Immobilization
Sperm Injection
Insemination
Micro Drop Culture
Fertilization Check
FERTILIZATION
Embryo Culture
Oil Overlay
Benefits
Disadvantages
Cleavage
Embryo Grading
EMBRYO TRANSFER
Embryo Transfer Procedure
Pregnancy Success Rates Depend on Many Factors
Embryo Transfer
Variables Affecting Embryo Transfer
Four Important Steps
Preparation Before ET
Technical Aspects of ET Catheter
The ET Procedure
Post Transfer Aspects
Impact of Mucus or Blood on or in the Catheter
Uterine Contractions
Trial Transfer
Technique of Embryo Loading
Type of Catheter
Loading of the Catheter
Placement of Catheter Tip
Location of Catheter
Ultrasound Guided Transfer
Number of Embryos Transferred
Catheter, Syringe and Air Column
Syringe Type
Placement of Catheter
Direct/after Loading
Rest after Embryo Transfer
CHAPTER 13:
IVF—Protocol General
EVALUATION FOR IVF—PREREQUISITES FOR RECRUITMENT
Patient Selection
Husband
Wife
PATIENT SELECTION FOR TREATMENT IN DIFFERENT INFERTILITY CARE UNITS
Single Defect in one of the Partner
Multiple Defects in one or both Partners
No Detectable Defect in Either Partner (Unexplained or Idiopathic Infertility)
SELECTION CRITERIA FOR ART
SELECTION CRITERIA FOR IN VITRO FERTILIZATION AND EMBRYO TRANSFER (IVF-ET)
SELECTION CRITERIA FOR GAMETE INTRA-FALLOPIAN TRANSFER (GIFT) (LESSER PRACTISED)
CHOOSING BETWEEN IVF-ET AND GIFT
MICRO-ASSISTED FERTILIZATION (SUZI AND ICSI)
CHAPTER 14:
Gynecological Complications of ART
OHSS
Presentation of OHSS
Symptoms
Timing
Grades of OHSS
Mild
Moderate
Severe
Critical OHSS
2. GENERAL ANESTHETIC AND INTRAVENOUS SEDATION
3. CANCER
4. OPERATIVE COMPLICATIONS
5. MISCARRIAGES
6. ECTOPIC PREGNANCY
7. HETEROTROPHIC PREGNANCY
8. PSYCHOLOGICAL
9. PELVIC INFECTION
10. LABORATORY RISKS
CHAPTER 15:
Obstetric Complications
HIGH ORDER MULTIPLE PREGNANCY
AGED PREGNANCY COMPLICATIONS
OPERATIVE DELIVERY
PLACENTA PREVIA
CHAPTER 16:
Cryobiology of ART
CHAPTER 17:
Technological Advances—Future Frontiers
OVARIAN TISSUE CRYOPRESERVATION AND GRAFT
Autografting
Pre-implantation Genetic Diagnosis
Preventing Transmission of Genetic Disorders
In Vitro Oocyte Maturation
Procedure
Assisted Hatching (Fig. 17.2)
Assisted Hatching Methods
Partial Zona Dissection
3D Partial Zona Dissection (PZD)
Laser Assisted Hatching (See Video)
Blastocyst Culture (Fig. 17.3)
Advantages
Disadvantages
SPINDLE VIEW
Assessment of Oocyte Quality
Spindle
Zona Pellucida
Improve Treatment Outcome
INTRACYTOPLASMIC MORPHOLOGICALLY SELECTED SPERM INJECTION (IMSI)
CHAPTER 18:
Ethics and Law
BIOETHICS
PATIENT COUNSELING
Egg, Sperm, and Embryo Donation
Selection and Screening of Donors
Quarantining Donated Semen
Legal Issues
Adoption
Adoption after Infertility Treatment
Adoption Agencies and the Assessment Process
SURROGACY
Types of Surrogacy Arrangement
Partial Surrogacy
Full Surrogacy
Issues Explored in Counseling for Surrogacy
Accepting a Child-free Lifestyle
Counseling
CHAPTER 19:
Counseling in Infertility
PATIENT CENTRED CARE AND COUNSELING
Counseling of Commissioning Couples
Counseling of Surrogate Mother
Special Situations—Sexual Dysfunction
Counseling in HIV Discordant Couples
HIV Positive Woman
HIV Positive Men
FUTURE TARGETS
CHAPTER 20:
NARI (National ART Registry of India)
NARI GUIDELINES 2006
A. FRESH CYCLES
1. Total Cycle
2. Indication
3. Stimulation Protocol
4. Eggs Retrieved
5. Number of Embryos Transferred per ET
6. Outcome
B. THAW ET
1. Protocol
2. Number of Embryos Transferred per ET
3. Outcomes
C. EGG DONATION
1. Type of Donor
2. Indications
3. Age of Recipient
4. Number of Eggs Retrieved
5. Number of Embryos Transferred per ET
6. Outcome
D. RECIPIENTS OF EGG SHARING
1. Age of Recipients
2. Indications
3. Number of Eggs Shared
4. Number of Embryos Transferred per ET
5. Outcome
E. EMBRYO DONATION
1. Number of Embryos Transferred
2. Outcome
F. SURROGACY
1. Indication
2. Number of Embryo Transferred
3. Outcome
COMPARISON OF PREGNANCY RATES AND OUTCOMES OF DIFFERENT PROCEDURE IN 2006
CHAPTER 21:
Regulation and Laws in ART
APPENDIX:
Consent Forms
IDEAL LAB PLANS
ALGORITHM OF ASSISTED REPRODUCTION: A PROCESS FOR SUCCESS
APPROACH TO AN INFERTILE COUPLE
INDEX
TOC
Index
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