Post on 30-May-2018
transcript
8/14/2019 IVF - Hyderabad Conference
1/94
8/14/2019 IVF - Hyderabad Conference
2/94
Egg plus sperm = baby
8/14/2019 IVF - Hyderabad Conference
3/94
8/14/2019 IVF - Hyderabad Conference
4/94
8/14/2019 IVF - Hyderabad Conference
5/94
Traditional approach
Infertility is a common problem
Important and urgent for the patient
However, most doctors take a wait
approach
Often , patients get fed up andfrustr
drop out oftreatment
This is a shame !
8/14/2019 IVF - Hyderabad Conference
6/94
8/14/2019 IVF - Hyderabad Conference
7/94
Need to change !
Patients are getting married at an ol
Time is running out as the biological
ticks on
We now have effective technology to
them !
8/14/2019 IVF - Hyderabad Conference
8/94
8/14/2019 IVF - Hyderabad Conference
9/94
IVF cycle
4 basic steps
1. Superovulation
2. Egg collection
3.In vitro fertilisation
4. Embryo transfer
8/14/2019 IVF - Hyderabad Conference
10/94
IVF cycle
1. Superovulation
1.With HMG ( gonadotropins)
Natural hormones
Newer recombinant preparations muc
expensive, but no better
2. Downregulation with Buserelin ( Gn
3. GnRH antagonists to prevent LH surg
4. Low cost clomiphene plus HMG
8/14/2019 IVF - Hyderabad Conference
11/94
IVF cycle
Superovulation
Monitor follicular growth ( ovarian r
Vaginal ultrasound scans
Day 3, 10, 12, 14
Rarely need to measure blood estrad
levels !
8/14/2019 IVF - Hyderabad Conference
12/94
8/14/2019 IVF - Hyderabad Conference
13/94
IVF cycle
2. Egg collection
Vaginal ultrasound guida
Non-surgical
8/14/2019 IVF - Hyderabad Conference
14/94
8/14/2019 IVF - Hyderabad Conference
15/94
8/14/2019 IVF - Hyderabad Conference
16/94
8/14/2019 IVF - Hyderabad Conference
17/94
8/14/2019 IVF - Hyderabad Conference
18/94
IVF cycle
3.Insemination
Sperm added to egg in the incubato
Kept in vitro in conditions which mim
conditions
The incubator is the heart ofthe IVF
8/14/2019 IVF - Hyderabad Conference
19/94
IVF cycle
4. Embryo transfer
Non-surgical
Number ofembryos ?
When to transfer ? Day 2 or 3 or 5
8/14/2019 IVF - Hyderabad Conference
20/94
8/14/2019 IVF - Hyderabad Conference
21/94
8/14/2019 IVF - Hyderabad Conference
22/94
IVF cycle
No needfor bed rest you cannotthe embryo out !
Still a matter ofluck !
Not the patients fault ifshe doeconceive
She cannot reject the embryo !
8/14/2019 IVF - Hyderabad Conference
23/94
8/14/2019 IVF - Hyderabad Conference
24/94
Risks ofIVF
1. No pregnancy
2. Multiple pregnancy
3.
Ectopic pregnancy4. OHSS ovarian hyperstimula
syndrome. Managed conserv
8/14/2019 IVF - Hyderabad Conference
25/94
Limitations ofIVF
Few medical risks
Major risks are
FinancialEmotional
8/14/2019 IVF - Hyderabad Conference
26/94
Advancedfertilisation tech
Intracytoplasmic Sperm Injection
Assisted Hatching
Blastocyst transfer
Preimplantation Genetic Diagno
8/14/2019 IVF - Hyderabad Conference
27/94
ICSI
Microinjection ( Intracytoplasmic spe
injection)
One egg + one sperm = one embryo
Can use testicular sperm evenfrom
testicular failure ( with high FSH leve
small testes)
8/14/2019 IVF - Hyderabad Conference
28/94
8/14/2019 IVF - Hyderabad Conference
29/94
Blastocyst transfer
The high implantation rate is becaus
1. improved selection ofviable embr
2. better synchronization between e
and the endometrium at the time of
8/14/2019 IVF - Hyderabad Conference
30/94
8/14/2019 IVF - Hyderabad Conference
31/94
Freezing - cryopreservat
8/14/2019 IVF - Hyderabad Conference
32/94
Vitrification
Can store and preserve
Sperm
Embryos
Eggs
Ovarian tissue
8/14/2019 IVF - Hyderabad Conference
33/94
The promise of ART
We can help any couple to hababy, no matter what their mproblem !
Third party reproduction
Embryo adoption
Donor eggs
Surrogate uterus
8/14/2019 IVF - Hyderabad Conference
34/94
PGD the newest ART
PGD marries genetic technology and
technology
The newest patient is the embryo !
8/14/2019 IVF - Hyderabad Conference
35/94
Procedure for preimplanta
genetic diagnosis
1.IVF cycle
2. 8-cell embryo at Day 3
3. Biopsy embryo ( micromanipulato
4. Fix blastomere
5. Study genetic composition ofblas
using genetic probes ( FISH)
6. Transfer selected embryos into ute
8/14/2019 IVF - Hyderabad Conference
36/94
8/14/2019 IVF - Hyderabad Conference
37/94
8/14/2019 IVF - Hyderabad Conference
38/94
8/14/2019 IVF - Hyderabad Conference
39/94
8/14/2019 IVF - Hyderabad Conference
40/94
8/14/2019 IVF - Hyderabad Conference
41/94
8/14/2019 IVF - Hyderabad Conference
42/94
Signal interpretation
Evaluate slides with a fluorescence m
Locate nucleus using DAPI filter
Interpret signals
Probe will bind to specific chromosom
Pink = Y ( Spectrum Orange)
Green = X ( Spectrum Green)
8/14/2019 IVF - Hyderabad Conference
43/94
8/14/2019 IVF - Hyderabad Conference
44/94
Normal blastomere
8/14/2019 IVF - Hyderabad Conference
45/94
Trisomy 21
8/14/2019 IVF - Hyderabad Conference
46/94
8/14/2019 IVF - Hyderabad Conference
47/94
Comparative Genomic Hybrid
8/14/2019 IVF - Hyderabad Conference
48/94
PCR
8/14/2019 IVF - Hyderabad Conference
49/94
Indications for preimplanta
genetic diagnosis
1. Sex linked genetic disorders
Hemophilia
Duchenne muscular dystrop
2.Chromosomal disordersDowns syndrome ( Trisomy
8/14/2019 IVF - Hyderabad Conference
50/94
Indications for preimplanta
genetic diagnosis
3. Single gene diseases ( using PCR)
Thalassemia
4. Older womendoing IVF
Screen embryos for aneuplo
5.Recurrent pregnancy loss because
chromosomal anomalies
8/14/2019 IVF - Hyderabad Conference
51/94
Future advances
Cloning
Reproductive cloning
Therapeutic cloning
8/14/2019 IVF - Hyderabad Conference
52/94
Embryonic stem cells
Can change the face ofmedicine
Very promising future
Lots ofresearch still needs to be Indian can be a leading center in
Collaboration betweenIVF clinic
basic research labs
8/14/2019 IVF - Hyderabad Conference
53/94
Weve come a long way, b
8/14/2019 IVF - Hyderabad Conference
54/94
8/14/2019 IVF - Hyderabad Conference
55/94
8/14/2019 IVF - Hyderabad Conference
56/94
8/14/2019 IVF - Hyderabad Conference
57/94
ART is a medical success s
However, advances inIVF havwith government guidelines a
The purpose ofthese guidelinensure that these technologiused safely and responsibly
It is time to ask how well thes
guidelines work and what puthey really serve.
8/14/2019 IVF - Hyderabad Conference
58/94
Regulating, Reporting Validating ART are guide
rules and laws ofany us
8/14/2019 IVF - Hyderabad Conference
59/94
Human Fertilisation and Embry
Authority (HFEA) Act
Laiddown to protect the welfare of
Theory - It should be the parent(s) o
who should be empowered to make
decisions for their child
Practice - An impersonal governmen
without a heart or a soul makes thes
decisions, claiming that they are act
interests ofthe child.
8/14/2019 IVF - Hyderabad Conference
60/94
Global picture
What is remarkable about the
regulations which governART in
country is that they vary so wide
Guidelines are arbitrary and ofte
designed to fulfill prevailing polit
pressures, rather than being bas
scientific principles.
8/14/2019 IVF - Hyderabad Conference
61/94
Global picture
Rules vary from country to country
They also vary in an individual count
time to time.
Thus, the UK HFEAnow allows paren
select embryos ( using PGD for tissu
so that the baby created can becom
donor to an ill sibling ( saviour siblin
something which they had banned i
8/14/2019 IVF - Hyderabad Conference
62/94
UK v/s US
Interestingly, the US has nfound it necessary to pass federal law to regulate IVF
And they are doing fine tyou very much !
8/14/2019 IVF - Hyderabad Conference
63/94
Doctors v/s politician
Is it better to allow doctorsmake medical decisions ( adone in the USA) ?
Or to have legal hurdles, aspractice in many Europeancountries ?
Who can we trust ?
8/14/2019 IVF - Hyderabad Conference
64/94
Law ofunintended consequ
In Spain, it is legal to put embryos instorage, but it is illegal to destroy emto donate them to research
There are currently 50
,000
embryos unused infrozen storage in Spain- sbeyond the five-year storage limit.
What a sad mockery it is, when the lwas designed to protect embryos onends up destroying them in practice
8/14/2019 IVF - Hyderabad Conference
65/94
IVF laws anddoctors
By forcing doctors to practmedicine as laiddown in amindless statue drafted bybureaucrats, rather than bapplying their own judgmeare ending up harming ourpatients.
8/14/2019 IVF - Hyderabad Conference
66/94
8/14/2019 IVF - Hyderabad Conference
67/94
Playing God ?
Whendoes life begin? and what are
ofan embryo?
Can human embryos be usedfor har
embryonic stem cell lines ?
Should cloning be allowed ?
8/14/2019 IVF - Hyderabad Conference
68/94
Two views
Playing God ! This technologycouples to manipulate Natureproduce children
v/s
This technology is a triumph ingenuity which can be used
overcome Nature's constraint
8/14/2019 IVF - Hyderabad Conference
69/94
Who decides ?
This decision shouldnot be lemoralists, or philosophers or government, or the doctors.
Instead, the decision is best leach individual couple, who pthe reproductive apparatus to
the baby.
8/14/2019 IVF - Hyderabad Conference
70/94
Should embryo research
banned ?
Banning research ends up stopp
scientific progress
We are not mad scientists trying
God
We are doctors trying
to do the best for our patients
8/14/2019 IVF - Hyderabad Conference
71/94
Doctors are trusted profess
Our freedom to do what is beour patients will be curtailedbureaucrats , activists and po
Ifdoctors can be trusted to manddeath decisions in the ICwhy cant we be trusted to mdecisions about IVF responsib
8/14/2019 IVF - Hyderabad Conference
72/94
Useful regulation
Most doctors would agree that thereto regulate the practice ofIVF, so thaclinics meet certain basic standards.
Need to protect infertile patients, wemotionally vulnerable, and can geteasily by unscrupulous doctors
8/14/2019 IVF - Hyderabad Conference
73/94
Theory v/s practise
8/14/2019 IVF - Hyderabad Conference
74/94
8/14/2019 IVF - Hyderabad Conference
75/94
8/14/2019 IVF - Hyderabad Conference
76/94
Surrogacy
One ofthe thorniest issues !
Who has the rights ?
What happens when something goe
Will India become the surrogacy out
capital ofthe world ?
Are we exploiting poor women by h
wombs ?
8/14/2019 IVF - Hyderabad Conference
77/94
How many embryos to tran
Ideal would be one. However, the te
is still not perfect
The law is blind limit of2for every
Why ? Makes sense for the NHS !
Does this make sense for a 43 year o
doing her 5th IVF cycle ?
Let the couple decide for themselvesthe pros and cons
8/14/2019 IVF - Hyderabad Conference
78/94
3 principles ofmedical et
Autonomy
Beneficence
Non-maleficence
8/14/2019 IVF - Hyderabad Conference
79/94
The very fact that rules vary so muchcountry to country means that thereno right answers.
In such circumstances, is it a good id
impose rules on infertile couples ? Might it not be better to allow docto
couples to decide what is best for th
Rather than apply rules blindly, isnt
to allow doctors the freedom to selebest for their patients ?
8/14/2019 IVF - Hyderabad Conference
80/94
Solution ?
Let patients decide for themselves its their life and their baby !
Ademocracy empowers people to m
own choices and they should be aluse the technology to fulfill their perreproductive desires, as long as theyharm anyone else !
Its unethical to interfere in their perfamily-building plans !
8/14/2019 IVF - Hyderabad Conference
81/94
Simplifying IVF to make it affo
Low cost IVF
Young couples ( get married y
Cannot afford expensive trea Mistake have copied the W
blindly so far
Need to adapt IVF for India !
8/14/2019 IVF - Hyderabad Conference
82/94
Low cost innovations
Minimal stimulationIVF
( gentle IVF)
Transport IVF eggs and stransported to central IVF
Satellite IVF
8/14/2019 IVF - Hyderabad Conference
83/94
Intravaginal Culture
Use the patients vagina as an incuba
No needfor expensive incubator or
supply
Stepped care IVF can be made ava
government hospitals indistrict tow
Should be part ofeach teaching hos
India
8/14/2019 IVF - Hyderabad Conference
84/94
8/14/2019 IVF - Hyderabad Conference
85/94
What society cando
Infertility treatment should be a part
Family Planning and Family Welfare
Should be covered by medical insura
because infertility is a disease andnmedical treatment
8/14/2019 IVF - Hyderabad Conference
86/94
8/14/2019 IVF - Hyderabad Conference
87/94
8/14/2019 IVF - Hyderabad Conference
88/94
8/14/2019 IVF - Hyderabad Conference
89/94
8/14/2019 IVF - Hyderabad Conference
90/94
8/14/2019 IVF - Hyderabad Conference
91/94
8/14/2019 IVF - Hyderabad Conference
92/94
8/14/2019 IVF - Hyderabad Conference
93/94
8/14/2019 IVF - Hyderabad Conference
94/94