The document summarizes key milestones and advances in assisted reproductive technology (ART) from the 1970s to present day. Some of the major developments include: - The first "test tube baby", Louise Brown, was born in 1978 using in vitro fertilization. - Techniques like intracytoplasmic sperm injection (ICSI) and cryopreservation in the 1980s and 1990s improved fertility treatment options. - New methods to select embryos with the highest implantation potential include preimplantation genetic screening, metabolomic profiling, and time-lapse imaging to observe development. - Fertility preservation options for cancer patients now include egg, embryo and ovarian tissue freezing with some successful ovarian transplants reported

1. Dr.M.Gouri Devi. M.D.
Director, Gouri Hospital Ltd,
Director Ridge IVF group,
Vice President , Indian Fertility Society,
Member excecutive- AOGD, NARCHI, DGES

2. Not Very Long Ago
07/78Louise Brown
was born
Birth after reimplantation of a human embry
Steptoe P.C. / Edwards R.G.
Lancet 2 (1978): 366

3. Introduction
 Advances in assisted reproductive
technology for infertile couples were
among the great medical successes of
the last century.
 ART has made huge strides and fast
progress towards finding suitable
treatment options for each infertile
couple

4. Milestones in reproductive
medicine
 1960 - ovarian stimulation with clomifene and gonadotrophins
- radioimmunoassay
 1970 - secretion, synthesis, mechanism of GnRH a.
gonadotrophins
- in vitro fertilisation
 1980 - GnRH-agonists and gonadotrophins
- cryopreservation
 1990 - recombinant gonadotrophins
- preimplantation genetic diagnosis
- intracytoplasmatic sperm injection (ICSI)
- GnRH-antagonists
 2000 - in vitro maturation of oocytes
- embryonic stemcells
- SET (single embryo transfer)
- vitrification

5. History of ovarian
stimulation
 1970 Clomifen
hMG
 1980 GnRH-agonist / hMG
 1990 recFSH
GnRH-antagonist / hMG or
recFSH
 2000 long acting FSH

6. long acting FSH
1 2 3 4 5 6 7 8 9 10 11 12 13 14 ….
FSH-CTP
10000
IE hCG
follicle aspiration
after 36h
GnRH-Antagonist
LF 10 mm LF 14 mm LF 17mm

7. Kisspeptins
The First IVF baby born by Kisspeptins
2013 at
Hammer smith hospital, U.K

8. What are Kisspeptins?
 Naturally occuring hormones which is
an important regulator of reproductive
axis , and it is safer as the chance
OHSS is reduced.
 Instead of HCG, Kisspeptin is used as
the trigger
 Dosage is still under trial ( 0.6-1.2 nmol)

9. Mild stimulation Protocols
 The "mild" stimulation approach for IVF treatment is
aimed to develop more patient-friendly protocols in which
the risks are minimized and the results are still acceptable
.
 A "mild" IVF cycle is defined (ISMAAR association) either
as (a) a stimulation regimen in which gonadotropins are
administered at a lower-than-usual dose and/or for a
shorter duration throughout a cycle in which GnRH
antagonist is given as co-treatment.
 (b) a stimulation in which oral compounds (e.g. anti-
estrogens) are used either alone or in combination with
gonadotropins and GnRH-antagonists.
( Nargund .G et al Hum.Reprod
:2011)

10. Male Infertility
 Per Cutaneous Epidydimo aspiration.
(PESA)
 Testicular epidydimo sperm aspiration.(TESA)
 Microsurgical epidydimo sperm aspiration
(MESA)
 Harvesting sperm from testicular tissue+ICSI:-
Even in patients with sertoli cell only syndrome
scattered pockets of sperms exist .Even with FSH> 3times
,sperms are found in30%of cases ( Kim et al: 2012)

11. Exciting new development in
male infertility
In non –Obstructive azoospermia:
Though these men may have no sperm in their
semen, we can now find sperm between the cells of
the testicles in almost half of these cases.
By using an operating microscope and doing micro
dissection TESE, pregnancies have been acheived
in one third of those men in whom sperm can be
found within the testicle

12. ICSI-Micro TESE
 179 cycles of Non- Obstructive azoospermia
22 cycles done
Fertilisation rate : 33.2%
6 Cycles chemical pregnancy
3 cycles :Normal pregnancies with 3 healthy babies.
(Ragaa.T Mansour et al:2013).
 Fertilisation rate :48.3%
Pregnancy rate :28.9%
( Sousa. M.:Hum. Repro. 2012)

13. Advanced Sperm Preparation
methods
Newer strategies of sperm preparation .
1. Morphological assessment by means of ‘motile sperm
organelle morphological examination (MSOME)' :-
2. Electrical charge: This from the seminal plasma membrane –
zeta potential-allows them to adhere to the surface of a positively
charged tube. The resulting population has better quality, with normal
DNA and chromatin condensation
3. Molecular binding characteristics of the sperm cell:
The two methods currently used are sperm binding to
AnnexinV and Hyaluronan(PICSI)
4. Raman microspectrometry and Polarisation microscopy
are in the offing
( Henkel R : Asian j.of Andrology:2012)

14. Motile sperm organelle morphological examination
(MSOME).
 With MSOME, the morphological status of the acrosome,
post-acrosomal lamina, neck, mitochondria, flagellum and
the sperm nucleus is examined. For the latter, the shape, as
well as the presence and size of vacuoles, is observed.
 The combination of MSOME and ICSI has been named
intracytoplasmic morphologically selected sperm injection
(IMSI).
IMSI has beenshown to increase fertilisation rate, blasocyst
formation rate,implantation and pregnancy rates.
( Setti et al :Repro.bio.med.online:2013)

18. Can we select the best
embryo?
Attempts have been made to do so

19.  The best available method for embryo
selection is morphological evaluation.
(Ebner et al., 2003; Gerris, 2005).
 However implantation rates in
general do not exceed 35%, although
varying results have been reported,
(Centers for Disease Control and Prevention
et al., 2010).
 Hence a strong drive for finding alternative
selection methods

21.  Preimplantation genetic
screening (PGS).
 The biopsy at Day 3 of embryo
development of a single cell and
analysis of this cell by fluorescence in-
situ hybridization (FISH) for
aneuploidies, for a limited number of
chromosomes.

22. Selection of best embryo by
CGH array
 Pre-implantation genetic diagnosis with
testing of all 23 pairs of chromosomes
by a microarray technique, which allows
us to differentiate chromosomally normal
from abnormal embryos
 Replace only the normal ones on day
five, discarding the abnormal embryos

23. Selection of single blastocysts for fresh transfer
with array CGH and standard morphology alone
for good prognosis IVF patients.
Clinical preg. Rate -70.9%vs 45.8%
Ongoing preg.rate -69.1%vs 41.7%
Twin - nil
Aneuploidy rate
-44.9% among biopsied blastocysts
Yang Z et al (Mol Cytogenet.2012 May)

24. PGD
 Pre-implantation genetic diagnosis can
also be utilised for translocations and
single gene defects, eg. BRCA1 and
BRCA2 and cystic fibrosis

25. Non Invasive methods –
”Omics”
 High-tech, non-invasive methods to
select the best embryo includes
metabolomic profiling, amino acid
profiling, respiration-rate measurement
and birefringence imaging.
(Nagy, 2008).

26.  Metabolomic profiling:
spectrophotometric tests are used to
measure metabolomic changes in the
culture medium of embryos.
 Proteomic profiling: proteins produced
by the embryo and released into the
culture medium are identified.
 Amino acid profiling: amino acid
depletion and production by the embryo
is assessed using the culture medium

27.  Respiration-rate measurement: the
respiration rate of embryos is assessed.
 Birefringence imaging:polarization light
microscopy is used to assess the
meiotic spindle or the zona pellucida .
( Negy ZP:
Reprod.Biomed.Online 2008)

28. Embryoscope
 The novel monitoring system for
continuous observation of early embryo
development around the hour
(EmbryoScope®) was introduced by
Unisense Fertilitech, USA.
 In December, the world’s first twins born
by use of the new Embryo Scpe® at
Cleveland Reproductive Center, Ohio,
USA.
(2011)

31. Time Lapse Imaging
 Now the incubator is hooked upto a video
system capturing thousands of images of
embryo upto blastocyst.
 A normal embryo forms a blastocyst 6hrs
earlier than an abnormal one.
 The embryos need not be disturbed as in
the conventional IVF. Better success orates
are claimed. Still waiting for a randomised
controlled trial.
( Reprod.bio med:2013, Alison
Campbell:2013)

33.  The recent increased sensitivity of these
techniques has allowed for the
development of new protocols that are
capable of not only profiling the
proteome of individual human oocytes
and embryos, but also the proteins
produced by the embryo into the
surrounding medium (the secretome)
( Katz Zaffe M g et al: Reprod.Bio med
.on Line :2013)

34. Human Cloning
 The first succeessful human cloning
(Cell 2013:Shoukrat Mitalipov et al).
 Cloning of human embryos for therapeutic
purposes was made legal ( Amendment to
the human embryology act :2001.)
 Cloning human for reproductive purposes
remain illegal.

43. Fertility Preservation in female
cancer patients
 Oocyte freezing.
 Embryo Freezing
 Ovarian tissue cryopreservation
 Ovarian transplantation

44. Clinical: 2000 onwards
 First successful ovarian tissue transplant
after
frozen storage ( Kutluk Oktay et al:New Eng.J.of
med:2000).
 Pregnancy after transplantation of ovarian
cortex retransplants ( Meirow et al:2005)
 Ovarian transplant between 2 identical twin
sisters.
( Sherman Silber :2005)

45. Ovarian transplantation

46. Ovarian Transplants
 Review of 60 cases .
 24 live births reported till date.
( Donnez .J.Et al: Fert.Ster.:2013).
Future: Better Freezing techniques
Enhance the vascular bed
before
transplantation

47. Uterine transplantation
 Transplant done from a donar. Hysterectomy done 99days
after due to acute vascular thrombosis. (Saudi Arabia )
(Faqweeh.W.et al:Intl.J.Obst
andGyn:2002).
 Patient conceived with IVF , miscarried at 8weeks.(Turkey)
(Erman Akar .M.et al
:Fert.Ster:2013)
 Nine successful Transplants (Sweden)
(Brannstorm .M et al
:2013)
 Live birth after uterine transplant remains challenging
( Fert.Ster.: 2013)

48. Sperm/egg from embryonic
stem cell
 In 2008, a flurry of announcements revealed further
developments with human same-sex reproduction, with a
patent application filed by an American
researcher.(Gregory Aharonian) specifically on methods
for creating human female sperm using artificial or natural
Y chromosomes and testicular transplantation.[( Human
same sex reproduction project)
 A UK-based group, in an interview, predicted they would
be able to create human female sperm within five years.[
McRay,Fiona:2008)
 Another group at the Butantan Institute in Brazil is
working on creating male eggs from embryonic stem cells,
and if successful, from adult skin cells, though their
current experiments are on mice

49. Artificial uterus and pregnancy
outside the body

50. To Conclude
 The field of Reproductive medicine is
fast progressing.
 Aim of infertility treatment is to be
simple, safe, successful and cheap.
 In donar programmes, surrogacy,same
sex reproduction etc there is a lot of
political,legal and ethical issues
involved.
 Future looks like a well-lit tunnel

51. Thanks