Mark Perloe, MD Atlanta, 404-843-2229 Learn about the factors that can adversely affect fertility and the tests that can help pinpoint problems. Fertility treatment options including IVF and other high tech options are presented.

1. Fertility Options Mark Perloe, M.D. Georgia Reproductive Specialists www.ivf.com

7. Months % women pregnant Cumulative frequency of pregnancy in couples trying to conceive Let’s look first at how easy, or difficult, it is to get pregnant… Fecundity

8. Graafian follicle Oocyte Membrana granulosa Theca interna Basement membrane Antrum

9. -50 -4 +10 -9 +1 -180 Time (days) 0 Very little atresia Ovulation Corpus luteum Large antral Recruited Growing 50 - 80% atresia Primordial Small Antral Pre-ovulatory Possible time of action of nutrition on folliculogenesis Selected

11. Blastomeres undergo compaction and form morula. Gap junctions and tight junctions will form placenta. The cells gain distinct polarity (i.e. have inside and outside faces) and flatten against each other. Embryo growth

12. Embryo Cleavage The cleavage divisions produce cells called blastomeres.

13. Fertilization occurs in the ampulla of the oviduct, implantation in the uterus. Motile systems are important: cilia and smooth muscle. The Fallopian tube produces secretions which control and provide a vehicle for transport. Control over embryo transport may also operate at the ampullary isthmic junction and at the utero-tubal junction. Embryo transport

14. Hatching from zona The zona pellucida must be lost before the embryo can contact the uterine epithelium. Observations in vitro suggests that the blastocyst squeezes out of fractures in the zona (“hatches”). Identical twins may be produced if the embryo breaks into two during this process. Empty zona Zona free blastocysts

15. Apposition Attachment Invasion Uterine responses In humans, the maternal epithelium and stroma in invaded by the embryo…

16. The syncytiotrophoblast proliferates and invades the extracellular matrix of the stroma. Cytotrophoblast cells migrate between the syncytia, followed by fetal stroma - leading to placental villi. Implantation

19. PCOS Ovarian Drilling 65-85% success not effective in smokers 1/3 require ovulation meds requires surgery adhesion formation

21. Age related infertility Reduced pregnancy rates Increased miscarriage rates Increased risk fetal anomalies

22. Pregnancy, Live Birth, and Singleton Live Birth by Age,* 2001 *For consistency, all rates are based on cycles started.

23. Miscarriage Rates by Age, 2001

25. Sperm Chromatin Structure Assay SCSA®/SDFA test is a good predictor, relative to other sperm measures, for the clinical diagnosis of male infertility

27. P34H Testing

28. P34H Testing Sullivan, Fertil & Steril, 2006

30. Advanced Sperm Testing Panel

31. Uterine Evaluation

32. Uterine Fibroids

34. Congenital Uterine Anomalies Bicornuate Vs Septate Uterus

35. Hydrosalpinx

36. Abnormal Hysterosalpingogram

37. Pelvic Adhesions

38. Hydrosalpinx

39. What do we know about pregnancy losses?? 6 20 40 Weeks gestation 100 50 % Pregnancies can easily be recognized clinically by 6 wks. Ovulation rates are high! So probably are fertilization rates! Early human embryos may show a high incidence of developmental abnormalities. 10-15% of of all clinically recognised pregnancies are lost in the 1st trimester; 2-3% are lost later. 50% of these losses have cytogenetic abnormalities. 1/3 of all pregnancies are lost soon after implantation - before they are clinically recognised.

40. Unexplained Infertility Letrozole or Clomid/IUI Letrozole/HMG/IUI IVF

41. Injectable Gonadotropins

43. In vitro fertilization Screening Optimize reproductive health Psychological counseling Financial counseling Nursing education Ovarian hyperstimulation Egg retrieval Embryo culture Embryo transfer Cryopreservation The wait!

56. Success Rates (2001 SART Data) Age Clinical Pregnancy Live Birth < 35 47.1% 36.5% 35-37 28.6% 23.8% 38-40 21.4% 14.3% 41-42 3/5 2/5

57. 2007 GRS IVF Statistics Age <35 35-37 38-40 >40 Donor # cycles 105 63 39 12 28 birth/cycle 33.3% 27.0% 28.2% 2/12 60.7% Avg # ET %Twins %FET del 2.3 29.2 30.8 2.4 29.2 33.2 2.9 7.6 42.8 3.3 - - 2.0 - 36.8

58. Success Rates: What do they mean? Pregnancies per cycle Live births per retrieval Live births per cycle Live births per transfer Singleton live births per transfer Singleton live births per cycle

59. Live Birth Rates by Diagnosis, 2001

60. Live Birth Rates by Woman’s Age and Previous Live Births, 2001

61. Live Birth Rates by Age and History of Miscarriage, with No Prior Births,* 2001 *Women reporting only previous ectopic pregnancies or pregnancies that ended in induced abortion were not included in the above statistics.

62. Live Birth Rates by Woman’s Age and History of Previous ART Cycles, 2001

63. Live Births per Transfer and % Multiple Births in Women <35 by Number of Embryos Transferred, 2001 (100.0)* (59.3)* (39.6)* (53.4)* (38.8)* (7.8)* (49.1)* (41.3)* (9.6)* (43.3)* (46.8)* (9.9)* *Percentages of live births that were singletons, twins, and triplets or more are in parentheses. Note: In rare cases a single embryo may divide and thus produce twins. For this reason a small percentage of triplets resulted when two embryos were transferred. 30.0 51.7 46.9 42.9 43.1 (1.2)*

64. Frozen Embryos vs. Fresh Embryos, 2001 Frozen embryos Fresh embryos

65. Live Births per Transfer Using Fresh Embryos From Own and Donor Eggs, by ART Patient’s Age, 2001

66. Success Rates vs. Multiple Births Type of ART

68. Multiple Births rates are NOT 1996, 2000 and 2001