Please enable JavaScript.
Coggle requires JavaScript to display documents.
In-Vitro Fertilisation (NICE CG 156 - Feb 2013) - Coggle Diagram
In-Vitro Fertilisation
(NICE CG 156 - Feb 2013)
Prediction of Success
Female age
: Chance of live birth falls with rising age
Number of previous treatment cycles
: Overall chance falls as number of unsuccessful cycles increases
Previous pregnancy history
: More effective in women who have previously been pregnancy and/or had a live birth
BMI
: Ideal range 19-30
Lifestyle factors
: Maternal and paternal smoking, maternal caffeine consumption, and consumption of >1 unit of alcohol/day reduces success rates of IVF
Referral Criteria
Women aged 40-42 who have not conceived after 2 years of regular UPSI or 12 cycles of artificial insemination (6 or more by IUI)
:
Offer 1 full cycle of IVF, with or without ICSI, provided 3 criteria are fulfilled:
No previous IVF treatment
No evidence of low ovarian reserve
Discussion of implications of IVF and pregnancy at this age
Full cycle of IVF
, with or without intracytoplasmic sperm injection (ICSI), should comprise 1 episode of ovarian stimulation and the transfer of any resulting fresh and frozen embryo(s)
Women aged under 40 who have not conceived after 2 years of regular UPSI or 12 cycles of artificial insemination (6 or more by IUI)
:
Offer
3 full cycles of IVF
, with or without ICSI
If reaches age 40 during treatment, complete the cycle but do not offer further full cycles
Note that for women aged under 40, any
previous full IVF cycle
, whether self or NHS funded, should count towards the 3 full cycles offered by the NHS
ICSI
Recognised indications
Severe deficits in semen quality
Obstructive azoospermia
Non-obstructive azoospermia
Consider when previous IVF treatment cycle resulted in failed or very poor fertilisation
Genetic issues and counselling
Offer genetic counselling and testing if a specific genetic defect associated with male infertility is known or suspected
Establish the
man's karyotype
if there is severe deficit of semen quality or non-obstructive azoospermia
Testing for Y chromosome microdeletions
: Significant proportion of male infertility results from abnormalities of genes on the Y chromosome involved in regulation of spermatogenesis
Known to
improve fertilisation rates
compared to IVF alone
Procedures Used During IVF
1. Pre-treatment
Using
pre-treament (either with the OCP or a progestogen)
does not affect chances of having a live birth
Consider in order to
schedule IVF treatment
for women who are not undergoing long down-regulation protocols
2. Down-regulation and other regimens to avoid premature LH surges in IVF
Use regimens to avoid premature LH surges in gonadotrophin-stimulated IVF treatment cycles
Use either GnRH agonist down-regulation or
GnRH antagonists as part of gonadotrophin-stimulated IVF treatment cycles
Only offer GnRH agonists to women who have a
low risk of ovarian hyperstimulation syndrome
When using GnRH agonists as part of IVF treatment, use a long down-regulation protocol
3. Controlled ovarian stimulation
Use ovarian stimulation in the form of either
urinary or recombinant gonadotrophins
as part of IVF treatment
When using gonadotrophins for ovarian stimulation
: Use an individualised starting dose of FSH, based on factors that predict success such as
age, BMI, polycystic ovaries, ovarian reserve
.
DO NOT
use a dose of
FSH >450 IU/day
.
Offer
ultrasound monitoring
(with or without oestradiol levels) for efficacy and safety throughout ovarian stimulation
DO NOT
offer natural cycle IVF or use GH or DHEA as adjuvant treatment
Clomifene citrate-stimulated and gonadotrophin-stimulated
IVF cycles
have higher pregnancy rates per cycle than natural cycle IVF
4. Triggering ovulation
Offer
HCG (urinary or recombinant)
to trigger ovulation
Offer
ultrasound monitoring
of ovarian response
Protocols should be in place for managing
ovarian hyperstimulation syndrome
5. Oocyte and sperm retrieval
Offer
conscious sedation
to women undergoing transvaginal retrieval of oocytes
Women who have developed
at least 3 follicles
before oocyte retrieval should
NOT
be offered follicle flushing as it increases duration of oocyte retrieval and pain
Surgical sperm recovery
before ICSI may be performed and facilities for cryopreservation of spermatozoa should be available
6. Embryo transfer strategies
Offer
ultrasound guided
embryo transfer as this improves pregnancy rates
Replacement of embryos with an
endometrium <5mm thickness
is unlikely to result in pregnancy and is
NOT
recommended
Bed rest of >20 minutes
duration following transfer does NOT improve outcomes
Women under 37 years
First full cycle
: Single embryo transfer
Second full cycle
: Single embryo transfer if 1 or more top quality embryos available, otherwise consider using 2 embryos
Third full cycle
: Transfer no more than 2 embryos
Women 37-39 years
First and second full cycles
: Single embryo transfer if 1 or more top quality embryos, otherwise consider double embryo transfer
Third full cycle
: Transfer no more than 2 embryos
Women 40-42 years
: Consider double embryo transfer
Evaluate
embryo quality
at both cleavage and blastocyst stages
For IVF with donor eggs, use an embryo transfer strategy based on the
age of the donor
No more than 2 embryos
should be transferred during any one cycle of IVF treatment; counsel of the risks of multiple pregnancy
Where a
top-quality blastocyst
is available, use
single embryo transfer
Offer
cryopreservation
to store any remaining good-quality embryos
Advise women with regular ovulatory cycles that likelihood of a live birth after replacement of
frozen-thawed embryos
is similar for embryos replaced during
natural cycles and hormone-supplemented cycles
7. Luteal phase support after IVF
Offer
progesterone
for luteal phase support up to 8 weeks
DO NOT
offer HCG due to increased likelihood of ovarian hyperstimulation syndrome
Donor Insemination
Effective in managing infertility associated with
:
Obstructive azoospermia
Non-obstructive azoospermia
Severe deficits in semen quality in couples not wishing to undergo ICSI
Consider in conditions such as
:
High risk of transmitting genetic disorder to offspring
High risk of transmitting infectious disease to offspring or woman from the man
Severe rhesus isoimmunisation
Offer
IUI
in preference to intracervical insemination as it improves pregnancy rates
Assessments for the woman
Confirm that the woman is ovulating
Offer tubal assessment in women with a history suggestive of tubal damage
Offer tubal assessment after 3 cycles if treatment by donor insemination has been unsuccessful
Women who are ovulating regularly should be offered
a minimum of 6 cycles of donor insemination without ovarian stimulation
to reduce the risk of multiple pregnancy
Oocyte Donation
Effective in managing infertility associated with
:
Premature ovarian failure
Gonadal dysgenesis including Turner syndrome
Bilateral oophorectomy
Ovarian failure following chemotherapy or radiotherapy
Certain cases of IVF treatment failure
Consider where there is high risk of transmitting genetic disorders to offspring
Need to screen for
infectious and genetic diseases
before donation is undertaken
Cancer Patients and Fertility
Cryopreservation in males
Offer sperm cryopreservation to males preparing for medical treatment for cancer likely to make them infertile
Use freezing in liquid nitrogen vapour for sperm cryopreservation
Cryopreservation in females
Offer oocyte or embryo cryopreservation to females preparing for medical treatment for cancer likely to make them infertile if:
They are well enough to undergo ovarian stimulation and egg collection
This will not worsen their condition
Enough time is available efore start of cancer treatment
Uise vitrification instead of controlled rate freezing
Use
sperm, embryos, or oocytes
Store cryopreserved material for an initial period of
10 years
. Offer continued storage of
cryopreserved sperm
, beyond 10 years, to men who remain at risk of of significant infertility.
Long-Term Safety of ART
IVF treatment
Small increased risk of borderline ovarian tumours cannot be excluded
Absolute risks of long-term adverse outcomes in children born from IVF are low
Limit drugs used for controlled ovarian stimulation in IVF treatment to the lowest effective dose and duration of use
Ovulation induction and stimulation
No direct association between treatments and invasive cancer
No association in short-medium term between treatments and adverse outcomes including cancer in children born
Limit use of ovulation induction or ovarian stimulation agents to the lowest effective dose and duration of use