Ovulation Induction &

Controlled Ovarian Hyperstimulation

J Witjaksono
History

 Louise Brown born July 25, 1978

– First IVF baby worldwide
– Pioneering work of Robert Edwards and Patrick Steptoe,
England
 Elizabeth Carr born December 28, 1981
– First American IVF baby
– Drs. Howard and Georgeanna Jones, Norfolk
 Melati Sukma Lestari born 2 Mei, 1988
– First Indonesia IVF baby
– Prof Sudradji Sumapradja – Klinik Melati RSAB Harapan
Kita
Progress

 Improving success rates

 Lower rates of multiple pregnancies
 New therapies
 Simpler therapies

 Flexibility of American system

– Advantage compared to Europe
– Risk of impeded progress with regulation of
therapy
Rate of follicular growth
in human ovary
Follicle size
(mm)
Increasing rate of
2mm/d at the follicular 20
phase
Leading mature 10
preovulatory follicle in
a diameter of 16-28mm
5

0.40
0.20
0.12

0 5 15 25 35 45 55 65 75 85
Days
The follicular fate

Time course for recruitment,

selection, and ovulation of the
dominant ovarian follicle
(DF) with onset of atresia
among other follicles of the
cohort (N-1)
Hodgen GD. The dominant ovarian
follicle. Fertil Steril 1982; 38:281-
300
Nonsteroidal factors produced by the Ovary affecting
follicular development & follicular function
Nonsteroidal factor Proposed Function
Activin Stimulates FSH release
Adenosine Regulation atresia & oocyte maturation
Angiogenic factors Angiogenesis corpus luteum
Cathecholamine Modify Steroidogenesis
Eisosanoids Ovulation and corpus luteum regulation
Follicular-regulating protein Regulation atresia, aromatase inhibitor, inhibition FSH action
Follistatin Supressed FSH release
FSH binding inhibitor Inhibit binding of FSH to FSH-R
Gamma-Aminobutyric acid Modulation ovarian function
LHRH-like peptides Stimulatory & inhibitory of FSH & LH, regulation atresia
GH - Epidermal GF Mitogenic granulosa, inhibits steroidogenesis, atresia follicle
GH - Fibroblast GF Mitogenic granulosa, inhibits steroidogenesis, atresia follicle
GH - Insulin-like GF Mitogenic, stimulate steroidogenesis
GH - Platelet-derived GH Enhanced steroidogenesis
GH - Transforming GF alpha Growt regulation
GH - Transforming GF beta Stimulates FSH release & steroidogenesis granulosa granulosa theca
Inhibin Inhibits FSH release
LH-binding inhibitor Inhibits binding of LH to LH-R
Luteinization inhibitor Inhibits corpus luteum development & function
Luteinization stimulator Stimulates corpus luteum
Antimullerian hormone Development & function unknown
Oocyte maturation inhibitor Inhibit meiosis
Oxytocin Modulates progesterone secretion and life span corpus luteum
Relaxin Modulates corpus luteum
Renin-angiotensin Ovulation, regulation of steroidogenesis
Substance P Regulation of ovarian blood flow
Tissue plasminogen activator Ovulatin, atresia follicle
Vasoactive intestine peptide Stimulates steroidogenesis
Vasopressin Unknown
Induction of Ovulation
Indication

 Infertility associated with normal (or inappropriate) gonadotropic

and normal prolactinemic anovulation
 Infertility associated with luteal phase dysfunction
 Infertility associated with oligoovulation
 Infertility requiring improved timing of artificial insemination
 Unexplained infertility requiring controlled hyperstimulation and
intrauterine insemination
 Unexplained infertility requiring controlled hyperstimulation for
the purpose of in-vitro fertilization
Clomiphene Citrate

 Commencing on D1-5 for 5 consequtive days

 Clinical optimizing of dose effect : 50-100mg/d;
greater dosage increases risk of antiestrogenic effect
 Incremental dose (up to 1000mg/d) and extension
duration of treatment (up to 8-10d) have been
reported resulting ovulation in 10-75% cases but no
conceiving cycles documented
Follicular development and ovulation
disorders
 Reproductive hormones test (FSH, LH, prolactin,
estradiol and progesterone)
 The use of U/S for monitoring of follicular growth
and ovulation
 Other possible causes :
 Thyroid function test (hormones, imaging)
 Obesity in PCO : androgen, growth factors, insulin
Induction of Ovulation Programme
 Clomiphene citrate
 Gonadotropins
 Urinary hMG
 Purified FSH
Ovulation Induction
 FSH reccombinant
 Gonadotropin releasing hormone
 Pulsatile GnRH
 GnRH analog
Controlled Ovarian
 GnRH antagonist
Hyperstimulation
 (Bromocriptin)
 human Chorionic Gonadotropin
 LH reccombinant
 Monitoring ovarian stimulation

Transvaginal ultrasound scanning :

. No. & size of follicles
. Pattern & thickness of endometrium
 Estrogen blood level
 Clinical Outcome of Ovulation Induction

 Cochrane Studies
– Randomized Controlled Trial Design, double-blind
studies
– Meta-analysis for improving statistical power
2004 Issue 2
2004 Issue 2
 2004 Issue 2

Clomiphene citrate in oligo-amenorrheic women vs placebo

No. of No. of Statistical

Outcome title Effect size
studies participants method

01 Ovulation following all 4 279 P-OR 95% CI 4.60 [2.84, 7.45]

dose ranges

02 Pregnancy following all 2 192 P-OR 95% CI 3.41 [1.23, 9.48]

dose ranges
2004 Issue 2
2004 Issue 2
 2004 Issue 2

Clomiphene vs pacebo/no treatment in unexplained infertility

No. of No. of Statistical
Outcome title Effect size
studies participants method

01 Pregnancy per patient analyzed 5 455 P-OR 95% CI 2.37 [1.43, 3.94]

03 Pregnancy per treatment cycle initiated 5 1511 P-OR 95% CI 2.50 [1.57, 3.99]

04 Pregnancy per treatment cycle prior to 4 651 P-OR 95% CI 5.01 [2.25, 11.13]
cross-over

05 Spontaneous abortion per pregnancy 2 28 P-OR 95% CI 0.79 [0.06, 10.14

Gonadotrophin therapy for ovulation
induction in subfertility associated
with polycystic ovary syndrome 2004 Issue 2

01 FSH versus hMG

No. of
Outcome title No. of participants Statistical method Effect size
studies
01 pregnancy rate (per cycle) 8 627 P-OR 95% CI 0.89 [0.53, 1.49]

02 ovulation rate (per cycle) 8 627 P-OR 95% CI 0.75 [0.52, 1.07]

03 miscarriage rate (per pregnancy) 4 47 P-OR 95% CI 0.85 [0.24, 2.96]

04 multiple pregnancy rate (per pregnancy) 4 50 P-OR 95% CI 0.62 [0.11, 3.58]

05 overstimulation rate (per cycle) 5 212 P-OR 95% CI 0.85 [0.40, 1.81]

06 OHSS rate (per cycle) 7 396 P-OR 95% CI 0.33 [0.16, 0.65]

02 GnRH-a + gonadotrophin versus gonadotrophin

No. of
Outcome title No. of participants Statistical method Effect size
studies
01 pregnancy rate (per cycle) 4 211 P-OR 95% CI 1.43 [0.67, 3.04]

02 ovulation rate (per cycle) 3 187 P-OR 95% CI 0.59 [0.31, 1.12]

03 miscarriage rate (per pregnancy) 1 12 P-OR 95% CI 0.44 [0.02, 9.57]

04 multiple pregnancy rate (per pregnancy) 1 12 P-OR 95% CI 0.36 [0.03, 4.08]

05 overstimulation rate (per cycle) 2 181 P-OR 95% CI 3.15 [1.48, 6.70]

06 OHSS rate (per cycle) 3 187 P-OR 95% CI 1.41 [0.50, 3.95]
2004 Issue 2
2004 Issue 2
Gonadotrophin therapy for ovulation 2004 Issue 2

induction in subfertility associated

with polycystic ovary syndrome

Main Results

(1) A reduction in the incidence of OHSS with FSH compared to hMG

in stimulation cycles without the concomitant use of a GnRH-a (OR
0.20; 95% CI 0.08-0.46) and
(2) A higher overstimulation rate when a GnRH-a is added to
gonadotrophins (OR 3.15; 95% CI 1.48-6.70).
Gonadotrophin-releasing hormone
analogue as an adjunct to
gonadotropin therapy for clomiphene- 2004 Issue 2
resistant polycystic ovarian syndrome

GnRH-a + HMG/FSH vs HMG/FSH

No. of No. of Statistical

Outcome title Effect size
studies participants method

01 Pregnancy per 3 239 P-OR 1.50 [0.72, 3.12]

cycle 95% CI

02 Moderate to 2 180 P-OR 1.40 [0.50, 3.92]

severe OHSS 95% CI
 Evidence of treatments for PCOS
Intervention Decision/ evidence
Clomiphene citrate 50- An effective method of inducing ovulation and improving fertility in oligo-
150 mg/ day ovulatory women. There is a risk of ovarian cancer.
Gonadtrophin therapy Unclear evidence about the effectiveness as the studies are lacking the
sufficient power. Urinary-derived FSH preparations did not improve pregnancy
rates when compared to the traditional and cheaper hMG preparations.
The benefit is reduction in the risk of OHSS in cycles when administered
without the concomitant use of GnRH analogues. Neither rFSH nor uFSH is
preferable to each other when used.
GnRH analogues as an Ineffective. In addition to the risks of using GnRHa , so this shouldn't be
adjuvant therapy recommended as a standard treatment for patients with PCOS.
Metformin It is difficult make a decision from currently available research.
The addition of metformin to CC results in an improved ovulation and pregnancy
rate in both CC-resistant PCOS women. In obese PCOS patients it improves
both restoration of regular menses and spontaneous ovulation, but there are no
data supporting an improvement in pregnancy rate.
Pulsatile GnRH Insufficient evidence for its use because of lack of sufficient power of the 4
studies addressing its use.
Ovarian drilling Insufficient evidence of a difference in cumulative ongoing pregnancy rates
between laparoscopic ovarian drilling after 6-12 months follow up and 3-6 cycles
of ovulation induction with gonadotrophins as a primary treatment. Multiple
pregnancy rate is considerably reduced in women who conceive following
laparoscopic drilling.
ART Reporting
1985 – 1999

Reporting initiated in 1985:

 Annual reports published by ASRM (American Society of
Reproductive Medicine) and its SART (Society for Assisted
Reproductive Technologies)
 Voluntary at first, now a requirement of membership and
federally mandated

Reported cycles:
 647, 208 treatment cycles
 155,661 clinical pregnancies
 177,745 babies Fertil Steril 78:943-50, 2002.
 Pregnancy rates
Clinical Pregnancy / Transfer

60%

50%

40% IVF
Donor Egg
30% Cryo
GIFT
20% ZIFT

10%

0%
1980 1985 1990 1995 2000

Fertil Steril 78:943-50, 2002.

 Program Melati – RSAB Harapan Kita Jakarta
Jumlah Pelayanan FIV 1987 - 2002

300
N = 2875 treatment cycles
250
Jumlah siklus pengobatan

200

150

100

50

0
87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02
Tahun
 Program Melati – RSAB Harapan Kita Jakarta
Jenis Pelayanan FIV 1987 - 2002
Konservatif Mixed ICSI MESA Thawing
180

160
Jumlah sikllus pengobatan

140

120

100

80

60

40

20

0
87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

Tahun
 Program Melati – RSAB Harapan Kita Jakarta
Keberhasilan FIV 1987 – 2002
40
% Keberhasilan Kehamilan

30

20

%PR/OR %PR/ET %PR/TC

10
PR pregnancy rate ET embryo-transfered
OR oocyte –retrieved TC treatment cycle

0
87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

Tahun
 Fewer Multiple Pregnancies
8%
% Triplet / Deliveries

6%

IVF
4% Donor Egg
Cryo

2%
Triplet delivery rates
Quadruplet delivery rates
0%
0.8%

% Quadruplet (or +) / deliveries

1994 1996 1998 2000

0.6%

0.4% IVF
Donor Egg
Cryo
0.2%

0.0%

Fertil Steril 78:943-50, 2002. 1994 1996 1998 2000

 Strong effect of woman’s age
40%

<35
30%
35-37 • Pregnancy rates
% Deliveries / retrieval

within each age range

continue to climb,
20% 38-40 but….
• Maternal age still a
critical factor in overall
10% 41-42 success, i.e., success
very limited when age
43+ > 40 years.
0%
1985 1990 1995 2000
Fertil Steril 78:943-50, 2002.
New therapies

 Sperm problems: ICSI (Intracytoplasmic sperm

injection)

 Egg problems: Donor Egg

 Uterine problems: Gestational
carrier
 Surplus embryos: Cryopreservation
 Genetic problems: PGD (Preimplantation genetic
diagnosis)
Innovations
Clinical Pregnancy / Transfer

40% Nuclear Transfer X

35% IVF
Cytoplasmic Transfer X
PGD
30% Hatching
ICSI
25%
Subzonal Insertion
20% Partial Zona Dissection

15%
Co-Culture X
ZIFT
10% GIFT
Donor Egg
5% Cryopreservation
0%
1980 1985 1990 1995 2000
ICSI to overcome Male Factor

0.5

0.4

% lower Fertilization
0.3
% fewer Deliveries
% micromanip.
0.2
% ICSI
% lower Fertilization
0.1
% fewer Deliveries
0
1988 1990 1992 1994 1996 1998 2000
-0.1

Fertil Steril 78:943-50, 2002.

Simpler treatments

 Laparoscopic egg retrieval

– Now: transvaginal ultrasound-guided
 Laparoscopic replacement of eggs / embryos
– Now: transcervical embryo transfer
 Daily monitoring of response
– Now: every few days during stimulation
 Intramuscular injections of hormones
– Now: many given subcutaneously
 US versus Europe
IVF, 1998

+9.1
50%
+10.8
Clinical Preg / transfer

40%
+9.8
30%

Europe
20%
U.S.
0.1% 0.2%
10% 100% 2.3% 6.2%

80%
0%
Proportion of
quads +
IVF Donor Cryo.
deliveries
60%
Egg triplets
40% tw ins
singletons
20%

0%
Fertil Steril 78:943-50, 2002. Europe U.S.
History of reporting results

# Cycles
# Clinics
100,000 400
Series2
350
80,000 No. Reporting
300

60,000 250

# Clinics
# Cycles

200 CDC system

40,000 150
Wyden law
100
20,000 Voluntary reporting
50

0 0

1980 1985 1990 1995 2000

Fertil Steril 78:943-50, 2002.
FDA regulations

 Advances to date developed without government

funding, using traditional IRB / informed consent
process
 In past year, FDA has asserted authority over ART
procedures, and has prohibited:
– Cytoplasmic Transfer
– Nuclear Transfer
– Embryo Co-Culture
 Consequences unpredictable, but now have “serious
federal regulations without serious (?any) federal
support”
Progress

 Improving success rates

Lower rates of multiple
60%

50%

pregnancies 40% IVF

Donor Egg

New therapies
30% Cryo
 GIFT
20% ZIFT

 Simpler therapies 10%

0%
1980 1985 1990 1995 2000

 Flexibility of American system

– Advantage compared to Europe
– Risk of impeded progress with regulation of therapy

Fertil Steril 78:943-50, 2002.

Controlled ovarian hyperstimulation

The rationale
•  Number of oocytes available
(  chance of fertilization )
•  Steroid production
(  chance of implantation )
• It may correct subtle ovulatory disorders, such as
luteinized unruptured follicle syndrome, not detected
with routine diagnostic studies
• More exact time to ovulation and insemination can be
determined
 Synchronization of the
menstrual cycle
Brown 1978

- Menses is the marker for onset of uterine/endometrial cycle.

- inter-cycle FSH is the marker for functional onset of ovarian cycle.

- Only those antral follicles which coincide with the inter-cycle rise in

FSH can enter the final stages of follicular growth

 Synchronization of the
menstrual cycle

Controlling the timing of occurrence of inter-cycle increase

in FSH :

 Timely use of E2 (2 mg estradiol valerate, PO BID starting 3

days before the onset of menses of the previous cycle.
 Short-term use of the OC pill for 7 to 21 days in the cycle
preceding stimulation cycle
 In IVF cycle : GnRH-agonists in long/short protocols
 COH with or without IUI
Ovarian Stimulation Protocols
 Clomiphene citrate or similar drugs
 u-hMG or highly purified u-hMG
 Purified u-FSH or highly purified u-FSH
 Recombinant (r-FSH)
 Combinations
----------------------------------------------------------------------
 GnRH agonists in combination with hMG and/or FSH (long,
short or ultra short protocol)
 GnRH antagonists in combination with hMG and/or FSH
(fixed or variable protocol)
 Protocol for
Low-Dose Gonadotropin Therapy
on IUI
 hMG/FSH given by daily intramuscular injection
 Treatment started with the onset of spontaneous or progestin-induces menses
 Starting dose : 0.7 ampule (52 IU) per day
 Response assessed primarily by ultrasound, supported by estradiol and LH
measurements
 After 14 days (7 day in subsequent cycles) if no dominant follicle, dosage
incerased by 0.3-0.5 ampule per-day
 When follicle >10mm, dose maintained until hCG maximum daily or threshold dose
reached
 hCG 5000 IU given when follicle >17mm, witheld if more than three follicles
>15mm
 Progesterone plus hCG 5 to 8
 Next cycle started after menses at subthreshold dose
 COH with or without IUI
Which ovarian stimulation needed ?
Drug Cost; Drug availability and Patient acceptability
 CC is an effective alternative for young women with good
prognosis, whereas in the remaining cases hMG or FSH would
be the preferable drug.
 rFSH Vs Urinary preparations : No difference in clinical
pregnancy rate.
 There is no advantage in routinely using GRh-a in conjunction
with gonadotrophins for ovulation stimulation

At the moment one should use the least expensive

medication.
 COH with or without IUI
Endometrial thickness & Monitoring
ovarian stimulation

3500
E2 n = 183
3000
(pmol/L)
2500
2000
1500
1000
500
0
0 5 10 15 20
Shoham, 2002 Endometrium (mm)

Correlation between E2 and endometrial thickness

 COH with or without IUI
Optimum ovarian stimulation

 2 - 4 follicules with Ø 18 – 19 mm.

 Estradiol blood level :

150-250 pgm / ml per  15 mm follicle.

 Endometrium  9 mm thick & trilaminar.

 hCG injection of 5-10.000 U

 Time intercourse or IUI advisable since ovulation occurs 36-40

hrs later.
Cancellation :
  3 follicles  15 mm irrespective of E2 level

 Estradiol  1500 pg/ml.

 Measures to improve results

 Use of Aspirin in IUI Cycles Hsieh YY et al, 2000 RCT:

Higher pregnancy rate and better endometrial pattern were
achieved in patients with thin endometrium after aspirin
administration.
 Type of catheter Smith et al, 2002, RCT :
No difference in PR when using softer Wallace catheter or the
less pliable Tomcat catheter
 Vaginal misoprostol at the time IUI Brown et al. 2001 RCT :
200 - 400 μg of misoprostol vaginal insertion at the time of
insemination is associated with higher PR.
 Measures to minimize risk of
OHSS
 Shalev E, et al, 1995 RCT :
s.c. injection of 0.1 mg GnRHa (decapeptyl) instead of
hCG in IUI treatment cycles at high risk of OHSS.
 De Geyter, et al 1996 RCT :
Transvaginal aspiration of supernumerary follicles
(more than three follicles sized > 14 mm) does not
reduce the PRs and reduce multiple pregnancy rate.
 Multiple Gestation

From curiosity to
epidemic
Septuplets following Ovulation induction;
Miracle in Iowa?
 Multiple Gestation

Rate
Japan 66.7/1000
US / Europe 11/1000
Africa 40/1000
Monozygous 3.5/1000
Ovulation Induction / ART 37%
Multiple birth rate in Ovulation
Induction and ART
Unacceptable high.
Triplet and higher order is a major medical problem.
Twins are also a medical problem.
Can only be overcome by carefull management of
ovulation induction and reducing number of embryos
transferred.
Twins born in Western Australia
1991
4 times more likely to be stillborn.
5 times more likely to dies as neonates.
16 times more likely to weight less 1500g at
birth.
CP 8 times more often than a singeltone.
Required neonatal intensive care 8 times more
often than singleton.
 Multiple pregnancy rate related to the
number of follicles > 16 mm on hCG
day
No. of No. of No. of Clinical No. of Birth No. of Multiple
follicles on cycles clinical pregnancy birth rate twins birth rate
day hCG pregnancy rate (%) (%) (%)

1 foll. 277 47 17.09 39 14.18 2 5.13

2 foll. 77 20 25.97 17 22.08 2 11.76
3 foll. 32 11 34.38 10 31.25 2 20.00
>3 foll. 19 5 26.32 4 21.05 2 50.00
Overall 405 83 20.60 70 17.37 8 11.4
 FSH Administration Regimen
Chronic Low Dose (CLD): S. Franks et al.

75 IU 75 IU 112.5 IU 150 IU hCG

Days 7 14 21 28

Step Down (SD): B. Fauser et al.

150 IU 112.5 IU 75 IU hCG

Foll.  10 mm

Sequential (SE): J.N. Hugues et al.

½
112.5 IU 150 IU
75 IU 75 IU hCG
6 12
Foll.  14 mm
 How to minimize the risk of
multiple birth
Strict criteria for hCH administration.

Replacing hCG with rec-LH or GnRH-a

Optimize Follicular Development?

The use of different doses of rec-LH
ART : Controlled Ovarian Hyperstimulation
Intervention Decision/evidence
Use of GnRH antagonist short protocol using: it is short and simple protocol with a
Pituitary significant reduction in incidence of severe OHSS but a lower pregnancy rate compared to the
GnRH agonist long protocol.
desensitization
depot Vs. daily administration of GnRHa : not beneficial
rFSH Vs. hMG : No difference in clinical pregnancy rate. More large RCTs are needed to
estimate the difference between them.
rFSH Vs. uFSH :definite increase in the clinical pregnancy rate with the former.
Highly purified hMG Vs. rFSH: No difference in clinical pregnancy rate; the first is much
more costly.

Stimulation CC + recombinant FSH + recombinant LH Vs. Long protocol: same effectiveness . The former
regimens is less expensive, less monitoring, less burden on the patient and the clinic, less risk of OHS.

Use of growth hormone:

*no previous poor response to ovulation induction: No improvement in pregnancy rate
*In poor responders : no evidence.

Use of R-hCG in the final oocyte maturation: effective, well-tolerated by the patient. 250 ug
of R-hCG equals 10000 IU of U- hCG.
Intravenous administration of albumin at the time of oocyte retrieval: beneficial
Prevention Withholding gonadotrophins ( coasting) :insufficient evidence of effectiveness.
of OHS
Embryo freezing: insufficient evidence of effectiveness ( only 2 trials were eligible)
Pregnancy Outcome
Ovulation Induction & OHS

 Treatment protocols and medication (?)

 Factors influencing infertility
– Subfertility (immunology, adhesions)
– Sperm function (antisperm antibody, sperm survivals)
 Outcome of ovulation induction beyond the ovaries
– Endocervical mucous
– Optimizing fertilization period
– Implantation markers
RCOG EBM - THE MANAGEMENT OF
INFERTILITY IN SECONDARY CARE

 Recommendation 14
– Intrauterine insemination with or without ovarian stimulation is an
effective treatment where the man has abnormalities of semen quality,
but it has to be remembered that the pregnancy rates even after
treatment remain very low (A)
 Recommendation 29
– Patients undergoing ovulation induction must be given information
about the risks of hyperstimulation multiple pregnancy, ovarian and
the possibility of fetal reduction (C)
 Recommendation 30.
– Clomiphene is an effective treatment for anovulation in appropriately
selected women (A) .
– Up to 12 cycles of treatment should be considered (B)
RCOG EBM - THE MANAGEMENT OF
INFERTILITY IN SECONDARY CARE

 Recommendation 31
– Ovulation induction with clomiphene should only be performed in
circumstances which allow access to ovarian ultrasound
monitoring. If GPs are involved, there should be an agreed shared
care protocol (C)

 Recommendation 32
– FSH and hMG are both effective for ovulation induction in women
with clomiphene-resistant polycystic ovarian syndrome (PCOS) (A)
The fertilized egg (also called a zygote or 1-cell embryo). The cumulus
mass has been removed manually. The egg is the larger of the two balls contained within the
thick circular rubbery coat called a zona pellucida. Within the egg, are two smaller concave-
looking spherical objects -- each of these is a 'pro-nucleus' contributed by one parent or the
other and containing the parental DNA. Next to the egg (but within the zona pellucida) is
spherical object called a 'polar body'. The polar body is extruded from the egg proper after
fertilization with a second portion of maternal genetic material.
The 4-cell embryo. Once again, each of the cells in the embryo divides. At this stage, it
is still possible for each individual cell to become an entire human being. If the embryo breaks
apart into its four cells at this stage, four identical quadruplets could develop to birth. Although
a rare event, there are many known cases.
The 2-cell embryo. The first cell division takes place a day after fertilization. (At this stage,
it is no longer appropriate to call it a zygote or egg.) From the 1-cell stage of embryogenesis all
the way down to the blastocyst stage (shown below), the embryo is floating freely without a
source of nutrients and it is physically constrained within the zona pellucida. So during this entire
period, the embryo remains the same size.
The 8-cell embryo. Differentiation has still not taken place. Each cell could become an
entire human being (in theory). Therefore, any cell can be removed at this point for genetic
diagnosis without any effect on the development of the remaining embryo.
Intra Cytoplasmic
Sperm Injection
 The History of Great Performance of
Melati Program RSAB Harapan Kita
Jakarta

• IVF-ET
• 1 (single) 2 May 1988
• 2 (twin) 8 August 1989
• 3 (triplet) 27 March 1989
• 4 (quantiplet) 18 August 1991
• ICSI 10 April 1996
• Frozen technique
• ET 6 July 1997
• Frozen sperm MESA/TESA 14 April 1998
• ICSI 24 June 1998
• 2003 Pregnancy rate 35-50% The 600th IVF baby was born
on September 25th, 2003