Infertility Treatments and Procedures

Introduction

Treatment for infertility varies widely from patient to patient. Over the past several years, the improvement in techniques and procedures in reproductive medicine has increased the variety and availability of procedures to assist couples in achieving pregnancy. Treatment for your situation must be based on your particular diagnosis and your decision on the aggressiveness of your treatment.

Depending upon the diagnosis, treatment may include timing of intercourse, hormone therapy to correct abnormalities in the natural menstrual cycle, intra uterine insemination (IUI) to bypass problems with sperm/cervical mucous interactions, in vitro fertilization (IVF-ET) with embryo transfer, Gamete or Zygote intra fallopian transfer (GIFT/ZIFT), frozen embryo transfer (FET), or intra cytoplasmic sperm injection (ICSI).

We offer you a variety of options during the course of your evaluation and treatment. Testing procedures to determine male partner status, uterine/ovarian status, and tubal status provide us with information to recommend treatment options for you. Many patients attempt a less invasive treatment plan at first such as timed intercourse or IUI. If after several (usually 3-6) cycles the treatment does not result in pregnancy, the patient then moves to a more aggressive treatment such as IVF or GIFT.

Some patients decide to attempt a more aggressive procedure immediately because they desire to get pregnant as soon as possible without losing time with procedures that are less likely to be successful.

If the initial screening tests reveal blocked tubes or extremely low sperm counts, the options become more limited to achieve pregnancy. In this case your options would be to attempt to repair blocked tubes by surgery, undergo IVF which completely bypasses the blocked tubes, or in the case of low sperm counts, undergo ICSI to fertilize the eggs by micromanipulation using one sperm for one egg.

Whatever the ultimate treatment plan becomes, we want you to understand that the ultimate decision making remain with you and your spouse. We are here to educate and inform you and suggest recommendations about your particular case, then you decide where to go with the information. Below you will find more information about treatments and procedures we provide to begin your education process.

Timed Intercourse

This is the most basic treatment for infertility. If a basic workup determines normal tubal patency, follicular development, endometrial development, and semen analysis, you can attempt pregnancy through timed intercourse. This procedure may include using a urine surge test kit to determine the time of ovulation upon which you and your partner will have intercourse at a given time. This is to attempt to have the sperm in the fallopian tube at the time the egg is released and begins to travel down the tube.

A more advanced form of this treatment may include a monitoring ultrasound to determine follicular development as well as the development of the uterine lining. A trigger shot of Human Chorionic Gonadotropin (also known as Profasi) can be given to trigger ovulation and set up the timing for intercourse.

Intra Uterine Insemination (IUI)

This in-office procedure also known as "artificial insemination" involves placing washed sperm into the uterus with a small catheter through the cervix. Sperm can be from the husband or from frozen donor sperm, depending upon your situation and needs. The sperm is washed several times to remove substances that can cause cramping or shock. Once the sperm is washed, it can remain viable for 24-48 hours.

IUI is often performed if you have had failed attempts at timed intercourse or if there is a determination of abnormal cervical mucous/sperm interaction, poor mucous, or hostile mucous which renders the sperm unviable. In the later case, the sperm is injected past the cervical barrier to enable them to then move into the fallopian tube and reach the egg. Variations in the procedure include taking medications to produce multiple follicles and the release of more than one egg (superovulation) in order to achieve fertilization.

Insemination may bring your potential to a 20% pregnancy rate/cycle. Usually a patient will undergo from three to six IUI cycles before moving to a more aggressive procedure.

In Vitro Fertilization-Embryo Transfer (IVF-ET)

IVF-ET is probably the most well known of the Assisted Reproductive Technologies. It is otherwise known as "test tube baby" and has helped infertile couples conceive and bear children for over a decade. These days fertilization actually occurs in a dish and not a test tube. It was originally developed to help couples overcome tubal factor infertility, but has become useful in treating other factors such as immunological problems and unexplained infertility.

IVF is basically a four step process. First, you take medications to make multiple follicles begin to develop on your ovaries. This step is referred to as ovarian stimulation or superovulation. Step two involves monitoring follicular growth by ultrasound to determine egg growth and uterine lining development. When it is determined that the follicles and the uterine lining are appropriately mature, a trigger shot of Human Chorionic Gonadotropin is then administered.

Thirty six hours after the trigger shot, the third step begins with retrieval of the eggs by ultrasound-guided-needle aspiration, an in-office procedure. A sperm specimen is then washed and prepared for insemination. The washed sperm is then placed in a dish with the eggs and they are placed in an incubator for 18 hours. After 18 hours, the embryos are observed for normal fertilization which can be visualized under a microscope where the pronucleus of egg and sperm can be seen. The proembryos can then be transferred to the uterus or incubated for further development into multi-cell embryos.

The fourth and final step involves transferring the embryos into the uterine cavity via a tube inserted through the cervix. The number returned varies with the desires of the patient under the guidelines of age categories; under 35 years old, up to four embryos, 35 years and older, up to six embryos. Additional embryos may be frozen and stored for future use (see Cryopreservation).

National statistics for women 39 or less without male factor is 27% pregnancy rate per embryo transfer, for women over 39 without male factor, 14% pregnancy rate per embryo transfer. Keep in mind that delivery rates will be lower due to miscarriage.

Gamete Intra Fallopian Transfer (GIFT)

GIFT can also be classified as a four step process. This form of assisted reproduction involves the same first and second step as in vitro fertilization, namely superovulation and monitoring follicular and endometrial growth by ultrasound.

The third and fourth steps occur in the operating room of a hospital where the patient is placed under general anesthesia. The eggs are retrieved, again by ultrasound-guided-aspiration of the follicles on the ovaries. A previously washed and prepared sperm specimen is obtained. The eggs and sperm are then placed together in a catheter.

In step four, a laparoscopy is performed on the patient and a small camera is placed just under the naval into the pelvic area. The fallopian tube is then grasped using special instruments and the catheter containing the eggs and sperm are threaded into the fallopian tube. The eggs and sperm are then injected into the fallopian tube.

The idea is to circumvent physical barriers to normal egg and sperm transport due to adhesions, endometriosis, and immunological problems. Although the process places the egg and sperm in close proximity which enhances the chance of collision, it does not guarantee fertilization. Extra eggs can be taken back to the lab for in vitro fertilization and possible embryo freezing for future use. This also helps determine if normal fertilization can take place. In cases of questionable sperm motility or fusion, achieving fertilization in the lab may be preferable. It is difficult to improve on mother nature and we recommend a patient consider GIFT over IVF if she has open, healthy fallopian tubes and her husband has normal sperm.

National statistics for women 39 or less with no male factor is 39% pregnancy rate per gamete transfer, for women over 39 with no male factor it is 20% pregnancy rate per gamete transfer. Keep in mind that delivery rates per gamete transfer will be less due to miscarriage.

Zygote Intra Fallopian Transfer (ZIFT)

Experience with GIFT has shown that couples with male factor infertility have a significantly lower success rate that couples experiencing other problems. This is believed to be caused because in the GIFT procedure there is no way to verify whether fertilization does in fact take place.

This problem can be overcome using ZIFT, which is a combined procedure between IVF and GIFT. The first three steps of a ZIFT procedure are identical to the IVF procedure. This allows the determination of normal fertilization before the patient has to undergo a surgical procedure and general anesthesia.

After fertilization has been achieved, the patient is then taken to the operating room at the hospital and placed under general anesthesia. Step four then becomes identical to step four in the GIFT procedure only pronuclear embryos are placed in the catheter and transferred to the tube instead of gametes.

National statistics for women 39 or less with severe male factor is 28% pregnancy rate/zygote transfer.

If pregnancy is successfully established with any of the aggressive Assisted Reproductive Technologies, multiple gestation, miscarriage, ectopic pregnancy, preeclampsia, stillbirth, and/or congenital anomalies (birth defects) may occur. The miscarriage rate is equivalent to that seen in pregnancies with superovulation without Assisted Reproduction, but is slightly higher than natural cycle pregnancies. Ectopic (tubal) pregnancies may have a higher incidence than in the general population, but this is more a factor of chance reflux into the tube during embryo transfer or tubal status which is not caused by the procedure itself. The incidence of stillbirth or congenital anomalies is not increased beyond that seen in the general population. Multiple gestation is a REAL risk. Reduction in fetal number should be a consideration in gestations beyond triplets.

Intra Cytoplasmic Sperm Injection (ICSI)

ICSI is a type of assisted microsurgical fertilization that involves the injection of a single sperm directly into an egg. Over the last few years, various methods of assisted microsurgical fertilization (micromanipulation procedures) have been developed for use when the male partner exhibits severe oligoasthenospermia or asthenospermia (poor motility and/or low sperm count). ICSI allows a much higher fertilization rate for these patients with "normal" fertilization in over 50% of the eggs.

Eggs for ICSI are obtained in exactly the same way as those for IVF. Following egg retrieval, the cells surrounding each egg are carefully removed. The eggs are then examined under a microscope and only those which have extruded the first polar body (a structure indicating egg maturity) are suitable for injection. Typically, 70% of the eggs that are obtained are suitable for ICSI.

The sperm are washed and prepped. Theoretically, the minimum number of sperm needed is equal to the number of eggs to be injected. The egg and the sperm are then placed on a special microscope which has micromanipulators attached to it. One micromanipulator holds the egg in place, while the other is used to inject the sperm into the egg. The remainder of the procedure is similar to standard in vitro fertilization with regard to incubation of the eggs and transfer of the resulting embryos. The ZIFT procedure may also be used to place the embryos directly into the fallopian tube. Excess embryos can be frozen for use in the future.

This technique was pioneered by a group of physicians in Belgium. As of April, 1994, the group reported the live birth of 289 children through this technique. They have noted 7 major malformations or birth defects. The percentage of major birth defects (7 out of 289 or 2.4%) falls within the range of malformations in the general population.

Donor Oocyte Program

The purpose of the Donor Oocyte (or "Egg") Program is to enable infertility couples to become pregnant by implanting an embryo or embryos into a woman (the "Recipient") who wishes to become pregnant but who is not able to do so because she cannot produce eggs. In order to implant embryos, it is necessary to retrieve unfertilized eggs from another woman (the "Donor") who is willing to donate her eggs for this purpose. Using techniques that are common in in vitro fertilization, the physician and staff of IVF Phoenix will attempt to retrieve eggs from a donor, fertilize the eggs with sperm of the Recipient's partner or with sperm from a sperm donor, and to transfer the resulting embryo(s) into the womb of the Recipient.

The physician may either approve a Donor for a Recipient who provides the Donor (a "known donor"), or the Physician may provide a Donor (an "anonymous donor") for Recipients who are seeking a donor. In order to maximize the success of the program, anonymous Donors may provide eggs for more than one recipient, at the discretion of the Physician.

The testing and evaluation of the egg donor is similar to the screening of a sperm donor. She will be between the ages of 18 and 36. She will report a negative history for genetically transmissible (inherited) diseases, current infection, malignancy (cancer), substance abuse (drugs, tobacco, alcohol, etc.), medication use, and prior chemotherapy or radiation therapy. In addition, she will be tested/screened for sexually transmitted diseases as appropriate. Insofar as possible, the donor's physical characteristics will be matched to yours. If the donor is recruited by you, you will assume responsibility to screen the donor's background as mentioned above and decide if they are acceptable to you.

Cryopreservation

Cryopreservation involves slowly freezing embryos to store them for future use. This process involves a special liquid nitrogen freezer and the use of cellular antifreezes. The embryos are then stored, submersed in liquid nitrogen until they are thawed and placed into the uterus.

Not all embryos survive the freeze-thaw process. A 50% survival rate is considered reasonable. After the thaw, embryos retaining 50% or more of the cells they had before freezing are cultured and placed back into the uterus exactly like step four in in vitro fertilization.

Clinics all over the world have reported clinical pregnancies and normal, live births. Embryo freezing in laboratory animals, as well as the experience with human embryos, has shown that the rate of congenital anomalies or malformations in offspring is the same as that of the general population.

Embryo freezing is a new area in which legal principles and requirements have not been firmly established. Based on currently accepted principles regarding legal ownership of human sperm and ova, each embryo resulting from the fertilization of the wife's egg and the husband's sperm will remain with the couple, unless there is no legal marriage or husband, then ownership of the embryo resides solely with the woman signing the consent form. This principle may change at any time based upon the laws of the state or guidelines being revised. Documents must be in place which instruct the laboratory what to do in the event that the wife can no longer have the embryos transferred into her uterus. Disposition of frozen embryos may also be subject to and controlled by final decisions of a court or other governmental authority having jurisdiction.

Fertilethoughts Homepage  

 

 

 

 

 

 

 

 

 

[an error occurred while processing this directive]