Introduction
The 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 specific diagnosis as determined by your medical history and various testing procedures. These may include testing of your uterus, fallopian tubes, and ovaries as well as testing the quality of your partner’s sperm. The results of these tests help us to recommend the treatment options that would be best for you. Our recommendation, along with your desires, will determine the aggressiveness of treatment.
Depending upon your diagnosis, the treatment options advised may include: timed intercourse, hormone therapy to correct abnormalities in the natural menstrual cycle, intrauterine insemination (IUI) to bypass problems with sperm-cervical mucous interactions, in vitro fertilization with embryo transfer (IVF-ET), Gamete or Zygote intrafallopian transfer (GIFT or ZIFT), frozen embryo transfer (FET), or intracytoplasmic sperm injection (ICSI).
Many patients attempt a less invasive treatment plan at first (timed intercourse or IUI). If, after several cycles (usually 3-6), the treatment does not result in pregnancy, the couple may move to a more aggressive treatment plan such as IVF or GIFT/ZIFT. Some couples decide to begin with a more aggressive approach.
If initial screening tests reveal blocked tubes or extremely low sperm counts, the treatment options become more limited. If this is your situation, treatment options include tubal reanastamosis/reconstruction, (repair) IVF to bypass blocked tubes, or, ICSI, in the case of low sperm counts, for fertilization by micromanipulation using one sperm for one egg.
We are here to educate, inform, and recommend treatment options. The ultimate decisions belong to you and your partner.
Below you will find more information about procedures and treatment options to assist you in your decision making process.
Timed Intercourse
Timed intercourse is the most basic treatment for failure to achieve pregnancy. If a basic work-up determines that your fallopian tubes are open, your ovaries are producing normal follicles, the lining of your uterus is developing adequately, and your partner’s semen is normal, you may be advised to attempt pregnancy through timed intercourse. This procedure includes the use of an LH surge testing kit to predict the time of ovulation and determine the times you and your partner will be advised to have intercourse. Timing of intercourse in this way helps to insure that sperm will be in the fallopian tube at the time the egg is released and begins to travel down to the uterus.
A more advanced form of this treatment includes the use of ultrasound to monitor the development of the follicle/egg and the lining of the uterus. Additionally, a “trigger shot” of Human Chorionic Gonadotropin (hCG, or, Profasi) may be given to stimulate ovulation and assist in the timing of intercourse.
Intra Uterine Insemination (IUI)
Artificial insemination is a procedure performed in the office by which prepared sperm is placed into the uterus using a small catheter inserted through the cervix. Sperm can be from your partner or a donor, depending on your situation and needs, but all sperm is prepared through a series of washes that remove substances that can lead to cramping or shock. Once sperm is washed, it can remain viable for 24-48 hours.
Intrauterine insemination is often performed if you have unsuccessful with timed intercourse, or, if it has been determined that your cervical mucus is inadequate, the sperm and mucus do not interact normally or your mucus is hostile to the sperm causing it to become nonviable. In the case of sperm-mucus incompatibility, IUI allows the sperm to bypass the cervical barrier enabling them to move into the fallopian tube and reach the egg.
There are several variations to the insemination procedure. Taking medications to stimulate the ovary to produce multiple follicles and release of more than one egg is one of the most common.
Intrauterine insemination may increase your potential to achieve pregnancy to 20%/cycle. If a couple does not achieve pregnancy after three to six cycles, they may wish to progress 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. Otherwise known as “test tube baby,” (fertilization actually takes place in a dish and not a test tube) IVF-ET has helped many infertile couples conceive and bear children for more than a decade. Originally IVF-ET was developed to help couples overcome infertility due to a problem with a woman’s fallopian tubes. Now it has become a useful treatment option with other factors such as immunological problems or unexplained infertility.
IVF is basically a four step process:
First, you take medications to cause your ovaries to make multiple follicles. This step is referred to as ovarian stimulation or super-ovulation.
Second, the growth of the follicles and development of the uterine lining is monitored by the use of ultrasound. When it is determined that the follicles and the uterine lining are appropriately mature, a trigger shot of Human Chorionic Gonadotropin (hCG) is administered.
The third step begins thirty-six hours after the trigger shot with the retrieval of eggs/oocytes. Guided by ultrasound, the doctor aspirates the eggs from the follicles during a procedure performed in the office.
At the same time, a sperm specimen is collected from the partner or thawed from a donor and prepared for mixing with the eggs. The two are then placed together in a dish and incubated for 18 hours. After 18 hours, the embryos are examined for normal fertilization. Normal fertilization is characterized by a pronucleus of the egg and sperm that can be visualized under a microscope.
The proembryos can then be transferred to the uterus or incubated for further development into multi-cell embryos and transferred two to four days later.
The fourth and final step is the transfer of the embryos into the uterine cavity using
a small tube that is inserted through the cervix. The number of embryos transferred varies with the desires of the couple, their feelings about selective reduction in the case of multiple pregnancies, the quality of the embryos, and the age of the woman. Using guidelines of age only, the following recommendations would be made:
Age 30 and under………………….2 embryos
Ages 31-35.…………………Up to 4 embryos
Ages 36-40………………….Up to 6 embryos
Any remaining embryos may be frozen and stored for future use (see Cryopreservation).
National delivery rates for women who undergo IVF-ET (with or without male factor) are as follows:
Under age 35 35% per embryo transfer
Ages 35-37 30.8% per embryo transfer
38-40 22% per embryo transfer
Over 40 11.6% per embryo transfer
(SART, 1998)
Recent information indicates an increase in the incidence of major birth defects in pregnancies conceived with IVF as compared to pregnancies conceived during natural occurring cycles (9.0% as compared to 4.2%) (New England Journal of Medicine, Volume 346:725-730, March 7, 2002, Number 10)
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 seconds step as in vitro fertilization, specifically, super-ovulation and ultrasound monitoring of the follicles and lining of the uterus.
The third and fourth steps of a GIFT procedure, however, occur in the operating room of a hospital. Under general anesthesia, the eggs are again retrieved using an ultrasound-guided aspiration of the follicles on the ovaries. Sperm is collected or thawed and prepared and the eggs and sperm are then placed together in a small tube or catheter.
In step four a laparoscopy is performed. With laparoscopy, a small incision is made just beneath the navel and an instrument containing a small camera is inserted into the pelvic area. The fallopian tube is then grasped with a special instrument 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 where fertilization takes place.
The goal of GIFT is to circumvent any physical barriers that would interfere with the normal egg and sperm function. These include adhesions, endometriosis, and immunological problems. Although this procedure places the egg and sperm together in the fallopian tube where fertilization takes place, it does not guarantee that fertilization will occur. Any eggs that are not used during the GIFT procedure can be taken back to the laboratory for in vitro fertilization, placed in an incubator and observed. If normal fertilization takes place, the embryos can be frozen for future use.
The national delivery rates for women who undergo GIFT and have no male factor contributing to infertility are as follows:
Under age 35………………...35% per gamete transfer
Ages 35-37…………………..31% per gamete transfer
Ages 38-40…………………..30% per gamete transfer
Over 40……………………….9% per gamete transfer
(SART, 1998)
Zygote Intra Fallopian Transfer (ZIFT)
ZIFT is a procedure that combines both IVF and GIFT techniques and may be used in couples who have a contributing male factor. Experience has shown that couples with male factor infertility have significantly lower pregnancy rates than couples experiencing other infertility problems. With the GIFT procedure there is no way to verify whether or not fertilization takes place whereas with ZIFT fertilization is verified before a woman has to undergo a surgical procedure and general anesthesia.
The first three steps of a ZIFT procedure are identical to the IVF procedure: ovarian stimulation, ultrasound monitoring, and egg retrieval with sperm collection and preparation. The sperm and eggs are then combined, placed in an incubator, and observed. If normal fertilization takes place, a laparoscopy is performed and the fertilized embryos are transferred to the fallopian tubes using a small tube or catheter. These embryos, however, are transferred in a pronuclear phase of development only.
The national pregnancy rate for women undergoing a ZIFT procedure is 26.5% per zygote transfer. (SART, 1998)
Any pregnancy that is successfully achieved with the use of aggressive Assisted Reproductive Technologies, such as IVF-ET, is at risk for multiple gestation (twins, triplets, etc.), miscarriage, ectopic (tubal) pregnancy, preeclampsia, stillbirth, and congenital anomalies (birth defects). The rate of miscarriage in cycles stimulated with super-ovulation drugs is the same whether or not Assisted Reproduction Technologies were used, but slightly higher than in spontaneous pregnancies achieved during a woman’s natural cycle. Ectopic or tubal pregnancies occur at a higher rate than in the general population. This is thought to be due to either chance reflux into the fallopian tube during embryo transfer or compromised fallopian tube status and not caused by the procedure itself. The incidence of stillbirth or congenital anomalies is the same as seen in the general population, but the risk of multiple gestation is REAL. If a pregnancy results in more than triplets, a selective reduction should be considered.
Intra Cytoplasmic Sperm Injection (ICSI)
Over the past several years, various methods of assisted microsurgical fertilization or /micromanipulation procedures have been developed for use when the male partner exhibits poor motility (asthenospermia) or abnormal count, motility, and shapes (oligoasthenospermia). ICSI is a type of assisted microsurgical fertilization that involves the injection of a single sperm directly into an egg and improves the chances that fertilization will occur.
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 that exhibit characteristics of maturity are suitable for injection. Typically, 70% of the eggs that are obtained are suitable.
Theoretically with ICSI, a minimum number of sperm is needed: one sperm for each egg. Sperm is collected, washed, and prepared appropriately then placed, along with the egg, on a special microscope which has micromanipulators attached to it. One micromanipulator holds the egg in place while the other one is used to inject the sperm into the egg.
The remainder of the procedure is similar to standard in vitro fertilization: the eggs are incubated and transferred into the uterus when appropriate growth has been achieved. ZIFT may also be used to place the embryos directly into the fallopian tube and any excess embryos can be frozen for use in the future.
ICSI was pioneered by a group of physicians in Belgium. As of April, 1994, this group reported 289 live births using this technique. Of these, 7 major malformations or birth defects were identified which falls within the range of malformations found in the general population. Recent information, however, indicates an increase in the incidence of major birth defects in pregnancies conceived using ICSI as compared with pregnancies conceived during natural occurring cycles (8.6% as compared to 4.2%). This may be result of ART/IVF and not ICSI.
Donor Oocyte Program
Donor Egg or Oocyte Programs were established to assist couples whose female partner cannot produce eggs. In this program, a donor, known or unknown to the couple, volunteers to undergo a procedure similar to IVF: medications, ultrasound monitoring, and egg retrieval. The eggs from the donor are then fertilized with sperm of the recipient’s partner or with sperm from a sperm donor, and the resulting embryos are transferred into the uterus of the recipient.
Egg/oocyte donors, known or unknown to the couple, must pass evaluation and testing procedures similar to that required of sperm donors. She must be between the ages of 18 and 30, report a negative medical 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. Insofar as possible, the donor’s physical characteristics will be matched to yours. If you recruit you own donor, you must assume the responsibility to screen your donor’s background and decide if they are acceptable to you. Ultimately, the physician will give medical approval for all donors. The physician may also provide an anonymous donor for any couple who requests it. It is important to know that anonymous donors, at the discretion of the physician, may provide eggs for more than one recipient.
Cryopreservation
Cryopreservation is a process that cools an embryo to –40 C. The purpose of embryo freezing is to save embryos that are the product of an IVF/ART cycle. This allows the couple to use the embryos obtained from one fresh IVF/ART cycle for future transfer to the uterus without the need to repeat another ovarian superovulation cycle. Once frozen, the embryos remain stored in liquid nitrogen until the couple requests a transfer of the embryos into the uterus or advises IVF Phoenix to destroy them. Not all of the embryos will survive the freeze-thaw process: approximately 50% are expected to survive.
Worldwide experience has resulted in several clinical pregnancies and normal live births. Embryo freezing has been used in cattle and laboratory animals with no known adverse results in the offspring and, while the long term effects with human embryo freezing are unknown at the present time, the rate of congenital anomalies or malformations in the offspring of fresh assisted reproduction pregnancies is the same as that of the general population.
Legal principles and requirements regarding IVF and embryo freezing have not been firmly established. Currently, there are no Arizona State Laws dealing specifically with these issues. It is generally accepted that each embryo resulting from the fertilization of woman's egg by a man's sperm shall remain the joint legal property of both. If anonymous donor sperm is used, ownership of the embryo(s) will remain with the couple, unless there is no legal marriage or husband, then ownership of the embryo will reside solely with the woman signing the consent form. Disposition of the frozen embryos are subject to legal requirements that have been established by the state and those guidelines can change at any time.
