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Infertility Treatment

•  Assisted Reproductive Technology (ART)

The term ART is used in different contexts but should cover induction of ovulation, sperm preparation, intrauterine insemination, IVF, ICSI, (GIFT, ZIFT,), SSC and genetic testing and manipulation. Many of these treatments fall outside the scope of this ebook and so I have limited the discussion to those listed below.

1) IN VITRO FERTILISATION (IVF)

This type of treatment, the first to be introduced in 1978 still remains as the mainstay of ART today. The object of IVF is to add sperm to eggs in the laboratory (instead of the Fallopian tube) in situations where the normal pathway via the Fallopian tubes is damaged or absent, or sperm is not functioning normally. The process of IVF requires a significant time contribution and is emotionally stressful. When performed for the correct reasons, it offers a pregnancy (success) rate of approximately 30-50% percent per single attempt. Units specialising in ART undertake this type of treatment. (see choosing an IVF unit)

A treatment cycle requires the stimulation of multiple eggs in the ovary using drugs such as clomiphene citrate, HMG, FSH GnRH agonists/antagonists and/or HCG. At an appropriate time, eggs are collected either by ultrasound as an outpatient procedure, or rarely by laparoscopy. The sperm is collected, prepared and added to the eggs in the laboratory. Once fertilisation and division of the eggs has occurred, usually after forty-four hours, normally one or two embryos are replaced into the mother's uterus by means of a thin plastic tube (transfer catheter) inserted via the vagina and cervix. (See Fig. 7.1 ).

2) INTRACYTOPLAMIC SPERM INJECTION (ICSI)

ICSI represents one of the major advances in human reproduction and ART that occurred in the 90's. It differs from IVF by what happens once the eggs and sperm reaches the laboratory. Essentially a single moving sperm is injected into a single mature egg. Thus the couple requires very few sperm for this type of therapy. ICSI has opened up treatment to a whole new group of patients in whom classical IVF was unsuccessful. This includes males with very low sperm counts (< 5 million / ml), males with antisperm antibody problems, couples who have had failed fertilisation at IVF. Once embryos are formed, embryo transfer is identical to IVF.

3) GAMETE INTRAFALLOPIAN TRANSFER (GIFT)

This procedure developed as an offshoot of the IVF technology in the 1980's. It differs from IVF in that it requires the presence of normal Fallopian tubes. Today because of the high success rates achieved with IVF it is seldom used. The procedure did involve the placing of an egg sperm mixture in the Fallopian tube via laparoscopy.

4) EMBRYO FREEZING AND REPLACEMENT (Transfer)

Advances in freezing technology allow unused embryos, provided they are structurally normal, to be frozen and stored. Embryos can be stored for years without any apparent defects occurring. These can be thawed and replaced in normal cycles greatly simplifying the patient's treatment cycle and costs. At this time it would appear that the pregnancy rate from frozen embryos is lower than that from fresh embryos.

Unfortunately at the time of writing while some eggs have been successfully frozen the technology has not reached the same level as that for embryos and is not a routine clinical procedure.

5) BLASTOCYST CULTURE

The embryo is usually replaced at the 2-8 cell stage of development. The blastocyst (multicellular stage with fluid compartment) stage may be reached by prolonging the culture of the embryo in the laboratory for a longer period and if it reaches the blastocyst stage can be transferred to the uterus at that time. This scientific approach helps in selecting the embryo(s) with a greater chance of succeeding. To achieve this degree of development special laboratory conditions are required.

6) ASSISTED HATCHING

7) GENETIC TESTING

Genetic testing represent one of the most exciting fields of medicine in the new century and its impact is and will be enormous. Genetics involves the study of heredity, by testing the information carried in each and every human cell that makes each one of us unique. In the field of fertility certain genetic tests are already available. These genetic tests can already be performed to diagnose special causes of infertility. In addition the embryo can undergo certain genetic tests before it is returned to the mother's uterus during IVF/ICSI cycles to exclude certain genetic problems and this is referred to as Pre-implantation Genetic Diagnosis (PGD).

For more information you will need to discuss these topics with your fertility specialist.

8) CHOOSING AN IVF UNIT

There is little doubt that many couples experience a great deal of difficulty in choosing an IVF unit. Obviously many factors are involved in this decision, including cost, convenience, level of emotional and medical care, but one of the most important is success rate. In determining a unit's success rate, certain basic information is needed and any unit you choose must provide this data. If they cannot, one should be cautious!

In order to achieve a pregnancy the process of ART requires the replacement of embryos. Poor quality units will often replace a large number of embryos to achieve a success as their business depends upon success. Unfortunately replacing high numbers of embryos increases the chances of a pregnancy but at the same time also increases the chance of a multiple pregnancy. Multiple pregnancy carries its own risks for mother and babies not to mention the impact of multiple pregnancies on the couple. In addition some units offer selective reduction of multiple pregnancies and in general this is unacceptable medical practice, as multiple pregnancies should be avoided if possible or kept to twins if at all possible!

The essential information you require is listed below:

1. How many treatment cycles has the unit performed in the last year? Preferably 150 or more.

2. What is the average number of embryos transferred? Preferably 1 or 2 under exceptional circumstances 3.

3. What is the overall pregnancy rate for the last year? = N x 100 / T

N= number of women achieving a pregnancy, meaning having a pregnancy sac in the uterus with a foetus and foetal heart at 6 weeks gestation, as seen on ultrasound

T= number of women having an embryo transfer per year.

This answer will depend upon female age and so one should request results as follows

Pregnancy Rate (%) Per Transfer (Embryos transferred 2) 

By transferring no more than 2 embryos the only risk of multiple pregnancies would be twins. Some good units are now considering the transfer of a single embryo only! Be extremely cautious of units that ROUTINELY transfer 3 or more embryos, as there are both medical and social complications associated with multiple pregnancies!

Frozen embryo pregnancy rates using the same criteria and 2 embryos per transfer would be 5-15% for an average unit and 15-25% for a good unit.

When it comes to cost remember that cost effectiveness is more important than cost! In addition always ensure that you have a full breakdown of the costs in writing so you can avoid so called hidden costs!

Finally make sure that all your queries have been answered to your satisfaction and don't accept vague statements but get information and results in writing!

9) FUTURE

Fortunately for you, the patients, our knowledge of human reproduction and treating the related problems are progressing so rapidly that over 80% of couples attending a fertility specialist can be helped to have their own child. It pays you to keep up to date and updates of this book will be released when appropriate.