Assisted Reproduction
Intra-Uterine Insemination (IUI)
Definition
Intra-uterine Insemination (IUI) is the placement of sperm
directly into the uterus of the woman, bypassing the cervix.
Indications
This procedure is performed for patients with a cervical factor (cervicitis,
cervical stenosis, inadequate mucus or hostile mucus), unexplained infertility,
male factor infertility or immunological infertility.
Procedure
The female's ovaries are stimulated hormonally to produce follicles
containing the eggs. An ultrasound scan is performed to determine
the number and size of the follicles and also the thickness of the endometrium,
lining the uterus, to see whether it is ready for implantation. Also,
blood hormone levels will be measured. Ovulation will be induced
by an injection of human chorionic gonadotrophin (hCG), and the egg will
be released 36-48hr later. The male partner's semen is processed to select
the highest quality sperm. The physician will then inject this sperm
via a catheter through the vagina and cervix, into the uterus.
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For
IUI, sperm are first washed and placed into a sterile medium.
The sperm are then concentrated in a small volume of medium and
are injected directly into the uterus. |
Therapeutic
Insemination with Donor Sperm (TID)
Definition
TID is the placement of donor sperm directly into the uterus of the patient.
Indications
In cases of severe male factor infertility, i.e., very low sperm count and/or
motility, or no sperm at all, TID may be indicated. TID may also be used if
the male partner carries a genetic disorder.
Procedure
The procedure is the same as for IUI, but with the use of donor sperm.
Donor sperm are frozen and stored for 6 months, to enable adequate screening
and help prevent communicable diseases from being transmitted.
Frozen donor sperm will be thawed and processed to isolate the highest
quality sperm and then placed directly into the uterus via a catheter.
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Through
the process IUI, sperm are placed high in the female reproductive
tract to enhance the chance of successful fertilization. |
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In-Vitro Fertilization (IVF)
Definition
In-vitro fertilization (IVF) is the process whereby the female partner's ovaries
are stimulated to produce eggs. These are then removed and placed together with
her partner's sperm in a petri dish and allowed to fertilize. The resulting embryos
are then transferred into her uterus after 2-3 days.
Indications
IVF is used in cases of tubal blockage, male factor infertility or previously
failed IUI cycles.
Procedure
The ovaries will be stimulated to produce eggs. Firstly, a gonadotropin-releasing
hormone (GnRH) analogue is given for about 8-10 days. Secondly, daily
injections of human menopausal gonadotrophin (hMG) are given to stimulate
the ovaries to produce an increased number of follicles containing the
eggs. After about 8 days, the number and size of the follicles will be
measured using ultrasound. When 1-2 of the follicles reach 18mm
in diameter, an injection of human chorionic gonadotrophin is given,
and the oocyte retrieval scheduled for 36hrs later.
The oocytes will be retrieved via transvaginal ultrasound. Ultrasound
allows the physician to visualize the follicles and can then push a needle
into each of them and aspirate the fluid inside the follicle containing
the oocyte. The follicular fluid is examined by laboratory personnel
for the presence of the egg and if found, is placed in an incubator.
This is done for all the follicles. At the time of oocyte retrieval or
immediately thereafter, the male partner's perm will be processed to
isolate the highest quality sperm. Approximately 5hrs after the oocyte
retrieval, the oocytes and sperm are put together in a petri dish and
placed in an incubator.
The next day, the oocytes are observed to see whether normal fertilization
has occurred. The fertilized oocytes are then left in the incubator to
develop into embryos. After 2-3days after oocyte retrieval, the
embryos are transferred into the uterus of the woman using a special
catheter.
Hormonal treatments are given for the following 3 weeks, after which
a pregnancy test is scheduled. Any excess embryos not transferred
may be cryopreserved for later use (see Embryo
Cryopreservation and Thawing)
Success Rates
The normal success rate with this procedure is about 25-30% depending
on the age of the patient.
Gamete Intra-Fallopian
Transfer (GIFT)
Definition
GIFT is the direct placement of eggs and sperm into the fallopian tube.
Indications
GIFT is usually performed in cases of unexplained infertility.
Procedure
The oocytes/eggs are removed from the woman's ovaries and the sperm
is processed in the same manner as for IVF. The difference is that instead
of allowing the oocytes to be fertilized in a petri dish, the sperm and
up to 3 eggs are injected directly into the fallopian tube and allowed
to fertilize there. Hormones are given for the next 2 weeks to help maintain
a pregnancy. Any extra eggs
may be fertilized in vitro (IVF), cryopreserved, or donated.
Success Rates
The success rate with GIFT is approximately 30% depending
on the age of the patient.
Intra-Cytoplasmic Sperm Injection (ICSI)
Definition
The process whereby a single sperm is injected directly into the cytoplasm of
the egg.
Indications
ICSI is the method of choice for patients with severe male factor infertility,
and for patients who have had previously failed or poor fertilization resulting
from conventional IVF.
Procedure
The eggs are retrieved from the woman's ovaries in the same way as
for IVF. The
eggs are then stripped of all surrounding cells and placed in a droplet
and the male partner's sperm placed in another droplet. The sperm can
be obtained via ejaculation or in severe cases, directly from the testis
or epididymis using microsurgical sperm retrieval techniques.
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The oocyte is held in place by a specialized holding micropipette.
With a microinjection pipette, one sperm is picked up (aspirated) and
then carefully injected into the cytoplasm of the oocyte. This
is done for all the eggs. The eggs are then placed in the incubator,
and checked the next morning for fertilization.
The fertilized eggs are then allowed to develop for another 24-48hr,
after which they are transferred into the uterus via a thin catheter.
Hormonal treatment to help maintain a pregnancy is given for the next
2 weeks.
Success Rates
The success rate for ICSI is usually around 30-35%.
Microsugical Epidiymal Sperm Aspiration
Testiculat Sperm Extraction (TESE)
Round Spermatid Injection (ROSI)
Definition
MESA is the retrieval of sperm from the epididymis
by means of aspiration. TESE is the retrieval of sperm from the testis
by means of testicular biopsy.
ROSI is the injection of round spermatid (immature spermatozoa) when
no mature sperm can be found in the testis.
Indications
When sperm are unable to move through the genital tract due to uncorrectable
damage, sperm can be extracted directly from the epididymis or testes
via microsurgical techniques. Congenital absence of the vas deferens
(CAVD) or failed sterilization reversal are other indications.
Procedure
Around the time that the woman has her eggs retrieved, the husband/male
partner will undergo a surgical procedure that will either take a very
small piece of testicular tissue (TESE) or aspirate the fluid from the
epididymis (MESA). For
TESE/MESA the testicular tissue/epididymal
fluid will be examined for the presence of sperm cells. These can then
be injected into the oocyte via ICSI. In cases where no sperm are seen,
round spermatids (immature sperm seen on right) can be used for ICSI
(ROSI).
We at the Kentucky Center for Reproductive Medicine and IVF in cooperation
with the Andrology Institute of America and Dr. Zavos, along with other
Scientists and Physicians from Japan, Greece and France, have been successful
in developing and employing the new ROSI Technique. This method
enables the micro-injection of round spermatids (immature spermatozoa),
recovered from the testes or from post-ejaculated fractions into retrieved
oocytes via ICSI techniques and achievement of fertilization and pregnancies.
This technique will assist a great number of azoospermic males with round
"spermatid-type" arrest in their testes and other male infertility
patients with other severe spermatogenic deficiencies to achieve pregnancies,
throughout the World.
Sperm Cyropreservation
and Thawing
Definition
The process of preserving sperm by means of freezing for use at a later time.
Indications
Sperm can be cryopreserved in cases where the male might have difficulty in producing
a specimen at a given time. If sperm were retrieved microsurgically, excess
sperm may be stored to avoid having to repeat the invasive surgical procedure.
Also, for patients planning to undergo chemotherapy or radiotherapy (for cancer),
sperm may be cryopreserved as the therapy may diminish their sperm production.
Sperm can also be frozen for persons wishing to donate their sperm to infertile
couples.
Procedure
Sperm retrieved by masturbation, testicular biopsy or microsurgical
epididymal sperm aspiration are placed together with a cryoprotectant
and stored in cryostraws in liquid nitrogen at a temperature of -196°C.
This can be thawed at any time, and the cryoprotectant can be removed
and the sperm used for ART procedures.
Embryo Cryopreservation
and Thawing
Definition
The process of storing embryos by means of freezing in liquid nitrogen for use
at a later time.
Indications
When excess embryos are present after an embryo transfer, these can
be frozen and then transferred in subsequent cycles, if the patient does not become
pregnant. This would save her from undergoing another oocyte retrieval
procedure. She may also elect to have her embryos donated to another
infertile couple.
Procedure
Excess embryos are place with a cryoprotectant and aspirated into cryostraws,
and then gradually frozen to a temperature of -196°C, and placed in liquid
nitrogen. Storage can be indefinite but KCRM requires written approval/consent
from the parents every 3 years.
When the patient wants to transfer embryos that are in cryostorage,
these can be thawed prior to or on the day of transfer, assessed for
survival and development, and then transferred.
Sperm Donation
Definition
The donation of sperm for the use by infertile couples with severe male factor
infertility.
Indications
Donor sperm may be used when the male partner has azoospermia or severe male
factor, has a know hereditary/genetic disorder that could be carried over to
biologic offspring, or has had previously failed IVF attempts and do not choose
to have ICSI. Donor sperm may also be used in females without male partners.
Oocyte Donation
Definition
The donation of oocytes for the use by infertile couples.
Indications
Women may choose to have donated oocytes if they have hypergonadotrophic
hypogonadism, have diminished ovarian response, have persistently poor
oocyte and/or embryo quality in previous ART's, or have known hereditary/genetic
defect that can be carried over to the offspring.
Assisted Hatching
Definition
Assisted hatching is the opening of the zona
pellucida , surrounding the embryo, to help the embryo/blastocyst "hatch" or
emerge from the zona and implant in the uterus.
Indications
Assisted hatching is usually indicated in older women, and those with failed
implantation in previous cycles.
Procedure
Prior to embryo transfer, a small opening is made in the zona pellucida
using microdissection tools. The embryos are then transferred normally.
Gender Selection
Definition
The process of gender selection increases the chance of having a female or male
child, by separating sperm that bear the X chromosome (female) and those that
have the Y chromosome (male), and inseminating with whichever sample is desired.
Indications
The procedure can be employed for couples who want a child of a specific gender.
Procedure
The procedure used is the sedimentation method. This method is used
similarly for both male and female selection and takes approximately
2-2½
hours to process. On average, it takes about 3-4 cycles to achieve
a pregnancy with this method.
Success Rates
Our success rate is approximately 80% for male selection and 72% for
female selection.
Traditional Surrogacy
Definition
A traditional surrogate is one who donates her oocytes and carries the pregnancy
using sperm from the intended natural father (husband) or a donor.
Indications
The surrogate's ovaries are stimulated hormonally to produce follicles
containing the eggs. An ultrasound scan is performed to determine the number and
size of the follicles and also the thickness of the endometrium, lining the
uterus, to see whether it is ready for implantation.
Also, blood hormone levels will be measured. Ovulation will be
induced by an injection of human chorionic gonadotrophin (hCG), and the
egg will be released 36-48hr later. The semen from the intended
natural father is processed to select the highest quality sperm. The
physician will then inject this sperm via a catheter through the vagina
and cervix, into the uterus. If conception occur, the surrogate will
carry the pregnancy to term.
Gestational Surrogacy
Definition
The gestational surrogate is one who only carries the pregnancy to term, and
the eggs are derived from another source.
Indications
This procedure is very similar to IVF, except that instead of transferring the
embryos into the female patient, they are transferred into the uterus of the
designated surrogate.
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