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.

1) In Vitro Fertilisation (IVF)

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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.

A treatment cycle requires the stimulation of multiple eggs in the ovary using drugs such as, FSH GnRH agonists/antagonists and/or HCG (less commonly clomiphene citrate, HMG). 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 (of the eggs) and division (of the embryos) has occurred, usually after 2 days, ideally one embryo is transferred into the mother’s uterus by means of a thin plastic tube (transfer catheter) inserted via the vagina and cervix.

2) Intracytoplamic Sperm Injection (ICSI)

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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)

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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)

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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

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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. While the pregnancy rate per transfer of blastocyst versus day 2-3 embryos is higher the overall number of pregnancies achieved (requiring more transfer attempts) still remains higher with the day 2-3 embryos.

6) Assisted Hatching

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The term hatching applies to the embryo (which has now reached the blastocyst stage), which develops in the original egg covering called the Zona Pellucida or clear zone. Once the embryo reaches the uterus and before it can implant into the uterine wall this outer clear zone must open and the embryo comes out (hatches). Failure of hatching will prevent conception and currently it is thought that, it may apply to a small number of patients, especially those on ART programmes who are 38 years and older, who have had many embryos replaced without a pregnancy and embryos that have been frozen prior to replacement. Assisted hatching means procedures which artificially thin out the zona pellucida. Different techniques to assist hatching exist and one of these involves the use of a non-contact laser.

7) Genetic Testing

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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).