Full investigation of the causes of infertility specific to the presenting couple.

Physical examination, health history, fertility history, blood tests, hormone profile, scans, vaginal & cervical swabs, occasionally post-coital test (6-12hrs post intercourse) to check sperm survival. Laparoscopy to assess pelvic organs. Hysterosalpingogram (X-ray of uterus and fallopian tubes) Hysteroscope (look inside the uterus) Ultrasound (transvaginal ultrasonography) to assess ovaries/uterus/endometrium. Doppler ultrasound to measure blood flow to uterus and ovaries.

Follicular stimulation and ovulation induction Andrology analysis of seminal plasma/volume, sperm motility/structure/count/abnormality, preparation and sex selection.
Normal (WHO): Ejaculate 1.5-5ml; Sperm >20mill/cc; Motility >50%; Forward progression 2 (scale 1-4); Morphology 30% normal forms. Testicular factors – may affect quality of sperm, or insufficient testosterone Bloods – FSH, LS, Testosterone, Prolactin – if abnormality in sperm quality. Bloods – disease, STD (sexually transmitted disease), HIV, Hep B. Varicocele – varicose vein draining blood from testicle – possible sperm damage. Blockage of ejaculatory ducts – inhibits sperm transfer to female. Sexual issues – intercourse problems – functional / psychological. Autoimmunity – immune system antibodies damage sperm.

AIH

Artificial Insemination with Husband’s Sperm, intrauterine or into the cervix, or vagina at ovulation. Usually this also involves ovulation induction. The follicle development is monitored by ultrasound and blood tests. When ovulation has occurred the male is asked for a semen sample which is prepared in the lab and the healthiest sperm are selected. Some of these are then placed in the female via a fine catheter.

AID

Artificial insemination with Donor Sperm(as previously). Donor sperm must remain frozen for at least 6 mths before use so the donor can be tested twice to ensure absence of infectious disease, inc. HIV. Frozen sperm are less effective than fresh sperm. The couple can choose sperm from a donor resembling the male partner.

IUI

Intrauterine Insemination – placing of sperm into the uterus at ovulation by catheter. Used if:
Tests show no cause for infertility (unexplained).
Retrograde ejaculation – the man’s semen releases to the bladder instead of the penis.
Male sterility – sperm absent (azoospermia)/low quantity and poor quality.
Cervix problem – structural or functional preventing/affecting sperm viability
Female without male partner.
Treatment success is influenced by the woman’s age and egg quality.Superovulated IUI is double the success rate of superovulated AI. Superovulation insemination increases the risk of multiple pregnancies. Some women experience severe cramping during insemination. Rest is recommended. Acupuncture is an option known to relax the uterus prior to, and post, insemination to improve conception success.

IVF

In Vitro Fertilization

Once the ovarian follicles are ready to be induced to ovulate, an hCG injection is given which triggers the maturation process of the eggs.

In the clinic, the eggs are recovered from the ovary 36hrs after the hCG injection, and the male is required to produce a semen sample.
You are given an anaesthetic, then the eggs (oocytes) are recovered from the follicles using ultrasound to guide a needle inserted through the vaginal wall to the ovaries.

The oocytes are carefully identified and washed before being placed in an incubator. Some hours later, they are inseminated in a petri dish with the specially prepared sperm. The oocytes and sperm are then cultured together overnight in the incubator and inspected the following day for fertilization – indicated by the presence of two small dots within the egg, the pronuclei. If this has occurred, the fertilized egg (zygote) continues to divide into a multicell embryo.

2-3 days after egg recovery, 2-3 embryos should be ready for transfer into the uterus. If there are more than three, the extra embryos can be frozen for future attempts.

Approx two weeks later, you will be able to take a pregnancy test.

GIFT Gamete Intrafallopian Transfer

A ‘gamete’ is a single sex cell (sperm or egg) containing one half of the required set of chromosomes (genetic code).

Suitable for patients with at least one fully patent fallopian tube.

Oocytes are recovered by laparoscope technique and mixed with lab prepared male sperm. The mixture is placed into a fine catheter and passed down the end of the fallopian tube(s).

If surplus oocytes remain they will be inseminated in vitro and checked for fertilization the following day, they can also be frozen for future attempts.

ZIFT Zygote Intrafallopian Transfer

Considered the most invasive of the fertility treatments, but offers more assurance than GIFT because it’s confirmed that the eggs are lab fertilized pre fallopian insertion.

The zygotes (up to 4) are then inserted into the fallopian tubes through a small abdominal incision using a laparoscope, a fibre-thin tube. Extra zygotes, if any, may be frozen in case this cycle fails.

If the treatment works, a zygote will travel through the fallopian tube and implant itself in the uterus, gradually developing into a foetus.

ICSI Intracytoplasmic Sperm Injection

A number of patients undergoing IVF fail to become pregnant. One cause can be due to an inadequate number of sperm or the sperm being unable to penetrate the outer shell of the egg.

ICSI involves directly injecting the sperm into the cytoplasm of the egg so that it bypasses all the natural barriers sperm normally have to encounter.

The eggs are recovered from the ovary and fertilized by injecting one sperm into the egg using a tiny injection glass micropipette.

The rest of the process is the same as the IVF proceedure.

TESE/ICSI PESA/ICSI

Testicular sperm extraction and intracytoplasmic sperm injection
Percutaneous epididymal sperm aspiration & intracytoplasmic sperm injection


Occasionally sperm are formed in the testes but are not present in the ejaculate due to blockage or absence of the vas deferens, ejaculatory dysfunction or the presence of necrozoospermia.
Viable sperm can be recovered usually by testicular biopsy (TESE), or by aspirating from the proximal part of the epididymis (PESA), and can be used to fertilize the egg by

ICSI proceedure

A blastocyst is an embryo that has developed for 5–7 days after fertilization and has developed 2 distinct cell types and a central cavity filled with fluid – blastocoel cavity. The blastocyst culture and day 5 embryo transfer for IVF facilitates the selection of the best quality embryos for transfer to the uterus, this reduces risk of multiple pregnancy while keeping pregnancy rates high.

AH

Assisted hatching

Involves thinning or making a small hole in the zona pellucida, a protective layer surrounding the embryo, this may improve implantation rates.

Before the embryo can implant into the uterus it must hatch from the zona pellucida. Sometimes the zona becomes toughened, restricting the embryo to hatch.

PGD

Preimplantation Genetic Diagnosis

Technique used to identify genetic defects in embryos created through IVF before pregnancy. Specifically refers to when one or both genetic parents has a known genetic abnormality and testing is performed on an embryo to see if it also carries a genetic abnormality. Only unaffected embryos are transferred to the uterus.

Freezing & storage of embryos

Cryopreservation

Following IVF a maximum of 3 embryos may be transferred in each cycle. Only good quality embryos survive the freezing process so fragmented, abnormal or damaged embryos will be discarded. Depending on the quality of the spare embryos, they may be frozen for embryo transfer at a later date.

Freezing & storage of sperm – Cryopreservation.

Used to overcome possible sterility, the sperm can be stored for as long as you wish although in some countries there is a legal time limit and conditions.

Ovum or Egg donation
program

Healthy women 20-35yrs having healthy children. Conditions must comply with the requirements of the European Society for Human Reproduction.
Following the first interview to evaluate general abilities and intellectual capacity, further requirements are for a health & reproductive history, gynaecological disorders, genetic history, ultrasound examination of ovaries and uterus, blood screening every 3 mths for HIV, Hepatitis B & C, chromosome screening, clinical blood tests per month, clinical urine tests, biochemical blood tests monthly for liver kidney sugar and protein, blood coagulation tests monthly, electrocardiography annually, lung x-ray annually, cytology smear annually, smears for genital infections (chlamydia, etc), bacteriology smear monthly, annual GP appointment, annual psychiatrist appointment.

Ovarian Hyperstimulation Syndrome (OHS)

Over stimulation of the ovaries that may result from assisted reproduction technology (ART). Normally, the ovaries produce 1 egg at ovulation. With ART the technique is to have the ovaries produce multiple eggs to increase the chances of producing embryos for fertilization.

In the ‘up’ regulation stage of infertility treatment, medication or hormones are used to stimulate the ovaries to produce multiple eggs (superovulation). The most viable eggs are then collected. Occasionally superovulation over stimulates the ovaries – Hyperstimulation. If this occurs the medication is stopped and the cycle is postponed until the symptoms are gone, usually 4 weeks.

Mild OHS symptoms: enlargement of the ovaries, abdominal discomfort and fluid build-up.
Moderate “additional symptoms – nausea, vomiting, shortness of breath. May require bed rest.
Severe Life threatening fluid build-up around the heart, in the lungs and abdomen, and a drop in blood fluid content. Requires immediate medical care to prevent liver failure, stroke, or heart damage.

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