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Treatments for Infertility

We offer a wide variety of laboratory techniques to help patients achieve success with assisted reproduction. These include:

IUI: Intrauterine Insemination

Intrauterine insemination (IUI) has a long history and is much less “hi-tech” than some other methods of assisted conception. IUI can help couples where the man has a low sperm count or poor motility (the ability of the sperm to move), as long as there are sufficient levels of healthy, motile sperm to make the treatment worthwhile. If not, IVF or ICSI will be more suitable. Because sperm is placed directly inside the woman, IUI can also help couples who are unable to have intercourse because of disability, injury, or difficulties such as premature ejaculation. It is also recommended for women with mild endometriosis, and is often used as the first line of assisted conception treatment for couples with “unexplained infertility”.

The development of the ovarian follicles is monitored with ultrasound .When ovulation has occurred, the male partner is asked to produce a semen sample. This sample is prepared in the laboratory, and is then introduced into the woman’s uterus (womb) by means of a fine catheter, with the aim of getting the sperm nearer to the egg.

Examples of catheters used for IUI
Women usually remain lying down for 5-10 minutes following the procedure. Since the sperm is above the level of the vagina, it will not leak out when she stands up. There are no restrictions on activity following the IUI procedure.

How the IUI procedure is performed
The amount of motile sperm available for IUI is very important. The chances of success with IUI are best if the total motile sperm count at the time of insemination is > 5 million. If the total motile sperm count is below one million, success rates are very low. Therefore, in vitro fertilization or donor sperm insemination is usually performed for these cases.

Donor insemination can be used in cases where the man is producing no sperm in the ejaculate, or for couples who do not wish to undergo the ICSI procedure.

In Vitro Fertilization (IVF)

In vitro fertilization (IVF)is the most effective treatment for women with absent, blocked or damaged fallopian tubes. IVF is a major treatment in infertility when other methods of assisted reproductive technology have failed. It is now used to treat a wide range of fertility problems.

Fertility drugs are used to stimulate the ovaries to produce multiple follicles. Each follicle should contain one egg. The chances of pregnancy are increased if more than one egg can be obtained and fertilized. The response to stimulation is monitored by ultrasound scan measuring the number and size of the developing follicles in the ovaries and by measuring the blood oestrogen level. The final preparation for egg collection involves a hormonal injection given to the woman 36-40 hours pre-operatively. This mimics the natural process which triggers the eggs to complete their maturation making them ready for fertilization.

The eggs are collected vaginally using ultrasound guidance, under general or local anaesthesia. After egg collection the eggs are fertilised by sperm outside the womb, in vitro.Embryo transfer is usually done two or three days after egg collection. Even on day five it can be done as desired by the embryologist.

ICSI: Intracytoplasmic Sperm Injection

Intracytoplasmic sperm injection (ICSI) is an in vitro fertilization procedure in which a single sperm is injected directly into an egg. This procedure is most commonly used to overcome male infertility problems, although it may also be used where eggs cannot easily be penetrated by sperm, and occasionally as a method of in vitro fertilization, especially that associated with sperm donation.

Couples go through the same preparatory processes as with IVF, namely ovulation induction and egg collection. Under high-power magnification, a glass tool (holding pipette) is used to hold an egg in place. A microscopic glass tube containing sperm (injection pipette) is used to penetrate and deposit one sperm into the egg. After culturing in the laboratory overnight, eggs are checked for evidence of fertilization. After incubation, the eggs that have been successfully fertilized (zygotes) or have had 3 to 5 days to further develop (zygotes or blastocysts) are selected. Two to three are placed in the uterus using a thin flexible tube (catheter) that is inserted through the cervix. The remaining embryos may be frozen (cryopreserved) for future attempts. ICSI

Stages of Embryo Development

Day of egg retrieval. Motile sperms are selected by the swim-up procedure for IVF or ICSI.
An egg shortly after retrieval
A mature egg without its ‘cumulus’ cells.
ICSI
A fertilised egg displaying male and female ‘pronuclei’
A 4 Cell Embryo on day 2
A 8 Cell Embryo on day 3
Morula stage on day 4
Blastocyst on day 5
Blastocyst embryo starting to hatch from its shell on day 6
A healthy blastocyst will implant within about one to two days following IVF transfer, very soon after blastocyst hatching.

Testicular Biopsy

Among one of the most common male infertility tests that examine the underlying causes of fertility problems is the testicular biopsy. This fertility test involves the removal of testicular tissue in order to analyze any abnormalities that may be causing infertility. Sperm is produced in the testicles, and any testicular abnormalities can seriously affect male fertility.

The following are some fertility complications that may be identified by a testicular biopsy:

  • The absence of cells needed to produce sperm maturity
  • Hypospermatogenesis (the production of abnormally low numbers of sperm)
  • Germinal cell aplasia (lack of germ cells that enable sperm production)
  • Evidence of previous testicular infection
  • Abnormalities of Leydig cells

A testicular biopsy involves a small surgical procedure that takes place while a patient is under light sedation. This involves the insertion of a small needle into the testis in order to obtain a small sample of tissue. The procedure can take between fifteen minutes to a half an hour. The tissue that is extracted is then prepared for laboratory analysis to determine the presence of sperm. This sperm can then be used in infertility treatments usingassisted reproductive techniques (ART). More specifically, the sperm retrieved can be injected into an egg for fertilisation using intracytoplasmic sperm injection (ICSI) or in vitro fertilisation (IVF). The retrieved sperm can be stored and frozen for later use.

Cryopreservation

Cryopreservation refers to the storage of a living organism at ultra- low-temperature such that it can be revived and restored to the same living state as before it was stored.

Embryo Cryopreservation (Freezing)
Embryo cryopreservation (the process of freezing, storage and thawing embryos) can enhance pregnancy rates by allowing excess embryos not replaced in a fresh embryo transfer to be stored for future use.

Embryo freezing may also be performed when a fresh embryo transfer is not performed for any of the following reasons: (1) Risk of ovarian hyperstimulation syndrome (OHSS), (2) Poor quality endometrium (a thin uterine lining), (3) Intermenstrual bleeding, (4) Planned “banking” cycle in which the patient elects to store all embryos, (5) Extremely difficult embryo transfer.

Embryos are placed into straws or vials containing anti-freeze or cryoprotectant solutions. These are transferred to a programmable biological freezer which is used to achieve a controlled slow rate of cooling. During cooling, cells dehydrate and as the temperature is reduced, more ice forms and water is removed gradually from the cells. Slow cooling is continued to ~ -35°C at which point embryos are rapidly cooled by plunging into liquid nitrogen (-196°C). Embryos are kept in storage tanks of liquid nitrogen until thawing is performed.

Vitrification

Vitrification in IVF can allow freezing of spare embryos with better post-thaw survival rates and higher pregnancy and live birth rates from the frozen embryo transfer cycles. We started vitrification of embryos in our IVF lab and have seen excellent post-thaw embryo survival and high pregnancy rates after frozen embryo transfer procedures.

Semen Cryopreservation

Semen freezing is useful for men who find it difficult to ejaculate on demand which may result in their inability to produce a sample on the day of egg collection.

Sperm from two sources can be frozen: from ejaculates or from fluid extracted in the operating room during surgical procedures (vasal, epididymal and testicular sperm specimens). The sperm is usually frozen for a period of one year; at that time, future arrangements are discussed. It is generally believed that sperm that have been through the freeze-thaw process are no more likely to result in birth defects than freshly ejaculated sperm.

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