In vitro fertilization (IVF) women's eggs are retrieved from the ovaries and mixed with male sperm in a test tube in a laboratory.
Who helps IVF? IVF can help with fertility problems in one or both partners. For example, with obstruction of pipes or a woman with small changes of sperm in men. IVF is also used for unexplained infertility, especially for those couples who can not conceive of more than three years.
Couples who are trying to stimulate ovulation and medical intrauterine insemination without success, can also be directed to IVF.
How do IVF? Usually women are prescribed drugs that stimulate the ovaries to produce multiple mature eggs. (Usually during the menstrual cycle matures only one egg). You can refuse to take these drugs, but for successful fertilization better to have more than one mature yaytsekleti.
There is a standard set of drugs to stimulate ovulation, your doctor will choose the combination that suits you.
Some fertility specialist believe that it is important to fully control the menstrual cycle of women. They start treatment with the use of analogue gonadotropin releasing hormone, which inhibits or "off" menstrual cycle. This drug is administered as a nasal spray or injection.
After this is done the injection of the hormone, which stimulates ovulation, such as human menopausal gonadotropin (HMG) and human chorionic gonadotropin (hCG). During and after administration of these drugs you will be under the supervision of physicians, as women react differently to these drugs, and some are different side effects.
Watching the hormone levels in your blood, your doctor can determine when ripe ovum. Ultrasound will confirm their willingness to exit. Shortly thereafter, you will be given a soothing anesthetic - you'll be sleeping, but will remain in the mind, and the doctor will extract the eggs from your ovaries using a thin hollow needle. During the procedure, the doctor will use ultrasound machine to locate the eggs.
Around the same time that the ovum will be extracted, your partner should buzhet provide a sperm sample. When using donor semen, it is removed from the freezer. In both cases, the sperm were washed (cleaned) and is ready for fertilization. Then the sperm and ovum are mixed in a test tube filled with the nutrient medium. The tube was then placed in an incubator.
Within two days after that the doctor checks, fertilizing whether any of the eggs in vitro. The fertilized eggs remain in the tube for one or two days. Each fertilized egg becomes a group of cells, which are now called an embryo. Most healthy embryos and then sit down in the woman's uterus.
Until that moment a woman takes hormone progesterone, which thickens the lining of the uterus, and thus prepares the uterus for embryo replanting. Progesterone take injectable gel or pessary. If your endometrium (uterine vytsilka) is too thin, the IVF attempt may be unsuccessful. Studies confirm that with a thin endometrium embryo is difficult to gain a foothold in the uterus.
Usually one or two embryos hooked into the uterus using a thin catheter. It uses ultrasound machine that allows to monitor the process. Can be simultaneously podsazheny no more than three embryos in order to avoid multiple pregnancies. Number sits embryos depends on your age and the chances of success. And this, in turn, depends on, what exactly is the problem you faced with conception.
Women younger than 40 years old are allowed a maximum of two embryos implanting. A female 40 years and over - three, because such women are less likely to become pregnant with her egg. Depending on the ovarian reserve - the ability to respond to ovarian stimulation and "egg issue", used or own a woman's egg, or donor. If the egg donor, regardless of age podsazhivayut maximum of two embryos. According to doctors, it reduces the number of frequent cases of multiple pregnancies resulting from IVF. If you are the "extra" embryos, they are stored in the freezer for future use - for example, if this IVF attempt fails.
The doctor may advise you to lie down after the procedure. But there is no reason to believe that if you lie more than 20 minutes, it somehow affect your chances of success.
If a positive result, one or more embryos attach to the wall of your uterus and continue to grow. After about two weeks you can do a pregnancy test.
If the pregnancy is a result of IVF was confirmed for a period of about six weeks, you will be referred for an ultrasound to check that the embryo was fixed in your uterus.
What are the chances of success?
The result may be different - depending on what exactly you have a problem, and most importantly - depending on your age. The younger you are, the healthier your eggs and the greater your chances of success. For women younger than 30 years the chances of successful IVF is one to four, and for women over 40 - one to ten.
If before you were pregnant or you already have a child, your chances of success are also increasing.
Women with normal weight (body mass index (BMI) between 19 and 30) also have a greater chance of success with IVF. If you are overweight, you can increase your chances, lose weight before beginning treatment.
Overall, the average success rate of IVF is 35%.
What are the disadvantages of IVF?
Because during the procedure often sits more than one embryo, you risk getting pregnant with twins or even triplets. Approximately every fourth couples who conceived using IVF, twins are born. The same statistics among couples conceive naturally, is a case of 80. And while many couples are very happy twins, multiple pregnancy increases the risk of miscarriage and other complications.
Drugs to stimulate ovulation can have serious side effects. You should be under close medical supervision while taking these drugs, to be sure that you will not develop ovarian hyperstimulation syndrome.
Pregnancy is often more difficult and subject to greater risk of miscarriage or premature birth. A woman should be under constant supervision of a physician and restrict their activity.
Preparing for IVF
Psychological and social preparation: Before you start asking for assisted reproduction you should realize the responsibility you are going on, as this is not simple decision to be mam, and it should be combined decision with your husband.
Answer the following question: Is this is the appropriate time (Am I ready for this)? You should chose the time where you are out of stress psychological and physical stress As this is a highly private issue you should to decide it away from any other person except your husband
As any person know about it will ask you soon or later what you do, what happened, what, what, what, and this is a source of stress
Try to be away of this please.
Shoes the time when you feel your self sharful and able to give and adaptable, and patient
Financial issued should be secured to release you from stress and burdens, and troubNutrition and lifestyle for both spouses.
In order to prepare the body for the upcoming pregnancy, observe a healthy lifestyle. Food should be varied, rich in vitamins and proteins containing a moderate amount of fat and carbohydrates. No strict diets. In the days of blood donation on biochemical and hormonal studies Breakfast is only possible after collection.
Shows the intake of vitamin-mineral complexes intended for pregnant women. Alternatively we can advise folic acid, potassium iodide and vitamin E in small doses, a month before the IVF program. Avoid taking medications contraindicated in pregnancy.
It should exclude smoking, including passive. Coffee recommended to 2 cups a day. Avoid hot tubs, baths and saunas. Try to keep active, mobile lifestyle. Do not concentrate on the treatment, let it not affect your mood. Avoid pronounced stress, and physical and mental overexertion.
Character sexual activity, in general, not be changed. You can have sex with the same frequency as always. But for 3-4 days prior to follicle puncture and IVF should refrain from sexual acts with the aim of "accumulation" of sufficient sperm. Duration of abstinence should not exceed 7 days. Sex is not recommended until after IVF pregnancy tests. During the period of ovulation stimulation of the ovaries can increase pain during intercourse.
Before the procedure, IVF may require testing for some infections that pose a risk to the fetus and may adversely affect its development and child bearing. These include, for example, herpes, cytomegalovirus, rubella, toxoplasmosis, and several other diseases. These infections are common and often insidious. Volume determines the physician diagnosis.
Infertility often accompany hormonal abnormalities. Their timely identification and correction can improve the chance of pregnancy and its favorable course. Most hormones are studied in the early days of the menstrual cycle, usually from 1 to 5 days. Therefore, the first schedule a visit to the doctor at that time. The blood from the vein shall, as a rule, in the morning, on an empty stomach.
Visit andrology, the study of sperm.
Treatment of infertility by IVF involves mandatory inspection at the Andrology and semen analyzes. Before the visit to the doctor and the delivery of semen for analysis spouse must comply with certain rules: to refrain from sexual activity between 3 and 7 days (optimally 5) do not take hot baths, do not urinate for 2 hours before visiting the doctor, do not eat fatty and spicy food.
Planning procedures and doctor visits.
IVF treatment is an outpatient basis, but requires the patient discipline and punctuality. Before the start of the IVF program, plan their affairs in such a way that you have not had night duty, so you can arrive about 4-5 times in the IVF clinic during ovulation stimulation (2-4 weeks) and then come on the appointed day puncture and embryo transfer. The presence of the husband is required for the preliminary examination and for delivery of sperm a day follicle puncture. After the embryo transfer, you will be issued a medical certificate.
Intracytoplasmic sperm injection (ICSI, pronounced /ɪksiː/, IK-see) is an in vitro fertilization (IVF) procedure in which a single sperm is injected directly into an egg. Defective sperm function remains the single most important cause of human infertility. Although certain severe forms of male infertility have a genetic origin, others may be the result of environmental factors. During the past decade, ICSI has been applied increasingly around the world to alleviate problems of severe male infertility in human patients who either could not be assisted by conventional IVF procedures or could not be accepted for IVF because too few motile and morphologically normal sperm were present in the ejaculate of the male partner.
Schematic image of intracytoplasmic sperm injection in the context of IVF.
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 in addition to sperm donation.
It can be used in teratozoospermia, because once the egg is fertilized, abnormal sperm morphology does not appear to influence blastocyst development or blastocyst morphology. Even with severe teratozoospermia, microscopy can still detect the few sperm cells that have a "normal" morphology, allowing for optimal success rate.
The first child born from a gamete micromanipulation (technique in which special tools and inverted microscopes are used that help embryologists to choose and pick an individual sperm for ICSI IVF) was a child in Singapore-born in April 1989.
The technique was developed by Gianpiero Palermo at the Vrije Universiteit Brussel, in the Center for Reproductive Medicine headed by Paul Devroey and Andre Van Steirteghem.
The procedure itself was first performed in 1987, though it only went to the pronuclear stage. The first activated embryo by ICSI was produced in 1990, but the first successful birth by ICSI took place on January 14, 1992 after an April 1991 conception.
There are some requirements that an IVF lab need to correctly perform ICSI technique. There are basically 5 main elements: laminar flow cabinet, inverted microscope, micromanipulators, microinjectors and anti-vibration table.
Laminar flow cabinet. It has to contain a hot surface and an environment with 5% of CO2.
Inverted microscope. It should have 20X and 40X lens, with Hoffman optics, and a 37 °C surface to have an optimal maintenance of the biological material.
Micromanipulators. They allow us to move in three dimensions, so that there will be one on the left to control the holding of the micropipette and another to the right for the injection micropipette. In addition, there is an electric manipulator for large movements and an hydraulic one for the finest (adjustment of the pipettes is done with the hydraulic and quick movements to place them with the electric).
Microinjectors. They are hermetic syringes filled with mineral oil controlled by the micromanipulators and connected to the microinjection pipettes (to aspirate and inject the spermatozoa) by a flexible tube.
Anti-vibration table. It has to contain hydrogen to assure the optimal work conditions.
ICSI is generally performed following a transvaginal oocyte retrieval procedure to extract one to several oocytes from a woman.
In ICSI IVF, the male partner or a donor needs to provide a sperm sample on the same day when your eggs are collected. The sample will be checked in the lab, and If there is no sperm in his semen, doctors will extract sperm from epididymis or testicle. The extraction of sperm from epididymis is also known as percutaneous epididymal sperm aspiration (PESA) and extraction of sperm from testicle is also known as testicular sperm aspiration (TESA).
The procedure is done under a microscope using multiple micromanipulation devices (micromanipulator, microinjectors and micropipettes). A holding pipette stabilizes the mature oocyte with gentle suction applied by a microinjector. From the opposite side a thin, hollow glass micropipette is used to collect a single sperm, having immobilised it by cutting its tail with the point of the micropipette. The oocyte is pierced through the oolemma and directed to the inner part of the oocyte (cytoplasm). The sperm is then released into the oocyte. The pictured oocyte has an extruded polar body at about 12 o'clock indicating its maturity. The polar body is positioned at the 12 or 6 o'clock position, to ensure that the inserted micropipette does not disrupt the spindle inside the egg. After the procedure, the oocyte will be placed into cell culture and checked on the following day for signs of fertilization.
In contrast, in natural fertilization sperm compete and when the first sperm penetrates the oolemma, the oolemma hardens to block the entry of any other sperm. Concern has been raised that in ICSI this sperm selection process is bypassed and the sperm is selected by the embryologist without any specific testing. However, in mid-2006 the FDA cleared a device that allows embryologists to select mature sperm for ICSI based on sperm binding to hyaluronan, the main constituent of the gel layer (cumulus oophorus) surrounding the oocyte. The device provides microscopic droplets of hyaluronan hydrogel attached to the culture dish. The embryologist places the prepared sperm on the microdot, selects and captures sperm that bind to the dot. Basic research on the maturation of sperm shows that hyaluronan-binding sperm are more mature and show fewer DNA strand breaks and significantly lower levels of aneuploidy than the sperm population from which they were selected. A brand name for one such sperm selection device is PICSI. A recent clinical trial showed a sharp reduction in miscarriage with embryos derived from PICSI sperm selection.
'Washed' or 'unwashed' sperm may be used in the process.
Live birth rate are significantly higher with progesterone to assist implantation in ICSI cycles. Also, addition of a GNRH agonist has been estimated to increase success rates.
Ultra-high magnification sperm injection (IMSI) has no evidence of increased live birth or miscarriage rates compared to standard ICSI.
Assisted Zona hatching (AH)
Patients with repeated failed implantation or who have a thick zona pellucida (covering around the embryo) are ideal candidates for Assisted Zona Hatching or AH. The procedure involves creating a hole in the zona, that improves the chances of normal implantation of the embryo in the uterus.
Pre-implantation genetic diagnosis (PGD)
PGD is a process in which one or two cells from an embryo on Day 3 or Day 5 are extracted and the cells genetically analyzed. Couples who are at a high risk of having abnormal number of chromosomes or who have an history of single gene defects or chromosome defects are ideal candidates for this procedure. It is used to diagnose a large number of genetic defects at present. We have highly experienced and trained genetic counselors who would meet with you to discuss your genetic issues and your odds of having to do PGD.
Success or failure factors
One of the areas in which sperm injection can be useful is vasectomy reversal. However, potential factors that may influence pregnancy rates (and live birth rates) in ICSI include level of DNA fragmentation as measured e.g. by comet assay, advanced maternal age and semen quality.
A systematic meta-analysis of 24 estimates of DNA damage based on a variety of techniques concluded that sperm DNA damage negatively affects clinical pregnancy following ICSI.
There is some suggestion that birth defects are increased with the use of IVF in general, and ICSI specifically, though different studies show contradictory results. In a summary position paper, the Practice Committee of the American Society of Reproductive Medicine has said it considers ICSI safe and effective therapy for male factor infertility, but may carry an increased risk for the transmission of selected genetic abnormalities to offspring, either through the procedure itself or through the increased inherent risk of such abnormalities in parents undergoing the procedure.
An online news story on MSNBC.com by Marilynn Marchione of the Associated Press, released on Saturday, May 5, 2012, discussed the risk of birth defects in ICSI versus natural conception or normal IVF; the following is a directly quoted segment of that release:
"Test-tube babies have higher rates of birth defects, and doctors have long wondered: Is it because of certain fertility treatments or infertility itself? A large new study from Australia suggests both may play a role.
Compared to those conceived naturally, babies that resulted from simple IVF, or in vitro fertilization—mixing eggs and sperm in a lab dish—had no greater risk of birth defects once factors such as the mother's age and smoking were taken into account.
However, birth defects were more common if treatment included injecting a single sperm into an egg, which is done in many cases these days, especially if male infertility is involved. About 10 percent of babies born this way had birth defects versus 6 percent of those conceived naturally, the study found. ..."
There is not enough evidence to say that ICSI procedures are safe in females with hepatitis B in regard to vertical transmission to the offspring, since the puncture of the oocyte can potentially avail for vertical transmission to the offspring.
Follow-up on fetus
In addition to regular prenatal care, prenatal aneuploidy screening based on maternal age, nuchal translucency scan and biomarkers is appropriate. However, biomarkers seem to be altered for pregnancies resulting from ICSI, causing a higher false-positive rate. Correction factors have been developed and should be used when screening for Down syndrome in singleton pregnancies after ICSI, but in twin pregnancies such correction factors have not been fully elucidated. In vanishing twin pregnancies with a second gestational sac with a dead fetus, first trimester screening should be based solely on the maternal age and the nuchal translucency scan as biomarkers are significantly altered in these cases.