Assisted reproduction

Artificial insemination – AIH

Artificial insemination is a process of collecting semen (sperm) of the husband and introducing it by artificial injection into:

• Cervical canal - cervical insemination
• Uterine cavity trans-cervical – intrauterine insemination (IUI)
• The Fallopian tube trans-cervical – intratube insemination

Insemination is carried out for the purpose of increasing the chances of the couple for conception.
It may be achieved:

• In a spontaneous (natural) cycle at the time of expected ovulation (by determination of the level of luteinizing hormone)
• With stimulation during the expected ovulation (by determination of the level of luteinizing hormone)
• With stimulation at the time of planned ovulation (using medicaments that allow scheduling the ovulation time), but always with the previous preparation of semen for the purpose of achieving maximal fertile potential of the spouse.

The precise timing of insemination is very important, because this procedure is done immediately before or immediately after ovulation. There are several methods that are available to doctors to determine the exact date insemination such as ultrasound examinations and determination of luteinizing hormone.

 

Insemination is a simple intervention; lasting from 5-10 minutes in most cases is completely painless. In the womb, the doctor introduces a special catheter with 1-1.5ml pre-prepared seeds. After insemination, it is recommended that women continue to rest for a while. Two weeks after the insemination is necessary to do the blood test for pregnancy.

 

IUI in the treatment of infertility is recommended up to 3-4 times. If the cause of infertility, lack of ovulation, may be attempted in several cycles of insemination, however, most couples who have a problem with the realization of pregnancy are turning IVF after 3 unsuccessful insemination procedures.

Vitro fertilization- IVF i ICSI

In vitro fertilization is performed as a fertility treatment only when there is no other simpler way of treatment. This method is the culmination of fertility treatment, and for many couples, the only way of becoming a parent. We have to emphasize that the pregnancies that are result of IVF treatment are as any other pregnancy formed in the usual way. Possible complications in this pregnancy can’t be attributed the IVF treatment.

 

There are two methods within the artificial insemination process and these are classical method of in vitro fertilization and microfertilisation ICSI. The choice of the procedure is based upon the number of collected egg cells, their quality, as well the number of motile sperms. Regardless the method of IVF the procedure of stimulation of ovaries is the same.

 

Stimulation of ovulation
Egg cells develop inside cavities in the ovaries. These cavities are filled with liquid, and they are called follicles and these grow in size during maturing of the egg cell. Controlled hyper stimulation of ovulation is a procedure used in IVF in order to stimulate the ovaries to produce as much egg cells as possible, compared to only one as it is the case with natural cycles. More egg cells, meaning more embryos, provide the possibility for selecting embryos of the highest quality for embryo transfer thus increasing the possibility of conception when these embryos are introduced to the uterus.
Ultrasonic examination reveals the number of cavities (follicles) and enables us to measure them. Ultrasound also helps us to control the thickness and maturity of the uterine mucus membrane. The hormone level and sonographic image give us insight into the effects of the therapy used in order to stimulate ovulation.

 

Follicle puncture and aspiration of egg cells
Puncturing cavities is called follicle puncture in medical terminology, and absorbing egg cells is called egg cell aspiration. The intervention is carried out transvaginally, under the control of ultrasound. A biologist has to examine the supplied material immediately under the microscope and report the number of obtained egg cells.

 

Laboratory phase – classical IVF
After the acquisition of egg cells, they are transported to the laboratory, where they are identified, reviewed and prepared for mixing with spermatozoa. When the egg cells are inseminated, they are examined approximately 14-18 hours afterwards, in order to find out whether fertilization has occurred, and again 24 hours later in order to check whether an adequate cell division has occurred.

 

Laboratory phase - microfertilisation ICSI
In vitro fertilization by introplasmic sperm injection (IVF-ICSI) Micro fertilization is a procedure used when we want to increase chances for a couple which is taking part in an in vitro fertilization procedure but for which there is only a minimum probability of achieving a fertilization by natural means (classic IVF method).

 

The clinical indications due to which this procedure is applied include:

Male infertility factor

• Decreased total count of spermatozoa
• Insufficient motility of spermatozoa
• Low quality of sperm
• Spermatozoa which lack the capability to penetrate into the egg cell

Immunological factor

• Idiopathic infertility (unknown, of undiscovered cause)
• Fertilization has not been achieved in the previous IVF attempts or has been significantly decreased; i.e. only a very small number of egg cells were fertilized

In normal circumstances the egg cell is surrounded by clusters of cells which all have to be removed and the egg cell has to be cleaned before the ICSI technique is applied. Sperm is collected from the male partner. In the cases of total absence of spermatozoa in the ejaculate (azoospermia) an aspiration biopsy of the testicle (TESA) can be carried out, or a real surgical biopsy of the testicles (TESE). When both the sperm and the egg cells are collected, we continue with the injection of one spermatozoon into the egg cell. When a spermatozoon is injected, the egg cell is examined within about 14-16 hours upon the intervention to determine whether fertilization was successful, and 24 hours later, whether proper cell division has taken place.

 

Embryo transfer

Embryo transfer is carried out 30 hours after the intervention. That means that the embryo transfer comes within 36- 48 hours upon follicle puncture and oocyte aspiration. In certain cases this period is extended for most five days and enables embryo development to the blastocyst stadium. It is very important to emphasize that the „blastocyst culture„ is not an option for all couples. It is not recommended to the ones that have six or less successfully fertilized egg cells.

 

Outcome
Within a fortnight upon the embryo transfer, early pregnancy test should be carried out. This delicate test is based on the analysis of beta-subunit of chorionic gonadotrophin (beta-HCG), a pregnancy characterizing hormone.

Hatching

Hatching is a new method, which in certain cases can improve chances for success of in vitro fertilization. The essence of the idea of micromanipulation that is called „hatching„ arrived from studying the embryos in laboratory, where was noticed that embryos surrounded with thin natural coating have a greater percentage of implementation in the uterus.

 

On what principles is hatching based?
The embryo that is transferred into the uterus is surrounded with thin shell. Before an embryo implant into the uterus, it must break free from its shell (zona pellucida), to hatch like bird from an egg. Sometimes, this shell is very toughened, restricting the embryo to hatch, and therefore it can’t implant. The solution for this problem is hatching. The assisted hatching procedure involves thinning or making a small hole in the zona pellucida that surrounds the embryo (protective layer). Making a small hole in this shell using a micromanipulation, makes it easier for hatching to occur. Methods that are used are chemical, mechanical and laser. Nowadays, the laser is accepted as the most reliable and is performed in all famous biological laboratories. The benefits of laser are numerous, but the precision and speed are the most important. Hatching is performed immediately before the embryotransfer, and can be done even in frozen embryos.
The rate shows that less than 1% of quality embryos suffers damage during this procedure, that makes them unable to implant. Even so, this is the reason why hatching is not performed if there is only one embryo. In terms of practice, the hatching can be performed in all forms of in vitro fertilization.
But, it was shown that this method is very helpful in patients:
a) that are in late reproductive age, patients older than 37
b) with elevated level of FSH
c) whose embryo’s cells are fragmentary and have slow cellular division
d) whose embryos exhibit thick zona pellucida
e) with recurrent failure of embryo implantation (tree or more embryotransfers without a pregnancy)
There is evidence that assisted hatching can improve implantation rate for 20%.