Infertility examination and treatment

Laboratory in Jevremova hospital

The center for reproductive medicine, within Specialized hospital „Jevremova”, practices team approach in examination and treatment of infertility of married. Thus, starting from the first interview with our physicians, all up to the sophisticated methods of assisted reproduction such as microfertilization (ICSI), patients of „Jevremova” dispensary have in one place all that modern medicine offers as routine methods and treatments for infertility diagnosis and treatment of married couples. Examination of infertile couples starts with anamnestic data on the general health of both partners, duration of infertility and the time that spouses spent trying to conceive, woman’s gynecological health, ultrasonographic, gynecological and cytological examination, hormone level testing, microbiological examination of both partners, indirect confirmation of ovulation ability and the Fallopian tube patency examination, spousal fertility examination and a series of other specific examinations whether these prove necessary. Applying the methodical approach, as a rule, examination starts with a simple diagnostic procedures while those more complex are left for the end, with maximal psychological support to the married couple.

Regarding to that, Specialized hospital „Jevremova” offers to its patients the possibility of the following diagnostic methods and treatments.

• Spermogram - Analysis of ejaculate in examination of male fertility:
  • - Cytomorphology analysis of ejaculates
  • - Volume
  • - Color
  • - Morphology
  • - Total spermatozoa count
  • - Motility
  • - Vitality
  • - Pathological forms
  • - Immature forms
  • - Biochemical analysis of ejaculates
  • - Microbiological analysis of ejaculates
  • - Immunological test (MAR test)

• Postcoital test
  Examination of vitality, motility and immunological properties of spermatozoa in the cervical mucus
• Microbiological and virology examinationas
• Examination of hormonal level
• Folliculometry
  Ultrasound control of growth, maturation and breaking of follicles.
• Biopsy and histological analysis of endometrium
• Cytohormonal analysis of vaginal epithelium
• FERN test
  Estimation of estrogen effect on cervical glands during preovulatory phase of the menstrual cycle.
• Sonohysterosalpingography screeening
  Ultrasound examination of cervical canal, uterine cavity, the Fallopian tubes and periadnexal areas.
• Histeroscopy
  Endoscopic method which enables visualization of cervical canal and uterine cavity.
• Laparoscopy
  Endoscopic method performed under a general anesthesia, this technique enables direct visualization into internal genital organs and provides plenty of information on the abnormalities and pathological changes inside the true pelvis.

ASSISTED REPRODUCTION

Method of assisted reproduction is based on the improvement of natural fertile ability of the couple. Those are directed toward making the contact of egg cells and spermatozoa, shortening the process of their fusion (artificial insemination - AIH) or bringing them into direct contact (in vitro fertilization (IVF). These methods are basically in the induction of ovulation and pushing the prepared semen more or less close to the egg cell inside the body in assisted insemination hatching (AIH) or outside the body in the case of in vitro fertilization (IVF).

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 transcervically – intrauterine insemination (IUI)
• The Fallopian tube transcervically – 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.

At the time of planned intervention, in for that purpose specifically prepared catheter, 1-1,5 ml previously prepared spouse’s semen is taken and introduced in one of described ways into the genital tract (cervical canal, uterine cavity and the Fallopian tubes).

IN VITRO FERTILIZATION - IVF

In vitro fertilization is carried out as a therapy against infertility only when there is no other simpler way for infertility treatment. Fusion of male and female gametes is carried out in a laboratory, and the method was named after it. Pregnancy resulting from in vitro fertilization is completely the same as any other ordinary pregnancy. Possible complications in such a pregnancy can in no way be assigned to in vitro fertilization. There are two basic types of IVF. Classic in vitro fertilization (IVF) and introplasmic sperm injection (ICSI). Depending on the number and quality of egg cells and the quality of spermatozoa (their total count, morphology and motility) you will be told which method provides the best (most realistic) chances for success of the procedure. However, the final decision regarding the selection of the in vitro fertilization method (IVF or ICSI) will be left to the couple.

1. CLASSIC IVF

Previous to the in vitro fertilization procedure, the female patient is treated with drugs that stimulate ovulation, egg cells are collected and the husband's material is prepared.

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

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.

2. MICROFERTILIZATION – ICSI

Microfertilization procedure

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

Laboratory phase

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 recomended 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.

Embryo freezing-kriopreservation

When, in vitro fertilization results in more than four vital embryos, or any other limited number chosen by the patients, „Jevremova” offers the possibility that the surplus of vital embryos (good quality embryos) is preserved for future use according to the procedure of controlled freezing and thawing.

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.

Hatching

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%.