Although many factors must be considered before deciding on a course of treatment, options generally progress from the most basic to more sophisticated surgical procedures. Options include:
Assisted Reproductive Technology Services (ARTS) is dedicated to helping you pursue treatments that can lead to a healthy pregnancy. Once a healthy ongoing pregnancy is confirmed by ultrasound, you will be referred back to your obstetrician for care. Your ARTS team will work with your doctor for a smooth transition during your first trimester.
If you don't have an obstetrician, our Physician Referral Service can help you. For more information, call 1-877-THR-WELL (1-877-847-9355).
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Intrauterine Insemination (IUI)
Often referred to as artificial insemination, IUI is a simple procedure in which sperm is placed directly into the wife's uterus, using a catheter inserted through the cervix. The procedure is done in a physician's office and takes only a few minutes. Medication may be prescribed prior to the IUI to stimulate the woman's ovaries. Sperm is prepared for the IUI in the ARTS Andrology Laboratory through a washing procedure which concentrates and separates the usable motile sperm cells from non-motile sperm, debris and surrounding seminal fluid.
For patients who experience infertility due to a complete lack of sperm donor, sperm may be used. These patients can arrange to have sperm sent to the ARTS Andrology Lab from a certified sperm bank for use during a treatment cycle.
For women with no cause of infertility other than the sperm factor, an IUI can be performed around the time of ovulation during a natural cycle. Usually one IUI is done on each of the two days following a positive home ovulation test to cover the possible time of ovulation. The natural cycle may also be monitored with ultrasounds and blood tests.
For women in whom natural cycle IUI has been unsuccessful or who have other causes of infertility in addition to the sperm factor, such as endometriosis or a single blocked fallopian tube, ovulation can be triggered when the egg is mature with an injection of hCG. An IUI can then be performed during each of the two days following the trigger shot.
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In Vitro Fertilization (IVF)
The most common form of assisted reproductive technology is IVF, which is the process of uniting the egg and the sperm in the laboratory and then transferring selected embryos into the uterus. A typical IVF cycle includes the following steps:
- Ovulation induction: The prospective mother receives daily hormone injections prescribed by her physician that stimulate her ovaries to produce several mature eggs, rather than the single egg normally produced by the body each month. Blood hormone tests and ultrasound examinations of the ovaries determine when the eggs are mature.
- Egg retrieval: Egg retrieval is an ultra-sound guided procedure in which a special needle is placed into the ovarian follicle, and the fluid that contains the egg is removed. A strong, short-acting intravenous sedation is provided to avoid any discomfort.
- Fertilization and embryo culture: An embryologist examines the follicular fluid from the follicle and then identifies the eggs. The eggs are placed in an incubator. The eggs are fertilized with sperm later that day by conventional insemination or by intracytoplasmic sperm injection.
- During conventional insemination, sperm are placed with each egg in a culture dish and left together overnight to undergo the fertilization process. The eggs are checked each day for fertilization and early cell division. Upon fertilization, the eggs become embryos.
- Preimplantation genetic diagnosis and screening are available to identify which embryos are free of abnormalities and more likely to achieve the goal of a healthy pregnancy.
- Embryo transfer: Embryo(s) may be transferred on day two, three, five or six after egg retrieval. Transfers on day five or six are called blastocyst transfers. Embryo(s) are transferred into the uterus using a catheter inserted through the cervix. Physicians on the medical staff are committed to offering single embryo transfer, giving infertile couples the opportunity of becoming pregnant without risking the significant consequences of twin and triplet pregnancies commonly associated with assisted reproductive technologies.
- Pregnancy testing: The intense activity leading up to embryo transfer is followed by a waiting period. Two weeks after egg retrieval, a blood pregnancy test is performed to determine whether implantation into the uterus has occurred.
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Intracytoplasmic Sperm Injection (ICSI)
In cases of male factor infertility, intracytoplasmic sperm injection (ICSI) can be used. In this advanced procedure, an embryologist injects a single sperm directly into a mature egg to achieve fertilization. Embryos are then transferred to the uterus. When sperm cannot be obtained by ejaculation from the husband (e.g., due to spinal cord injury or a break or obstruction in the vas deferens), sperm can be harvested directly from the testicle or epididymis. These sperm can then be used for ICSI.
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Preimplantation Genetic Diagnosis and Screening (PGD/PGS)
Preimplantation Genetic Diagnosis (PGD) may be recommended by your physician when there is a possibility, indicated by your medical history or advanced maternal age, that your embryos could be affected by a genetic disease. PGD is used in conjunction with in vitro fertilization (IVF), which allows access to the embryo in the lab. Genetic testing of embryo cells can improve the chances of transferring embryos that are healthy and do not carry defective genes.
At the earliest stage of development, one or two cells are removed from each embryo through a procedure called embryo biopsy. The cells are analyzed by a genetics laboratory to determine which embryos are free of genetic abnormalities.
Similar to PGD, preimplantation genetic screening (PGS) is recommended for patients with recurrent miscarriages, unsuccessful IVF cycles and for advanced maternal age to screen the embryos for chromosomal abnormalities. Chromosomal abnormalities can interfere with embryo implantation, result in pregnancy loss, or result in the birth of a child with disabilities. Embryos free of genetic disease are transferred to the patient's uterus to increase the chance of conception and ultimately a healthy baby.
PGD or PGS may be recommended for patients with:
- Recurrent miscarriage
- Unsuccessful IVF cycles
- Advanced maternal age
- Male factor infertility
- Inherited genetic disorders
- Unexplained infertility
What causes genetic defects?
Chromosomes are long pieces of DNA found in the center (nucleus) of cells. DNA is the material that holds genes. A gene is a short piece of DNA, which tells the body how to build a specific protein. There are approximately 30,000 genes in each cell of the human body. The combination of all genes makes up the blueprint for the human body and its functions.
Chromosome abnormalities are responsible for most genetic diseases. These abnormalities include when there are too few or too many chromosomes; when chromosome pieces are attached to the wrong chromosome; when one is missing a piece of chromosome; when part of a chromosome is upside down; or when the gene's DNA sequence is changed.
Most cells contain 23 pairs, or 46, chromosomes. These include chromosomes 1 to 22 (the autosomes) and chromosomes X and Y (the sex chromosomes). Sperm and eggs only contain 23 single chromosomes — one from each chromosome pair. During fertilization, the embryo receive one chromosome of each pair from each parent resulting in a normal male or normal female. If the sperm or egg harbors a chromosome abnormality, this can be transmitted to the embryo, resulting in a genetic disorder.
In the IVF setting, as well as in natural conception, chromosomally abnormal embryos have a low implantation rate. If they do implant, the pregnancy often results in miscarriage or the birth of a baby with physical problems, developmental delay and/or mental retardation. According to the American College of Obstetricians and Gynecologists, more than half of miscarriages in the first 13 weeks of pregnancy are caused by problems with the embryo's chromosomes.
Single gene mutation
A single gene mutation is a permanent change in the DNA sequence that makes up a gene. Genes produce proteins that make cells work properly. Single gene disorders usually show a characteristic family history of a specific genetic disease. Gene mutations can alter the cells' normal function due to a lack of a required protein.
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Single Embyro Transfer
Physicians on the medical staff are committed to giving infertile couples the opportunity of becoming pregnant without risking the significant consequences of twin and triplet pregnancies commonly associated with assisted reproductive technologies. Risks for the infants associated with multiple pregnancies include learning disorders, lower IQ scores, eye problems, lung problems, neonatal deaths and premature births.
The ARTS Program gives patients the option of limiting twin pregnancies, without necessarily compromising their chance of becoming pregnant, through single embryo transfer. While many infertility programs transfer two or more later-stage embryos, called blastocysts, ARTS offers couples the option of transferring a single blastocyst to the woman's uterus and cryopreserving (freezing) extra embryos for transfer in future cycles.
Physicians believe that transferring two embryos at different times gives couples who meet certain criteria the same chance statistically to become pregnant as what they would have had if they had chosen to transfer two blastocysts in the original cycle.
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In order to improve embryo selection and decrease high order multiple birth rates, embryos may be transferred on the fifth day of development known as the blastocyst stage. The ability to grow embryos for five or six days to the blastocyst stage of development in the laboratory, rather than the traditional three days, allows the embryology team to determine, with greater certainty, which embryos are the "best" in terms of their potential for implantation.
As a result, fewer embryos — the best one to two — can be transferred to the mother, lowering the occurrence of potentially risky multiple births.
What is blastocyst culture and transfer?
Traditionally, embryos have been transferred to the uterus on the second or third day of development after in vitro fertilization and initial embryo cell division. Because of advances in the way embryos are cared for in culture, embryos can now grow for five days in the lab, becoming a multicelled structure called a blastocyst. Embryos that survive to this stage of development are more likely to be strong, healthy and robust.
Allowing embryos to grow to the blastocyst stage facilitates a natural winnowing process that leaves only the most viable embryos, as opposed to day three embryos whose viability is not as well known.
Is blastocyst culture and transfer for everyone?
Blastocyst culture and transfer is not for everyone. Your physician and the embryology team will consider a number of factors, such as the number of growing embryos on day three, to determine if blastocyst culture is right for you.
About half the embryo transfers at ARTS are day three and half are day five. Many women undergoing day three embryo transfer still have good pregnancy success rates.
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Egg donation has become an integral part in the management of infertility for women who are unable to conceive due to egg factors. Women who have premature menopause, absence of ovaries, carriers of a genetic disorder or poor response to hormonal stimulation are candidates for this type of technology. High pregnancy rates may be achieved using this type of technology.
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Women who cannot carry a pregnancy themselves, due to conditions in which she has had her uterus surgically removed or the uterus no longer functions properly, may want to consider a gestational carrier. A gestational carrier is a woman who volunteers to carry a pregnancy derived from in vitro fertilization of the egg and sperm of another couple.
A gestational carrier is not a surrogate, as a surrogate is a woman who donates her egg and then carries the child. A gestational carrier is in no way biologically or genetically related to the child she is carrying; she is providing a nurturing environment in the form of a uterus for the child to grow.
The need for a gestational carrier
Surgical removal of the uterus may result from conditions such as cervical or uterine cancer, fibroids, severe endometriosis or any other conditions requiring a hysterectomy. In other cases, the woman may have her uterus intact but nonfunctional. This may be as the result of scarring from prior surgeries, infections or cancer treatments. As long as the ovaries are intact and functional, there is a good possibility that eggs can be harvested, fertilized in the lab with the male partner's sperm to create embryos, and the embryo(s) may then be placed in the uterus of the gestational carrier.
All gestational carriers and intended parents must seek legal counsel, even when the gestational carrier is a family member or friend, before a cycle can begin.
Screening the gestational carrier
The female serving as the gestational carrier must be free of communicable diseases. This is essential to decrease the likelihood of transferring disease to the fetus. The gestational carrier is tested for HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, herpes simplex virus, toxoplasmosis and CMV.
Under the guidelines of the American Society of Reproductive Medicine, the gestational carrier undergoes a thorough psychological evaluation and a written psychological screening; has a physician evaluation and uterine evaluation; and must be in excellent physical health. She must have a normal and up to day pap smear, and must not use tobacco, alcohol or illegal drugs. The gestational carrier's partner, if applicable, must also consent to infectious disease screening and psychological testing.
Testing for the intended parents
The intended parents also undergo medical and psychological screening, including testing for communicable diseases, since their embryos will be placed in the uterus of the gestational carrier. The male intended parent will be asked to freeze a sperm sample for testing. Psychological evaluation will take place individually, as well as with the gestational carrier and her partner, if applicable.
Steps in the cycle
The intended mother will undergo an in vitro fertilization (IVF) cycle, including ovulation induction, egg retrieval, fertilization and embryo culture. The embryo(s) will then be transferred into the uterus of the gestational carrier.
While the intended parent is undergoing the IVF cycle, the gestational carrier will be given estrogen and progesterone in sequential fashion to prepare her uterine lining for implantation. She will undergo a "mock" cycle first, which is a practice cycle. The mock cycle involves injections of estrogen, followed by a mid-cycle uterine evaluation to confirm the endometrial thickness is appropriate. If the lining is not favorable, adjustments will be made for the fresh cycle.
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