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Intra-Uterine Insemination (IUI)

Definition

Intra-uterine Insemination (IUI) is the placement of sperm directly into the uterus of the woman,  bypassing the cervix.

Indications

This procedure is performed for patients with a cervical factor (cervicitis, cervical stenosis, inadequate mucus or hostile mucus), unexplained infertility, male factor infertility or immunological infertility.

Procedure

The female's ovaries are stimulated hormonally to produce follicles containing the eggs.  An ultrasound scan is performed to determine the number and size of the follicles and also the thickness of the endometrium, lining the uterus, to see whether it is ready for implantation.  Also, blood hormone levels will be measured.  Ovulation will be induced by an injection of human chorionic gonadotrophin (hCG), and the egg will be released 36-48hr later. The male partner's semen is processed to select the highest quality sperm. The physician will then inject this sperm via a catheter through the vagina and cervix, into the uterus.

Sperm in Sterile Medium Sperm Injected into Uterus
For IUI, sperm are first washed and placed into a sterile medium. The sperm are then concentrated in a small volume of medium and are injected directly into the uterus.

Therapeutic Insemination with Donor Sperm (TID)

Definition

TID is the placement of donor sperm directly into the uterus of the patient.

Indications

In cases of severe male factor infertility, i.e., very low sperm count and/or motility, or no sperm at all, TID may be indicated. TID may also be used if the male partner carries a genetic disorder.

Procedure

The procedure is the same as for IUI, but with the use of donor sperm. Donor sperm are frozen and stored for 6 months, to enable adequate screening and help prevent communicable diseases  from being transmitted. Frozen donor sperm will be thawed and processed to isolate the highest quality sperm and then placed directly into the uterus via a catheter.

Sperm Injected into Uterus
Through the process IUI, sperm are placed high in the female reproductive tract to enhance the chance of successful fertilization.

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In-Vitro Fertilization (IVF)

Definition

In-vitro fertilization (IVF) is the process whereby the female partner's ovaries are stimulated to produce eggs. These are then removed and placed together with her partner's sperm in a petri dish and allowed to fertilize. The resulting embryos are then transferred into her uterus after 2-3 days.

Indications

IVF is used in cases of tubal blockage, male factor infertility or previously failed IUI cycles.

Procedure

The ovaries will be stimulated to produce eggs. Firstly, a gonadotropin-releasing hormone (GnRH) analogue is given for about 8-10 days.  Secondly, daily injections of human menopausal gonadotrophin (hMG) are given to stimulate the ovaries to produce an increased number of follicles containing the eggs. After about 8 days, the number and size of the follicles will be measured using ultrasound.  When 1-2 of the follicles reach 18mm in diameter, an injection of human chorionic gonadotrophin is given, and the oocyte retrieval scheduled for 36hrs later.

IVF Diagram

The oocytes will be retrieved via transvaginal ultrasound. Ultrasound allows the physician to visualize the follicles and can then push a needle into each of them and aspirate the fluid inside the follicle containing the oocyte.  The follicular fluid is examined by laboratory personnel for the presence of the egg and if found, is placed in an incubator. This is done for all the follicles. At the time of oocyte retrieval or immediately thereafter, the male partner's perm will be processed to isolate the highest quality sperm. Approximately 5hrs after the oocyte retrieval, the oocytes and sperm are put together in a petri dish and placed in an incubator.

The next day, the oocytes are observed to see whether normal fertilization has occurred. The fertilized oocytes are then left in the incubator to develop into embryos.  After 2-3days after oocyte retrieval, the embryos are transferred into the uterus of the woman using a special catheter.  Hormonal treatments are given for the following 3 weeks, after which a pregnancy test is scheduled.  Any excess embryos not transferred  may be cryopreserved for later use (see Embryo Cryopreservation and Thawing)

Success Rates

The normal success rate with this procedure is about 25-30% depending on the age of the patient.


Gamete Intra-Fallopian Transfer (GIFT)

Definition

GIFT is the direct placement of eggs and sperm into the fallopian tube.

Indications

GIFT is usually performed in cases of unexplained infertility.

Procedure

The oocytes/eggs are removed from the woman's ovaries and the sperm is processed in the same manner as for IVF. The difference is that instead of allowing the oocytes to be fertilized in a petri dish, the sperm and up to 3 eggs are injected directly into the fallopian tube and allowed to fertilize there. Hormones are given for the next 2 weeks to help maintain a pregnancy.  Any extra eggs may be fertilized in vitro (IVF), cryopreserved, or donated.

Gamete Intra-Fallopian Transfer (GIFT)

Success Rates

The success rate with GIFT is approximately 30% depending on the age of the patient.



Intra-Cytoplasmic Sperm Injection (ICSI)

Definition

The process whereby a single sperm is injected directly into the cytoplasm of the egg.

Indications

ICSI is the method of choice for patients with severe male factor infertility, and for patients who have had previously failed or poor fertilization resulting from conventional IVF.

Procedure

The eggs are retrieved from the woman's ovaries in the same way as for IVF.  The eggs are then stripped of all surrounding cells and placed in a droplet and the male partner's sperm placed in another droplet. The sperm can be obtained via ejaculation or in severe cases, directly from the testis or epididymis using microsurgical sperm retrieval techniques.

ICSI ICSI


The oocyte is held in place by a specialized holding micropipette.  With a microinjection pipette, one sperm is picked up (aspirated) and then carefully injected into the cytoplasm of the oocyte.  This is done for all the eggs. The eggs are then placed in the incubator, and checked the next morning for fertilization.

The fertilized eggs are then allowed to develop for another 24-48hr, after which they are transferred into the uterus via a thin catheter. Hormonal treatment to help maintain a pregnancy is given for the next 2 weeks.

Success Rates

The success rate for ICSI is usually around 30-35%.



Microsugical Epidiymal Sperm Aspiration
Testiculat Sperm Extraction (TESE)
Round Spermatid Injection (ROSI)

Definition

MESA is the retrieval of sperm from the epididymis by means of aspiration. TESE is the retrieval of sperm from the testis by means of testicular biopsy.  ROSI is the injection of round spermatid (immature spermatozoa) when no mature sperm can be found in the testis.

Indications

When sperm are unable to move through the genital tract due to uncorrectable damage, sperm can be extracted directly from the epididymis or testes via microsurgical techniques.  Congenital absence of the vas deferens (CAVD) or failed sterilization reversal are other indications.

Procedure

Around the time that the woman has her eggs retrieved, the husband/male partner will undergo a surgical procedure that will either take a very small piece of testicular tissue (TESE) or aspirate the fluid from the epididymis (MESA).  For TESE/MESA the testicular tissue/epididymal  fluid will be examined for the presence of sperm cells. These can then be injected into the oocyte via ICSI. In cases where no sperm are seen, round spermatids (immature sperm seen on right) can be used for ICSI (ROSI).

We at the Kentucky Center for Reproductive Medicine and IVF in cooperation with the Andrology Institute of America and Dr. Zavos, along with other Scientists and Physicians from Japan, Greece and France, have been successful in developing and employing the new ROSI Technique.  This method enables the micro-injection of round spermatids (immature spermatozoa), recovered from the testes or from post-ejaculated fractions into retrieved oocytes via ICSI techniques and achievement of fertilization and pregnancies.  This technique will assist a great number of azoospermic males with round "spermatid-type" arrest in their testes and other male infertility patients with other severe spermatogenic deficiencies to achieve pregnancies, throughout the World.


Sperm Cyropreservation and Thawing

Definition

The process of preserving sperm by means of freezing for use at a later time.

Indications

Sperm can be cryopreserved in cases where the male might have difficulty in producing a specimen at a given time. If sperm were retrieved microsurgically, excess sperm may be stored to avoid having to repeat the invasive surgical procedure. Also, for patients planning to undergo chemotherapy or radiotherapy (for cancer), sperm may be cryopreserved as the therapy may diminish their sperm production. Sperm can also be frozen for persons wishing to donate their sperm to infertile couples.

Procedure

Sperm retrieved by masturbation, testicular biopsy or microsurgical epididymal sperm aspiration are placed together with a cryoprotectant and stored in cryostraws in liquid nitrogen at a temperature of -196°C. This can be thawed at any time, and the cryoprotectant can be removed and the sperm used for ART procedures.


Embryo Cryopreservation and Thawing

Definition

The process of storing embryos by means of freezing in liquid nitrogen for use at a later time.

Indications

When excess embryos are present after an embryo transfer, these can be frozen and then  transferred in subsequent cycles, if the patient does not become pregnant.  This would save her from undergoing another oocyte retrieval procedure. She may also elect to have her embryos donated to another infertile couple.

Procedure

Excess embryos are place with a cryoprotectant and aspirated into cryostraws, and then gradually frozen to a temperature of -196°C, and placed in liquid nitrogen.  Storage can be indefinite but KCRM requires written approval/consent from the parents every 3 years.

When the patient wants to transfer embryos that are in cryostorage, these can be thawed prior to or on the day of transfer, assessed for survival and development, and then transferred.


Sperm Donation

Definition

The donation of sperm for the use by infertile couples with severe male factor infertility.

Indications

Donor sperm may be used when the male partner has azoospermia or severe male factor, has a know hereditary/genetic disorder that could be carried over to biologic offspring, or has had previously failed IVF attempts and do not choose to have ICSI. Donor sperm may also be used in females without male partners.


Oocyte Donation

Definition

The donation of oocytes for the use by infertile couples.

Indications

Women may choose to have donated oocytes if they have hypergonadotrophic  hypogonadism, have diminished ovarian response, have persistently poor oocyte and/or embryo quality in previous ART's, or have known hereditary/genetic defect that can be carried over to the offspring.


Assisted Hatching

Definition

Assisted hatching is the opening of the zona pellucida , surrounding the embryo, to help the embryo/blastocyst "hatch" or emerge from the zona and implant in the uterus.

Indications

Assisted hatching is usually indicated in older women, and those with failed implantation in previous cycles.

Procedure

Prior to embryo transfer, a small opening is made in the zona pellucida using microdissection tools. The embryos are then transferred normally.   


Gender Selection

Definition

The process of gender selection increases the chance of having a female or male child, by separating sperm that bear the X chromosome (female) and those that have the Y chromosome (male), and inseminating with whichever sample is desired.

Indications

The procedure can be employed for couples who want a child of a specific gender.

Procedure

The procedure used is the sedimentation method. This method is used similarly for both male and female selection and takes approximately 2-2½ hours to process.  On average, it takes about 3-4 cycles to achieve a pregnancy with this method.

Success Rates

Our success rate is approximately 80% for male selection and 72% for female selection.


Traditional Surrogacy

Definition

A traditional surrogate is one who donates her oocytes and carries the pregnancy using sperm from the intended natural father (husband) or a donor.

Indications

The surrogate's ovaries are stimulated hormonally to produce follicles containing the eggs.  An ultrasound scan is performed to determine the number and size of the follicles and also the thickness of the endometrium, lining the uterus, to see whether it is ready for implantation. Also, blood hormone levels will be measured.  Ovulation will be induced by an injection of human chorionic gonadotrophin (hCG), and the egg will be released 36-48hr later.  The semen from the intended natural father is processed to select the highest quality sperm. The physician will then inject this sperm via a catheter through the vagina and cervix, into the uterus. If conception occur, the surrogate will carry the pregnancy to term.


Gestational Surrogacy

Definition

The gestational surrogate is one who only carries the pregnancy to term, and the eggs are derived from another source.

Indications

This procedure is very similar to IVF, except that instead of transferring the embryos into the female patient, they are transferred into the uterus of the designated surrogate.

   

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