At first step, the couple has an appointment with a fertility specialist. The doctor will review all previous tests and treatments, takes the couple’s medical history and performs complete physical examination. Investigations are then carried out to diagnose the infertility reason. Semen analysis is the first step in evaluation of the male partner. The patient may benefit from some surgical procedures in next steps like Varicocelectomy, PESA, MESA or TESE. Female investigation begins with a blood test to assess the hormonal profile and an ultrasound to evaluate the uterus, ovaries and pelvis. The woman may be required to undertake some procedures like Hysterosonography, Hysterosalpingography, Hysteroscopy or Diagnostic laparascopy to complete the diagnosis. Once all the investigations are complete, the infertility specialist will make a diagnosis leading to the appropriate treatment option.
Once a diagnosis is made, the appropriate treatment will be structured so that the least involved, least invasive and least expensive fertility procedures are utilized. During the course of treatment, it may be necessary to have follow-up consultations or more procedures and tests to assess the progress. This insures that the fertility treatment process is as efficient as possible.
Intra-uterine insemination (IUI), also known as artificial insemination, is the process of preparing and delivering a highly concentrated amount of active motile sperm into the uterus using a very thin flexible catheter through the cervix. IUI is commonly performed as a cost effective approach to enhance fertility in couples with following problems:
IVF is a more intensive treatment program that involves stimulating multiple follicles and eggs to develop in the ovaries then taking eggs out of the woman, fertilizing them in the laboratory with her partner’s sperm and transferring embryos back to her uterus. IVF bypasses the fallopian tubes and is therefore the first choice treatment for most patients with damaged, blocked or absent fallopian tubes. IVF is also used in helping patients with endometriosis, moderate to severe male factor infertility, Failed IUI, Reduced ovarian reserve or infertility of unknown causes.
ICSI is a very effective method to fertilize eggs after they have been retrieved from the female. The process is initially the same as IVF cycle. When the eggs and sperms are collected in the laboratory, the scientist isolates a single sperm and injects it directly into the egg. This is a procedure which is mostly reserved for previous IVF failures, men with poor quality sperm, or men whom sperm has had to be collected directly from the testicle using a local or general anesthesia or for women with a low yield of eggs at egg retrieval.
Embryo transfer is the last step of the in vitro fertilization process. It is a critically important procedure. No matter how good the IVF laboratory culture environment is, the entire IVF cycle depends on delicate placement of the embryos at the proper location near the middle of the endometrial cavity.
Most of the embryo transfers are performed on day two or three after fertilization. However, recently, improvement in embryo culture conditions have allowed sustained embryo development to the blastocyst on day 5 (the stage at which the embryo naturally arrives to the uterine cavity and implantation occurs). The pregnancy rate does not seem to be significantly different from day three transfers, but the implantation rate (number of gestational sacs by ultrasound / number of embryos transferred) is assumed to be higher. In a small percentage of patients, none of the embryos progress to the blastocyst stage, therefore, the procedure is not appropriate for every couple.
For a pregnancy to result from any assisted reproductive technology procedure, the embryo must successfully implant into the uterus following the embryo transfer. Failure of the embryo to implant is one of the main reasons that some ART procedures don’t result in a pregnancy. When sperm and eggs are combined in the laboratory, the zona pellucida (the shell surrounding the fertilized egg) hardens, making it more difficult for the embryo to implant.
The laser micromanipulation technique called Laser Hatching is an additional technique designed to improve the efficiency of assisted reproductive technology procedures. Using a precision laser, an opening is made in the zona pellucida to weaken the wall of the embryo. The opening helps the embryo hatch from the zona pellucida and implant correctly.
Preimplantation genetic diagnosis (PGD) is a procedure which allows screening of embryos for specific genetic diseases / chromosomes before the embryos are placed in the uterus. The procedure involves making a small hole in the zona pellucida (the shell-like coating surrounding the embryo) of the 8 cell embryo and removing a single cell from the embryo.
Removing one cell does not harm the embryo at this stage and as the cell is identical to the rest of the embryo, it can be used to make a genetic diagnosis. If the cell is a carrier for that disease or is affected by the disease, we do not transfer the embryo. Embryos that are unaffected by the disease are placed into the uterus to establish pregnancy.
These patients benefit from PGD:
Cryopreservation (freezing) of embryos is offered when the number of viable embryos produced during an IVF cycle exceeds the number of embryos that are transferred fresh into the uterus.
Cryopreserved embryos can be subsequently thawed and placed into the uterine cavity even after many years of being frozen.
Like embryo freezing, the freezing and storage of sperm allows us to collect sperm ahead of time if the male partner will be unavailable for a future IVF cycle. Oocyte cryopreservation is a much newer technology in which a woman’s eggs are extracted, frozen and stored. Later, when she is ready to become pregnant, the eggs can be thawed, fertilized, and transferred to the uterus.
Cryopreservation of embryo and gametes is also a fertility preservation option for those patients with cancer or other chronic diseases that are facing the possibility of infertility due to chemotherapy or radiation treatments.