Assisted Reproductive Technologies (ART) are a group of treatments whose intent is to increase the possibility for the successful interaction of the sperm and egg.

Superovulation and Intrauterine Insemination

The simplest form of ART is superovulation [SO] (also called controlled ovarian hyperstimulation [COH]) plus intrauterine insemination (IUI). The process involves:

• The use of fertility drugs to increase the number of eggs that are released at the time of ovulation
• Placing sperm directly into the uterine cavity around the time that ovulation is occurring.
• Supplemental progesterone may be prescribed after ovulation and is continued for the first 10 weeks of pregnancy. The progesterone is usually administered in the form of creams or suppositories.

The concept is that an increased number of eggs in close proximity to an increased concentration of sperm will improve the chances for pregnancy. The success of this form of therapy requires:

1. The release of the egg(s) from the ovary
2. That the egg(s) are picked up by the tubes
3. That the sperm is able to reach the egg in the tube
4. That fertilization takes place

• Indications: This form of therapy has been utilized in patients with unexplained infertility, cervical factor infertility, male factor infertility, or in cases of endometriosis in which the tubes are unobstructed. Intrauterine insemination is also utilized along with ovulation induction in patients with defects of ovulation who have not conceived with timed intercourse.
• Risks: The use of superovulation creates the potential for the ovarian hyperstimulation syndrome and for multiple gestation. The use of IUI carries the potential for pelvic infection due to bypassing the normal defense mechanisms of the cervical mucus.

In-Vitro Fertilization and Embryo Transfer (IVF-ET)

In-Vitro Fertilization and Embryo Transfer consists of:

• Removing the egg(s) from the ovary after which insemination, fertilization, and early embryo development occur in the controlled environment of the laboratory.
• This early pregnancy is then transferred directly into the uterine cavity.

The process of IVF-ET was originally developed to treat women with damaged, blocked, or absent tubes. Since the first successful pregnancy in 1978, thousands of babies have been conceived and the indications for IVF-ET have been expanded to include all causes of infertility which have not responded to simpler forms of therapy.

The usual steps in IVF-ET are as follows:

• Superovulation: In contrast to the natural cycle in which one egg is available for fertilization, superovulation involves the use of various combinations of hormones in order to make multiple eggs available for attempted fertilization. The treatment strategies that are used are undergoing constant revision in an attempt to obtain the highest quality eggs with the least amount of risk to the woman who is undergoing stimulation.Ultrasounds and hormonal studies are performed on a frequent basis to assure that the medications are working and to reduce the risk of ovarian hyperstimulation. When sufficient eggs are ready, other medications are administered to induce or mimic the normal midcycle surge of Luteinizing Hormone.
  The medication that has been most commonly used has been the hormone, human chorionic gonadotropin. Human chorionic gonadotropin (hCG) is similar in structure to Luteinizing hormone (LH) so the ovary will respond to hCG as it would to the natural midcycle LH surge. Purified Luteinizing hormone can also be administered as well as drugs that cause the pituitary to release LH. Ovulation will usually occur approximately 36 hours after administration of hCG.
• Retrieval: Retrieval is timed to occur just prior to the time when the eggs would normally be released in response to the midcycle hormonal surge. Thus, retrieval is scheduled for approximately 34 hours after administration of hCG.

Technique:

• The egg retrieval is done under conscious sedation. This is a type of anesthesia where medication is given through an IV to cause drowsiness. Most patients say that they do not remember most of the procedure.
• The procedure is done with the use of vaginal ultrasound to visualize the ovary. A needle, attached to the ultrasound probe, is used to aspirate the fluid from the follicles (egg, fluid, and surrounding cells) and the fluid is immediately examined to determine whether an egg is present.
• The procedure generally takes 30-45 minutes.
• The patient will spend approximately 2 hours in the recovery room.
• She should plan to spend that day in bed, resting.

• Insemination and Fertilization:

• On the day of retrieval, the partner will need to provide a semen specimen or donor sperm must be available.
• Approximately four hours after the egg retrieval has been performed and the semen has been collected and prepared, the eggs are inseminated, i.e. exposed to sperm.
• On the following day, the eggs are evaluated to see if fertilization has occurred. The fertilized egg still consists of a single cell, but within the egg are two structures called pronuclei. One pronuclei contains the genetic material from the egg and one pronuclei contains the genetic material from the sperm. The term for a fertilized egg is an embryo.

• Embryo Development: The embryos are maintained in the laboratory in a very careful environment. After fertilization has occurred and the genetic materials from the egg and sperm have joined together, the embryo begins to divide.

  • The embryo is described by the number of cells that are present (2 cell, 4 cell, 8 cell, etc.).
  • If the embryos are left in culture beyond three days, they will develop more cells than can be counted and are know called morulas.
  • At five to six days the cells began to separate into those that will form the placenta and those that will develop into the fetus. A small amount of fluid accumulates in the center of this mass of cells. This structure is called a blastocyst.
• Transfer: There exists a great deal of controversy as to whether one should transfer embryos on day 3 or transfer blastocysts on day 5. The transfer of high quality day 3 embryos or day 5 blastocysts can result in a greater than 60% "take home baby rate". Just as the number of embryos to be transfered differs based on the patient's age, we feel that the optimum time for transfer also differs between patients. The response to superovulation and the number and quality of the developing embryos enters into this decision. Our goal is obtain high quality embryos and blastocysts that will allow us to meet or be more stringent than the recommendations of the American Society of Reproductive Medicine in hopes of obtaining a single healthy pregnancy. Extra embryos or blastocysts will not be transferred during that cycle but can be cryopreserved (frozen) and saved for later use. (See Embryo Cryopreservation below).
  
  • Technique:
    • Whichever day it is done, the embryo transfer takes place in the same procedure room as the egg retrieval.
    • The discomfort of embryo transfer is minimal, similar to that of a pelvic exam and Pap smear or intrauterine insemination so no anesthesia is required.
    • We use the "full bladder" technique for embryo transfer, asking the patient to arrive for the transfer with a full bladder. With this technique, an ultrasound scanner is placed on the patient's lower abdomen over the bladder, allowing visualization of the uterus. In this way, the passage of the catheter containing the embryos can be seen on the ultrasound screen to assure optimal placement of the embryos.
    • After the transfer is completed, the patient stays in the Recovery Room for one hour on complete bed rest with the pelvis elevated. She is then allowed to return home.
• Luteal support: Following ovulation, supplemental progesterone is administered and is utilized for the first 10 weeks of pregnancy. Different preparations of progesterone can be used including: oral, creams, suppositories, and intramuscular injections.

Gamete Intrafallopian Transfer (GIFT)

Gamete Intrafallopian Transfer (GIFT) is a procedure in which eggs are removed from the ovaries, mixed with prepared sperm, and then placed into the fallopian tubes. The improvement in pregnancy rates with IVF-ET has markedly reduced the use of GIFT.

• Just as with IVF-ET, superovulation is performed but instead of retrieving the eggs by vaginal ultrasound, laparoscopy is used. This procedure depends on the presence of normal fallopian tubes and that fertilization will take place in the tube.

Donor Oocytes

This is when eggs from an anonymous or known donor are used for in-vitro fertilization. Donor oocytes can be used in the following situations:

1. The prior loss of one's ovaries due to surgery
2. Premature ovarian failure
3. Increased age with poor response of the remaining eggs
4. Genetic conditions of the woman that would be transmitted to her offspring

Procedure

• The procedure is identical to IVF-ET except that the donor is the one who is undergoing superovulation and retrieval.
• The recipient will then undergo hormonal therapy so as to coincide with what is going on in the donor.
• When the embryo(s) are ready, the embryos are transferred into the recipient.
• The transfer is done as with IVF-ET and the recipient remains in the recovery room for 2 hours after the procedure.
• The recipient is then placed on supplemental estrogen and progesterone for the first third of pregnancy.

Cryopreservation and Frozen Embryo Transfer

In cases where there are multiple embryos or blastocysts, we offer cryopreservation, or freezing.

• Specimens are frozen in separate, labeled, specially developed catheters or straws and are stored in tanks of liquid nitrogen at a temperature of about -196 oC. This method is considered safe and nondestructive to human cells. By using cryopreservation, it is possible to preserve specimens for an extended period of time.
• The availability of the frozen embryos means that superovulation and retrieval does not have to be repeated.
• Specimens are specially thawed and prepared for transfer into the uterine cavity. Transfer is performed after having prepared the uterine lining with estrogen and progesterone as is done in donor oocyte cycles.
• The transfer is done as with IVF-ET and the recipient remains in the recovery room for one hour after the procedure.
• The recipient is then placed on supplemental estrogen and progesterone for the first third of pregnancy.

Micromanipulation

Micromanipulation is a laboratory procedure that is used to assist in fertilization and implantation of embryos.

• Intracytoplasmic sperm injection (ICSI): The normal sperm is able to attach to and penetrate a special layer or "shell" that surrounds the egg called the zona pellucida. When there are sperm antibodies, inadequate numbers of sperm, inadequate sperm function, or unexplained failure to achieve fertilization with standard insemination during IVF-ET, then an individual sperm must be directly inserted into the egg in order to achieve fertilization. The process of ICSI captures one sperm and by using special microscopes, a micro needle is pushed through the zona pellucida into the interior of the egg (cytoplasm) and the sperm is injected.
• Assisted hatching: Under normal circumstances, the embryo is able to escape (hatch) from the surrounding zona pellucida. This step is necessary for normal implantation to occur. In some cases this shell is too thick to occur. Using various techniques, the zona is altered so as to allow "hatching" of the embryo. This procedure may be required more often in older patients.
• Defragmentation: As some embryos develop, a portion of the newly developed cells are abnormal and form fragments. This may be a mechanism whereby the embryo rids itself of abnormal cells. When a significant number of fragments are present, they may interfere with the development of a normal pregnancy. Prior to transfer, these fragments can be microscopically removed. Removal of these fragments does not injure the normal cells and this procedure improves the chances for a successful pregnancy.
• Preimplantation Genetic Diagnosis: This is a procedure that is used for couples who are carriers for serious genetic conditions that might be transmitted to their offspring. After embryos are available as a result of IVF, one of the cells from the developing embryo can be removed and submitted for genetic evaluation while allowing the remaining cells in the embryo to continue developing normally. The couple then has the option of transferring only the unaffected embyos.