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What is in vitro fertilization?

IVF involves taking eggs from the woman, fertilizing them in the laboratory with her partner's sperm and transferring the resulting embryos back to her uterus 2-6 (usually 3 or 5) days later.

In general, it is appropriate to see a physician for infertility after 12 months of trying to get pregnant on your own.

Perhaps you know that you have a condition that predisposes to infertility, such as irregular menstrual cycles, endometriosis, previous tubal pregnancy, polycystic ovary syndrome, etc.

Also, female age is an important issue. If the female partner is over 37, you may want to seek help sooner than 12 months (e.g. after 6 months of trying). It is appropriate for women 40 and older to see a fertility specialist if not pregnant after 3-6 months of trying. A high percentage of women 5over 40 will need help in order to conceive.

Infertility

Definition, Infertility Causes, Infertility Testing and Infertility Treatment

Definition

Infertility is defined as 12 months of unprotected intercourse without pregnancy.
- Primary infertility: Infertility without any previous pregnancy.
- Secondary infertility: When there has been a previous pregnancy.
Sterility: Is when there is no chance for a pregnancy. This is different from infertility which generally represents a reduced potential for pregnancy.

Most childless couples with a female age under about 42-44 that are having problems getting pregnant are infertile but not sterile.

The cause of infertility is sought by performing a basic infertility evaluation.
These tests can usually be completed in one menstrual cycle.

Most common causes:

Ovulation problems
Tubal infertility
Sperm problems
Unexplained infertility
Age-related factors
egg quantity and quality problems
Other, less common causes of infertility
Uterine problems
Infertility and endometriosis
Previous tubal ligation
Previous vasectomy
Infertility associated with immunological problems

Ovulation problems

Some women do not properly develop and release a mature egg every month as they should normally. We call this condition anovulation.

Some women never develop and release an egg without medication - we say that these women are anovulatory. These women will have no menstrual periods for several months or years at a time. The medical term for this is amenorrhea. Often, when they do have a period it is quite heavy. In some cases, the woman may even require medical attention because of the degree of blood loss.

Some women ovulate once or twice a year and need medication to stimulate egg development to occur in every menstrual cycle to increase the chance for pregnancy.

Diagnostic testing for ovulation disorders. Usually the doctor can tell from discussing the details regarding previous menstrual cycles whether there is likely to be an ovulation disorder. In addition, blood testing at various times of the menstrual cycle and sometimes an ultrasound study of the ovaries can clarify whether ovulation is occurring.

Polycystic ovarian syndrome is a very common cause of an ovulation and infertility. When it is suspected, additional testing may be indicated.

Laparoscopic view of a typical, enlarged, polycystic ovary

Ultrasound image of a polycystic ovary. Note many immature small follicles (black circles) around periphery of ovary. Blue circle is around the ovary

What is ICSI?

ICSI involves injection of single sperm in to single eggs in order to get fertilization. First, the woman must be stimulated with medications and have an egg retrieval so that we can obtain several eggs in order to attempt in vitro fertilization. The eggs are injected using specially designed microscopes, needles and micromanipulation equipment.

Who should be treated with intracytoplasmic sperm injection?

All couples with severe male factor infertility that do not want donor sperm insemination.
All couples with infertility with:
- Sperm concentrations of less than 15-20 million per milliliter OR
- Sperm motility less than 35% OR
- Very poor sperm morphology (subjective - specific cutoff value not appropriate)
All couples having IVF who have had a previous cycle with no fertilization - or a low rate of fertilization (low percentage of mature eggs that are normally fertilized).
All couples having IVF who have a very low yield of eggs at the egg retrieval - our current cutoff is 5-6 (or less) eggs. In this scenario, ICSI is being used to try to get a higher percentage of eggs fertilized than with conventional insemination of the eggs (just mixing eggs and sperm together).

How is ICSI performed?

The mature egg is held with a specialized holding pipette.
A very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm.
This needle is then carefully inserted through the zona (shell of egg) and in to the cytoplasm of the egg.
The sperm is injected in to the cytoplasm and the needle carefully removed.
The eggs are checked the next morning for evidence of normal fertilization.

ICSI in progress

Needle with a sperm inside is advanced to the left
Shell of embryo has already been penetrated by needle
Membrane of egg is stretching and is about to break
Sperm head visible at tip of needle

Intrauterine insemination - IUI

Intrauterine insemination with partner's sperm can be used as a potentially effective treatment for infertility of all causes in women under about age 45 except for cases with tubal blockage, severe tubal damage, very poor egg quantity and quality, ovarian failure (menopause), and severe male factor infertility. In vitro fertilization with the woman's eggs or IVF with donor eggs are alternatives for couples that are not candidates for artificial insemination.

It is most commonly used for infertility associated with endometriosis, unexplained infertility, anovulatory infertility, very mild degrees of male factor infertility, cervical infertility and for some couples with immunological abnormalities.

It is a reasonable initial treatment that should be utilized for a maximum of about 3-6 months in women who are ovulating (releasing eggs) on their own. It can be reasonable to use it for somewhat longer than this in women with anovulation that have been stimulated to ovulate.

It should not be used in women with blocked fallopian tubes. Tubal patency should be demonstrated prior to performing insemination. This is usually done with an x-ray study called a hysterosalpingogram.

It has very little chance of working in women that are over 40 years old, or in younger women with a significantly elevated day 3 FSH level, or other indications of significantly reduced ovarian reserve.

If the sperm count, motility or morphology is more than slightly low, insemination is quite unlikely to be successful. In that situation, IVF with ICSI is indicated and has high success rates.

Surgical treatment for tubal factor infertility

Hydrosalpinx, a blocked right fallopian tube prior to surgical repair. The end of the tube is stuck in pelvic scar tissue to the ovary. Tubal factor infertility accounts for about 20-25% of all cases of infertility. The treatment for tubal factor infertility is usually either tubal surgery to repair some of the damage or in vitro fertilization (IVF). The pros and cons of surgery versus IVF are discussed on the tubal factor infertility page.

What can be done to repair damaged tubes?

The options for surgical treatment of tubal factor infertility depend very much on the degree of tubal damage.Lysis of adhesions can be performed (resection of scar tissue) or blocked tubes can be re-opened with surgery. Various levels of reconstruction in between these two extremes is also possible. Subsequent pregnancy rates depend upon several factors including the amount of tubal damage that was initially present before the procedure, the degree of damage to the internal lining of the fallopian tubes which can no be corrected, the age of the woman, the situation with the male partners sperm, the skill of the surgeon, and other factors.

Laparoscopy and Laparotomy

Laparoscopic repair of a blocked fallopian tube (neosalpingostomy)

Grasping instrument is holding end of tube at newly created opening, "O"

Many tubal surgeries can be performed laparoscopically ("belly-button" or "Band-Aid" surgery).This allows the woman to go home the same day, return to work in 3-4 days, and have only small scars (each less than 1") on her abdomen. However, not all tubal surgeries can be performed as well through the laparoscope as by laparotomy (bigger incision - about 4 inches long). This also depends on the skill and training of the surgeon.

Tubal Reversal Surgery

The biggest advantage of tubal reversal surgery over IVF is that once the women has gone through the surgery she hopefully will not need any intervention through a physician such as drugs, medications or procedures in order to get pregnancy. Obviously, the idea is that good old fashion sex will then give them the baby that they want. There is also very low risk for multiple pregnancy - twins occur naturally in only 1 in 90 pregnancies. The biggest disadvantage is the fact that the women has to go through a big surgery and if pregnancy does not result after the tubal reversal her only option remaining is IVF. A small disadvantage is that after she has her additional children, she will need to use contraception or have her tubes (or her husband’s) tied again.