In Vitro fertilization (IVF + ICSI)
The Assisted Reproductive Technologies (ART) is a group of treatment options used for couples with infertility that cannot be treated using simpler methods. These procedures have excellent success rates but require significant effort and might be expensive. For all of those reasons, advanced treatment options of infertility can be stressful, but worthful. This natural stress can be minimized if you understand the nuances of the various procedures. I encourage you to learn more, to watch and read additional educational sources listed in the web site and to freely ask any question. Understanding the purpose of each procedure will help you obtain the appropriate treatment and maximize your chance of success. The unknown is always stressful. Knowing what is awaiting you, will minimize the stress.
There are a number of different types of treatments belonging to the ART methods. The main treatment of infertility is In Vitro Fertilization or IVF.
IVF indications or when to use IVF?
In case of problems of the Fallopian tubes, especially if they are blocked, IVF is the 1st line of treatment to bypass the tubes. IVF is also the 1st line of treatment to avoid hereditary and genetic problems or in case of family planning for sex selection by using PGD + IVF or in case of female age factor (advanced age) or in case of egg donation. In other cases, IVF is recommended if simpler treatments fail.
List of Indications for IVF treatment.
1) Fallopian Tube Damage/Tubal Factor:
The fallopian tubes might get damaged or blocked after some pelvic infections or after previous abdominal surgeries such as C - sections for example. The only option for treating significant tubal damage, especially if both tubes are blocked is by bypassing the tubes with IVF. This decision must be carefully individualized in each situation.
The Fallopian tubes might be damaged and filled by a liquid. This is called a hydrosalpinx. In case of hydrosalpinx of the tubes, it is advised to remove or close the damaged tubes by Laparoscopy before doing an IVF procedure to increase the success rate.
2) Male Factor Infertility:
IVF is used in case of a decreased sperm count or sperm motility or sperm morphology using Intra Cytoplasmic Sperm Injection (ICSI). One of the most advances in the treatment of infertility has been to obtain fertilization and pregnancy in the IVF lab with severely abnormal sperm samples by using IVF + ICSI (Intra Cytoplasmic Sperm Injection). ICSI is recommended if there is any suggestion of a sperm problem. If sperm are obtained surgically in case of obstructive Azoospermia, or if there has been a prior failure of fertilization, ICSI is used.
Endometriosis may be treated by a combination of surgical and medical therapy. But it’s better to stay away from surgery or to postpone the surgery to treat endometriosis as it damages the ovarian reserve and leads to a decrease in the ovarian reserve, which makes the chances of pregnancy more difficult. It is advised to use surgery to treat endometriosis only after having had children, then the reserve will not matter anymore if damaged. IVF is considered a very effective and successful treatment of infertility caused by the endometriosis.
4) Female age related Infertility:
In normal reproductive life, a woman's ovarian function is decreased with age. As a woman grows older, especially after the age of 35, her ovarian reserve and egg quality decreases, making the chances of a successful pregnancy more difficult and increases the number of miscarriages. Age is the biggest factor affecting a woman's chance to conceive and have a healthy baby. A Woman's fertility starts to decline in her early 30s, with the decline speed increasing after the age of 35. In many cases, this reduced function of the eggs can be overcome through the use of IVF alone or in conjunction with techniques such as Assisted Hatching and ICSI.
Fertility preservation by freezing their own eggs until later use is also a perfect solution for women to keep the conceiving abilities as the woman gets older. After freezing her eggs, a woman can use them later using IVF. The quality of the frozen eggs depends on the age of the woman at the time when it was done.
IVF + Egg donation might also be a solution for women above 40 years old or for those who have premature ovarian failure before the age of 40.
5) Anovulation / Irregular menstrual cycle:
The majority of patients with anovulation will get pregnant using simpler treatments. However, those patients requiring IVF are typically "high responders" to gonadotropin therapy and have a good prognosis, because they usually have good ovarian reserve especially those suffering from polycystic ovaries (PCO).
6) Unexplained Infertility:
Approximately 20% of couples will have no known cause of infertility after completing a fertility evaluation. IVF is often successful even if more conservative treatments have failed, especially that some of those couples have some block to fertilization.
7) Some cases of polycystic ovaries
8) Some cases of repeated miscarriages
9) Some cases of endometritis and repeated implantation failures
10) Frozen embryos and frozen semen
11) Pre-implantation Genetic Diagnosis (PGD) or Pre-implantation Genetic Testing (PGT) or PGS:
PGT or PGD technology reduces the potential for adverse pregnancy outcomes for couples ‘at risk’ by testing the embryos for certain genetic abnormalities before they are chosen for transfer.
Genetic testing or diagnosis on pre-implantation embryos may be indicated for patients who are at risk for genetic disorders such as Thalassemia and for patients with infertility related to chromosomal abnormalities such as recurrent pregnancy loss or repeated unsuccessful IVF or for gender (sex) selection (to choose boys or girls).
Pre-implantation genetic testing (PGT) or PGD is a procedure used in conjunction with in vitro fertilization (IVF) to select embryos free of chromosomal abnormalities and specific genetic disorders before transfer to the uterus. PGT improves the likelihood of a successful pregnancy and birth for two distinctly different groups of patients; couples with infertility related to recurrent miscarriage or unsuccessful IVF cycles and couples who are at risk for passing on an inherited genetic disease to their offspring.
Pre-implantation genetic testing may be recommended by your physician when there is a possibility, indicated by your medical history or advanced maternal age, which could affect your embryos by a genetic disease. PGD can only be performed during an IVF cycle where eggs and sperm, united in the laboratory, then develop into embryos. On the 3rd day or 5th day a biopsy is done on each embryo to make a chromosomal study and after the testing results on day 5, only the normal embryos would be selected for embryo transfer, reducing the possibility of miscarriage or birth defects.
We can also use PGD for gender selection. We choose the required embryos upon their sex, boys or girls before doing the embryo transfer for family planning. We can freeze the healthy embryos that were not chosen for the transfer.
12) Gender or sex selection / Family planning:
IVF + Pre-implantation genetic diagnosis (PGD) is an excellent tool to choose the sex of the embryo before uterine embryo transfer. 3 or 5 days after fertilization in the IVF lab a cell biopsy is done from each embryo using laser and under a special microscope. It is 99% precise in detecting the gender of the embryo. After the embryo biopsy, a chromosome study will be done on the Y and X chromosomes to determine the exact sex, a boy or a girl.
The women will start on the 2nd or 3rd day of the period injections for about 8 - 12 days before making the egg retrieval and fertilization. The embryo transfer of the desired embryos depending on their sex will be done on day 5 after the fertilization. The embryos that were not transferred could be frozen for later use or if not frozen they will stop growing on day 5 - 7 because the embryos cannot live in the culture media of the IVF Lab more than that.
13) Cancer patients and IVF:
All young cancer patients willing to have children in the future have to freeze their eggs in case of women or their sperm in case of men before starting any cancer treatment.
Frozen eggs or frozen sperm procedures are done before starting cancer treatments to preserve female and male fertility after recovery from cancer. The frozen eggs and frozen sperm are used later by their owners to have children using IVF.
14) Egg donation:
Egg donation is the best solution for women after the age of 40 or in case of premature ovarian failure before 40 years.
We use donated eggs from young and healthy donors instead of using a woman's old eggs. In the IVF laboratory, healthy and young donated eggs (donors 18-27 years old) are fertilized with the husband's sperm. Then, on day 3 or day 5 after fertilization the embryos are transferred into his wife's uterus. Pregnancy success rate of egg donation is at least 70%. Once the woman gets pregnant from donor eggs, her pregnancy continues normal development as any other normal pregnancy.