Assisted Reproduction
Reproductive Endocrinology
In Vitro Fertilization IVF
Benefits and Indications of IVF
Reproductive Endocrinology
Endocrinology is the study of hormones- the unique chemical substances that encode signals found circulating in everyone's bloodstream. Their role is critical to the process of reproduction as well as functional activity of bodily organs. It is through these hormones that the brain orchestrates and coordinates egg and sperm production from afar.
Reproductive endocrinology is the study of hormones that affect the reproductive system. Because many infertility problems are caused by hormone-related disorders, the doctor, a reproductive endocrinologist, can help to resolve a wide variety of hormone dysfunctions. The reproductive endocrinologist (Fertility Specialist) is required to complete two years of sub-specialty training in reproductive endocrinology and infertility.
For an infertility couple, the best evaluation and treatment is from a physician with a special interest and expertise in the area of infertility.
Major hormone-related problems:
· Infertility:
· Anovulation(no ovulation)
· Oligoovulation(infrequent ovulation)
· Luteal phase defects(poor ovulation)
· Amenorrhea
· Endometriosis
· Recurrent pregnancy loss
· Tumor associated with elevation of hormone
· Early or late onset of menstruation
Infertility is a concern
A condition of infertility exists when a couple is unable to achieve a pregnancy after a minimum of 12 consecutive months of unprotected relationship. Contrary to common belief, infertility is not rare. Approximately about one out of every six to ten couples are having fertility problems.
Finding the cause of infertility and treating it is a complex process. Problems with women reproductive health account for about 60 percent of fertility problem diagnosis. About 30 percent of the problems are associated with sperm production in men. In spite of all available medical work-up there remains about 10 percent of infertile couples with unknown causes. Timing, the health of both male and female reproductive system, and their physiological compatibility are all important variables in conception.
An important part of an infertility work-up involves a series of blood tests on the couple. The semen analysis is the corner stone of the evaluation of possible male factor infertility. Other lab tests and a careful history and physical help to diagnosis the cause of male infertility:
· Sperm production
· Anti-sperm antibodies (SpAb)
· Sperm Penetration Assay (SPA)
· Hormonal disorders
· Anatomical problems
· Sexual dysfunction
To evaluate infertility in a female, a general physical is done to determine the size, shape, position and condition of pelvic organs. Blood is drawn and analyzed to assess the levels of hormone activity in the body as well as the ovaries. A Hysterosalpingogram (HSG) and a Hysteroscopy is also indicated to evaluate the fallopian tubes and the uterus respectively.
Further procedures such as Diagnostic Laparoscopy which allow the physician to directly view the fallopian tubes, the uterus, and the pelvic cavity is also necessary.
In their attempt to overcome infertility, many patients will seek treatments such as surgery of pelvic organs to correct any anatomical conditions or ovulation induction to improve the number of eggs and to correct ovulation problems. For other patients, the solution may require more involved procedures. Such revolutionized procedures are designed to increase the amount of sperm and/or eggs or bring them closer together, thus improving chances of conception for an infertility patient. These medical approaches have expanded into a whole family of treatments, known by the term Assisted Reproductive Technology (ART). The most commonly known ART procedure is in vitro fertilization (IVF). Since the first IVF baby was born on Dec. 28, 1981 in Norfolk Virginia, with the assistance of pioneer physicians, Howard and Georgeanna Jones, the growing popularity of the technique has been phenomenal.
IVF is a sequential process by which eggs are retrieved from the ovaries, fertilized with sperm in the laboratory and cultured into cleaved embryos and then transferred into the uterus.
In-vitro fertilization(IVF) has four stages:
Stage 1 - Controlled Ovarian Hyperstimulation
Stage 2 - Egg(Oocytes) Retrieval
Stage 3 - Fertilization/Incubation
Stage 4 - Embryo Transfer ET
Stage 1 - Controlled Ovarian Hyperstimulation
To program the cycle, the patient starts with oral contraceptive pills followed by Lupron injections subcutaneously until and during ovarian stimulation following onset of next menstrual cycle. Lupron induces a condition called pituitary desensitization. Desensitized pituitary glands minimizes the chance of premature LH surge. Such a surge results in a canceled procedure because the follicles can not be retrieved.
Rather than having a single egg developed each month and in order to maximize chances for a successful IVF cycle, a physician will stimulate ovaries to produce as many ovarian follicles as possible using hormonal medications. Follicle Stimulating Hormone (FSH) is a hormone necessary for multiple follicles development and it is in a form of injection. Usually, daily injection of FSH (Gonadotropin) starts on cycle day 3 to cycle day 9. Along with the injection, ultrasound and estradiol (E2) level will be performed to monitor ovarian response to FSH. Ultrasound scan will be utilized to observe the size and number of follicles, and can determine follicle maturity. Developing follicles secrete increasing amounts of estradiol (E2). Blood estradiol levels are used along with the ultrasound scans to determine the optimal timing for the administration of Human Chorionic Gonadotropin (HCG) which acts as an ovulation inducer and is the final step leading to egg retrieval.
Stage 2 Egg Retrieval
The oocyte retrieval is performed under conscious sedation by an anesthesiologist. After a 30 to 50 minute procedure, the patient will be discharged post recovery from anesthesia. The oocyte retrieval usually takes place 34 to 36 hours following the administration of HCG. Egg retrieval procedure is performed by vaginal ultrasound using a long, small diameter needle inserted in a guide on the ultrasonic probe. The needle is connected to a suction pump and the fluid from any accessible follicle within the ovary is aspirated. The fluid is then examined by an embryologist under the microscope for presence of eggs. The process is repeated until all the mature follicles have been aspirated. After egg recovery, the eggs are transferred to a sterile Petri-dish to await fertilization.
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Stage 3 Fertilization
To facilitate fertilization, sperm washing is performed to obtain the strongest and most active sperm from the ejaculate. Sperm are placed together with eggs in a dish and incubated at an environmentally constant temperature and appropriate levels of humidity and carbon dioxide level. Approximately 72 hours post oocyte retrieval, if the eggs have successfully been fertilized and are cleaving normally, they will be transferred into the uterus.
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When indicated, i.e. poor quality/quantity sperm and/or egg, special micomanipulation procedure called Intracytoplasmic Sperm Injection (ICSI) is needed to increase chances of fertilization. This laboratory procedure involves the injection of a single sperm into the egg, bypassing the need to have sperm penetrate the egg.
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A special surgical procedure called Microsurgical Epididymal Sperm Aspiration (MESA), where sperm can be extracted directly from the epididymis due to uncorrectable blockage of the male genital tract, congenital absence of the vas deferens and vasectomy. MESA can provide sperm for IVF cycle but it needs to be used in conjunction with ICSI.
Stage 4 - Embryo Transfer - ET
Not all inseminated eggs will go on to fertilization. The number of eggs achieving fertilization depends on many factors including egg quality, sperm quality and the binding process. Not all embryos will be transferred to the patient. The number of embryos transferred depend on the maternal age as well as the quality of the embryos. The doctor will suggest the optimal number of embryos to be transferred. If there are any remaining embryos, they can be cryopreserved and stored indefinitely. Frozen embryos can be thawed and used for future transfer.
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Embryo transfer procedure is performed without anesthesia. The embryos are placed in a special soft plastic catheter and transferred into the uterus. Similar to artificial insemination, the physician will pass the catheter through the cervix into the uterine cavity. The patient will rest for two hours and will then be discharged. Pregnancy test is usually done in about 12 to 14 days after embryo transfer. During this time daily injection or vaginal creme of supplemental progesterone is also required.
Benefits and Indications of In Vitro Fertilization - IVF
· The ability to know if the male’s sperm has actually fertilized the eggs.
· Tubal bypass procedure, because the embryos are placed directly in the uterus, the women does not need to have functioning fallopian tubes.
· Women with Endometriosis, Pelvic Adhesion Disease, Tubal Ligation.
· Unexplained Infertility.
· Male factor infertility, i.e. severe oligozoospermia