For many people, the dream of having a family is not easily realized. At WVU’s Center for Reproductive Medicine, our doctors can help couples have a child using assisted reproductive technology (ART).
ARTs are treatments that help increase the likelihood of the successful union of a sperm and egg, leading to the development of a viable fetus, and, ultimately, to the birth of a healthy baby.
ART procedures include:
- Superovulation and intrauterine insemination (detailed below)
- In vitro fertilization and embryo transfer (IVF-ET) (detailed below)
- Cryopreservation and frozen embryo transfer (detailed below)
- Micromanipulation (detailed below)
- Intracytoplasmic sperm injection (ICSI)
- Preimplantation genetic diagnosis (PGD)
- Testicular biopsy and testicular sperm extraction (TESE)
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:
- Using 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.
This therapy has been used for 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 used with inducing ovulation in patients with ovulation defects who have not conceived with timed intercourse.
Risks – The use of superovulation creates the potential for 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.
- Inseminations usually are performed the day of or the day following a luteinizing hormone (LH) surge as detected by ovulation predictor kits or 34-36 hours after administration of human chorionic gonadotropin (hCG).
- The semen will undergo special preparation in the laboratory and will be placed in a syringe attached to a special catheter.
- When the concentrated sperm is ready, a speculum is placed in the vagina.
- The catheter is inserted into the uterine cavity, and the prepared sperm is injected into the uterine cavity.
- You will need to lie still for the next 10 minutes.
- There are no restrictions on your activities for the remainder of the day.
In Vitro Fertilization and Embryo Transfer (IVF-ET)
In vitro fertilization and embryo transfer consists of:
- Removing the egg(s) from the ovary, followed by insemination, fertilization, and early embryo development in the controlled environment of the laboratory.
- This early embryo 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 using IVF-ET have been expanded to include all causes of infertility that 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. Ultrasounds and hormonal studies are performed frequently 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 mid-cycle surge of luteinizing hormone (LH).
- Retrieval – Retrieval is timed to occur just prior to when the eggs would normally be released in response to the mid-cycle hormonal surge. Thus, egg retrieval is scheduled for approximately 34 hours after administration of hCG.
- Egg retrieval is done under conscious sedation, a type of anesthesia where medication is given through an IV to cause drowsiness.
- The procedure is done using 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 patient will spend approximately two 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 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.
Transfer – The transfer of high quality day-three embryos or day-five blastocysts can result in a greater than 60 percent “take home baby rate.” Just as the number of embryos to be transferred differs based on the patient’s age, we feel that the optimum time for transfer also differs between patients. 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 will not be transferred during that cycle but can be frozen and saved for later use.
- 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 the uterus to be viewed. 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. She is then allowed to return home.
Cryopreservation and Frozen Embryo Transfer
In cases where there are multiple embryos, we offer cryopreservation (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°C. This method is considered safe and non-destructive to human cells. By using cryopreservation, it is possible to preserve specimens for an extended period of time.
- 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 egg cycles.
- The transfer is done as with IVF-ET, and the recipient remains in the recovery room for one hour after the procedure.
Micromanipulation is a laboratory term for procedures that are 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, an individual sperm must be directly inserted into the egg to achieve fertilization.
- 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. 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.
- Pre-implantation genetic diagnosis – This procedure 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 embryos.