The most appropriate treatment method shall be determined depending on the cause detected. Infertility shall be treated by medication, surgery, or any of the assisted reproduction methods.
Timing of the sexual intercourse
On occasions, the initial interview would reveal that sexual intercourse is performed too rarely, at an unsuitable time or for a short time. In these cases, it is sufficient to monitor the cycle and time the sexual intercourse properly.
Treatment by medication
If a hormonal level imbalance is detected that prevents ovum maturation or release of the mature ovum from the follicle (ovulation) and no other cause of infertility is apparent, treatment shall be performed by administering the appropriate medication. Similarly, the treatment of endometriosis, thyroid gland disorders, or chronic sex organs infection is sometimes sufficient.
Treatment by surgery
In some cases, abrasions in the abdominal cavity are removed by surgery (by laparoscopy) or making the ovarian ducts passable, but this has recently been abandoned due to the low success rate.
Assisted reproduction is a set of procedures designed to help overcome the obstacles that prevent natural fertilization and pregnancy. Within assisted reproduction, several different methodologies are applied, each of them being appropriate for various infertility factors.
- Intrauterine insemination (IUI).
The IUI consists of administering the selected highest-quality sperms from the partner’s ejaculate (AIH -artificial insemination by husband) or that from a donor (AID – artificial insemination by donor) through a thin tube (catheter) directly into the uterus. The ovulation of the ovum will occur in the body of the woman (in the ovarian duct), therefore the ovarian ducts must be passable. Prior to insemination, mild ovarian stimulation is usually carried out by hormonal injections which cause the maturation and release of at least one ovum and at most three ova. Intrauterine insemination may also be performed in the natural cycle without hormonal stimulation, but the success rate is then lower. The performance is painless and after a half-hour rest, the woman leaves for home.
With the following two assisted reproduction techniques, the ovum is fertilized outside the female body. Also, hormonal stimulation is aimed at maturation of a larger number of the ova than with the intrauterine insemination.
- In vitro fertilization (IVF – “tube” fertilization, extra-corporeal fertilization).
This is most frequently performed when a woman has ovarian ducts damaged, also in cases of inexplicable infertility, or after a repeated failure of simpler methods of infertility treatment. The fraction of the highest-quality sperms from the ejaculate shall be added to the oocytes taken in the culture solution. The embryos that are conceived in the above way shall be transferred in the uterine cavity after several days of cultivation.
- Intracytoplasmic sperm injection into the oocyte (ICSI).
Intracytoplasmic sperm injection into the oocyte is a special method of in vitro fertilization. It is especially effective in cases of severe male infertility when there is a very low number of the sperms with insufficient mobility in the ejaculate, when these are unable to fertilize the ovum by conventional in vitro fertilization. The principle of this micromanipulation technique is that a single sperm is introduced into each ovum under a microscope by a very thin needle. A further fertilization process and embryo development take place like with the in vitro fertilization.
In the spontaneous cycle, one ovum usually matures in the ovary. If a woman is to undergo extra-corporeal fertilization, she would pass the so-called controlled ovarian hyperstimulation, which causes more ova to mature in the ovary. The more ova mature, the more high-quality embryos can be obtained, and thus increase the chances of becoming pregnant. Ovarian response to hormonal stimulation is individual – one may get 20 or more ova in a woman, and only 2-3 in another one.
The ovaries are stimulated by sex hormones in the form of injections. There exist several formulations that contain follicle-stimulating (FSH) and some even luteinizing (LH) hormone. Currently, highly purified formulations are used that can be administered subcutaneously, in the underbelly, in the thigh or the arm. Depending on the individual response of the ovaries to treatment, hormone dosing and duration of administration are adjusted. The duration of medication administration for ovarian stimulation depends on the type of protocol, usually lasting 2 to 4 weeks.
Repeated follow-up tests during ovarian stimulation include blood collection and ultrasound examinations to monitor follicle and ovum growth and maturation. On the basis of hormonal levels and ultrasound examination, the date of the oocyte collection shall be determined.
At a time when a minimum of 2 follicles become sufficiently large, a choriogonadotropic hormone (HCG) shall be administered to ensure the final maturation of the ova in the follicles.
The ova are collected approximately 36 hours after the HCG injection. Collection is performed under the ultrasound control, the individual follicles are stabbed via the vagina wall and their content is sucked off together with the ovum. The performance is carried out in the total anaesthesia.
On the day of the ova collection, you will arrive on an empty stomach (you will not eat or drink anything from the midnight of the previous day), you will have your personal stuff for changing your clothes and the results of both internal and anaesthetic examinations. The partner shall be available on that day at the time of collecting the ova to give a sperm sample.In order to obtain the best quality of the sperms, it is desirable to refrain from ejaculation for 3-5 days before collection!
Collection of the ova is painless; it is performed under a short-term total anaesthesia, under ultrasound control through the wall of the vagina. After the performance, you will stay lying for 3-4 hours. If everything goes without complications, you will go home a few hours after the collection.
Mature ova shall be prepared in the laboratory, by the in vitro fertilization or by the intracytoplasmic sperm injection into the oocyte, and cultured for several days until they are transferred into the uterus.
This performance consists of inserting the embryos by a thin tube (catheter) into the uterine cavity and is painless. After a short rest you may go home. After transferring the embryos, you will be taking the medication as advised by your doctor, and you will appear for making a blood test in 12 to 14 days to show if you are pregnant or not.
The number of embryos transferred depends on the following several factors: embryos quality, the age of the woman, the endometrial quality (uterine mucosa). As a rule, 1 to 3 embryos are transferred. The remaining embryos shall be frozen and represent still another chance for becoming pregnant if the woman fails not become pregnant after the transfer of fresh embryos.
The period after transferring the embryos
After transferring the embryos, it is necessary to create the best possible milieu for hatching the embryo in the uterus. The progesterone hormone action is very important during this period. Since the ovaries usually create insufficient amounts of that hormone after ovulation, the woman should be taking progesterone-containing medicines.
Now a period of expectation starts, during which hope for a positive result is mixed with the fear that the whole effort was unnecessary. Even though it is difficult, it is important for the woman to remain calm and continue her usual way of life. It is desirable to avoid excessive physical activity, hot baths, and sunbathing. Staying in bed is not necessary.
12-14 days after the embryo transfer, if menstruation does not occur, the level of the choriogonadotropin hormone (HCG) blood test reveals whether or not pregnancy has occurred. If the menstruation comes earlier, it means that the attempt was not successful and it is advisable to inform the doctor by phone of the fact to decide on the next procedure.
Some special procedures for assisted reproduction
Prolonged embryo cultivation
This is based on embryo out-of-body development for longer than three days and the embryo transfer usually on the fifth day of fertilization. The advantage of extended cultivation is in the choice of the best embryos to transfer to the uterus and increasing the probability of their hatching in the uterine mucous membrane. Suitability of extended cultivation shall be determined by an embryologist by a variety of many factors.
The principle of this technique is to gently disturb the embryo’s protective envelope (mechanically, chemically or by laser) just prior to the embryo transfer into the uterus, which facilitates the embryo hatching in the uterine mucous membrane. The method is performed in case of repeated failure to achieve pregnancy after the embryo transfer or in the patients over 35 years of age.
Embryo Freezing (Cryopreservation)
One to three of the best embryos are usually transferred into the uterus. Other high quality embryos are frozen using a special instrument and stored in liquid nitrogen at -196° C. This way they can be stored for as long as several years, without consequences to their further development.
If a woman does not become pregnant after the transfer of fresh embryos, other 2 to 3 embryos are thawed and transferred to the uterus. Freezing and thawing represents stress for the embryos, so not all the embryos will survive this process.
Microsurgical sperm collection
Microsurgical sperm collection is performed in males with no sperms found in their ejaculate. The reason for that may be obstruction in the seminiferous channel caused by infection, genetically or by sterilization (vasoconstriction) or by the disturbed sperm production.
In these cases, we can try and obtain vivacious sperms directly from the epididymis (MESA – Microsurgical Epididymis Sperm Aspiration) or from the testicle (TESE – Testicular Sperm Extraction). If the sperms can be obtained, these may be used to fertilize the ova most often by intracytoplasmic sperm injection into the oocyte.
Seborrheic or testicle sperm collection is a minor surgical procedure that is performed in the general anaesthesia and is usually associated with a 1-2-day hospital stay.
Sexual cell donation
This is used in cases of a severe partner spermiogram failure, in the absence of any sperms in the ejaculate, in the failure of the assisted reproduction methods, or in the case of a male who has a genetic disorder that could be transferred to a child.
The sperm donation programme is simplified by the fact that the sperms are relatively easy to freeze and have a good survival rate after thawing. The donated sperms may be used for the intrauterine insemination (AID), for the in vitro fertilization (IVF) or for the intracytoplasmic oocyte sperm injection (ICSI), as appropriate.
Sperm donors must be tested for genetic and sexually transmitted diseases. Sperm donation is anonymous, a suitable donor is selected from a sperm bank based on a questionnaire focusing on the appearance, blood group, and the couples’ wishes.
Donating the ovum
Ovum donation is a method of assisted reproduction for women who do not develop their own ova (premature ovarian failure, cancer treatment, genetically conditioned dysfunction of the ovaries). It is also suitable for women with a genetic disorder that they could transfer to a child.
The ovum donation programme is considerably more complicated than in the sperms, as the ovum donor undergoes the same hormonal treatment as a female undergoing the in vitro fertilization (IVF). At present, it is not yet possible to successfully freeze the non-fertilized ova. Therefore, the oocyte collection of the donor must be synchronized with the recipient’s cycle. The donor must also undergo genetic and sexually transmitted diseases examination. While the donor undergoes a programme of ovarian stimulation and ovum collection, the recipient must be ready for pregnancy, including by means of hormones, oestrogen, and progesterone. These prepare the uterus mucosa so that the embryo may hatch. The collected donor ova are fertilized by the sperms of the recipient’s partner, and 1 to 3 of the best embryos are transferred to the recipient’s prepared uterus. The remaining high-quality embryos are frozen.
Risks in assisted reproduction
Failed assisted reproduction cycle
Since none of the Assisted Reproduction Methods offers a 100% success rate, the greatest risk for the couples undergoing Assisted Reproduction is disappointment. However, one or several of the unsuccessful cycles often do not mean anything and the likelihood of the success rate increases with each attempt made!
The risk of miscarriage after assisted reproduction is the same as in natural pregnancy: 20% to 30%.
The risk for assisted reproductive pregnancy in a woman who has functional ovaries slightly higher than in normal pregnancy.
Since more embryos are usually transferred into the uterus, the incidence of multiple pregnancies is higher than in natural insemination. Multiple pregnancy is associated with a higher risk of miscarriage, immaturity, and a lower birth weight of newborns. However, nowadays, the solutions in which embryos are cultivated are of such a high quality that a sufficient number of suitable embryos are usually available for the transfer to the uterus. The embryologist selects one or two of the highest quality embryos for the transfer. In the case of a patient’s older age, repeated unsuccessful assisted reproduction cycles, or a lower quality of all the embryos, the embryologist would select a maximum of three embryos.
Ovarian Hyper Stimulation Syndrome (OHSS)
In some women, the hormonal treatment for ovarian stimulation may induce an over-response (the so-called uncontrollable hyper stimulation) of the ovaries. Milder forms of hyper stimulation are manifested by pain in the lower abdomen, nausea, vomiting, swelling. Approximately 0.2-1.9% of the stimulated women may develop a more severe form of illness that requires hospitalization. If you notice these symptoms during your treatment, you should consult your doctor.