April 20, 2014
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Fertility


Fertility treatment options (e.g., ovulation induction, IVF)

Learn more about the wide range of fertility treatments available to help you get pregnant:

OVULATION INDUCTION (OI)

After conducting a physical exam and a fertility workup, your doctor may recommend that you begin treatment. If fertility testing reveals that you have an ovulatory problem, your doctor may recommend starting medication therapy with fertility drugs to induce ovulation.

How the reproductive cycle works with OI

To get a better idea of how OI works, let's look at a woman's reproductive cycle while she is taking OI medications.

During the follicular phase of a woman's reproductive cycle, a medication such as a follicle stimulating hormone (FSH) may be prescribed. FSH stimulates the development of follicles in the ovary and helps produce eggs. Clomiphene citrate also accomplishes the same outcome by signaling the pituitary gland to release FSH and luteinizing hormone (LH).

Around the 11th day of the cycle, a single injection of a medication called a human chorionic gonadotropin (hCG) may be given to facilitate the last step in the maturation of the developing eggs and trigger ovulation. The eggs are released, ready to be fertilized.

At this point, fertilization is attempted either through sexual intercourse or artificial insemination (AI). AI is a procedure in which the health care provider inserts a man's sperm directly into a woman's reproductive tract. AI is usually performed in cases where a woman has poor or absent cervical mucus or a man has a low sperm count or sperm motility. A common AI procedure is intrauterine insemination (IUI), a procedure in which the health care provider inserts sperm directly into the uterus near the time of ovulation.

Medications that may be used during OI

Some of the following medications mimic your body's naturally occurring hormones and have different roles in ovulation induction and egg development. Some of these medications are available in both recombinant and urinary (often called human) versions. Both recombinant and urinary versions are effective. Recombinant medications use advanced manufacturing techniques and produce the hormones using deoxyribonucleic acid (DNA) technology. Urinary versions of the medications are extracted and purified using urine for postmenopausal women.

  • Clomiphene citrate (Serophene®, Clomid®) is a medication that your doctor may prescribe to stimulate the pituitary gland to release FSH and LH.
     
  • Follicle-stimulating hormone (FSH) (GONAL-f®, , Puregon®, Bravelle®) helps eggs develop in the ovaries.
     
  • Gonadotropin-releasing hormone (GnRH) agonist (Lutrepulse®) stimulates the pituitary gland to release FSH and LH.
     
  • Gonadotropin-releasing hormone (GnRH) antagonist (Cetrotide®, Orgalutran®) blocks the effects of GnRH, and are used to prevent premature ovulation from occurring.
     
  • Human menopausal gonadotropin (hMG) (Menopur®, Repronex®) works by stimulating the ovaries to induce ovulation.
     
  • Luteinizing hormone (LH) (Luveris®) is used to help egg development in the ovaries.
     
  • Human chorionic gonadotropin (hCG) (Ovidrel®) is used to stimulate the final growth and release of a mature egg from the ovaries (ovulation). It is often used in combination with the above fertility medications.
     
  • Progesterone (Crinone® , Endometrin®) is used to help prepare the lining of the uterus for implantation of fertilized egg(s) during and sometimes after the use of procedures such as intrauterine insemination (IUI) or in-vitro fertilization (IVF).

ASSISTED REPRODUCTIVE TECHNOLOGIES (ART)

To find out if assisted reproductive technologies (ART) may be right for you, speak to your doctor or fertility specialist. Use the fertility clinic locator to find a nearby fertility clinic.

Intrauterine insemination (IUI)

IUI is a common type of artificial insemination. IUI is usually combined with controlled ovarian stimulation, so you may be prescribed some of the medications in the "Ovulation induction" section.

When the injection of hCG has triggered ovulation, your doctor inserts sperm directly into your uterus by a catheter to improve the chances of fertilizing the egg. The injected sperm has undergone a procedure where it is separated from the semen and washed to obtain the strongest and most active sperm. IUI may be used if you have poor or absent cervical mucus, or if your partner has low sperm volume, low sperm concentration, or decreased sperm motility. IUI is usually a relatively simple and painless procedure performed at your fertility clinic.

Figure 1

Intrauterine insemination (IUI)
Enlarge diagram
Image © Dr. J. Herrero Garcia

In-vitro fertilization (IVF)

In-vitro fertilization, the most common ART procedure, is used to overcome a variety of fertility difficulties, particularly tubal problems and sperm deficiencies.

During IVF, medications are often used to help stimulate the development and release of a woman's eggs. The eggs and sperm are then collected and placed together in a laboratory dish to fertilize. If the eggs are successfully fertilized, embryos are then formed and start to divide and develop. Once those embryos reach a certain stage in their development, they are then transferred into a woman's uterus. Hopefully, one of the fertilized eggs will implant and develop just as in unassisted conception.

An IVF cycle is broken down into four stages:

Figure 2

One possible IVF treatment protocol

One possible IVF treatment protocol
GnRH Agonist - gonadotropin-releasing hormone agonist
FSH - follicle stimulating hormone
LH - luteinizing hormone
HCG - Human chorionic gonadotropin
Enlarge diagram
Image © Dr. J. Herrero Garcia

Stage 1: Ovarian stimulation, monitoring, and ovulation triggering

The goal of the first stage is to create a large number of mature follicles to increase the chances of having healthy, good-sized mature eggs or oocytes. Since a woman's body normally releases one mature egg every month, a medication called a follicle stimulating hormone (FSH) can be used to stimulate the ovaries to develop more follicles. Follicles are fluid-filled sacs in which eggs mature. Each follicle holds one egg. At the beginning of the cycle, each follicle is approximately 1 mm to 2 mm in diameter.

During this stage, you may also be prescribed other medications used to block, supplement, or even augment your body's natural hormonal cycle. Treatments are individualized and vary significantly. Your fertility specialist is the best person to talk to for more information.

During this stage, your fertility specialist may use ultrasound to monitor the number and size of maturing follicles in your ovaries. Blood tests may also be used to monitor hormone levels, which will help determine the best time to administer medication and to retrieve the eggs. Figure 2 shows a diagram outlining one possible treatment protocol. Please remember that there are many different protocol options, so don't be concerned if you are doing something different. Your fertility specialist will pick the best protocol for you. See Figure 2.

Figure 3

Retrieving the oocytes (eggs) for IVF

Retrieving the oocytes (eggs) for IVF
Enlarge diagram
Image © Dr. J. Herrero Garcia

Stage 2: Egg retrieval

In the second stage, another medication called human chorionic gonadotropin (hCG) is used to stimulate the release of mature eggs. Your fertility specialist will identify the mature follicles using ultrasound, and then, with a needle, withdraw as many eggs as possible from both ovaries. At this point, each follicle is approximately 16 mm to 20 mm in diameter. Figure 3 outlines this process, showing how the eggs are retrieved from their follicles.

Figure 4

The fertilization process for both IVF and ICSI

The fertilization process for both IVF and ICSI
Enlarge diagram
Image © Dr. J. Herrero Garcia

Stage 3: Fertilization

About 2 hours before the eggs are retrieved, a semen sample is collected, usually from the male partner unless you are using donor sperm. Approximately 50,000 sperm are placed with each egg in the incubator where they will hopefully form an embryo. When only a few sperm are available, intracytoplasmic sperm injection (ICSI) may be attempted. In this procedure, a single sperm is injected into an egg to facilitate fertilization. ICSI is outlined in more detail in the section on intracytoplasmic sperm injection.

The next day, called "Day 1" in the lab, the eggs will be examined under a microscope to determine whether fertilization has occurred. If it has, the embryos will be ready to transfer into the uterus within 2 to 4 days of "Day 1." Figure 4 outlines the fertilization steps.

Figure 5

Transferring embryos for IVF procedures

Transferring embryos for IVF procedures
Enlarge diagram
Image © Dr. J. Herrero Garcia

Stage 4: Embryo transfer

The embryos are placed in a tube and transferred back into the uterus. The procedure is usually painless, though some women may experience some cramping. The number of embryos transferred depends on a woman's age, cause of infertility, pregnancy history, embryo quality, and other factors. More and more fertility clinics will opt for single embryo transfer to reduce the risk of multiple pregnancies. In some cases, based on the your treatment response, clinics may transfer 2 or 3 at most. Though transferring more embryos may increase the chance of pregnancy, it can also increase the risk of multiple pregnancies (twins or triplets). Your fertility specialist would decide the appropriate number of embryos to transfer for you. Figure 5 outlines the embryo transfer steps.

The uterine lining is prepared for implantation, often by supplementing with progesterone medication. This is sometimes called luteal phase support.

Looking for definitions of fertility terms? Visit our Fertility glossary.

Intracytoplasmic sperm injection (ICSI)

Intracytoplasmic sperm injection (ICSI) (pronounced "ICK-see") is a procedure used in conjunction with IVF in which a laboratory technician, using a microscope, attempts to inject a single sperm directly into each egg. To better understand the procedure and steps involved with ICSI, please refer to the steps outlining the IVF procedure, above. The only difference with ICSI is during stage 3, fertilization. Rather than placing the eggs in a dish surrounded by many sperm, a single sperm is injected into each egg. ICSI is often used if the male partner has very low sperm count, low sperm motility, or poor quality sperm. If fertilization occurs after ICSI, the embryo may then be transferred into the uterus.

In some cases, fertility specialists may use other advanced procedures to extract the sperm directly from a man's testicle or epididymis (a section of sperm duct at the back of the testicle).

The use of ICSI and these sperm extraction techniques has greatly improved the ability of fertility specialists to treat male factor infertility. However, these treatments are not effective for men who do not produce any sperm at all. In these cases, donor sperm would be necessary.

Figure 6

Intracytoplasmic sperm injection (ICSI)
Enlarge diagram
Image © Dr. J. Herrero Garcia

Assisted hatching

Before implanting in the uterus, the embryo must emerge from its membrane (covering) in a process called "hatching." In some women, the membrane seems to harden, particularly as women age. This can interfere with the hatching process. In these cases, the embryo membrane can be thinned with a dilute acidic solution or laser prior to embryo transfer. This may help the hatching process, and may increase the chances of pregnancy in older women or those who have not achieved pregnancy after several IVF cycles. Assisted hatching may also be done in some cases following embryo freezing or cryopreservation, and embryo thawing.

Figure 7

Assisted hatching
Enlarge diagram
Image © Dr. J. Herrero Garcia

Preimplantation genetic diagnosis (PGD)

Preimplantation genetic diagnosis (PGD) is a technique that can be used during in-vitro fertilization to test embryos for a variety of genetic disorders. PGD testing is done before the embryo is transferred to the uterus. This would allow you and your partner to decrease the risk of having a child with a serious inherited disorder.

When is PGD used?

PGD is generally used with couples who have lost pregnancies due to genetic disorders, who already have one child with a genetic problem, or who are carriers of a genetic disease. The procedure may detect Down syndrome, cystic fibrosis, hemophilia A, Tay-Sachs disease, and Turner syndrome, along with other disorders.

PGD is performed in the laboratory by removing a single cell from each embryo. This cell is then analyzed for the presence of a specific genetic disorder. Once a diagnosis is made, which usually takes about a day, only unaffected embryos are transferred back into a woman's uterus.

If you are considering PGD you should talk with your fertility specialist about potential risks associated with this technique. Not all disorders can be detected with PGD. Furthermore, not all clinics in Canada use PGD resources.

Figure 8

Preimplantation genetic diagnosis
Enlarge diagram
Image © Dr. J. Herrero Garcia

Embryo freezing

Cryopreservation, also known as "freezing," involves storing embryos at a very low temperature so that they can be thawed and used later. Many fertility clinics now offer this option.

There are many reasons for using cryopreservation. It is often done when there are more embryos than are needed for a single (IVF) cycle. The extra embryos are saved and may be used during later cycles. As well, many cancer patients of reproductive age are now freezing their embryos before they proceed with their radiation treatment or chemotherapy that may damage their fertility. IVF success rates are generally lower with frozen embryos than with freshly fertilized embryos, although pregnancy rates with frozen embryos have been improving in recent years. The survival rate after thawing often depends on the quality of the embryos at the time of freezing.

Gametes (eggs or sperm) and ovarian tissue freezing are experimental techniques being investigated for fertility preservation. These techniques have the potential to be helpful for cancer patients, as chemotherapy and radiation treatment can often have a harmful effect on fertility. Gametes and ovarian tissue freezing is still a relatively new technique, and is not available at all fertility clinics.

To learn more about cryopreservation, talk with your fertility specialist.

Reference: Fertility LifeLines

SURGICAL PROCEDURES RELATED TO FERTILITY

Depending on your diagnosis, your doctor may recommend surgery as an initial treatment. For example, when conditions like endometriosis or fibroids are diagnosed, the fertility specialist may recommend surgery first to correct problems that may be interfering with conception. In other cases, surgery may be reserved as a later option. Your doctor will consider the specifics of your case when recommending a plan of care.

In some cases, your fertility specialist may use medications in conjunction with surgery to improve the chances of conception. Or he or she may administer other treatments first, reserving surgery as an option if those treatments aren't successful. Every person is different, and your doctor's plan of care will be based on your specific diagnosis and history.

Some anatomical problems that could be treated with surgery include:

Endometriosis

The treatment of endometriosis depends upon its severity. In some cases, your doctor may recommend treatment with medication before attempting surgery. In other cases, your doctor may recommend surgery to remove the endometriosis. One form of surgery is called a laparoscopy. An incision is made in the lower part of the abdomen and a laparoscope (a telescope-like instrument with a camera) is used to examine the pelvic cavity. Then, using microsurgery or laser surgery, the endometriosis is removed. Sometimes your doctor may use other medications along with the surgery to improve your chances of conception. If that is unsuccessful, your fertility specialist may suggest other treatments.

Adhesions

Adhesions are often diagnosed and treated with laparoscopy, a surgical procedure that allows a health care provider to visualize a women's internal pelvic cavity and reproductive organs. During this procedure, a telescope-like instrument with a camera, called a laparoscope, is inserted into the pelvic cavity through a tiny incision made just below the woman's navel. Other instruments, such as laser or electrocautery, may also be used to remove the adhesions during the surgical procedure. They, too, are inserted through small incisions.

To diagnose intrauterine adhesions, a doctor may use an X-ray procedure called a hysterosalpingogram (HSG). However, a more accurate method for diagnosis is hysteroscopy. During this procedure, a hysteroscope (also a thin telescope-like instrument) is inserted through the cervix in order to visualize the uterine cavity. Generally, intrauterine adhesions are removed with hysteroscopic guidance using instruments such as a laser, electrocautery, or scissors.

Fibroids

Your fertility specialist may need to conduct a hysterosonogram to detect if there are any fibroids. During this procedure, your doctor injects a small amount of sterile saline into the uterus by passing a small catheter through the cervix. An ultrasound is then performed. This test may be performed in your doctor's office.

If your doctor suspects that fibroids are causing fertility difficulties, they may recommend surgery. One procedure is a myomectomy, in which the fibroid tumour or tumours are surgically removed. Laparoscopic myomectomy, which is less invasive, is sometimes possible and has a much shorter recovery time.

Uterine malformation

There are many types of uterine malformation. The most common type, bicornuate uterus limits the space embryo and fetus can grow in the uterus. Surgery may be performed to correct this and create a larger uterine cavity.

A septate uterus is a uterus that is divided by a wall on the inside. In some cases, this wall can extend the entire length of the uterine cavity to the cervix. To correct this condition, surgery is performed to remove the septum (wall). The procedure is performed either with hysteroscopy or via laparoscopy (see Adhesions) with an abdominal incision. Typically, once you've had this corrective surgery, your chances of conceiving will improve.

Reference: Fertility LifeLines

DONATION AND SURROGACY

There are several kinds of donation that may be used in assisted reproductive technologies.

Egg donation involves one woman (a donor) "donating" her eggs so that another woman (a recipient) might be able to conceive.

In egg donation, in-vitro fertilization (IVF) is performed in the usual manner, with the donor receiving fertility medications to stimulate the production of multiple eggs in her ovaries. At the same time, the recipient may also receive medications so that her cycle mirrors the cycle of the donor and her body is prepared to receive the embryo. The egg is then fertilized in a laboratory and the embryos are implanted in the recipient's uterus.

Generally, egg donation may be an option for a woman if she:

  • is older and has not succeeded with other therapies
  • has reached menopause prematurely
  • may carry a genetic disorder that may have been determined through blood testing
  • has experienced unexplained and repeated miscarriages
  • has a sister or close friend who would be willing to act as an egg donor

The success rate for couples undergoing in-vitro fertilization (IVF) with egg donation - even when a woman is over age 40 - is approximately the same as the success rate of IVF in young women.

To learn more about egg donation, or to determine if you are an appropriate candidate, talk to your fertility specialist.

You and your partner may elect to use donated sperm if the male partner has no sperm or very poor quality sperm, if he has undergone previous radiation or chemotherapy treatment, or if he has a genetic disorder that might be inherited. Single women and same-sex couples who want a child will also use donor insemination. To learn more, talk with your doctor or fertility specialist.

Embryo donation involves donor eggs that have been fertilized with sperm by the donor's partner or with donor sperm. Some women or couples who undergo IVF may choose to donate the fertilized embryos not used in their cycle. If it is a couple, consent by both parties must be given. The donated embryos are then transferred to the recipient's uterus.

Surrogacy involves one woman carrying a pregnancy for another woman. There are two types of surrogacy: gestational and traditional surrogacy.

Gestational surrogacy involves a woman carrying a pregnancy created by the egg and the sperm of two other people. For instance, in the case of a woman with functioning ovaries but with no (or a malformed) uterus, she and her partner may opt to use IVF, then have the resulting embryos transferred into a gestational surrogate.

In traditional surrogacy, the surrogate undergoes IVF with her own eggs, which have been inseminated with the sperm from the male partner of an infertile couple. The female partner or couple must legally adopt the child after birth.

Emotional aspects of donation or surrogacy

Undergoing fertility treatments may be an emotional, frustrating process. Deciding whether or not to use donation or surrogacy can add another emotional layer to your relationship. For this reason, you and your partner may want to seek legal and psychological counselling before undertaking this procedure. There are many resources and organizations available to help.

In addition to emotional and psychological issues, there are often complicated legal issues surrounding donation and surrogacy. It's a good idea to consult an attorney knowledgeable in this area before proceeding with reproductive techniques involving a third party.

To determine if you are a candidate for donation or surrogacy, talk with your fertility specialist.

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