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ART Services - Detailed Descriptions
Intrauterine insemination (IUI)
Intrauterine insemination with washed sperm is an
effective and economical treatment for infertility.
It is not recommended for patients with infertility
due to blocked or absent Fallopian tubes or severe
male factor infertility.
Semen is processed to remove the seminal plasma
(the liquid portion of the semen), cellular debris,
and bacteria and to separate the moving from the
non-motile sperm. The resultant sample contains the
most vigorous and healthy sperm.
The sample is then loaded into a thin plastic
tube or catheter. A nurse or physician passes the
catheter through the cervix and into the uterine
cavity. The sperm are then deposited in the uterus
and the catheter removed.
Insemination with donor sperm.
Frozen donor sperm can be purchased from
commercial cryobanks and shipped to our laboratory
in Bethesda for storage. The cryobanks provide
catalogs of donors from which patients can make
their choices based on a number of characteristics
(eye color, hair color, height, weight, complexion,
etc). The donors are thoroughly screened for genetic
diseases and familial disorders and all frozen sperm
samples must be quarantined for at least six months
to allow for testing or the donor for infectious
diseases. Although there are many cryobanks that
provide an excellent product and service, we are
only able to use sperm from cryobanks licensed in
the state of Maryland. Donor sperm purchased from
unlicensed banks cannot be used at The Columbia
Fertility Associates.
In vitro Fertilization (IVF)
In vitro fertilization was first developed as a
treatment for infertility due to blocked Fallopian
tubes, but is now used to treat many different
problems. To maximize chances of achieving a
pregnancy, ovarian stimulation is used to produce
many follicles (each containing an egg). During a
normal, unstimulated cycle, only a single follicle
develops and one egg is ovulated. Growth and
development of follicles are monitored very
carefully during a stimulated cycle. When the
follicles (and eggs) are mature, a hormone known as
human chorionic gonadotropin (hCG) is given and egg
retrieval is scheduled 34-36 hours later. Egg
retrieval is usually performed under light
anesthesia and using ultrasound guidance, but under
certain circumstances, may require laparoscopy. The
follicular contents are aspirated and handed to a
laboratory technologist who then looks for eggs. The
eggs are placed in dishes containing culture medium
and incubated in a chamber maintained at body
temperature. Shortly after the eggs have been
retrieved, the male partner produces a semen sample.
The semen is processed to isolate the most vigorous
sperm to inseminate the eggs.
The day after retrieval and insemination, the
eggs are examined for fertilization. Normal
fertilization is indicated by the presence of two
pronuclei. One pronucleus contains the genetic
material from the mother and the other from the
father. The fertilized eggs are examined every day
until embryo transfer. Embryos can be transferred 2
to 6 days after egg retrieval and may be from the 2-
to 4-cell (2-3 days after retrieval) stages of
development to blastocyst (5-6 days after
retrieval).
Embryo transfer is usually a simple procedure
that does not require anesthesia. Embryos are loaded
into a catheter (a thin plastic tube) and catheter
is gently passed through the cervix into the uterus.
Ultrasound is commonly used to confirm that the
catheter tip is in the proper position in the
uterine cavity. Embryos that have not been
transferred can be frozen and stored for use in the
future.
Gamete Intrafallopian Transfer
(GIFT)
The initial steps for GIFT are the same as for
IVF. The ovaries are stimulated to produce many
follicles. Sperm are prepared before egg retrieval.
Eggs are retrieved under general anesthesia and
using ultrasound guidance. Once eggs have been
retrieved, the physician uses a laparoscope to
locate the Fallopian tubes. Mature eggs are loaded
into a catheter along with sperm and transferred
directly to one or both of the Fallopian tubes.
Fertilization and early embryo development occur in
the Fallopian tubes, just as they do in a natural
cycle.
The success rate for GIFT is generally higher
than that for IVF, however, it is important to
realize that those patients who are candidates for
GIFT have completely different infertility diagnoses
than those who must undergo IVF. Patients who are
candidates for GIFT must have at least one
functional Fallopian tube. GIFT is a surgical
procedure requiring a general anesthetic and does
not allow for confirmation of fertilization because
fertilization occurs inside the body instead of in a
culture dish.
Zygote Intrafallopian Transfer
(ZIFT)
The initial steps for ZIFT are the same as for
IVF. The ovaries are stimulated to produce multiple
follicles. Eggs are retrieved using ultrasound
guidance and inseminated by conventional IVF or
ICSI. The day after retrieval, the eggs are examined
for fertilization and if fertilization has occurred,
the zygotes (single cell embryos with 2 pronuclei)
are transferred to one or both Fallopian tubes using
laparoscopy and under general anesthesia. The early
embryos develop in the Fallopian tubes just as they
do in a natural cycle.
Like GIFT, ZIFT more closely mimics a natural
cycle. ZIFT is surgical procedure requiring general
anesthesia and early embryo development cannot be
documented since it occurs inside the body. At least
one Fallopian tube must be open and functional.
Intracytoplasmic Sperm Injection
(ICSI)
Intracytoplasmic sperm injection was developed to
treat severe male factor infertility, but has since
been used successfully after fertilization has
failed in previous IVF cycles and to overcome some
egg defects. The procedures for ICSI are same as for
standard IVF except for the method of insemination.
After eggs are retrieved, the surrounding cumulus
cells are removed. Using a microscope and very fine
needles, each mature egg is injected with a single
sperm. Injected eggs are cultured for approximately
18 hours and examined for fertilization. Normal
fertilization is indicated by the presence of two
pronuclei, as in standard IVF. Each pronucleus
contains the genetic material from one of the
parents. After examination for fertilization,
embryos are cultured for a further 24-48 hours and
transferred to the uterus. Embryos resulting from
ICSI can be frozen and stored for return at a later
data.
Concerns about ICSI.
Although ICSI has been shown to be an effective
treatment for male factor infertility and has
resulted in fertilization where standard IVF has
failed, ICSI is still a relatively new technology
[although it is no longer considered to be
"experimental" by the American Society for
Reproductive Medicine (ASRM)].
The rapid acceptance of ICSI as a routine
practice without clinical trials has raised major
concerns about the outcomes of the procedures,
especially the outcomes of resulting pregnancies and
the health of the children born from the technology.
A recent report on the follow-up of 1987 children on
the basis of data from genetic counseling, prenatal
diagnosis, neonatal data, congenital malformations,
growth parameters and developmental milestones
(Human Reproduction, Vol. 14, (Suppl.1) pp. 243-264,
1999) indicates that the malformation rate in
children born after ICSI does not differ from that
of children in the general population. However,
there is evidence that there is a higher incidence
of chromosomal aberrations in men with fertility
problems and that these problems can be passed on to
male offspring.
The use of Epididymal (MESA) and
Testicular (TESE) Sperm for ICSI
The treatment of male infertility has made
incredible advances in the last few years. Men
previously thought to be hopelessly infertile can
now become fathers with the help of
micromanipulation.
Microsurgical epididymal sperm aspiration (MESA)
is particularly useful in men with obstruction of
the vas deferens (the tube through which sperm
passes from the testicle to the urethra). Pregnancy
rates using epididymal sperm and conventional IVF
techniques have resulted in relatively low success
rates per attempt due to low fertilization rates.
However, when ICSI is utilized, the pregnancy rates
are equal to those in IVF in the absence of a male
factor problem.
Testicular sperm exaction (TESE) has recently
been used with ICSI to achieve good pregnancy rates
when MESA is not feasible.
As with any new technology, there are concerns.
Some men with severe male factor infertility have
been shown to have chromosomal aberrations that are
responsible for their infertility. These defects can
be inherited by male offspring who may suffer from
the same fertility problems as the father.
Congenital absence of the vas deferens has been
found to be associated with mutations of the cystic
fibrosis (CF) gene. Men with congenital absence of
the vas deferens should be screened for CF gene
mutations and if mutations are found it is important
that the female partner be evaluated for her CF
status to assess the risk of transmission of the
disease to children born from the reproductive
technologies. The long-term consequences of any of
the new assisted reproductive technologies are
unknown.
Micromanipulation-Assisted Hatching
The egg and early embryo are surrounded by a
protective "shell" know as the zona pellucida.
Before the embryo can implant in the uterine wall it
must escape or "hatch" from the zona. Some embryos
have zonae that are thick and/or hard and become
trapped within their shell.
Micromanipulation-assisted hatching was developed to
overcome these problems. A small hole is made in the
zona pellucida and as the embryo grows, it squeezes
through the hole and implants in the uterine wall.
Micromanipulation-assisted hatching doesn't help
everyone, but is recommended for women 40 years or
older, women with elevated basal FSH levels, women
who respond poorly to ovarian stimulation, patients
with a history of implantation failure, or for
embryos with thickened zona pellucidae.
Embryo Freezing (Cryopreservation)
Embryos not used for transfer can be frozen for
transfer at a later date. Embryos can be frozen at
the pronucleate stage, 2- to 4-cell stages, 8-cell
stage, and blastocyst. Embryos are cryopreserved
using a cryoprotectant substance. The cryoprotectant
acts like an anti-freeze to preserve the embryos at
very low temperature. Embryos are thawed by
returning them to warmer temperatures and by
removing the cryoprotectant. Embryos can then be
transferred to the uterus in the same way as "fresh"
embryos.
One advantage of cryopreservation is that embryos
not used for transfer during an assisted
reproductive technology cycle can be stored for
future use in a cycle without ovarian stimulation.
Cryopreservation maximizes the chance of achieving a
pregnancy from a single cycle. Cryopreservation may
also lower the cost of infertility treatment because
the ovulation induction, egg retrieval,
insemination, and embryo culture are not required
when frozen embryos are used.
Blastocyst Transfer
Within 24 hours after fertilization, embryos
begin to cleave, from 1 to 2 cells and then to 4. In
the next 24 hours embryos cleave again to 8 cells.
When they reach 32 to 64 cells they become
blastocysts. At this stage of development, for the
first time, different parts of the embryo are
visible. A thin layer of cells encircles a
fluid-filled cavity. A small group of cells known as
the inner cell mass eventually develops into the
fetus itself.
Culture systems capable of supporting blastocyst
growth were first developed in Europe. In many
European countries, IVF clinics are required, by
law, to transfer no more than 2 embryos during each
IVF cycle in an effort to limit high-order multiple
pregnancies (greater than twins). However, at the 2-
to 8-cells stages it is often quite difficult to
determine which embryos are most likely to result in
a pregnancy. Since many embryos are incapable of
developing to blastocysts the ability to culture
embryos for a few more days makes the task far
easier.
We only recommend blastocyst culture to those
patients who respond well to ovarian simulation,
have many eggs, good fertilization rates, and many
good quality early stage embryos. These patients are
most likely to have embryos capable of surviving in
culture and developing to blastocysts. They are also
at risk of having a high-order multiple pregnancies
if more than 2 embryos are transferred.
Patients, who do not respond well to stimulation,
have poor quality eggs, and/or less than good
quality embryos may not benefit from extended
culture. Blastocyst culture is not a solution for
poor ovarian function or poor egg and embryo
quality.
Donor Egg Program
Our Donor Egg Program offers an alternative to
women with infertility due to ovarian failure. The
eggs from carefully selected and screened donors are
fertilized with the sperm from the recipient's
partner. The embryos are then transferred to the
uterus of the recipient. Women who are carriers of
genetic disorders, women who have undergone surgery
to remove the ovaries, radiation, chemotherapy, and
patients who cannot become pregnant after IVF due to
poor quality eggs and embryos may also consider the
use of donor eggs.
The Columbia Fertility Associates work with local
and national agencies that recruit egg donors. Some
egg donors are friends or family members and are
known to the recipients.
Host Uterus
Some women produce eggs and embryos, but are
unable to become pregnant or carry a pregnancy to
term. These women include those who have had a
hysterectomy, have a uterus that does not function
properly, women who have repeated miscarriages, or
who are in danger of becoming seriously ill should
they become pregnant. Although the Columbia
Fertility Associates do not recruit women for the
Host Uterus Program, we do work with other agencies
that provide the service and with patients who have
friends or family members willing to carry a
pregnancy for them.
Electroejaculation (EEJ)
Men with spinal cord injuries used to be
considered infertile because they were unable to
ejaculate sperm. Electroejaculation is a relatively
simple and painless office procedure. Electrical
stimulation is applied in the region of the prostate
gland and results in ejaculation. The sperm can be
used for IUI, IVF, or ICSI depending upon the
density, motility, and morphology. In some cases
they can also be frozen and stored for use in the
future.
Pre-Implantation Genetic Diagnosis
(PGD))
Pre-Implantation genetic diagnosis is a
relatively new technology that is used to test
embryos for severe genetic disorders (including, but
not limited to
sickle cell anemia,
hemophilia,
cystic fibrosis and
Tay-Sachs), aneuploidy (abnormal numbers of
chromosomes), and translocation (chromosomal
rearrangements). To use PGD, conception must occur
using IVF or ICSI. Women must take medications that
stimulate the ovaries to produce many eggs. Sperm
are then added to the eggs in the laboratory. Eggs
that fertilize grow and develop into embryos. A
single cell is then removed from each embryo. The
cells are then sent to a highly specialized genetic
testing laboratory for diagnosis. The Columbia
Fertility Associates collaborate with
REPROGENETICS. Their genetic team includes Drs.
Satntiago Munné, Jacques Cohen and Dagan Wells, who
are some of the most experienced scientists in the
field of preimplantation genetic diagnosis. Once
testing has been completed, the results are sent
back to the doctors at the Columbia Fertility
Associates. Only unaffected embryos are selected and
transferred to the women's uterus.
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