The term includes IVF procedures and techniques that are designed to help couples who have difficulty having a child. The strong current lifestyle and health problems, may be difficult to capture. Before couples resort to IVF solution must have frequent sexual intercourse for at least a year. Then with the help of a physician identified the causes of infertility and the couple decided jointly by the method to be followed.
IVF is a process by which the fertilization of the ovum by the sperm is made in the laboratory by professional staff.
With IVF many infertile couples have been able to have children.
When selected as a treatment
Treatment IVF is mainly used in cases where there is a malfunction or blockage of the fallopian tubes, HORMONOLOGICAL problems, polycystic ovaries, endometriosis, problems in the male reproductive system and various other known or unknown causes infertility.
The treatment cycle of IVF involves the following steps:
- Suppression and Stimulation of the ovaries with medication - ovulation
In the first stage of treatment, the ovaries are stimulated with hormones to produce multiple eggs. If one considers that the normal female body develops and releases one mature egg per month, the development of more follicles is possible by hormones (combination of GnRH analogues and FSH) that cause controlled ovarian stimulation in order to develop multiple follicles.
- Monitoring the excitation range ultrasound and hormonal determinations
During the treatment of ovarian induction, the woman undergoes systematic ultrasound examination to evaluate if the follicles which are the eggs have the desired size and maturity. The ultrasound and hormonal assay is needed to monitor the excitation and the administration of human chorionic gonadotropin (hCG). The induction of ovulation about midnight injection, about 36 hours before egg collection and completes the medication treatment protocol that has followed.
- Collection of ova (egg retrieval)
Below is the egg collection (collection of ova develop), the process of making a transvaginal follicular puncture under ultrasound guidance, with precise and delicate gynecological. The follicular fluid from embryologist immediately examined under the microscope to confirm the ovum pick up and the process is repeated for all mature oocytes in the ovary. The embryology laboratory shall end on the final number of eggs collected. The egg retrieval is performed under intravenous analgesia (sedation) and is practically painless and quick procedure.
Two hours before taking ova, semen sample taken from the woman's husband. The sample is subjected to a special treatment where activation selected the most mobile and healthy sperm. They remain in the laboratory on nutrient material until placed together with the eggs. If non-free exception sperm in the fluid, testicular biopsy is performed.
Testicular biopsy (MESA / TESA)
In cases of azoospermia (where no spermatozoa in the ejaculate) is testicular biopsy to obtain sperm from testis or epididymis for fertilization.
Two methods are used to obtain semen: the head of the epididymis under local anesthesia and aspiration (MESA), or with a small incision in the testicle, or general anesthesia and biopsy (TESA). The procedure is done by a doctor or a urologist on the same day of egg collection or woman one day earlier.
If male or unexplained infertility suspected to be due to difficulty of sperm to penetrate the egg normally used method of ICSI (Intra-Cytoplasmic Sperm Injection). After oocyte retrieval, ICSI is performed with the help of special equipment placed where one sperm to each egg to be fertilized.
This technique is indicated in cases of problems related to sperm quality (count decreased, low motility, abnormal morphology, etc.) since essentially bypasses almost all causes of infertility compared to men. If the sperm is viable, then over 50% of eggs fertilized normally, regardless of the quality of sperm. ICSI is combined with IVF is the most effective way of treating male infertility today.
This stage of treatment evolves in laboratories by experienced embryologists. Fixed number of sperm with eggs placed in dishes (especially tubes) with nutrient culture medium to germinate under laboratory conditions where they remain for 16-20 hours.
The next morning the eggs are examined with a microscope and it is checked whether fertilization has been achieved. The embryologist record the number of eggs fertilized normally and monitor the smooth evolution for the next 2-3 days where the ova remain in the lab and continue to grow.
In classical IVF ova are placed in a high concentration of spermatozoa, in contact with the egg alone and one of them is inserted into the egg and fertilize. In cases of male infertility in this step applies ICSI ICSI, namely the placement of the sperm into the egg using a micropipette. (See ICSI ICSI).
In the fourth phase of treatment is the embryo transfer, ie the transfer of embryos that have developed in the laboratory into the uterine cavity. This is a painless procedure that is two to three days after egg collection or the fifth and sixth day to the blastocyst stage. The embryologist selects the best embryos are transferred into the uterus using a thin catheter to continuously checked by ultrasound guidance. The number of embryos transferred depends on many factors but typically carried by two to four embryos. If there are other very good quality embryos can be cryopreserved. As in natural conception, then the embryos are implanted by themselves in the mucosa of the uterus, the endometrium. If there will be no implantation and pregnancy. The first pregnancy test done about 13 days after embryo transfer.
Recently, the development of ideal growing media resulted in embryo transfer done at the blastocyst stage. The term refers to specific blastocyst stage of embryo development after 5-6 days of culture. It is basically the last developmental stage of the embryo before implantation in the endometrium to establish pregnancy. The transfer process is identical to the blastocyst embryo is only the 5th or 6th day after egg retrieval.
This method applies to couples who end up having many embryos available for transfer. In these cases it may be a few embryo blastocyst (embryo), one or two, so as to avoid multiple pregnancies without simultaneously decreasing the success rate.
The embryo at the blastocyst stage allows the selection of the best quality embryos (the most healthy, morphologically intact and more evolutionarily developed embryos), since only genetically healthy and potentially able to be implanted embryos will reach that stage (20-40%) . Also, mimics more natural reproductive process offers better timing embryos - endometrium.
If the percentage of embryos that will survive at this stage is zero, then it can not be performed embryo transfer.
There are many ovarian stimulation protocols, but IVF is usually used three, the long, the short and competitors. According to the physician's discretion and depending on the specifics of each woman, we selected the appropriate protocol per case. The duration of GnRH analogue is the basic difference in the therapeutic protocol to be followed, but according to the reaction of each organization medicines, the protocol can be changed during the treatment.
- Long protocol (long)
In the long protocol distinguish two phases of suppression and ovarian stimulation. In the first phase, a single woman with a regular 28 day cycle, suppression starts 2nd or 21st day by administering agonistic analogs of GnRH (Arvekap, Daronda, Suprefact). The course of taking these drugs is about 10-15 days. The control of suppression of pituitary and ovarian function is Unit with ultrasound uterus and ovaries and measurement of hormone estradiol in the blood. If sedation is given adequate instructions for downloading of gonadotropins in the second phase.
Ovarian stimulation starts when judged that the suppression is insufficient, and prepared by administering pharmaceutically gonadotropins (Puregon, Gonal-F, Altermon, Merional, Menopur), under continued suppression of pituitary function, namely making analog to the end of treatment, in dosage will be suggested by the doctor. The second phase is about 10-14 days ie the long protocol lasts about a month.
- Protocol competitors (antagonists)
With the use of competitors, the treatment did not exceed 10-12 days. The effectiveness of competitors in achieving pregnancy has been confirmed by the latest scientific data and although administered always with the specificities of women, are the treatment of choice in older breeding centers in Europe.
In Protocol gonadotropins - antagonists, stimulation with gonadotropins begins the second or third day of the cycle, followed by administration by the use of competitive analog GnRH, to exclude the event of ovulation. The start of administration of competitors can be done either on the 6th day of stimulation with gonadotropins, either based on ultrasound and hormonal criteria during IVF treatment.
- Short Protocol (short)
To short protocol (flare-up GnRH agonist protocol) selected primarily for women with poor ovarian response in inducing multiple follicular development or older. It takes almost half the time of the long protocol (10-15 days) after the stimulation and suppression phases are almost simultaneously. The initiation of GnRH agonist usually begins the first-second day of the cycle and the start of the pharmaceutical gonadotropins 2 to 3 day cycle. During therapy is frequent ultrasonographic evaluation and measurement of estradiol in the Unit for monitoring of ovarian response and the correct dosage of drugs. When satisfied that the follicles have grown (acquired diameter greater than 17mm) and the price of estradiol has reached the desired levels, then it becomes the maturation of oocytes with the midnight injection (Pregnyl, Ovitrelle) and the one after that is the egg retrieval. Taking other medicines discontinued (depending, gonadotropins).
- Natural Cycle
Recommended for ages young women, in cases of male infertility, or women with poor response to medication. During the cycle is no systematic monitoring of the progress of follicle number with ultrasound and hormonal determinations. In the natural cycle we have only one follicle to produce eggs for fertilization and ultimately embryo for transfer.
Proper medication is one of the most basic steps of IVF success. In recent years, significant amount of research breeding is focused on creating new drugs to improve the treatment of women. The drugs used are increasing success rates of pregnancy and are considered harmless. Granted because IVF is an effort to compel the ovary to produce several follicles to produce enough eggs to be fertilized to create embryos of good quality will be transferred to the uterus.
Treatment protocols used in IVF applied depending on the particularities of each woman's cycle, age, ovarian response in previous attempts, etc.
- Depending of GnRH (agonists and antagonists)
The pharmaceutical analogues of the hormone GnRH temporarily suspend the functioning of the pituitary thereby preventing undesirable rupture follicles prior to oocyte retrieval. To achieve multiple follicular development must be perfectly controlled doses of pituitary gonadotropins (follicle stimulating hormone FSH / luteinizing hormone LH), which is best achieved when the pituitary gland does not produce its own hormones such but with the help of "similar" hormone GnRH drugs.
Divided into "militants" and marketed under the trade names Superfact, Daronda, Arvecap and "competitors" with the names Orgalutran and Cetrotide. Their reactive components are similar. Current or in a nasal spray or in the form of subcutaneous injections daily administration, in either slow-acting injection lasting four weeks. Depending on the drug protocol will be and the choice of the kind of analogue of GnRH, the mode of administration and dosage.
Ovarian stimulation for growth and maturation of several follicles is sponsored pituitary gonadotropins marketed under the trade names Puregon, Gonal-F, Altermon, Menopur. Because these hormones are proteins may be administered only injectables, either subcutaneously or intramuscularly, with a special device in pen form.
- Chorionic Gonadotropin (hCG)
It is the last injection of drug therapy. Administered at the same time when the follicle growth is satisfactory since this medicine causes ovulation 32-36 hours after administration, so following the egg retrieval. These drugs come in the form of injectable solution or powder that is mixed with specific soluble or syringe form and pen are the trademarks Ovitrelle, Pregnyl, Profasi.
With appropriate formulations progesterone prepares the environment of the uterus to receive the embryo. Administered after the stage of embryo transfer. Marketed under the name Utrogestan - composition can be used as a pill by mouth or pessary - and vaginal gel Crinone.