Encyclopedia

Intrauterine lnsemination (IUI)

Intrauterine Insemination (IUI) is when the sperm are injected directly into the uterus. Insemination into the uterus can be performed in the natural cycle or in combination with a hormonal stimulation of the ovaries.

The course of this treatment is usually as follows:
If the size of the follicle is around 1.6 cm when monitoring the ovaries and the hormone values ​​have the desired results, then ovulation can be triggered with a special drug (HCG). After injection of HCG, the ovulation takes place at the earliest 36 hours later. It is also possible to wait for the natural ovulation. If natural ovulation is chosen then the IUI will be performed between day 12 and 16 of your monthly cycle. Blood and/or urine test will be done to identify when you are about to ovulate.

On the day of the procedure semen will be collected in order to be subsequently treated (duration of preparation: approx. 1-2 hours). In this process they wash away the fluid surrounding the sperm. The purpose of this preparation is to obtain a high concentration of mobile sperm. Only then is the actual insemination carried out.

While on the gynecological examination chair, a speculum is placed into the cervix so that the opening of the cervical canal can be seen. After dabbing the entrance to the uterine cavity and removing the visible cervical mucus, a soft, flexible catheter (tube) is inserted into the uterine cavity through the canal of the cervix. There is usually nothing to be felt about this. The sample has already been prepared in the laboratory with the corresponding seed concentrate. This preparation is now slowly injected into the uterine cavity. The catheter is then withdrawn and the patient rests for 10 minutes. The process should only take a few minutes and you may experience temporary menstrual-like cramping.

Success rate:
The chances of achieving a pregnancy with the IUI procedure depends on the reasons that led to this therapy. In a restricted spermiogram, the success is decisively influenced by the number of sperm injected into the uterus. Per cycle, a success rate of 8-12% is assumed. Keep in mind, under optimal conditions, that the probability of a pregnancy is not greater than 25% (with normal cycle, normal spermatozoa and regular transport).

Risks of the technique:
When using a drug stimulation of the ovaries, the danger of multiples is possible. A percentage risk can not be given here since the type of hormone treatment and the number of follicles plays a decisive role in this. Also the possibility of an overwhelming ovarian stimulation syndrome can occur. Very rare do infections occur in the uterine cavity.

In Vitro Fertilization / Embryo Transfer

There are several steps involved in the in vitro fertilization (IVF) and embryo transfer (ET) procedures. Medications will be prescribed to induce the maturation of multiple oocytes (eggs). During this time, bloodwork and an ultrasound (sonogram) will be done to manage the IVF cycle. An egg retrieval procedure will be done by directed ultrasound-guided needle aspiration, under local or general anaesthesia. Follicles that are evident on the ultrasound will be aspirated and follicular fluid and eggs will be collected. The eggs will be prepared and fertilized in the laboratory using your partners or, where applicable, donor sperm. Embryos resulting from this procedure will then be transferred back into the uterine cavity through the cervix using a catheter.

Stimulation of follicle growing and ovulation induction
A variety of medications are available for the stimulation of follicle growth, including Clomiphene Citrate (Clomid), Human Menopausal Gonadrotopin (e.g., Menopur/Menogon), Follicle Stimulating Hormone (e.g., Gonal-F/Puregon/Pergoveris), GnRH-Analoga – Triptorelin Acetate (Decapeptyl ), GnRH-antagonists (Orgalutran/Cetrotide), Estrogen Patches or tablets (Climara) and for the induction of ovulation we normally use Human Chorionic Gonadrotopin (HCG). Some of these medications are administered by subcutaneous injection and may cause bruising and discomfort at the injection site. GnRH-analogas may result in side effects, including fatigue, muscle and joint pain, and transient menopausal-like symptoms (headaches, hot flashes, mood swings, sweats, insomnia, fatigue, ect.). Clomiphene Citrate may result in side effects, including hot flashes, abdominal distention, bloating, headache and visual changes. Gonadrotopines (Menopur/Gonal-F/Puregon/Pergoveris) may have side effects, including a situation where the ovaries become overstimulated, leading to a condition called Ovarian Hyperstimulation Syndrom (OHSS). In the most severe form of OHSS, serious complications may result, which may require hospitalization and medical intervention. Some reported complications, while rare, include ovarian torsion (twisting of the ovary), blood clots, kidney failure, fluid overload and death. It is important to maintain close contact with the IVF team while receiving these medications and for a minimum of two (2) weeks afterwards.

Monitoring Protocol
While receiving the medications described above, you will be closely monitored by the IVF team. This monitoring may be as frequent as daily and carries the risk of mild discomfort and bruising at the venipuncture (blood draw) site. Transvaginal ultrasound examinations will be performed, as necessary, and there may be some discomfort with this procedure. If monitoring suggests a low probability for successful egg retrieval, the stimulation cycle may be stopped and no egg retrieval will be performed. Alternatively, if the response to the medications is too high, and the likelihood of OHSS is increased, the stimulation medications may be discontinued and the cycle cancelled or the embryos cryopreserved (frozen).

Egg Retrieval
At a time determined by the IVF team, you will be asked to come to the Kinderwunschzentrum Amberg as an ambulatory patient. Egg retrieval will be performed by ultrasound-guided transvaginal needle aspiration of the follicles. The vaginal wall and ovary will be punctured and the follicular fluid aspirated. The follicular fluid will be analyzed under the microscope to locate the eggs.

Risks related to this procedure include infection, bleeding and injury to pelvic or abdominal organs. If an infection occurs admission to the Klinikum St. Marien, Amberg, or any other hospital, may be necessary in order to administer intravenous antibiotics. If bleeding occurs, stitching of the vaginal puncture site may be necessary. In rare circumstances, observation in a hospital, a blood transfusion and/or laparoscopy or laparotomy (abdominal surgery) may be required to stop the bleeding and repair the injury.

Antibiotics may be prescribed, in the form of tetracycline or a similar antibiotic, following the egg retrieval.
Side effects from the use of tetracycline may include nausea, vomiting, diarrhea, loss of appetite, skin rash, sensitivity to the sun, and, rarely, hypersensitivity reactions result in shock or blood abnormalities.

At a time determined by the IVF team, you will be advised to use progesterone after the transfer of the embryos. This could be a daily vaginal application of capsules or an s.c.-injection. This medication can cause hypotension and dizziness. This medication is tested for safety in many studies – but in Germany it is not allowed for the routine use in early pregnancy – it is an off-label use.

If the ovaries are not accessible by transvaginal ultrasound, and laparoscopy another procedure may be required to perform the egg retrieval. If this is the case, alternatives will be discussed before the procedure.

Egg Fertilization
On the day of egg retrieval, the designated sperm will be used to attempt to fertilize the eggs.
If frozen sperm is to be used, additional consents are required.
Authorization for the storage and use of frozen sperm is also required for the Andrology Laboratory

Following the egg retrieval, the eggs will be evaluated and prepared for the fertilization process by the embryology staff. Fertilization may be achieved by insemination (IVF) or intracytoplasmic sperm injection (ICSI).
Fertilization by insemination (IVF) occurs when the eggs are exposed to prepared sperm. This means the sperms have to penetrate the shell of the oocytes by themselves – equal to natural fertilization in the tube.
Intracytoplasmic sperm injection (ICSI) is a procedure involving the direct injection of a single sperm into each egg (see description of ICSI)
The clinical decision to proceed with insemination (IVF) versus ICSI is made by the phyisican/embryology staff and is based on sperm and/or egg quality.

Embryo Transfer
While on the gynecological examination chair, a speculum is placed into the cervix so that the opening of the cervical canal can be seen. After dabbing the entrance to the uterine cavity and removing the visible cervical mucus, a soft, flexible catheter (tube) is inserted into the uterine cavity through the canal of the cervix. After the placement of the first catheter the biologist will prepare the final transfer catheter in the lab. Here the embryos will be transferred into the catheter – this catheter is given to the doctor and placed in the first catheter. Then under sonographic control the embryo/embryos is placed in the cavity of the uterus. The transfer of embryo/embryos into the uterine cavity may cause some discomfort such as cramping, and possibly a small amount of bleeding. There is also some risk of infection, which may require antibiotic treatment.

There is no guarantee that any of the embryos transferred will result in a pregnancy. The outcome of IVF correlates with the number and quality of embryos transferred to the uterus. There is a risk of multiple gestations (more than one baby) following IVF, and the risk correlates directly with the number of embryos transferred. It is our policy to limit the number of embryos transferred according to maternal age and embryo quality. The purpose of this policy is to maximize the chance of pregnancy while reducing the rate of multiple gestations. Remaining viable embryos may be frozen for possible transfer in a subsequent cycle.

Post-Transfer Management
In an attempt to increase the chance of successful implantation, post-transfer management may include progesterone either by vaginal suppository or subcutaneous injection. The progesterone will be continued, until a negative blood pregnancy test or the pregnancy is confirmed by ultrasound. During this period blood testing for hormonal evaluations will be performed as instructed by the IVF team.

There is no guarantee that a pregnancy will occur as a result of this treatment. The chance of a successful outcome during IVF treatment will be explained by the IVF team.

Pregnancies resulting from IVF are subject to the same complications as pregnancies achieved without medical intervention, such as miscarriage, ectopic (e.g., tubal) pregnancy, preterm labor, or other complications. There is no current consensus as to whether the likelihood of certain birth defects or other abnormalities may be increased in children conceived with IVF technologies, as opposed to naturally conceived children.

Discarded Material
Any unused biological material including follicular fluid, sperm, immature and/or unfertilized eggs, abnormal and/or arrested embryos (those which have stopped developing) will be discarded after the IVF treatment.

Intracytoplasmic Sperm Injection (ICSI)

The procedure for ICSI is the same as IVF, the only difference is the fertilization of the egg. During the ICSI procedure a single sperm is placed directly into the oocyte (egg) using a microneedle. The clinical decision to proceed with ICSI is made by the physician/embryology staff and is based on sperm and/or egg quality and/or quantity.

ICSI may be performed in the event of any of the following, and as deemed necessary by the IVF-Team:

– Low sperm motility.
– Poor sperm morphology.
– The use of frozen sperm.
– The use of donor sperm.
– The use of surgically retrieved sperm.
– Sup-optimal fertilization in a prior IVF cycle.
– Low egg yield.
– The use of previously cryopreserved eggs.

During ICSI, spermatozoa are deposited into a viscous solution that will slow their motion, allowing for visualization and selection. The eggs are treated with an enzyme to remove the granulosa cells (cell surrounding the egg). ICSI can only be performed on mature eggs. A single sperm is then injected directly into the cytoplasm (center) of the egg. There is a risk of damage to the egg(s) when ICSI is performed. However, typically, fewer than seven percent (7%) of eggs are damaged by ICSI. When ICSI is performed, most eggs fertilize normally. Some eggs may fail to fertilize or fail to develop normally.

The likelihood of success cannot be based solely on semen and/or egg characteristics. ICSI, as well as all assisted reproductive technologies, may increase the chances of high order gestations, including identical and non-identical twin pregnancies.

Assisted Embryo Hatching

The natural process of embryo hatching involves the shedding of the zona pellucida. Embryo hatching directly affects the ability of an embryo to implant into the uterine lining. To perform assisted embryo hatching the embryology team use a laser to weaken the zona pellucida.

The embryology staff will examine the zona pellucida (the shell-like layer surrounding the embryo) and the general appearance of each embryo. This assessment is required to determine whether assisted hatching may be indicated for embryos selected for transfer. The need for performing assisted hatching is determined by the embryology staff.

There is a very low risk of damage during the manipulation. Single cells of the embryo(s) are damaged in less than 1% of all cases.

Natural IVF

In this procedure there is no stimulation to start follicle growth. The cycle is monitored by sonogram and labwork. The natural grown follicle is then removed by sonographic guided aspiration as described in the IVF article. The oocyte is treated by ICSI – and replaced after showing positive development after 2-5 days.

Advantages:
-No hormonal stimulation has to be done.
-No egg selection has to be done.
-Much cheaper than the classical IVF/ICSI procedures.
-Single embryo transfer leads to much lower chances of a multiple pregnancy.

Disadvantages:
-Only one oocyte.
-No possibility of egg selection.
-No possibility to cryopreserve any additional oocytes.
-Lower succesrates because of transfer of only one embryo.

Hystero Contrast Sonography ( HyCoSy) Tubal Patency Test

HyCoSy is a special ultrasound test using contrast foam solution, like a dye, to show if the fallopian tubes are open or not. Painkillers (Paracetamol or Ibuprofen) should be taken about 1 hour before the appointment. You will be asked to empty your bladder before the procedure.

In this procedure a speculum is placed in the vagina and a catheter, small tube, is inserted into the uterus. There is a small balloon that holds the catheter in place. The speculum will then be removed and the ultra sound will continue. The foam solution is then passed through the catheter into the uterus and fallopian tubes, which is seen on the ultra sound. This may cause some period like pain, and on occasions women may feel faint. To help prevent this we ask that you have something to eat and drink before the procedure. There may be period like pain and a white/pink discharge after the procedure but it should go away with time. Rarely does this procedure cause infection and the results will be explained to you on the same day.