Last week, we started a discussion on secondary infertility and it is the emotional impact on couples diagnosed with it. We also talked about some causes of secondary infertility. This week, we will discuss possible solutions and management of secondary infertility.
SECONDARY INFERTILITY TREATMENTS OPTIONS
It is a common misconception that fertility treatment should automatically be in vitro fertilization (IVF). The truth is that there are varieties of fertility treatments for secondary infertility that range from infertility medications for purpose of ovulation induction with timed intercourse to intrauterine insemination (IUI) also known as artificial insemination and beyond.
Infertility medications commonly used include oral medication such as CLOMIPHENE CITRATE and LETROZOLE which are used to stimulate ovarian follicles to mature and also promote the release of more eggs. Injectable hormonal medication containing follicle stimulation hormone (FSH) and luteinizing hormone (LH) also used to produce more eggs. Oral and injectable ovarian stimulation medication may be used together during an intrauterine insemination procedure.
In the Intrauterine insemination (IUI) procedure, a semen sample from the partner or donor may be prepared and injected directly into the woman‘s uterine cavity (womb) during ovulation. In vitro fertilization (IVF), eggs are combined with sperm outside the body to create an EMBRYO which is transferred back into the uterus (womb) on the second, third or fifth day of development for implantation and further growth.
Insemination is the process of injecting the sperm through a thin flexible tube directly into a woman’s vagina, cervix uterus, or fallopian tube. This puts sperm closer to the egg and it can overcome barriers such as low sperm count and cervical mucus. Insemination can be used with donor sperm. It can be combined with other fertility treatments such as CLOMIPHENE OR HORMONE SHOTS.
ASSISTED REPRODUCTIVE TECHNOLOGY (ART)
ART is used to remove eggs from a woman’s ovaries (or used donor eggs and fertilize them with the man’s sperm (or donor sperm) outside the body. One or more fertilized eggs are then transferred to the woman’s uterus (womb). Before deciding on ART treatment consider the possible emotional, social, financial, religious, ethical and legal questions that may come up for you and your partner.
ZYGOTE INTRA FALLOPIAN TUBE TRANSFER (ZIFT)
Eggs are stimulated and collected using IVF methods. These eggs are mixed with the sperm in the laboratory. Fertilized eggs (ZYGOTES) are then laparoscopically returned to the fallopian tube where they will be carried into the uterus (womb) The goal is for the zygote to implant in the uterus and develop into a foetus.
PRONUCLEAR STAGE TUBAL TRANSFER (PROST)
Similar to ZIFT, fertilized eggs are transferred to the fallopian tube before cell division occurs. These procedures have higher costs and risks related to laparoscopy and they do not provide as much more useful information about embryo development as IVF does. For these reasons, these procedures are rarely used.
IN VITRO FERTILIZATION (IVF):
In vitro means “outside the body.” IVF is a process whereby eggs are collected and then fertilized by sperm outside the body, in an embryology laboratory. The first IVF baby was born in 1978 in England. Not long after, the United States delivered its first IVF baby, and the use of IVF has grown dramatically. IVF was a major breakthrough because it allowed for successful pregnancies in women that were previous deemed permanently infertile, such as when the fallopian tubes are both markedly damaged. IVF involves the removal of eggs directly from the ovary, fertilization with sperm in the laboratory, followed by the transfer of the embryos directly into the uterus, thereby bypassing the tubes. Although the tubal disease was the original indication for IVF, many more indications have developed over the years. These include advancing maternal age, severe male factor infertility (whereby ICSI can be used to fertilize the egg), and endometriosis, amongst many others.
IVF IS GENERALLY PERFORMED IN THE FOLLOWING MANNER
The woman undergoes gonadotropin injections, which stimulate the ovaries to produce many eggs. Once the follicles (fluid-filled sacs containing the eggs) reach a mature size, an HCG injection is administered which leads to the final development and maturation of the eggs. Just before those eggs would otherwise be ovulated, they are retrieved under mild anaesthesia in an operating room. This procedure is done by ultrasound guidance where the physician utilizes a narrow needle to retrieve eggs from the ovary through the vaginal wall. This sterile needle is attached to sterile suction tubing and a collecting vial. Once the fluid containing the eggs is removed from the follicles into the vials, they are handed to the embryologist who finds the eggs, places them in tiny droplets on a Petri dish, and then fertilizes the eggs using their partner’s or donor sperm. The sperm can either be mixed with the eggs to allow normal fertilization (conventional insemination) or by injecting one sperm into each mature egg (ICSI).
The fertilized eggs, now embryos, are allowed to grow and develop in culture media for typically 3 to 5 days. Then, generally, one or two embryos, which have demonstrated appropriate development, are carefully and gently transferred into the uterine cavity. Embryos transfer is performed in the office under abdominal ultrasound guidance using a small, soft, sterile and flexible catheter. The embryos are placed within the tip of the transfer catheter and then injected within the uterine cavity once the catheter is placed through the cervical canal to the ideal spot within the uterus.
The pregnancy test is then performed 2 weeks after the egg retrieval. Currently, egg retrieval is by an ultrasound-guided method which is easier and safer. The success rate of IVF ranges from 25-45% with cycle to cycle variation.
This IVF process has revolutionized the way Reproductive Endocrinologists can help couples in having a healthy baby despite diagnoses of either primary or secondary infertility.