There are a number of ways for you to receive the treatment you need. One option is to start by speaking with your obstetrician/gynaecologist, another is to go directly to a reproductive specialist. Both physicians will start by performing initial tests to assist in identifying potential causes of your infertility.
An obstetrician or gynaecologist can complete the initial testing, do surgery to correct identified problems, or prescribe a medication to help with ovulation. However, a reproductive specialist generally does further exploration of potential causes and provides more advanced treatments.
Intrauterine Insemination (IUI)
IUI is a fertility procedure whereby the best quality sperm that has been prepared and selected in the laboratory are then placed inside the uterus around the time that the egg is being released.
There are two types of IUI. The first is the natural cycle IUI, where the woman is able to ovulate on her own. The second is the stimulated IUI, where women who are unable to ovulate are given drugs such as clomiphene to stimulate ovulation.
IUI is useful when the patient's spouse has mild or moderate sperm problems.
The process involves the woman doing serial ultrasound scans to monitor the growth of the follicle (which contains the egg), in order to detect ovulation. Once the size of the ovarian follicle reaches 18mm, she will then be given a subcutaneous injection, hCG, to mature the follicle.
The IUI will then be performed 36 hours after the injection.
The husband will have to produce a semen sample on the morning of the IUI. The sample will then be prepared in the laboratory so that the best quality sperm is selected.
The procedure itself is quick and painless. A speculum will be placed in the vagina to visualize the cervix. The sperm is then placed in the uterus using a thin catheter.
If the husband cannot be present during the IUI, it is possible for the husband to provide semen sample in advance and for the specimen to be frozen. On the day of the IUI, the sample will be thawed and prepared in the usual way. It is usually advisable to provide fresh semen sample. The other option will be to cancel the cycle and try again when the husband can be present.
Natural cycle IUI does not pose much risk at all. Stimulated IUI can lead to multiple follicular growth, and therefore increasing the chance of a multiple pregnancy.
Doctors might try three cycles of IUI, and if these are not successful, recommend more advanced methods such as In Vitro Fertilisation (IVF). Unlike IVF, IUI does not involve egg collection or IV sedation.
IVF is a technology that introduces the female egg (oocyte) and male sperm together in a specialised culture medium where the chances of successful fertilisation are greatly enhanced. The embryos are observed and grown in our IVF laboratory, where they are graded for quality and reintroduced to the recipient's uterus at a multicell embryo stage, or later at the blastocyst embryo stage.
Example of an IVF Calendar
IVF Pre-Treatment steps
Part 1: Egg Retrieval
Part 2: ICSI
Part 3: IVF & Embryo Transfer
During IVF, the embryos are cultured for up to six days and receive quality grades each day.
Day Zero - Egg Retrieval and Insemination
Egg maturity is important because a mature egg has the best chance of being fertilised. There are three different stages of egg maturation:
- Germinal Vesicle (GV): The egg has not begun meiosis yet, so it is considered immature.
- Metaphase I (MI): The egg is in the first phase of meiosis; however, it is still not completely mature because it has not entered the second phase of meiosis. This kind of immature egg may mature after a couple of hours of temperature-controlled incubation.
- Metaphase II (MII): The egg is in the second phase of meiosis and is mature. Eggs at this stage of maturity are ready for fertilisation.
Egg quality is graded on a good-fair-poor scale
- Clear cytoplasm/normal shape
- Single distinct polar body
- Clear/thin zona pellucida
- Slightly grainy cytoplasm/misshapen
- Fragmented/abnormal polar body
- Slightly pigmented/amorphous zona
- Cytoplasmic bodies
- PV debris
- Dark/grainy cytoplasm/misshapen
- >1 polar body structure
- Pigmented/thickened zona
- PV debris
Day One - Fertilisation Check
Fertilisation can be seen 16 to 22 hours post insemination. Normal fertilisation is identified by exactly two pronuclei in the centre of the single cell zygote. Fertilisation is considered abnormal when there is only one pronucleus or when there are more than two pronuclei.
Days Two and Three - Multicell Grading
On day two, the single cell zygote should divide into an embryo (approx. two to four cells). On day three, the embryo should continue to divide (four to eight cells).
- Good: cells are symmetrical with clear cytoplasm
- Fair: cells are slightly asymmetrical and/or have slight cytoplasmic irregularities
- Poor: cells are significantly asymmetrical and/or have dark, grainy cytoplasm
Fragmentation refers to little bits of cytoplasm that escape during cellular division and stay within the embryo. The ranges of fragmentation are listed below from least heavy to heaviest. Fragmentation ranging from A to B is most preferred.
- A = No fragmentation
- B = 25-50% fragmentation
- C = 10-35% fragmentation
- D = >35% fragmentation
On day four, embryos begin their transition from a multicell embryo to a more advanced developmental stage. Embryos should begin compacting and forming morulae. Cells of a morula-stage embryo are not as distinct as in previous days. These embryos therefore do not receive quality grades.
Days Five and Six - Blastocyst Stage
A blastocyst is a highly developed embryo that is composed of two different cell types: one group of cells, called the inner cell mass, leads to foetal tissue and another group of cells, called the trophoectoderm, forms the placenta. Blastocysts are graded on their expansion (early, expanding, expanded, and hatching), as well as the quality of the two different cell types (graded on a good-fair-poor scale). Blastocysts that are good to fair quality meet freeze criteria.
Oocyte cryopreservation, or egg freezing, is a relatively new procedure in the field of assisted reproductive technologies. Overall, this technology increases a woman's potential to have children later in life. Since the first successful pregnancy using egg freezing was reported in 1986, approximately 600 babies have been born. Currently, pregnancy rates are between 30 and 40 percent.
Egg freezing allows a woman to preserve her fertility until she is ready to start her family. During an egg-freezing cycle, a patient will go through many of the same steps that are involved in a typical IVF cycle- ovulation stimulation, ultrasound monitoring, and egg retrieval. After egg retrieval, the eggs will be cultured for a few hours and then frozen the same day for future use.
Embryo freezing is a technique that is recommended when high-quality embryos remain after embryo transfer. These embryos remain frozen until the patient is ready to use them. If patients have completed their families, they have the option to donate these frozen embryos to research, another couples, or training. The embryos can also be discarded.
Male Infertility Treatment
The importance of a thorough evaluation of both partners in the relationship cannot be overestimated. Male factors account for at least 30 to 50 percent of all fertility issues in patients.
The semen analysis is done on an ejaculated sample collected after masturbation. It is best to do this test after a patient has abstained from sexual activity for two to five days. The test can be inaccurate if there has been recent ejaculation (the count may be too low), or if ejaculation has not occurred in a long time (many dead sperm). Once the sample has been taken to the laboratory, it is analysed for many different parameters, including fluid volume, sperm numbers, sperm motility (the percentage of moving sperm), and sperm morphology (the shape and appearance of the sperm). Variations can occur from test to test, even in the same man, and sometimes the test needs to be repeated.
When a man has little to no sperm in his ejaculate, it may be possible to retrieve sperm from his testicles or epididymis. This is a procedure performed by a urologist. The sperm retrieved can either be frozen for future use or used immediately for an IVF cycle.
There are several other laboratory procedures that can be used to diagnose and treat infertility.
- Intracytoplasmic Sperm Injection (ICSI)
- Preimplantation Genetic Diagnosis (PGD)
- Assisted Hatching
- Embryo Grading
- Fertility Preservation
Intracytoplasmic Sperm Injection (ICSI)
Within IVF, there are two different insemination techniques: standard insemination and ICSI insemination. Standard insemination is a procedure in which the eggs retrieved are maintained within their cumulus complex and are combined with sperm in the same culture dish. Because their cumulus complex is maintained, egg quality and maturity cannot be evaluated.
In order to perform ICSI insemination, the cumulus complex of the egg is removed and the egg maturity and quality are evaluated. Maturity of the oocyte is important because only mature eggs have the opportunity to fertilise. ICSI involves the insertion of a single sperm directly into the cytoplasm of a mature egg.
Preimplantation Genetic Diagnosis (PGD)
PGD is a technique that can be used in conjunction with IVF to test embryos for genetic disorders prior to their transfer to the uterus. PGD makes it possible for couples with serious inherited disorders to decrease the risk of having an affected child. PGD also can be considered for couples experiencing repeat pregnancy loss due to genetic disorders, couples that already have one child with a genetic disorder and are at high risk of having another, and couples interested in family balancing.
PGD is performed using a high-powered microscope. A single cell is removed from each embryo on day three of development and tested for the genetic trait of interest. The unaffected embryos are identified, separated from the affected embryos, and transferred into the uterus.
Assisted hatching is a technique where a small opening is created in the outer shell of the embryo (zona pellucida), which weakens the shell and improves the likelihood of successful hatching and embryo implantation. Indications for assisted hatching include advanced age, thick or pigmented zona, and previous IVF failures. This technique is typically performed with fresh multicell-stage embryos and all frozen embryos.
This is an alternative for couples who have not found success with some treatment option.