Assisted Reproduction

Definitions of Infertility

The World Health Organization (WHO) defines infertility as:

“A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12months or more of regular unprotected sexual intercourse”

Primary Infertility

When a woman is unable to ever bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth would be classified as having primary infertility (WHO).

Secondary Infertility

When a woman is unable to bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous inability to carry a pregnancy to alive birth would be classified as having secondary infertility (WHO).

Intrauterine Insemination (IUI)

Intrauterine insemination (IUI) is a fertility treatment that involves placing sperm inside a woman’s uterus to facilitate fertilization.

The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization.

IUI provides the sperm an advantage by giving it a head start, but still requires a sperm to reach and fertilize the egg on its own. It is a less invasive and less expensive option compared to IVF.

Before intrauterine insemination, ovulation stimulating medications may be used, in which case careful monitoring will be necessary to determine when the eggs are mature.

The IUI procedure will then be performed around the time of ovulation, typically about 24-36 hours after the surge in LH hormone that indicates ovulation will occur soon.

A semen sample will be washed by the lab to separate the semen from the seminal fluid. A catheter will then be used to insert the sperm directly into the uterus. This process maximizes the number of sperm cells that are placed in the uterus, thus increasing the possibility of conception.

In Vitro Fertilisation (IVF)

In vitro fertilization (IVF) is a fertility treatment that involves stimulating the ovaries to produce several eggs in the same cycle, fertilize them with sperm in the lab, let them develop over a few days and then transfer them into the uterus. There are 8 stages to IVF:

Step 1: suppressing the menstrual cycle. Medication will suppress the natural menstrual cycle. It can be given as a daily injection or as a nasal spray. Not all IVF cycles need suppression of the natural cycle.

Step 2: ovarian stimulation. Medication is given to stimulate the ovaries to produce more eggs. Ultrasound scans are used to monitor the response of the ovaries to the stimulation.

Step 3: trigger injection. When there’s a good amount of follicles, of the right size, the ovarian stimulation ends. The doctor will tell you when to take the trigger injection that helps the egg’s final maturation and loosen it from the follicle wall.

Step 4: egg and sperm collection. About 34-36 hours after the trigger injection, the eggs need to be collected. This is a procedure done under sedation. The doctor will place a needle through the vagina and into each ovary under ultrasound, to collect the eggs. In couples, the partner will be asked to produce his semen sample. In sperm donation, this sample will have been chosen previously.

Step 5: fertilization. The collected eggs are mixed with the sperm in a laboratory. After 16 to 20 hours, they're checked to see if any have been fertilized. The fertilized eggs (embryos) continue to grow in the laboratory for up to 6 days before being transferred into the uterus. Whilst the embryos are developing, women take medication to prepare the uterus lining for transfer.

Step 6: embryo transfer. A few days after the eggs are collected, the embryos are transferred into the uterus. This is done using a catheter that's passed into the vagina, through the cervix and into the uterus.

Step 7: two week wait. The two-week wait is the period between the embryo transfer and the pregnancy test. It can be one of the most challenging times of fertility treatment.

Step 8: pregnancy test. It measures the level of hCG hormone which is produced by the embryo once it has implanted in the uterus.

Risks of IVF

Medication side effects:

• Hot flushes
• Feeling down or irritable
• Headaches
• Weight gain
• Ovarian hyperstimulation syndrome

Multiple births, if more than one embryo is placed in the uterus. Having twins or triplets increases the risk of miscarriage, high blood pressure, diabetes, anaemia, premature birth and caesarean section.

Ectopic pregnancy, where the embryo implants in the fallopian tubes rather than in the uterus.

Intracytoplasmic Sperm Injection (ICSI)

ICSI is used in the following circumstances:

• Where there is a severe problem with sperm quality; such as very low numbers, a high percentage of abnormally shaped sperm or a low percentage of mobile sperm)
• Where in previous IVF treatment(s) none or few of the eggs fertilised
• Where sperm was obtained surgically, directly from the testicle (TESE) or epididymis (PESA)
• Where sperm quality on the day of egg collection is insufficient for IVF, most likely due to natural variation in semen samples. In this procedure, the embryologist places the sperm inside the egg (instead of allowing them to fertilize naturally in the petri dish).