Assisted reproductive techniques, in vitro fertilization, embryo freezing

Conventional in vitro fertilization (IVF-ET- In Vitro Fertilization-Embryo Transfer).

Conventional extracorporeal fertilization, commonly known as in vitro fertilization is recommended when all possible methods of conceiving a baby have already been applied. It is performed in cases of total or partial occlusion of the fallopian tubes, semen pathology, chronic anovulation, immunological factors, endometriosis, unsuccessful attempts to inseminate with sperm of the husband or a donor, as well as when the causes of infertility remain unknown.

It is a multistage procedure. After controlled ovarian hyperstimulation, egg cells are aspirated from the ovaries during their puncture. Puncture is done vaginally often under short general anaesthesia. Next, the aspirated oocytes and previously obtained and prepared husband's or a donor's semen are put together in a Petri dish to fertilize. A fertilized egg cell is called a zygote. A zygote develops into an embryo. Embryos are then cultured in a laboratory under strictly controlled conditions for three to five days. The next stage is transfer of an embryo to the uterine cavity. The efficiency of the traditional IVF is 25% - 45% of pregnancies per the embryo transfer.

In Vitro Fertilization (IVF) combined with Intracytoplasmic Sperm Injection (ICSI).

The ICSI method is one of the greatest achievements in the treatment of male infertility. During the procedure, a single sperm cell is inserted with a small micropipette into the mature oocyte under the microscope. We apply ICSI when male fertility is greatly decreased (low sperm count, poor sperm motility, and many abnormal sperm cells), when traditional IVF fails (no fertilization), or when oocytes have integuments which prevent sperm from penetrating. Additionally, it is possible to aspirate sperm from the epididymis (MESA - Microsurgical Epididymal Sperm Aspiration, PESA - Percutaneous Epididymal Sperm Aspiration) if the vas deferens are occluded, or from the testicle (TESE - Testicular Sperm Extraction, TESA- Testicular Sperm Aspiration) if convoluted tubules in the testis do not function well. The ICSI method applied by an experienced embryologist raises the probability of oocyte fertilization as much as up to 90%.

In vitro fertilization, both traditional and the micromanipulation method (ICSI) using donors' oocytes

The only difference comparing to the above described procedures is that we use an egg cell of a female donor for fertilization. The donor's oocytes are necessary for patients, who want to have offspring, but either they have no ovaries, or they have lost ovarian function prematurely, or their age makes proper maturation of their own reproductive cells impossible. Oocyte donors undergo medical examination to exclude genetic defects, sexually transmitted diseases including HIV, and the use of stimulants (alcohol, nicotine, and drugs).

Blastocyst cultures

Traditionally embryos obtained after IVF are transferred to the uterine cavity about the third day after fertilization. On the fifth day of development, embryos reach the so called blastocyst stage. This is when an embryo is naturally implanted in the uterine cavity. However, culturing blastocysts under laboratory conditions is very difficult. Blastocyst transfer may lead to a higher pregnancy rate and decrease the risk of multifetal pregnancies.

Assisted Hatching

This technique is used to improve the efficiency of embryo implantation in the uterine cavity. Under the microscope we make a small opening in the outer shell of the embryo (so called zona pellucida). This allows the embryo to leave the zona pellucida, which is necessary for its proper implantation.

Freezing and transfer of cryopreserved embryos

Embryo freezing procedure is performed if the number of embryos obtained after IVF is greater than need to be transferred to the uterine cavity on the third or fifth day after fertilization. Cryopreserved embryos can be used in the following cycles without the necessity for the initial stimulation..

Andrological laboratory procedures

Semen analysis with morphological evaluation

Semen analysis serves for quantitative and qualitative evaluation of sperm cells. We assess several characteristic features: the volume of the semen sample, as well as the number, motility, and morphology of sperm. A semen sample should be delivered to the laboratory no later than 1 hour after it was collected. It is recommended that semen is collected and analyzed in the same place. A sterile container is required. In our centre the sperm is analysed immediately after collection, which eliminates any errors resulting from the prolonged storage of the sample.

Semen preparation

It is a laboratory process performed to isolate spermatozoa from ejaculate. Its aim is to achieve a high concentration and motility of morphologically normal sperm in the special culture medium which is next transferred to the uterine cavity (see below).

Homologous and heterologous intra uterine insemination (AIH-Artificial Insemination by Husband, AID-Artificial Insemination by Donor).

During these procedures, specially prepared sperm of the husband or a donor is artificially placed into the uterus by means of a catheter. It is performed in cases of immunological infertility, decreased fertilizing potential of semen, cervical factor infertility, chronic anovulation, endometriosis, idiopathic infertility, as well as impotence, hypospadia and retrograde ejaculation. Insemination can be done either during a natural ovulation cycle, or pharmacologically stimulated cycles if patients do not ovulate. Efficiency of insemination is up to 20% depending on indications.

Freezing and storing semen

Semen can be frozen, and then stored as long as we want. This procedure does not have a strong impact on semen quality, so it can be successfully used in assisted reproductive techniques (AIH, AID, IVF-ET, and ICSI) after thawing.

Additional semen evaluation

There are several tests to assess the ability of sperm to fertilize eggs. They are not part of routine semen analysis, and include bacteriological examination and measuring the concentration of zinc and fructosamine. An extremely important examination to evaluate sperm ability to fertilize oocytes is sperm chromatin integration assay (SCIA).

Other diagnostic methods for infertility

Monitoring ovulation

It is done by ultrasound scanning performed several times during a series of tests. We use ultrasonography (intravaginal method) to assess the ovarian follicle growth, the presence of the leading follicle, growth of and changes in the endometrium, and the occurrence of ovulation. In our centre, we monitor also the second phase of the cycle, which means that we perform additional ultrasonography after ovulation.

Reproductive genetic testing

Genetic tests (e.g. karyotype or cytogenetic examination) are performed in couples with recurrent pregnancy loss, unexplained causes of infertility, male factor infertility, and also those who have not conceived despite several in vitro fertilization attempts (no embryos or implantation). The material to be analyzed is venous blood collected from both partners.

Immunological testing of reproductive disorders

The presence of autoantibodies against components of cell membranes (APA - antiphospholipid antibodies), and some other cell components, mainly cell nucleus (ANA - antinuclear antibodies) is mostly associated with recurrent pregnancy loss. Still, the part it plays in infertility cannot be excluded either. Immunological reasons for infertility and recurrent pregnancy loss may result from over-reactivity of some immune system cells (NK cells) and excessive HLA compatibility between mother and father or so called histocompatibility antigens (MHC - HLA classes I and II).

Endometriosis

It is the growth of endometrial tissue (lying of the womb) outside the uterus, usually in the peritoneal cavity, on the surface of ovaries, fallopian tubes, uterus, intestines and urinary bladder. Endometriosis is an important reason for problems with getting pregnant. If there are indications, we apply surgical (laparoscopic) and pharmacological treatment, and in the first place in vitro fertilization.

Recurring miscarriages

We talk about recurring miscarriages if a woman has had two or more miscarriages during the first trimester. Recurring miscarriages are diagnosed by ultrasonography (in some cases by HSG), as well as cytogenetic and immunological examinations.

Hormonal disorders

Ovulatory disorders

Ovulatory disorders include mainly interrupting maturation of the egg cell or its improper release. They may be the consequence of many diseases, e.g. hypogonadotropic hypogonadism, polycystic ovary syndrome (PCOS), adrenal hyperandrogenism, hyperprolactinaemia, hyperthyroidism, luteal phase failure or premature ovarian failure.

Polycystic Ovary Syndrome (PCOS)

In ultrasonographic examination, multiple ovarian follicles prevail. They are small in size and do not reach maturity. Ovulation does not occur. The level of male sex hormones can be too high. It is a result of insulin resistance and secondary abnormal hormone concentrations in the ovary and in the blood.

Hirsutism

Hirsutism is an excessive hair growth in a woman, especially on her face, chest, stomach, legs and back. It is usually a symptom of PCOS or adrenal hyperandrogenism. In most cases we apply pharmacological treatment

Premenstrual syndrome (PMS)

In this condition, menstrual bleeding is preceded by a number of symptoms such as changing moods, edema, fatigue, breast pain and muscle cramps. We use pharmacological treatment combined with physical exercises and modification of the diet.

Menstrual irregularities

This is the situation when menstrual bleeding does not occur in regular 28-day cycles. Instead, a woman may have frequent bleeding in the cycles shorter than 28 days, rare bleeding in the cycles longer than 28 days or complete amenorrhea. Menstrual irregularities are a sign of ovulatory disorders.

Menopausal disorders

Menopausal disorders are all types of physical and mental conditions associated with the cessation of ovarian function, provided that this process results from age and there are no other reasons for it.

Gynaecological surgical procedures

Laparoscopy

During this procedure, performed under general anaesthesia, a mini-camera is inserted through the abdominal integuments to the abdominal cavity in order to visually assess true pelvis (diagnostic laparoscopy). If necessary, the same route can be used to perform therapeutic procedures such as surgical division of adhesions, removal of cysts or endometriosis and reconstruction of various organs, e.g. fallopian tubes injured in the past..

Hysteroscopy

This is the endoscopic examination, performed under so called short general anaesthesia. It allows visual evaluation of the cervical canal structure, the uterine cavity and the uterine outlet of fallopian tubes. It helps to locate and remove any irregularities, such as polyps, uterine septum, intrauterine adhesions and submucosal myomas.

Microsurgical procedures and fallopian tube reconstruction

The aim of these surgical procedures is to reconstruct normal, patent fallopian tubes. The most common causes of fallopian tube damage are post-inflammatory changes. These procedures are particularly effective in case of uterine outlet occlusion.

Surgical treatment for both congenital and acquired anatomical defects of the reproductive system

Congenital and acquired defects of the uterus and fallopian tubes are anatomical abnormalities, which are responsible for infertility and problems with carrying the pregnancy to term. They can be corrected either by endoscopic or open surgery (laparotomy).

Adhesiolysis

It is surgical, usually laparoscopic, division of adhesions. An adhesion is a band of scar tissue, which can form around true pelvis as a consequence of previous surgeries, inflammatory processes or other damage

All other types of gynaecological surgical procedures

We perform all types of surgical procedures depending on indications and patient qualifications by the doctor in charge of the case.