Types of Assisted Reproductive Treatments (ARTs)

Ovulation Induction (OI) and Timed Intercourse

This treatment is often used when women have problems with ovulation. Drugs that stimulate ovulation could be given as tablets (Clomid) or injections (Gonadotrophin). The procedure is monitored through the use of ultrasound scans. At the proper time, ovulation is induced with Human Chorionic Gonadotropin (HCG) hormone. The couple can then be advised to proceed with sexual intercourse.

Artificial Insemination / Intrauterine Insemination (IUI)

This treatment is recommended when women have problems with ovulation, when men exhibit mild male factor infertility, when the couple's reasons for infertility remain unexplained, or when the couple is unable to have normal intercourse. In IUI the ovaries are stimulated with hormone tablets (clomiphene) and gonadotropin injections (FSH), in order to allow more than one follicle to develop. If several follicles develop and mature, they will each release an ovum. Therefore, the probability of fertilization increases due to the presence of a greater number of ova. Men are asked to produce a sperm sample, which is usually processed. During processing, the sperm is removed from the seminal fluid, and often the most active and motile sperm are separated and concentrated. The sperm concentrate is then injected into the uterine cavity through the cervix by using a catheter at the time of ovulation.

Gamete Intra-Fallopian Transfer (GIFT)

GIFT is used in couples who have unexplained infertility, but who have proven fertility from a previous pregnancy or during IVF. During this procedure, the gametes (sperm and eggs) are injected into the Fallopian tubes. In order for this treatment to take place, both sperm and eggs have to be collected. The men are asked to donate a sperm sample, and this sample is processed in a way that concentrates healthy and normal sperm. The eggs of the woman are usually collected vaginally. In order for this to take place, the female is first given hormonal injections to stimulate follicular development. This will help the doctor aspirate a greater number of eggs during the egg retrieval procedure. In order for egg retrieval to take place, the woman is usually placed under anesthesia or is sedated. A vaginal ultrasound probe with an attached aspiration needle is inserted through the vagina and into the follicles of the ovary. The fluid within each follicle is then aspirated into a test tube, and the tubes are sent to the lab in order for the eggs to be recovered and isolated. The desired number of eggs and sperm are then placed in a catheter and injected into a Fallopian tube. In order for GIFT to take place, the woman is usually placed under general anesthesia since the transfer procedure is done through laparoscopic surgery.

Zygote Intra-Fallopian Transfer (ZIFT)

ZIFT is similar to GIFT, except in this procedure zygotes instead of gametes are transferred into the Fallopian tubes. The main advantage of ZIFT is that it uses fertilized eggs; therefore, in comparison to GIFT it is one step closer to pregnancy. During this procedure the man's semen is again collected and processed. The female undergoes ovarian stimulation and the egg retrieval procedure. The eggs and sperm that have been collected are then placed in a petri dish inside an incubator until fertilization takes place. Using laparoscopy, the resulting zygotes are then transferred to the Fallopian tubes with a catheter.

In-Vitro Fertilization

IVF is often used when women have occluded or absent Fallopian tubes. This treatment is also used when other ARTs, such as GIFT, IUI, and OI, failed to result in pregnancy. Often before beginning IVF, the male and female are required to undergo a screening process. The female is usually asked to provide blood for routine lab investigations. In addition, the woman will usually have a trans-vaginal ultrasound to evaluate the thickness of the endometrial lining, the curvature of the cervix, the position of the uterus, and the ovaries. Often a mock-embryo transfer is conducted to measure the depth of the uterine cavity. 

IVF is often divided into four main steps:

1. Ovulation Induction

Ovulation induction is the process by which the ovaries are stimulated at around the time of menstruation, so that multiple follicles are produced. In the month before ovulation induction, the woman is given oral contraceptives. The purpose of the contraceptives is to prevent ovarian cyst formation. A few days before finishing the oral contraceptives, the patient is administered certain drugs that help 'turn off' or reset the individuals normal menstrual cycle (the process of down regulation of the pituitary gland). At around the time of menstruation, the patient is required to take a blood test and have an ultrasound. The blood test helps measure the estrogen in the blood and determine if it is at the proper level. The ultrasound helps ensure that ovarian cysts are absent. If both these test are in order, the stimulation protocol can begin. Gonadotropin injections are taken either once or twice a day after the menstrual period. These gonadotropins will allow several follicles to develop and enlarge (in natural cycles only one follicle releases an ovum). Each woman responds to gonadotropins differently, and therefore in each individual case the dose administered may vary. When ultrasound examination and blood estrogen levels reveal that the follicles are large enough one injection of another hormone called HCG is given to the patient to prepare the egg for ovulation. It is then necessary to proceed with egg retrieval 35 hours after the HCG injection.

2. Oocyte (Egg) Retrieval

The woman needs to be fasting for 8 hours before the procedure. The egg retrieval should take place between 35 to 36 hours after administration of the HCG injection. The procedure is performed as a day case surgery under a general anaesthetic. A vaginal sonar probe with an attached aspiration needle is used to pierce the vaginal wall and pass through to the nearby ovary, then puncture each follicle, aspirate the fluid with the eggs. Each retrieved egg is collected in a test tube and immediately transferred to a nearby embryology lab where the fluid is emptied in a petri dish and examined under a stereomicroscope to identify the presence of an egg (ova). The entire procedure is usually completed within half an hour. Furthermore, recovery is fairly rapid. The woman may feel some cramping, heaviness, soreness, and there may be some spotting. However, after two hours or less the patient is usually able to return home. When the patient returns home, she should relax and refrain from sexual intercourse for a week. Finally, alcohol and caffeine should not be consumed during this time period.

The male will be asked to produce a sperm sample on the day of the egg retrieval. He should ensure that he has not ejaculated for 2 to 5 days before this donation. The sperm is removed from the seminal fluid, and then the healthiest and most motile sperm are concentrated.
The couple should be available for contact at all times following this procedure until the time of embryo transfer.

3. Insemination and Fertilization

After the egg retrieval is completed, the eggs are left to mature in a Petri dish containing a special media for several hours then the sperm that was collected from the male is usually added to the Petri dish containing the eggs (insemination). The Petri dish is then placed in an incubator in order to allow fertilization and cleavage to take place. Fertilization occurs when the sperm penetrates the egg, forming a single cell with 2 pro-nuclei (one from the egg and from the sperm) called a zygote. The two pro-nuclei will then fuse. The embryo will then undergo cleavage (division). The 4-cell stage usually can be seen approximately 36-48 hours after fertilization, and the 8-cell stage can be seen approximately 72 hours after fertilization. The embryo is examined by a microscope and transferred to the uterine cavity after 3 days (the 8-cell stage), or after 5 days (as a well-developed blastocyst), making use of advanced culture media. 

4. Embryo Transfer

The Embryo Transfer usually takes place approximately 3 or 5 days after egg retrieval, depending on the number and quality of embryo division. This procedure is not performed under anesthesia. It is recommended that the patient comes with her bladder half-full since this helps facilitates the transfer procedure under ultrasound guidance. The doctor will show the couple the number and quality of the embryos available for transfer on a screen. Together, they will decide on the number to be transferred. The remaining embryos can then be preserved or discarded according to their quality.

For the procedure, the patient will be asked to lay on her back. A catheter with a long, flexible, thin tube is used to transfer the embryos under the guidance of an ultrasound. The catheter is inserted through the cervix and the embryos are injected into the uterus. The catheter is then given to the lab, and is checked microscopically to ensure that all the embryos have been transferred. The patient will then be requested to rest for 60 minutes after the embryo transfer.

Following the procedure a progesterone supplement (tablets, vaginal suppositories or injections) is prescribed to help support the pregnancy (luteal support). This treatment will continue throughout the next two weeks and during early pregnancy.

The patient will be asked to take a blood-pregnancy test two weeks after the embryo transfer. If the results of the test turn out to be positive, another blood-pregnancy test will be taken two days later. A doubling of the beta-HCG value is usually an indication that implantation has occurred. If the second blood test shows a doubling in this hormone's level, this is referred to as a biochemical pregnancy. An ultrasound is required two to four weeks after the first blood test to actually confirm true pregnancy (clinical pregnancy with a pregnancy sac inside the uterine cavity).

Intra-Cytoplasmic Sperm Injection (ICSI)

ICSI is a procedure used for couples where men have proven to have severe infertility. The male may have a very low sperm count, a high percentage of abnormal sperm, or sperm that is immotile. This treatment is also recommended for couples that did not fare successfully during the egg retrieval process. If only a few eggs were collected from the female, it is often wiser to use ICSI to ensure fertilization. During ICSI, a single sperm is injected into the egg's cytoplasm. The procedure requires extremely advanced microscopes with micromanipulation devices (microinjections and micropipettes). The sperm's tail is cut off to prevent the possibility of movement. The egg is then held in place, while the sperm is inserted into its cytoplasm.

Sub-Zonal Insemination (SUZI)

This procedure is recommended for patients with sperm male factor infertility. During this procedure, a sperm cell is injected directly under the zona pellucida (the outer protein matrix of the ovum).