The normal physiological process of fertility is that the woman lays eggs, the eggs are fertilized in the fallopian tube by sperm from the man, and the fertilized egg implants in the uterus until the baby is born.
Infertility/subfertility means that the process described above cannot be successfully completed within a certain time frame.
To help complete the process successfully we have what is called the assisted reproductive techniques (ART).
On July 25, 1978, a girl named Louise Brown was born in Oldham, United Kingdom, after her parents underwent in vitro fertilization— a process in which a human egg is fertilized outside a woman’s body
Since then, approximately 8.5 million babies have been born worldwide through in vitro fertilization.
Assistance may be offered in any of the following ways:
- Egg production- controlled ovarian hyperstimulation (COH)
- Intra uterine insemination (IUI)
- In vitro fertilization (IVF)
- Intra cytoplasmic sperm injection (ICSI)
- Sperm and egg donation
- Some surgical interference in the male e.g. varicocelectomy TESA etc.
- Pre-implantation genetic diagnoses and treatment
- Genetic condition may be isolated with appropriate action taken.
- Sex determination may be undertaken
Controlled Ovarian Hyperstimulation (COH)
The ovaries are stimulated to produce more oocytes (eggs) by various drugs (tablets and injections given to the woman). Between 8 and 15 eggs may be produced in IVF clients.
If the other factors involved in fertility – the sperm, the fallopian tubes and the uterus – are all in normal condition fewer than 8 eggs produced can be used for timed intercourse.
Intra Uterine Insemination (IUI)
IUI is very similar to timed sexual intercourse. In patients requiring IUI, all factors related to fertility are near normal. COH is performed to produce more than one egg. The sperm is processed to separate the good sperm from the bad sperm. The good sperm are inserted into the uterus through a thin catheter. This procedure also bypasses the cervix, avoiding cervical problems associated with the suitability process.
In Vitro Fertilization (IVF)
Fertilization of the egg by the sperm takes place in the fallopian tubes. The removal of the eggs (egg retrieval) and the addition of sperm in a petri dish/test tube for fertilization is in vitro fertilization – i.e. fertilization of eggs in a jar (in vitro; the Greek term for “in glass”). It’s basically fertilization outside the body. Successfully fertilized eggs, called embryos, are transferred to the uterus 3 to 5 days after fertilization.
The research into this procedure took almost 30 years and culminated in the birth of Louise Brown in 1978. This procedure revolutionized the treatment of infertility.
Intracytoplasmic Sperm Injection (ICSI)
ICSI is a variant of IVF (i.e. slightly different from IVF). In the normal physiological process, an egg must be surrounded by about 500,000 (½ million) sperm in order for only one sperm to enter and fertilize one egg. In intra uterine insemination (IUI) with washed sperm, about 50,000 sperm are needed to fertilize an egg.
But in ICSI, only a single sperm is injected into the egg to bring about fertilization. ICSI has made a huge advance in the treatment of male infertility – from ½ million to a single sperm.
The embryos are transferred in a similar way to IVF treatment.
Sperm and Egg Donation
Some clients lack sperm that can be used for the ICSI procedure and some women are unable to produce eggs. This subgroup of clients benefits from gamete (eggs or semen) donation.
Women who are menopausal or approaching menopause may have difficulty producing quality eggs. All women are endowed with a certain number of eggs at birth, (primordial follicles), about 1-2 million of them.
With the onset of menarche (i.e. the first menstruation), the number of eggs decreases by 30%. Each menstruation is associated with the recruitment of 40-60 primordial follicles, only one of which sticks its neck out to be fertilized; the rest dissolve. The eggs gradually run out as no new ones are added. This process is also the answer to the question of oocyte depletion in COH.
.The eggs touched in IVF would have been wasted anyway.
Cryopreservation of Gametes/Embryos
Sperm can be stored at low temperatures for later use. Ova can also be stored, although this is not as popular as embryo storage. Embryo storage works very well and is very popular for surplus embryos produced.
Ideally only one embryo is transferred, although we can also transfer two or a maximum of three embryos if the patient so wishes. Soon there will be legislation requiring the transfer of only one embryo.
Storage under nitrogen cryopreservation can continue for as long as one wishes. Legislation in the UK allows storage for up to 10 years. Of course, one can understand the need for this procedure in certain cases, but one must also bear the cost of housing these children.
Some Surgical Interventions in the Male
In certain cases of male problems, some surgical procedures may be performed, e.g. varicoelectomy, TESA, etc.Varicolectomy is a procedure in which the varicose veins around the testis are ligated (bound) to reduce blood stasis (decrease in flow speed) and thus the temperature around the testis. Incidentally, the testicle in the he-man (male), as in the he-goat, etc., lies in a sac outside the main body. Testicles that are not properly cooled lead to malfunction.
Another intervention is known as TESA, in which sperm are collected by suction around the testis and used to fertilize the eggs in an IVF situation.
Pre-Implantation Genetic Diagnosis (PGD)
During an IVF process, a cell from an early embryo may be taken to be examined for some genetic conditions like sickle cell disease, etc. Cells may also be examined for the sex of the baby. Appropriate embryos are then used for embryo transfer.
Unfortunately, this procedure has not caught up well with us. It is still under scrutiny.
For some clients, the main problem is that the woman is unable to carry a pregnancy to term successfully.
Then getting a donor uterus may be necessary. The embryo from the egg fertilized by the man’s sperm is placed in the womb of a third person. This is known as surrogacy.
In certain situations, the surrogate mother’s own egg is fertilized by the sperm of the intended parent.
This is traditional surrogacy. This type is not desirable. Surrogacy is more suitable.
In most countries, the one who carries a baby and gives birth is the mother of the child. You can see immediately the controversy this method of childbirth causes. So it is a procedure that is fraught with legal issues, but they have been properly resolved with the involvement of social services.
All these procedures/methods described are fraught with ethical issues. At every step taken to help a couple in need of a child, one question arises: IS IT RIGHT or IS IT WRONG?
Since Louise Brown was born, various individuals, groups and even nations have spoken out on this issue. However, in most countries, IVF itself is no longer an ethical issue.
Client motivation is of paramount importance and sincere consent from those involved is essential.