Conceiving with Medical Assistance
It has been said that if the sexuality of men were as complex as that of women, humanity would become extinct. In regard to reproduction, the contribution of women seems amazingly simple, because all of their egg follicles are already present in the body before birth. At the beginning of each cycle, about 30 to 40 egg cells stand at the ready, but only one will mature. In contrast, a man’s sperm cells are produced anew during various processes over the course of ten to twelve weeks.
In cases of infertility, if medical measures are necessary, they do target the woman to a special extent. In Vitro Fertilization (IVF) or Intrauterine Insemination (IUI) are the two most commonly used treatments in fertility clinic around the world. Treatments that may last several years, and the necessary hormone injections could lead to mood swings, weight gain, edema or even an increased risk of cardiac infarction. Additionally, any surgical removal of the eggs themselves is associated with a risk of injury or infection.
The Role of the Reproductive Physician
When encountering fertility problems, initial discussions with the gynecologist will probably result in a referral to a reproduction endocrinologist with special training in the areas of infertility and fertility treatment for both women and men. At that point, an array of test procedures such as chromosome investigation or diagnosis of serious hereditary diseases are available.
For example, with men, determining the azoospermia factor indicates whether the production of mature sperm can be expected. Andrologists are urologists who specialize in treating male infertility. They analyze the sperm’s characteristics, and will possibly do a biopsy or extract sperm cells. Their findings also help decide whether pregnancy may be achieved without artificial fertilization, and if not, which procedure is worth considering. Andrologists also offer help for couples who cannot successfully be intimate due to a medical condition or premature ejaculation.
As long as the man has enough healthy, mobile (even if mobility is reduced), and viable sperm, one of the most economical fertility treatments can be considered: Intra-uterine Insemination (IUI).
What Is Intrauterine Insemination?
During IUI, at the approximate time of ovulation, prepared sperm cells are introduced into the uterus in order to bring them closer to the woman’s egg. This type of artificial insemination works by placing sperm, which is washed and concentrated, in order to increase effectiveness, directly into the uterus right before ovulation.
Who Should use Intrauterine Insemination?
Though intrauterine insemination is used in a variety of cases, it is recommended for a few particular situations. IUI is often one of the first attempts at artificial insemination if the male has a low sperm count, since it concentrates a sperm sample. It is also common if the female is using a sperm donor or if she is unable to have vaginal intercourse. Men with HIV can also use intrauterine insemination in order to lessen the likelihood of passing HIV to their partner and child.
How Is the Procedure Done?
The first step in intrauterine insemination is to ensure that the uterus and fallopian tubes are fully functional. A day is then scheduled for the procedure. If the female is taking fertility drugs, the intra-uterine insemination will occur 36-40 hours after ultrasound scans indicate that an egg is mature and ready for release. Otherwise, it happens during the window of fertility in the woman’s ovulation cycle. The male then provides a sperm sample, and the sample is washed to remove excess fluid and slower sperm. The sperm is then inserted into a small flexible tube, called a catheter, which is then inserted through the cervix into the uterus.
Are There Any Risks in Intrauterine Insemination?
Intrauterine insemination is mostly safe, and there are few serious complications. However, a few issues may occur. During the procedure, some women may contract an infection, but this happens to less than 1 percent of patients. The procedure is mostly pain free, but some cramping or spotting may occur. When intrauterine insemination is combined with fertility drugs, the chances of having a multiple pregnancy greatly increases.
How Successful is Intrauterine Insemination?
Intrauterine Insemination is often successful. For women who received IUI, the percentage of women who successfully gave birth is 15.8 percent for women under the age of 35, 11 percent for women aged 35 to 39, 4.7 percent for women aged 40 to 42, and 1.2 percent for women aged 43-44. It is common for doctors to recommend three to six attempts at IUI before other fertility treatments are discussed.
ICSI (intracytoplasmic sperm injection) is the most commonly used method of artificial insemination. It offers men who are struggling with considerable fertility problems the opportunity to realize the dream of having their own children.
When is ICSI performed?
This method is used when a man has poor sperm quality. Among the possible reasons why conception cannot occur are:
- Low sperm count
- Limited motility of the sperm
- Abnormal sperm
- Obstructive azoospermia (blocked ejaculatory ducts prevent sperm from entering the seminal fluid)
- Antisperm antibodies in the ejaculate
- Diseases, such as cancer, that mean only frozen sperm is available
Preparation for ICSI
Before the ICSI, the eggs of the woman are hormonally stimulated so that several fertilized eggs are available. During this process, specified quantities of the hormones FSH (follicle stimulating hormone) and LH (luteinizing hormone) are injected subcutaneously once a day. The injections can be made at home by the woman or her partner. Ultrasound scans are used to check whether the follicles have reached an appropriate size. If this is the case, the hormone HcG is administered to induce ovulation. 36 hours later, the eggs are removed transvaginally.
The sperm can be obtained either via masturbation or surgery. The latter is advisable in case of obstructive azoospermia, for example. In addition, it is possible to extract sperm cells directly from the epididymides (via MESA, microsurgical epididymal sperm aspiration). Masturbation takes place the day the egg is removed after no ejaculation has occurred for two to three days.
Sperm Injection
The removed eggs and sperm are then fused in a laboratory. The process of fertilization is carried out under a special microscope. Using a micropipette, the sperm is placed directly into the egg cell’s interior. How many of the eggs were able to be successfully fertilized is checked the following day.
Embryo Transfer
The embryo transfer takes place approximately two to five days after fertilization. Two to five embryos (only the highest-quality embryos are used) are inserted into the uterus using a catheter. If multiple embryos are available, those that are not needed for the transfer can be frozen at a later stage. The procedure takes only a few minutes and takes place on an outpatient basis.
Risks
In about one percent of cases, ovarian hyperstimulation may occur due to the hormonal treatment. Symptoms include water retention, nausea, vomiting, diarrhea and breathing problems. The risk is greatest for younger and overweight women as well as those with PCOS. It also increases the chance of a multiple pregnancy. For this reason, only three embryos may be used per treatment.
Chances of Success
Per cycle, ICSI carries a 15 to 20 percent chance of pregnancy – similar to IVF. The advantage of this method is that the sperm is injected directly into the egg, while with IVF, the fertilization takes place in a glass vessel. Various factors such as age, underlying diseases and personal lifestyle play an important role in success. In addition, the chances of conception increase with the number of attempts.
In Vitro Fertilization (IVF), from the Latin vitro, meaning “glass”, involves fertilization outside of the human body. IVF is more complicated than IUI, and affects the woman more because a longer program of hormones is necessary.
What Happens During In Vitro Fertilization?
With IVF, the activity of the ovaries is suppressed. Next, the maturation of approximately 15 eggs is promoted.
During this process, the woman must inject herself for several days under the skin of her abdomen with the follicle-stimulating hormone. At the right moment, ovulation is initiated by a pregnancy hormone called human chorionic gonadotropin, or hCG. Afterwards the follicle material is harvested via the vagina. Sperm is then made available for the fertilization of the egg cells, usually from ejaculated semen, but occasionally by means of a testicular biopsy or harvesting from the epididymis using an operating microscope. Thanks to natural selection, in 50 to 70 percent of procedures, fertilization then takes place in a test tube by the most mobile sperm cells.
Several Techniques
With IVF, different supporting techniques may be used: for instance by means of pipette (Intracytoplasmic Sperm Injection, ICSI), or under the microscope (Intracytoplasmic Morphologically Selected Sperm Injection, IMSI). For women under age 35, on the second or fifth day, ideally only two fusions (embryos) will be placed in the womb after a short stay in an incubator – a practice intended to avoid pregnancies with multiples and the associated risks. Under observance of strict legal conditions, surplus egg cells can theoretically be saved frozen in liquid nitrogen. 14 Days after the withdrawal of the follicle liquid from the uterus and the subsequent fertilization, a pregnancy test can give an initial confirmation of pregnancy. However, a positive test result is only the first step; a large amount of uncertainty remains.
Legal Aspects
In the U.S., fertility hospitals and specialized centers perform approximately 126 in-vitro cycles per one million people annually, with an average cost of around $12,400 per cycle. More than 200,000 IVF babies are born worldwide each year. Health insurance companies in the U.S. may or may not cover the procedure, but even those who offer partial coverage will usually cap the number of attempts that are covered. Among additional criteria is the age limit, which is usually age 50-55.
Before deciding to commit to medical assistance, there are some common concerns to consider. Many couples have been right where you are right now, and not all couples succeed with their wish of having children. It’s important to understand the physical, emotional, and financial toll medical procedures like In-Vitro Fertilization (IVF) and Intrauterine Insemination (IUI) take on a couple.
Depression
Only around four out of every ten IVF pregnancies end successfully, a statistic strongly correlated to the age of the woman and the associated legal conditions. Despite the mental and emotional burden, couples often undergo repetitive procedures. If the chance of having a child, which lies so close, does not materialize, in extreme cases depression or the breakup of the relationship can occur.
Ethical Questions
“The Facts of Life” were drastically revolutionized worldwide by reproductive medicine. In extreme cases, IVF theoretically makes possible a parent generation community of up to five humans: a sperm donor, an egg donor, a surrogate mother who delivers the child for its social parents, who become father and mother in the law’s eyes. In 2008, thirty years after the birth of the first test-tube baby Louise Joy Brown on July 27th, 1978, and more than five million other test tube girls and boys later, a comprehensive workshop was held at the Humboldt University in Berlin over ethical and legal questions. In the triangle between sperm donors, intended parents, and a child, the situation involving insemination from an anonymous donor is not without problems. If the husband or a partner of the mother recognizes paternity, the child produced with foreign sperm is considered his legitimate descendant.
In the U.S., neither the sperm donor, nor the child born as a result of using a sperm donor, has any rights, obligations, or legal interest in respect to one another, nor do the legal parents have any legal obligation to inform the child of his or her conception by donor. Although in principle, a donor would be under obligation to pay alimony and his child entitled to inherit from him – instead, by contract, the social (or legal) parents take over the fulfillment of these requirements. It’s likely that hundreds of thousands of later generations will be conceived with foreign sperm, and according to estimations only a very few of them will know this truth. The majority of psychologists look at this fact skeptically, considering non-enlightenment in regard to one’s family situation as delusion or deception.
Medical Risks
As with all medical interventions, artificial insemination involves some risks. As these methods use increased hormones, the vessels become more permeable and cause increased fluid retention in the abdomen and tissue. In addition, dysfunctions of the kidneys and dyspnea may occur. With a pregnancy of more than one embryo comes an intensified risk of dangers like thrombosis and convulsions, in addition to mental strain due to the high probability these children will not reach a minimum weight necessary for good physical and mental health.
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