Infertility and Assisted Reproductive Technology (ART)

Infertility is the inability to conceive after 1 year of unprotected and regular sexual intercourse.
There are two types of infertility: primary infertility (couples have never had children) and secondary infertility (couples initiated conception in the past and then had difficulty).

In the USA, the infertility rate for women is:
- 4.1% for ages 20-24
- 5.5% for ages 25-29
- 9.4% for ages 30-34
- 19.7% for ages 35-39

IUI involves depositing a sperm sample in the uterus just before the release of an oocyte (s) in a natural or stimulated cycle using a soft catheter.
hCG is given at injection or up to 24 hrs later.
Sperm volume is 0.2-0.3 ml.
Pregnancy rates are around 15% per cycle.

Assisted conception techniques are designed to assist couples in their effort to procreate.
The objective is to bring sperm and oocyte close to each other to promote chances of fertilization and achieve a pregnancy.

Superovulation involves hormonal manipulation to enhance ovulation and release multiple oocytes during an ovulatory cycle.
Drugs used include:
- Human menopausal gonadotropin (taken from the urine of postmenopausal women)
- Recombinant FSH
- Recombinant LH
The protocol involves:
- Gonadotropin administration for 9-11 days
- Monitoring follicular development by transvaginal ultrasound
- Follicles 16-18 mm in diameter, 10,000 IU hCG, and oocyte maturation

Sperm preparation involves selecting progressively motile normal sperm (PMNS) and removing seminal plasma, WBC, and bacteria.
Sperm capacitation allows sperm to become fertile.

GIFT involves a laparoscopic technique in which oocyte and sperm are placed in a fallopian tube, allowing for in vivo fertilization.
The procedure involves:
- Superovulation
- Ultrasound (US) guided transvaginal oocyte retrieval
- 0.1-0.2 ml sperm with 2-3 oocytes

IVF involves taking oocytes from a woman, fertilizing them in a lab with her partner's sperm, and transferring the resulting embryos back to her uterus 3 or 5 days later.
The procedure involves:
- Superovulation
- Insemination
- Embryo transfer
- Luteal support

Superovulation involves:
- Gonadotropin stimulation
- Monitoring follicular development
- Ultrasound guided transvaginal oocyte retrieval
- Oocyte fertilization with sperm

Insemination involves:
- Containers used: test tubes, Petri dishes, multi-well dishes
- Each oocyte inseminated with 0.5-1.0 ml processed motile normal sperm (PMNS)
- Fertilization detected 12-20 hrs later by presence of 2 pronuclei in oocyte cytoplasm or 2 polar bodies in perivitelline space

Luteal support involves:
- Progesterone (P4) necessary for pregnancy maintenance
- Premature luteolysis in some superovulatory regimens
- P4 supplementation until menstrual period occurs or the woman has a positive pregnancy test

ICSI involves the injection of a single sperm into a single oocyte to achieve fertilization.
Procedure involves:
- Superovulation
- US guided transvaginal oocyte retrieval
- IVF
- Oocytes injected with sperm using special microscopes, needles, and micromanipulation equipment

Indications for assisted hatching include:
- Couples having IVF with female partner's age over 37
- Poor quality embryos
- Excessive fragmentation
- Slow rates of cell division