- Clomiphene Cycles
Clomiphene citrate (Clomid®, Serophene®) is an oral medication commonly used for ovulation induction. It makes
the brain sense a low estrogen level. The brain responds by increasing the
amount of follicle stimulating hormone (FSH) released into the blood stream,
with resultant ovarian follicle recruitment and growth. Each follicle contains
an egg. Between one and three tablets of clomiphene citrate are taken starting on cycle day
three, four, or five and continued for five days. Ovulation typically occurs
between cycle days eleven and seventeen. Intrauterine Inseminations are often
performed in conjunction with clomiphene ovulation induction.
- Gonadotropin Cycles
In a Gonadotropin cycle the use of follicle stimulating hormone (FSH) injections
intramuscularly or subcutaneously results in high levels of FSH circulating in
the blood stream. FSH acts directly on ovarian follicles resulting in
recruitment and stimulation of many eggs. Injectable FSH comes from two sources:
the urine of post-menopausal women (Repronex, Menopur, and Bravelle {FSH +LH})
and through recombinant DNA technology (Follistim, and Gonal-F). Injectable FSH
medication is typically started on the third day of a menstrual period and is
continued for approximately ten days. Intrauterine inseminations are frequently
used in conjunction with injectable gonadotropins.
- Intrauterine Insemination (IUI)
Intrauterine insemination (IUI) (also termed artificial insemination) is a
fertility procedure in which sperm are washed, concentrated, and injected
directly into a woman's uterus. In natural intercourse, only a fraction of the
sperm makes it up to the woman's fallopian tubes. IUI increases the number of
sperm in the fallopian tubes, where fertilization takes place.
- In Vitro Fertilization (IVF)
IVF involves taking oocytes from the woman, fertilizing them in the lab with
sperm and transferring the resulting embryos back to her uterus 2-6 (usually
3-5) days later.
The woman is stimulated with injected medications (FSH or
hMG) to stimulate multiple follicles to develop. These injections continue for
about 8 - 10 days. Blood and ultrasound testing is done every 1-3 days to
monitor the development of the follicles (fluid filled sacs containing oocytes)
in the ovaries. When the woman's follicles are mature, an oocyte (egg)
retrieval (egg aspiration) procedure is performed to remove the eggs from the
follicles. The eggs are then fertilized in the lab with her partner's sperm.
The embryos are cultured in the lab for 2-6 days.
The embryo transfer
procedure is done which places the embryos in the woman's uterus where they will
hopefully implant and develop to result in a live birth. If there are leftover
embryos (of sufficient quality) beyond the number that is transferred, many
couples prefer to have them frozen (cryopreserved) for use in a future cycle
(Frozen Embryo Transfer or FET). Embryo Cryopreservation can be used for
another attempt at having a baby if the "fresh" cycle fails - or as an attempt
to have another child if the fresh cycle is successful.
- Intracytoplasmic Sperm Injection (ICSI)
ICSI involves injection of single sperm into a single oocyte in order to achieve
fertilization in cases of severe male factor infertility. First, the woman must be stimulated with medications and have an
oocyte retrieval. The eggs are injected using specially designed microscopes,
needles and micromanipulation equipment.
How is ICSI performed?
- The mature egg is held with a specialized holding pipette.
- A very delicate, sharp and hollow needle is used to immobilize and pick up a
single sperm.
- This needle is then carefully inserted through the shell and in to the
cytoplasm of the egg.
- The sperm is injected in to the cytoplasm and the needle carefully removed.
- The eggs are checked the next morning for evidence of normal
fertilization.
- Assisted Hatching
Assisted Hatching is a micromanipulation technique in which the shell around the
oocyte is opened or thinned to facilitate the embryo hatching process. Assisted
hatching involves drilling through the shell using an acid solution or a laser to partially
thin an area of the egg, and in some cases create a small hole all the way
through the shell.
How is assisted hatching performed?
- The embryo is held with a specialized holding pipette.
- A very delicate, hollow needle is used to expel an acidic solution against
the outer "shell" of the embryo.
- A small hole is made in the shell by digesting it with the acidic solution.
- The embryo is then washed and put back in culture in the incubator.
- The embryo transfer procedure is done shortly after the hatching procedure.
Embryo transfer places the embryos in the woman's uterus where they will
hopefully implant and develop to result in a live birth.
- Gamete Intra-fallopian Transfer (GIFT)
GIFT stands for Gamete Intra-Fallopian Transfer. Which means male gametes
(sperm) and female gametes (eggs) are placed into the fallopian tube where
fertilization will take place. Careful monitoring is done to check the response
to the medications by trans-vaginal ultrasounds & the measurement of blood
estrogen levels. Once the follicles are of appropriate size and the estrogen
levels have risen, arrangements are made for the GIFT procedure. GIFT is done
either in the hospital or an IVF center containing an operating room. The eggs
are retrieved either trans-vaginally under IV sedation or with a laparoscope
under general anesthesia. Once the eggs have been retrieved, they are combined
with the washed sperm and immediately placed back into the fallopian tube with a
special catheter and a laparoscope under general anesthesia. Usually up to 6
eggs are placed back. The GIFT procedure takes appropriately 60 to 90 minutes.
Any extra eggs obtained during the retrieval can be fertilized in the laboratory
and frozen for future use.
- Zygote Intra-fallopian Transfer (ZIFT)
ZIFT, which stands for Zygote Intra-Fallopian Transfer, is the already
fertilized egg or zygote as in IVF, but transferred back into the fallopian tube
instead of the uterus. ZIFT is basically the same concept as GIFT in the
transfer location of the fallopian tube and in the fertilization of the egg in
the laboratory as in IVF. It was developed to prove fertilization prior to
transferring back to the fallopian tube. ZIFT requires the same protocol of
fertility medications causing ovary stimulation & monitoring as described in
GIFT.
- Frozen Embryo Thaw (FET) Cycle
For individuals who undergo IVF and have additional viable embryos after
transfer, freezing these embryos increases their opportunity to achieve one or
more pregnancies as a result of a single egg retrieval procedure. Usually about
75% of the frozen embryos survive the thawing process, but it will vary
depending on when the embryos are frozen.
In the treatment month, a
mid-cycle ultrasound is performed to confirm adequate follicle and uterine
lining growth. The patient monitors herself for ovulation at home using a home
ovulation predictor kit purchased from a pharmacy. When the kit is positive the
patient takes a HCG injection and the transfer is performed a few days later. Or
the cycle may be assisted by administration of exogenous hormones (e.g.
estrogen/progesterone) at specific doses and times to build the endometrial
lining in the uterus prior to timed transfer of the frozen embryo/s.
- Pre-implantation Genetic Diagnosis (PGD)
Pre-implantation genetic diagnosis (PGD) is a technology used in conjunction
with IVF and includes testing embryos for single gene defects (like cystic fibrosis) or for common chromosome abnormalities
(pre-implantation genetic screening or PGS). This type of embryo screening has been shown to be effective in preventing genetic diseases and may improve
IVF outcomes although its efficacy for that has yet to be definitely proven.
- Fluorescence in Situ Hybridization (FISH)
FISH is a technique used to detect and localize the presence or absence of
specific DNA sequences on chromosomes. FISH is commonly used in prenatal diagnosis and has been used for aneuploidy screening.
- Array Comparative Genomic Hybridization (aCGH)
Array Comparative Genomic Hybridization (aCGH) is a technique used to evaluate
and screen all 23 chromosome pairs of a human embryo cell for abnormalities. In
contrast, pre-implantation genetic screening using the FISH technique has only allowed for the evaluation of 9 to 12
chromosomes.
- In-vitro Maturation (IVM)
In-vitro Maturation is the technique of helping immature eggs (oocytes) to mature in the laboratory in order to use them for IVF.