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Services - Detailed Descriptions
Intrauterine insemination (IUI)
Intrauterine insemination
[PDF] with washed sperm is an effective and economical treatment for infertility. It is not recommended for patients with infertility due to blocked or absent Fallopian tubes or severe male factor infertility.
Semen is processed to remove the seminal plasma (the liquid portion of the semen), cellular debris, and bacteria and to separate the moving from the non-motile sperm. The resultant sample contains the most vigorous and healthy sperm.
The sample is then loaded into a thin plastic tube or catheter. A nurse or physician passes the catheter through the cervix and into the uterine cavity. The sperm are then deposited in the uterus and the catheter removed.
Insemination with donor sperm.
Frozen donor sperm can be purchased from
commercial cryobanks and shipped to our laboratory in
Washington, D.C. for storage. The
cryobanks provide
catalogs of donors from which patients can make
their choices based on a number of characteristics
(eye color, hair color, height, weight, complexion,
etc). The donors are thoroughly screened for genetic
diseases and familial disorders and all frozen sperm
samples must be quarantined for at least six months
to allow for testing or the donor for infectious
diseases.
In Vitro Fertilization (IVF)
In vitro fertilization was first developed as a treatment for infertility due to blocked Fallopian tubes, but is now used to treat many different problems. To maximize chances of achieving a pregnancy, ovarian stimulation is used to produce many follicles (each containing an egg). During a normal, unstimulated cycle, only a single follicle develops and one egg is ovulated. Growth and development of follicles are monitored very carefully during a stimulated cycle. When the follicles (and eggs) are mature, a hormone known as human chorionic gonadotropin (hCG) is given and egg retrieval is scheduled 34-36 hours later. Egg retrieval is usually performed under light anesthesia and using ultrasound guidance, but under certain circumstances, may require laparoscopy. The follicular contents are aspirated and handed to a laboratory technologist who then looks for eggs. The eggs are placed in dishes containing culture medium and incubated in a chamber maintained at body temperature. Shortly after the eggs have been retrieved, the male partner produces a semen sample. The semen is processed to isolate the most vigorous sperm to inseminate the eggs.
The day after retrieval and insemination, the eggs are examined for fertilization. Normal fertilization is indicated by the presence of two pronuclei. One pronucleus contains the genetic material from the mother and the other from the father. The fertilized eggs are examined every day until embryo transfer. Embryos can be transferred 2 to 6 days after egg retrieval and may be from the 2- to 4-cell (2-3 days after retrieval) stages of development to blastocyst (5-6 days after retrieval).
Embryo transfer is usually a simple procedure that does not require anesthesia. Embryos are loaded into a catheter (a thin plastic tube) and catheter is gently passed through the cervix into the uterus. Ultrasound is commonly used to confirm that the catheter tip is in the proper position in the uterine cavity. Embryos that have not been transferred can be frozen and stored for use in the future.
Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic sperm injection was developed to treat severe male factor infertility, but has since been used successfully after fertilization has failed in previous IVF cycles and to overcome some egg defects. The procedures for ICSI are same as for standard IVF except for the method of insemination.
After eggs are retrieved, the surrounding cumulus cells are removed. Using a microscope and very fine needles, each mature egg is injected with a single sperm. Injected eggs are cultured for approximately 18 hours and examined for fertilization. Normal fertilization is indicated by the presence of two pronuclei, as in standard IVF. Each pronucleus contains the genetic material from one of the parents. After examination for fertilization, embryos are cultured for a further 24-48 hours and transferred to the uterus. Embryos resulting from ICSI can be frozen and stored for return at a later data.
Concerns about ICSI.
Although ICSI has been shown to be an effective treatment for male factor infertility and has resulted in fertilization where standard IVF has failed, ICSI is still a relatively new technology [although it is no longer considered to be "experimental" by the
American Society for Reproductive Medicine (ASRM)].
The rapid acceptance of ICSI as a routine practice without clinical trials has raised major concerns about the outcomes of the procedures, especially the outcomes of resulting pregnancies and the health of the children born from the technology. A recent report on the follow-up of 1987 children on the basis of data from genetic counseling, prenatal diagnosis, neonatal data, congenital malformations, growth parameters and developmental milestones (Human Reproduction, Vol. 14, (Suppl.1) pp. 243-264, 1999) indicates that the malformation rate in children born after ICSI does not differ from that of children in the general population. However, there is evidence that there is a higher incidence of chromosomal aberrations in men with fertility problems and that these problems can be passed on to male offspring.
The use of Epididymal (PESA) and Testicular (TESE) Sperm for ICSI
The treatment of male infertility has made incredible advances in the last few years. Men previously thought to be hopelessly infertile can now become fathers with the help of micromanipulation.
Percutaneous epididymal sperm aspiration (PESA) is particularly useful in men with obstruction of the vas deferens (the tube through which sperm passes from the testicle to the urethra). Pregnancy rates using epididymal sperm and conventional IVF techniques have resulted in relatively low success rates per attempt due to low fertilization rates. However, when ICSI is utilized, the pregnancy rates are equal to those in IVF in the absence of a male factor problem.
Testicular sperm exaction (TESE) has recently been used with ICSI to achieve good pregnancy rates when
PESA is not feasible.
As with any new technology, there are concerns. Some men with severe male factor infertility have been shown to have chromosomal aberrations that are responsible for their infertility. These defects can be inherited by male offspring who may suffer from the same fertility problems as the father. Congenital absence of the vas deferens has been found to be associated with mutations of the cystic fibrosis (CF) gene. Men with congenital absence of the vas deferens should be screened for CF gene mutations and if mutations are found it is important that the female partner be evaluated for her CF status to assess the risk of transmission of the disease to children born from the reproductive technologies. The long-term consequences of any of the new assisted reproductive technologies are unknown.
Micromanipulation-Assisted Hatching
The egg and early embryo are surrounded by a protective "shell" know as the zona pellucida. Before the embryo can implant in the uterine wall it must escape or "hatch" from the zona. Some embryos have zonae that are thick and/or hard and become trapped within their shell. Micromanipulation-assisted hatching was developed to overcome these problems. A small hole is made in the zona pellucida and as the embryo grows, it squeezes through the hole and implants in the uterine wall.
Micromanipulation-assisted hatching doesn't help everyone, but
may be helpful for women 40 years or older, women with elevated basal FSH levels, women who respond poorly to ovarian stimulation, patients with a history of implantation failure, or for embryos with thickened zona pellucidae.
Embryo Freezing (Cryopreservation)
Embryos not used for transfer can be frozen for transfer at a later date. Embryos can be frozen at the pronucleate stage, 2- to 4-cell stages, 8-cell stage, and blastocyst. Embryos are cryopreserved using a cryoprotectant substance. The cryoprotectant acts like an anti-freeze to preserve the embryos at very low temperature. Embryos are thawed by returning them to warmer temperatures and by removing the cryoprotectant. Embryos can then be transferred to the uterus in the same way as "fresh" embryos.
One advantage of cryopreservation is that embryos not used for transfer during an assisted reproductive technology cycle can be stored for future use in a cycle without ovarian stimulation. Cryopreservation maximizes the chance of achieving a pregnancy from a single cycle. Cryopreservation may also lower the cost of infertility treatment because the ovulation induction, egg retrieval, insemination, and embryo culture are not required when frozen embryos are used.
Blastocyst Transfer
Within 24 hours after fertilization, embryos begin to cleave, from 1 to 2 cells and then to 4. In the next 24 hours embryos cleave again to 8 cells. When they reach 32 to 64 cells they become blastocysts. At this stage of development, for the first time, different parts of the embryo are visible. A thin layer of cells encircles a fluid-filled cavity. A small group of cells known as the inner cell mass eventually develops into the fetus itself.
Culture systems capable of supporting blastocyst growth were first developed in Europe. In many European countries, IVF clinics are required, by law, to transfer no more than 2 embryos during each IVF cycle in an effort to limit high-order multiple pregnancies (greater than twins). However, at the 2- to 8-cells stages it is often quite difficult to determine which embryos are most likely to result in a pregnancy. Since many embryos are incapable of developing to blastocysts the ability to culture embryos for a few more days makes the task far easier.
We only recommend blastocyst culture to those patients who respond well to ovarian simulation, have many eggs, good fertilization rates, and many good quality early stage embryos. These patients are most likely to have embryos capable of surviving in culture and developing to blastocysts. They are also at risk of having a high-order multiple pregnancies if more than 2 embryos are transferred.
Patients, who do not respond well to stimulation, have poor quality eggs, and/or less than good quality embryos may not benefit from extended culture. Blastocyst culture is not a solution for poor ovarian function or poor egg and embryo quality.
Donor Egg Program
Our Donor Egg Program offers an alternative to women with infertility due to ovarian failure. The eggs from carefully selected and screened donors are fertilized with the sperm from the recipient's partner. The embryos are then transferred to the uterus of the recipient. Women who are carriers of genetic disorders, women who have undergone surgery to remove the ovaries, radiation, chemotherapy, and patients who cannot become pregnant after IVF due to poor quality eggs and embryos may also consider the use of donor eggs.
Columbia Fertility Associates work with local and national agencies that recruit egg donors. Some egg donors are friends or family members and are known to the recipients.
Host Uterus
Some women produce eggs and embryos, but are
unable to become pregnant or carry a pregnancy to
term. These women include those who have had a
hysterectomy, have a uterus that does not function
properly, women who have repeated miscarriages, or
who are in danger of becoming seriously ill should
they become pregnant. Although Columbia
Fertility Associates do not recruit women for the Host Uterus Program, we do work with other agencies that provide the service and with patients who have friends or family members willing to carry a pregnancy for them.
Pre-Implantation Genetic Diagnosis (PGD))
Pre-Implantation genetic diagnosis is a relatively new technology that is used to test embryos for severe genetic disorders (including, but not limited to sickle cell anemia, hemophilia, cystic fibrosis and Tay-Sachs), aneuploidy (abnormal numbers of chromosomes), and translocation (chromosomal rearrangements). To use PGD, conception must occur using IVF or ICSI. Women must take medications that stimulate the ovaries to produce many eggs. Sperm are then added to the eggs in the laboratory. Eggs that fertilize grow and develop into embryos. A single cell is then removed from each embryo. The cells are then sent to a highly specialized genetic testing laboratory for diagnosis.
Columbia Fertility Associates collaborate with
Genzyme. Once testing has been completed, the results are sent back to the doctors at
Columbia Fertility Associates. Only unaffected embryos are selected and transferred to the women's uterus.
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Columbia Fertility Associates
Comprehensive Fertility Work-up
