Reprosys Fertility Center provides solutions to those in need to identify and treat infertility problems. Through our services we wish to explore the female and male reasons of fertility problems, to provide customized treatment, to reduce hardship and eventually to achieve child blessing. Our activities can be characterized with a holistic approach, with the joint application of medical and natural therapeutic techniques.
Infertility testing and treatment
According to a WHO recommendation it is advisable to consult a specialist if after 12 months of regular unprotected (without contraception) sexual intercourse - after 6 months in case of females over the age of 35 - the intended pregnancy is not achieved. Lack of success is caused by reasons due to the female in 30% of the cases, by the male in 30% and by both in another 30% of cases. In the remaining almost 10% of cases failure occurs despite of the fact, that no justifiable reasons are found in neither one of the couple. This latter category is referred to as infertility of unknown cause. In this regard, one must differentiate between infertility and sterility. Sterility, absolute reproductive inability is when either one of the couple has such a definitive, permanent cause, due to which conception/achievement of pregnancy is impossible. Certain developmental defects, conditions produced by surgical interventions, high degree loss or total absence and disorder of gametes. Infertility is when less or moderately severe causes make the achievement of pregnancy difficult, or when achieved pregnancy repeatedly miscarries at an early stage of the pregnancy.
Since infertility primarily involves the couple as a whole, in the course of assessment both of them need to be examined. In the following the adequate testing of the couple and treatment possibilities are listed. It must be noted, that overall examination is performed with the involvement of an andrologist specialist. On a minimum level ovarian activity, semen production, anatomical conditions (uterus, Fallopian tube), and follicle maturation. Further tests may be indicated as necessary. Several techniques are available for a single purpose, and in such cases it is practical to chose the one, which is the least burden to the patient. Following proper work up the simplest possible, productive and personalized therapeutic procedure should be sought for the couple. Basically in vivo and in vitro possibilities are available. All in vivo procedures support the achievement of pregnancy, but insemination and early embryo development occurs in the Fallopian tube. A characteristic of in vitro procedures is that fertilization happens outside the body, and then the embryo or embryos are transferred to the uterus.
Causes of Female Infertility
Female Fertility Testing Protocol
Male Fertility Testing Protocol
Available Assisted Reproductive Technologies (ART)
Most Commonly Applied Assisted Reproductive Technologies (ART)
In case during the examination of the couple no problems are revealed, which would prevent the achievement of pregnancy (so-called infertility of unknown cause), the time of the egg split can be determined more accurately in the natural or medicinal stimulated cycle. In a natural cycle, without medicinal treatment to enhance egg maturation, and in a stimulated cycle, after the taking of medication to stimulate egg maturation, from an ultrasound test carried out on given days of the cycle the egg split is monitored, and when the adequate egg size is achieved, the time of optimal sexual intercourse is determined for the couple after the administration of an injection to "enhance" the egg split. Afterwards, the medicinal supporting of progesterone activity is also possible.
In the case of minor fertility disorders of the male (low degree of semen insufficiency, or decreased ratio of sperm motility), if the female Fallopian tube is unobstructed, then homologous intrauterine insemination is the available solution. This means the artificial transfer of sperms to the uterine. If the sperm of the partner is not fertile, heterologous intrauterine insemination is possible with a donor's sperm. In this case the Fallopian tube must be unobstructed. If heterologous insemination is chosen, both of the couple must agree with and give their consent to the procedure. This requires the signing of a legal document. With the use of follicles developing in the natural, non-stimulated cycle of the female, or in order to avoid multiple pregnancies, mild hormonal stimulation is applied in order to promote a low number of follicle (1-3) development. Follicle development and recovery of the endometrium is verified through ultrasound tests. Based on follicle size, the thickness of the endometrium, and ovulation tests, the time of the egg split can be determined within the cycle. The process is also induced through medication when a given follicle size is reached, thus the optimal time of insemination can be specified. For the insemination process, the sperm obtained through masturbation undergoes special laboratory preparation. Then it is transferred into the uterine through the cervix using a flexible plastic tube. During the procedure normally no complications, no pain or uncomfortable feeling occurs. With the reduction of the path sperms need to take, and with the use of prepared, selected sperms, there is a greater chance for the fertilization of the egg. The probability of successful conception with this method is approximately 15% with this method.
Should in vivo treatments turn out unsuccessful, or in cases when such techniques are not considered to be useful (just to mention the two most common reasons: due to the blockage, or acquired absence of the Fallopian tubes, or due to a severe reproductive inability, so-called oligo-astheno-teratozoospermia [OAT syndrome] of the male partner), in vitro fertilization - embryo transfer are applied. In the course of the procedure, with a rare exception, when normal cycle IVF is applied, the female receives a combined medication and injection pre-treatment to induce ovulation, a so-called controlled ovarian hyperstimulation, so that more mature eggs are generated through the process. Continuously following follicle development through ultrasound and hormone tests, eggs are extracted at an optimal time under short-term anesthesia with the help of ultrasound monitoring, by follicle puncture and suction through the vagina. Under laboratory conditions, and with the application of fertilization enhancing micromanipulation procedures (ICSI, Assisted Hatching), as required, several human embryos can be created from these eggs. During embryo transfer, the most suitable looking one or two embryos are implanted. Embryo transfer through the cervical canal of the uterus does not require anesthesia. After the procedure and 1-2 hours of relaxation the female may leave the treatment center. A blood test is performed 12-14 days after the transfer in order to verify, whether the procedure was successful. The chance of achieving pregnancy with the IVF procedure is approximately 30-40% per cycle, which depends on the age of the couple, on their hormonal conditions, other existing diseases (e.g. diabetes, hypertension), and lifestyle (being overweight, stress, nicotine dependency, increased alcohol consumption, etc.).
Cryopreservation means the freezing of cells to -193 degrees Celsius in liquid nitrogen. With the help of this special procedure, the longer term storage of embryos and sperms is possible in a frozen state. Embryo cryopreservation: If during the IVF or ICSI treatment several eggs are retrieved and fertilized, unused embryos can be frozen. Cryopreservation is only useful in the case of embryos, which are found suitable in terms of quality, as these have a survival rate of 70% after defrosting. An advantage of embryo cryopreservation is that patients may have another chance to achieve pregnancy without hormonal stimulation and follicle puncture. Through the monitoring of the cycle, or within a drug-controlled cycle, follicle maturation and recovery of the endometrium are followed. Frozen embryo transfer can only be planned from the time of the - expected or drug-induced - egg split. Defrosted and normally developing embryos are transferred into the uterus through the ora using a plastic tube. Progesterone support is launched from the time of the egg split, in order to prepare the endometrium for attachment of the embryo. Achievement of pregnancy can be verified two weeks after the egg split by measuring the beta-hCG pregnancy hormone level, or with a rapid test (from urine). The chance of conception with the frozen embryo transfer procedure is approximately 25-30%, depending on the age, hormonal conditions, existing diseases and lifestyle of the patients. Sperm cryopreservation: Should the male partner be unable to give sperm at the time of the actual treatment due to medical or other reasons, the prior freezing of sperms is possible. These can be defrosted and used for fertilization when required. Patients with an indication of aggressive therapy due to cancer, are normally informed about possible solutions to maintain fertility. Radiation and/or chemotherapy treatments can lead to reproductory disturbance, in which case the cryopreservation of sperm prior to such treatment makes future parenthood possible. Testicular tissue cryopreservation: In case the ejaculate does not contain sperms (azoospermia), through testicular puncture, or by surgical testicular biopsy, tissue samples can be extracted, which can be examined for sperm cells under a microscope. If sperm suitable for fertilization is found in the tissue samples, these can be frozen and used later for insemination with the ICSI procedure.
The process of in vitro fertilization
With only a few exceptions, the IVF procedure is applied following the hormonal stimulation of the ovary.
The objective is to achieve the maturation of several follicles in both ovaries simultaneously, so that the most possible fertile eggs can be retrieved.
With a preliminary down regulation, i.e. the shutting down of pituitary-ovarian hormones, the organism is "tuned" to the subsequent stimulation. This can be achieved with the oral administration of a contraceptive drug, by daily subcutaneous injections, or with a nasal spray. An advantage of this preliminary inhibiting treatment is that the stimulation phase can be better controlled externally.
In the subsequent stimulation phase, for the stimulation of ovary activity FSH (follicle stimulating hormone) and LH (luteinizing hormone) are applied either in pure or combined form. During hormone treatment, a specific dose (depending on weight and age) of these hormones is administered on a daily basis, around the same time of the day, by means of subcutaneous injections.
The administration of these drugs is explained, and demonstrated to the patient in detail until the time of starting the treatment, so that the patient or her partner can learn the procedure and need not visit the physician on a daily basis.
With frequent follow-up through ultrasound tests, or with hormone tests from blood, as necessary, the number of follicles and recovery of the endometrium is monitored. When follicles develop to the required size, egg split is induced surgically by the administration of the hCG (human Choriongonadotropin) hormone. Thus, after the administration of the injection, just before the egg split, the retrieval of eggs can be performed.
36 hours after the administration of the injection to induce egg split, follicles are punctured with a specially developed needle with the help of ultrasound monitoring, and the follicle fluid containing the egg is extracted. Searching under a microscope, cells are removed from the follicle fluid and placed into a similar medium containing special nutrients. The eggs are incubated for 3-5 days at 37 degrees Celsius, under a proper carbon-dioxide, nitrogen and oxygen gaseous medium.
The follicle puncture process normally lasts for 5-15 minutes, depending on the number of follicles. Puncture is performed on an outpatient basis, under short-term anesthesia in order to facilitate the intervention. Afterwards, only a couple of hours of observation is required in the relaxation room. Then the patient can leave the center.
Sperm is collected by means of masturbation after 3-5 days of abstinence, on the same day, when eggs are extracted. This can be difficult to perform on order and in an unfamiliar environment, the sperm sample can also be brought from home, provided that the sample is submitted strictly within no more, than two hours after ejaculation.
If the ejaculate does not contain sperm (azoospermia), the following solutions are available: Extraction of sperm suitable for insemination can be attempted surgically by means of percutaneous epididymal sperm aspiration [PESA], or through testicular biopsy [MESA, TESE].
MESA (microsurgical epididymal sperm aspiration): The procedure involves the retrieval of sperm from the epididymis using a thin tube. The resulting amount is usually insufficient, therefore a direct tissue ablation from the testis (TESE) is also required.
TESE (testicular sperm extraction): The procedure involves the extraction of tissue directly from the testis, either by means of puncture (through skin), or open testicular biopsy (following the surgical excavation of the testis). Several samples are collected in general, from which mature sperms are explored under a microscope and the ones appearing to be the most fertile are collected.
With such a – usually – low number of sperm cells, or preliminary cell formations, the egg can be inseminated only through the ICSI procedure.
If the above mentioned sperm extraction techniques turn out unsuccessful, high quality donor sperm is also available for insemination.
Eggs are inseminated also on the same day of extraction. Initially, the eggs and prepared sperm cells are placed into separate laboratory glass dishes. Fertilization then happens naturally, without intervention.
In case of a low sperm count, reduced sperm motility, high ratio of irregularly formed sperm cells, or after repeated (at least tow) unsuccessful IVF treatments, it is very likely, that natural fertilization is impossible, and the application of microinjection (ICSI, IntraCytoplasmic Sperm Injection) may be necessary. The chance of achieving pregnancy through ICSI is nearly similar to that of natural IVF. During the process, the egg is positioned using a micropipette under a specially developed microscope, then a single sperm cell appearing to be suitable is injected into the egg through a 7 micron diameter glass micropipette. Subsequently, the egg starts to develop the same way as in the case of natural fertilization.
PICSI ("preselected" ICSI): There is a special sensor, receptor in the head of mature sperm cell for the identification of hyaluronic acid. Immature sperm cells lack this receptor. Hyaluronic acid is a primary constituent of the egg membrane, thus the mature sperm cells with the receptor are more able to attach to the egg cell also under natural conditions. According to studies, a significantly higher percentage of such better-attaching, mature sperm cells are free of DNA defects. During the PICSI procedure, sperm cells are selected with the application of hyaluronic acid, to separate better quality, mature ones from the ones that are useless. These can then be selected for the ICSI procedure under a microscope based on appearance. As a result, the chance of successful fertilization is also higher.
No matter which fertilization technique is applied, the number of eggs actually showing the signs of fertilization (two pronuclei and four polar bodies) is verified.
2-5 days after fertilization 2-3 embryos are transferred into the uterus through a thin plastic tube with the help of ultrasound monitoring. Among others, the day of the transfer depends on the number of fertilized eggs. In case only a few (1-4 eggs) were fertilized, transfer is performed 2-3 days after puncture, at the 4-8 cell stage of embryo development. During this time embryos development is monitored and evaluated on a daily basis based on specific criteria, such as the rate and regularity of cell division. The best quality embryos are selected for the actual transfer.
In case 5 or more eggs were fertilized, implantation is performed on the 5th day after fertilization by means of the so-called blastocyst transfer procedure. If an excessive number of suitable quality embryos are available, the cryopreservation of these is possible (by freezing in liquid nitrogen).
The transfer of embryos into the uterus only requires a couple of minutes and is generally painless. Finally, patients are advised to relax for 20-30 minutes after the intervention in the relaxation rooms.
The egg and the embryo is surrounded by a strong membrane called the zona pellucida. When the embryo reaches the blastocyte stage of development it must break out from this membrane in order to attach to the endometrium. In some cases this membrane is too strong or too thick, making attachment impossible. As a solution, the zona pellucida layer is thinned using laser technology or mechanically by a micropipette in order to assist the hatching of the embryo.
In terms of hormones by the retrieval of eggs, the second phase of the cycle, the progesterone phase is started. During this phase progesterone hormone production is supported through medication in order to help prepare the lining of the uterus (endometrium) for the embryo to stick or implant. Required medication can be administered in various ways, including intramuscular injections, subcutaneous injections, tablets, or in the form of vaginal suppositories.
Achieved pregnancy can be verified 2 weeks after fertilization by hCG hormone detection from blood or urine.
In case pregnancy is verified, support of the luteal phase is continued up to the 12th week of the pregnancy.