15 percent of the population is considered infertile. Infertility is described as not having a baby after 6 months of unprotected intercourse.
Infertility is increasing in modern communities. In men declines in sperm count due to toxic environment and possible evolutionary effects is noted. Also women due to educational and career concerns are married at a later age. Average menopausal age ranges between 48 and 52 in women. We now know that, several years before the menopause women are unable to bear children due to the diminished ovarian function.
Historically, the menopausal age did not change and the chance of having a baby is very slim as the female approaches menopause. Therefore we recommend that all women especially with the family history of early menopause should have a baby at an earlier age. All the infertility treatments and even IVF cannot be successful if women’s ovarian function is diminished.
How do we approach the infertile couple?
We first evaluate the male partner. Two or three sperm counts one month apart are ordered and evaluated. WHO (World Health Organization) and Krugers` criteria is used to analyze the sperm parameters. If the sperm count is abnormal, hormonal tests and ultrasound of the testes is performed. This way, hormonal and vascular problems may be detected. In male infertility however, medical and surgical therapies are getting less and less popular due to high failure rates.
Therefore for male infertility, currently artificial insemination or IVF/ICSI is recommended, depending on sperm count results.
For women, we order FSH, LH, E2, PRL, and TSH levels on the third day of the period. If these are normal, ovulations are monitored with ultrasound. If there is an ovulation problem it is treated by oral medications or hormonal injections, monitored by ultrasound. If the ovulation is normal, then Hysterosalpingography ( X-ray of the uterus and tubes) is performed to rule out the tubal blockage. If there is a problem with the tubes, laparoscopic correction is tried in certain cases. However, in recent years due to highly successful IVF/ICSI results, tubal surgery is performed less often.
In some couples no cause is found. This is called as unexplained infertility. In this group, firstly 3 to 6 months of ovulation induction treatment is given. If this is unsuccessful, artificial insemination is used for 3 to 6 months as well. If all these fail, then IVF/ICSI should be performed
In general, below age 40 with normal hormones of the female, classical treatments are successful in almost 70 percent of the cases. IVF/ICSI would be the answer if the classical treatments are unsuccessful, the sperm count is very low, and both tubes are blocked.
The age of woman is a serious factor. If the age is over 40, the chance of getting pregnant is lessened, so the classical non-IVF treatments should be given for a short time only. Therefore IVF/ICSI is used earlier and more often.
In 1978, the first test tube baby Louisa Brown is born in London. This revolutionized the infertility technology. Millions of IVF babies have been born and procedure is getting more and more popular.
In normal conditions, women produce an egg and this egg is captured by the Fallopian Tube. Egg travels in the tube and meets the sperm. Fertilization occurs in the tube and 2-3 days later, the fertilized egg (zygote) enters the uterine (womb) cavity. Under natural circumstances, this zygote implants in the endometrium (lining of the womb) and the chance of pregnancy is 20% only. For some reason, these events cannot occur in infertile couples.
IVF/ICSI procedure mimics these natural events. Women are received hormonal injections to increase their number of available eggs. The eggs are monitored closely by ultrasound. When they reach to 18-20 mm in size, they are triggered by HCG injection to complete maturity which happens after 36 hours. At this time patients are taken to the operation room and under sedation anesthesia eggs are retrieved by ultrasound guided follicle puncture.
Meanwhile, male partner gives sperm. Sperm is evaluated and most mobile and normal part is taken to be used for the IVF/ICSI procedure.
In normal IVF procedure, eggs are placed in a Petri dish and inoculated with 100.000 sperm per egg. Mixture is placed in incubators and following day eggs are checked for fertilization. In normal circumstances with a good sperm count approximately 70/80 percent of the eggs are fertilized. The eggs continue to divide and two days after the egg recovery they achieve 4 cell stage. On the third day, embryos reach 8 cell stage. Same day, healthiest three embryos are taken and placed in the women’s uterus by plastic catheter. In our center all the embryo transfers are performed under careful ultrasound guidance in which uterus is seen easily, and embryos are transferred exactly 2cm below the top of the cavity. This is gives the best pregnancy chance. Pregnancy test is performed 12 days later.
ICSI procedure ( Intracytoplasmic sperm injection)
In IVF procedure sperm and egg are placed in the same dish and fertilization of the eggs by the sperm is expected. However, if the sperm count is extremely low or the sperm is mostly abnormal, fertilization cannot occur. Even with the normal sperm sometimes fertilization cannot happen for some unknown reason. In ICSI procedure single sperm is taken and injected into the egg by means of micro needles which guarantees the fertilization.
ICSI procedures are getting more and more popular, because it does not take a chance of “sperm not fertilizing the egg”. In our clinic, ICSI is used routinely and therefore the pregnancy rates are increased. Unlike other clinics in the western world, there is no surcharge for ICSI at IVF Cyprus Clinic.
Sometimes no sperm is found due to congenital absence of connecting tubes between the testes and the penis. In this situation, sperm can be found by testicular biopsy. This is called TESE procedure. Sperm achieved this way can also be used for ICSI.
How do we increase the pregnancy rates?
In order to increase the success rates, certain procedures are performed as necessary. For example, some embryos have a thick outer layer which prevents the embryos to attach the lining of the womb. To solve this problem, the laser is used to thin out the outer layer. This is called the Assisted Hatching. Also in some cases, the embryos are transferred not 3 but 5 days after the egg recovery to select best embryos. 5th day embryo is called blastocyst and this procedure is called blastocyst transfer.
In multiple IVF/ICSI failures, one reason maybe chromosomally abnormal embryos. For this reason PGD (preimplantation genetic diagnosis) is performed. With this technique one cell from the 4 cell embryo is taken carefully and examined for chromosome analysis. Embryos, which have normal chromosomes are then selected, and transferred to the woman’s uterus the following day.
In some IVF/ICSI cycles several embryos are produced and three of them are given, remaining good quality Donor embryos are frozen for the future use. Embryo freezing is a well developed technique today that allows women to have another chance of pregnancy. Embryo freezing is much cheaper than regular cycle because no medication is used and no anesthesia is required. Embryos are frozen for several years and can also be used in the future if the couple desires another child or if the first cycle is unsuccessful.