Infertility. Family planning. Curation of the patient. Defense of the female history.
Prepared by Korda I.
Marriage is considered to be sterile, if during 1 year of regular sexual life without using of contraceptives, pregnancy does not occur. Infertility happens in 10-12% of all marriages. it is subdivided into male, female and mixed. About 45% of sterile marriages are connected with male infertility, 55% of them with female infertility.
Absolute infertility, when there are such changes in organism, at which pregnancy is absolutely impossible (absence of uterus, ovaries), and relative, infertility when sterility is caused by some factors, that can be removed are distinguished. Primary infertility (when a woman has never had pregnancy) and secondary infertility (if there was pregnancy in the past) are distinguished also.
For finding out infertility cause, couple examination is necessary. Usually examination begins with husbands because of considerable simplicity.
Physiology of male reproductive system
A hypothalamic-pituitary-testicles system in men is a permanently functioning closed loop system providing biological reliability of reproductive function, producing few millions of spermatozoa daily. Mature male sexual cells consist of head, neck and tail portion. A head has an ovoid shape 4,5 micrometers long, 2,5 micrometers in width, that contains a big nucleus. A tale provides active cell mobility in woman’s genital tract. spermatozoa receive energy, necessary for motion by endogenous and exogenous substrates’ metabolism. Mechanism of motive spermatozoa function is extraordinarily complicated, each oscillation is an enzyme-ionic-motive complex. The sperm flagellar axonema is structurally and chemically complicated organelle, which is capable to generate undulate waves from ATP hydrolysis energy.
Spermatozoa motility changing takes place in-parallel with acquiring of fertilizing properties — capacitation. This process begins still in epidydymus, where immature spermatozoa acquire qualitatively new characteristics and turn into mature, mobile forms, and accomplishes in woman’s genital ways, where sperm gets after ejaculation.
Sperm characteristics. The sperm samples agglomerate after 2-3-day up keep from sexual life. For spermogram it is necessary to analyze sperm not later than in 1-1,5 hours after ejaculation. It is received either by means of masturbation, or during the interrupted sexual act. Men agglomerate it into clean dry vessel and supply into laboratory.
Volume of ejaculate in healthy men is from 2 to 5 ml. General amount of spermatozoa must compose not less than 50 mln. The lowest norm border is 20´106. The sperm which contains not less then 50% of spermatozoa and has a good movabitity is considered to be normal. Spermatozoa motion must be forward, in one direction. Spermatozoa with oscillatory or circle motions refer to infertile or low-fertile ones.
Pathological changes can be manifested in irregular form and dimensions of head or tail.
Azoospermy (absence of spermatozoa), necrospermy (dead spermatozoa), oligospermy (decreasing of spermatozoa amount), theratozoospermy (dominance of pathologically altered spermatozoa forms), can be found at sperm research.
Causes of male infertility are violation of spermatogenesis as an outcome of carried inflammatory process, traumas, infectious diseases in childhood (especially epidemic parotitis), urinary-genital infections in manifestation of orchitis and epidydymitis (gonorrhea), cryptorchism, varicocele, and also intoxication with alcohol and chemical agents.
Frequently infertility is a result of ionizing radiation action, electromagnetic radiation, high temperature. Herpes simplex virus and Chlamydia infection are of a great importance in development of infertility. At these infections sperm can carry infection into female genital organs. Infertility happens also at exhausting liver, kidneys, lungs diseases, endocrine pathology (diabetes mellitus, Kushing illness).
Sometimes infertility appears as a result woman’s sensibilization to the men’s sperm.
In case, when there are changes in spermogram, a man is directed to sexopathologist or andrologist.
If all spermogram indexes are normal, examination of the woman should be started.
Evaluation of the male partner
The male partner must submit a semen sample for a comprehensive semen analysis. Previous paternity does not guarantee that his reproductive system has not been affected since the birth of his offspring. The comprehensive semen analysis must be performed in a certified andrology laboratory, and the semen sample, preferably, should be collected at the same andrology laboratory that will conduct the test. However, if the sample must be collected at home, it must be collected in a sterile plastic container and delivered to the andrology laboratory at body temperature not later than 30 minutes after ejaculation.
Some patients cannot produce a semen sample through masturbation. Therefore, the sample can be collected through intercourse, using a special nonspermicidal condom provided by the andrology laboratory. To optimize results, the semen sample should be collected after a period of 3 days but no more than 5 days of sexual abstinence.
The basic semen analysis assesses the characteristics of sperm concentration, motility, morphology, and viability. The World Health Organization's semen analysis parameters (with the variable and the corresponding reference range) are as follows (World Health Organization, 1992):
Volume - 2-5 mL
pH - 7.2-7.8
Sperm concentration - 20 million or greater
Motility - 50%, forward progression
Morphology - Normal sperm (50% or greater)
White blood cells - Fewer than 1 million cells/mL
Morphology has become an important parameter to evaluate the quality of the sperm and to assess the fertilization capability. Kruger reported a new classification based on strict sperm morphology after fixing and staining the sperm (Kruger, 1986). Using the Kruger criteria, sperm morphology must be greater than 14% to be considered normal. Morphology of less than 4% is associated with severe infertility and is an indication for ART/ICSI.
Specific biochemistry analyses relevant to the accessory sex gland functions can be performed using the semen sample. These include fructose from the seminal vesicles, zinc and acid phosphatase from the prostate gland, and alpha-glucosidases and carnitine from the epididymis (Zeneveld, 1990).
Sperm agglutination indirectly indicates the presence of sperm antibodies. The immunobead test can be performed either directly on the sperm or indirectly on the sperm and blood. Surface antibodies against immunoglobulin A (IgA) or immunoglobulin G (IgG) may be present. The antibodies can be specific for the head or for the tail of the sperm (Clarke, 1985; Clarke, 1988; Barratt, 1992). IgA sperm antibodies interfere with the sperm-oocyte interaction and account for a lack of fertilization, whereas IgG sperm antibodies are more responsible for decreasing sperm motility. Sperm antibodies are associated with infection (ie, orchitis), testicular trauma, and a history of vasectomy.
Interpretation of semen analysis
Spermatogenesis takes approximately 72 days. Abnormal semen analysis results can be attributed to various unknown reasons (eg, short period of sexual abstinence, incomplete collection, poor sexual stimulus); therefore, repeating the semen analysis at least 1 month later is important before a diagnosis is made. Explaining to the patient the normal fluctuation that can occur between semen samples is also important. Avoid a hasty diagnosis that may create unnecessary anxiety for the couple.
Azoospermia indicates absence of sperm that could be related to congenital absence or bilateral obstruction of the vas deferens or ejaculatory ducts, history of spermatogenesis arrest, Sertoli cell syndrome, or postvasectomy.
Oligozoospermia indicates a concentration of fewer than 20 million sperm/mL and could be associated with ejaculatory dysfunction such as retrograde ejaculation.
Asthenozoospermia indicates sperm motility of less than 50%. Extreme temperatures and delayed analysis after sperm collection are among the factors that decrease sperm motility.
Teratospermia indicates an increased number of abnormal sperm morphology at the head, neck, or tail level.
Hypospermia indicates a decrease of semen volume to less than 2 mL per ejaculation.
Hyperspermia indicates an increase of sperm volume to more than 8 mL per ejaculation.
Sperm function tests
After ART, a proliferation of different sperm tests have been developed to evaluate and predict the sperm fecundability, including (1) the acrosome reaction test with fluorescent lectins or antibodies, (2) computer assessment of the sperm head, (3) computer motility assessment, (4) hemizona-binding assay, (5) hamster penetration test, and (6) human sperm-zona penetration assay (Margalioth, 1986; Franken and Burkman, 1989; Franken and Oehninger, 1989; Oehninger, 1989). Numerous publications describe the positive and negative aspects of these tests. The tests are diagnostic tools, and the results are subject to many variations in their interpretation, which render them of more academic interest than of practical therapeutic value.
Basic causes of infertility in women are:
l disorders of ovogenesis and absence of ovulations — 35-40%
l tubal factors 20-30%
l diseases of genitals — 15-25%
l immunological causes — 2%
Diagnosis of female infertility is based into careful history taking (age, profession, influence of harmful factors of production, carried diseases, harmful habits). Tactfully learning of the psycho-sexual life conditions, genital function, meaning that primary infertility is frequently a result of infantilism, and secondary one is a result of carried inflammatory processes.
In objective examination attention is paid to body building, expressiveness of secondary sexual signs, presence or absence of infantilism. Carefully examination of internal organs, and in necessity — function of incretion glands should be performed.
During gynecological examination an attention is paid to hairiness on pubis, external genital organs’ abnormalities, state of Bartholin’s glands. Examination of vagina (its width, vaults depth), form and size of uterine cervix, presence of erosive ectropion is indicated. Uterine size, position, consistence, form, movability and correlation between cervix and uterus dimensions is examined also.
Most frequently the causes of female infertility are endocrine diseases, which are associated with ovogenesis and ovulation disorders. Patients with different forms of hyperprolactinaemia, hyperandrogeny, with polycystic ovarian syndrome, postpuberty form of adrenogenital syndrome and with other forms of endocrine disorders suffer from infertility.
Considerable number of infertility cases is a result of endocrine ovarian dysfunction, and these violations can be both primary and secondary with carried inflammation. Anovulation or retardation of follicle maturing with defective luteal phase appear as a result of dysfunction of cyclic processes in ovaries.
Endocrine infertility happens also at dysfunction of hypothalamic-pituitary system. The irregular menstrual cycle in the form of amenorrhea, hypomenstrual syndrome and uterine bleeding is attached to infertility of endocrine origin.
Examination of patients should include:
l tests of functional diagnostics: measuring of basal temperature (BT) during 3-6 months for estimation of ovulation presence and duration of luteal phase; “pupil” and “fern” symptoms estimation, tension of cervical mucus, taking smears on «hormonal mirror»
l determination and estimation of hormones level in blood
l biopsy of endometrium with determination of full value of secretion phase
l sonography follicle growth control and endometrial thickness during menstrual cycle
Treatment is in regulation of menstrual cycle, correction of basic disease manifestations, that caused endocrine infertility, and in stimulating of ovulation. Ovulation can be stimulated by prescription of Clomiphene citrate in the dose 50 mg from 5th till 9th cycle day, by Pergonal in combination with chorionic Gonadotropin.
Tubal and peritoneal infertility
The adhesions process in small pelvis causes the bend of the tube with preserving of their patency. This is the reason of peritoneal infertility. Tube infertility is conditioned by anatomic and functional disorders in uterine tubes.
Occlusion of uterine tubes happens as a rule after gonorrheal salpingitis, however it can be a result of nonspecific inflammatory process. Inflammatory processes can be a cause of not only uterine tubes’ impassability, but also by dystrophic changes in their walls, violation of peristalsis. abortions also play a great role in etiology of infertility, because they bring on inflammatory processes in uterine mucous membrane with the following dystrophic changes that interfere with implantation.
Finally, salpingoovophoritis can cause ovulation disturbance, and if it takes place, then the adhesions process doesn’t give a possibility for ovum to get into tube. Ordinary ovarian endocrine dysfunction can usually happen.
Diagnosis of tube infertility is held by means of hysterosalpingography, hydrotubation or pertubation. It is better to make hysterosalpingography with water soluble roentgen-contrast solutions (Kardiotrust, Urographyn, Verographyn, Trioblast). This method gives a possibility to estimate the capacity of uterine tubes (fig. 104, 105).
The state of uterine tubes can also be estimated during the contrasting sonography, that is made by introduction of a contrasting substance Echovist into uterine cavity under ultrasonic control.
4 degrees of uterine tubes occlusion are distinguished. They are:
l complete permeability of uterine tubes: a solution from syringe passes into uterus easily and after removing of a cervical tip it does not return back
l tubes are impassable in isthmic department: one solution portion (up to
2 ml) passes more or less easily, and then during the introduction a barrier is felt. During decreasing of piston’s pressure, liquid goes back into syringe. The liquid outpours from uterus after removing of the tip from the uterus
l tubes are impassable in ampullar region: reflux appears at the end of insertion (more than 4-5 ml of liquid)
l tubes are partially passable: a liquid slowly goes into uterine cavity, slightly expressed and quickly passing reflux is observed at lowering of pressure on piston
Sometimes dye-stuffs are used. For example, Speck’s test with 0,06% solution of Phenolsulfophtalein is common. At permeability of uterine tubes this dye-stuff appears in urine in 40-60 minutes. After addition to it several drops of 10% NaOH solution it is coloured into red colour. Aburell’s test is performed by analogy (with 0,3 % solution of Indigocarmine, which tinctures urine into green).
As a rule, diagnosis of permeability is made in the stationary during the first phase of menstrual cycle, on condition that there are no inflammation signs and the first degree of vagina purity is present.
Laparoscopy with the use of chromosalpingography with Methyl blue is also of a great importance. This method allows to estimate the tubal permeability and to find the occlusion place.
Infertility caused by uterine
and cervical factors
Infertility can be caused by the state of uterine mucous membrane, when endometrium undergoes dystrophic changes that interfere with implantation process and cause uterine form of amenorrhea in the result of carried inflammatory processes, repeated curretages of uterine cavity and action of cauterizing chemical substances.
Diagnosis is ought to be made in such directions:
l one should ascertain ovarian function in case of irregular menseses by tests of functional diagnostics
l to make hormonal tests with progesterone, combined with gestagen-estrogen preparations. they are negative due to uterine amenorrhea
l to make hysterography, hysteroscopy for exposure of synechias in uterine cavity
l to control by sonography the endometrial thickness once or twice during the menstrual cycle
l to make the biopsy of endometrium
l to hold the sperm contact test with cervical mucus
Infertility can happen as a result of uterine cervix inflammation — endocervicitis. This is an outcome of cervical canal epithelial structural changes, viscidity and acidity of cervical mucus, that causes the violation of capacitation processes, interferes with penetration of spermatozoa into uterine cavity.
In order to exclude influence of vaginal and uterine cervix secrets on sperm Shuvarsky-Khurner’s test is made. This test is made during the day of expectative ovulation. Before this test one should refrain from sexual intercourse for 3-4 days. In examination day after sexual intercourse the contents of posterior vault is put on object plate and examined under the microscope; the mobile spermatozoa within eyeshot are quantifying. The test is considered to be positive at the presence of 5 active spermatozoa within eyeshot. the test should be repeated 1-2 times more in case negative reaction.
Treatment of infertility
A choice of treatment method depends on infertility cause. Inflammatory process as the infertility cause must be treated. Physiotherapy methods (diathermy, ozokerite therapy, mud cure, magnet therapy, laser therapy), biostimulators, contrainflammatory remedies are widely used.
In case of uterine tubes impassability treatment is made by method of hydrotubation — introduction into uterus and tubes medical mixtures, that include antibiotics, enzymes, korticosteroids.
It is recommended to take three courses of treatment (6 hydrotubations every other day), interruption between courses is 1 month. After the third course of hydrotubations a control of uterine tubes’ permeability is recommended. If tubes are passable, it is recommend to prevent from pregnancy for 5-6 months, making during this time additional course of hydrotubation and mud care.
In treatment of tube infertility in case of poor efficiency from conservative therapy surgical methods are used: salpingolysis — release of tubes from adhesions and renewing of their abdominal parts’ passability (fig. 106); salpingostomatoplasty — formation of the hole at abdominal part of a tube (fig. 107); salpingoanastomosis — suturing the tube together “end in end” (fig. 108), ovarian implantation into the tube or uterus, tubal implantation into uterus.
In case of infertility because of synechias presence in uterus their destruction is made under hysteroscopy control with the following prescribing of contrainflammatory resorption therapy and hormonal preparations during 2-3 menstrual cycles for renewing of menstrual function.
In case, when infertility is associated with underdevelopment of genital organs replacement therapy, physiotherapy procedures (mainly thermal ones — ozokerite, mud cure), gynecological massage in combination with hormonal therapy is prescribed. Hormonal therapy is obligatory administrated according to the phase of menstrual cycle. Estrogen-gestagen preparations, ovulation stimulators — Clomiphen citrate, Puregol, Pregnil are used.
Prophylaxis of infertility is the prevention of diseases, that lead to it: infectious diseases in childhood and in the period of pubescence, inflammatory processes in adult women.
An important role in infertility prophylaxis belongs to the doctors of female dyspencery, which are to propagandize the contemporary methods of contraception, that will give a possibility to prevent abortions.
While making sanitary-educational work one should pay a special attention to the question of hygiene of sexual life, to the harm of abortion, especially during the first pregnancy.
The immunological form of infertility, which is caused by formation of antispermal antibodies (LsLb) in the man’s or woman’s organism happens relatively rarely. Its frequency is 2 % among all infertility forms. In 20-25% of couples with uncertain infertility ethiology the antibodies to sperm are found at further examination.
antispermal antibodies are generated in men, than in women more frequently. Mainly this is a result of barrier break between male reproductive tract and immune system. The cause of this can be vasectomy, damage of testicles at orchitis, traumas, infections of reproductive tract.
Antispermal antibodies influence on such reproduction links as: spermatogenesis, transport of sperm, gamete interaction. Antibodies (IgG) that are connected with spermatozoon head, disturb the fertilization process. Antibodies (IgA) attached to the flagellar axonema in the tail part of spermatozoon, influence on cells’ mobility.
In women the formation of gumoral tissue antibodies and spermatozoa phagocytosis are the basic reactions of antisperm immunity. Immunity-competent cells phagocyte sperm and then use taken information for recognition of antigens. The formation of antibodies takes place in uterine cervix most actively, more rarely — in endometrium and tubes. Uterine cervix is the main link of local immunity in female reproductive system. IgA are generated in uterine cervix. Their concentration change during menstrual cycle and decrease in the period of ovulation.
Antibodies to antisperm antigens have precipitating, agglutinating, immobilizing properties. there is a sperm contact test with cervical mucous as a screening-test .
The intrauterine insemination is the most effective method in case of this form of infertility. A mechanical method of contraception during 6 months using condoms for removal of sperm contact with female genitals is recommended. It is necessary to examine a couple for latent infection, because infectious agents contribute to formation of antisperm antibodies.
In majority of women with infertility various violations of psychoemotional sphere such as: feeling of inferiority, loneliness, strained waiting of next menses and hysterical states connected with its beginning appear. A complex of these symptoms composes the so-called «pregnancy expecting syndrome».
Indexes of psychological tests, that characterize a degree of personal qualities instability, fear, confidence in oneself, expressence of psychological reactions on environment, in families, that do not have children are considerably raised. In sterile women a high degree of neurotizing is observed. in men there is the tendency to oppression, violation of behavior reactions. Frequently there happens deviation from normal scheme of sexual conduct, violations of erection and ejaculation.
A great stress for a couple is examination necessity and later on the execution of doctor’s recommendations concerning the rhythm of sexual life, specifically determination of ovulation period of wife according to the tests of functional diagnosis and advice to use for conception exactly a certain time. Sometimes insistent demand of a wife to have sexual intercourse namely in the certain period can cause functional impotency in husband and appearing of fear before sexual act and other potency disorders. diagnosis of azoospermy or other pathology of sperm can influences unfavorably on man’s potency state. Such news cause impotence in more than in half of men, and frequency of its beginning depends on wife’s reaction. Likely, such disorders when absence of organic changes are temporal and afterwards potency renews spontaneously or under the psychotherapy influence.
For women the necessity of sexual life according to results of functional diagnostics tests is also a stress situation, upon which not only psyche, but organs of sexual tract, specifically uterine tubes react. Their spasm (antiperistalsis) can occur. It disturbs gametes transport even on condition that the tubes are passable. That’s why sometimes woman’s fervent desire to become pregnant becomes her enemy. There are described many cases, in which long-waited pregnancy came after woman has decided to stop cure, to cancel measuring of basal temperature and waiting attantively for the time of expectative ovulation.The same thing has happened, when a pair, loosing a hope for own descendants, adopts a child.
Causes and types of psychological disturbances of persons in sterile marriage are various, that’s why doctor’s experience, patience, tact during taking history are necessary to define personality character, peculiarities of matrimonial relations and psychosexual reactions. Interpretation of analyses results and also choosing of examination and treatment methods demand a special caution, specifically, for the newest reproductive technologies — extracorporal fertilization, insemination with donor sperm etc.
Question about application of additional reproductive technologies is decided by skilled competent specialist on request of couple after corresponding inspection. It includes determination of blood type, rhesus-factor, HIV, Wassermann reaction, HBs antigen, bacterioscopy of vaginal smear, diagnostics of gonorrhea, toxoplasmosis, trichomoniasis, ureaplasmosis, gardnerelosis, micoplasmosis, making tests of functional diagnostics for characteristics of menstrual cycle, ultrasonic examination of uterus and ovaries, hysterosalpingography, for indications — laparoscopy, double study of men’s (donor) sperm and other necessary examinations. At presence of some anomalies in reproductive function of couple and at presence of indications for using additional reproductive technology a correspondent treatment is indicated.
Generally, all the contemporary methods of additional reproductive technologies are based in vitro fertilization biotechnology. insemination with man’s (donor) sperm — instrumental sperm introduction into internal woman’s genitals is widespread.
Female indications for using of this method are:
l anomalies of reproductive organs (old perineum ruptures, which cause sperm effluence outside just after sexual intercourse, ankylosive damage of hip joint, different pelvis bone deformations, in the result of which sexual intercourse can not take place, anatomic vaginal or uterine anomalies in case of congenital pathology or acquired stenoses)
l severe forms of vaginism
l immunological and cervical factors
l infertility of uncertain etiology
l sexual dysfunctions of different ethiology
l large sizes of hydrocele or inguinal-scrotal hernia, that makes sexual intercourse impossible
l ejaculation praecox; retrograde ejaculation
l expressed hypospady, some forms of oligoastenospermy, azoospermy, aspermy
l unfavorable medical-genetic prognosis for having children
Presence of inflammatory, neoplastic and hyperplastic processes in uterus and its adnexa, somatic and mental diseases, impassability of uterine tubes, women’s age after 40 years are contra-indications for using insemination by donor’s sperm.
Insemination is made during one menstrual cycle in periovulatory period. For women with normal menstrual function and full value ovulation one insemination is sufficient. However, 2-3 procedures in case when there are some problems connected with establishment of exact time of ovulation are made. In this case due to the long functional spermatozoa ability (72 hours) fertilization probability is increased.
vaginal, cervical, uterine and peritoneal methods of insemination are distinguished depending on sperm introduction way. intrauterine insemination is considered to have the highest effectiveness. It provides introduction of specially processed sperm by catheter into uterine cavity. pressing on syringe piston the sperm gradually is introduced during 2-3 min. An extremely fast sperm hit on uterine mucous membrane can cause its reflectory contraction, that is followed by pain or expulsion of contents from uterus into vagina.
Attached to intraperitoneal insemination specially processed sperm is introduced by means of the posterior vault punction into cul-de-sac. a test on peritoneal spermatozoa migration is made as a rule, before insemination. This test is considered to be positive at preserving of spermatozoa motility in peritoneal liquid in vitro.
For sperm indexes improving, before insemination ejaculate is fractionated, motile forms are separated by filtration, several ejaculates by cryoconserving are accumulated and some medications (Callicreine, Dextrose, Arginin, Caffeine or prostaglandins) are added.
Method of insemination requires the functionally full value uterine tubes and ovulation in woman. So, before the procedure there must be provided a qualitative diagnostics of reproductive sphere state, normalization of menstrual cycle, medicinal stimulation of ovulation and preparation of endometrium for perception of impregnated ovum. For this reason hormonal, clinical and ultrasonic monitoring are used. The concentration of gonadotropic hormones, progesterone, estradiol in blood is determined. Accessible and sufficiently informative are the tests of functional diagnostics and menocyclogram charts.
Using of ultrasonic diagnostics allows to speak not only about passability of uterine tubes, growth and development of follicles, but also about quality and full value of the ovum. Transvaginal sonography enables to get clear image of ovaries and to realize a follicle growth monitoring even in those patients, which have had operations on organs of small pelvis, and also in those, which have exessive body weight.
The program of extracorporal fertilization with transferring of embryo into uterus (in vitro fertilization — IVF) is recommended in those cases, when conservative methods have failed. Absolute indication to application of this method is tube infertility due to severe dysfunction or absence of uterine tubes. Relative indications are previous plastic operations on tubes (woman’s age is less than 30 years, time interval after operation is not more than one year), ineffectual salpingolysis (ovarylysis) in women aged 35 years, some forms of endometriosis and polycystic ovarian syndrome, infertility of unknown genesis, immunological infertility in women with constant high titre of antisperm antibodies during one year, some forms of male infertility.
The method of extracorporal fertilization with transfer of embryo into mother’s uterus includes few stages:
l selection and preparation of patients to program
l stimulating of superovulation
l follicle growth and maturing monitoring with their following punction and aspiration
l spermatozoa preparation
l fertilization in vitro, cultivation (cryoconserving)
l transplantation of an embryo into uterus
l pregnancy development control
In practice a superovulation stimulating is employed. This is caused by the fact, that in natural menstrual cycle the chance of simultaneous maturing of several ovums composes 5-10%, while in stimulated cycles chance of two and more follicles development can reach 35-60 %. With aim of superovulation stimulating Clomifene citrate or its analogues in combination with chorionic gonadotropin is used. Chorionic gonadotropin is used in all schemes of superovulation stimulation. It is introduced in case of enlarging of dominant follicle diameter up to 18-20 mm. In 35-36 hours after introduction ovocytes are aspirated from the follicle together with follicle liquid. For this purpose laparoscopy is indicated, during which a mature follicle is punctured with the needle, creating negative pressure of 120-200 mm Hg. Recently the method of transvaginal access to follicles during ultrasonic scanning becomes wide-spread.
Received follicular liquid is studied under the microscope for exposure of follicular-ovocyte complexes in it. At their presence the material is washed by special environment, that removes a larger half of follicular liquid. Considerable attention is paid to sperm preparation stage. Its main aim is in spermatozoa capacitating, because this moment during extracorporal fertilization is absent.
For fertilization a spermatozoa suspension is put into the environment, which contains 1-3 ovocytes in 1 ml. Incubation duration is 16-20 hours. Received embryos are cultivated at temperature 37°С in atmosphere containing 5% СO2, 5% O2 and 90% N2 in environment with pH = 7,3.
A fertilization fact is determined to the presence of pronucleus in ovocyte’s ovoplasm and a second polar body in periviteline space.
Transfer of embryo into uterus is made on the 3-4th day from fertilization moment, that should correspond to the stage of 8 or 16 cells. For this reason a special catheter is used, with the help of which an embryo with some cultural environment is conducted to uterine fundus through cervical canal.
For guaranteeing of long adequate function of yellow body in the day of embryo transfer and in 4 days after this the woman additionally gets 5000 units of Chorionic gonadotropin. For women with severe pathology of ovaries (for example, early or physiological menopause), donation of ovocytes is recommended. In that case embryo, which is developed in the result of fertilization of woman-donor’s ovum by husband-recipient sperm, is put into uterine cavity of his wife, who carries a child.
In recent years a method of gametes’ implantation into cavity of uterine tube is successfully used, which is a variant of additional reproductive technologies. ovocytes are received, a suspension of enriched sperm is added to them and inserted during laparoscopy with special probe into one or two uterine tubes from mature follicles on background of ovulation stimulating.
In this case both fertilization of ovum taken from the follicle and elementary stages of embryo dividing take place in uterine tube, that is in natural conditions, not in incubation ones.
The newest achievement of contemporary reproductology is intracytoplasmatic injection of one spermatozoon (intracytoplasmatic injection sperm ISCI). This program allows to become pregnant in those cases of male infertility, which were considered to be hopeless before. A spermatozoon is inserted into the selected ovum. Embryo, being got by such method is transfered into uterine cavity.
Program of surrogate maternity include the women, which because of pathology of reproductive sphere can not be pregnant with a child (uterus is absent because of operative intervention or can’t function). Genetically native embryo is transfered into uterine cavity of a woman, who has given a consent to carry a child.
A consultation with the infertile couple once the evaluation has been completed is imperative. Outline a treatment plan according to the diagnosis, duration of infertility, and the woman's age. If pregnancy has not been established within a reasonable time, consider further evaluation or a different treatment plan. In many instances, patients are not well advised; therefore, their expectations are unrealistic, and the lack of success exacerbates their anxiety and frustration levels.
Medical treatment is directed toward suppressing estrogen production by the ovary. Different modalities of treatment are available. Depending on the therapeutic agent and the duration of treatment, endometriosis can be treated with oral contraceptives, progestins, androgens, or GnRH agonists.
The progestins that can be used and the doses are as follows:
Medroxyprogesterone acetate (eg, Provera 40-60 mg PO qd, Depo-Provera 200 mg IM q2wk)
Megestrol acetate (eg, Megace 20-40 mg PO qd)
Norethindrone acetate (eg, Aygestin 15 mg PO qd) (Johnston, 1976; Hasson, 1979; Hull, 1987; Keye, 1987; Telimaa, 1987; Olive, 1989)
The androgens used are 17-ethinyl testosterone derivatives (eg, Danazol 400-800 mg PO qd) (Dickey, 1984; Henzl, 1988; Bayer, 1989)
The GnRH agonists used are as follows:
Leuprolide acetate (eg, Lupron 3.75 mg IM q4wk or 11.25 mg IM every 3 mo)
Nafarelin acetate (eg, Synarel 400 mcg IN qd)
Goserelin acetate (eg, Zoladex 3.6 mg SC q4wk or 10.8 mg SC every 3 mo)
GnRHa therapy can be administered along with cyclic or continuous progestins or with cyclic or continuous estrogen and progestins in cases of severe hot flashes (Henzl, 1988; Olive, 1989).
Medical and surgical treatments are usually combined for the treatment of severe endometriosis. No consensus exists as to whether the medical treatment should precede surgery or vice versa (Wheeler, 1981; Ronnberg, 1984; Buttram, 1985). Those who prefer medical treatment first argue that the size of the endometriosis decreases; therefore, surgery will be easier and shorter. Those who prefer surgery first argue that because the size of endometriosis decreases, lesions that cannot be observed during surgery may be present; therefore, the operation is less than ideal and is associated with an increased chance for early recurrence.
Regardless of the treatment approach, establish a 6- to 12-month interval during which a spontaneous pregnancy is expected to occur. Otherwise, a second-look laparoscopy is indicated for further evaluation of recurrent endometriosis and to exclude any other infertility factor.
A more proactive approach now exists. Ovulation induction and IUI are used after completion of the treatment in hopes of expediting the establishment of a pregnancy before relapse of the disease (Chaffkin, 1991; Dodson, 1991; Fedele and Bianchi, Fertil Steril, 1992).
Treatment of ovarian factors
Ovulation induction is the treatment for infertile patients who still have oocytes within the ovaries but in whom a dysfunction of the hypothalamic-pituitary-ovarian axis exists. The ovulation induction agents used include CC, hMG, hCG, recombinant FSH, and recombinant LH.
Clomiphene citrate (Clomid, Serophene)
The chemical formula for CC is 2-[p-(2-chloro-1,2-difhenylvinyl) phenoxy] triethylamine dihydrogen citrate. CC is a nonsteroidal estrogen capable of interacting with estrogen receptor–binding proteins in a manner similar to estrogen but in a more prolonged way (Clark, 1974; Clark 1981). Therefore, CC behaves similar to an antiestrogen.
CC has been in clinical use since the early 1960s. Its mechanism of action is still not well understood, but it competes for the estrogen receptor at the hypothalamus, pituitary, and ovarian levels. Because of the action at the estrogen-receptor level within the hypothalamus, CC alleviates the negative feedback effect exerted by endogenous estrogens (Tobias, 1981; Adashi, 1984; Kokia, 1990). As a result, CC normalizes the GnRH release; therefore, the secretion of FSH and LH is capable of normalized follicular recruitment, selection, and development to reestablish the normal process of ovulation (Tobias, 1981; Miyake, 1983).
The standard dose of CC is 50 mg PO qd for 5 days, starting on the fifth menstrual cycle day or after progestin-induced bleeding. As an antiestrogen, CC requires that the patient have some circulating estrogen levels; otherwise, the patient will not respond to the treatment. The CC response is monitored using pelvic ultrasonography starting on the 12th menstrual cycle day. The follicle should develop to a diameter of 23-24 mm before a spontaneous LH surge occurs.
BBT can be used to observe the thermogenic shift (temperature rises 0.5°F above the basal level) induced by the early secretion of progesterone. The only disadvantage with BBT is that in many instances, the shift does not occur in a clear way, and the patient misses the time of ovulation. While BBT is an inexpensive way to monitor ovulation, it is often impractical.
Urinary monitoring of the LH surge (eg, with an LH Predictor Kit) can be a substitute for BBT. The patient should start monitoring the urinary LH secretion daily starting on the 12th menstrual cycle day. Ovulation usually occurs within the 32-40 hours after the indicative color change. Serum LH determination is more precise, especially when performed in combination with pelvic ultrasonography. A postovulatory ultrasonography should be performed during the first CC cycle to exclude the presence of LUF syndrome.
Because of the antiestrogenic effect, CC may desiccate the cervical mucus, creating an iatrogenic cervical factor that can be responsible for the lack of pregnancy in a patient who has otherwise ovulated (Shirai, 1972). Therefore, a PCT must be performed during the first CC cycle and every time the doses of CC are increased. Other adverse effects associated with CC are hot flashes, scotomas, dryness of the vagina, headache, and ovarian hyperstimulation, which, although rare, has been reported in patients who are sensitive to CC (Southam, 1962; Scommegna, 1969). Whether the use of CC increases the risk of ovarian cancer is unknown, although 2 articles illustrate a potential risk (Rossing, 1994). Other authorities disagree with this assumption.
The principal indications for CC use are in patients with oligomenorrhea, especially PCOD, and for patients with slight menstrual irregularities. CC is indicated in the treatment of patients with LPD due to small-size follicle development (van Hall, 1969; Garcia, 1977). Its use has been extended to ART.
The use of CC is contraindicated in cases of ovarian cyst, pregnancy, and liver disease. Its use is controversial in patients with a history of breast cancer.
Human menopause gonadotropins
Crowe discovered that the gonads were under the control of the anterior hypophysis (Crowe, 1966). Zondek and Aschheim discovered that FSH and LH were responsible for the development of the gonads in immature animals and confirmed Crowe's work (Mettler, 1979; Daniel, 1984; Schlaff, 1991). In the 1930s, ovulation induction was attempted by using gonadotropins from a mare, but its use was discontinued because of the development of antibodies (Cole, 1930; Leethem, 1948).
Borth et al demonstrated the effect of FSH and LH extracted from menopausal urine (Borth, Experientia, 1954; Borth, Human Pituitary Gonadotropins, 1961). Gemzell reported the first ovulation induction using human pituitary gonadotropin in 1958, and the first pregnancy was reported in 1960 (Gemzell 1958; Gemzell, 1960). Lunenfeld reported preliminary results using hMG; however, in 1963, it was definitely established as a real ovulation induction agent (Lunenfeld, 1963; Domini, 1964; Spadoni, 1974).
hMG (Repronex) contains 75 U of FSH and 75 U of LH per mL, although the concentration may vary among batches (ranges from FSH at 60-90 U and LH at 60-120 U). In the 1980s, a pure form of FSH became available. Bravelle contains 75 U of FSH. The new generations of available gonadotropins are produced by genetically engineered mammalian cells (ie, Chinese hamster ovary cells), in which the gene coding for the alpha and beta FSH subunits has been inserted (Gonal F and Follistim) (Devroey, 1992). Recombinant LH is currently undergoing clinical trials.
The administration of hMG and its derivatives should be under the direct supervision of a reproductive endocrinologist. An ultrasonography unit and an endocrine laboratory capable of performing daily determinations of E2, FSH, and LH are necessary (Cabau, 1981; Garcia, 1983; Hackeloer, 1984; Lequin, 1986).
Multiple adverse effects and complications may occur during the use of the gonadotropins, to include (1) multiple pregnancy (24-33%); (2) ectopic pregnancy (5-8%); (3) miscarriages (15-21%); (4) ovarian torsion and rupture; and (5) ovarian hyperstimulation syndrome (OHSS), which is the most severe (Schenker, 1979; Brown, 1986). Whittemore et al, using a large combined data set derived from case-controlled studies in the United States, showed that the increase of ovarian cancer associated with infertility might be due to the use of fertility drugs (Whittemore, 1992).
OHSS is an iatrogenic condition that occurs in patients undergoing ovulation induction with hMG or controlled ovarian hyperstimulation (COH) for ART. The incidence rate fluctuates from 0.1-2%. The pathophysiology of the disease is not well understood, but a massive extravascular accumulation of fluid occurs that is associated with a severe depletion of the intravascular volume responsible for dehydration, hemoconcentration, and electrolyte imbalance (ie, hyponatremia, hyperkalemia) (Tollan, 1990). OHSS can be mild, moderate, or severe (Golan, 1989).
Mild OHSS is characterized by ovarian enlargement (up to 5 cm in diameter), minimal ascites, and weight gain of less than 10 lb. Moderate OHSS is characterized by ovarian enlargement (5-12 cm in diameter) moderate ascites, nausea, vomiting, abdominal discomfort, and weight gain greater than 10 lb. Severe OHSS is characterized by easily palpable ovaries, severe ascites, nausea, vomiting, diarrhea, shortness of breath, hydrothorax, peripheral edema, oliguria, hemoconcentration (eg, hematocrit level >48% and hemoglobin level >16 g), and creatinine level greater 1.6 mg/dL. Renal failure and thrombosis can occur if the patient is not treated correctly (Whelan, 2000).
Some patients have a greater risk of developing OHSS. They usually are young patients with a history of oligo-ovulation who responded with elevated E2 levels (3000 pc/mL) and multiple follicles (>15) and patients in whom the ovulation has been triggered by the administration of exogenous hCG (Navot, 1988; Asch 1991).
OHSS usually has 2 phases. The first phase develops between the second and seventh day after ovulation, and the second phase only occurs if the patient becomes pregnant. The first phase is self-limited, and the symptoms subside by the end of the luteal phase and by the beginning of the next menstruation (Lyons, 1994).
Patients with mild and moderate OHSS are treated at home with bedrest and strict control of fluid intake and output. If weight gain greater than 2 lb occurs, evaluate the patient to determine if hospitalization is required.
Patients with severe OHSS must be hospitalized and confined to bed, with strict control of fluid intake and output. Intravenous fluids (ie, isotonic sodium chloride solution) must be administered until hemodilution is achieved; at this point, diuresis must be forced with intravenous furosemide. If the urinary output remains low, albumin 25% (50 mL/h IV for 4 h) has been effective in promoting diuresis. Perform abdominal paracentesis if the patient becomes uncomfortable. Thoracentesis is indicated in cases of pleural effusion. Because of the risk of thrombosis, heparin (5000 U SC q12h) is recommended (Whelan, 2000).
hMG and its derivatives are indicated for ovulation induction in patients with primary amenorrhea due to hypopituitarism and in patients with secondary amenorrhea who did not respond to CC ovulation induction. For the past 20 years, hMG and its derivatives have been the first choice for COH in ART.
Synthetic GnRH (eg, Factrel, Gonadorelin, Lutrepulse) has a chemical composition similar to native GnRH and is indicated for patients with hypothalamic dysfunction, especially those who do not respond to CC (Zacur, 1985; Schriock, 1986). This drug is administered in a pulsatile fashion every 60-120 minutes, intravenously or subcutaneously using a delivery pump. The starting dose is 5 mcg per pulse intravenously or 5-25 mcg subcutaneously. The administration on GnRH should be extended throughout the luteal phase, or this should be supplemented with the administration of exogenous hCG (Homburg, 1989).
Monitoring folliculogenesis is simpler than using hMG. Because OHSS does not occur, the patient's response is slow. In most cases, only one follicle is recruited and develops until ovulation. A urinary LH kit is a practical way to monitor these patients. Pelvic ultrasonography can be used once a week until the dominant follicle is detected; once this occurs, ultrasonography can be used more frequently until ovulation occurs. Determination of serum E2 and LH levels can also be performed (Hopkins, 1989).
Treatment of primary amenorrhea
hMG is the treatment of choice for patients with primary amenorrhea due to hypopituitarism. Generally, their response to hMG ovulation induction is too brisk or delayed, and no way exists to predict whether the patient will respond easily. The risk of OHSS and multiple pregnancy is heightened; therefore, hMG should be started at the minimal dose (75 IU SC qd for 7 d). On the seventh day, E2 measurement and ultrasonography are performed. If the E2 level is below 100 pc/mL and the sonogram shows small follicular development, hMG is increased to 150 IU/d for an additional 5 days. However, if the E2 level is greater than 100 pc/mL and the follicles are 10 mm in diameter, hMG should be continued at the same dose. Once the follicular diameter reaches 18 mm and the E2 level is below 2000 pc/mL, ovulation is triggered by the administration of hCG (10,000 IU IM).
The ideal response is one in which only 2-3 follicles develop. If the response is exaggerated, with more than 5 sizable follicles (18 mm in diameter), and the E2 level is greater than 2500 pc/mL, cancelling the ovulation is better in order to avoid the risk of OHSS and a high order of multiple pregnancy. In current practice, an alternative for patients with more than 5 sizable follicles is to convert the treatment to IVF.
Treatment of secondary amenorrhea and oligo-ovulation
Once the diagnosis is established and any other endocrinopathy has been excluded, the ovulation induction agent of choice depends on the estrogen levels of the patient. In hypoestrogenic patients (ie, E2 <20 pc/mL), the treatment of choice is hMG, and the protocol is similar to that for patients with primary amenorrhea. If the E2 levels are higher than 20 pc/mL, CC is the drug of choice, as previously described.
PCOD is the most frequent indication for ovulation induction. CC is the drug of choice. Restrict the treatment to 4 ovulatory cycles because 85% of patients conceive by the fourth ovulatory cycle (Garcia, 1977). If pregnancy is not achieved, further evaluation is required to exclude other factors that may be associated with infertility and may interfere with the success of CC therapy. If ovulation does not occur with the 50-mg dose, the CC dose must be increased in subsequent cycles to 100 mg for 5 days. If ovulation still does not occur, modify the CC regimen to 50 mg for 10 days. Although the total CC dose is the same, the follicular stimulation is different. The maximum recommended dosage is 150 mg/d for 5 days. CC failure may indicate either lack of ovulation or lack of pregnancy.
Lack of ovulation
Patients with anovulation who did not ovulate after several cycles of CC at different doses of treatment are deemed clomiphene-resistant. This situation can be related to the presence of other endocrine disorders such as hyperprolactinemia, congenital adrenal hyperplasia, adrenal tumors, Cushing syndrome, thyroid dysfunction, and extreme obesity. Therefore, this problem must be corrected first or concomitantly to obtain an ovulatory response. Although obesity is well known to be associated with insulin resistance, women with PCOD are even more resistant to insulin than other obese patients.
A subgroup of patients has PCOD with hyperinsulinism, hyperandrogenism associated with acanthosis nigricans, and resistance to CC (Stuart, 1986; Dunaif, 1989). This group is amenable to metformin treatment (Nestler, 1998; Kolodziejczyk, 2000). Metformin improves insulin sensitivity and decreases hepatic gluconeogenesis and, therefore, reduces hyperinsulinism, basal and stimulated LH levels, and free testosterone concentration. Consequently, the patient with PCOD becomes responsive to CC ovulation induction.
Adverse effects of metformin include GI intolerance, nausea, vomiting, and abdominal cramps. Weight loss has also been observed. Therefore, patients must build up tolerance. The initial dose is 500 mg PO qd for 7 days, then 500 mg bid for another 7 days, and, finally, 500 mg tid. Start CC at the initial dose of 50 mg/d for 5 days. In many instances, patients can ovulate while on metformin treatment. Therefore, pelvic ultrasonography is required before CC is initiated (Nestler, 1998).
Pure FSH treatment for ovulation induction is another alternative for patients with PCOD who are clomiphene-resistant. Start pure FSH at 37.5 IU/d SC. The dosage is increased by 37.5 IU every 5 days until follicle development is detectable based on an elevation of the E2 levels and the presence of follicle development on sonograms. Using this small amount of FSH, the patient generally develops 1-2 follicles, decreasing the risk for multiple pregnancy and eliminating the risk of OHSS
The first successful human IVF attempt resulted in the 1978 delivery of Louise Brown in England and is considered the beginning of a new era for the treatment of infertility (Steptoe, 1978).
Since 1981, the understanding of the ovulatory process has been revolutionized, hopelessly infertile patients have seen their dreams fulfilled, and success has shown that patients who were considered sterile in the past are now capable of having children.
IVF indications have departed from the narrow scope of tubal infertility to other indications that were almost impossible to overcome, including infertility related to oligospermia and obstructive azoospermia.
In vitro fertilization
IVF consists of retrieving a preovulatory oocyte from the ovary and fertilizing it with sperm in the laboratory, with subsequent embryo transfer (replacement) within the endometrial cavity. Biologists and veterinarians have used IVF for several decades in the laboratory for applications such as animal husbandry and cattle breeding. Lack of understanding of human embryo development and special metabolic needs accounted for the delay in achieving success. The pioneering work of Edwards and Steptoe has been duplicated worldwide, and IVF is now recognized as an established treatment for infertility.
Absence of the fallopian tubes and severe pelvic adhesions were the absolute indications for IVF, but they have been broadened. Patients with a history of endometriosis unsuccessfully treated medically or surgically can undergo IVF. Patients with some malformation of the uterus related to DES exposure during pregnancy are candidates. Patients with husbands who have severe oligospermia or a history of obstructive azoospermia are also candidates for IVF. Finally, patients with an unknown etiology of infertility (ie, NICs) may undergo IVF.
IVF consists of retrieving a preovulatory oocyte from the ovary and fertilizing it with sperm in the laboratory, with subsequent embryo transfer (replacement) within the endometrial cavity. The following steps are required during an IVF cycle:
Ovarian stimulation for IVF
Although the world's first IVF pregnancy, which occurred in England, followed the fertilization of a single oocyte obtained during a spontaneous menstrual cycle, IVF success is related to the patient's age and the number of embryos transferred into the endometrial cavity, among other factors (Garcia, 1981; Romeu, 1987; Murdock, 1988). The number of embryos obtained in any given IVF cycle depends on the number of oocytes obtained after ovulation induction, follicular aspiration, and fertilization.
Several protocols are available for ovarian stimulation, and all are based on the principles of follicular recruitment, selection, and dominance.
Today, CC is used infrequently in IVF. A clomiphene-only protocol consists of 5-7 days of treatment, with doses of 50-150 mg starting on the second menstrual cycle day (Marrs, 1984). The ovarian response is monitored using pelvic ultrasonography and determinations of serum E2 and LH levels. When the follicle diameter reaches 18 mm, LH must be measured every 3-4 hours to detect a premature LH surge that generally occurs when the follicle reaches 23-24 mm in diameter (Punnonen, 1988). Oocyte retrieval must be performed within 24-26 hours after the LH surge.
The advantages of the CC protocol include low cost and an almost nonexistent risk of OHSS.
The major disadvantages include (1) low oocyte yield (1-2 per cycle), (2) frequent LH surges that lead to oocyte retrieval at any time of the day, (3) high cancellation rate (25-50%), and (4) low pregnancy rate.
Clomiphene citrate and human menopausal gonadotropins
This combination has the advantage of increasing the number of recruited follicles. The doses of CC are similar, but the hMG (150 IU qd) is administered for a period of 2-7 days after the CC (Diamond, 1986). Frequent pelvic ultrasonography and daily determinations of E2 levels are required, as are frequent determinations of LH once the follicular diameter reaches 15 mm. Remember that the follicle is smaller with this protocol. The follicle completes its development at 17-18 mm; therefore, hCGs (10,000 IU IM) must be administered at this time to complete the oocyte maturation. Oocyte aspiration should be performed 35 hours after the hCG injection.
The advantage of the CC/hMG protocol is an increase in the number of recruited follicles. The disadvantages of the protocol are premature luteinization, spontaneous LH surge (20-50%), and high cancellation rate (15-50%).
Human menopausal gonadotropins
The administration of hMG for ovarian stimulation in a healthy anovulatory patient has been one of the groundbreaking discoveries in IVF (Garcia, Fertil Steril, 1983, 167-73; Garcia, Fertil Steril, 1983, 174-9). The use of hMG has evolved with the introduction of new technologies and the generation of pure FSH gonadotropins that can be used subcutaneously (Edelstein, 1990). Furthermore, recombinant FSH and LH gonadotropins are currently available (Weatherbee, 1999). hMGs are as follows:
Human menopausal gonadotropin (Repronex) - FSH of 75 IU and LH of 75 IU
Pure FSH (Bravelle) - FSH of 75 IU and LH of less than 1 IU
Recombinant FSH (Gonadal F, Follistim) - FSH of 75 IU and LH of 0 IU
Recombinant LH (in clinical trials) - FSH of 0 IU and LH of 75 IU
The doses of gonadotropins vary from 150-450 IU/d, depending on the patient's age and history of previous ovulatory response. In general, patients are started on the second or third menstrual cycle day. The response is monitored using daily serum E2 determination and later using pelvic ultrasonography (Garcia, Fertil Steril, 1983, 174-9).
Once most of the follicles reach 17-18 mm in diameter, the gonadotropins are discontinued. hCG (10,000 IU) is administered that evening, and oocyte retrieval is performed 35 hours later. With the use of gonadotropins, ovulation induction appears to be more predictable. However, a spontaneous LH surge occurs in approximately 25% of cycles, which is one of the reasons for cancellation.
Regardless of the use of gonadotropins, a group of patients, known as poor responders, develops only 2-3 follicles, and their oocytes are of poor quality (Schoolcraft, 1997). The possibility of a successful pregnancy in this group of patients is seriously compromised. In general, these patient responses are related to poor ovarian reserve (POR) (Scott, 1989).
Patient response, which is defined by an elevated baseline FSH level (>10 mIU/mL), a low E2 level (<20 pg) associated with an absence of follicle development on sonograms, or elevated E2 levels (>100 pg) associated with early follicle recruitment, characterize POR. Some patients respond with premature luteinization due to elevated tonic LH levels and subsequent premature elevation of progesterone that compromise oocyte quality. Analysis of each ovarian stimulation cycle is important to modify future stimulations and to increase the patient's response.
Initially, GnRHa agonists were used in IVF patients who had a history of premature luteinization, spontaneous LH surge, and an ovarian stimulation response that was less than acceptable or ideal (Meldrum, 1989). The GnRHa agonists can be used in 2 protocols known as the flare-up protocol and the luteal-phase protocol (Garcia, 1990; Padilla, 1991; Hughes, 1992; Marci, 2001).
The flare-up protocol has the advantage of using the transitory elevation of FSH (agonist effect) that occurs during the first 4 days of the follicular phase. This elevation helps in the follicular recruitment process; after 5 days of GnRHa administration, the pituitary gland undergoes down-regulation, which prevents premature luteinization and the spontaneous LH surge. The administration of gonadotropins must be initiated on the fifth menstrual cycle day (Garcia, 1990).
The modified flare-up protocol is the administration of birth control pills for 4-21 days during the preceding IVF menstrual cycle. A microdose of GnRHa agonist leuprolide acetate is administered twice daily subcutaneously starting on day 1 of the menstrual cycle, and the human menopause gonadotropin (recombinant FSH) begins on day 4 of the menstrual cycle.
In the luteal-phase protocol, GnRHa is started on the 17th or 21st menstrual cycle day. By the onset of the menstrual cycle, the phenomenon of pituitary down-regulation is in effect, so the administration of the gonadotropins begins on the second day of bleeding (Hughes, 1992; Marci, 2001).
The adjunctive use of GnRHa in ovarian stimulation leads to an overall improvement in IVF. This accounts for the increase in the number, quality, and synchronization of the oocytes recovered per cycle and improves the fertilization rate, the number of embryos, and the pregnancy rate (Garcia, 1990). Furthermore, because more embryos are available than the number used in fresh embryo transfer, an opportunity exists to cryopreserve the excessive number of embryos for future embryo transfer(s).
Potential risks and disadvantages with the use of GnRHa include (1) increased requirements of gonadotropins, (2) increased costs due to additional days of therapy, (3) the risk of OHSS due to excessively high E2 levels, and (4) an increased rate of multiple pregnancies.
The GnRHa antagonists are the latest generation of GnRHa that block LH secretion without a flare-up effect (North American Ganirelix Study Group, 1999). The GnRHa antagonists (eg, cetrorelix [Cetrotide], ganirelix [Antagon]) are administered (1) as a single dose on the eighth menstrual cycle day; (2) in small amounts over 4 days, starting on the seventh menstrual cycle day; (3) when the largest follicle reaches a diameter of 14 mm; or (5) when the LH levels in serum are greater than 10 mIU/mL (Olivennes, 1995).
GnRHa antagonists have the advantage of blocking the LH surge at the periovulatory period; therefore, premature luteinization or spontaneous LH surge does not occur. Because the pituitary gland is not down-regulated at the beginning of the menstrual cycle, smaller amounts of gonadotropins are required to stimulate ovulation. Another advantage with this protocol is the prevention of OHSS, especially in patients with elevated E2 levels (>3000 pg/mL) or more than 15 follicles during the stimulation. Because the half-life of the GnRHa antagonist is short, it is possible to elicit the preovulatory LH surge by the administration of leuprolide acetate and avoid the long-term effects of the hCG injection that are responsible for triggering the ovarian hyperstimulation.
Oocyte aspiration is undertaken 35-36 hours after hCG administration. Originally, all aspirations were performed using laparoscopy (Jones, 1982). This requires general anesthesia, a skillful laparoscopist, major discomfort for the patient, and the risks involved with the laparoscopy. Oocyte aspiration in patients with severe pelvic adhesions is extremely difficult with most patients and virtually impossible with others .
Follicular aspirations under ultrasonographic guidance were first performed transabdominally, then transurethrally, and, finally, transvaginally (Lenz, 1981). The transvaginal route became the preferred procedure for most IVF programs. The procedure consists of placing the patient in the dorsal lithotomy position for the transvaginal oocyte aspiration. The bladder is catheterized, and the vaginal wall is prepared with povidone iodine. A 5- to 7-MHz ultrasonographic probe is inserted in the vagina to localize the ovaries and the follicles. A 17-gauge needle is subsequently passed through the vaginal fornix into the ovaries. Image 86 illustrates how the follicular fluid is aspirated. The fluid is delivered to the IVF laboratory, which, ideally, is located adjacent to the operating room.
General anesthesia is not required for ultrasonographic-guided oocyte aspiration. Heavy sedation is suitable for this procedure. The risk of bowel injury is almost zero and allows for oocyte retrieval in patients with a frozen pelvis in whom laparoscopic retrieval is not possible. Furthermore, it avoids the use of carbon dioxide pneumoperitoneum. The major risks are infection and damage to the pelvic vessel, but they should not be a problem if the procedure is carefully performed (Howe, 1988).
The classification of the oocyte is a crucial step for success with IVF (Elder, 1992). The follicular fluid is scanned under either a dissecting microscope or an inverted microscope. The oocytes are graded according to the appearance of the corona-cumulus complex. The presence of a polar body (metaphase II stage) and/or germinal vesicle (prophase stage) is a determining factor for the preincubation time prior to the insemination. Other oocytes are degenerated (atretic and fractured zona). The last category constitutes fewer than 15% of the total oocytes obtained
Sperm preparation and oocyte insemination
A semen sample is obtained after a 3- to 5-day period of sexual abstinence immediately prior to the oocyte retrieval. For IUI, IVF, and ICSI procedures, the removal of certain components of the ejaculate (ie, seminal fluid, excess cellular debris, leukocytes, morphologically abnormal sperm) with the retention of the motile fraction of sperm is desirable.
For most specimens, the greatest recovery of the motile portion results from separation via centrifugation through a discontinuous density gradient system. However, for certain very poor specimens with low original concentrations of motile sperm, the use of the gradient system results in such a negligible recovery that it is rendered useless. The recourse for these specimens is to simply remove the seminal fluid through successive media washes.
Furthermore, a small number of specimens have acceptable original concentrations of motile sperm but poor recoveries with the gradient system. These specimens benefit most by layering a washed pellet of sperm with nutrient media and allowing the motile fraction to swim up into the media before being separated (Kerin, 1989).
The sperm are incubated for 60 minutes in an atmosphere of 5% carbon dioxide in air. Finally, the supernatant containing the motile fraction of sperm is removed. Sperm concentration and motility are determined. A final concentration of 50,000 motile sperm per mL of insemination media is added to the oocytes.
The inseminated oocytes are incubated in an atmosphere of 5% carbon dioxide in air with 98% humidity. Ideally, the presence of 2 pronuclei and the extrusion of a second polar body are the criteria required to ascertain fertilization, which should occur approximately 18 hours after insemination (see Image 92). The presence of 3 or more pronuclei can be related to polyspermia or to the retention of the second polar body. This occurs in 9% of all fertilized oocytes (see Image 93). Mechanical dispersion of the cumulus is required when the oocytes are heavily covered by the cumulus; with this, the number of pronuclei can be visualized.
The fertilized oocytes (embryos) are transferred into growth media and placed in the incubator. No further evaluation is performed over the next 24 hours. A 4- to 8-cell stage preembryo is observed approximately 36-48 hours after insemination. A 10- to 16-cell embryo is observed after 48-72 hours. The morula or blastocyst stage is observed after 96-120 hours. Although the goal is to observe the embryos as described, pregnancy has been achieved from embryos with slow or delayed cleavage. Embryos are classified according to symmetry, presence of fragments, clarity, and number of blastomeres (see Images 94-100) (Elder, 1992).
Transcervical transfer under transabdominal ultrasonography is the most common method used for embryo transfer. The procedure is usually performed within 42-72 hours after oocyte insemination. However, pregnancies have been reported after transfer performed at the 2-pronuclei stage. Lately, a tendency to delay the transfer until the embryo reaches the blastocyst stage has been noted (Testart, 1986; Scott, 1998; Schoolcraft, 1999; Shapiro, 2000).
Several catheters have been designed for embryo transfer (see Image 101). All are equally suitable for embryo transfer, and their use is a matter of physician preference rather than a specific catheter being synonymous with a greater pregnancy rate. The embryos should be loaded with 30 mL of culture media. The catheter is advanced up to the fundus of the endometrial cavity, then withdrawn slightly. The embryos are ejected with a small amount of air (see Image 102). Subsequent to the embryo transfer, the patient must be on bedrest for 30-60 minutes.
Management of the luteal phase
Progesterone supplementation during the luteal phase is started 72 hours after oocyte retrieval (Garcia, 1981). The exogenous progesterone is administered because of concerns that superovulation and the aspiration of granulosa cells at the time of oocyte retrieval may induce an abnormal endocrine milieu (Soliman, 1994). Recent publications support the benefits of supporting the luteal phase with exogenous progesterone. Several preparations are available; for example, natural progesterone in oil base is administered intramuscularly and vaginal progesterone suppositories and capsules of micronized progesterone are used intravaginally or sublingually (Fanchin, 2001).
Normally, progesterone supplementation is continued for approximately 2 weeks. If the pregnancy test result is positive, progesterone is continued until the eighth week of pregnancy.
Natural family planning
Natural family planning (NFP) comprises the family planning methods approved by the Roman Catholic Church for both achieving and avoiding pregnancy. In accordance with the Church's teachings regarding sexual behavior in keeping with its philosophy of the dignity of the human person, NFP excludes the use of other methods of birth control, which it refers to as "artificial contraception."
Periodic abstinence is the only method deemed moral by the Church for avoiding pregnancy. When used to avoid pregnancy, NFP limits sexual intercourse to naturally infertile periods; portions of the menstrual cycle, during pregnancy, and after menopause. Various methods may be used to identify whether a woman is likely to be fertile; this information may be used in attempts to either avoid or achieve pregnancy.
Possibly the earliest Christian writing about periodic abstinence was by St. Augustine. In the year 388, he wrote, "Is it not you who used to counsel us to observe as much as possible the time when a woman, after her purification, is most likely to conceive, and to abstain from cohabitation at that time...?" The Manichaeans (the group the early church father St. Augustine wrote of and considered to be heretics) believed that it was immoral to create any children, thus (by their belief system), trapping souls in mortal bodies. Augustine condemned them for their use of periodic abstinence: "From this it follows that you consider marriage is not to procreate children, but to satiate lust.
However, the Council of Trent issued the following anathema: "If any one saith, that the Church errs, in that she declares that, for many causes, a separation may take place between husband and wife, in regard of bed, or in regard of cohabitation, for a determinate or for an indeterminate period; let him be anathema."
If the Manichaeans had an accurate idea of the fertile portion of the menstrual cycle, such knowledge died with them.Documented attempts to prevent pregnancy by practicing periodic abstinence do not appear again until the mid-19th century, when various calendar-based methods were developed "by a few secular thinkers." The Roman Catholic Church's first recorded official statement on periodic abstinence to avoid pregnancy is from 1853, where a ruling of the church's Sacred Penitentiary addressed the topic of periodic abstinence to avoid pregnancy. Distributed to confessors, the ruling stated that couples who had, on their own, begun the practice of periodic abstinence—especially if they had "legitimate reasons"—were not sinning by doing so.
In 1880, the Sacred Penitentiary reaffirmed the 1853 ruling, and went slightly further. It suggested that, in cases where the couple was already practicing artificial birth control, and could not be dissuaded to cease attempting birth regulation, the confessor might morally teach them of periodic abstinence.
Early 20th century
In 1905, Theodoor Hendrik van de Velde, a Dutch gynecologist, showed that women only ovulate once per menstrual cycle. In the 1920s, Kyusaku Ogino, a Japanese gynecologist, and Hermann Knaus, from Austria, working independently, each made the discovery that ovulation occurs about fourteen days before the next menstrual period. Ogino used his discovery to develop a formula for use in aiding infertile women to time intercourse to achieve pregnancy.
In 1930, John Smulders, a Roman Catholic physician from the Netherlands, used Knaus and Ogino's discoveries to create a method for avoiding pregnancy. Smulders published his work with the Dutch Roman Catholic medical association, and this was the official rhythm method promoted over the next several decades. While maintaining procreation as the primary function of intercourse, the December 1930 encyclical Casti Connubii by Pope Pius XI gave the highest form of recognition to a secondary—unitive—purpose of sexual intercourse. This encyclical stated that there was no moral stain associated with having marital intercourse at times when "new life cannot be brought forth." Although this referred primarily to conditions such as current pregnancy and menopause, the Sacred Penitentiary in yet another ruling in 1932, and the majority of Catholic theologians also interpreted it to allow moral use—for couples with "upright motives"—of the newly created rhythm method.:231
In 1932, a Catholic physician published a book titled The Rhythm of Sterility and Fertility in Women describing the method, and the 1930s also saw the first U.S. Rhythm Clinic (founded by John Rock) to teach the method to Catholic couples. It was during this decade that Rev. Wilhelm Hillebrand, a Catholic priest in Germany, developed a system for avoiding pregnancy based on basal body temperature.
Later 20th century to present
A minority of Catholic theologians continued to doubt the morality of periodic abstinence. Some historians consider two speeches delivered by Pope Pius XII in 1951 to be the first unequivocal acceptance of periodic abstinence by the Catholic Church. The 1950s also saw another major advance in fertility awareness knowledge: Dr. John Billings discovered the relationship between cervical mucus and fertility while working for the Melbourne Catholic Family Welfare Bureau. Dr. Billings and several other physicians studied this sign for a number of years, and by the late 1960s had performed clinical trials and begun to set up teaching centers around the world.
Humanae Vitae, published in 1968 by Pope Paul VI, addressed a pastoral directive to scientists: "It is supremely desirable... that medical science should by the study of natural rhythms succeed in determining a sufficiently secure basis for the chaste limitation of offspring." This is interpreted as favoring the then-new, more reliable symptoms-based fertility awareness methods over the rhythm method. Just a few years later, in 1971, the first organization to teach a symptothermal method (one that used both mucus and temperature observations) was started. Now called Couple to Couple League International, this organization was founded by John and Sheila Kippley, lay Catholics, along with Dr. Konald Prem. During the following decade, other now-large Catholic organizations were formed: Family of the Americas (1977), teaching the Billings method, and the Pope Paul VI Institute (1985), teaching a new mucus-only system called the Creighton Model.
Today, use of the term natural family planning to describe calendar-based methods is considered incorrect by the United States Conference of Catholic Bishops: it considers such methods "inaccurate". Still, some organizations still consider calendar-based methods to be forms of NFP.:154 For example, in 1999 the Institute for Reproductive Health at Georgetown University developed the Standard Days Method (SDM), which is more effective than the rhythm method. SDM is promoted by Georgetown University as a form of natural family planning.
It is estimated that 2–3% of the world's reproductive age population relies on periodic abstinence to avoid pregnancy. However, what portion of this population should be considered NFP users is unclear. Some Catholic sources consider couples that violate the religious restrictions associated with natural family planning to not be NFP users.
There is little data on the worldwide use of natural family planning. In Brazil, NFP is the third most popular family planning method. The "safe period" method of fertility awareness is the most common family planning method used in India, although condoms are used by some.
Use of NFP in developed countries is low, even among Catholics. While Catholics made up 24% of the U.S. population in 2002, of reproductive age American women using birth control, only 1.5% were using periodic abstinence.
Use of NFP is not restricted to Catholic couples. In 2002, Sam and Bethany Torode, then a Protestant Christian couple, published a book advocating NFP use. (Five years after writing the book, the Torodes retracted their advocacy of pure NFP and also supported barrier methods as moral; the couple also converted from Protestantism to the Eastern Orthodox Church.) In addition, many NFP clinics and teaching organizations are not specifically associated with the Catholic Church. It has also been shared by members of the Latter-Day-Saints  and some members of the Muslim faith.
Some proponents of NFP differentiate it from other forms of birth control by labeling them artificial birth control. Other NFP literature holds that natural family planning is distinct from contraception. Proponents justify this classification system by saying that NFP has unique characteristics not shared by any other method of birth regulation except for abstinence. Commonly cited traits are that NFP is "open to life," and that NFP alters neither the fertility of the woman nor the fecundity of a particular sex act. That NFP can be used to both avoid or achieve pregnancy may also be cited as a distinguishing characteristic. Additionally, NFP differs greatly from contraception because, according to action theory, NFP does not "break" the sexual act (separating the action from its purposes) in the way contraception does.
There are three main types of NFP: the symptoms-based methods, the calendar-based methods, and the breastfeeding or lactational amenorrhea method. Symptoms-based methods rely on biological signs of fertility, while calendar-based methods estimate the likelihood of fertility based on the length of past menstrual cycles.
Clinical studies by the Guttmacher Institute found that periodic abstinence resulted in a 25.3 percent failure under typical conditions, though it did not differentiate between symptom-based and calendar-based methods.
Some methods of NFP track biological signs of fertility. When used outside of the Catholic concept of NFP, these methods are often referred to simply as fertility awareness-based methods rather than NFP. The three primary signs of a woman's fertility are her basal body temperature, her cervical mucus, and her cervical position. Computerized fertility monitors may track basal body temperatures, hormonal levels in urine, changes in electrical resistance of a woman's saliva or a mixture of these symptoms.
From these symptoms, a woman can learn to assess her fertility without use of a computerized device. Some systems use only cervical mucus to determine fertility. Two well-known mucus-only methods are the Billings ovulation method and the Creighton Model FertilityCare System. If two or more signs are tracked, the method is referred to as a symptothermal method. Two popular symptothermal systems are taught by the Couple to Couple League and the Fertility Awareness Method (FAM) taught by Toni Weschler. A study completed in Germany in 2007 found that the symptothermal method has a method effectiveness of 99.6%.
In Canada, the symptothermal method is taught by SERENA Canada which is an inter-denominational organization which has been developing the Symptothermal Method as a part of NFP since 1955. They are also not specifically affiliated with the Roman Catholic Church. It is also taught by Justisse Healthworks for Women, a pro-choice feminist organization that allows and supports women to combine other methods of birth control with their fertility awareness practice. A study by the World Health Organization involving 869 fertile women from Australia, India, Ireland, the Philippines, and El Salvador found that 93% could accurately interpret their body's signals regardless of education and culture. In a 36-month study of 5,752 women, the method was 99.86% effective.
Calendar-based methods determine fertility based on a record of the length of previous menstrual cycles. They include the Rhythm Method and the Standard Days Method. The Standard Days method was developed and proven by the researchers at the Institute for Reproductive Health of Georgetown University. CycleBeads, unaffiliated with religious teachings, is a visual tool based on the Standard Days method. According to the Institute of Reproductive Health, when used as birth control, CB has a 95% effectiveness rating. Computer programs are available to help track fertility on a calendar .
The lactational amenorrhea method (LAM) is a method of avoiding pregnancy based on the natural postpartum infertility that occurs when a woman is amenorrheic and fully breastfeeding. The rules of the method help a woman identify and possibly lengthen her infertile period. A strict version of LAM is known as ecological breastfeeding
Some Catholics have indicated significant disagreement with the Church's stance on contraception. The Canadian Conference of Catholic Bishops issued what many interpreted as a dissenting document, the Winnipeg Statement. In it, the bishops recognized that many Catholics found it "either extremely difficult or even impossible to make their own all elements of this doctrine" (that of Humanae Vitae). Additionally, they reasserted the Catholic principle of primacy of conscience, a principle that they said should be properly interpreted, since they insisted that "a Catholic Christian is not free to form his conscience without consideration of the teaching of the magisterium, in the particular instance exercised by the Holy Father in an encyclical letter". Catholics for a Free Choice claimed in 1998 that 96% of U.S. Catholic women had used contraceptives at some point in their lives and that 72% of Catholics believed that one could be a good Catholic without obeying the Church's teaching on birth control. According to a nationwide poll of 2,242 U.S. adults surveyed online in September 2005 by Harris Interactive (they stated that the magnitude of errors cannot be estimated due to sampling errors, non-response, etc.), 90% of Catholics supported the use of birth control/contraceptives. Use of natural family planning methods among United States Catholics purportedly is low, although the number cannot be known with certainty. In 2002, 24% of the U.S. population identified as Catholic. But of sexually active Americans avoiding pregnancy, only 1.5% were using NFP.
Much criticism of NFP stems from the Church's stance of NFP as the only allowable form of birth control. In 2009, Pope Benedict XVI asserted that handing out condoms is not the solution to combating AIDS and actually makes the problem worse. Some senior Catholic authorities, such as Belgian Cardinal Emeritus Godfried Danneels, believe the Catholic Church should support condoms used to prevent serious diseases such as AIDS, because non-use is tantamount to murder. In 2003, BBC's Panorama claimed that the Vatican is intentionally spreading lies that HIV can pass through the membrane of the condom.
Family planning proponent Stephen D. Mumford has argued that the primary motivation behind the Church's continued opposition to contraceptive use is the Church's fear of losing papal authority if the pope were to contradict the dogma of papal infallibility. Mumford gives as an example the citation made by August Bernhard Hasler of a comment by Pope John Paul II prior to his papacy:
If it should be declared that contraception is not evil in itself, then we should have to concede frankly that the Holy Spirit had been on the side of the Protestant churches in 1930 (when the encyclical Casti Connubii was promulgated), in 1951 (Pius XII's address to the midwives), and in 1958 (the address delivered before the Society of Hematologists in the year the pope died). It should likewise have to be admitted that for a half century the Spirit failed to protect Pius XI, Pius XII, and a large part of the Catholic hierarchy from a very serious error. This would mean that the leaders of the Church, acting with extreme imprudence, had condemned thousands of innocent human acts, forbidding, under pain of eternal damnation, a practice which would now be sanctioned. The fact can neither be denied nor ignored that these same acts would now be declared licit on the grounds of principles cited by the Protestants, which popes and bishops have either condemned or at least not approved.
However, none of the instances cited actually falls under the domain of papal infalliblity, since the Pope is not considered infallible except in the rare, solemn occasions when he is speaking ex cathedra. Even the encyclicals Casti Connubii and Humanae Vitae are considered by most, though not all, Catholic theologians to be non-infallible documents.
Theological opposition has additionally come from Protestant Christianity. John Piper's Desiring God ministry states of NFP, "There is no reason to conclude that natural family planning is appropriate but that 'artificial' (non-abortive) means are not." Sam and Bethany Torode, former advocates of NFP-only, have redacted their position to include barrier methods and explain their current theology this way:
We also see honest congruity with the language of the body by saying "no" to conception with our bodies (via barrier methods or sensual massage) when our minds and hearts are also saying "no" to conception. We don’t believe this angers God, nor that it leads to the slippery slope of relativism or divorce. We strongly disagree with the idea that this is a mortal sin.... it’s a theological attack on women to always require that abstinence during the time of the wife’s peak sexual desire (ovulation) for the entire duration of her fertile life, except for the handful of times when she conceives.