Stepped-Care Approach
It is normal to feel worried when you have difficulty achieving a pregnancy but there are many treatment options for infertility and most couples achieve their goal if they consult on time. The different treatments will be suggested in a stepped approach to care system in which after a careful, individual and personalized analysis of each case the couple discusses the different factors that will determine the best option for each particular case.
What is the Stepped-Care Approach?
A fertility treatment does not always mean “In Vitro Fertilization”. While it is true that this technique offers a very good chance of success, in more than half of the cases, pregnancy is achieved with treatments considered as basic. The stepped approach to care consists in to individualize each case to recommending start with the simplest and most effective management according to your medical history, diagnosis and personal circumstances.
Basic Treatments
Most couples achieve pregnancy with basic treatments ranging from timed intercourse, ovulation induction to intrauterine insemination. In these treatments the encounter of the egg and the spermatozoid happens in the body of the woman (fallopian tube) and not in the laboratory (in vitro). Learn more about these basic treatments.
Timed intercourse
Timed intercourse is a simple and useful strategy to treat some situations that affect the fertility.
This treatment consists of scheduling sexual intercourse on the most fertile days of the woman. This period is included during the days immediately prior to ovulation. Ovulation occurs approximately 14 days before the arrival of menstruation, meaning that if a woman has 30 day cycles she will ovulate on day 16 of the cycle.
When couples are rarely engaged in sex for different reasons, programming them helps increase the effectiveness of these intercourse. They are also used when performing treatments through ovulation induction.
First of all we have to be sure that ovulation is occurring naturally or through medication. If ovulation has been previously documented during the initial evaluation, the day of ovulation can be calculated by the length of the menstrual cycles. It can also be programmed by ultrasound, monitoring the developing follicle (cystic structure in the ovary where the egg is found) by ultrasound or measuring the hormone LH in blood or urine, this hormone triggers ovulation and rises 24 to 36 hours before ovulation occurs. Occasionally an injectable medication is administered to trigger ovulation and intercourses are programmed between 24 and 40 hours after the injection.
Ovulation Induction
It is the treatment aimed at the maturation and release of the eggs with the help of medicines or another strategy.
Ovulation is the release of a mature egg from the ovaries, it is critical to the achievement of pregnancy. Up to 25% to 30% of women experience infertility due to ovulation disorders.
When ovulation disorders are detected as a cause of infertility as long as a severe concomitant alteration in the man is ruled out by performing a semen analysis and also is rule out an obstruction or damage of the tubes by a hysterosalpingography or laparoscopy. When there is unexplained infertility accompanied by intrauterine insemination. When in vitro fertilization is required as a treatment of different causes of infertility, promoting the maturation of several eggs.
It is not recommended as an empirical treatment (“to see if it works”) in women with infertility who have been ruled out of ovulation disorders, because in these cases it has been shown that it does not increase the chance of pregnancy and could even decrease it.
When it is desired to correct an ovulation disorder and to produce the maturation and release of a single egg, oral medications are generally used in the form of tablets, these are taken in cycles usually of 5 days beginning between the third and fifth day of the menstrual cycle. In these cases the treatment is accompanied by timed intercourse or intrauterine insemination oriented by ultrasound monitoring, measurement of the hormone LH (hormone that triggers ovulation) or the administration of an injection of hCG (Gonadotropic Chorionic Hormone) that has the same effect of LH, causing the release of the egg when it is mature. The most commonly used drugs in these cases are Omifin (clomiphene citrate) and Femara (Letrozole). When these drugs do not work, the follicle stimulating hormone (FSH) is directly injected or the so-called “surgical ovulation induction” or “ovarian drilling” can be performed, a procedure that involves performing several perforations in the ovary with an electric instrument or laser beam through laparoscopy. Injectable medications are also used if several eggs (multiple ovulation) are required to mature during in vitro fertilization treatments.
When ovulation is achieved through these treatments the likelihood of pregnancy is equal to that of any couple without infertility as long as the semen analysis and tubes are normal.
Intrauterine insemination
Insemination is one of the basic procedures with which many couples initiate treatment for infertility.
For a pregnancy to occur, the spermatozoa must reach and fertilize the egg in the tube ascending from the vagina through the cervix, which acts as a filter, limiting the quantity of sperm that reaches the tubes. Through insemination, the sperm are placed directly inside the uterus shortening their journey towards the tubes, allowing more sperm to be in contact with the egg thus increasing the possibility of pregnancy.
It is recommended in cases of unexplained infertility, mild alterations of the male factor (semen analysis), alterations in the cervix that hinder or prevent the rise of spermatozoa usually caused by procedures in the cervix such as conization or cauterization, sometimes as complement to ovulation induction, in the case of men who have frozen spermatozoa for fertility preservation previous to treatments for cancer or vasectomy and in treatments in which donor sperm is required.
In the laboratory by a special procedure, the spermatozoa are separated from the semen sample and concentrated in a small amount of culture medium. In this way a greater quantity of sperm with very good mobility can be deposited in the uterine cavity by means of a small plastic tube or catheter which is introduced through the cervix. This procedure takes a few minutes, is performed in the office and is scheduled at the time of ovulation, which is determined by ultrasound monitoring and measurement of the hormone LH (hormone that triggers ovulation). It can be performed in a natural cycle or after ovulation induction.
The chance of pregnancy in a normal couple before the woman age reach 35 years is about 20% when having intercourse in the days around ovulation. This possibility decreases after this age in such a way that after 40 years the chance drops to 5%. The probability of pregnancy with intrauterine insemination also depends on the age of the woman and the reason why it is performed and ranges from 8% to 15% for each cycle or attempt of insemination. It does not work well in the case of male factor, presence of moderate or severe endometriosis, and fallopian tube alteration. Because the chance of pregnancy per cycle (try) is relatively low, it is recommended to try more than once but usually if there is no result after 3 cycles or attempts it is recommended to move to a more advanced treatment such as in vitro fertilization.
Advanced treatments
Advanced treatments for infertility are those that involve techniques of assisted reproduction. In these cases the encounter of sperm and egg occurs in the laboratory (in vitro) and not in the body of the woman.
In vitro fertilization
It is the most effective treatment to treat any cause of infertility, it requires advanced technology which makes it more expensive and therefore it is recommended for couples who cannot benefit from basic treatments. Learn more about this treatment.
In vitro fertilization, the eggs are collected directly from the ovary to join them with the sperm in the laboratory and then, once fertilized and progressed to embryos in early stages of development, be transferred to the uterus.
In vitro fertilization was initially used to treat women with obstructed, damaged or absent fallopian tubes. Today, thanks to the technological advance that has increased the chances of success with this type of treatment, it is also indicated in couples with infertility due to male factor, endometriosis, ovulation alterations, advanced maternal age, unexplained infertility, repeated abortions, genetic abnormalities and unexplained infertility.
In vitro fertilization consists basically of 3 phases:
1) Stimulation of the ovaries with hormones so that several eggs can mature, instead of one as it regularly does in a natural cycle, in order to increase the chances of success since not all mature eggs fertilize or develop embryos suitable for the implantation and development of a pregnancy. This phase lasts approximately 8 to 14 days during which you will be scheduled several times in the morning to monitor the treatment using ultrasound and hormonal analysis.
2) Egg collection: Once the ultrasound and hormonal results indicate that the eggs are already mature, the collection will be programmed by a puncture with a needle that is inserted through the vagina to the ovary guided with ultrasound. This procedure lasts from 20 to 30 minutes and is done in a special room similar to a surgery room, where you will receive sedation or superficial anesthesia so you do not feel any discomfort. On the same day the sperm must be obtained to join with the eggs obtained in the laboratory.
3) Embryo Transfer: If fertilization occurs, embryos will be developed in the laboratory, which will be transferred to the uterus within 3 to 6 days after collection. This procedure is performed in the same place where the capture was performed. The embryos are placed on the tip of a thin soft plastic tube (catheter) which is inserted through the cervix into the uterine cavity guided by ultrasound performed this time through the abdominal wall. This procedure lasts between 15 and 20 minutes, is not painful and does not require sedation or anesthesia. You will remain at rest for approximately 1 to 2 hours after the procedure after which you will be discharged with instructions until the time of the pregnancy test to be done 12 to 13 days later.
Results (Success Rates)
Más de la mitad de todas las pacientes que llegan a transferencia de embriones, logran embarazarse.
Success rates comparable to those reported in the United States
Better success rates than those reported throughout Latin America
ICSI
The ICSI is an acronym that means intra cytoplasmic sperm injection, which means that in the laboratory during an in vitro fertilization procedure and through micromanipulation, a single spermatozoon is injected into the egg.
There are 2 ways to fertilize an egg during an in vitro fertilization procedure: one is to add a quantity of spermatozoa so that they “swim” next to the egg in a drop of culture medium in the laboratory, in this case, the spermatozoon will have to cross on its own the cells surrounding the egg to reach its outer membrane, penetrate it and enter its cytoplasm (inner part of the egg). The other is by directly injecting a single spermatozoid into the cytoplasm of the egg with a special needle called a micropipette, this procedure is called ICSI
ICSI is recommended when there are too few spermatozoa available to ensure fertilization of the egg naturally, or even through intrauterine insemination or conventional in vitro fertilization. Also in cases with history of failure to fertilize the eggs in any previous cycle of in vitro fertilization, unexplained infertility, when previously frozen eggs are used and when a genetic evaluation of embryos will be performed.
In the laboratory of in vitro fertilization, the egg obtained directly from the ovary are analyzed with a microscope to determine their maturity, since only mature eggs will be able to be fertilized by ICSI. Once the mature eggs are chosen, they are injected with a micropipette to introduce a single spermatozoon into its cytoplasm. When fertilization occurs, the fertilized egg will form embryos, which will be transferred to the uterus or womb (embryo transfer) between 3 and 6 days later.
This procedure allows between 50% and 80% of the eggs to be fertilized (Fertilization rates)
Transfer of frozen embryos
Embryo freezing is a tool that increases the chance of becoming pregnant with a single cycle of stimulation for in vitro fertilization. Learn more about this technique.
To increase the chance of pregnancy during an in vitro fertilization, stimulation of the ovaries is done in order to obtain several eggs, which is why it is sometimes possible to have more embryos available to transfer than necessary to ensure a good chance of pregnancy. Thanks to the technological advances it is possible to freeze the embryos that result in excess and to avoid transferring to the uterus a greater number of embryos that can cause a very high risk of multiple pregnancies.
In addition to the indication when having excessive embryos, it is also recommended to freeze the embryos when the hormonal evaluation performed during an in vitro fertilization cycle detects that the endometrium (inner layer of the uterus or womb where the embryo is implanted) may not be suitable to receive fresh embryos during that cycle or for preservation of fertility in stable couples for social reasons or in women with stable partners who require some treatment of chemotherapy or radiotherapy that may affect the quality and quantity of their eggs (ovarian reserve). Freeze the embryos is sometimes recommended in order to prevent Hyperstimulation Ovarian Syndrome, a complication during the In Vitro Fertilization process.
In order to have frozen embryos it is necessary to have an in vitro fertilization cycle. Frozen embryos are stored in small, well-marked devices maintained at very low temperatures in liquid nitrogen tanks. If you have frozen embryos, you can have them after your child is born to have a sibling or after an in vitro fertilization cycle with no result. The procedure is simpler since does not require exhaustive monitoring. Ovulation is usually suppressed with an injection that is administered in the previous cycle and once the menstruation arrives, estrogen tablets are prescribed to stimulate the growth of the endometrium (internal layer of the uterus or matrix where the embryo is implanted). Once the ultrasound shows that the endometrium is thick enough, progesterone is initiated in injections or in vaginal tablets and the transfer of the embryos is scheduled. In these cases the hormones should continue to be administered until the pregnancy test or if the pregnancy results, for 10 more weeks.
Results (Success rates)
Half of the patients who are transferred with a previously frozen embryo become pregnant.
These outcomes are better than those reported throughout Latin America
Assisted Hatching
Assisted Hatching is a procedure that can help a certain group of patients. Learn more about this procedure
Before implantation in the uterus, the embryo develops inside a protective layer called pellucida zone. In order to be implanted, the embryo must exit or hatch from this protective layer. It is possible in some cases to make a small hole in the pellucid zone of the embryo before transferring it to the uterus to facilitate its implantation and pregnancy.
Some medical studies suggest that the assisted hatching may benefit patients with a history of previous in vitro fertilization failure or a lower prognosis for a successful outcome. This procedure is also done in cases where a genetic evaluation of the embryos will be performed to facilitate the obtaining of a biopsy of the embryo and thus to be able to analyze its genetic material.
In the past a substance was used to dissolve a segment of the pellucid zone. Nowadays, a laser beam is used to achieve greater accuracy by minimizing the risk of damage to the embryo. Our laboratory has a new laser beam of last generation for the realization of the assisted hatching.
Medical studies show a slight but significant increase in the chances of pregnancy in patients in whom this technique is used. However, there is no scientific evidence that it should be routinely used in all patients.
Genetic evaluation of embryos (PGD, PGS)
The pre-implantation genetic test consists of examining the embryos before they are transferred to the uterus in order to detect if any of their chromosomes have any abnormalities that could lead to disease. This is done while the embryo is growing in the in vitro fertilization laboratory.
There are two types of pre-implantation genetic tests: Pre-implantation genetic diagnosis and pre implantation genetic screening (PGD and PGS).
Through PGD, the embryo can be examined for a single gene producing a specific disease already known and to detect if the embryo is normal or affected by the disease. The test can also show if the embryo carries the disease but is not affected by it, that is to say that it can transmit the disease to it’s future children but that it will not develop symptoms or signs of the disease during its life.
Many embryos from apparently healthy partners have chromosomal abnormalities, these embryos will not give rise to a pregnancy or if it occurs, it will end in abortion. This is because both males and females may have some chromosomally abnormal sperm and eggs, alterations that may be affected by age or family history. Examining an embryo in order to detect any chromosomal abnormality is called screening or pre implantation genetic screening (PGS). By means of this technique it is possible to detect alteration in the number of chromosomes and to diagnose alterations like the Down syndrome or mongolism.
A pre-implantation genetic test is recommended in all couples with or without a known genetic disease, couples with a history of repeated abortions, women with advanced reproductive age or a decrease in ovarian reserve without an apparent cause, couples with multiple failed fertility treatments. The couple can also choose to do so for personal reasons.
Every day, the development of these techniques is advanced, allowing genetic exams to be more accurate, and giving more information in a faster way. One or more cells from each embryo are sent for a genetic examination and thus healthy embryos are identified to be transferred to the uterus where they will be implanted to give rise to a pregnancy.
Donation of gametes (Reproduction with donors)
There are several causes that explain the difficulty in conceiving. Some are easy to solve, others involve the challenge of more complex treatments. Sometimes, despite having a diagnosis, it is not possible to obtain a pregnancy through different treatments including in vitro fertilization. It also happens that on some occasions it becomes difficult or impossible to obtain a pregnancy with the couple’s own gametes (eggs or sperm). There is hope and the option of using eggs, sperm or embryos donated by a third person (donor) to help an individual person or infertile (recipient) partner to achieve a pregnancy. The egg or sperm donor may be known or anonymous.
Donation of spermatozoids
The use of donated spermatozoa for reproductive purposes has been used for many years. Following the discovery of AIDS since the 1980’s, the use of donated spermatozoa is done after they have been frozen in quarantine and you are sure that the donor is not carrying this or any other infectious disease such as hepatitis.
If your difficulty in achieving a pregnancy is alteration in or absence of sperm, the use of donated spermatozoa is a very good alternative to achieve pregnancy.
Sperm donation is an option in the following cases:
- Heterosexual couples with infertility in men due to severe causes
- Heterosexual couples in which the man cannot ejaculate or carries some genetic alteration and does not choose to consider genetic evaluation of the embryos to avoid transmitting the alteration to his children.
- Women with Rh-negative blood sensitized (with antibodies against Rh + blood) and male partners Rh +
- Single or unmarried woman
- Woman with same sex partner
The first thing to do is to evaluate the woman to rule out other causes of infertility other or additional to the male factor in order to determine the type of technique to be used with the donated spermatozoa (intrauterine insemination or in vitro fertilization). The decision to opt for the use of donated spermatozoa to achieve a pregnancy is often not easy for people and psychological assistance is offered to those who request it. Once the decision is made and the tests are completed, the donor is chosen. There is a semen bank of selected donors in the Reproductive Medicine Unit of the Centro Médico Imbanaco after conducting interviews to detect possible inherited diseases that can be transmitted genetically and tests to rule out sexually transmitted diseases. In the case of insemination with anonymous donors, there is information on physical characteristics and personality of the donor that can be shared with the receiving party to assist in their choice. In case the donor is known, the donor must undergo the same process of selection of an anonymous donor including the freezing of the quarantine sample for 6 months.
The probability of pregnancy depends on different factors in the recipient woman, such as age, presence of other causes of infertility such as endometriosis, fallopian tube status, ovulation disorders and decreased ovarian reserve. In general through intrauterine insemination the possibilities of pregnancy oscillate between 8% and 18% per cycle (intent). That is why it is recommended to be programmed for several attempts at insemination in order to achieve a higher probability of pregnancy. It should be remembered that the probability of pregnancy per cycle in a normal couple without infertility is about 20% before the woman is 35 years old.
Egg Donation
When the probability of achieving pregnancy with the eggs themselves is very low or not an option, donating eggs is a very good alternative. Learn more about this process that gives a very good chance of success.
Treatment by donating eggs consists of an in vitro fertilization cycle in which the woman uses another woman’s (donor) egg instead of her own.
Treatment with donated eggs may be required in the following cases:
- Women with premature ovarian failure (premature menopause) as a result of an illness, chemotherapy, radiation therapy, or ovarian surgery for tumors or endometriosis.
- Women with or carrying a genetic disease and who do not choose to consider genetic evaluation of the embryos in order to avoid transmitting the alteration to their children.
- Women who ovulate normally but the apparent cause of their infertility is associated with their eggs as is the case of multiple failures to in vitro fertilization treatments, advanced reproductive age or inadequate response to ovulation induction.
- Men with same sex partners
Once the egg donor is selected following a selection process that includes interviews for the detection of possible genetic diseases that can be transmitted genetically and tests to rule out sexually transmitted diseases, their eggs are obtained through an in vitro fertilization process and donated to the recipient. These eggs are fertilized with the spermatozoa of the recipient pair or a sperm donor and the resulting embryos are transferred to the uterus of the recipient. If a pregnancy occurs, the mother (recipient) will have a biological but non-genetic relationship with the child or product of this conception and her partner or the father (in case of being the sperm contributor) will have a biological and genetic relationship.
