Intrauterine insemination, or IUI, refers to the placement of washed or processed sperm directly into the uterus, just where the fallopian tubes begin. It is relatively simple treatment for infertility designed to get more sperm to meet the egg. IUI is performed near the time you ovulate. IUI is recommended when there is a problem with the male partner’s sperm, such as low sperm count or his sperm do not move well. IUI may also be useful if there is a problem with a woman’s cervical mucus. IUI may also be an option when the man is not able to ejaculate inside the vagina because of erectile dysfunction, premature ejaculation, or other medical conditions. Sometimes, IUI may also be recommended if the infertility is unexplained.

There are two versions of IUI:

1. Intrauterine insemination with partner sperm;
2. Intrauterine insemination with donor sperm.

IUI includes:

• The doctor may recommend fertility medication (if it is necessary) before the procedure to stimulate ovulation. During this process doctor will monitor the maturity of the follicles with blood tests and ultrasound.
• The semen samples processed by washing, centrifugation and migration in order to separate higher percent motile spermatozoa with normal morphology.
• Placing washed sperm directly into the uterine cavity around the time that ovulation is occurring using a thin, soft catheter.
• In some cases after IUI treatment the progesterone may be administrated to help the corpus luteum function.

The pregnancy rate from IUI depends on sperm quality and ovarian factors, such as age and response to fertility medications. Read more...

In Vitro Fertilization procedure involves taking mature eggs from the woman, fertilizing them with sperm in a special dish in a laboratory and then transferring the resulting embryos back to the woman’s uterus 2 to 5 days after fertilization is confirmed. IVF is treatment of choice in cases of infertility when both fallopian tubes are blocked. However, IVF may also be used for unexplained infertility, endometriosis, cervical factor infertility, ovulation disorders, early ovarian aging, or when there are light to moderate forms of male factor infertility.

Approximately 25-35 percent of women who try in vitro fertilization conceive – however, the likelihood of success can vary from 0 to 70 percent depending on such factors the women’s age, the reason for the infertility, and the experience of the IVF program.

IIVF can be physically and emotionally draining, however stress and anxiety can be reduced if the patients have a clear understanding of the procedures.

IVF includes the following steps:

Initial visit:

During an initial visit, your doctor will outline the IVF treatment plan, or protocol. The patients will be asked to sign consent forms. During this visit, the doctor most likely will evaluate the patient’s uterus using a catheter to measure the size, shape, and direction of the uterus. This will help the doctor to determine where to place your embryos on the day of embryo transfer.

Before starting the IVF treatment cycle, a semen sample will be collected from male partner for analysis. If donor semen is to be used, the couple will need to select a donor.

Stimulation of Ovaries

The doctor will discuss with the patient which medication protocol might work best for her. The woman will then be given medications to stimulate her ovaries to form multiple eggs and the doctor will monitor this process with blood tests and ultrasound examination. Usually, the patient will receive a drug known as a gonadotropin-releasing hormone agonist (Decapeptyl) or a gonadotropin-releasing hormone antagonist (Orgalutran, Centrotide) – these drugs prevent the patient’ ovaries from releasing eggs too early during the IVF cycle.

The patient will then be given one or more medications known as gonadotropins, which can stimulate the patient’ ovaries to produce many eggs. The gonadotropins are given daily as an injection in-patient’ abdomen, thigh, or upper arm. The doctor will determine the most appropriate dose for every patient and will inform her of the possible risks, side effects, and benefits of these medications.

Egg retrieval

The egg retrieval is done under conscious sedation. Usually the procedure takes approximately 30 minutes and it depends on the follicles number. The procedure is done with the use of vaginal ultrasound to visualize the ovary. A needle, attached to the ultrasound probe, is used to aspirate the fluid from the follicles and the fluid is immediately examined under microscope to determine whether an egg is present. The eggs are placed in a special dish in an incubator that is supporting the needed temperature and conditions for fertilization and further development of the embryos.

After the egg retrieval the patient will spend approximately 2 hours in the recovery room. The procedure does not demand the stay in the hospital.

Insemination and fertilization

On the day of retrieval, the partner will need to provide a semen specimen. It is recommended 3-5 days of abstinence. Approximately four hours after the egg retrieval has been performed and the semen has been collected and prepared, the eggs are inseminated, i.e. exposed to sperm. On the following day, the eggs are evaluated to see if fertilization has occurred. The fertilized egg still consists of a single cell, but within the egg are two structures called pronuclei. The ones pronuclei contain the genetic material from the egg and the other pronuclei contain the genetic material from the sperm.

Mature oocyte	Fertilized oocyte with 2 pronuclei

Embryo development and embryo transfer

The fertilized eggs known as embryos are left in culture minimum 48 hours their replacement in the woman’ uterus. Embryo transfer can be done on second, third or fifth day after oocytes aspiration. The doctor and the embryologist will discuss with the couple the condition of embryos and how many will be transferred into woman’s uterus. In general, there will be transferred 1-4 embryos, depending on patient’s age and other factors such as the quality of embryos and the cause of infertility.

2-cell embryo	4-cell embryo	8-cell embryo

Pregnancy test:

The doctor will schedule a pregnancy test about two weeks after your egg retrieval and embryo transfer procedure.

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Известно е, че степента на забременяване е пропорционална на броя на трансферираните ембриони с добро качество. При прилагане на съвременните IVF протоколи се използват високи дози гонадотропни хормони за стимулация на яйчниковите структури, в следствие на което се образуват множество фоликули, респективно яйцеклетки и ембриони. Не е за пренебрегване обаче, цената платена от пациентите (в буквален и преносен смисъл). Някои жени са екстремно сензитивни при стимулация с екзогенни гонадотропини и при тях е повишен рискът от развитие на овариален хиперстимулационен синдром (OHSS), водещ до хоспитализация на около 2-3 % от случаите. Тежките форми на OHSS понякога предизвикват усложнения като белодробен тромбоемболизъм, отпадане на бъбречната функция, респираторен дистрес (ARDS) и в много редки случаи – смърт. От друга страна, все още не са известни евентуални бъдещи странични ефекти върху здравословното състояние на организма и репродуктивната система след приложението на гонадотропини. Редица автори лансират хипотезата, че в някои случаи, по-ниската степен на имплантация при трансфериране на ембриони с добро качество е в резултат на намаляване рецептивността на маточната лигавица, в следствие на свръхфизиологичните хормонални нива по време на стимулация. Безпокойство буди и фактът, че при чести стимулации в неопределено бъдеще има риск от поява на яйчников и ендометриален карцином и особено карцином на млечните жлези. Освен това, не е ясно дали множеството стимулации не биха довели до ранно изчерпване на яйчникововия резерв.
Поради тези причини се проучват и обсъждат алтернативни възможности за лечение на безплодието чрез асистирани репродуктивни технологии (АRТ). Ин витро матурацията /зреене/ (IVM) на незрели яйцеклетки се явява потенциална терапия, елиминираща посочените по-горе рискове .
IVM е метод, който може да се изполва за лечение при всички форми на безплодие, без необходимост от хормонална стимулация .
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