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In Vitro Fertilizace (IVF)

The first successful attempt for artificial fertilization was performed in 1978 when thanks to Dr. R. Edwars and Dr. P. Steptoe was the first child born as a result of the IVF/ET method (Louise Brown, Great Britain). More than 3.7 million children conceived using assisted reproduction methods are born around the World every year.

It is a complex of procedures when the egg and sperm are manipulated outside of the female body.

Following the hormonal stimulation leading towards a higher number of mature eggs these are retrieved straight from ovaries and brought in to a special cultivation solution together with selected sperm. After the fertilization eggs are cultivated in to embryos in special mediums completely naturally without any other intervention. Embryos are later transferred back in to the women’s body.

Preparation for IVF:

Hormonal stimulation:

Multiple growth of follicles increases the chances for achieving a bigger amount of quality eggs and consequently more embryos suitable for transfer. This is achieved by hormonal stimulation under constant doctor’s control.

Egg retrieval:

The egg retrieval is performed under short general anesthesia guided by trans-vaginal ultrasound and it takes about 5-10 minutes. The procedure is done with a special thin needle, which goes via vaginal whole straight to an ovary. From there are the eggs suctioned. The patient is discharged about 2 hours post procedure.

The sperm collection and preparation:

A sperm sample is collected from a partner on the day of egg retrieval in special room. Sexual abstinence is recommended 2-5 days prior the collection in aim to get the best possible quality sample. Following its laboratory preparation eggs are fertilized by partner’s sperm in a special solution. Fertilization happens spontaneously, the sperm moves towards the egg and penetrates its shell. The common cultivation of eggs and sperm lasts 16-20 hours. After this time the embryologist finds out about the success of fertilization which is proved by the presence of two pronucleus and two polocyts.

If the man is in any doubt about the ability to give a sample in the day of egg retrieval, he can use the option of cryopreservation in advance.

For men who have no sperm in the ejaculate is MESA/TESE one of the options to get the sperm in IVF cycle.

Embryo cultivation:

Embryos are cultivated in thermostat in special mediums for 2-6 days. After this time they are transferred in to the uterus. Surplus embryos can be frozen and stored for potential use in the future.

Embryo-transfer (ET):

Is a procedure when the embryos are brought back in to the womb cavity using a special thin catheter. Embryos are transferred together with a small volume of the media. This procedure is quick and in most cases painless, does not require GA. The number of embryos transferred is depending mostly on the age of the patient, number of previous failed IVF cycles and on wishes of the patient. Mostly 1-2 embryos are transferred. The patient is leaving the Clinic in about 1 hour post ET. One week after the transfer the patient is coming back to the Clinic for pregnancy test.

ICSI

A revolution in the male infertility was the news in the 1992 about first pregnancies achieved by injecting single sperm in to the egg through its shell (zona pellucida). This method helps countless couples who’s cases were hopeless and were forced to use a donor sperm only few years before.

The method of ,,intracytoplasmatic injection of sperm (ICSI) is a elaborate micromanipulation technique when the sperm is aspirated in to a thin sharp glass capillary and inserted in to an egg through its shell.

Indication for ICSI is the inability of the sperm to fertilize the egg spontaneously (low count, low motility), immunological causes of infertility, failing of classical IVF cycles, later age, low amount of matured eggs, when cryo-preserved sperm is used or when the sperm is collected by MESA/TESE method, when donors eggs are used etc. This method has a very high success rate of fertilization. The patient has to indeed undergo the normal procedure of super-ovulation and egg retrieval and the partner has to provide the sperm. In the view of collected data we can say that by fertilization of the egg using this method is not increased risk of a child with congenital developmental defect when compared to spontaneous conception.

PICSI

This is a laboratory technique (improved ICSI) which enables us to pick and transfer only single one mature sperm in to the oocyte. This increases the success rate of the infertility treatment. Naturally only matured sperm able to specifically connect to so called oocyte’s complex (hyaluronan) are able to fertilize the egg. In mature sperm was demonstrated much lower appearance of chromosomal aberrations than in immature one.

When using only the simple ICSI method the sperm is picked by its morphology and motility. This does not guarantee the sperm with optimal genetic pack will be chosen. PICSI method combines the benefits of ICSI (high probability of fertilization) with the possibility to pick the mature sperm based on its ability to connect with the hyaluronan hydrogel. PICSI is imitating the connection of the mature sperm to the oocyte’s complex which is very important for the selection of suitable sperm during the natural fertilization. This technique is possible to use only under the condition that there is enough sperm with good motility in the ejaculate.

Above standart embryo cultivation

Extended embryo cultivation is a method which improves the results of the conception by techniques IVF and ET. Eggs, sperm and embryos are stored in a special media (cultivation solution) which is creating suitable conditions for its development. Cultivation solution is exchanged every day in the aim to provide conditions for the development of embryos as natural as possible.

Cultivation to the state of blastocyst

By using the special solutions it is possible to extend the time of cultivation of embryos for up to 5 or 6 days (state of a blastoyst). The benefit of this procedure is the option to choose the best quality embryos for transfer and increase the chances for pregnancy. Use of the long cultivation is suitable especially when the number of mature eggs is sufficient (6 and more). Determination of an optimum date for ET is very individual and can be different in repeated cycles.

Assisted hatching

A additional technique during which a small hole is made into the shell of a 2-4 day old embryo. The embryo then uses it to leave the shell. It is recommended to use this technique for embryos with thicker shell or in cases of repeated implantation fail (in previous cycles the embryo did not implant spontaneously).

Cryopreservation of embryos

Freezing of embryos is a method thanks to which we are able to preserve surplus quality embryos for as long time as needed. They are kept in liquidized nitrogen and ready for later transfer. Cryopreservation in used when there is enough of quality embryos which have not been transferred in given cycle (for example for the risk of multiple pregnancy). In case of serious Ovarian hyper-stimulation syndrome or not suitable conditions for transfer (other illness of the patient, low lining etc.) all of the embryos are frozen. Despite of standardization of the procedure not all of the embryos will survive the defrosting in a condition suitable for transfer.

The success rate of the transfer of frozen embryos- defrosted embryos (cryo-embryo transfer) is lower than with fresh embryos. For the lady this is more convenient as she does not need to repeated hormonal therapy and egg retrieval. Based on current knowledge there is not know increased risk of abnormalities or congenital developmental defects caused by this method.

Donated eggs, sperm or embryos

In the case the couple does not have own suitable sperm, eggs or either, the situation can be solved by the use of sperm, eggs or embryos from a anonymous donor. Donors have to undergo genetic tests (karyotype, CFTR) a serological test to exclude possibility of inherited diseases and infectious diseases (HIV, hepatitis B and C, syphilis and in male Chlamydia test as well). Despite of all these tests we can not conclusively exclude transmission of infectious diseases or genetic disorders from donors to recipients or their offspring. The facility is bound by law to secrecy and must not give the identity of a donor or a recipient up.

PGD, PGS

PGD, PGS are diagnostic methods, which enable us to test some of the genetic attributes of embryos prior their transfer in to the uterus. From an embryo (D3) we are able to extract 1 or 2 cells and put them through the genetic analysis. Embryos usually survive this procedure without any harm and are developing in a normal manner.

The pre-implantation screening helps to discover obtained or inherited deviations in the number or the structure of a chromosome. These abnormalities are often connected with spontaneous abortion.

Using pre-implantation tests we can also discover changes (mutations) of particular genes connected to particular inherited disease which has occurred in the family (PGD).

PGS and PGD methods are recommended to couples when:

  • The age of the lady is over 35 years and therefore the risk of a birth of a child with higher number of chromosomes (i.e. Down syndrome) is increased.
  • There occurred a miscarriage or birth of a fetus with chromosomal deviation.
  • There are repeatedly failed IVF treatments or repeated miscarriages in early phase of gravidity.
  • There is known chromosomal conversion in one of the partner’s results. Without been obviously affected this could lead to a production of affected sperm or eggs and handing it over to descendants.
  • Where there is an illness connected to sex (the illness affects males only, but it is handed over by female – for example hemophilia).
  • When one of the partners underwent or is undergoing chemotherapy or radiotherapy.

The Pre-implantation diagnostic can not fully guarantee the choice of an embryo which has no defect. It is given by the principle of the method. We can test only particular spectrum of deviations which could compromise the embryo of a given couple the most. As well as we are unable to guarantee the success of the IVF program meaning implantation of an embryo after the transfer and creation of a pregnancy. We can not guarantee birth of a healthy child. All this is affected by loads of other factors.

MESA and TESE (Micro Epididymal Sperm Aspiration and Testicular Sperm Extraction)

MESA - microsurgical aspiration a of the sperm from a epididymis. A procedure performed in case of distraction of a sperm transport between epididymis and urethra. The procedure is in most case performed as an open surgery in general anesthesia. That mean via cca. 3 cm long cut in the scrotum access to the ipididymis is gained and the fluid is aspirated using a pipette straight from the channels. The fluid is analyzed during the procedure in the embryology laboratory. If some live sperm is present it is used for eggs fertilization using the ICSI method.

In the case there has been no sperm obtained during MESA we proceed to TESE. This is a procedure when we can get the sperm from the epithelium if the sperm is unable to travel from the testicle in to the epididymis.

Via a small cuts in the testicles cover we get a piece of the tissue. This is proceeded in the lab. If any live sperm is present it is used for fertilization. If azoospermia(no living sperm) is repeatedly confirmed, gain of a suitable sperm is not guaranteed using these methods. The patient is informed about the outcome of a procedure straight post procedure.

 

  

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