Artificial Insemination (AI)
Artificial Insemination (AI) is the deliberate introduction of sperm into a female’s uterus for the main purpose of achieving a pregnancy through in vivo fertilization by means apart from sexual intercourse. This procedure is the beginning process for couples with either male or female with struggles in fertility.
Couple Who Should Proceed with Artificial Insemination
1. Male with low sperm count, but sperm has normal motility.
2. Male with less semen.
3. Male has hypospadias or impotence.
4. Female has cervical stenosis or vaginismus.
5. Couple who cannot detect the causes of infertility.
Artificial Insemination Procedure
1. The female visits one to three days post-menstruation to receive medication for ovulation induction.
2. The female visits to examine ovum size by ultrasound scan in order for the doctor to predict the ovulation date.
3. The doctor specifies the ovulation date for sperm injection. This process may involve superovulation injection.
4. The couple visits to collect sperm on the day of sperm injection. The male must strictly preserve ejaculation for three to five days before the assigned date.
5. After the sperm injection, the couple can live normally.
6. If menstruation does not occur within two weeks after the injection, try pregnancy test.
Each couple with infertility has success rate of approximately 10% per one treatment. If artificial insemination still does not work after three to six months, different methods may need to be considered in order to proceed a more successful pregnancy.
In vitro fertilization (IVF) is a fertilization process in which an egg is fused with sperm outside human body, and in vitro (“in glass“) instead. The process involves monitoring and stimulating female’s ovulatory process, removing an ovum/ova (egg/eggs) from the female’s ovaries and allowing sperm to penetrate into the egg. Then, the final product will be transferred back to the female’s uterine cavity. However, this process only suits for couples with non-severe infertility conditions.
Intracytoplasmic sperm injection (ICSI) is also an IVF procedure in which a single sperm is injected directly into an egg. This process will be used with a couple where the male either contains no sperm in semen or has severe infertility conditions.
Couple Who Should Proceed with In Vitro Fertilization
1. Female ages more than 35 years;
2. Female has constricted uterine tubes;
3. Female has serious endometriosis;
4. Female has polycystic ovary syndrome (PCOS);
5. Male has critical low sperm count or abnormal sperm motility, or no detection of sperm;
6. Couple who cannot detect the causes of infertility after trying to have a child for quite some time;
7. Couple who has tried artificial insemination for several times but never succeeded.
In Vitro Fertilization Procedure
1. The female visits within one to three days post-menstruation through ultrasound scan, and receive medication for ovulation induction in order to develop multiple of healthy ova.
2. The female visits to examine ovum size and receive ultrasound scan for two to three times as assigned by the doctor.
3. If the ova grow sufficiently strong and big, the female will have to be injected with medication to induce ovulation for ovum retrieval.
4. The couple visits to pick up ovum on the assigned date. The male must strictly preserve ejaculation for three to five days before sperm collection.
5. Ova and sperms will be fertilizing in the laboratory.
6. The female has to visit for embryo transfer three to five days after the ovum retrieval takes place.
7. In case the doctor advises to freeze embryos and wait, the doctor will schedule the female to visit after one to two days post the next menstruation for endometrium preparation medicine.
8. After fourteen days of embryo transfer, the female has to visit for pregnancy hormone test.
Embryo transfer (ET) is the last one of the IVF process. It is a critically important procedure. The entire IVF cycle depends on the delicate placement of the embryo at the proper location in the uterine cavity – with minimal trauma and manipulation. There are two different protocols to perform:
1. Fresh embryo transfer (Fresh ET) is a protocol which follows the IVF cycle of ovarian stimulation and occurs very soon after the initial ovum retrieval procedure. The transfer can take two to six days after successful fertilization. This protocol is used when the female is aged and develops only a few ova. This protocol specifically requires the female to have healthy endometrium as well.
2. Frozen-thaw embryo transfer (FET) is a transfer protocol after embryo freezing. The doctor will consider this protocol if there is sufficient amount of strong embryos. Due to the inducing medication that the female takes to develop multiple of healthy ova, the huge amount of hormones generated will weaken endometrium, consequently lessening the success rate of the transfer regardless of the perfect condition of embryos. Given the circumstance, FET may not be an effective protocol. However, a number of research institutes find that FET offers better and higher chance of pregnancy because endometrial tissue is in more proper state for embryos. Therefore, the doctor will have to decide which protocol fits best for each couple.
Testicular Sperm Extraction
Testicular sperm extraction (TESE) is the process of removing a small portion of tissue from the testicle under local anesthesia and extracting the few viable sperm cells present in that tissue for ICSI. This TESE process is for male who cannot produce sperm by ejaculation due to azoospermia, such as that caused by primary testicular failure, congenital absence of the vas deferens or non-reconstructed vasectomy.
Male Who Should Proceed with TESE
1. Male with no detection of sperms in semen or no semen;
2. Male who has had sterilization.
The patient will receive anesthetic, then the doctor will cut open a small wound of half to one centimeter to access sperm duct in order to select the best sperm for ICSI. The doctor will then use absorbable sutures for stitching so there is no need to remove stitches later. The patient need to lie down for 30 to 60 minutes after the operation is done. Afterwards, the patient can go back home right away. Usually, the doctor will perform TESE along with ovum
Oocyte freezing is a procedure to preserve a female’s ova. The eggs are extracted, frozen and stored. The intention of the procedure is that, in the future, the female may choose to have the ova thawed, fertilized, and transferred to the uterus as embryos to facilitate a pregnancy. Female who wants to perform oocyte freezing needs to keep in mind that:
1. Oocyte freezing is a process in which a female freezes her ova for future fertilization with a legitimate husband only.
2. Performing oocyte freezing before chemotherapy or other treatments could potentially harm the ovary.
Oocyte freezing has become a popular fertilizing procedure because people tend to get married and have a child in their older age. Therefore, there is a significant chance that their child could suffer from chromosomal abnormalities. Oocyte freezing allows the female to freeze the age of ova when the female collects them. However, these frozen ova have less durability that they could produce less embryos compared to fresher ones.
Oocyte freezing procedure is similar to ovulation induction for IVF where the patient is required to run health and blood diagnosis first. If no abnormalities are detected, the patient then can proceed with ovulation induction. After the ovum retrieval, the ova will be stored in an operation lab with proper temperature control.
Pre-implantation Genetic Diagnosis
Pre-implantation Genetic Diagnosis (PGD) is the genetic profiling of embryos prior to implantation to select the best embryo for fertilization.
Pre-implantation Genetic Diagnosis can be operated when:
1. Either female or male has genetic abnormalities that could pass down and cause their child severe disabilities or death;
2. Couple with no genetic abnormalities can run PGD if:
a. Female has experienced pregnancy with a child who has severe genetic abnormalities which can solved by PGD;
b. Their child/children was/were born with disorders which can be cured by HLA matching. The HLA matching will be useful when the stem cells from blood in the umbilical cord post-delivery, can be used to treat the patient’s child due to the matching tissues;
c. Female has experienced twice or more times of miscarriage within the first twelve weeks of pregnancy, or there is a valid report that genetic abnormality was the cause of the female’s last miscarriage;
d. Female ages more than 35 years and has medical abnormalities stating that the embryo may possibly have some kinds of specific genetic disorders;
e. Female has not got pregnancy two times in a row after applying to the assisted reproduction technology.
Pre-implantation Genetic Diagnosis Procedure
The procedure is exactly the same as IVF procedure, beginning from ovulation induction to the phase of embryo preparation. Normally, the appropriate embryonic development period to perform PGD for biopsy can be divided into 3 stages:
1. Polar body stage is the stage appropriate to take a sampling of a polar body from an oocyte or the embryo before the fertilization process for the diagnosis;
2. Cleavage stage is the third day post-fertilization;
3. Blastocyst stage is the stage where a doctor normally performs the diagnosis due to the amount of cells which least distracts the whole embryonic development process. Moreover, this stage is where the doctor can diagnose less chromosomal differences (or known as “mosaicism”) between each cells, compared to the cleavage stage. After taking care of embryo until it reaches the sufficient amount of divided cells, which normally occurs during the third or fifth day post-fertilization, the doctor will have to pick each of the embryos for PGD in order to identify whether the embryo is ready or not. Then, the doctor will select the healthiest embryo to place into the uterine cavity for implantation and pregnancy.
Today, it is pervasively accepted that the baby who has been through PGD is identical to the ones who are born naturally because such diagnosis is technically a genetic diagnosis from only one represented cell from the whole embryo. This means this kind of diagnosis requires meticulousness and precision, and is therefore more complicated than diagnosing from blood or other tissues due to the less amount of genetic materials contained in one cell.
Simply put, PGD takes time and needs to be in responsibility of highly experienced doctors and medical team for the least distraction to the embryo, and for the most accuracy during the diagnosis for the best outcome possible.
Blastocentesis is a procedure in taking a sampling from blastocyst fluids (BFs) for the chromosome diagnosis of the embryo. This procedure is considered widely today as the fluids contain a greater number of cell-free DNAs than in both blastomere and trophectoderm which can greatly facilitate the whole diagnosis.
The advantage is that this procedure can enormously lessen distractions for the embryonic development due to the cell minimization used for the diagnosis. This means it can develop the embryo more greatly, while narrowing the chance of generating chromosomal differences between cells at the same time. The result of diagnosis from chromosomes in the fluids and cells during blastocyst stage also affirms to be identical.
Today, blastocentesis is considered the technology which reflects better result regarding less distractions for the embryo and more accuracy in chromosomal diagnosis than any other traditional processes. Genesis Fertility Center has been applying this modern technology for PGD, and is anticipating to bring the highest level of satisfaction to every couple with infertility who needs to perform the screening of the embryo before placing it back to the uterine cavity.
Techniques in Pre-implantation Genetic Diagnosis
PGD can be performed in a number of ways and each way reflects variable levels of accuracy. Genesis Fertility Center has selected the best and the most modern way of PGD for every couple to meet the highest level of satisfaction with our most advancing assisted reproduction technology today.
Comparative genomic hybridization (CGH) is one of the techniques of PGD diagnosing all 23 pairs of chromosomes – 22 pairs of autosomes (body chromosomes) and one pair of allosomes (sex chromosomes). This procedure analyzes in molecular level which is applied to the technique called whole genome amplification (WGA) to increase the amount of genetic materials before being brought to perform in the diagnosis for deeper details of genetic statuses. While in chromosomal level, the technique of labelling genetic materials with fluorescein dyes with different colors is used to both the materials from the embryo and the standard samples. Then, these labelled materials will go through chain reaction and the result will be interpreted by computer, which can completely detect aneuploidy, unbalanced translocation, or even chromosome deletion or duplication. However, this technique finds its own limits in detecting the genetic materials with balanced translocation or inversion. As these abnormalities do not differ the significant amount of genetic materials in a chromosome compared to the standard samples, this technique requires at least 24 to 72 hours to be completed, depending on sub-techniques.
Next generation sequencing (NGS) is pervasively known as one of those assuredly effective sub-techniques. Normally, a human body consists of 23 pairs of chromosomes and, as aforementioned, each of the chromosomes contain genetic materials essential for the organism to develop and grow and to function properly. One chromosome consists of genes, and each of these genes consist of amino acids containing a great amount of base sequences. This means that one abnormal or mutated gene can inevitably pass body disorders and malfunctions from its inheritor to its offspring. Given that, performing PGD with NGS is the special technique in detecting abnormalities of a gene deep to its base sequences, the smallest component of one chromosome, by comparing these sequences of abnormal gene to the normal one. Therefore, this technique can be highly accurate in detecting the abnormalities occurring in any genes, and is now applied to pre-implantation genetic screening (PGS), one of the best means for diagnosis in the present.
The advantage of performing PGD with NGS is that the result of diagnosing abnormalities in all 23 pairs of chromosomes can be 99.9% accurate and can reflect detailed data afterwards. Moreover, NGS also takes less time to perform as the procedure can be completed within 24 hours.
Limitations in Pre-implantation Genetic Diagnosis
Despite giving 95 to 99% correct results, PGD still has a gap regarding accuracy, making it not a 100% perfect protocol to identify genetic abnormalities pre-delivery. Therefore, a thorough pre-delivery diagnosis is still recommended. In addition to that, the couple should acknowledge the chance of proper embryo acquisition since, quite a number of times, the embryos acquired are not in healthy condition. For example, filtering thalassemia along with HLA. Therefore, the couple is recommended to attend a series of medical treatment before performing the implantation.
Our Advance Technology at Genesis Fertility Center
Genesis Fertility Center utilizes modern PGD technology for quick and accurate results while least distracting the embryo, and that technology is to collect sample cells or blastocyst fluids for a genetic analysis using NGS. The results will help the doctor decide which embryo is the best for the implantation. Performing a genetic analysis on the embryo pre-implantation makes identifying the embryo’ abnormalities significantly more accurate. It also provides the doctor and the couple detailed information which are considerably useful for making deliberate decisions later. In addition, this process also lessens the chance of picking an embryo with genetic abnormalities while increases the pregnancy chance of the couple. If interested, the couple needs to make sure there are proper indicators. After making the decision, the doctor will inform the couple about the procedure, limitations, result analysis accuracy, implantation success rate and estimate cost before proceeding the whole process. If they find success with pregnancy, a thorough pre-delivery diagnosis is highly recommended.