Stress and Infertility

Stress is defined as any event that a person perceives as threatening or harmful. Stress can result in the heightened activity of many body organs. This increased activity is offset by hormones secreted by the adrenal glands and through the nervous system. Acute stress can result in increased heart rate, blood pressure, and respiration, as well as sweaty palms and cool, clammy skin. Chronic stress can also cause depression and result in changes in the immune system and sleep patterns.

Stress… causing Infertility

Although infertility is a highly stressful experience, there is very little evidence that infertility can be caused by stress. In rare cases, high levels of stress in women can change hormone levels and cause irregular ovulation. Some studies have sown that high stress levels may also cause fallopian tube spasm in woman and decreased sperm production in men.

Infertility…causing Stress

Research has shown that women undergoing treatment for infertility have a similar, and often higher, level of “stress” as women dealing with life-threatening illnesses such as cancer and heart disease. Infertile couples experience chronic stress each month, first hoping that they will conceive and then dealing with the disappointment if they do not.

Why Infertility is so stressful?

When diagnosed with infertility, many couples no longer feel in control of their bodies or their life plan. Infertility can be a major crisis because the important life goal of parenthood is threatened. Most couples are accustomed to planning their lives. Experience has shown that if they work hard at something, they can achieve it. With infertility, this may not be the case. Infertility testing and treatments can be physically, emotionally, and financially stressful. A couple’s intimacy is often reduced by the infertility experience, which further contributes to increased stress levels. Trying to coordinate medical appointments with career responsibilities can also increase pressures on infertile couples.

TIPS for stress reduction:

• Keep the lines of communication open with your partner.
• Get emotional support so you don’t feel isolated. Individual or couple counselling, support groups, and books on infertility can validate your feelings and help you cope.
• Learn stress reduction techniques such as meditation or yoga.
• Avoid excessive intake of caffeine and other stimulants.
• Exercise regularly to release physical and emotional tension.
• Have a medical treatment plan your and your partner are comfortable with.
• Learn as much as you can about the cause of your infertility and the treatment options available. Check your local library, bookstore, or the Internet for additional information on infertility.

Prediction of Fertility Potential in Female Patients

A woman’s reproductive potential declines with age. This is reflected in the decreased ability to conceive (become pregnant) and increase in the rate of spontaneous abortions (miscarriages).
Although fecundity (the ability to achieve a pregnancy that results in a live birth) decreases in all women as they age, the precise age when a woman can no longer conceive varies between individuals. Approximately one-third of couples in which the female partner is in age 35 or older will have problems with fertility. It is estimated that two-thirds of women will not be able to get pregnant spontaneously by the age of 40.

Several tests may be useful in assessing fertility potential in older patients. For those patients with poor fertility potential predictions, the use of donor eggs (egg donation) or embryos (embryo adoption) can be considered.

Day 3 levels of FSH, LH, and estradiol. The determination of blood concentrations of follicle stimulating hormone (FSH) and estradiol levels on menstrual cycle day 3 has been used to estimate fertility potential. Women with elevated levels of FSH and/or estradiol measurements on cycle day 3 have very poor pregnancy rates with both ovulation induction and assisted reproductive technologies (ART) such as in vitro fertilization (IVF). More recently, it has been shown that women with elevated blood levels of luteinizing hormone (LH) on cycle day 3 also have poor pregnancy outcomes with fertility therapy.

Clomiphene citrate challenge test.
This test entails the oral (by mouth) administration of 100 milligrams of clomiphene citrate on menstrual cycle days 5-9. Blood levels of FSH are measured on cycle day 3 and again on cycle day 10. Elevated blood levels of FSH on cycle day 3 or cycle day 10 are associated with very low pregnancy rates with both ovulation induction therapy and ART.

Response to gonadotropins.

Gonadotropins (Pergonal (R), Humegon (R), and Repronex (R)) are concentrated mixtures of FSH and LH or FSH alone (Fertinex (R), Follistim (R), or Gonal-F (R)), which are given as injections to stimulate the ovary to produce multiple eggs in preparation for various fertility therapies. The amount of gonadotrophins required to induce egg development increases with increasing chronological age. Patients requiring large amounts of gonadotropins to induce egg development generally have lower pregnancy rates with both ovulation induction therapy and ART.

Several laboratory methods are currently used to measure blood levels of FSH, LH, and estradiol. Measurement of these hormone levels may vary considerable depending upon the particular laboratory method used. Therefore, it may be difficult to compare blood levels of these hormones that are measured at different laboratories or by different laboratory techniques. It is important that normal and abnormal test values be based on the pregnancy rates achieved by women studied at a particular center using the same laboratory methods.

Planning an Effective Infertility Treatment Strategy

referred to Michael Kettel, M.D. and William Hummel, M.D
from San Diego Fertility Center

• Establish a Diagnosis
• The Infertility Evaluation
• Age and the Reproductive Process
• Formulating a Game Plan
• When to Move On
• When to Stop
• Conclusion

ESTABLISH A DIAGNOSIS

The normal menstrual cycle is a repetitive process which might be viewed as “reproductive failure.” As the normal physiologic intention of the menstrual cycle is to result in a pregnancy each and every time it occurs, menstrual bleeding might be viewed as failure of this process to occur. The hallmarks of the menstrual cycle include a dynamic coordination of the hypothalamic- pituitary-ovarian-endometrial axis to culminate in the release of a mature oocyte.

This mature oocyte must be successfully retrieved by the fimbriated end of the fallopian tube and made available for fertilization. In an independent process, sperm placed in the vagina at the time of intercourse must successfully survive the hostile environment of the vagina, enter the favourable confines of the cervical mucus and ultimately work themselves into the upper genital tract. The head of each sperm contains specific binding sites for the outer layer of the egg (zona pellucida). Once the sperm has bound to the zona pellucida then the fertilization process can occur. After ovulation, the egg lives for approximately 72 hours. Therefore, intercourse every other day around the mid cycle should successfully result in a condition in which fertilization can be maximized. Realizing the intricacies of this system, the normal fertility curve can be appreciated.

Cycle fecundity is a term used to describe the likelihood of a pregnancy occurring with each individual menstrual cycle. The human is a relatively inefficient reproducer and, in fact, the cycle fecundity is approximately 22%. If one views this fertility curve over time, successful reproduction is a result of repetitive attempts at this intricate fertilization process. Realizing, and keeping in perspective the normal fecundity curve can allow patients and physicians to embark in fertility treatments with realistic expectations.

INFERTILITY EVALUATION

The infertility evaluation consists of a variety of tests to document normal sperm, normal ovulation, fallopian tubal patency, normal endometrial environment, and a normal pelvis. There are multiple, controversial tests that have been proposed to evaluate the reproductive condition and identify particular pathologic disorders. Tests that fall into this controversial category including the following: post coital test, late luteal phase endometrial biopsy, antisperm antibody determinations, penetration tests, and serial ultrasounds to determine the luteinized-unruptured-follicle syndrome. All of these controversial tests have relatively poor sensitivity and specificity and, as a result, are fraught with false negatives and false positives. Using these tests, therefore, should be approached with caution. Certainly many pregnancies have resulted in couples whom antisperm antibodies have been identified…

The diagnosis of “unexplained infertility” then becomes a diagnosis of exclusion. It reflects our lack of understanding of the reproductive process and includes couples that are normal as well as couples who may have subtle defects in the reproductive process. The treatments for unexplained infertility places a couple in a relatively favourable prognostic category. When viewed with other common causes of infertility, unexplained infertility often results in both treatment dependent and treatment independent success.

AGE AND THE REPRODUCTIVE PROCESS

Most people are aware that increasing maternal age leads to a decline in fertility. In fact, this decline occurs fairly acutely after the age of 37 and continues to decline up through the menopause. In almost any arena in which age is evaluated, advancing age leads to a decline in either treatment success or ultimate pregnancy outcome. With advancing maternal age increases also miscarriage rate and increase chromosomal abnormalities . Once a pregnancy has successfully entered the second trimester, it does not appear that other pregnancy risks are increased. One test which can offer some insight into this aging process is the “day 3” FSH. FSH is the pituitary hormone which is primarily responsible for folliculogenesis. As such, an increasing day 3 FSH reflects ovarian resistance to ovulation. In some studies the day 3 FSH has been shown to be a better predictor of pregnancy success than chronologic age. A day 3 FSH of greater than 25 mIU/mL places the woman in a relatively poor prognostic category whereas a day 3 FSH of less than 15 mIU/ml places the woman in a good prognostic category. It must be emphasized that the day 3 FSH value varies from cycle to cycle and that a singled isolated, elevated day 3 FSH is not the final bad signal for a woman considering pregnancy.

FORMULATING A GAME PLAN

The treatment of many causes of infertility revolves around a concept to increase cycle fecundity. Cycle fecundity is the likelihood of a pregnancy resulting in any given menstrual cycle. Treatments that increase cycle fecundity can be applied to a multitude of pathologic conditions. These treatments accelerate the “fertility curve” and may improve the otherwise protracted curve of patients with unexplained infertility. There are three basic techniques to increase cycle fecundity:

1. The first technique is intrauterine insemination(IUI). Intrauterine insemination involves a process that improves the timing of insemination to ovulation, increase the number of motile sperm that reach the fallopian tubes and may increase the number of capacitated sperm that reach the upper genital tract.
2. The second technique to increase cycle fecundity is superovulation. Superovulation requires the use of fertility drugs. Clomiphene citrate, human menopausal gonadotropins (Pergonal, Humegon, hMG) or rec(recombinant)FSH (Gonal-F, Puregon) have been used to induce a condition of superovulation. When these drugs are prescribed, the expected result is an increase in the number of ovulated eggs per cycle to result in an increase in the likelihood of fertilization occurring. Fertility drugs may also increase the efficiency of folliculogenesis and may improve subtle luteal phase insufficiencies.There is now a body of literature which hasexamined each of these techniques in unexplained infertility. It appears that intrauterine insemination and clomiphene citrate do a relatively poor job of increasing cycle fecundity when used alone. It is the combination of clomiphene citrate plus intrauterine insemination which results in an increase in cycle fecundity. The use of hMG or recFSH either alone or in combination with intrauterine insemination has been shown to increase cycle fecundity. Overall, the best results are seen when these drugs are used together with IUI.
3. The third technique that results in an increase in cycle fecundity are assisted reproductive technologies, which include a variety of procedures including IVF-ET, ICSI-ET.

WHEN TO CHANGE TREATMENT SCHEME

Each treatment cycle should be viewed as an independent event. This means that if the first cycle fails, the next cycle has an equal chance of working! this cycle independence holds true for each type of treatment for three cycles of treatment. If you examine the clinical efficacy of a given treatment protocol, the cumulative pregnancy should be viewed as the likelihood of conception within a reasonable time frame, approximately 3-4 cycles, and NOT after only one attempt.

When deciding when to move from one treatment protocol to another, it is important to review what has been learned from the preceding treatments. Did the ovaries respond appropriately? Did the endometrium reach a target thickness? Did the follicles release the eggs? Were the hormone levels correct? By examining the response to treatment the patient and physician can decide when it is appropriate to move from one treatment protocol to another.

By and large, if a treatment is going to work, it will be effective within three cycles. The majority of success occur during the first three attempts and this presents a reasonable interval in which to schedule a re-evaluation consultation with your physician. Before this visit, the patient must re-evaluate their feelings and comfort zone about treatments. It is interesting to observe the changes in a couple’s comfort zone as they experience successes and failures with differing treatments. A couple who first thought they would not possibly consider artificial insemination may seriously look at IVF after a few cycles of hMG injections!

WHEN TO STOP TRYING…

The decision to stop treating is probably one of the most difficult decisions faced by any couple who struggles with infertility. A sense of when to stop and when to continue can be reached if a couple has a firm grasp on their objectives. For instance, one couple may have as their goal to have a baby in their home and are willing to consider adoption or egg donation as a route to achieve this goal, whereas another couple is not at all interested in this approach and have decided that if they cannot conceive using their own egg/sperm they would not have children. Very personal choices that differ from couple to couple.

Unfortunately, your doctor may not help much with this decision. Remember…it is the doctor’s job to think of alternatives and choices for you to consider. It is your job to decide which choice is best for you. One couple may enthusiastically proceed with egg donation IVF whereas another stops short of laparoscopy to correct endometriosis.

CONCLUSION

• Establish a diagnosis
• Begin treatment at an appropriate level
• Evaluate a treatment plan at three cycle intervals
• Keep an open mind and long-term goals in perspective

A sexually active woman between the ages of 20 and 30 has a monthly pregnancy probability of approximately 25%. This means that out of every ten women trying to conceive, about nine will successfully become pregnant within a year.

However, one in ten will not conceive – meaning these women are either infertile or have reduced fertility. Clinically, infertility is generally defined as the inability to achieve pregnancy after one year of regular, unprotected intercourse.

Fortunately, many women facing fertility challenges can successfully achieve pregnancy using assisted reproductive technologies (ART), such as IVF. Additionally, a variety of other medical treatments and diagnostic evaluations are available for couples to explore prior to pursuing artificial insemination. It is also quite common for a woman who has previously participated in a fertility program to later conceive naturally, despite having faced years of unexplained infertility in the past.

Through comprehensive clinical diagnostic testing, the underlying cause of infertility can usually be identified. The cause remains unexplained in about 20% of cases, and even within this group, couples are frequently able to achieve a successful pregnancy. Statistically, female factor infertility accounts for approximately 40% of cases, while male factor infertility accounts for another 40%.

To determine the specific cause of fertility challenges, standard diagnostic evaluations include:

• For women: Ovulation tracking, hormone level testing, and evaluation of fallopian tube patency.
• For men: Assessment of sperm production—including sperm count, motility, and morphology—which requires a comprehensive semen analysis.

Female Infertility Causes

• Hormonal imbalances: Endocrine disorders that disrupt the development of ovarian follicles or prevent the release of a mature egg from the ovary (ovulatory dysfunction or anovulation).
• Damaged or blocked fallopian tubes: Tubal factor infertility that prevents the egg and sperm from meeting or stops a fertilized embryo from reaching the uterus.
• Endometriosis: A condition where tissue similar to the lining of the uterus grows outside the uterine cavity, causing inflammation and damaging neighboring reproductive organs.
• Hostile cervical mucus: Abnormally thick cervical mucus that acts as a barrier, preventing sperm from surviving and passing into the uterus.

Male Infertility Causes

• Low sperm count (Oligozoospermia): A healthy sperm count typically contains at least 15 to 20 million sperm per milliliter of semen. Counts below this threshold are considered a factor in reduced male fertility.
• Poor sperm motility (Asthenozoospermia): The sperm lack the progressive movement required to travel through the cervix and reach the egg in the fallopian tubes.
• Abnormal sperm shape (Teratozoospermia): Structural irregularities prevent the sperm from penetrating the outer layer of the egg or successfully completing fertilization.
• Azoospermia: The complete absence of sperm in the ejaculate, which can result from a failure in sperm production (testicular failure) or a blockage in the reproductive ducts (obstructive azoospermia).
• Sexual dysfunction: Difficulties during intercourse, such as ejaculatory dysfunction or erectile dysfunction (impotence).

The Role of Assisted Reproduction

Guidelines for Semen Analysis (Sperm Test)

• Abstinence window: The male partner must abstain from ejaculation for 2 to 7 days prior to the test.
• Sample collection: The semen sample is collected via masturbation in a private room directly at the laboratory facility to ensure optimal sample processing.

Advanced Male Fertility Investigations

Diagnostic Examinations

Gynaecological Ultrasound

• Transabdominal Ultrasound: Performed by moving a transducer across the lower abdomen. This approach requires a full bladder to optimize imaging.
• Transvaginal Ultrasound: Performed by gently inserting a specialized probe into the vagina. This is the preferred method in gynecology as the shorter distance allows for significantly clearer, high-resolution images of the pelvic structures. This approach requires an empty bladder.

HyCoSy (Hysterosalpingo-Contrast-Sonography)

• Procedure: A speculum is placed to visualize the cervix, and a thin, flexible catheter with a small retaining balloon is gently inserted. After removing the speculum, a safe contrast medium is introduced into the uterine cavity via the catheter. A transvaginal ultrasound probe is then used to track the contrast fluid as it fills the uterus, travels through the fallopian tubes, and spills out from the fimbriated ends (the uterine horns).
• Duration & Comfort: The procedure takes about 20 minutes. No anesthesia is required, though mild, temporary cramping may occur, which can be managed with over-the-counter pain relievers before or during the session. Patients must empty their bladder prior to the procedure.
• Advantage: It combines structural uterine screening with tubal patency testing in a single outpatient visit without exposing the patient to X-ray radiation.

Hysteroscopy

• Procedure: A thin, fiber-optic telescope (hysteroscope) is guided through the vagina and cervix into the uterine cavity, providing a clear, illuminated view on a monitor. Upon removal, an endometrial biopsy (tissue sample) is typically taken to verify if the lining matches the expected phase of the patient’s menstrual cycle.
• Treatable Conditions: Uterine polyps, uterine septums (a congenital tissue band dividing the cavity), and uterine fibroids (myomas).
• Anesthesia & Recovery: Performed as a day-case procedure under general or local anesthesia, lasting 20 to 40 minutes. Post-procedure, patients may experience mild discomfort and mild cramping manageable with pain medication. Most patients return to normal activities the same day; if operative corrective surgery is performed, a few days of home rest are recommended.

Surgical Treatments for Female Infertility

Laparoscopy

• Procedure: Under general anesthesia, a small incision is made near the navel, and carbon dioxide ($CO_2$) gas is introduced into the abdomen to separate the organs and optimize visualization. A fiber-optic laparoscope is inserted, and a second micro-incision may be made for a secondary probe to safely manipulate tissues.
• Tubal Patency Dye Test: To test for blockages, a colored dye can be injected into the uterus through the cervix. If the fallopian tubes are open, the dye will be seen flowing through them and exiting into the pelvic cavity.
• Duration & Recovery: The procedure takes approximately 20 minutes. Post-operative effects include mild pelvic discomfort and bloating from residual gas. Displaced gas near the diaphragm may cause temporary shoulder pain, which responds well to analgesics. Patients typically resume normal daily routines within 2 to 3 days.

Adhesiolysis

• Procedure: Performed under general anesthesia. It is ideally completed laparoscopically, though severe, extensive cases may require a conventional laparotomy (abdominal incision). Specialized microsurgical instruments are used to carefully divide the tissue bands.
• Recovery: Following a laparoscopic approach, discomfort is mild and easily managed with analgesics; patients are discharged the same or next day, returning to full activity within a week. A conventional laparotomy requires up to 5 days of hospitalization and a recovery window of up to 6 weeks.
• Prognosis: Because adhesions can recur to varying degrees in some patients, couples are generally advised to try to conceive within one year following the surgery.

Salpingostomy

• Procedure: Under general anesthesia, any restrictive scar tissue covering the end of the fallopian tube is meticulously cleared. The tube is then opened, and its edges are delicately folded back and secured to ensure it remains permanently open. The surgery lasts 40 to 60 minutes and is performed either laparoscopically or via a conventional abdominal incision.
• Recovery: Prophylactic antibiotics are administered post-op to prevent subsequent infections that could cause re-scarring. Pain is managed effectively with analgesics. Laparoscopic patients go home the same day and recover within a week, whereas conventional surgery requires a 5-to-7-day hospital stay and up to 6 weeks of recovery.
• Success Rates: While surgical opening of the tubes is successful in up to 80% of cases, the subsequent functional pregnancy rate is approximately 20% due to potential underlying microscopic damage to the inner cilia of the tubes.

Tubal Reversal (Reversal of Sterilization)

• Preparation: The first step is to determine the length of the functional tube sections and locate the occlusion. This is assessed via a HyCoSy ultrasound or a hysterosalpingography (HSG) X-ray.
• Procedure & Recovery: Performed under general anesthesia via laparoscopy or a mini-laparotomy. Post-operative discomfort is successfully managed with pain medication. Laparoscopic patients are discharged on the day of surgery and recover within a week. Conventional open approaches require 4 to 6 days of hospitalization and a 4-to-6-week recovery period.
• Timeline: Couples are recommended to actively try to conceive within 6 to 12 months post-surgery, as long-term healing can sometimes trigger new scar tissue formation that could re-block the tubes.

Polycystic Ovary Syndrome (PCOS) Treatments

• Medical Management: Aims to restore endocrine balance and induce ovulation. Medications like clomifene citrate work by modulating estrogen feedback, which increases the secretion of Follicle-Stimulating Hormone (FSH). Elevated FSH levels trigger healthy follicle maturation and subsequent ovulation.
• Surgical Management (Ovarian Drilling / Diathermy): If medical management is unsuccessful, laparoscopic ovarian drilling is an option. Under general anesthesia, a laparoscope is used to view the ovaries, and a laser or specialized electrocautery (diathermy) probe applies precise local heat to puncture the ovarian cortex. This reduces hormone-producing tissue, lowers androgen levels, and helps restore regular ovulatory cycles. The procedure takes roughly 30 minutes, and patients return to regular activity within 2 to 3 days.

Surgical Treatments for Male Infertility

Varicocele Ligation

• Procedure: Performed under general anesthesia, taking approximately 30 minutes. It can be executed as a day-case laparoscopic procedure or via conventional open surgery. The surgeon identifies the dilated veins and either ligates (ties them off) or injects a sclerosing solution to close them.
• Recovery & Success Rates: Post-operative discomfort is mild and managed with standard pain medication. Varicocele ligation successfully improves sperm count, motility, and morphology parameters in 40% to 60% of patients.

Vasectomy Reversal (Vasovasostomy)

• Procedure: Performed under general anesthesia and can last over an hour. The surgeon makes an incision in the scrotum or lower groin to locate the severed ends of the vas deferens on both sides. Using specialized multilayered microsurgical techniques (vasovasostomy), the pathways are meticulously reconnected to allow sperm to pass from the testes into the urethra for ejaculation.
• Recovery: Patients return home the same day. Strenuous physical exertion must be avoided during the immediate post-operative days, with full recovery achieved within 1 to 2 weeks. Mild soreness is managed with analgesics.
• Follow-up & Success: A semen analysis is scheduled three months post-surgery to evaluate the return and quality of sperm in the ejaculate. While anatomical success (sperm returning to the semen) is achieved in 70% to 80% of cases, successful natural conception depends heavily on the time elapsed since the original vasectomy. A longer interval increases the risk of permanent sperm quality decline or the development of anti-sperm antibodies.
• Sperm Cryopreservation Backup: If cryopreservation facilities are available at the clinic, sperm can be harvested directly during the surgical procedure and frozen. If post-operative semen quality is insufficient for natural conception, this frozen backup can be utilized in assisted reproductive treatments like IVF or ICSI.

• Ovulation Induction (OI)
• In Vitro Fertilization (IVF)
• Intrauterine Insemination with Donor Sperm (IUI-D / AID)
• Intrauterine Insemination with Partner’s Sperm (IUI-H / AIH)
• Oocyte (Egg) Donation combined with IVF
• Intracytoplasmic Sperm Injection (ICSI)
• Assisted Hatching (AH)
• Testicular Sperm Aspiration (TESA)
• Microepididymal Sperm Aspiration (MESA)

Ovulation Induction (OI)

• Indications: This protocol is highly effective for women experiencing endocrine disorders or Polycystic Ovary Syndrome (PCOS).
• Monitoring: To optimize the cumulative pregnancy rate and mitigate the risk of multiple pregnancies or ovarian hyperstimulation, response to treatment is closely monitored via transvaginal ultrasound and tracking follicle growth.
• Success Rates: The average clinical pregnancy rate per treatment cycle ranges between 15% and 25%.

In Vitro Fertilization (IVF)

The General IVF Protocol:

1. Controlled Ovarian Hyperstimulation: A customized medication regimen is administered to stimulate the maturation of multiple ovarian follicles.
2. Cycle Monitoring: Follicle growth is carefully tracked using transvaginal ultrasound examinations (typically 2 to 3 times per cycle) and blood serum hormone assays to tailor medication dosages and prevent severe side effects.
3. Oocyte Retrieval (Egg Collection / Follicular Puncture): Mature eggs are harvested from the ovarian follicles via a minimally invasive ultrasound-guided procedure.
4. Sperm Collection: The male partner provides a fresh semen sample on the day of egg retrieval, or a previously cryopreserved sample is prepared.
5. Insemination: Collected mature eggs and processed, high-motility sperm are co-incubated overnight in a controlled laboratory environment.
6. Fertilization Assessment: The following day, microscopic evaluation confirms the presence of successful fertilization.
7. Embryo Transfer: One (or a maximum of two) high-grade embryo is gently transferred into the patient’s uterus under transvaginaal ultrasound guidance.
8. Embryo Cryopreservation: Any remaining high-quality embryos are safely vitrified (frozen) for future use.
9. Pregnancy Confirmation: Follow-up clinical screening and quantitative hCG testing are performed to track early pregnancy status.

Intrauterine Insemination (IUI)

IUI with Donor Sperm (IUI-D / AID)

IUI with Partner’s Sperm (IUI-H / AIH)

The General IUI Protocol:

1. Mild Ovarian Stimulation: A gentle medication course is used to promote the maturation of 2 to 3 follicles.
2. Follicle Monitoring: Progress is monitored 2 to 3 times per cycle via transvaginal ultrasound, combined with targeted hormone assays to optimize timing and ensure safety.
3. Ovulation Tracking: Assessment of basal body temperature and specialized ovulation prediction kits are utilized to identify the precise fertile window.
4. Sperm Processing: On the day of ovulation, the semen sample is washed and processed to isolate the highest quality, motile sperm.
5. Insemination: The concentrated sperm sample is transferred into the uterine cavity on the exact same day.
6. Follow-up: Clinical tracking is conducted to confirm successful implantation and pregnancy.

Intracytoplasmic Sperm Injection (ICSI)

ICSI with Surgical Sperm Retrieval (MESA/TESA)

• MESA (Microepididymal Sperm Aspiration): Harvesting sperm directly from the epididymis.
• TESA (Testicular Sperm Aspiration): Extracting sperm tissue directly from the testes.

The General ICSI Protocol:

1. Controlled Ovarian Hyperstimulation: Customized medication protocols are used to induce multiple follicle development.
2. Cycle Monitoring: Ultrasound scans and hormone level checks ensure safety and individualize dosing.
3. Oocyte Retrieval: Mature eggs are collected from the follicles.
4. Sperm Procurement: Sperm is obtained via fresh ejaculation or through surgical TESA/MESA extraction.
5. Micromanipulation (Injection): Mature eggs are denuded (cleared of outer cumulus cells), and one healthy sperm is carefully injected into each viable oocyte under a microscope.
6. Fertilization Verification: Microscopic evaluation the following day assesses fertilization progress.
7. Embryo Transfer: One or two high-grade embryos are transferred into the uterine cavity.
8. Vitrification: Remaining viable blastocysts/embryos are cryopreserved.
9. Pregnancy Care: Implantation is monitored through post-transfer diagnostics.

Embryo Transfer Procedure

Post-Transfer Care and Luteal Support:

• Hormonal Support: For the subsequent two weeks, the patient receives luteal phase support to promote uterine receptivity and support implantation. This consists of either targeted hCG injections or daily vaginal progesterone administrations.
• Embryo Banking: All additional viable embryos can be cryopreserved and securely stored for up to seven years, allowing for future Frozen Embryo Transfer (FET) cycles without the need for repeated ovarian stimulation.
• Lifestyle Guidance: Patients can immediately resume their daily routines. However, during the post-transfer window, it is highly recommended to avoid sexual intercourse, refrain from lifting heavy objects over 10 kilograms, and avoid hot baths, saunas, or steam rooms.

Surgical Sperm Retrieval: TESA and MESA

• TESA (Testicular Sperm Aspiration): A procedure where sperm or tissue samples are collected directly from the testes using a fine needle.
• MESA (Microepididymal Sperm Aspiration): A procedure where sperm is harvested from the epididymis, often performed microsurgically.

Psychological Stress and Treatment Failure

Multiple Gestations (Multiple Pregnancy)

Ovarian Hyperstimulation Syndrome (OHSS)

Spontaneous Abortion (Miscarriage)

Required Screenings for the Male Partner

Required Screenings for the Female Partner:

Pioneer Milestones of Our Medical Team:

• August 1995: The birth of the first IVF (In Vitro Fertilization) baby in Estonia.
• July 1996: The birth of the first Estonian baby achieved using a donated oocyte (egg donation).
• September 1996: The birth of the first baby achieved using embryo donation.
• March 1997: The birth of the first baby conceived via IVF using cryopreserved donor sperm.
• June 1997: The birth of the first baby resulting from a frozen-thawed embryo transfer (FET) processed entirely within our own IVF laboratory.
• 1998: The birth of our first baby achieved via ICSI (Intracytoplasmic Sperm Injection) micromanipulation technology.
• 2001: The birth of the first baby achieved using Assisted Hatching (AH) laboratory techniques.
• 2002: The birth of the first baby achieved following our own surgically performed TESA (Testicular Sperm Aspiration) extraction combined with an ICSI procedure.