In vitro fertilization

Problems with infertility will affect about one couple in seven. Of these, approximately half will end up undertaking some form of assisted conception treatment. In vitro fertilization can be viewed both as a test of reproductive potential, allowing detailed assessment of oocytes, oocyte sperm interaction and embryo quality, as well as an effective treatment for most forms of subfertility. The dramatic improvements in pregnancy rates seen with IVF treatment since its inception some 22 years ago have occurred due to close collaboration between biological scientists and clinicians with interests in the area. There have been several important landmarks, including the use of drugs for superovulation and pituitary downregulation, the introduction of transvaginal ultrasound for monitoring of follicle growth and oocyte collection, and embryological developments in embryo culture and, most recently, ICSI. Despite this progress, the majority of IVF cycles do not produce a viable pregnancy and the psychological stresses imposed upon couples by assisted conception treatment need to be managed carefully and sympathetically.     

Risks of fertilization in vitro

The authors report the results of four IVF attempts, performed on the same couple, in 16 months, because of tubal problems. June 1985 (T1): spontaneous miscarriage after 8 weeks of amenorrhea; october 1985 (T2): negative tap; january 1986 (T3): extra-uterine pregnancy; october 1986 (T4): rejected because of "poor response" and spontaneous extra-uterine pregnancy during the same cycle.     

Mycoplasmas and in vitro fertilization

Semen samples taken from 135 patients attending an in vitro fertilization clinic were shown to be colonized, 53 with Ureaplasma urealyticum (39%) and 16 with Mycoplasma hominis (12%). An unidentified mycoplasma species was isolated from the sperm of two patients. M. hominis was recovered from all the washed sperm samples taken from colonized semen, whereas washing the sperm eradicated U. urealyticum from 71% of colonized semen. The presence of mycoplasmas in semen made no significant difference to the sperm count, sperm motility, sperm abnormalities, or fertilization of eggs.     

Ovulation induction in in vitro fertilization

The main goal of an in vitro fertilization (IVF) program is to maximize the number of women who become pregnant in any treatment cycle. In order to achieve pregnancy, many steps should be successfully accomplished. The number of mature oocytes that are retrieved and fertilized in a treatment cycle has the major impact on the success rate of the IVF program. The chances of achieving conception increases dramatically when the number of embryos replaced into the uterus increases^1-3. Hence, most IVF treatment programs currently use some combination of ovulation induction agents in order to stimulate and aspirate as many follicles as possible.     

In vitro fertilization

Assisted reproduction techniques (ART) have become the ultimate treatment for different types of infertility as it circumvents many natural barriers to conception. Evolution of ART has not only included its indications but also the methods of ovarian stimulation, ovarian monitoring, gamete selection, fertilization techniques, embryo selection and culture and embryo storage. This article reviews the currently agreed and controversial indications of assisted reproduction and the preparatory steps before starting treatment. It also summarizes the basic concepts of pituitary down regulation and various protocols to achieve it, the main clinical and laboratory aspects of treatment cycle and complications of treatment.     

Hyperprolactinemia.

Prolactinomas are the most common pituitary tumors. Hyperprolactinemia is characterized by increased production of prolactin, often leading to reproductive dysfunction and galactorrhea. Prolactinomas may also cause male-factor infertility by producing hypogonadism. In addition, if large, they can produce neurologic symptoms by mass effect in the sellar area. The diagnostic evaluation first requires exclusion of other causes of hyperprolactinemia, such as pregnancy, primary hypothyroidism, numerous medications, and miscellaneous causes. The second step in the diagnostic evaluation is to perform a head scan, preferably an MRI. This is essential in order to exclude a "pseudoprolactinoma" which would require surgery. Following diagnostic evaluation, the next step is to determine whether a patient with hyperprolactinemia has an indication for therapy, such as a macroprolactinoma (tumor >1 cm), hypogonadism (risk of osteoporosis), infertility, significant galactorrhea, acne, hirsutism, or headache. The treatment of choice for nearly all patients with hyperprolactinemic disorders is medical. In most cases, dopamine agonists (bromocriptine, pergolide, cabergoline) are extremely effective in lowering serum prolactin, restoring gonadal function, decreasing tumor size, and improving visual fields. The main limitation is side effects, particularly nausea or orthostatic dizziness. The newest dopamine agonist, cabergoline, can be given just once or twice a week, is more effective in normalizing prolactin and restoring menses than bromocriptine, and is significantly better tolerated. However, it is not yet recommended as first-line therapy for patients seeking fertility, because adequate safety data in pregnancy are not available. For the infrequent patient unable to tolerate, or resistant to, medical therapy, neurosurgical transsphenoidal resection may be necessary, particularly if the patient has a large lesion jeopardizing the optic chiasm. Hyperprolactinemia is a rewarding disorder to manage because patients typically respond well to medication, with restoration of menses and fertility.     

Oocyte maturation and fertilization in vitro

From the time of early follicular growth to some time after ovulation, the oocyte undergoes many critical changes in its biochemistry. In this paper the author describes different steps in oocytes maturation some of which, during the early period, will require support from the follicle cells, while later in development endogenous synthetic activity can be maintained in the absence of such support.     

Male indications of fertilization in vitro

The place of male indications in FIV remains very limited. However, the best test of sperm fertility is the specific in-vitro fertilization. The search for improvement of the conditions of contact and fusion of the gametes seems well-founded. However, the therapeutic value of FIV in male indications remains debatable.     

Triploid embryo after in vitro fertilization

A case of a triploid embryo (69,XXX) resulting from in vitro fertilization is reported. The pregnancy ended in spontaneous abortion 44 days after embryo transfer. The embryo showed anomalies considered typical of triploidy but molar changes were not noted. The origin of extra chromosomes was apparently maternal.     

Antisperm antibodies and in vitro fertilization

The purpose of this study was to investigate the influence of antisperm antibodies in the male, the female, or both partners on the outcome of in vitro fertilization treatment. The results in terms of ongoing pregnancies in the male and female antibody-positive group were the same as in the antibody-negative group. In the double antibody-positive group two of the three patients became pregnant. When high levels of antisperm antibodies were present on the spermatozoa, the fertilization rate was significantly reduced. In the female positive group no clear relationship between the antibody titer and the fertilization percentage could be detected. Abnormal semen quality was responsible for a much lower fertilization rate than the presence of antibodies. The conclusion of this study is that in vitro fertilization provides an equal chance of conception in couples with antisperm antibodies in comparison with couples with no antibodies if the other semen parameters are normal.     

Human rights to in vitro fertilization

The Inter-American Court of Human Rights (the Court) has ruled that the Supreme Court of Costa Rica’s judgment in 2000 prohibiting in vitro fertilization (IVF) violated the human right to private and family life, the human right to found and raise a family, and the human right to non-discrimination on grounds of disability, financial means, or gender. The Court’s conclusions of violations contrary to the American Convention on Human Rights followed from its ruling that, under the Convention, in vitro embryos are not “persons” and do not possess a right to life. Accordingly, the prohibition of IVF to protect embryos constituted a disproportionate and unjustifiable denial of infertile individuals’ human rights. The Court distinguished fertilization from conception, since conception—unlike fertilization—depends on an embryo’s implantation in a woman’s body. Under human rights law, legal protection of an embryo “from conception” is inapplicable between its creation by fertilization and completion of its implantation in utero.     

Superovulation strategy before in vitro fertilization

This chapter reviews current understanding of the control of spontaneous preovulatory follicular development in the natural ovarian cycle as a basis for the design and use of superovulation strategy before clinical IVF. The principles, limitations and practical aims of therapy using clomiphene citrate and HMG to stimulate multiple follicular development are outlined together with details of methods in current use to monitor ovarian response to these drugs and to time ovulation induction and egg collection with HCG. Examples of successful IVF treatment cycles are given. It is stressed that properly controlled clinical trials to judge the relative merits of the various superovulation methods in current use for IVF have not been undertaken. Possible new approaches to ovarian stimulation before IVF include the use of 'pure' FSH, LHRH and pulsatile gonadotrophin administration.