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IVF is the best treatment for a number of fertility problems. In cases of tubal disease or absent fallopian tubes, or when there is extensive scarring of the tubes and ovaries, IVF may allow a woman to achieve a pregnancy. If young and healthy, she should respond well to fertility drugs. Another group are women who have had surgical sterilizations, where large sections of the fallopian tube have been removed: their chances of a successful microsurgical sterilization reversal may be low.

Different protocols are now used in IVF for stimulating the ovaries to produce multiple eggs. One approach is used for patients with very sensitive ovaries, such as young women or women with polycystic ovary disease (PCO). A different regimen is called for in patients with more resistant ovaries, such as women who are over 35 or 40 or who have not responded well to Pergonal or Metrodin in the past.

Another variation on the IVF theme is natural cycle IVF. Natural cycle IVF has the advantage of being less expensive -- but it also has a lower success rate. The key difference between this program and regular IVF is that no fertility drugs are used to stimulate the ovaries. In most cases, only one egg is retrieved, so no extra embryos can be frozen.

Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) were developed to take advantage of the fallopian tube as nature's incubator. In GIFT, the eggs and sperm are loaded into a catheter and injected into the tubes, where fertilization occurs naturally. GIFT is acceptable to some religious groups that otherwise oppose IVF. The disadvantage of GIFT and ZIFT is that they both require an additional surgical procedure -- a laparoscopy, in order for eggs and sperm (GIFT) or early embryos (ZIFT) to be transferred back to the tubes.

Intrauterine Insemination

Intrauterine insemination (IUI) utilizes the sperm preparation techniques from IVF to concentrate the best sperm and place them high in the uterus, to increase the likelihood that sperm will meet and fertilize the egg. IUI is often combined with fertility drug stimulation to treat unexplained infertility, endometriosis, certain sperm problems, and several other conditions. Sperm preparation for IUI is often modified depending on the count, motility and morphology of the individual's sperm specimen.

Male Factor

A group of new treatments for male factor problems that has evolved in the past several years is assisted fertilization or micro manipulation. These techniques are used for men with very low sperm counts or in cases of previous failure with fertilization. Microinsemination involves incubating very high concentrations of sperm with eggs in a tiny amount of fluid, to increase the success of fertilization. In subzonal insertion (SUZI), a microneedle is inserted just under the capsule of the egg, and one to several sperm are injected. SUZI may be replaced by a new technique called intracytoplasmic sperm injection, or ICSI (see above article), in which just one sperm is injected directly into the egg. Assisted hatching disrupts the shell of the embryo to promote growth and implantation.

Just as advances with donor egg IVF are allowing previously infertile women to experience pregnancy and childbirth, new techniques in the treatment of male factor problems are yielding some remarkable successes.

Great progress has been made in the field of in vitro fertilization (IVF) since the first successful delivery after IVF by Drs. Steptoe and Edwards in England in 1978. Many variations of techniques for the stimulation of ovulation, egg recovery, egg and sperm culture, embryo culture, and transfer of embryos have been visualized and tried by various groups of investigators around the world.

  • Ovulation cycle stimulation has run the gamut from no stimulation to mild stimulation to controlled ovarian hyperstimulation even to the point of overstimulation.
  • Egg recovery started with a laparoscopic technique and has evolved through various ultrasound-guided recoveries via the abdomen, periurethral route and now, the most common route, the vaginal canal.
  • Egg and sperm culture have gone through varying degrees of pre-incubation time, and the advantages of many different media have been described by different groups.
  • Embryo transfer was initially done through the cervix as a simple procedure. Later, a laparoscopic replacement of the zygotes into the fallopian tube was advocated.
  • Finally, there has been debate about the optimum time or freezing "extra embryos," ranging from the early to the later stages of the embryonic development.

Now, after a little more than fifteen years of worldwide experience with these techniques, we have put together a simple, effective and low-cost protocol at West Coast Infertility And Reproductive Associates that has resulted in a cumulative pregnancy rate of 32% for the year 1994. That puts us in the top 5% in the country, according to the previously published data. With this technique, the use of controlled ovarian hyperstimulation is encouraged. Egg recovery is done under local anesthesia, in the comfort and privacy of our office. Egg and sperm are fertilized in a small dish in our office laboratory in a standard culture medium. Then, in our office, embryo transfer is done easily through the cervix. Extra embryos can be frozen.

Of course, there are always exceptions to the above regimen, and treatments are always custom-tailored to the individual circumstances of the patients.

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