During a native cycle (the woman’s natural cycle), no hormonal medication is used to stimulate the ovaries. The purpose of treatment is to obtain one mature egg, which is subsequently fertilised using the ICSI method. The PICSI and assisted hatching (AH) methods are also recommended.
Cycle with minimum stimulation
A very small amount of hormonal medication is used during a cycle with minimum stimulation. The purpose of this treatment is to obtain at least 2 to 5 mature eggs. The ISCI, PISCI and assisted hatching (AH) methods are recommended for this type of cycle.
IUI (Intrauterine Insemination)
Intrauterine insemination (IUI) is a method of assisted reproduction. It takes place in the event that the semen analysis results in pathological values (reduced motility, low sperm count). At least one Fallopian tube must be fully functional (no blockage) for this treatment.
In the event that the woman does ovulate, insemination can be performed during a “native cycle”, which means without hormonal stimulation.
How therapy takes place
At the beginning of the menstrual cycle (1st day of the MC) you will call the clinic and inform staff that your cycle has begun. Hormonal stimulation is usually commenced on the 3rd day of your MC and regular ultrasound examinations are performed from the 10th day of your MC. The physician plans the precise date of insemination and the time of application of the hCG injection depending on the ultrasound results. Ovulation occurs approximately 34 to 36 hours after application of the hCG injection, which is the most suitable time to perform IUI.
The infertile couple comes to the clinic for the procedure, with the man providing ejaculate an hour before the procedure for processing into an insemination dose. The sperm is subsequently inserted right into the uterine cavity or into the uterine cervix using a thin insemination catheter.
This medical procedure is performed on an out-patient basis, is not painful and is similar to a normal gynecological examination. The patient rests for 5 to 10 minutes after the operation and may leave the clinic after receiving a medical report and instructions. No sick-leave is necessary.
IVF (In Vitro Fertilisation)
IVF is a process during which the egg is fertilised by a sperm outside the woman’s body (in vitro). This is one of the main methods of assisted reproduction used to treat infertility.
This method includes hormonal stimulation of the ovaries for the purpose of producing multiple follicles on the surface of the ovary, from which it is possible to obtain a greater number of eggs.
Stimulation is monitored by ultrasound. When the follicle reaches the required size, the patient is given an injection of hCG hormone (36 to 40 hours before collection of the eggs).
Collection of the eggs (OPU – ovum pick up)
The eggs are collected under general anesthesia and the procedure takes between 15 and 30 minutes. After OPU the patient is transferred to the recovery room, where she rests for 2 hours and can then go home with an adult accompanying her.
After removal from the follicle, the eggs are transferred to a special medium (solution), to which normally shaped and motile sperm is added. After 16 to 18 hours, the embryologist establishes how many eggs have been fertilized. The fertilized eggs gradually divide into 2, 4, 8 and more cells. The embryologist determines the most suitable day for embryo transfer. The male partner must be present on the day of OPU so that he can provide a sperm sample. After OPU the couple is informed of the quantity and quality of the eggs, and the procedure for use of special laboratory methods is also determined (ICSI, PICSI, IMSI, AH, EC, PGS, EmbryoGlue, embryo cryopreservation).
ICSI (Inracytoplasmic Sperm Injection)
This micro-manipulation method consists of selecting one quality sperm, which is immobilized using a special glass micro-pipette (it is prevented from moving by severing the microtubules in the tail); the sperm is drawn into the pipette and inserted directly into the cytoplasm of a mature egg capable of fertilization.
Use of this method is sometimes unavoidable due to low sperm count, poor sperm morphology or motility. This method is also recommended in women from whom a low number of eggs has been collected (5 or fewer), when fertilization of eggs did not occur during the previous IVF cycle, during the unfavourable development of the embryo, repeated miscarriage during previous IVF cycles and in women over 35 years of age.
Due to the high success rate of fertilization achieved using this method, it has become standard procedure in IVF practice (7 to 10 eggs are fertilized).
The PICSI method is a micro-manipulation method of narrower selection of sperm fit for ICSI for fertilization. Selection of this sperm is possible due to “hyaluron”, a protein which occurs naturally in the layer of cells surrounding the egg.
Only sperm capable of fertilization are bound thanks to receptors for this substance, which is contained in a gel in a Petri dish, where actual sperm selection takes place. Sperm with the ability to bind to hyaluron has been proven to have a lower incidence of chromosomal anomalies and better DNA integrity.
The PICSI method is recommended where low fertilization follow ICSI occurs, sperm values are below standard limits, after a repeated miscarriage in the anamneses of the couple undergoing therapy, and in women aged over 35.
Special laboratory methods
IMSI (intracytoplasmic injection of morphologically selected sperm)
This method uses a special microscope which is used to assess sperm quality in detail under high magnification (6,000 x).
Extended cultivation (EC)
The embryo is in the blastocyst phase of development on the 5th day after cultivation. Extended cultivation and transfer (5th to 6th day after fertilization) imitate the progress of a natural pregnancy, during which the embryo moves along the Fallopian tube during the first days after fertilization and reaches the uterus on the 5th to 6th day.
Embryos are normally cultivated under laboratory conditions for 2 to 4 days from the day the egg was collected. Only one-third of embryos reach the blastocyst phase and so extended cultivation may be considered a method for selecting the highest-quality embryos. Extended cultivation is not realized if only a small number of embryos has resulted.
Determination of the optimum day for embryo transfer is completely individual and may differ during repeated IVF cycles.
Assisted hatching (AH)
The embryo develops for a certain period within a tough shell. If pregnancy is to occur, the embryo must leave this shell (zona pellucida) after being transferred to the uterus and implanted in the uterine lining. Disruption of this “shell” allows the cells to leave the external shell (trophectoderm) and increases the probability of implantation and pregnancy.
Assisted hatching is a micro-manipulation technique usually performed on a 3- to 6-day-old embryo, immediately before it is inserted into the uterus. The embryo cannot be damaged after assisted hatching.
Hormonal therapy (stimulation) is applied during fertility treatment and causes multiple eggs to develop and mature in the ovaries at once. The physician decides at the beginning of stimulation and the period over which hormonal medication is applied in relation to the results of testing and the woman’s health.
Several “stimulation protocol” treatment charts are used during hormonal stimulation (short, long, protocol with antagonists).
A physician monitors the progress of stimulation of the ovaries using ultrasound. During this examination, he also assesses the thickness of the uterine lining, measures the size of the follicles (cavities containing fluid in which the egg develops), checks their number and monitors hormone levels in the blood.
EmbryoGlue is a special cultivation medium intended for transferring embryos into the uterus. This medium contains all the nutrients and sources of energy for optimum embryonic development. It also contains higher concentrations of the substance hyaluron, which occurs normally in the follicular fluid, in the Fallopian tubes and in the uterus, where it creates a more viscous environment.
Use of the EmbryoGlue medium during the transfer of embryos into the women’s uterus significantly increases the possibility of pregnancy compared to the use of a medium not containing hyaluron. This cultivation medium can be used with both fresh and frozen embryos.
The embryoscope is a device consisting of an incubator, microscope, camera and computer, which enables continuous monitoring and assessment of embryo development, all without the embryologist interfering in the embryo’s environment.
The incubator records images of each stored embryo on multiple levels every 20 minutes.
This device can be used to monitor and assess the following parameters:
- precise determination of the moment of the embryo’s first division and subsequent division
- morphology of the pronucleus and nuclei
- structure and location of the polar body
- appearance of the cytoplasm
- progress of fragmentation
- number, shape and symmetry of the blastomeres
- formation and number of nuclei after division of the embryo
Embryo transfer (ET)
This is the last step in the whole IVF procedure, where the embryos are transferred into the uterine cavity on the 3rd day after egg collection (the 4th to 6th day after egg collection if the extended cultivation method is used).
Embryo transfer is performed by thin transfer catheter when the position of the catheter is checked by ultrasound and so it is best if the patient has a full bladder. The partner may be present during the transfer. The transferred embryos can be observed on the ultrasound monitor. This operation is simple and pain-free for the patient, similar to a normal gynaecological examination.
The embryologist and the physician decide on the number of embryos to be transferred (one to three) on the basis of an assessment of the embryos’ development, taking into account the progress of previous IVF treatment, the patient’s health and her age. The wishes of the couple undergoing treatment are also taken into consideration. Rest is recommended after embryo-transfer.
Our clinic recommends transfer of only one embryo (SET) to reduce the risk of multiple-pregnancy.
Cryo-embryo transfer (CET)
Cryopreservation enables the preservation of embryos in a frozen state for their later use. During cryo embryo-transfer the embryos are thawed, their quality is assessed and after a brief period of cultivation, they are inserted into the uterine cavity using a thin transfer catheter.
This operation is simple and non-painful for the patient, similar to an ordinary gynecological examination.