Fertility Therapies

ICSI (intracytoplasmic sperm injection) is the most commonly used method of artificial insemination. It offers men who are struggling with considerable fertility problems the opportunity to realize the dream of having their own children.

When is ICSI performed?

This method is used when a man has poor sperm quality. Among the possible reasons why conception cannot occur are:

• Low sperm count
• Limited motility of the sperm
• Abnormal sperm
• Obstructive azoospermia (blocked ejaculatory ducts prevent sperm from entering the seminal fluid)
• Antisperm antibodies in the ejaculate
• Diseases, such as cancer, that mean only frozen sperm is available

Preparation for ICSI

Before the ICSI, the eggs of the woman are hormonally stimulated so that several fertilized eggs are available. During this process, specified quantities of the hormones FSH (follicle stimulating hormone) and LH (luteinizing hormone) are injected subcutaneously once a day. The injections can be made at home by the woman or her partner. Ultrasound scans are used to check whether the follicles have reached an appropriate size. If this is the case, the hormone HcG is administered to induce ovulation. 36 hours later, the eggs are removed transvaginally.

The sperm can be obtained either via masturbation or surgery. The latter is advisable in case of obstructive azoospermia, for example. In addition, it is possible to extract sperm cells directly from the epididymides (via MESA, microsurgical epididymal sperm aspiration). Masturbation takes place the day the egg is removed after no ejaculation has occurred for two to three days.

Sperm Injection

The removed eggs and sperm are then fused in a laboratory. The process of fertilization is carried out under a special microscope. Using a micropipette, the sperm is placed directly into the egg cell’s interior. How many of the eggs were able to be successfully fertilized is checked the following day.

Embryo Transfer

The embryo transfer takes place approximately two to five days after fertilization. Two to five embryos (only the highest-quality embryos are used) are inserted into the uterus using a catheter. If multiple embryos are available, those that are not needed for the transfer can be frozen at a later stage. The procedure takes only a few minutes and takes place on an outpatient basis.

Risks

In about one percent of cases, ovarian hyperstimulation may occur due to the hormonal treatment. Symptoms include water retention, nausea, vomiting, diarrhea and breathing problems. The risk is greatest for younger and overweight women as well as those with PCOS. It also increases the chance of a multiple pregnancy. For this reason, only three embryos may be used per treatment.

Chances of Success

Per cycle, ICSI carries a 15 to 20 percent chance of pregnancy – similar to IVF. The advantage of this method is that the sperm is injected directly into the egg, while with IVF, the fertilization takes place in a glass vessel. Various factors such as age, underlying diseases and personal lifestyle play an important role in success. In addition, the chances of conception increase with the number of attempts.

In Vitro Fertilization (IVF), from the Latin vitro, meaning “glass”, involves fertilization outside of the human body. IVF is more complicated than IUI, and affects the woman more because a longer program of hormones is necessary.

What Happens During In Vitro Fertilization?

With IVF, the activity of the ovaries is suppressed. Next, the maturation of approximately 15 eggs is promoted.

During this process, the woman must inject herself for several days under the skin of her abdomen with the follicle-stimulating hormone. At the right moment, ovulation is initiated by a pregnancy hormone called human chorionic gonadotropin, or hCG. Afterwards the follicle material is harvested via the vagina. Sperm is then made available for the fertilization of the egg cells, usually from ejaculated semen, but occasionally by means of a testicular biopsy or harvesting from the epididymis using an operating microscope. Thanks to natural selection, in 50 to 70 percent of procedures, fertilization then takes place in a test tube by the most mobile sperm cells.

Several Techniques

With IVF, different supporting techniques may be used: for instance by means of pipette (Intracytoplasmic Sperm Injection, ICSI), or under the microscope (Intracytoplasmic Morphologically Selected Sperm Injection, IMSI). For women under age 35, on the second or fifth day, ideally only two fusions (embryos) will be placed in the womb after a short stay in an incubator – a practice intended to avoid pregnancies with multiples and the associated risks. Under observance of strict legal conditions, surplus egg cells can theoretically be saved frozen in liquid nitrogen. 14 Days after the withdrawal of the follicle liquid from the uterus and the subsequent fertilization, a pregnancy test can give an initial confirmation of pregnancy. However, a positive test result is only the first step; a large amount of uncertainty remains.

Legal Aspects

In the U.S., fertility hospitals and specialized centers perform approximately 126 in-vitro cycles per one million people annually, with an average cost of around $12,400 per cycle. More than 200,000 IVF babies are born worldwide each year. Health insurance companies in the U.S. may or may not cover the procedure, but even those who offer partial coverage will usually cap the number of attempts that are covered. Among additional criteria is the age limit, which is usually age 50-55.

Before deciding to commit to medical assistance, there are some common concerns to consider. Many couples have been right where you are right now, and not all couples succeed with their wish of having children. It’s important to understand the physical, emotional, and financial toll medical procedures like In-Vitro Fertilization (IVF) and Intrauterine Insemination (IUI) take on a couple.

Depression

Only around four out of every ten IVF pregnancies end successfully, a statistic strongly correlated to the age of the woman and the associated legal conditions. Despite the mental and emotional burden, couples often undergo repetitive procedures. If the chance of having a child, which lies so close, does not materialize, in extreme cases depression or the breakup of the relationship can occur.

Ethical Questions

“The Facts of Life” were drastically revolutionized worldwide by reproductive medicine. In extreme cases, IVF theoretically makes possible a parent generation community of up to five humans: a sperm donor, an egg donor, a surrogate mother who delivers the child for its social parents, who become father and mother in the law’s eyes. In 2008, thirty years after the birth of the first test-tube baby Louise Joy Brown on July 27^th, 1978, and more than five million other test tube girls and boys later, a comprehensive workshop was held at the Humboldt University in Berlin over ethical and legal questions. In the triangle between sperm donors, intended parents, and a child, the situation involving insemination from an anonymous donor is not without problems. If the husband or a partner of the mother recognizes paternity, the child produced with foreign sperm is considered his legitimate descendant.

In the U.S., neither the sperm donor, nor the child born as a result of using a sperm donor, has any rights, obligations, or legal interest in respect to one another, nor do the legal parents have any legal obligation to inform the child of his or her conception by donor. Although in principle, a donor would be under obligation to pay alimony and his child entitled to inherit from him – instead, by contract, the social (or legal) parents take over the fulfillment of these requirements. It’s likely that hundreds of thousands of later generations will be conceived with foreign sperm, and according to estimations only a very few of them will know this truth. The majority of psychologists look at this fact skeptically, considering non-enlightenment in regard to one’s family situation as delusion or deception.

Medical Risks

As with all medical interventions, artificial insemination involves some risks. As these methods use increased hormones, the vessels become more permeable and cause increased fluid retention in the abdomen and tissue. In addition, dysfunctions of the kidneys and dyspnea may occur. With a pregnancy of more than one embryo comes an intensified risk of dangers like thrombosis and convulsions, in addition to mental strain due to the high probability these children will not reach a minimum weight necessary for good physical and mental health.