In Vitro Fertilization

In vitro fertilization is a technique of artificial (in vitro, that is, "in vitro") fertilization of the egg with subsequent transplantation of the embryo into the uterus. The method of in vitro fertilization has a limited list of strict indications, each of which is associated with an incurable form of infertility, therefore this technique is considered to be therapeutic.

A little terminology. The concept of "artificial insemination" implies several methods united by a single principle - the process of fertilization is not led by nature, it is induced by external manipulation.

Artificial insemination can be carried out in several ways:

- Sex cells (egg cells and spermatozoa) of donors are placed in a nutrient medium similar to the natural one, where spontaneous fertilization occurs. The embryo is then transferred to the uterine cavity for later development. This is the technology of in vitro fertilization.

- ICSI (or IRIS) technique - intracytoplasmic injection of spermatozoa. It differs from the extracorporeal method in that fertilization is performed artificially by direct instrumental introduction of the spermatozoon into the cytoplasm of the oocyte.

- Intrauterine insemination. In the uterine cavity is not placed ready embryo, and spermatozoa, which later independently rise in the fallopian cavity and "meet" there with the egg. The procedure is performed during the period of ovulation, it is used for sperm pathology (for example, low mobility of male sex cells) or with excessive viscosity of the cervical mucus.

Thus, artificial insemination is several methods united by a single goal, and extracorporeal is one of them.

Around the extracorporeal fertilization is a lot of the most ridiculous and unreliable myths, so the attitude towards it in society is very ambiguous.
The most common misconceptions about this method of infertility therapy are the following:

• The effectiveness of the method is very high.

This is not true. As a rule, the success of even the most highly qualified procedure depends on the reasons why a woman does not have the opportunity to conceive independently. The effectiveness of in vitro fertilization is low: only one in three patients after the procedure becomes pregnant, and only one in four is born and gives birth.

• Children "from a test tube" differ from those born after the natural conception of their peers.

In vitro fertilization mimics the physiological process of embryo formation, so neither its physical parameters nor mental abilities are affected. Moreover, the most viable and healthy embryos are selected for successful artificial insemination.

• In vitro fertilization is suitable only for "age" patients.

In fact, the closer the healthy woman approaches to the 40-year boundary, the less she has the chance to become pregnant and safely endure the child, and those who have infertility patients have even less chance. Therefore, in vitro fertilization in most situations has an age limit of 35 years.

• The method of in vitro fertilization can be recommended to all infertile couples.

Infertility, of course, is the main indication for this technique, but this is possible only if there are certain conditions and no contraindications. After all, it is important not only to implant an embryo for subsequent development, it is necessary to successfully complete the pregnancy. In vitro fertilization is suitable for those who are able to bear the child before the due date.

• Technology of in vitro fertilization always requires personal financial participation of patients.

The price of in vitro fertilization depends on many circumstances and can indeed be quite high. First of all, patients should remember that this procedure is included in the system of compulsory medical insurance, therefore it can be made free of charge. However, there is no specific order on compulsory free-of-charge carrying out of this type of treatment, so those who want to go through it for free are much more than specialists ready to conduct it. Patients have a choice - to undergo examination and enroll in the queue for free treatment or go to a paid clinic. But even if the procedure is done for free, you will have to spend money on medicines for the preparatory phase, as well as for subsequent preventive treatment.

Choosing a paid treatment option, patients should understand that the total amount of payment for services can be much higher than the declared one, since it is not always possible to predict in advance what medicines and how many will be needed, how many days a woman will have to spend in the clinic, therapy.

• The procedure for introducing the embryo into the uterus after in vitro fertilization is associated with severe pain.

A completely incorrect statement, since the technique implies the use of modern painkillers, which can save the patient from unnecessary suffering.

It should be noted that for the fertilization "in vitro" can be used sex cells of donors, if it is not possible to get them from a married couple.

To get the most reliable information about the method of artificial insemination and its possibilities, it is most reasonable to apply to a specialist in the Center for In Vitro Fertilization (they already exist in almost all megacities) or in the infertility treatment room of a women's consultation.

In vitro fertilization does not belong to the category of "simple" manipulations, it requires serious medication and psychological preparation. However, for a huge number of infertile patients, this procedure is the only opportunity to realize the right to motherhood, so the high cost of in vitro fertilization in the form of a long and difficult period of preparation is fully justified.

What is in vitro fertilization?

From Latin, "extracorporeal" is translated as "outside the body." In fact, the uterus does not care how the embryo got into it, if only it is ready to "grow" it, so the technique is as close as possible to the physiological situation, when after a preliminary medication preparation simulating readiness for usual pregnancy, a fetal egg appears in the uterine cavity .

Let's try to recall the physiological processes that provide natural fertilization, and the mechanisms of their regulation. As you know, the "motherland" of the ovum is the ovary - the paired hormonal gland, responsible for incredibly important functions: the formation of a female phenotype, the secretion of sex hormones and the constant reproduction of oocytes.

Clusters of immature follicles are located under the dense outer shell of the ovary. They resemble thin-walled vesicles, each of which has a very immature egg. Each month (respectively, each menstrual cycle) in one of the ovaries 10 - 15 of these immature "vesicles" begin to show signs of active growth (proliferation). Over time, only one of the proliferating follicles continues to mature, it becomes dominant and passes through all the remaining phases of maturation together with the egg inside.

By the end of the first phase of the menstrual cycle, the envelope of the dominant follicle acquires a more complex structure (granulosa), liquid contents appear in its cavity, and the egg inside has all the signs of final maturity. Such a follicle is called a primordial, or graafovym, vesicle. It is not only the container of the emerging egg, but also a temporary hormonal structure, since it is able to synthesize the hormone estrogen (estradiol).

The mature follicle is no longer needed, so in the middle of the cycle its temporary "shelter" is destroyed. On the site of the destroyed follicle, a new temporal structure is formed from the fragments of the granulosa, a yellow body capable of secreting the hormone progesterone.

The period of death of the follicle and the release of the ovum beyond the ovary is called ovulation. The ovary, which left the ovary in ovulation, is directed to the fallopian tube, where, in the case of a sperm there, fertilization takes place.

All described structural and functional changes are controlled by the central link of the nervous system - the hypothalamus and the pituitary gland. Hormones of the pituitary gland directly affect the events occurring in the ovaries: follicle stimulating (FSH) hormone is involved in the processes of folliculogenesis, and luteinizing (LH) hormone stimulates the destruction of the follicle and helps the yellow body form.

Thus, for the full realization of the reproductive function, it is necessary:

- a full-fledged ovulatory menstrual cycle;

- the proper concentrations of estrogens and progesterone, as well as FSH and LH;

- Correct interaction of the ovaries with the pituitary and hypothalamus.

The greatest number of cases of infertility is associated with the absence or distortion of the mechanism of ovulation and, accordingly, fertilization. If all the available methods of therapy can not restore the ability to reproduce, the option of artificial fertilization is considered. With in vitro fertilization, a mature egg is removed from the ovary and fertilized outside the female body, and then placed where pregnancy develops in all women, regardless of the mode of conception, into the uterine cavity. The further pregnancy proceeds absolutely similarly natural.

Indications for in vitro fertilization

The method of artificial insemination as infertility therapy is chosen only after a detailed examination of the infertile couple and unsuccessful attempts to cure pathology in other accessible ways. It should not be forgotten that the reason for the infertile relationship can be not only a woman, conducted research proves that male infertility in frequency of occurrence in recent years "catches up" with a female, so a survey in a pair should be symmetrical.

In vitro fertilization as the only suitable method of infertility therapy requires a clear justification. Indications for the procedure are:

- Absolute tubal infertility, which can not be cured. The most striking example of this is bilateral tubectomy - the removal of both fallopian tubes. In this situation, the egg and sperm have no chance to meet and connect.

Absolute tubal infertility should not be confused with the relative, when in the presence of the fallopian tubes (one or both) they have pathological changes that provoke their obstruction. With this form, infertility is first treated medically or surgically. As a rule, the patency of fallopian tubes is more often restored, and pregnancy occurs. If this does not happen, the following indication appears for artificial insemination.

- Lack of spontaneous pregnancy in over 30 patients who underwent tubal infertility treatment. In vitro fertilization is recommended if the pregnancy did not occur after the expiration of a five-year period of conservative therapy or a year after the operation.

- Infertility with an unknown cause (idiopathic) after a detailed examination.

- Immunological infertility. There are situations when a completely healthy couple does not become pregnant due to immune disorders, in particular - the development of antisperm antibodies. Antibodies to partner spermatozoa are produced by the epithelium of the cervical canal in women. It is also possible that when a man develops autoantibodies to his own spermatozoa.

- Pathology of partner sperm - a small amount of spermatozoa, their lack of mobility and the like.

- Hereditary pathologies of parents, which by all means will be transferred to the embryo ( hemophilia , cystic fibrosis and others).

Contraindications to in vitro fertilization

In vitro fertilization can not be called completely safe and simple in the technique of execution by manipulation. In some situations, the risk of complications is so great that the procedure is prohibited.

The existing contraindications are conditionally classified as absolute, in which the procedure of in vitro fertilization is dangerous, and relative. Relative contraindications include high-risk conditions or pathologies that can be eliminated.

More often refusal in artificial insemination is received by patients and by heavy somatic pathologies that will not allow to safely endure pregnancy: decompensated heart diseases, renal and hepatic insufficiency , blood system diseases, mental disorders and the like.

As a rule, with relative contraindications, in vitro fertilization is often not recommended only at a particular moment. So, for example, with exacerbation of some chronic pathologies, the procedure is postponed until the moment of remission.

Preparing for in vitro fertilization

The preparatory period takes most of the time of the entire procedure of in vitro fertilization. It begins 2-3 months before the fertilization and consists of several stages:

Stage I

After transferring "from the test tube," the embryo should fall into a favorable environment for implantation and further development. Therefore, a series of examinations of both partners for the presence of infectious and inflammatory processes of the genital area. If necessary, therapy is provided.

Phase II

To perform it, the menstrual cycle preceding the procedure for extracting the egg is selected. Its purpose is to establish the nature and duration of the follicular and luteal phases of the cycle, to determine the level of the main hormones and to medicate the stimulation of "superovulation".

For in vitro fertilization, several eggs are used, as the probability of procedure success increases - from among several embryos implanted, at least one will survive. But in one menstrual cycle, the ovary manages to "grow" only a single egg, and to have more, additional artificial medication is needed. Used hormonal drugs that stimulate the growth of follicles. The entire process of maturation of the follicles is controlled by ultrasound scanning.

Stage III

When the dominant follicles increase to 16-20 mm, one can already extract "mature" ovules from each one. The procedure is controlled by ultrasound equipment. A special needle of the follicles is punctured, then follicular fluid is taken from them. After this, make sure that the collected material has an egg, so it is studied under a microscope.

Stage IV

Each detected egg is washed from the follicular fluid and placed in an artificial environment similar to the physiological one. In anticipation of fertilization, eggs are stored in an incubator, where the necessary temperature and humidity are maintained.

Stage V

Getting and preparing sperm. It is carried out on the same day when the patient's follicles are punctured.

The partner's sperm is washed from the semen and examined for the purpose of selecting the most viable spermatozoa.

Thus, after the completion of the preparatory period, previously trained sex cells are available to specialists.

Procedure of in vitro fertilization

Occurs in vitro (from Latin - outside the living organism). To the ovules in the nutrient medium (each is separated), a suspension containing spermatozoa is added. After 2/3 hours with a microscope, one of the spermatozoa penetrated (literally, fertilized) into the egg, that is, a long-awaited embryo appeared.

Embryos continue to stay in the incubator for no longer than 6 days, and then they must be inserted into the uterine cavity.

The procedure for transporting the embryo takes several minutes and does not involve great inconveniences for the patient. Also, it is not painful. Some patients report a pronounced painfulness with this manipulation, however such complaints are not connected with the procedure itself, but with the negative psychological mood of a woman experiencing fear and anxiety. Also a similar situation occurs in patients with low pain threshold, which react poorly even to the most "simple" manipulations. If the patient can not properly orient and reassure in advance, anesthesia is used.

Embryos are transferred to the uterine cavity by means of a special elastic catheter with a small diameter. The performing specialist monitors the progress of the catheter with an ultrasound monitor.

Despite the seeming "simplicity" of performing the embryo introduction procedure, the technique requires high accuracy. After all, the embryo must "get" exactly into that area of ​​the uterus, where the development of subsequent pregnancy is most comfortable - in the area of ​​the uterine floor.

When introducing several embryos into the uterus, there is a high probability that they will all get accustomed. Meanwhile, the most successful is only pregnancy with two fruits, and bearing three or more children is always accompanied by complications. Therefore, according to the order of the Ministry of Health, transplantation of more than 4 embryos is not recommended, so usually specialists prefer to transfer only two.

After the successful completion of the embryo transfer procedure, it is necessary to "help" them to stay in the uterus for the first few weeks after implantation. More often the prevention of miscarriage is carried out before the 20th week of gestation. Progesterone preparations are used that can prevent miscarriage. Later, pregnancy after extracorporeal fertilization does not require special measures, since it proceeds in a similar way to physiological, therefore, a local specialist performs the surveillance.

If, for the procedure, the patient initially turned to the Center for In Vitro Fertilization, she is offered to continue to observe pregnancy in the future, but the choice is always made only by the couple.

Results of in vitro fertilization

The most important result of in vitro fertilization, of course, is a long-awaited pregnancy. However, this technique, like any other medical manipulation, is not deprived of the possibility of negative consequences.

As already mentioned, not every procedure of in vitro fertilization is successful, in 2/3 of the patients all embryos implanted do not take root. Even in the case of successful implantation, miscarriages often occur.

Multiple pregnancy after in vitro fertilization is considered a relatively negative consequence. Of course, for a woman with infertility, the appearance of two (and sometimes even more) children is a joy, but such pregnancies often go hard, because hormone dysfunction is considered one of the most popular causes of infertility, and against her background, bearing even a single fetus is often fraught with problems.

Complications of in vitro fertilization include:

- Ectopic pregnancy . Unfortunately, sometimes when entering the uterus, the embryo gets into the zone close to the entrance to the fallopian tube (uterine angle), and then "rises" upward. As a result, the pregnancy begins to develop in the tube. There are situations when two embryos develop symmetrically in the uterus - one in her cavity, and the other in the tube.

- Ovarian hyperstimulation syndrome. A serious and dangerous complication on the background of hormonal stimulation of the ovaries with the aim of inducing ovulation. Against the background of taking significant doses of hormonal preparations, the ovaries increase in size, their stroma swells. Against the background of increased vascular permeability, the liquid part of the blood can go beyond the ovaries and begin to accumulate in the parts of the pelvic cavity, provoking hypovolemia , thromboembolic states, impaired renal function and even shock. Severe forms of the syndrome are rare, often it is mild and well-timed docked.

However, even in the case of timely treatment, there is a possibility of long-term effects in the form of ovarian dysfunction, early menopause and changes in kidney function.

- Ovary rupture . It is rarely diagnosed. Happens as a consequence of excessive increase in the ovary on the background of hormonal hyperstimulation.

- Torsion of the ovaries. After hyperstimulation, the ovaries remain large in size and very mobile, so there is a possibility of their twisting around the ligaments.

- Bleeding and infection. They are the result of puncture of the ovaries for the extraction of eggs. Sometimes the source of bleeding is numerous large ovarian cysts.

In vitro fertilization for many women is the only opportunity to realize the possibility of having a child. However, one should not treat this technique too lightly. Selecting this method of therapy, each married couple should first make sure that the entire arsenal of available therapeutic tools is exhausted.