Acupuncture, a form of alternative medicine is the stimulation of specific acupuncture points along the skin of the body using thin needles. It is commonly used for pain relief, though it is also used to treat a wide range of conditions. Acupuncture is rarely used alone but rather as an adjunct to other treatment modalities. In Western settings acupuncture is used as a primary intervention for fertility problems. Acupuncture is increasingly used as an adjunct to assisted reproductive technologies and more widely in the complementary health care system.
The Western medical acupuncture approach involves using acupuncture after a medical diagnosis. In traditional acupuncture, the acupuncturist decides which points to treat by observing and questioning the patient to make a diagnosis according to the tradition used.
This method has always been applied to reproductive treatment in China. Western medicine may exert influence on neuroendocrine system, immunological functions and even signal pathway in consideration when discussing the efficacy of acupuncture and these still continue to be studied. The Chinese medicine evaluates the effect of acupuncture from an overall perspective. In Chinese medicine, reproductive function relates not only to reproductive organs, but also to the kidney, the liver, and the heart.
Acupuncture can be used as an adjuvant treatment for unexplained infertility. Although acupuncture did not increase the cumulative pregnancy rate, it decreased the number of control ovarian hyperstimulation (COH) cycles and more patients got pregnant in natural cycles after receiving acupuncture (Tab. 1).
Acupuncture treatment procedures should happen once or twice a week, and will continue for anywhere from a few weeks to a few months. Remember the process may take more time than just twice a week if you are combining it with medical infertility treatments, like IVF. In general, the acupuncture treatment can be completed in 12 appointments. At each appointment, your acupuncturist will most likely take additional time to discuss your current condition and answer any questions that you may have.
Physical exercise is performed for various reasons, including strengthening muscles and the cardiovascular system, honing athletic skills, weight loss or maintenance, and merely enjoyment. Frequent and regular physical exercise boosts the immune system and helps prevent the "diseases of affluence" such as heart disease, cardiovascular disease, Type 2 diabetes, and obesity. It may also help prevent depression, help to promote or maintain positive self-esteem, improve mental health generally, and can augment an individual's sex appeal or body image, which has been found to be linked with higher levels of self-esteem. Childhood obesity is a growing global concern, and physical exercise may help decrease some of the effects of childhood and adult obesity. Health care providers often call exercise the "miracle" or "wonder" drug—alluding to the wide variety of proven benefits that it can provide.
With use, muscles consume energy derived from both fat and glycogen. Due to the large size of leg muscles, walking, running, and cycling are the most effective means of exercise to reduce body fat.
Bariatric surgery offers a treatment that can reduce weight, induce remission (the state of absence of disease activity in patients with a chronic illness, with the possibility of return of disease activity) of obesity-related diseases, and improve the quality of life. Weight loss is achieved by reducing the size of the stomach with a gastric band or through removal of a portion of the stomach or by resecting and re-routing the small intestine to a small stomach pouch (gastric bypass surgery). Bariatric surgery is more effective than non-surgical treatments of obesity with a reduction in overall mortality of 30% demonstrated in surgical recipients.
All procedures can be performed laparoscopically (a type of surgical procedure in which a small incision is made, usually in the navel, through which a viewing tube with a small camera is inserted) with a lower rate of complications such as wound infection and incisional hernias. Future trends are attempting to achieve similar or better results via endoscopic (looking inside the body for medical reasons using an endoscope, an instrument used to examine the interior of a hollow organ or cavity of the body) procedures.
Procedures can be grouped in three main categories:
1. Predominantly malabsorptive (a state arising from abnormality in absorption of food nutrients across the gastrointestinal tract) procedures
In predominantly malabsorptive procedures, although they also reduce stomach size, the effectiveness of these procedures is derived mainly from creating a physiological condition of malabsorption.
Biliopancreatic diversion (BPD) (Pic. 1, 2) or the Scopinaro procedure is a complex of operation. The original form of this procedure is now rarely performed because of problems with malnourishment (a condition that results from eating a diet in which nutrients are either not enough or are too much such that the diet causes health problems). It has been replaced with a modification known as duodenal switch (see below).
2. Predominantly restrictive procedures
Procedures that are solely restrictive (limiting- já nenašla žádné další vhodné synonymum slova omezující) act to reduce oral intake by limiting gastric volume, produce early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications.
In the vertical banded gastroplasty (Pic. 3), also called the Mason procedure or stomach stapling, a part of the stomach is permanently stapled to create a smaller pre-stomach pouch, which serves as the new stomach.
The restriction of the stomach also can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin (Pic. 4, 5). This operation can be performed laparoscopically, and is commonly referred to as a "lap band". Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. It is considered one of the safest procedures performed today with a mortality rate of 0.05%.
Sleeve gastrectomy (Pic. 6), or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.
Intragastric balloon involves placing a deflated (the gas is released) balloon (Pic. 7) into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5–9 BMI (body mass index) over half a year. The intragastric balloon may be used prior to another bariatric surgery in order to assist the patient to reach a weight which is suitable for surgery, further it can also be used on several occasions if necessary.
Basically, the procedure can best be understood as a version of the more popular gastric sleeve or gastrectomy surgery where a sleeve is created by suturing rather than removing stomach tissue thus preserving its natural nutrient absorption capabilities. Gastric plication significantly reduces the volume of the patient's stomach, so smaller amounts of food provide a feeling of satiety. Weight loss outcomes are comparable to gastric bypass.
3. Mixed procedures
Mixed procedures apply both techniques simultaneously.
A common form of gastric bypass surgery is the Roux-en-Y gastric bypass (Pic. 8, 9), designed to reduce the amount of food a person is able to eat by cutting away a part of the stomach, gastric bypass is a permanent procedure that helps patients by changing how the stomach and small intestine handle the food that is eaten to achieve and maintain weight loss goals. After the surgery, the stomach will be smaller. A patient will feel full with less food.
A variation of the biliopancreatic diversion (portions of the stomach are removed then the small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the upper part of the small intestines) includes a duodenal switch (Pic. 10). The part of the stomach along its greater curve is resected. The stomach is "tubulized" with a residual volume of about 150 ml. This volume reduction provides the food intake restriction component of this operation. This type of gastric resection is anatomically and functionally irreversible. The stomach is then disconnected from the duodenum and connected to the distal part of the small intestine. The duodenum and the upper part of the small intestine are reattached to the rest at about 75–100 cm from the colon.
This procedure where a device similar to a heart pacemaker is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, is being studied in the USA. Electrical stimulation is thought to modify the activity of the enteric nervous system of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of bariatric surgery.
Patient selection criteria for bariatric surgery include body mass index (BMI), the presence of co-morbidities and a history of prior weight loss attempts. National Institute of Clinical Excellence (NICE) and National Institutes of Health (NIH) guidelines state that bariatric surgery should be offered to patients with a BMI of 35 to 40 kg/m2 who have obesity related conditions such as diabetes mellitus or obstructive sleep apnea, or in those with a BMI of 40 kg/m2 or greater regardless of weight related co-morbidities. Bariatric surgery for individuals with a BMI less than 35 kg/m2 with obesity related co-morbidities is under investigation but is not currently recommended.
Ovarian drilling is a surgical technique of puncturing the membranes surrounding the ovary with a laser beam or a surgical needle using minimally invasive laparoscopic procedures. It differs from ovarian wedge resection, because resection involves the cutting of tissue. Ovarian drilling is often preferred to wedge resection because cutting in to the ovary can cause adhesions which may complicate postoperative outcomes.
Anovulation (absence of ovulation) is a major cause of female infertility, and polycystic ovary syndrome (PCOS) is the leading cause of anovulation. While undergoing drug-induced ovulation, women with PCOS usually have a satisfactory response recruiting follicles, but some are unable to recruit follicles or often produce an excessive number of follicles, which can result in ovarian hyper-stimulation syndrome and/or multiple pregnancy. Surgical laparoscopy with ovarian drilling may prevent or reduce the need for drug-induced ovulation.
This procedure probably reduces the need for clinical induction of ovulation, or facilitates its use. The procedure can be performed with admission in "day hospitals", with very little surgical trauma compared to the initial laparotomy technique. Laparoscopic drilling is a minimally invasive surgery in which the ovaries are treated with small perforations using heat or laser. The mechanism by which partial destruction results in ovarian follicular development and ovulation is unknown. Despite the contribution of hormonal changes caused by the procedure, such as the reduction of serum androgens, it is not clear whether this is the basis of the ovulation restoration mechanism. The most plausible theory involves the sharp drop in intraovarian androgens (and perhaps estrogens) resulting in an increase in the secretion of follicle-stimulating hormone (FSH) and an intra-follicular environment more conducive to normal follicular maturation and ovulation.
Many forms of ovarian drilling are described, including electrocautery or laser use. All of these share a common goal, which is creating focal areas of damage in the ovarian cortex. There is no evidence that one method consistently produces results superior to another. Nevertheless, the use of laser therapy has become less popular. The method most commonly used worldwide at the moment is monopolar needle or hook due to ease of installation and the wide availability of the necessary equipment.
The procedure
Standardization of the surgical techniques is lacking. Reproductive outcomes are comparable with laser and diathermy. Electrocautery, using an insulated unipolar needle electrode with a non-insulated distal end measuring 1-2 cm, is the most commonly used method, although few authors have reported similar ovulation and pregnancy rates with bipolar energy.
The number of punctures is empirically chosen depending on the ovarian size. In the original procedure, 3-8 diathermy punctures (each of 3 mm diameter and 2-4 mm depth) per ovary were applied, using power setting of 200-300 W for 2-4 s. Most surgeons perform four punctures per ovary, each for 4 s at 40 W (rule of 4), delivering 640 J of energy per ovary (the lowest effective dose recommended). Nevertheless, clinical response is dose-dependent, with higher ovulation and pregnancy rates observed by increasing dose of thermal energy up to 600 J/ovary, irrespective of ovarian volume. Conversely, adjusting thermal dose based on ovarian volume (60 J/cc) has better reproductive outcomes with similar postoperative adhesion rates than fixed dose of 600 J/ovary. Despite lack of convincing evidence and significant reduction in operative time, most gynecologists still perform bilateral over unilateral drilling.
Different modifications of the classic needle electrode technique such as laparoscopic ovarian multi-needle intervention, ovarian drilling using a monopolar hook electrode, ovarian drilling using the harmonic scalpel and office microlaparoscopic ovarian drilling are proposed. Various transvaginal methods such as transvaginal hydrolaparoscopy (fertiloscopy) and transvaginal sonography - guided ovarian interstitial laser treatment are also developed. However, larger prospective studies are needed to validate the use, safety, efficacy and long-term effects of these alternate techniques.
Pharmacotherapy of Polycystic ovary syndrome represents various medications used in the treatment of this condition. Treatment for PCOS depends on the symptoms experienced by the woman and on whether she is seeking to become pregnant. The clinical manifestation of PCOS varies from a mild menstrual disorder to severe disturbance of reproductive and metabolic functions (processes necessary for the maintenance of a living organism).
For women who are diagnosed with PCOS as a result of infertility investigations, the immediate treatment/s focus on re-establishing regular ovulation to improve the chance of pregnancy. In PCOS, anovulation relates to low follicle-stimulating hormone concentrations and the arrest of antral follicle growth in the final stages of maturation. This can be treated with certain medications.
Common medications used to treat infertility in patients with PCOS include:
Clomiphene citrate
In anovulatory women with PCOS, clomiphene citrate (CC) treatment is the first choice for ovulation induction.
In normal physiologic female hormonal cycling, at 7 days past ovulation, high levels of estrogen and progesterone produced from the corpus luteum (a temporary, hormonally active structure in the ovary) inhibit GnRH (gonadotropin-releasing hormone), FSH (follicle-stimulating hormone) and LH (luteinizing hormone) at the hypothalamus and anterior pituitary (parts of the brain that control the production of many hormones). If fertilization does not occur in the post-ovulation period the corpus luteum disintegrates due to a lack of beta-hCG (human chorionic gonadotropin). This would normally be produced by the embryo in the effort of maintaining progesterone and estrogen levels during pregnancy.
Therapeutically, clomifene is given early in the menstrual cycle. It is typically prescribed beginning on day 3 and continuing for 5 days. By that time, FSH level is rising steadily, causing development of a few follicles (small vesicles in the ovary, each containing an oocyte). Follicles in turn produce the estrogen, which circulates in serum. In the presence of clomifene, the body perceives a low level of estrogen, similar to day 22 in the previous cycle. Since estrogen can no longer effectively exert negative feedback on the hypothalamus, GnRH secretion becomes more rapidly pulsatile, which results in increased pituitary gonadotropin (FSH, LH) release. (It should be noted that more rapid, lower amplitude pulses of GnRH lead to increased LH/FSH secretion, while more irregular, larger amplitude pulses of GnRH leads to a decrease in the ratio of LH/FSH.) Increased FSH level causes growth of more ovarian follicles, and subsequently rupture of follicles resulting in ovulation. Ovulation occurs most often 6–7 days after a course of clomifene.
CC is easy to use and effective in inducing ovulation in most of the patients (60%–90%), but the pregnancy rates are disappointing (10%–40%). CC treatments are also associated with risk of ovarian hyperstimulation syndrome and multiple pregnancies (10-20%). This is probably because CC causes down regulation of estradiol receptors in the pituitary, leading to oversecretion of follicle-stimulating hormone. Oversecretion of this hormone then causes formation of multiple follicles and, multiple pregnancies may be seen consequently.
Gonadotropins
The second-line pharmacological treatment of infertility in anovulatory women with PCOS includes the use of gonadotropins [recombinant follicle-stimulating hormone (FSHr) or human menopausal gonadotropin (HMG)] for timed intercourse or intrauterine insemination (IUI). Due to the higher cost of this therapeutic modality, an evaluation of the tubal patency is recommended prior to initiating the ovarian stimulation with gonadotropins if this procedure was not performed prior to initiating CC treatment. If the fallopian tube is open and the sperm concentration is suitable for in vivo fertilization, the ovarian stimulation begins with low doses of gonadotropins to achieve monofollicular growth and reduce the risk of complications (ovarian hyperstimulation syndrome and multiple gestation).
Aromatase inhibitors
Although aromatase inhibitors have been used in women with PCOS as an alternative method to avoid the anti-estrogenic effect of CC on the endometrium, these compounds are not typically used in clinical practice to treat infertility in these patients.
Oral administration of letrozole, the aromatase inhibitor, was found effective for ovulation induction in CC resistant, anovulatory infertile women and endometrial thickness was not affected adversely. In AIs (artificial insemination) treatment, cycles appeared with a better pregnancy rate, probably because of the lack of anti-estrogenic effects of AIs on the endometrium.
However, overall, the effectiveness of aromatase inhibitors in the treatment of PCOS remains controversial.
Metformin
Whether all women with PCOS will benefit from this insulin sensitizing agent is controversial. Insulin resistance is difficult to establish in clinical practice and many surrogate tests are available, although their value in the clinical setting is uncertain. Some experts have argued that women with PCOS should only be treated if there is confirmed insulin resistance. However, others report beneficial effects in most women with PCOS. For women with PCOS and menstrual irregularity, or obesity and clinical features of insulin resistance, it is reasonable to initiate treatment with metformin during an initial three month period during which the success with weight loss is evaluated. Metformin therapy should be considered at this visit and the patient warned about possible gastrointestinal side effects. Available data indicate a limited benefit of metformin on weight loss.
2. Women that do not wish to get pregnant
The aim of treatment for women not wishing to become pregnant in the near future is to provide relief from the various symptoms. In the past, treatments for PCOS often only focused on the cosmetic symptoms like acne, excessive hair growth and obesity. However, current treatment for PCOS also seeks to address the long-term health implications such as the increased risk of diabetes and cardiovascular disease. Such medications include:
Oral contraceptives
Oral contraceptives (OCs, Pic. 4) are frequently recommended as first-line medical treatment for the long-term management of menstrual disturbances and hyperandrogenism (elevated levels of male sex hormones, mainly testosterone) manifestations in women with PCOS who do not seek pregnancy.
The remedial effect of OCs is attributed to the suppression of pituitary gonadotropin secretion and a decrease in androgen (male sex hormone) secretion. In addition, the estrogen component of these compounds increases circulating levels of sex hormone-binding globulin (SHBG), which decreases androgen bioavailability.
Despite theoretical advantages of OCs with antiandrogenic properties from compounds such as cyproterone acetate (CA), drospirenone (DRSP), desogestrel (DSG), and ethinyl estradiol (EE) compared to OCs containing levonorgestrel (LNG), clinical advantages of these compounds remain unclear.
Antiandrogens
Hirsutism (facial hair growth in women), acne, alopecia are the androgen-related symptoms that appeared in patients with PCOS. Antiandrogens such as spironolactone, cyproterone acetate (CPA), or flutamide act by competitive inhibition of androgen-binding receptors or by decreasing androgen production.
Spironolactone is a specific antagonist of aldosterone, acting through block of the androgen receptors. Its treatment effect is dosage-dependent: low dosages are less effective than other antiandrogens, whereas high dosages (200 mg/day) are very effective but have several adverse effects such as dysfunctional uterine bleeding, but the concurrent use of OCPs (oral contraceptives) may prevent them.
Cyproterone acetate (CPA) is a progestin agent. This drug inhibits gonadotropin secretion and suppresses androgen action. CPA is effective for management of hirsutism and acne. It may lead to nausea, headaches, and breast tenderness, reduced libido, and weight gain. CPA rarely causes hepatotoxicity effects (damage to liver).This drug has feminizing effect (heightening female characteristics in men) similar to Spironolactone.
Egg donation is the process by which a woman donates eggs for purposes of assisted reproduction or biomedical research. For assisted reproduction purposes, egg donation typically involves IVF technology, with the eggs being fertilized in the laboratory; more rarely, unfertilized eggs may be frozen and stored for later use. Egg donation is a third party reproduction as part of ART.
Egg donor may have several reasons for donate her eggs:
Procedure
First step is choosing the egg donor by a recipient from the profiles on or clinic databases (or, in countries where donors are required to remain anonymous, they are chosen by the recipient's doctor based on recipient woman’s desired trait). This is due to the fact that all of the mentioned examinations are expensive and the agencies/clinics must first confirm that a match is possible or guaranteed before investing in the process.
Each egg donor is first referred to a psychologist who will evaluate if she is mentally prepared to undertake and complete the donation process. These evaluations are necessary to ensure that the donor is fully prepared and capable of completing the donation cycle in safe and success manner. The donor is then required to undergo a thorough medical examination, including a pelvic exam, blood tests to check hormone levels and to test for infectious diseases, Rh factor, blood type, and drugs and an ultrasound to examine her ovaries, uterus and other pelvic organs. A family history of approximately the past three generations is also required, meaning that adoptees are usually not accepted because of the lack of past health knowledge. Genetic testing is also usually done on donors to ensure that they do not carry mutations (e.g., cystic fibrosis) that could harm the resulting children; however, not all clinics automatically perform such testing and thus recipients must clarify with their clinics whether such testing will be done. During the process, which usually takes several months, the donor must abstain from alcohol, sexual intercourse, cigarettes, and drugs, both prescription and non-prescription.
Once the screening is complete and a legal contract signed, the donor will begin the donation cycle, which typically takes between three and six weeks. An egg retrieval procedure comprises both the egg donor's cycle and the recipient's cycle. Birth control pills are administered during the first few weeks of the egg donation process to synchronize the donor's cycle with her recipient's, followed by a series of injections which halt the normal functioning of the donor's ovaries. These injections may be self-administered on a daily basis for a period of one to three weeks. Next, FSH is given to the donor to stimulate egg production and increases the number of mature eggs produced by the ovaries. Throughout the cycle the donor is monitored often by a physician using blood tests and ultrasound exams to determine the donor's reaction to the hormones and the progress of follicle growth.
Once the doctor decides the follicles are mature, the doctor will establish the date and time for the egg retrieval procedure. Approximately 36 hours before retrieval, the donor must administer one last injection of hCG to ensure that her eggs are ready to be harvested. The egg retrieval itself is a minimally invasive surgical procedure lasting 20-30 minutes, performed under sedation (but sometimes without any). A small ultrasound-guided needle is inserted through the vagina to aspirate the follicles in both ovaries, which extracts the eggs. After resting in a recovery room for an hour or two, the donor is released. Most donors resume regular activities by the next day.
Laws by state
The legal status and compensation of egg donation has several models across states with examples:
During ICSI just one sperm is injected directly into the egg cytoplasm using a micromanipulative apparatus that transforms imperfect hand movements into fine and precise movements of micromanipulation tools.
Intracytoplasmic Sperm Injection (ICSI) is an assisted reproductive technique (ART) initially developed by Dr. Gianpiero D. Palermo in 1993 to treat male infertility. It is most commonly used in conjunction with in vitro fertilization (IVF). Following IVF procedure, the physician places the fertilized egg into the female’s uterus for implantation. Sperm are obtained by the same methods as with IVF: either through masturbation, by using a collection condom, or by surgically removing sperm from a testicle through a small incision (MESA, TESE). The females are treated with fertility medications for approximately two weeks prior to oocyte retrieval to stimulate superovulation, where the ovaries produce multiple oocytes rather than the normal one oocyte. The oocytes are retrieved by either laparoscopy, or more commonly, transvaginal oocyte retrieval. In the latter procedure, the physician inserts a thin needle through the cervix, guided by a sonogram and pierces the vaginal wall and then the ovaries to extract several mature ova. Before the embryologist can inject the sperm into the oocyte, the sperm must be prepared by washing and exposing it to various chemicals to slow the sperm movement and prevent it from sticking to the injection plate. Also, the oocytes are treated with hyaluronidase to single out the oocyte ready for fertilization by the presence of the first polar body. Then, one prepared sperm is injected into an oocyte with a thin needle. Often, embryologists try to fertilize several eggs so they can implant more than one into the uterus and increase the chance of at least one successful pregnancy. This also allows them to save extra embryos, using cryopreservation, in case later IVF rounds are needed.
After the embryologist manually fertilizes the oocytes, they are incubated for sixteen to eighteen hours and develop into a pronucleate eggs (successfully fertilized eggs about to divide into an embryo). The egg then grows for one to five days in the laboratory before the physician places it in the female’s uterus for implantation.
The chance of fertilization increases dramatically with ICSI compared to simply mixing the oocytes and sperm in a Petri dish and waiting for fertilization to occur unaided (classical IVF procedure). Studies have shown that successful fertilizations occur 50% to 80% of the time. Since the introduction of ICSI, intrauterine insemination (IUI) has decreased in popularity by 80%.
See full description of ICSI
Sperm donation is the donation by a male (known as a sperm donor) of his sperm (known as donor sperm), principally for the purpose of inseminating a female who is not his sexual partner. Sperm donation is a form of third party reproduction including sperm donation, oocyte donation, embryo donation, surrogacy, or adoption. Number of births per donor sample will depend on the actual ART method used, the age and medical condition of the female bearing the child, and the quality of the embryos produced by fertilization. Donor sperm is more commonly used for artificial insemination (IUI or ICI) than for IVF treatments. This is because IVF treatments are usually required only when there is a problem with the female conceiving, or where there is a “male factor problem” involving the female's partner. Donor sperm is also used for IVF in surrogacy arrangements where an embryo may be created in an IVF procedure using donor sperm and this is then implanted in a surrogate. In a case where IVF treatments are employed using donor sperm, surplus embryos may be donated to other women or couples and used in embryo transfer procedures.
On the other hand, insemination may also be achieved by a donor having sexual intercourse with a female for the sole purpose of initiating conception. This method is known as natural insemination.
The donation
Donor sperm and fertility treatments using donor sperm may be obtained at a sperm bank or fertility clinic. Here, the recipient may select donor sperm on the basis of the donor's characteristics, e.g. looks, personality, academic ability, race, and many other factors. Sperm banks or clinics may be subject to state or professional regulations, including restrictions on donor anonymity and the number of offspring that may be produced, and there may be other legal protections of the rights and responsibilities of both recipient and donor. Some sperm banks, either by choice or regulation, limit the amount of information available to potential recipients; a desire to obtain more information on donors is one reason why recipients may choose to use a known donor and/or private donation.
A sperm donor will usually donate sperm to a sperm bank under a contract, which typically specifies the period during which the donor will be required to produce sperm, which generally ranges from 6–24 months depending on the number of pregnancies which the sperm bank intends to produce from the donor. Donors may or may not be paid for their samples, according to local laws and agreed arrangements. Even in unpaid arrangements, expenses are often reimbursed. Depending on local law and on private arrangements, men may donate anonymously or agree to provide identifying information to their offspring in the future. Private donations facilitated by an agency often use a "directed" donor, when a male directs that his sperm is to be used by a specific person. Non-anonymous donors are also called known donors, open donors or identity disclosure donors.
Donor selection
A sperm donate must generally meet specific requirements regarding age (most often up to 40) and medical history. Potential donors are typically screened for genetic diseases, chromosomal abnormalities and sexually transmitted infections that may be transmitted through sperm. The donor's sperm must also withstand the freezing and thawing process necessary to store and quarantine the sperm. Samples are stored for at least 6 months after which the donor will be re-tested for sexually transmitted infections. This is to ensure no new infections have been acquired or have developed during the period of donation. If the result is negative, the sperm samples can be released from quarantine and used in treatments.
Screening includes:
Preparing the samples
A sperm donor is usually advised not to ejaculate for two to three days before providing the sample, to increase sperm count and to maximize the conception rate. A sperm donor produces and collects sperm by masturbation or during sexual intercourse with the use of a collection condom.
Sperm banks and clinics usually "wash" the sperm sample to extract sperm from the rest of the material in the semen. A cryoprotectant semen extender is added if the sperm is to be placed in frozen storage in liquid nitrogen, and the sample is then frozen in a number of vials or straws. One sample will be divided into 1-20 vials or straws depending on the quantity of the ejaculate and whether the sample is washed or unwashed. Following the necessary quarantine period, the samples are thawed and used to inseminate women through artificial insemination or other ART treatments. Unwashed samples are used for ICI treatments, and washed samples are used in IUI and IVF procedures.
Anonymity
Anonymous sperm donation occurs where the child and/or receiving couple will never learn the identity of the donor, and non-anonymous when they will. Non-anonymous sperm donors are, to a substantially higher degree, driven by altruistic motives for their donations.
Even with anonymous donation, some information about the donor may be released to the female/couple at the time of treatment. Limited donor information includes height, weight, eye, skin and hair color. In Sweden, this is all the information a receiver gets. In the US, on the other hand, additional information may be given, such as a comprehensive biography and sound/video samples.
Information made available by a sperm bank will usually include the race, height, weight, blood group, health, and eye color of the donor. Sometimes information about his age, family history and educational achievements will also be given.
Different factors motivate individuals to seek sperm from outside their home state. For example, some jurisdictions do not allow unmarried women to receive donor sperm. Jurisdictional regulatory choices as well as cultural factors that discourage sperm donation have also led to international fertility tourism and sperm markets.
Legal aspects
A sperm donor is generally not intended to be the legal or de jure father of a child produced from his sperm. Depending on the jurisdiction and its laws, he may or may not later be eligible to seek parental rights or be held responsible for parental obligations. Generally, a male who provides sperm as a sperm donor gives up all legal and other rights over the biological children produced from his sperm. However, in private arrangements, some degree of co-parenting may be agreed, although the enforceability of those agreements varies by jurisdiction.
Laws prohibits sperm donation in several countries: Algeria, Bahrain, Costa Rica, Egypt, Hong Kong, Jordan, Lebanon, Lithuania, Libya, Maldives, Oman, Pakistan, Philippines, Qatar, Saudi Arabia, Syria, Tajikistan, Tunisia, Turkey, UnitedArab Emirates, and Yemen.
See full description of Sperm donation
In vitro fertilization (IVF) is a process by which an egg is fertilised by sperm outside the body: in vitro . The process involves monitoring and stimulating a woman's ovulatory process, removing an ovum or ova (egg or eggs) from the woman's ovaries and letting sperm fertilise them in a liquid in a laboratory. The fertilised egg (zygote) is cultured for 2–6 days in a growth medium and is then implanted in the same or another woman's uterus, with the intention of establishing a successful pregnancy.
IVF techniques can be used in different types of situations. It is a technique of assisted reproductive technology for treatment of infertility. IVF techniques are also employed in gestational surrogacy, in which case the fertilised egg is implanted into a surrogate's uterus, and the resulting child is genetically unrelated to the surrogate. In some situations, donated eggs or sperms may be used. Some countries ban or otherwise regulate the availability of IVF treatment, giving raise to fertility tourism. Restrictions on availability of IVF include to single females, to lesbians and to surrogacy arrangements. Due to the costs of the procedure, IVF is mostly attempted only after less expensive options have failed.
The first successful birth of a "test tube baby", Louise Brown, occurred in 1978. Louise Brown was born as a result of natural cycle IVF where no stimulation was made. Robert G. Edwards, the physiologist who developed the treatment, was awarded the Nobel Prize in Physiology or Medicine in 2010. With egg donation and IVF, women who are past their reproductive years or menopause can still become pregnant. Adriana Iliescu held the record as the oldest woman to give birth using IVF and donated egg, when she gave birth in 2004 at the age of 66, a record passed in 2006.
Polycystic ovary disease (PCOS) is a hormonal imbalance in women that is thought to be one of the leading causes of female infertility. Polycystic ovary syndrome causes more than 75% of cases of anovulatory infertility. Not all women with PCOS have difficulty becoming pregnant. For those who do, anovulation is a common cause. The mechanism of this anovulation is uncertain, but there is evidence of arrested antral follicle development,which, in turn, may be caused by abnormal interaction of insulin and luteinizing hormone (LH) on granulose cells.
Endocrine disruption may also directly decrease fertility, such as changed levels of gonadotropin-releasing hormone, gonadotropins (especially an increase in luteinizing hormone), hyperandrogenemia, and hyperinsullinemia. Gonadotropins are released by gonadotroph cells in pituary gland, and these cells appear to harbor insulin receptors, which are affected by elevated insulin levels. A reason that insulin sensitizers work in increasing fertility is that they lower total insulin levels in body as metabolic tissues regain sensitivity to the hormone. This reduces the overstimulation of gonadotroph cells in pituitary.
