Therapy options

This application helps to propose an appropriate fertility therapy method and to find the most suitable clinic worldwide based on the price, duration and legislative options of the treatment in various countries.

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Uterine fibroids treatments

Acupuncture

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

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.

Traditional Chinese medicine

Traditional Chinese medicine (TCM) is a style of traditional Asian medicine informed by modern medicine but built on a foundation of more than 2,500 years of Chinese medical practice that includes various forms of herbal medicine, acupuncture, massage (tui na), exercise (qigong), and dietary therapy. It is primarily used as a complementary alternative medicine approach. TCM is widely used in China and is becoming increasingly prevalent in Europe and North America.

One of the basic tenets of TCM "holds that the body's vital energy (chi or qi) circulates through channels, called meridians, that have branches connected to bodily organs and functions." Concepts of the body and of disease used in TCM reflect its ancient origins and its emphasis on dynamic processes over material structure, similar to European humoral theory. Scientific investigation has found nohistological or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points. The TCM theory and practice are not based upon scientific knowledge, and its own practitioners disagree widely on what diagnosis and treatments should be used for any given patient. The effectiveness of Chinese herbal medicine remains poorly researched and documented. There are concerns over a number of potentially toxic plants, animal parts, and mineral Chinese medicinals. A review of cost-effectiveness research for TCM found that studies had low levels of evidence, but so far have not shown benefit outcomes. Pharmaceutical research has explored the potential for creating new drugs from traditional remedies, with few successful results. A Nature editorial described TCM as "fraught withpseudoscience", and said that the most obvious reason why it hasn't delivered many cures is that the majority of its treatments have no logical mechanism of action. Proponents propose that research has so far missed key features of the art of TCM, such as unknown interactions between various ingredients and complex interactive biological systems. 

TCM's view of the body places little emphasis on anatomical structures, but is mainly concerned with the identification of functional entities (which regulate digestion, breathing, aging etc.). While health is perceived as harmonious interaction of these entities and the outside world, disease is interpreted as a disharmony in interaction. TCM diagnosis aims to trace symptoms to patterns of an underlying disharmony, by measuring the pulse, inspecting the tongue, skin, and eyes, and looking at the eating and sleeping habits of the person as well as many other things.

Theories

The fundamental principles of TCM are based on the Yin-Yang doctrine, the symbolic way of designating opposing forces, and the five element theory that everything in the Universe is dominated and balanced by the five elements, wood, fire, earth, metal and water. The therapeutic mechanism of TCM focuses on enhancing human body's resistance to diseases by improving the inter-connections among self-controlled systems and integrating the human body with the environment. The practice of TCM involves physical therapy such as acupuncture and chemical therapy using materials originating from plants, minerals and animals, while TCM natural products may comprise one or more herbs in the form of decoctions.

In Chinese philosophy, the concept of yin yang sometimes referred to in the west as yin and yang) is used to describe how polar or seemingly contrary forces are interconnected and interdependent in the natural world, and how they give rise to each other in turn. Many natural dualities — e.g. dark and light, female and male, low and high, cold and hot — are thought of as manifestations of yin and yang (respectively).

Yin yang are complementary opposites within a greater whole. Everything has both yin and yang aspects, although yin or yang elements may manifest more strongly in different objects or at different times. Yin yang constantly interacts, never existing in absolute stasis. The concept of yin and yang is often symbolized by various forms of the Taijitu symbol, for which it is probably best known in western cultures. There is a perception (especially in the West) that yin and yang correspond to good and evil. However, Taoist philosophy generally discounts good/bad distinctions as superficial labels, preferring to focus on the idea of balance.

Diagnostics

In TCM, there are five diagnostic methods: inspection, auscultation, olfaction, inquiry, and palpation. 

Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge. 

Auscultation refers to listening for particular sounds (such as wheezing). Olfaction refers to attending to body odor. Inquiry focuses on the "seven inquiries", which involve asking the person about the regularity, severity, or other characteristics of: chills, fever, perspiration, appetite, thirst, taste, defecation, urination, pain, sleep, menses, leukorrhea. Palpation which includes feeling the body for tender A-shi points, and the palpation of the wrist pulses as well as various other pulses, and palpation of the abdomen. Examination of the tongue and the pulse are among the principal diagnostic methods in TCM.Certain sectors of the tongue's surface are believed to correspond to the zàng-fŭ. For example, teeth marks on one part of the tongue might indicate aproblem with the Heart, while teeth marks on another part of the tongue might indicate a problem with the Liver. Pulse palpation involves measuring the pulse both at a superficial and at a deep level at three different locations on the radial artery (Cun, Guan, Chi, located two fingerbreadths from the wrist crease, one fingerbreadth from the wrist crease, and right at the wrist crease, respectively, usually palpated with the index, middle and ring finger) of each, for a total of twelve pulses, all of which are thought to correspond with certain zàng-fŭ. The pulse is examined for several characteristics including rhythm, strength and volume, and described with qualities like "floating, slippery, bolstering-like, feeble, thready and quick"; each of these qualities indicate certain disease patterns. Learning TCM pulse diagnosis can take several years.

Chinese medicine therapies

  1. Herbology: It is traditionally one of the more important modalities utilized in traditional Chinese medicine (TCM). Each herbal medicine prescription is a cocktail of many herbs tailored to the individual patient. One batch of herbs is typically decocted twice over the course of one hour. The practitioner usually designs a remedy using one or two main ingredients that target the illness. Then the practitioner adds many other ingredients to adjust the formula to the patient's Yin Yang conditions. Sometimes, ingredients are needed to cancel out toxicity or side-effects of the main ingredients. Some herbs require the use of other ingredients as catalyst or else the brew is ineffective. The latter steps require great experience and knowledge, and make the difference between a good Chinese herbal doctor and an amateur. Unlike western medications, the balance and interaction of all the ingredients are considered more important than the effect of individual ingredients. A key to success in TCM is the treatment of each patient as an individual. Chinese herbology often incorporates ingredients from all parts of plants, the leaf, stem, flower, root, and also ingredients from animals and minerals. The use of parts of endangered species has created controversy and resulted in a black market of poachers who hunt restricted animals. Most herbal manufacturers have discontinued the use of any animal parts from endangered animals.
  2. Acupuncture: In traditional Chinese acupuncture it is thought Qi- the vital life energy found in the body’s meridians is disturbed, and an imbalance of relationships between Yin and Yang. The insertion of needles at acupoints mainly along the meridians would restore normal body equilibrium. This technique remains controversial as there are no anatomical or scientific evidence to validate the existence of Qi or meridians. A recent review claimed little convincing evidence traditional acupuncture is effective in relieving pain, and adverse events continue to be reported). However these claims are strongly contested and the counter claims that inappropriate methodology, interpretations and conclusions were reached.Acupuncture as a modality needs to be appraised, respected and require adequate proficiency gained before practice. Those who practice acupuncture approach the treatment by looking at pathology in the whole body. According to different body conditions, varied acupoints and manipulations are selected. The selection influences multiple targets and many diseases and stimulates the body to treat diseases, affecting the pathological process and improving physique. This adjustment is accomplished by the integration of the central nervous system, including cortex recombination, neural plasticity, and release of various neurotransmitters and hormones. The basis of acupuncture may be in changes in gene expression. Acupuncture anesthesia is a method used to prevent surgical pain and relieve physiological dysfunction. It is suitable for those who are allergic to narcotic drugs. Since 1958, Shanghai No. 1 People’s Hospital used it instead of narcotic drugs to perform tonsillectomies. Since then, acupuncture anesthesia has been passed from general usage to selected application. According to its clinical effect and scientific evaluation, acupuncture anesthesia is effectively used in thyroid surgery, surgery of posterior cranial fossa, craniocerebral operation, anterior cervical surgery, pulmonary resection, caesarean section, tubal ligation, and tooth extraction. It is also used in some surgeries with uncertain results like hysterectomy, caldwell-luc operation, subtotal gastrectomy, and strabismus surgery. It has not proved to provide effective anesthesia in limb surgery and perineal surgery.
  3. Moxibustion: It is a traditional Chinese medicine therapy using moxa made from dried mugwort (Artemisia argyi). Available scientific evidence does not support claims that moxibustion is effective in preventing or treating cancer or any other disease, but it plays an important role in the traditional medical systems of China (including Tibet), Japan, Korea, Vietnam, and Mongolia. Suppliers usually age the mugwort and grind it up to a fluff; practitioners burn the fluff or process it further into a cigar-shaped stick. They can use it indirectly, with acupuncture needles, or burn it on the patient's skin.
  4. Chinese massage therapy (referred to as tuina): It is commonly defined as the ancient healing art of fingers and strength. Tuina has been practiced in China for over 5000 years. It is a well-respected treatment modality known to be helpful and safe for a wide range of conditions. For these reasons, it is rapidly gaining international favor. Tuina involves a wide range of technical manipulations conducted by a practitioner’s finger, hand, elbow, knee, or foot applied to muscle or soft tissue at specific body locations. It incorporates many of the principles of acupuncture including the use of acupoints. For instance, tuina often uses manual techniques such as pushing, rubbing, kneading, or high-intensity, high-frequency patting to clear energy blocks along specific meridians associated with particular conditions. At present, Chinese massage therapy is widely accepted as a complementary and alternative medicine modality. Its efficacy has been demonstrated for the management of many medical and psychiatric conditions. These include, but are not limited to, failure to thrive in preterm infants, major depressive disorder, substance abuse and dependence, pain syndromes, and immune and autoimmune conditions. Massage therapy has been shown to be particularly effective for disorders of musculoskeletal origin. However, due to a paucity of high-quality studies, there remains controversy about the efficacy and effectiveness of massage. Many clinical trials suffer from inadequate sample size, low methodological quality, and/or sub-therapeutic massage dosing. 
  5. Qigong: It is a holistic system of coordinated body posture and movement, breathing, and meditation used for health, spirituality, and martial arts training. With roots in Chinese medicine, philosophy, and martial arts, qigong is traditionally viewed as a practice to cultivate and balance qi (chi), translated as "life energy". 
  6. Chinese food therapy: It is a mode of dieting rooted in Chinese understandings of the effects of food on the human organism, and centred on concepts such as eating in moderation. Its basic precepts are a mix of folk views and concepts drawn from traditional Chinese medicine. It was the prescientific analog of modern medical nutrition therapy; that is, it was a state-of-the-art version of dietary therapy before the sciences of biology and chemistry allowed the discovery of present physiological knowledge. It now qualifies as alternative medicine.

Myomectomy

Myomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. It is usually recommended when more conservative treatment options fail for women who want fertility preserving surgery or who want to retain the uterus. You may also be able to conceive after having MRI-guided ultrasound surgery, although this procedure is not widely available.
The presence of a fibroid does not mean that it needs to be removed. Removal is necessary when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction. The fibroids needed to be removed are typically large in size, or growing at certain locations such as bulging into the endometrial cavity causing significant cavity distortion.
A myomectomy can be performed in a number of ways, depending on the location and number of lesions and the experience and preference of the surgeon. Either a general or a spinal anesthesia is administered.

There are three types of myomectomy:

  • HYSTEROSCOPY

In a hysteroscopic myomectomy (also called transcervical resection), the fibroid can be removed by either the use of a resectoscope, an endoscopic instrument inserted through the vagina and cervix that can use high-frequency electrical energy to cut tissue, or a similar device. A fibroid that is located in a submucous position (that is, protruding into the endometrial cavity) may be accessible to hysteroscopic removal. This may apply primarily to smaller lesions as pointed out by a large study that collected results from 235 patients suffering from submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5 cm. However, larger lesions have also been treated by hysteroscopy. Recovery after hysteroscopic surgery is but a few days.

  • LAPAROSCOPY
A laparoscopic myomectomy is done through a small incision near the navel. The physician uses a laparoscope and surgical instruments to remove the fibroids. Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy. Using the laparoscopic approach the uterus is visualized and its fibroids located and removed. Morcellators are available to shred larger fibroids so that they can be removed through the small portholes of laparoscopy. As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids. Laparoscopic myomectomy has less pain and shorter time in hospital than open surgery.
  •  LAPAROTOMY

A laparotomic myomectomy (also known as an open or abdominal myomectomy) is the most invasive surgical procedure to remove fibroids. Traditionally a myomectomy is performed via a laparotomy with a full abdominal incision, either vertically or horizontally. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed. Recovery after surgery takes six to eight weeks. 

Myomectomy performed during pregnancy remains a rarity.

Pharmacotherapy of uterine fibroids

If there are no symptoms of uterine fibroids (non-cancerous smooth muscle tumours which grow in the uterus and its walls; Pic. 1 and 2) or if there are just slight symptoms which are not significantly affecting daily life of a woman, medical treatment is usually not necessary. Fibroids often shrink after the menopause and symptoms ease or disappear completely.

However, if the medical treatment is necessary, there are several possible options how to treat uterine fibroids by pharmacotherapy. Some of the options provides only symptomatic treatment and decrease the symptoms potentially related to fibroids by relieving the pain or heavy bleeding. Other of the options helps to shrink the uterine fibroids and thus to eliminate the primary cause. 

Contraceptive pills

It is a popular method of contraception. These pills stop an egg being released from the ovaries and thus to prevent pregnancy. Depending on the type of pills, they also make the menstruation bleeding lighter and may help reduce the period pain.

Anti-inflammatory drugs
The principle of non-steroidal anti-inflammatory drugs, such as ibuprofen, is that they reduce the body’s production of a hormone-like substance – prostaglandin, which causes the heavy periods. Anti-inflammatory drugs are not hormonal medication and they help relieve the pain related to fibroids or menstrual periods, but they don’t reduce bleeding caused by fibroids. Moreover, indigestion and diarrhoea are common side effects of these drugs.

Tranexamic acid

If contraception pills or progestogen pills or injection are not desired tranexamic acid tablets may be considered. This is a non-hormonal medication which helps to ease the heavy bleeding. The principle works on stopping the blood income in small vessels into the uterus lining and thus reducing blood loss approximately to a half of its amount.

Tranexamic acid tablets are taken three or four times a day during the menstrual period, for up to four days. As a side effects, indigestion and diarrhoea are possible.

Oral / injected progestogen
Progesterone, one of the most important progestogens in the body is possible to prepare in a synthetic way (man-made). Progesterone controls the uterine lining growth.

Taking progestogen may help to reduce heavy periods, by preventing the uterine lining grow quickly. Oral progestogen is usually taken as a daily tablet from day 5 to 26 of the menstrual cycle, counting the first day of the period as the day one. In form of injections, the progestogen is injected every 12 weeks for as long as treatment is required.

The side effects of taking progestogen may include weight gain or breast tenderness; furthermore the irregular bleeding or absent periods at injected progestogen.

Progestin-releasing intrauterine device (IUD)
Another option to oral or injected progestogen is a progestin-releasing IUD. It can also relieve heavy bleeding caused by fobroids as the previous options. Furthermore, it also prevents pregnancy. Such an example levonrgestrel intrauterine system (LNG-IUS) is provided.

Gonadotropin releasing hormone analogues (GnRHas)
If medication relieving the symptoms of uterine fibroids doesn’t help enough, gonadotropin releasing hormone analogues is a possible method how to eliminate the primary cause – it helps to shrink the fibroids.

GnRHas are hormones given by injection. They affect pituitary gland (pea-sized gland located at the bottom of the brain) which controls releasing gonadotropic hormones by reproduction system and make it blocking the production of estrogen and progesterone. Thus the menstrual cycle is stopped and the body is put into a temporary postmenopausal state. As a result, fibroids shrink and anemia (which often accompanies fibroids from heavy bleeding) improves. GnRHas are prescribed on a short-term basis. After the treatment, the fibroids may possibly grow back to their original size.

Even though that GnRHas stops the period, they are not a form of contraception. They don’t affect the chances of becoming pregnant after stopping their use.

As GnRHas stops the period and put a body into post-menopausal state-like, side effects, such as hot flushes, sweating, vaginal dryness, depressions or mood swings, may appear. A combination of GnRHas and low doses of hormone replacement therapy may be recommended to prevent the side effects.

Egg donation

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:

  • Unrelated donors to the recipients – they do it for altruistic and/or monetary reasons. The European Union limits any financial compensation for donors to at most $1500. In some countries, most notably Spain and Cyprus, this has limited donors to the poorest segments of society. In US, donors are paid regardless of how many egg she produces. In most countries (excluding the US and the UK), the law requires such type of donors to be anonymous.
  • Egg sharing – the woman decides to provide unused egg from her own IVF for another patient.
  • Designated donors – couple bring their friend or the donor specifically to help them.

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:

  • Totally illegal procedure (Italy, Germany, Austria, Costa Rica, Sunni Muslim countries, Bahrain, Egypt, Hong Kong, Lebanon, Lithuania, Maldives, Norway, Oman, Pakistan, Philippines, Qatar, Saudi Arabia, Syria, Tajikistan, Turkey, Yemen),
  • Legal, no compensation, anonymous donor (France),
  • Legal, no compensation, non-anonymous donor (Canada),
  • Legal, possible compensation, anonymous donor (Spain, Czech Republic, South Africa),
  • Legal, possible compensation, non-anonymous donor (the UK),
  • Legal, possible compensation, anonymous or non-anonymous (the US).

See full description of Egg donation

ICSI

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

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:

  • Taking a medical history of the donor, his children, siblings, parents, and grandparents etc. for three to four generations back. This is often done in conjunction with the patient’s family doctor.
  • HIV risk assessment interview, asking about sexual activity and any past drug use.
  • Blood tests and urine tests for infectious diseases, such as: HIV-1/2, HTLV-1/2, Hepatitis B and C, Syphilis, Gonorrhea, Chlamydia, Cytomegalovirus (CMV), not all clinics test for this.
  • Blood and urine tests for blood typing and general health indicators: ABO/Rh typing, CBC, liver panel and urinalysis
  • Complete physical examination including careful examination of the penis, scrotum and testicles.
  • Genetic testing for carrier traits, for example: Cystic Fibrosis, Sickle-cell disease, Thalassemia, other hemoglobin-related blood disorders.
  • General health
  • Semen analysis for: sperm count, morphology, motility, acrosome activity may also be tested

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. 

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Standard IVF

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.

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Surrogacy

Surrogacy describes an alternate means of conception for individuals who are unable to conceive a child naturally. In surrogacy, one woman (surrogate mother) carries a child for another person/s (commissioning person/couple), based on an agreement before conception requiring the child to be handed over to the commissioning person/couple following birth.

Traditional surrogacy is defined as a woman who agrees to carry a pregnancy using her own oocytes but the sperm of another couple and relinquish the child to this couple upon delivery. The surrogate is naturally or artificially inseminated via IUI, IVF or home insemination. With this method, the resulting child is genetically related to intended father and genetically related to the surrogate mother.

Gestational surrogacy, by contrast, involves a couple who undergoes IVF with their genetic gametes and then places the resultant embryo in another woman’s uterus, the gestational carrier, who will carry the pregnancy and relinquish the child to this couple upon delivery. The resulting child is genetically unrelated to the surrogate. There are several sub-types of gestational surrogacy as noted below.

  • Using the intended mother's egg - a surrogate is implanted with an embryo created by IVF, using intended father's sperm and intended mother's eggs.
  • Using an egg donor - a surrogate is implanted with an embryo created by IVF, using intended father's sperm and a donor egg where the donor is not the surrogate. The resulting child is genetically related to intended father and genetically unrelated to the surrogate.
  • Using a sperm donor - a surrogate is implanted with an embryo created by IVF, using intended mother's egg and donor sperm. The resulting child is genetically related to intended mother and genetically unrelated to the surrogate.
  • Using an embryo donor - a donor embryo is implanted in a surrogate; such embryos may be available when others undergoing IVF have embryos left over, which they opt to donate to others. The resulting child is genetically unrelated to the intended parent(s) and genetically unrelated to the surrogate.

Currently, the use of gestational carriers is far more common than that of surrogates.

The process 

A surrogacy contract is a contract no different to any other contract as it essentially relates to the agreement or promise made by both parties: contract law is primarily concerned with agreements that involve one party, or each party, giving an undertaking or promise to the other party. The rights and duties of the surrogate stem from two basic promises that she makes to the commissioning couple. First, she promises to be treated with the commissioning couple's genetic material (partial/full surrogacy) and carry the child to term. The surrogate will also give an assurance that she will attend regular prenatal appointments so as to ensure the health and safety of the foetus.

Secondly, the surrogate will promise to surrender all rights in the child to the commissioning couple. This latter promise may become complicated if the surrogate is married, as the law presumes that a child born to a married woman is the child of the woman and her husband. However, this presumption is rebuttable and thus, the commissioning couple should from the outset, make it a term of the contract that the surrogate and her husband explicitly agree to make no claim to the resulting child; without this statement, the intention of the parties may be undercut. Such a provision would help reduce emotional strain and the probability of litigation, and would avoid harming the child by involving it in custody proceedings.

A surrogacy arrangement based on contractual intention should not be designed to commodify offspring. Surrogacy arrangements do not deal with fungibles and must not encourage a system where children are treated as goods that may be contracted in and out of. While the notion of surrogacy could understandably figure centrally in the arena of family law, when examining the matrix of relationships embraced by surrogacy, one may see that surrogacy also has a basis in contract law. As with all contracts, they are designed to protect the interests of both parties as well as to bring to fruition, the express and implied terms of the contract. This perspective derives from the basic agreement made between the surrogate and the commissioning couple; the surrogate agrees to carry the foetus to term, for the benefit of the commissioning person/s and, the latter agree to re-compensate the surrogate for her time and expense in carrying out said procedure, of which, would not be possible without her agreement.

Surrogacy arrangement

There are 2 types of surrogacy arrangement:

  • Altruistic (non-commercial),
  • Commercial – there is a payment, reward or any material benefit for surrogate.

Legal aspects

If the jurisdiction specifically prohibits surrogacy, however, and finds out about the arrangement, there may be financial and legal consequences for the parties involved. Some jurisdictions specifically prohibit only commercial and not altruistic surrogacy. Even jurisdictions that do not prohibit surrogacy may rule that surrogacy contracts (commercial, altruistic, or both) are void. If the contract is either prohibited or void, then there is no recourse if one party to the agreement has a change of heart: If a surrogate changes her mind and decides to keep the child, the intended mother has no claim to the child even if it is her genetic offspring, and the couple cannot get back any money they may have paid or reimbursed to the surrogate; if the intended parents change their mind and do not want the child after all, the surrogate cannot get any reimbursement for expenses, or any promised payment, and she will be left with legal custody of the child.

Jurisdictions that permit surrogacy sometimes offer a way for the intended mother, especially if she is also the genetic mother, to be recognized as the legal mother without going through the process of abandonment and adoption.

Often this is via a birth order in which a court rules on the legal parentage of a child. These orders usually require the consent of all parties involved, sometimes including even the husband of a married gestational surrogate. Most jurisdictions provide for only a post-birth order, often out of an unwillingness to force the surrogate mother to give up parental rights if she changes her mind after the birth.

A few jurisdictions do provide for pre-birth orders, generally in only those cases when the surrogate mother is not genetically related to the expected child. Some jurisdictions impose other requirements in order to issue birth orders, for example, that the intended parents be heterosexual and married to one another. Jurisdictions that provide for pre-birth orders are also more likely to provide for some kind of enforcement of surrogacy contracts.

Additionally, the rights of the surrogate or gestational carrier to not relinquish the infant following deliver are not well described.

Parentage order

A parentage order is a court order that transfers parentage from the birth parent/s to the intended parent/s - as part of the surrogacy arrangement. This means the birth mother and her partner (if she has one) no longer have a legal parental relationship with the child and the intended parents become the child’s legal parents. A prebirth form of parentage order could be used.

Surrogacy laws by state

Surrogacy is completely prohibited in Finland, France, China, Iceland, Italy, Japan, Pakistan, Saudi Arabia, Serbia, Spain and Switzerland. 

Countries where a commercial surrogacy is legal and a woman could be paid to carry another's child through IVF and embryo transfer included Georgia, Russia, Thailand, Ukraine and a few US states.

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How can Uterine fibroids affect fertility

Occasionally fibroids may make it difficult to get pregnant although this is uncommon. While fibroids are common, they are not a typical cause for infertility, accounting for about 3% of reasons why a woman may not be able to have a child. The majority of women with uterine fibroids will have normal pregnancy outcomes. In cases of intercurrent uterine fibroids in infertility, a fibroid is typically located in a submucosal position and it is thought that this location may interfere with the function of the lining and the ability of the embryo to implant. Also larger fibroids may distort or block the fallopian tubes.

Calcified fibroids
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