What to expect during Artificial Insemination
In Vitro Fertilization and Intracytoplasmic Injection
In Vitro Fertilization and Intracytoplasmic Injection (ICSI) are an Assisted Reproduction Method directed to infertile couples. Its goal is to fertilize the eggs with the sperm outside the woman’s body, when they are unable to do so in their natural place, the fallopian tube. This procedure is performed in the laboratory, keeping eggs and sperm in a capsule with culture medium (liquid that simulates tubal fluid) and under controlled environmental conditions of temperature, humidity, oxygen concentration, carbon dioxide, etc.
If fertilization occurs and embryos are developed, they are preferably transferred to the uterus and in some cases to the fallopian tubes in order to continue their multiplication and development until they acquire the capacity to implant in the endometrium which is the inner layer of the woman uterus.
The stages of IVF / ICSI are:
1. Ovarian stimulation (Medications to grow multiple eggs)
2. Eggs retrieval from the ovary or ovaries (oocyte retrieval)
3. Insemination of eggs with sperm
4. Culture of any resulting fertilized eggs (embryos)
5. Transfer of one or more embryo(s) into the uterus
During a spontaneous ovulatory cycle, of all the follicles (ovary structure inside the oocytes) selected in each month (approximately 10), only one reaches maturity (dominant follicle). The rest of the follicles are reabsorbed and will no longer be used by the ovary. Thus only an oocyte has the opportunity to be fertilized in each cycle. On extraordinary occasions, more than one follicle is selected, with the consequent production of more than one oocyte. These are the cases in which spontaneous non-identical twins can occur.
The objective of ovulation stimulation is to recruit a larger number of oocytes in both ovaries and to avoid reabsorption of the population of follicles accompanying the dominant. This makes it possible to have a greater number of oocytes that once aspirated from the ovary can be inseminated to facilitate their fertilization.
Oocyte retrieval is a process that aims to extract oocytes from the interior of the follicles. It is performed by puncturing the ovary with a needle that is inserted through the vagina guided into the follicles by ultrasound visualization. This is an outpatient procedure that requires local and sometimes general anesthesia depending on the patient and the topographic location of the ovaries.
Fertilization is a process that begins with the contact of the spermatozoa with the covering that surrounds the oocyte (pellucid zone) and ends with the dissolution of pronuclei in a process called syngamy.In IVF, for fertilization to occur, each oocyte is incubated in the same culture medium with approximately 50,000 to 100,000 previously trained spermatozoa in the laboratory. As soon as a sperm is able to penetrate the pellucid zone, the oocyte reacts by activating this cell layer to block the entry of more spermatozoa.
The evidence of fertilization is given by the microscopic visualization of the pronuclei (male and female), 16 to 20 hours after the coincubation of both gametes.
Intracytoplasmic Sperm Injection (ICSI) is a form of in vitro fertilization directed at infertile couples in which due to multiple factors, spermatozoa do not have the ability to penetrate into the oocyte. This is done using magnification equipment (inverted microscope), equipped with hydraulic systems that allow the spermatozoon to be introduced smoothly, using a very fine glass needle. This procedure is performed in the laboratory, under controlled environmental conditions of temperature, humidity, oxygen concentration, carbon dioxide, etc.
If fertilization occurs and embryos are developed, they are transferred to the uterus in order to continue their multiplication and development, until they acquire the capacity to implant in the endometrium that is the inner layer of the woman’s uterus.
The transfer of embryos to the uterus is an outpatient procedure, without analgesia or anesthesia. This procedure lasts about 15 minutes and consists of depositing the embryos in the interior of the uterine cavity. To do this, a thin, inert, very soft plastic tube called catheter is used. The catheter is introduced through the cervix and once inside the cavity, the embryos are deposited in the uterine cavity.
The process of implantation of the embryo begins on the fifth day of fertilization. Thus the embryos are transferred on the second or third day, they must continue their development in the uterine fluid before making contact with the endometrium and initiate the implantation.
Eleven days after the transfer hormone (β-hCG), can be measured in the woman’s blood, which allows to determine the presence of pregnancy. This hormone doubles its value every 1.5 to 2 days. In this way, serial measurements can provide useful information regarding the quality of gestation before being visible with ultrasound. Transvaginal ultrasound allows visualization of a gestational sac within the uterus, 21 days after embryo transfer.
The purpose of this intervention is to re-construct the tubes that had been previously occluded, leaving them again permeable. Is indicated when the woman wants to regain her fertility after having undergone a tubal sterilization.
After applying regional anesthesia, a laparoscopy or laparotomy is performed. Tubes are identified and excision of the occluded area is performed and then anastomosed (joining) the remaining ends through sutures with microsurgical technique, after checking that the tissue is healthy and the tubal lumen is open.The intervention time is about 2 hours.
Indications to be taken into account for post-intervention
Postoperative hospitalization is usually 1 to 2 days and convalescence, until normal activity can be achieved in 2 or 3 weeks. The patient can then start normal activity. If at 6 months has not become pregnant, it is advisable to perform contrast x-ray (hysterosalpingography) to re-confirm the tubal permeability. Sometimes the tubes can be closed again due to defective healing.
Preimplantation genetic diagnosis
Preimplantation Genetic Diagnosis (PGD) is a technique used as a complement of In Vitro Fertilization (IVF), which purpose is to select those embryos free from the genetic or chromosomal alteration studied in each case.
The DGP technique is the result of the combination of:
1. In vitro fertilization with / without spermatic microinjection.
2. Biopsy of the polar corpuscle or embryonic cells.
3. Genetic diagnosis technique.
The most frequent indications fort the realization of the DGP are:
A. Communicable paternal / maternal genetic disorders:
• Diseases that affect a single gene or monogenic (dominant, recessive or linked to the X chromosome) whose mutation is known and can be analyzed.
• Disorders linked to the X chromosome, where the gene is not known or suffers some heterogenicity, which is avoided with sex selection.
• Structural chromosomal abnormalities, such as reciprocal or Robertsonian translocations.
B. Screening aneuploidies:
• Repeated abortion
• Repeated implantation failure
• Advanced maternal age.
• HLA typing (histocompatibility)
• Chromosomal alterations in spermatozoa
• Gender selection.
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