Blastosis transfer

• Recently , there is a remarkable development of stage specific sequential culture media which allows the embryos to develop further in vitro for up to 5-6 days after egg recovery and that embryo stage so called "Blastocyst". The advantages of blastocyst culture are to eliminate those embryos with little developmental competence and to facilitate the synchronization of embryonic stage with uterine endometrial development. This means that we can expect the higher pregnancy and implantation rate from the blastocyst transfer. However , there is considerable patient variation , which means that on the same day using the same media , one patient may get 90% blastocyst development while another patient get only 10%. Additional research data found that about 5 % of patients having blastocyst culture have not at least one embryo develop to blastocyst so they end up with no transfer. 

Embryo Freezing

Embryo Freezing

If patients have many embryos, they can preserve their embryos for the next cycle by freezing. There are two methods to preserve embryos. The first method is slow freezing which will be used when patients want to freeze embryo on Day 1. The other method is Vitrification. This is the newest method of freezing embryos to reduce damages in embryos. Mostly we will use this method to freeze embryos on Day 5.

Why embryo freezing is important?

We recommend patients to freeze their embryos so that if this cycle of ICSI fails, they still have embryos enough to do Frozen Embryo Transfer (FET). The women do not have to go through all ICSI processes. Plus the price of FET is less than the whole ICSI program.

Sperm Freezing

Sperm Freezing Preservation 

Preservation
The sperm freezing preservation preserves sperm inside -196 °C in Liquid Nitrogen, which can be saved up to 10 years. For men that do radiation therapy, men that use birth control, or men that cannot give sperm collection to combine with the egg on the same day , the clinic is able to provide the preserve sperm with the sperm freezing.

Factors for a successful sperm freezing include:
•The sperm quality before freezing
•The sperm type and strength of protective layer
•Freezing and Soluble temperature

Surgical sperm retrieval

Surgical sperm retrieval is a treatment option for men with an absence or blockage of the tube (vas deferens) or non- obstructive azoospermia.

Sperm can be collected directly from the epididymis situated inside the scrotum (the pouch holding the testicles) where sperm are stored and mature using a fine needle and syringe. This is known as ‘percutaneous epidydimal sperm aspiration’ or PESA. Sperm can also be retrieved from the testicles, a process known as ‘testicular sperm extraction’.

Surgical sperm retrieval is carried out by a Consultant Uroandrologist who works in close association with the fertility unit and the procedure is timed to coincide with the female partner’s egg collection. If enough sperm is retrieved it may be possible to freeze small amounts for use at a later stage. The sperm collected is then used to inject the eggs using ICSI.

TESE: testicular sperm extraction. This involves opening up the scrotum and taking a large volume of testicular tissue, perhaps from several regions of the testicle. Sperm are then retrieved using a microscope to identify individual sperm.

TESA: testicular sperm aspiration. This involves placing a needle attached to a syringe through the skin of the scrotum and simply sucking out the fluid inside the testicle.

MESA: microsurgical epididymal sperm aspiration. An open surgical sperm retrieval procedure that uses an operating microscopy to locate the tubules of the epididymis precisely, so that large numbers of sperm can be extracted.

Sperm Preparation

• Sperm Preparation
  
  An ideal isolation technique should be rapid , inexpensive & isolate all the sperm without damaging them. IUI offers a simple and cost effective method of isolating the most functional spermatozoa from the ejaculate. It helps obtain an enriched fraction of motile spermatozoa and also  removes of seminal plasma and other cellular components from ejaculate. This is important because the cellular debris, prostaglandins and any micro organisms if present must be removed so that the sample can be used for IUI procedure. However, there is no technique, which is superior to all other techniques. Ideally, at the end of a sperm wash, we should aim to be able to attain minimum criteria of sperm quality in order to enhance the chances of pregnancy.
 
• 1. Simple Washing
• Washing is oldest method described. The aim is to remove only the seminal plasma, and not the cellular debris, bacteria or non-motile spermatozoa.
  After liquefaction, the semen is mixed with culture medium (1:1) and centrifuged at 300-400 g for 10 minutes. The supernatant is discarded and pellet is suspended in 2 ml of culture medium. This is centrifuged again at 300-400 g for 5-10 minutes and supernatant against discarded. The final pellet is suspended in 0.4-0.5 ml of medium and immediately used for insemination. This is especially useful when sperm density is very low and you are doing an IUI.
  2. Gradient Separation
• The layers are made with 1-2 ml of gradient solution (80% lower and 40% upper layer) 2 ml of semen is then carefully layered on top of 40% and centrifuged at 400-600 g for 15-20 min. cell debris, immobile an abnormal sperm all accumulate at interfaces and a soft pellet is formed at the bottom of the tube. This pellet is aspirated and suspended in 2 ml of culture medium (Depending on sperm density either simple washing or wash with swim-up technique is used). This is centrifuged at 300 g for 5-10 min. the pellet is now suspended in 0.3-0.5 ml of culture medium and used for insemination. The final wash with culture medium to remove the gradient is drawback of this method. Sedimentation Method / Layering under paraffin.
  3. Swim up
  • Swim – up form Pellet
  • This is the most widely used technique for separation of most sperms from non-motile sperms and cellular debris. It is used with normal semen samples and is based on principle active self-migration.
    After liquefaction, the ejaculate is mixed with culture medium and then centrifuged at 300-400 g for 10 minutes. The supernatant is discarded and the sperm pellet is gently over lay with 1 ml of culture medium and stored inside incubator at 37°C for 30-45 minutes. The 0.4-0.5 ml of the supernatant is then gently aspirated and used for insemination.
    Swim-up from Ejaculate
  • This is the ideal method because it obviates the needs for centrifugation . There are some workers who still prefer to centrifuge the recovered sperms.

Micro Array

Micro Array, PGS or a-CGH is another method of chromosome screening. However it is better than PGD as Micro Array can detect all 23 pairs of chromosome. The embryologist can see which chromosome is normal or abnormal. Due to Micro Array, we can screen and find the healthiest embryos for your family. Also we can know the gender of embryos. It works by detecting small amounts of missing or extra genetic material (DNA).Microarray is able to detect small copy number variants that were not detectable by previous methods such as PGD.

 

Assisted hatching

Assisted hatching

Another technique that our clinic provides to increase the chance of getting pregnant is Assisted Hatching. Before the embryos that are transfered back into the uterus can implant, embryos must hatch from the outer layer named Zona Pellucida. Our embryologist will make a little hole on the zona pellucida in order to make the hatching easier for the embryos.

IUI (Intrauterine insemination)

IUI is an insemination treatment for the purpose of injecting sperm directly into the uterus, increasing the chances of pregnancy. If a woman’s body has sperm antibodies, or the male has a low sperm count, we recommend doing IUI if there is any detected cases of infertility.

ICSI (Intracytoplasmic sperm injection)

If there is a question of the sperm's ability to fertilize the egg, due to either a low sperm count or poor quality of the sperm, that poses no problem whatsoever. Intra-Cytoplasmic Sperm Injection (ICSI) would be performed instead of regular In Vitro Fertilization (IVF). With ICSI, the eggs are retrieved the same as if you were doing conventional IVF. However, the eggs and the sperm are then fertilized in the laboratory, by direct injection of a single sperm into each egg. Three days later the resulting embryos are simply placed into your uterus with no surgery, just as with IVF. Extra embryos are frozen for later attempts at pregnancy.

The availability of this Intra-Cytoplasmic Sperm Injection, "ICSI" technique (which was developed and perfected by the Brussels University and our institution in St. Louis) means that men whose sperm previously were too weak or too few to fertilize in vitro (IVF), now have no problem fertilizing their wife's eggs. The fertilization rate per egg using ICSI is about 70% despite the sperm being terrible, the fertilization rate per infertile couple is over 99% if the wife has adequate eggs, and the pregnancy rate per treatment cycle is over 50%. This is not significantly different from regular IVF with normal sperm. This technique is very cost-effective, and will give you the same high chance for getting pregnant as any couple with normal sperm.

ICSI can only be carried out on a mature egg. Unfortunately egg maturity can only be truly identified under the microscope and it is, therefore, possible that following egg collection, none of the eggs are suitable for ICSI. This situation is normally rare, but it is still a possibility.

IVF (In Vitro Fertilization)

IVF (In Vitro Fertilization) is one of the most natural method of in vitro fertilization, using natural means of selecting the most healthiest sperm, facilitating smoothly to combine with the eggs. Choosing the In Vitro Fertilization selection method is critically applicable infertility patients,

Infertility Patients whose conditions are not serious.

Couples suitable for IVF treatment include
•Female patients suffering from complications in the fallopian tubes
•Females whose pelvic has a large amount of connective tissues, or received surgical treatment with no effect
•Females who had endometriosis, and with no effect after the treatment
•Male sperm quality is not good enough, or still received the related treatment with no effect.
•Reasons for infertility remain unexplained

INFERTILITY DETECTION

Infertility detection

Male Infertility detection
From most of the Infertility issues that men face, about 30-4% is mainly due to abnormal ejacuation and sperm mobility, problems may occur at any stage, from hormone secretion, which ever case that affects sperm mobility, and genetic diseases. in any case, taking the treatment and following the procedure will help improve the chances of pregnancy.
The general situations
In most situations, the men receiving the first assessment of their sperm, the doctor will evaluate in accordance to its form, mobility, and sperm count to make an standard assessment.
Total Sperm Count > 40 million
Morphology (WHO) > 30% normal shape
Morphology (Kruger) > 14% normal shape
Volume > 2 milliliters
Motility > 50% motile
Liquefaction complete by 60 min
The amount of active sperm is an overall assessment, examining abnormal sperm with addition checkups, including analysis of hormones, testicular examination, and some that may need to check chromosome.
The Pituary secretion's hormone be a good data indicator of the semen. While taking the examination, it can detect any hormone abnormalty, one of the reasons resulting in infertility.
The following situation is advised to take a Hormone Check.
1. Having a sperm count less than 1 million
2. Sexual Dysfunction
3.Examined that the body's hormone is abnormal, Eg: Thyroid Hormone

Physical Exam an Blood 

Physical Exam an Blood Test taken before treatment
Male Blood test
•AIDS TEST
• Mediterranean Blood Disease Screening
•Hepatitis Check up
•Veneral Disease Checkup, For example Syphilis
Other Male-related Checks
•Sperm

Female Blood Test
•Blood cell verification analysis
•Thalassemia disease screening
•Ovaries and Uterus Ultrasound
•Infectious Hepatitis Checks
•Aids Check
Other Female-related checks
•Ultrasound check, detecting the status of the uterus and ovaries

INFERTILITY PREPARATION

PREPARATION

Treatment precautions for the men
•Try to avoid bacterial infections, it will reduce the sperm count and quality, therefore if you accept the treatment and had a fever 1-2 months prior, please inform the doctor
• High temperatures will interfere with the sperm production, so you should avoid taking a very hot bath or going to the sauna.
•Sperm production and position will be influenced by the testicular pressure, so try to avoid wearing tight underwear.
•Smoking, drinking, will directly affect the quality of the sperm, so you should avoid smoking and drinking during the first 3 months of treatment.
• Exercise can improve the quality of the sperm, so it is recommended to have a daily exercise routine
•Avoid having sex 3 days before th sperm retrieval, have plenty of rest. 

Women Precautions
In addition to the refined technology for the treatment, maintaining the body in good health can also improve the results of the treatment. This is mentioned following 3 points:
1.1 Diet
In order to prepare for the treatment, diet is one factor that influences the treatment. Firstly, pay attention to your water intake, in average each person should drink 2 liters of water per day.
Also keep in mind the intake of protein, take at least 60mg daily (equivalent to the consumption of 100g of liver, bee, fish, which contains 20 grams of protein) protein in the body is very important as it will affect the quality of the egg. Source of protein is very important, you should eat some healthy meals. Example: lean meat, beans, or a variety of fish.
The food should be avoided as follows
•To prepare for the treatment, at least three months prior avoid alcoholic beverages or food
•Refrain from eating chocolate or any other foods that's been processed. For example: canned, fermented foods, foods containing too much sugar.
• Avoid drinking coffee, if you cannot avoid this then do not drink more than 2 glasses per day.
• If you need to take any prescribed medication, inform the doctor if it will have any impact on your ovulation or other treatment practices.
1.2 Physical Health
During the treatment, you must keep your body weight stable, otherwise being obese or too thin will reduce the chances of pregnancy, so if your body weight is not within the standard range (BMI), please lose weight, diet and exercise properly, for example run or do yoga in safety measures. Restrict from smoking, because smoking will affect the endometrium, at least three months prior to the period before receiving treatment. Avoid sitting for long hours, especially if you sit in front of the computer all day as it will affect your blood circulation. If you need to work in front of the computer all day, then get up and move around occasionally. Avoid hot baths and sauna, or staying under the sun. 3-4 days before egg retrieval, until you confirm whether you are pregnant.
1.3 Emotional Readiness
Pay attention to resting, during the treatment you need to relax, and you should not be too reserved. In addition, during the treatment, if you feel something uncertain, ask the doctor or other health care workers, this will help reduce anxiety and raise the effectiveness of the treatment.