Assisted Reproductive Technology (ART): The Couple’s Journey

Step 1: Scheduling an Appointment with the Doctor

During the admission phase, patients are asked to provide their previous medical documentation for review during the diagnostic process. Appointments are scheduled for the initial three specialized examinations (gynecological, andrological, and genetic).

Step 2: Gynecological Examination

During the first gynecological examination, after a thorough assessment of the medical history, previous diagnostic tests, and any prior ART treatments, blood tests and instrumental tests are prescribed, if indicated, to complete the diagnostic process. A pelvic ultrasound is also performed to assess the patient's uterus, adnexa, and ovarian reserve.

Step 3: Andrological Examination

During the andrological examination, semen analysis evaluates sperm quality to guide the couple toward the most appropriate ART technique for their clinical situation.

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Step 4: Genetic Counseling

During the first visit, the couple's genetic and family history is collected, genetic pathology is assessed, and the risk of recurrence is explained. The couple is also informed about the different possibilities and techniques of preimplantation genetic diagnosis, with an assessment of the advantages, disadvantages, and success rates.

Finally, in the case of preimplantation genetic diagnosis, the couple and, if the chosen technique requires it, close relatives, provide a blood sample for DNA analysis to allow for personalized diagnosis.

Step 5: Interpretation of Analyses

Once the couple has completed the required tests, they return for a checkup and the treatment procedure is decided upon.

The procedure is then explained, any potential risks of the technique are discussed, the couple's questions are answered, and informed consent is obtained. The couple is then given a personalized and appropriate treatment protocol.

Step 6: Ovarian Stimulation

Ovarian stimulation involves the use of medications to induce multiple follicle growth. Depending on the stimulation protocol used, the duration of the complete ovarian stimulation cycle varies from 10 to 20 days. Different protocols are chosen based on the characteristics of the ovarian reserve, age, and clinical history of the patient.

Step 7: Egg Retrieval

Egg retrieval (pick-up) is performed transvaginally under ultrasound guidance, under local anesthesia or neuroleptanalgesia (light sedation) at the patient's request or as per medical instructions. Perioperative antibiotic prophylaxis is administered during this procedure. All present follicles, within certain diameters (>16 mm), are aspirated and the resulting follicular fluid is immediately examined under a microscope to search for oocytes.

An oocyte is considered mature (from a nuclear standpoint), and therefore usable for in vitro fertilization, if it has reached the metaphase II stage.

Step 9: Semen Collection and Preparation

On the morning of the egg retrieval procedure, the male partner provides a semen sample. The semen sample is then prepared in the laboratory using techniques designed to improve the fertilizing capacity of the sperm.

In the absence of sperm in the ejaculate (azoospermia) or in case of ejaculatory failure, sperm can be retrieved from the testicle and/or epididymis by surgical retrieval procedures (TESE, TESA/PESA).

Step 10: Sperm Assessment

Sperm are normally observed and selected at a magnification of 400 times. In some cases, for more precise selection, the IMSI (Intracytoplasmic morphologically selected sperm injection) technique may be indicated. This involves assessing the quality of individual sperm at very high magnification where it is possible to identify morphological abnormalities such as vacuoles and nuclear defects.

Step 11: ICSI - Intracytoplasmic Sperm Injection

This technique involves mechanically removing all barriers of the oocyte, consisting of cumulus cells and corona radiata, and introducing a single selected sperm directly into the cytoplasm of the oocyte.

ICSI offers the enormous advantage of being able to observe and select gametes (oocytes and sperm) before use. Embryos obtained by ICSI are cultured in vitro.

Step 12: Embryo Culture

After the fusion between the sperm and the oocyte, a cascade of events is triggered leading to the formation of the embryo. Signs of fertilization are expressed 18 to 20 hours after oocyte insemination.

Indeed, inside the fertilized cell (zygote), the presence of two nuclei can be observed, each carrying genetic information, one of maternal origin and the other of paternal origin. After a further period of in vitro culture (24-48 hours), the number of embryos formed and their embryonic quality are assessed.

The quality of an embryo is therefore given by a set of parameters that must be accurately assessed during the different phases of development.

Precise embryo assessment plays a fundamental diagnostic role in treatment and should therefore be considered of paramount importance.

Step 13: Embryo Biopsy

Embryo biopsy is performed according to the methods agreed upon with the couple and according to the specific diagnostic requirements on the 5th day of in vitro growth.

It consists of removing a few cells from the embryo without compromising its normal development.

Once the biopsy is performed, the embryos are frozen by vitrification until the diagnostic result is obtained, after which the suitable embryos are transferred to the uterus.

Step 14: Embryo Transfer

The resulting embryos are transferred to the uterus using a thin catheter and, in very rare cases, by transmyometrial transfer. This procedure is painless and therefore does not require anesthesia. From the day after egg retrieval, the patient begins receiving natural progesterone vaginally to support the luteal phase.

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