What are the most requested techniques in assisted reproductive technology (ART) or IVF?

What is in vitro fertilization?

In vitro fertilization (IVF) is an assisted reproductive technology (ART) technique that allows for the conception of a child in a laboratory. It is often used by couples experiencing infertility and who have not been able to conceive naturally. The first IVF was performed in 1978; since then, this technique has evolved and become increasingly common.

IVF involves stimulating the woman's ovaries to produce multiple oocytes (eggs). These oocytes are then retrieved and placed in a culture dish containing a nutrient solution. The sperm from the male partner or a donor is then added to the oocytes in the culture dish to allow fertilization.

Once the oocytes have been fertilized, they are left to develop for a few days until they become embryos. The healthiest embryos are then selected to be transferred into the woman's uterus. This step is called embryo transfer.

The steps of IVF can vary depending on the protocols used and the specifics of each patient. It is important to note that IVF can be a stressful and emotional process for couples who undergo it.

In short, IVF is an ART technique that allows for the conception of a child in a laboratory. It involves stimulating the woman's ovaries, fertilizing the oocytes in the laboratory with sperm, selecting the healthiest embryos, and transferring them into the woman's uterus. The first IVF was performed in 1978, and since then, this technique has allowed many couples to start a family.

How is diagnosis and therapeutic choice made in ART or IVF?

Gynecological examination

During the first consultation, a basic gynecological examination may be performed, which includes:

• Objective assessment of the cervix;
• Screening test (if necessary);
• Transvaginal ultrasound for ovarian assessment;

The gynecological examination is the basis of the diagnostic process, which will conclude with the therapeutic choice best suited to the couple.

Ovarian reserve assessment

During the early phase of the ovarian cycle, it is possible to assess a woman's ovarian reserve using transvaginal ultrasound and hormonal assay of the main hormones involved in ovulation: FSH (follicle-stimulating hormone) and AMH (anti-Müllerian hormone).

The ovarian reserve index can help the couple to assess a more conscious approach to the most advanced assisted reproductive techniques.

Semen analysis

The semen sample is evaluated through various tests:

• Basic semen analysis;
• Percoll test;
• Semen culture and antibiogram;
• DNA fragmentation analysis with the Halo test;
• MAR test for agglutination assessment;

Assessment of tubal patency

This examination consists of an ultrasound to diagnose structural defects in the female reproductive system, such as partial or total tubal stenosis. Tubal patency is essential to allow sperm passage and zygote descent into the uterus. An aqueous medium is introduced into the uterus, and the passage of the fluid into the fallopian tubes is observed by ultrasound. The examination should be performed in the days following menstruation, when the endometrium is not very thick, in order to have better ultrasound visibility.

3D Ultrasound

This is a non-invasive examination aimed at assessing the uterine cavity in three dimensions, which allows us to exclude abnormal formations in the cavity.

Hysteroscopy

Hysteroscopy allows direct and precise visualization of the uterine cavity through the insertion of a hysteroscope, a thin tube equipped with optical fibers that allows visualization of internal organs. It is only performed on the specific instructions of the doctors in the department.

Most frequently used ART therapies

Ovulation monitoring

Monitoring to assess follicular growth uses repeated ultrasounds from day 5 to day 7 of the cycle. The start of therapy and monitoring vary depending on the patient's cycle and/or the use of ovulation induction medications. In parallel with the ultrasound, a blood sample is taken for estradiol assay to more precisely follow follicular development. This diagnostic method can, in itself, constitute a therapy that allows monitoring of the most appropriate days to have sexual intercourse. If the patient has undergone pharmacological induction of ovulation, monitoring of follicular growth can be used both to time spontaneous intercourse and to prepare for insemination or a more invasive technique (IVF, ICSI). In all cases, a medication (hCG) is administered intramuscularly or subcutaneously to induce ovulation.

Artificial Insemination

Artificial insemination (IUI - Intrauterine Insemination) consists of depositing the seminal fluid inside the uterine cavity via a small catheter. In this way, fertilization will be natural and not artificial. The seminal fluid is observed and processed in the laboratory in order to select the most mobile spermatozoa with the best morphology.

This therapy is indicated in cases of:

• Unexplained infertility;
• Mild male infertility;
• Stage I-II endometriosis and some cases of stage III-IV of the American Fertility Society (AFS) classification, especially after surgery;
• Cervical factor;

Artificial insemination may involve moderate pharmacological stimulation of follicular growth.

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In what cases should in vitro fertilization be used?

In vitro fertilization (IVF) is an assisted reproductive technology (ART) used to treat infertility in couples who have difficulty conceiving naturally. IVF may be recommended in cases of male or female infertility, fallopian tube obstruction, ovulation disorders, endometriosis, advanced age, genetic problems, or recurrent miscarriages. There is no maximum age for undergoing IVF, but the chances of success decrease with the woman's age. The steps of IVF include ovarian stimulation to produce multiple eggs, egg retrieval by follicular aspiration, fertilization of the eggs in the laboratory, culture of the embryos to an advanced stage, and then transfer of one or more embryos into the woman's uterus. The IVF protocol may vary depending on individual cases and the recommendations of the ART specialist.

Here are the treatment phases in detail:

Ovarian stimulation

The ovaries are stimulated by the administration of hormones, while ovulation and follicular growth are monitored by ultrasound until they reach the optimal number and size.

Egg retrieval and in vitro fertilization

Egg retrieval is done by follicular aspiration.

Once the male and female gametes have been obtained, there are two fertilization options:

1. IVF (in vitro fertilization): the eggs are kept in a 37° incubator in special culture media for a few hours before insemination with the partner's seminal fluid treated for in vitro fertilization. The eggs and sperm, together, are left overnight in the laboratory and observed the next morning;
2. ICSI (intracytoplasmic sperm injection): fertilization is further "assisted" as the sperm is directly injected into the oocyte. 2 or 3 days later, the fertilized eggs are ready to be transferred into the uterus;

Embryo transfer

The fertilized eggs are inserted into the uterus via a thin catheter and deposited by the gynecologist at the end of the uterine cavity.

Cryopreservation

Untransferred embryos are frozen in liquid nitrogen and can be used for subsequent transfers if pregnancy is not achieved on the first attempt. Subsequent transfers do not require further ovarian stimulation or egg retrieval.

In vitro fertilization is indicated in cases of:

• Moderate male infertility;
• Tuboperitoneal factor: congenital or acquired tubal pathology or (previous ectopic pregnancy, previous tubal abortion, positive history of pelvic inflammation, pelvic surgery);
• Grade III or IV endometriosis;
• Unexplained infertility;

Other frequent ART therapies

• Specialized examinations and investigations for the assessment of the couple's fertility;
• Assisted conception cycles also with heterologous fertilization;
• Preimplantation genetic diagnosis;
• Cryopreservation of gametes (oocytes and sperm);
• Cryopreservation of surplus embryos;

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