Infertility Treatments

A step in the right direction could be the beginning of a life-changing event.

Doctors and staff at Pretoria Fertility Centre know and understand the anxiety and fears brought about by infertility. Our ultimate aim is to provide a safe space where cutting-edge infertility solutions can be applied with a human touch.

Fertility treatment remains unique to each couple and is determined by your specific situation. After thorough investigations a personal protocol will be allocated to you as couple / individual.

Our fertility clinic offers a variety of treatments, namely:

Artificial insemination

Intra-uterine insemination

Artificial insemination

The most commonly used method is intra-uterine insemination (IUI). There are three IUI treatment options:

Natural Cycle Insemination

This option does not involve any medication but follows the woman’s natural menstrual cycle. It is suitable for patients who are unable to have natural intercourse. It is not a successful method for women whose partners have poor sperm quality.

Clomiphene Citrate Ovulation Induction

This option involves the use of medication to stimulate the ovaries, causing or regulating ovulation. The medication in combination with IUI has been shown to increase pregnancy rates over natural cycle IUI.

FSH Ovulation Induction

Ovarian stimulation is stronger with this option and has been shown to increase pregnancy rates over natural cycle IUI and Clomiphene citrate IUI. Regular monitoring of the patient is required to minimise complications relating to overstimulation.

Most recent studies suggest that optimum pregnancy results are achieved using the Clomiphene citrate or FSH treatments.

IUI involves preparing or “washing” the sperm, which is then gently inserted into the uterine cavity using a speculum and a disposable catheter to bypass the cervix.


Sperm Selection

The technique of sperm preparation or “washing” involves separation of the seminal plasma from the spermatozoa and concentration of the more morphologically normal and motile sperm for insemination.

Insemination

The actual insemination is quite simple and painless– many women describe it as similar to a Pap smear. The entire procedure takes just a few minutes.

The patient’s treating specialist or fertility coordinator usually performs the insemination procedure and male partners are welcome to attend. Normal daily activities can be resumed immediately afterwards.

A pregnancy test should be performed about two weeks after the insemination. The patient should take good care of yourself during this period.

The period between insemination and the pregnancy test is often emotionally charged with expectation and anxiety. Our patients are encouraged to contact the clinic for support when dealing with the stress of waiting.

In the event of an unsuccessful procedure the patients is encouraged to schedule a follow-up appointment with her fertility specialist. During this appointment plans for further treatment can be discussed and any questions addressed.

After three unsuccessful IUI attempts, considering IVF is advised.

IVF * ICSI * Assisted hatching* TESA
(sperm obtained surgically)

In vitro fertilization

IVF

In vitro fertilisation (IVF) is an assisted reproductive technology (ART) used to treat infertility that has failed to respond to other medical or surgical interventions. IVF literally means “fertilization in glass” and involves the fertilization of the egg by the sperm in an incubator outside the body, followed by transfer of the embryo back into the uterus.
IVF was developed to treat infertility caused by tubal damage, endometriosis, sperm disorders and unexplained factors. Whether the patient needs IVF will depend on the infertility diagnosis and the treatment plan required in addressing the condition.

Potential risks and side effects associated with IVF procedures include:

  • An exaggeration of usual menstrual cycle symptoms (eg. bloating, breast tenderness and mood swings) because the ovaries have been stimulated to produce more than one follicle.
  • In about 1% of cases, ovarian hyper stimulation syndrome (OHSS) develops. The ovaries become extremely enlarged and extra fluid accumulates in the abdomen. This complication requires rest, close monitoring, intravenous fluids or even drainage of the abdominal fluid. In rare cases, if our patient seem to manifest a high risk of developing OHSS, the embryos may be frozen rather than replaced.
  • If more than one embryo are transferred into the uterus, a multiple pregnancy may occur. Multiple pregnancies carry a higher risk of pre-term delivery and other complications. Twins can occur in 10% to 20% of cases.
  • Fertility drugs have not been proven to increase the risk of breast, ovarian or uterine cancer; reassuring data is now available from several large follow-up studies. However, women who have never been pregnant presents a higher risk of breast or ovarian cancer. Past or future use of the birth control pill will lower the risk of ovarian cancer. An annual physical exam is essential to the prevention and early detection of all diseases.
  • IVF babies and babies born through natural conception are no different.
  • In 1978 the world’s first IVF baby, Louise Brown, was born in England. Since then, around 5 million babies have been born as a result of IVF.

 

Step one: Follicle development or ovulation induction

 

On day 1 of menstruation an appointment should be scheduled for day 3. In a natural menstrual cycle, hormones form the pituitary gland (FSH & LH) cause the growth of an egg within the fluid-filled space called a follicle. In an IVF cycle it is desirable for several eggs to mature simultaneously.

To prevent early or natural ovulation a GnRH agonist or antagonist is used to temporarily turn off your own FSH and LH secretions. These medications are administered at various stages of the IVF cycle.

Daily injections with FSH (Menopur, Gonal F, Fostimon or Puregon) is given for 6 – 8 days and most women administer it themselves. This stimulates the growth of several follicles instead of just 1 or 2. The response of the ovaries is monitored with ultrasound and will vary according to each woman’s ovarian reserve.

Click on IVF cycle calendar to see your very own cycle calendar for the benefit of your IVF treatment planning IVF cycle calendar

Step two: Egg retrieval

 

Once the ultrasounds indicates a reasonable size and number of the follicles an injection of hCG is given, causing final maturation and loosening of the egg from the follicle wall. The egg retrieval occurs on the second morning after the injections (36 hours later).

Egg retrieval is performed under conscious sedation by an ultrasound guided needle, puncture through the top of the vagina. The fluid is drained from each follicle and examined under the microscope, in order to determine the presence of an egg.

Step three: Fertilization

 

The sperm sample is washed and concentrated, then added to the eggs a few hours after retrieval. The next day the eggs are examined for signs of fertilization. If the sperm sample looks normal 70% of eggs can be expected to fertilise. Not every follicle will contain an egg. Not every egg will fertilise. Not every egg that fertilises will continue to form a good quality embryo.

The patient will receive a script for progesterone and an antibiotic to start on the evening of the egg retrieval. The embryologist will establish contact to schedule the date and time for embryo transfer.

Step four: Embryo transfer

 

Three to five days following egg retrieval the embryos are transferred to the uterus using a fine plastic tube. The exact number transferred depends on the patient’s age and embryo quality. This procedure takes only a few minutes and is usually not uncomfortable. The patient should report at the clinic with a full bladder at the given time.

Some couples have extra embryos that are suitable for freezing. The best quality embryos (those most likely to result in pregnancy) are usually transferred in the treatment cycle. To be selected for freezing, embryos must show minimal or no sign of fragmentation (cell breakdown) and no sign of abnormal development. Obviously not all embryos will meet these criteria. The patient is recommended to start with aspirin on the day of transfer (unless allergic) and to continue with the progesterone (Cyclogest).

Step five: Pregnancy test

The patient is advised to limit activity for 24 hours after the embryo transfer. Activity can be gradually increased over the next few days to non-strenuous activities. Some patients even return to work and continue with their normal routines.


 

Optimising success:

Underweight or markedly overweight patients may have difficulties during the treatment cycle or a resulting pregnancy. As medication doses and responses tend to be weight related, overweight patients may require much higher dosages of medication and may have difficulty absorbing it. This is also linked to increased risk of pregnancy loss.

Smokers should attempt to quit or at least minimise the number of daily cigarettes. Women who smoke have a lower chance of becoming pregnant and higher rate for miscarriages. A study indicated that women who smoke need twice as many IVF cycles to home a baby.

A daily dose of 0,5 mg Folic acid is recommended for all women trying to become pregnant. This vitamin reduces the risk of certain serious defects of the central nervous system in the foetus. It could be started a few weeks prior to the treatment.

The success rate of IVF is affected by several factors, a crucial factor being the age of the female partner.

Infertility and its treatment can be quite stressful from an emotional, physical and financial point of view. We encourage partners to be supportive and participate in the treatment process. It can also be helpful to develop a network of supportive friends and relatives.


ICSI (Intra-cytoplasmic-sperm-injection)

This technique involves the embryologist picking up one sperm in a very fine needle and injecting it into the cytoplasm of an oocyte that is being held in position with a fine holding pipette. ICSI can also be applied to semen samples with a very low sperm count and/or poor motility or morphology.

Assisted hatching

Assisted hatching is usually performed on day 3 of embryo culture whereby three small openings are drilled into the zona pellucida of the embryo with the aid of a laser beam. This is done in order to assist the embryo with hatching once it has reached the expanded blastocyst stage on day 5 of embryo culture.

TESA

TESA can be applied as a diagnostic procedure to determine whether there are sperm in the testes of men with azoospermia (a condition whereby no sperm is present in the seminal fluid), or as a procedure to recover sperm from the testicles of men with obstructions or ejaculatory problems that cannot be treated by any other methods.

TESA procedure involves a very fine needle being passed into the testicles under anaesthetic, in order to remove a tiny amount of material from the seminiferous tubules (network of tiny tubes where sperm is produced). These tubules are then processed in the laboratory and checked for the presence of sperm, which can be either used to fertilise eggs or frozen.

Sperm retrieved from the seminiferous tubules in a TESA procedure are less mature and less motile than sperm found in ejaculated seminal fluid. As such, ICSI (Intra cytoplasmic sperm injection) – a specialised form of IVF is required to achieve fertilisation with TESA sperm. In some cases sperm need to be retrieved doing an open testes biopsy in theatre.

Embryo, egg & sperm freezing+

Cryopreservation (freezing)

Cryopreservation of embryos, sperm, eggs and testes biopsies is done for various reasons. Some of the more common reasons are medical conditions that require treatment harmful towards reproduction. Sometimes it is due to logistical reasons or just to preserve fertility till the patient is ready to start with a family.

Embryos, sperm and eggs need to be of very good quality to withstand the freezing process so the procedure is no guarantee for a pregnancy.

Freezing of eggs

Egg freezing has the potential to assist female cancer patients, as chemotherapy and radiation treatment can often have a harmful effect on fertility, rendering many of these patients menopausal.

Women who are at risk of early menopause, have a genetic disorder potentially limiting fertility or wish to have children later can also have eggs collected and stored.

PFC uses vitrification when freezing eggs. In this process the solution containing the egg is cooled so rapidly that the water molecules do not have time to form damaging ice crystals and instantly solidify into a glass-like structure. The concept is based upon the idea that if the cell is dehydrated to a certain degree and then cooled fast enough, everything will “freeze” in place, leaving no time for damage to occur.

Freezing of eggs mainly consists of eight phases:

  • Evaluation of ovarian reserve
  • Ovulation induction
  • Egg retrieval & freezing
  • Storage, usually at an annual fee
  • Preparation for embryo transfer
  • Fertilization of eggs and embryo culture
  • Embryo transfer
  • Pregnancy test

Freezing of sperm

PFC performs short term freezing of sperm with the following requirements:

  • A semen analyses not older than 6 months.
  • Appointments are Mon – Fri between 8 – 10 am.
  • 3 day of abstinence (no intercourse or masturbation).
  • Consent form and payment on the day of freezing.
  • Should the sperm not be utilised within the first year it is recommended that the patient contacts Androcryos for long term storage.

Freezing of embryos

In most IVF cycles the best two embryos are transferred although the fertility industry/field is moving towards single embryo transfer. Should there be more than two embryos of good quality it is recommended to consider freezing them.

PFC uses vitrification with the following steps:

  • Consent form.
  • Payment on the day of transfer and then annually till the day of transfer.
  • Should the fresh cycle be unsuccessful preparation for frozen transfer.
  • Should the fresh cycle be successful contact regarding the frozen embryos should be made every two years.
PGD

PGD (Pre-implantation genetic diagnosis) and PGS (Pre-implantation screening)

PGD is generally used to detect genetic anomalies where one or both partners of a couple are carriers of a genetic condition. In these instances IVF is performed and the embryos are tested for this specific condition and disease-free embryos are transferred.

PGS entails embryos being screened for chromosomal abnormalities in patients undergoing routine IVF. It is known that the most common reason for IVF failure is chromosomal abnormal embryos. The percentage of abnormal embryos increases with the age of the female patient. Embryos with abnormal chromosomes may prevent implantation or lead to pregnancy loss.

The embryos are cultured to the blastocyst stage and a trophectoderm cells biopsy is performed. These cells are then tested for chromosomal abnormalities. All the embryos are frozen and only normal embryos are transferred during a later cycle.
 

Patients who experience the following may benefit from PGS:
  • Recurrent miscarriage.
  • Previous unsuccessful IVF cycles.
  • A family history of chromosomal disorders.
  • Advanced maternal age.
  • Part of routine care (Highly controversial)

Benefits of PGD
  • Reduced incidence of miscarriage. In women aged 35 and older, about 35% of pregnancies are miscarried. Aneuploidy accounts for 50% or more of these losses. By transferring only chromosomally normal embryos, the number of pregnancies going to term should increase. Recent studies have detected a significant reduction in pregnancy losses after PGD, from 23% to 9%. PGD may increase the implantation rate and decrease early miscarriages.
  • Improved IVF rates by prioritizing chromosomally “normal” embryos for transfer. It is important to understand that PGD is merely a technique to improve the chances of selecting a normal embryo and cannot change the fact that abnormal embryos exist. The pregnancy rate per started cycle is therefore not increased.
  • Reduced number of embryo transfers necessary to achieve a successful outcome because the healthy selected embryo may be selected earlier.
  • Reduced risk of twin-pregnancy by transferring a single normal embryo.

 

Potential Risks of PGD
  • An embryo is damaged by the biopsy, may not be suitable for transfer into the uterus. During the biopsy the risk of damaging an embryo is less than 1%.
  • Some biopsied cells may not yield a test result due to degraded DNA which cannot be amplified or loss of cells during transfer to the test tube for CGH analysis. The overall risk is less than 2% per cycle.
  • The risk of a clinical misdiagnosis resulting in a fetus or baby with chromosomal abnormalities is less than 2%. Due to the low risk of misdiagnosis, prenatal testing by CVS/NIPT or amniocentesis is strongly recommended.
  • A condition called mozaicism exists, where some cells are abnormal while the majority are normal. In this situation the test may lead to discarding of embryos that are actually normal.
  • All embryos need to be frozen with delayed transfer.

PGS increases the total cost of the procedure. The cost must be weighed against potential benefit.

Reproductive surgery
(Hysteroscopy, Myomectomy, Laparoscopy)

Reproductive surgery

Reproductive surgery includes laparoscopy, hysteroscopy, myomectomy (fibroid removal.)

Laparoscopy

Laparoscopy is a modern surgical technique. The main indication used to be diagnostic to determine whether any endometrioses or abnormalities of the fallopian tubes or ovaries exists. Currently it is a mode of access to perform surgical procedures allowing for removal of endometriosis, tubal surgery or myomectomy.Due to the high cost factor it should not be the first step in a couple’s evaluation.
Semen analysis and Hysterosalpingogram as well as the AMH should be available before the recommendation of a laparoscopy.
Currently laparoscopies are far less often performed than during the 1990’s, due to the major advantages of IVF techniques and higher success rates.

Hysteroscopy

A Hysteroscopy involves a camera being inserted into the vagina gently navigating through the cervix into the uterine cavity. It is typically performed to exclude any fibroids, polyps, scar tissue or a uterine septum.
This procedure is usually performed in the rooms.

Myomectomy

A Myomectomy is a surgical procedure during which uterine fibroids (leiomyomas) are removed. These common noncancerous growths appear in the uterus, usually during childbearing years, but can occur at any age.
During a myomectomy the goals are removing symptom-causing fibroids and reconstructing the uterus.

Patients who underwent myomectomy report improvement in fibroid symptoms, including heavy menstrual bleeding and pelvic pressure.
The removal of fibroids is not necessary in all cases and the position and size of fibroids will determine whether surgery is indicated.

Endometriosis

Endometriosis

Endometriosis is a common condition affecting women during the reproductive years. This condition occurs when the endometrial tissue (usually present on the inside of the uterus) is present outside the uterine cavity. This misplaced tissue could cause pain, heavy and prolonged menstrual bleeding, infertility and bleeding when passing stools or urine.
 

Diagnosis

  1. Symptoms, history and experience
  2. Vaginal ultrasound for the presence of chocolate cysts
  3. Laparoscopy

Stages of endometriosis

Endometriosis is classified into four stages (I-minimal, II-mild, III-moderate, and IV-severe) depending on location, extent, and depth of endometriosis implants. The presence and severity of adhesions as well as the presence and size of ovarian endometriomas.

Treatment

In treating endometriosis the goals are providing pain relief, restricting progression of the process, and restoring or preserving fertility where needed.


Treatment options:

  • Pain management

    Pain killers may be effective when combined with ovarian suppression through hormone therapy and exercise.

  • Hormonal therapy

    Hormonal therapy could vary between Gonadotropin releasing hormone (GnRH) and progesterone treatment. GnRH analogue usually comes in subcutaneous injections (monthly or 3 monthly).

    This medication allows shrinkage of the ectopic endometrial tissue by ceasing the production of estrogen. GnRH is very effective in relieving pain associated with endometriosis but long term use is limited by the risk of osteoporosis.

    Progesterone treatment is usually administered through tablets or injections. The treatment is effective in relieving painful symptoms but its side effects may be troublesome and include weight gain, abnormal bleeding and acne.

  • Surgery

    Laparoscopy is usually the most common surgery due to the advantages of diagnosis and treatment at the same time. Usually the endometriosis is destroyed using a laser or cautery and normal anatomy restored. In certain cases a combined approach of surgery and medication could be beneficial to the patient.

  • Infertility

    If a pregnancy is not achieved following a reasonable waiting period after a laparoscopy, ART (artificial reproductive technology) could be recommended. IVF is usually indicated if the fallopian tubes were blocked or damaged due to the endometriosis.

Coping with endometriosis

Many young women feel overwhelmed by endometriosis. The truth is that neither cause nor cure of the disease is known. However, accepting and learning to manage the chronic pain and dealing with infertility could be beneficial towards coping skills regarding the condition.

Helpful sites towards coping with endometriosis are www.endometriosis.org and http://www.endpain.co.za

Egg donation

Egg donation

PFC has been successfully performing egg donation for the past 20 years.

Egg donation is usually recommended as a last resort of treatment.

Patients most likely to undergo egg donation include:

  1. Patients in menopause
  2. Patients with a low ovarian reserve (low AMH level)
  3. Patients failing to conceive with their own eggs/embryos
  4. Patients who underwent chemotherapy or removal of ovaries

How does egg donation work?

An anonymous or known egg donor may be used. The patient will receive preparation for embryo transfer and the donor will receive IVF stimulation.

On the day of egg retrieval the donor eggs are fertilized with the patient’s partner/donor sperm and the embryo is transferred to the patient after 5 days.

The success rate is much higher because egg donors are young, healthy females.

Patients over the age of 50 are discouraged from proceeding with egg donation.

Typical steps towards egg donation:

  • A donor is selected from an egg donor agency.
  • The donor is subjected to strict medical and psychological assessments.
  • Synchronization of both the recipient and donor’s cycles is done, usually via the use of a light contraceptive.
  • Preparation for embryo transfer.
  • IVF stimulation on the donor.
  • Egg retrieval and sperm sample.
  • Embryo transfer.
  • Pregnancy test.

Quality literature about egg donation

We are fortunate to live in a time when there are not only many options for creating a family, but also access to literature illustrating to children how families can be created in various ways, assisting them in understanding the many dimensions thereof .

A touching children’s story, specially written for girls, of how a happy rabbit couple, Comet & Pally, have their own baby by means of egg donation.

The colorful book is ideal even for children unable to read, since the illustrations are detailed, grabbing the child’s attention.

http://www.carmenmartinezjover.com

Donor sperm

Donor sperm

Donor sperm is usually indicated for:

  1. Couples with a male fertility factor (Where ICSI will not be beneficial)
  2. Same sex couples
  3. Single females wanting to start a family

Once a patient has decided on using donor sperm she is advised to contact www.androcryos.co.za to select a donor.

Delivery of the sperm must be arranged prior to the patient’s day 9 of her cycle.

Surrogacy

Surrogacy

Surrogacy is an arrangement in which a woman carries and delivers a child for another couple or person. The intended parent or parents may arrange a surrogate pregnancy due to various reasons:

  • Pregnancy risks and unacceptable danger to the mother’s health.
  • Other medical issues (female fertility) rendering pregnancy or delivery impossible, risky or otherwise undesirable.
  • The intended parent or parents being male.

The sperm or eggs may be provided by the commissioning parents, but donor sperm, eggs and embryos may also be used.

Surrogacy requires a great deal of time, money and patience in order to succeed, but can bring joy to all concerned if the medical, legal, financial and emotional aspects are properly considered.

The South African Children’s Act of 2005 enables the “commissioning parents” and the surrogate to have their surrogacy agreement validated by the High Court even before fertilization. This allows the commissioning parents to be recognized as legal parents from the outset of the process and helps prevent uncertainty. However, if the surrogate mother is the genetic mother she has until 60 days after the birth of the child to change her mind.

The law permits single individuals and gay couples to be commissioning parents. However, only those domiciled in South Africa will benefit from the protection of the law, no non-validated agreements will be enforced, and agreements must be altruistic.

If there is only one commissioning parent, she must be genetically related to the child. If there are two, they must both be genetically related to the child unless that is physically impossible due to infertility or sex (as in the case of a same-sex couple).

The commissioning parent or parents must be physically unable (permanent and irreversible situation) to have a child birthed independently. The surrogate mother must have had at least one pregnancy and viable delivery and have at least one living child.