• Complete history and physical examination.
The PE Fertility Clinic encourages patients to
obtain all previous medical records for treatment related to
infertility, hormonal or menstrual disturbances, anovulation,
gynaecologic surgery, or pelvic infection. Appropriate medical
information should also be gathered on the husband i.e. previous
semen analysis and prior hormone tests Particular attention is
directed towards a review of medications that may interfere with
fertility (i.e. anti hypertensive and non-steroidal
anti-inflammatory drugs in males) or those that might be teratogenic
(harmful to the foetus).
• Semen Analysis:
A semen analysis is the easiest and most cost
effective test that a couple can undergo to determine fertility
potential. A semen analysis is considered current if it has been
obtained within the last 4 months and performed by a reputable
laboratory using
acceptable criteria. Semen analysis that show
abnormal values should be rechecked no sooner than 4 weeks prior to
any assisted reproductive treatment. The parameters for a normal
semen analysis are as follows:
Motility: > 30%
Forward Progression > 2
Count > 20 million/ml
Antibodies (MAR Test) < 60%
Morphology > 14%
Semen quality can always be improved through
lifestyle changes. Smokers should be advised to stop smoking and be
placed on antioxidant supplementation (Vitamin C 1gm/day and Vitamin
E 400ugm/day as well as folic acid). Men should also not consume
more than 4 units of alcohol a week and should be encouraged to eat
green leafy vegetables. These lifestyle changes should be undertaken
for a minimum of 3 months before a change can be seen in semen
quality.
• Initial Medical Laboratory Evaluation:
On the 2nd or 3rd day of the menstrual cycle ,
a basic hormone profile is performed (FSH, LH, Thyroid function,
Prolactin), together with a sexually transmitted disease profile
(HIV, Hepatitis B, VDRL) and assessment of immunity to German
Measles.
• Individualised Laboratory Testing:
When clinically indicated, further tests will
be performed by the reproductive specialist to diagnose
endocrinological abnormalities that may present with signs of
virilization, abnormal menstrual cycles or abnormal genital organ
anatomy as seen in chromosomal/genetic variants. The most common
endocrinopathy seen in the reproductive years is Polycystic Ovarian
Syndrome (PCOS), with usually some or all the features of absent or
irregular periods; signs of virilization such as acne or hirsutism
and abnormal ovaries on ultrasound evaluation. Due to the
association of infertility due to anovulation, the diagnosis
is important to establish a multidisciplinary approach to the
treatment of these patients.
An androgen profile is performed. A fasting
insulin and glucose may also be required. Some PCOS patients may
benefit from metformin (Glucophage) therapy.
• Post-coital Testing:
This test evaluates the interaction between the
sperm and the cervical mucus at mid-cycle and will give information
about the ability of the sperm to penetrate the mucus, which depends
on adequate estrogen levels.
A speculum is placed in the vagina, as it would
be for a pap smear. A syringe without a needle is then used to
remove some mucous from the cervical opening. The speculum is then
removed and your cervical mucous is examined.
• Endoscopy: Diagnostic Laparoscopy and Hysteroscopy
1. Diagnostic and surgical laparoscopy
Laparoscopy has been developed as part of
minimally invasive surgery. The reproductive specialist can, through
inserting special lenses with fibre optic light sources into the
pelvis of the patient, diagnose pelvic pathology under magnification
and when necessary , treat these conditions surgically without open
surgery (laparotomy). Gynaecological conditions often present in the
infertile female is Endometriosis with up to 25 % of infertile women
presenting with endometriosis, compared to a background incidence of
8-!0% in the general population.
Other common conditions are ovarian cysts,
tumours and tubal conditions such as peritubal adhesions,
hydrosalpinx (fluid filled obstructed tubes) and previous tubal
damage due to sterilization procedures, which can be reversed in
some cases.
2. Hysteroscopy
Direct visualization of the inner cervix and
the endometrial cavity is possible by inserting a scope into the
uterus to diagnose and treat uterine abnormalities such as uterine
septums, polyps and fibroids or benign uterine muscle tumours in the
wall or cavity. These fibroids or septae may result in either
infertility or recurrent pregnancy loss.
Treatment:
• Empirical Treatment:
Female patients are treated with periconceptual
folic acid (5mg per day) as well as medication where indicated to
treat underlying medical conditions i.e. Eltroxin for thyroid
abnormalities, Metformin for glucose intolerance and prolactin
antagonists for hyperprolactinaemia.
• Preconception Counselling:
The risks of genetic abnormalities are
discussed for those with a family history or age > 35. Smoking
cessation, alcohol restriction, weight loss, marital counselling are
recommended as indicated and the unit make use of the services of
dedicated Biokineticists, Dietitians and Psychologists with a
special interest in Reproductive Health.
Treatment Options:
Micro-Epididymal Sperm Aspiration (M E S A) /
Testicular Sperm Aspiration (TESA).
In cases were the ejaculate has no sperm or
there is a blockage (either natural or by means of a vasectomy),
Testicular Sperm Extraction (TESE) and Micro-Epididymal Sperm
Aspiration (MESA) procedures can be used to obtain sperm. The sperm
is surgically aspirated from the testicle or epididymis. Once the
sperm is obtained, the lab has to separate the viable sperm from the
blood and tissue.
An important point is that the sperm that are
removed via the MESA/TESE procedures can not be placed into the
uterus or Fallopian tubes. The sperm will simply not fertilize
normally and more advanced technologies are needed. Once the
extracted sperm is “washed”, a single sperm is injected into each of
the available eggs using Intra-Cytoplasmic Sperm Injection (ICSI).
• Micro-Surgery
Reversal of male sterilization
The fertility clinic offers the procedures of
having a vasectomy reversed by microsurgical techniques. This is
called Vaso-vasostomies.
A.R.T. is made up of the following procedures:
If a male were found to be sub-fertile or has
antibodies present, then this would be the method of choice. This is
also applied in couples with unexplained infertility and in
anovulatory women after failed home plan for 3-4 months
The male would provide a sample of sperm which
is then prepared by the laboratory. This preparation takes between
1.5 – 2 hours and once the sample is ready, your doctor using a
catheter, will put the concentrated sperm directly into your uterus.
The optimal time of IUI is 36 hours after an
induced LH peak, usually by HCG injection, in order to trigger
ovulation.
This procedure can be done with your partners’
sperm (AIH) or with donor sperm (AID) where indicated.
This procedure is similar to IVF, but allows
fertilization to occur naturally inside your Fallopian tubes.
Near the beginning of your menstrual cycle,
you'll take a fertility drug to stimulate your ovaries to develop
several mature eggs for fertilization. (You normally release only
one egg a month.) You may also have to take a synthetic hormone
called Lupron to keep your body from releasing your eggs too early.
You'll have to visit your doctors’ office or
clinic often so they can monitor your blood hormone levels to detect
when your eggs are mature. Once they're mature, your doctor will
give you an anesthetic and remove your eggs from your ovaries by
inserting a needle through your vaginal wall. The doctor will
combine your eggs with your partner's sperm and insert the mixture
into your Fallopian tubes through a small incision in your abdomen,
using a fiber-thin tube called a laparoscope.
If the treatment works, your partner's sperm
will fertilize one of your eggs, forming an embryo that will implant
in your uterus and grow into a baby. (In about 35 percent of GIFT
pregnancies, more than one embryo implants and women give birth to
multiples.)
You'll be able to take a pregnancy test about
two weeks after you undergo surgery.
This procedure is similar to GIFT. The main
difference is that your eggs are fertilized in a laboratory before
they're inserted into your Fallopian tubes.
A technique in which a woman's egg is
fertilized outside the body, then implanted in one of her fallopian
tubes. This technique is one of the methods used to overcome
infertility, the inability of couples to produce offspring on their
own.
First, the egg and the male sperm needed to
fertilize it are harvested. Then the egg and the sperm are united in
a petri dish, a multi-purpose glass or plastic container with a lid.
If all goes well, the sperm fertilizes the egg, and the physicians
then implant it in a fallopian tube. From there, nature takes its
course, and the egg eventually is deposited by the fallopian tube
into the uterus (womb) for development.
A zygote is the combined cell resulting from
the union of sperm and egg. A zygote develops into an embryo. An
embryo, a mass of cells with no recognizable human features, begins
formation of a human body. After about seven or eight weeks, the
embryo exhibits recognizable features such as a mouth and ears. At
this stage, the developing human becomes known as a fetus. The word
"zygote" is derived from the Greek word "zygon" (yoke).
The term "intrafallopian" means "inside the
fallopian tubes." ("Intra," a Latin word, means "within" or
"inside.") Thus, the term "zygote intrafallopian transfer" refers to
the transfer of a zygote into a fallopian tube.
This is known as the classical test tube
fertilisation whereby the ovum from the female and sperm from the
male are brought together outside of the body and fertilised in a
test tube. They are incubated for a few days and then placed in the
uterine cavity of the female either on day 3 post oocyte aspiration
or on day 5 (Blastocyst stage)
• IVF is a five-stage procedure:
1. Medication Stage:
Drugs that work centrally in the
Hypothalamus-Pituitary complex, are responsible for
hyper-stimulating the ovary, thus producing more than the normal one
follicle in a natural cycle. This process will lead to obtaining
several female gametes with which the fertility team can work, in
order to improve chances of fertilization.
2. Monitoring Stage:
This stage involves ultrasound scans after five
days of hormone injections to determine the number of follicles and
the follicle size. Not all follicles contain eggs, the size of the
follicle determines the maturity of the eggs. Usually the follicles
are small at the first scan, subsequent scans and hormone injections
will continue until the leading follicle reaches 18mm or more in
size.
3. Egg Retrieval Stage:
The eggs are retrieved from the ovaries while
the patient is under sedation so that she does not experience pain.
In theatre, under ultrasound guidance, a long fine needle is
attached to the vaginal probe and gently pushed though the vaginal
wall to the follicles on the ovaries. Each follicle is methodically
drained with the follicular fluid, in which the egg is suspended,
drained into test tubes. The procedure does not take more than 15 to
20 minutes.
4. Laboratory Stage:
An embryologist using a high powered microscope
identifies the eggs immersed in the follicular fluid. The eggs are
placed into a dish that contains specialized growth medium. This
medium allows the eggs and later embryos to continue developing as
they would in the fallopian tubes. The sperm sample is collected,
prepared and placed in the medium with the eggs (insemination).
Extensive infection tests on both male and female are necessary
before the IVF procedure to prevent the growth medium being
contaminated. The dish with eggs and sperm are placed in an
incubator, fertilization will occur naturally.
After three to five days the laboratory
scientists, who have been monitoring embryo development closely,
will according to international grading criteria decide which
embryos to replace into the uterus. Your doctor will discuss which
embryos and the number of embryos (not all the embryo’s will
necessarily be used) to be replaced at this stage. A more accurate
estimation of the success rate for the treatment will also be
covered. The embryo transfer is a minor procedure requiring no
sedation.
5. Waiting Stage:
Extra medication is given to maintain a healthy
endometrial lining. Emotionally this is a very taxing time. Hormone
levels are high and there is not much that can be or cannot be done
to influence the outcome of the treatment. Whether there is a
pregnancy has been determined physiologically soon after the embryo
transfer. It is recommended to resume normal activities after
approximately 2 days in this period. The pregnancy test is done two
weeks after the embryo transfer.
With this technique, a single sperm cell is
injected into the cytoplasm of the egg. The technology used in this
method is for the infertile male who has an extremely low or
immotile sperm count or when the morphology is low.
The process followed is that a single viable
sperm is injected with microscopic equipment directly into the ovum.
This brings about assisted fertilisation.
The actual treatment is the same as the 5
stages In Vitro Fertilisation. The only difference is that in the
laboratory stage sperm is not placed with the egg but a single sperm
is injected into every ovum (egg)
Cryopreservation involves the careful freezing
and storage of untransferred, good quality embryos and semen. The
freezing technique used at our unit is known as vitrification (fast
freezing) and only blastocysts (Day 5 embryos) are frozen using this
method. In case the cycle is not successful or they decide to have
another child later, these embryos may be unfrozen (thawed). Only
the healthiest embryos are frozen. The process can be very
successful – thousands of babies have been born from frozen embryos.
Semen is also frozen and stored for later use
in cases such as before a vasectomy or any cancer treatment where
fertility can be influenced due to the drugs administered.
Artificial Insemination with donor sperm is an
excellent option for couples whose infertility is caused solely by a
male factor that cannot be treated. It is also an option for couples
with severe male factor who do not want to pursue any of the
Assisted Reproductive Technologies. There are many donors available
with varying physical characteristics and each couple is assigned a
donor that most closely matches the husband as possible. If you are
interested in becoming a sperm donor or know of someone who is,
please contact Michelle Rijsdijk at
mrijdsijk@telkomsa.nett
for more information.
Egg donors are available through our unit with
all donors carefully screened. All donors are between the ages of 21
and 32 and 90% have already conceived their own child/ren. An egg
donor donates to the expectant couple and this is the extent of her
role in conception with both parties remaining anonymous. The
donated eggs are then fertilized by the biological father and placed
in the expectant mother’s uterus.
If you are interested in becoming an egg donor
or know of someone who is, please contact Ronel Jubber at
info@fertilityunit.com
for more information.
A surrogate is a woman who carries the
fertilized egg (embryos) to term in her uterus on behalf of the
intended parents. There are two kinds of surrogacy: classic and
gestational. A classic surrogate is inseminated with sperm from the
child’s father. Her own egg is fertilized, and she carries the baby
to term on behalf of the intended parents. In gestational surrogacy,
the baby is conceived entirely by the intended parents: the
biological mother’s egg is fertilized with the biological father’s
sperm. The embryo is then placed in the surrogate’s uterus and
carried to term.
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