Pregnancy Info

Many childless parents have been helped to become parents by using sperm, eggs, and even embryos given by other people. Surrogacy is also a form of donation-a woman donates her uterus to bear another couple’s biological child. Emotional costs can be high for all concerned, and all the issues need to be talked about openly.

Donor Insemination

The use of donor sperm can be an option in the following situations: when the male partner is sterile or has a very low sperm count that does not respond to treatment; for a couple with a major blood group incompatibility-for example, for a Rhesus­negative woman who has developed antibodies to the Rhesus­positive blood of her partner; when either partner carries a hereditary abnormality; or when a mature, stable, single woman wants a child but not a partner.

Donor insemination (DI) can look like an ideal solution for people in these situations, but there are a number of points that need careful thought. First, the feelings of your partner-some men feel inadequate or even jealous of donors who impregnate their partners. These feelings can affect your life together, and your child once it is born. In addition, some women are repelled by the way they are going to conceive or by the fact that a different man’s sperm is used at each visit. Others worry about what kind of man the donor was, or idealize him as a “perfect man.” They wonder if their child could unknowingly meet, and perhaps marry, a half-sibling. Using sperm from a donor that you know, or are related to by marriage, can relieve some of these problems, but it can make others worse. It also raises its own problems, such as what happens if the father wants visiting rights.

Most couples feel hesitant about this method of conception, and it’s exceedingly stressful, so you do need good counseling. You can insist that there is no mention of DI in your maternity records, and your and your partner’s names can be given on the birth certificate. The procedure is covered by law in many, but not all, states. All doctors should be familiar with the donor insemination laws in their state. Currently, donors are anonymous, but it has recently been suggested that their personal information should be kept on file. If children conceived this way want to know their donor’s identity once they reach adulthood, they could then be told, provided the donor agrees. Children born from donor insemination have routine pregnancy care and are not at increased risk of pregnancy complications.

Egg Donation

If a woman is unable to produce an egg herself, donor eggs may be used during IVF treatment. Egg donation does have the advantage that both of you are involved: your partner fertilizes the egg, and you will carry and give birth to the baby. However, it’s more complicated than sperm donation-hormonal drugs have to be taken and the eggs collected by surgical techniques-so donor eggs are hard to come by. The main sources are relatives, unknown donors (who, like sperm donors, will no longer have the right to anonymity), and IVF patients who may donate extra eggs produced during their treatment.

There can be problems with egg donation. For example, eggs donated by IVF mothers have an increased risk of chromosomal disorders because IVF patients tend to be older than average. When relatives or friends donate eggs, there can be tensions later. If you’re not producing eggs, you probably won’t be menstruating, and this means that the lining of your uterus (endometrium) will be thin and incapable of nourishing a developing embryo. Consequently, you’ll need to be given drugs to stimulate it to thicken so that the embryo can implant.

Embryo Donation

A couple who have been through IVF treatment may sometimes wish to donate unused frozen embryos to a childless couple. The embryo is implanted and the woman gives birth to the “adopted” child. Feelings run high on this, and many sensitive issues have been raised. For example, how would the donor parents feel if their own child, or children, die? And what are the chances of the siblings meeting and perhaps having children together?

Selecting Semen and Embryos

Semen Fresh semen is usually frozen and stored before being used for donor insemination. After collection, the semen is put into a sterile vial and frozen by immersing it in liquid nitrogen. It’s then stored while the clinic tests it and the donor for infections. The donor is tested to make sure that he’s free of infections, such as hepatitis B or HIV, that could be passed on via his semen. Once it’s been determined that the donor was free of infection when he made his donation, the semen is tested for harmful microorganisms, such as bacteria; if these tests prove negative, semen can then be used for insemination.

Up to 50 percent of sperm in the semen do not survive the freezing and thawing. This fall in sperm numbers is partly offset by the fact that it’s the healthiest, most robust sperm that do survive. Donor insemination is carried out under the same conditions as artificial insemination with sperm from a partner.

Embryos Storage of frozen embryos prevents embryo wastage if several embryos have been fertilized-no more than two are replaced in any cycle because of the risk of multiple pregnancy-and can help another infertile couple. Pregnancies resulting from the use of frozen embryos have raised the success rate of a cycle of IVF treatment from one to 10 percent.

Micromanipulation, an extraordinary technique in which not only eggs but individual sperm can be manipulated by a surgeon, makes it possible for a man with a very low sperm count and virtually no active sperm to fertilize his partner’s egg and so produce a baby.

Micromanipulation

ICSI (Intracytoplasmic sperm injection) is a technique that uses micromanipulation. A prepared egg is placed under a microscope and injected with an individual sperm. Sperm may be collected by masturbation or from the testis itself through surgical techniques such as MESA or TESE. Once fertilized, the embryo is incubated and implanted by embryo transfer when it reaches two to four cells in size. ICSI may be offered to couples who fail to conceive by other methods. However, there’s some controversy about this technique. For example, there’s concern that an egg could be fertilized with a substandard sperm, resulting in unhealthy children. But although the pregnancy rate with ICSI is not high, the babies born so far have been normal.

Embryo Transfer

All forms of IVF mean taking an embryo, usually between two and three days old, from the incubating dish in the laboratory and placing it inside a woman’s body. Sadly, two out of three embryo transfers fail to implant. Successful implantation depends on the age of the mother, how receptive her uterus is, and the quality of the embryo. One of the problems is that doctors still don’t know when is the best time to transfer an embryo. Studies seem to suggest that delaying the transfer of an embryo to the uterus can increase the chances of implantation. But in one study, there was no difference in pregnancy rates between embryos that were replaced 44 hours after insemination and those that were replaced 68 hours after insemination.

Also, pregnancy rates increase with the numbers of embryos that are replaced: for example, one embryo gives an eight percent chance of becoming pregnant; two embryos give a 25 percent chance. Usually, embryos are transferred at the 8- to 10­ cell stage, 72-80 hours after retrieval. Transfer of more than one embryo increases the chance of pregnancy, but the multiple pregnancy rate for IVF is up to 35 percent. This results in an increased likelihood of premature birth, cesarean sections, and newborn illnesses and mortality.

Cryopreserved embryos It’s also possible to thaw out cryopreserved (frozen) embryos or eggs from liquid nitrogen (-459°F/-273°C) and transfer them in the same way. The embryo is thawed slowly, at a rate of 46°F (8°C) per minute. However, not all embryos survive this process in a good enough state to implant. Replacement in the womb is done at a point in the menstrual cycle 100 hours after the LH (luteinizing hormone) peak, which is determined by serial blood tests. Pregnancy rates vary from one in six to one in four.

One of the aims of the primary tests you’ll have is to find out whether or not you are ovulating. If you are, the fertility clinic will start a range of more advanced tests to discover why you haven’t been able to conceive. These tests will check the condition of your hormones, ovaries, uterus, and fallopian tubes and look at how well they’re functioning.

Hormane and Ovulation Tests

Measuring the levels of hormones in your blood during your menstrual cycle can give useful information. Generally, levels are checked during the first three days of your cycle and again seven days before your period is due. The measurements show how your ovaries, brain, pituitary, and hypothalamus are interacting, and highlight any imbalance in your hormones that may be causing a problem with ovulation. Usually, your estrogen, progesterone, and LH levels are measured and compared to normal ones. Other hormones that can affect ovulation are FSH, testosterone, and prolactin; levels of these in the blood will be checked.

Ultrasound scanning - With a simple scan, your fertility specialist can check the development of your ovarian follicles and confirm that you’re ovulating. Tracking of the follicle in this way is important if you’re taking drugs to stimulate ovulation, as it can help avoid overstimulation, which can be dangerous. Your doctors will also need an accurate assessment of your follicular growth if they need to perform complex assisted conception procedures such as IVF (in vitro fertilization).

Endometrial biopsy - Under the influence of estrogen and progesterone, the endometrium (lining of the uterus) changes through the menstrual cycle. There’s a definite endometrial thickening and growth during the second half of the menstrual cycle following ovulation, because of the increased amount of progesterone in the body. But if not enough progesterone is made, the endometrium may not be sufficiently developed to allow the embryo to implant successfully. In a biopsy, a tiny sample of your endometrium is taken during the second half of the menstrual cycle. It’s examined under a microscope, where any changes due to progesterone levels will be visible.

Fallopian Tube Tests

The fallopian tubes are extremely delicate structures. Less than %2 in (4 mm) in diameter at their narrowest, they are easily damaged. Up to one-third of all of the women who attend an infertility clinic are found to have a problem with their fallopian tubes. Once the primary tests have been completed, there are a number of tests that are carried out to check the fallopian tubes. These are among the first investigations made when an infertile couple attends a specialist clinic.

Hysterosalpingogram - An HSG is an X-ray picture of the uterus and tubes and can reveal problems Inside them. A special dye that can be monitored on an X-ray screen is slowly injected into the uterus and should pass into the fallopian tubes. If it fails to do so, there may be some damage, distortion, or blockage.

Laparoscopy - The laparoscope is a slender telescope-only about the width of a fountain pen-that uses fiber optics to look directly into your abdominal cavity. It gives a superb view of all the organs, allowing your surgeon to assess their health and giving information on adhesions, endometriosis, and ovarian disease. High-quality videos can also be taken through the laparoscope so that your doctors can refer to them later. Although you’ll need to have a general anesthetic, laparoscopy can usually be done as an outpatient procedure.

Problems with the sperm themselves are the most common cause of male infertility, although there may also be anatomical problems that affect a man’s ability to ejaculate. The study of male fertility is
relatively new compared with female fertility, but doctors now know much more about it and about the role of sperm in particular.

Problems with Sperm

Sperm are extremely vulnerable cells. They take seven weeks to form and can be affected by outside influences at any point in their development. Because of this, it’s entirely possible for a man to give sperm samples on separate occasions that differ widely both in quality and quantity.

Testicular failure - The cause of this is usually hard to establish, but it may be due to a chromosomal problem such as Klinefelter syndrome (when a man has two or more X chromosomes rather than one), testes that did not descend properly after birth, a blow to the testes, such as a sports injury, or the man’s having suffered mumps as an adult.

Low sperm counts - By itself, a low sperm count does not mean infertility. Many men With low sperm counts father children, but conception tends to take longer. Unfortunately, when there are few sperm, the majority tend to be abnormal or are not very active. Low sperm counts and sperm abnormalities may be caused by hormonal problems, anatomical problems, immunological problems, or even environmental factors.

Immunological Problems

Both men and women may produce antibodies to sperm that can interfere with fertilization, but it’s mainly a problem for men. In men, the antibodies are on the surface of sperm, in the semen, or in the blood. In women, antibodies are found in the cervical mucus or in the blood. Antibodies are found in five to 10 percent of infertile couples, but two percent offertile men also have antibodies.

How antibodies affect fertility - The most important antibodies are those that are attached to the sperm themselves: they can affect the way sperm move and their ability to penetrate a woman’s cervical mucus and fertilize the egg. Antibodies can also affect the acrosome-the cap on the head of the sperm, which contains enzymes essential for egg penetration.

How fertility treatments are affected - Antibodies on the surface of the sperm can interfere with IVF (in vitro fertilization) and other kinds of ART (assisted reproduction technologies;). The antibodies can stop sperm from moving and even destroy them. However, the presence of antibodies doesn’t necessarily mean that a man can’t conceive a child, so many specialists recommend that antibody is not carried only in couples who have “unexplained infertility” and who’ve already had all the other tests. This is because treatment is difficult and hazardous. The mainstay is moderate to high dosage with steroids, which is known to cause serious fetal side effects in some cases.

A huge amount of research has been done over the last few decades into the reasons for female infertility, and great advances have been made in the diagnosis and treatment of problems. The causes of female infertility tend to fall into four main areas, and all of these types can now be treated with varying degrees of success.

Failure to Ovulate

About one-third of female infertility is caused by a woman’s failure to release an egg (ovulate). This is usually due to hormonal problems, but occasionally a woman’s ovaries are damaged or, more rarely, have run out of eggs.

Hormonal problems - In a woman with a normal ovarian cycle, the hormones from the pituitary gland and the ovary are responsible for the healthy growth and maintenance of an egg. In many cases of infertility, too little of one or too much of the other hormone may be present.

For example, at midcycle the hypothalamus should stimulate the pituitary gland to release a massive amount of FSH (follicle­stimulating hormone) and LH (luteinizing hormone) to bring about ovulation, but in 20 percent of cases it fails to do so. So although there may be some FSH and LH, there’s not enough for ovulation to take place. Alternatively, a woman’s pituitary gland may be damaged or malfunctioning, causing it to produce either too much FSH and LH or none at all. Or, as a result of too much LH stimulation and not enough FSH, the ovaries may become polycystic (see column, left for more information on this condition) and no longer capable of producing mature eggs.

Problems caused by abnormal hormone levels are often treated with fertility drugs. These include clomiphene, human chorionic gonadotrophin (hCG), and human menopausal gonadotrophin (hMG), in addition to female and pituitary hormones. For 90 percent of women whose infertility is caused by hormonal problems, modern drug therapy can bring about regular ovulation. Unfortunately, for reasons doctors do not yet understand, only about 65 percent of these women will actually get pregnant.

Hormonal Imbalance

Hormones may interfere with conception in other ways than influencing ovulation. For example, a fertilized egg needs progesterone in order to survive. If too little progesterone is produced or it’s produced for too short a time, the egg may not survive. Known as inadequate luteal phase, this condition can be treated with drugs.

Hyperprolactinemia - In this common condition, the body produces too much of the pituitary hormone responsible for milk production. The condition can sometimes be due to a small benign tumor on the pituitary gland called a prolactznoma. ThIs leads to an imbalance of FSH and LH, causing infrequent or absent periods in women and lowered sperm production in men.

Fibroids and Fertility

Fibroids are benign muscle tumors that can be from the size of pea to a tennis ball. They form within the uterine wall. Fibroids don’t necessarily affect fertility, but they can make the uterus misshapen and compress one or both of the fallopian tubes.

Effects on fertility - If no other cause for infertility is found, it may be that moderately sized fibroids close to the surface of the uterine lining are interfering with normal implantation of the embryo in the uterus. If they are near the junction of the uterus and the fallopian tubes, they may stop the fertilized egg from reaching the uterus at all.

Fibroids are most common in women over the age of 35, and about one in 45 women develops fibroids by the time she is 45. There’s often no cause for concern, since many women with fibroids have no trouble conceiving, but if fibroids do cause problems, they can be removed in an operation called a myomectomy. This operation should not be undertaken lightly-it carries a very high risk of bleeding and may require a blood transfusion in as many as 50 percent of cases.