Assisted reproduction: what is it and what are the different techniques?

After the diagnosis of infertility by both female and male factors, the main way to achieve pregnancy is to resort to MAP. Assisted reproduction consists of a set of medical and laboratory techniques that help the fertilization process, that is the path that the oocyte and the spermatozoon must travel after having met and fused inside the woman's body and which in these cases do not it can happen naturally.

With the help of Doctor Domenico Mossotto, specialist in obstetrics and gynecology and clinical manager of the Assisted Reproduction Center of the nursing home in Bra, we will try to clarify the various techniques of PMA.

Assisted reproduction: the three levels

By convention, three different levels are distinguished, based on the degree of complexity of the technique used, in each case preceded by cycles of hormonal stimulation of the woman.

Thus there are first level techniques, suitable for cases of unexplained infertility, which include mild hormonal stimulations, ovarian monitoring for targeted intercourse and intrauterine insemination with the partner's spermatozoa; or second level techniques to be used for example in case of alterations of the seminal fluid or malformations of the uterus and tubes, which essentially consist of IVF (in vitro fertilization of the eggs, later transferred into the uterus (IVF) and ICSI (injection intracytoplasmic spermatozoon).
The third level techniques, even more complex and, are reserved for severe cases of male or female infertility (such as when there are no sperm in the ejaculate). Performed under general anesthesia, these procedures consist of microsurgical removal of gametes from the testicle or oocytes laparoscopically.

With regard to the use of these techniques, Law 40 of 2004 provides for the obligation to follow a criterion of graduality, that is, always starting with the least invasive.

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See also: the path of the MAP

Intrauterine insemination

Intrauterine insemination, or IUI, involves the treatment of seminal fluid and its deposition in the uterine cavity and is usually performed in conjunction with ovarian stimulation. This technique is suggested in various situations that cause male infertility, including mild oligoasthenzoospermia, hypospermia, retrograde ejaculation, impotence and azoospermia with the use of donor sperm While for women, the most common cases that require it are cervical factor infertility, minimal endometriosis and small ovulatory defects.

As Dr. Mossotto explains, "the drugs used for the induction of ovulation are generally clomiphene citrate and gonadotropins, and their administration is started in the follicular phase (3rd day of the cycle), and continued until, after a "careful ultrasound and hormonal evaluation, the patient will not be ready for" insemination ". Compared to the more complex Pma techniques, the IUI has the advantage of less invasiveness, low cost and simplicity of execution. It is in fact carried out with simplicity in the clinic: after inserting the speculum into the patient's vagina, by means of a plastic catheter, the previously prepared seminal fluid, is slowly injected into the uterine cavity and after a few minutes, the patient can get up and go home.

IVF

IVF, in vitro fertilization with embryo transfer, is one of the major techniques and consists in "obtaining the fertilization of the oocyte outside the woman's body with consequent formation of the embryo and subsequent transfer into the uterus. This technique is divided into four stages:

• drug induction of multiple ovulation
• egg retrieval (pick-up)
• insemination and fertilization
• transfer of pre-embryos to the uterus (transfer)

Pharmacological induction: the patient is administered drugs in various combinations that stimulate the ovary. These allow to facilitate the growth and maturation of numerous follicles and to control the moment of ovulation, so that it is possible to collect the oocytes before the their spontaneous release from the follicles. When the follicles reach the optimal diameter, the patient is given a drug (hCG) that causes ovulation and the egg retrieval is scheduled about 34-36 hours later, ie just before what would be the spontaneous "outbreak". Follicle monitoring is generally performed every other day and is performed with an empty bladder vaginal probe.

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The stages of IVF

Egg retrieval: usually takes place by puncture and aspiration of the follicles via the vagina under ultrasound control. After the collection, the patient remains under observation for 2-3 hours and then is discharged.
Insemination and fertilization: the freshly collected oocytes are examined for the evaluation of the degree of maturity and transferred for 2-3 hours in a special incubator at 37 ° C. Then they are inseminated: a certain number of previously prepared spermatozoa are introduced into each capsule containing an oocyte. This is how fertilization always takes place in the incubator, approximately 18 hours after insemination. After 12 hours, the fertilized oocyte begins to divide into two cells and 48 hours after taking the embryo, which normally has 4-8 cells. it is ready to be transferred to the uterus.

Embryo transfer: it is a very simple procedure, it is done in the clinic and does not require analgesia. One to three embryos, suspended in a drop of culture medium, are aspirated into a thin catheter. This is then gently inserted into the uterus. and the pre-embryos are placed in the uterine cavity. The procedure takes a total of 10-15 minutes, after which the patient rests for a few hours.
Depending on the number and quality of the embryos, doctors may decide to transfer a blastocyst, which is the embryo 5 days after fertilization.

An IVF can also occur with gametes (sperm or oocytes) or embryos or oocytes previously cryopreserved and thawed to carry out that course of treatment.

The ICSI

ICSI is the intracytoplasmic injection of the sperm into the oocyte and is structured in four phases practically identical to those of IVF. The only aspect for which they differ is that in ICSI the fertilization does not occur alone, due to the simple contact of the eggs with the spermatozoa, but thanks to the intervention of the biologist himself who will then carefully choose the best spermatozoon from the point of view of mobility and morphology (head, neck and tail) to be injected into the oocyte through a fine needle.

In vitro fertilization with ICSI, which was recently introduced, has revolutionized the limits imposed on the methods of MAP in cases of severe or very serious male factor. In fact, while the IVF requires a minimum number of spermatozoa, this allows to carry out an intervention of MAP having also a very low number of spermatozoa available. ICSI is recommended in some cases including the presence of a low number of motile spermatozoa, severe teratospermia (presence of abnormally shaped spermatozoa), impaired ability of the sperm to bind to and penetrate the egg, low quantity and quality in the case of spermatozoa frozen, repeated failure with other IVF techniques, and irreparable obstruction of the male reproductive tract.

IMSI (Intracytoplasmic Injection of Morphologically Selected Sperm) is a second level technique similar to ICSI, but able to improve the possibilities of fertilization, thanks to a morphological analysis of the spermatozoa and their selection carried out with a microscope even more powerful.

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