Clinical In Vitro Fertilization

In vitro fertilization has resulted in an estimated 4000-5000 births in the world. The procedure has been accepted in Europe, America and Australia and several hundred IVF clinics are operating successfully. The newer procedures of GIFf, embryo freezing and donor oocyte IVF have become established and are dealt with in several chapters. GIFf has become the procedure of choice for patients with infertility of unknown origin. Oocyte freezing represents an important new technology which is being developed. The routine IVF procedure has improved slightly; variation in results can be reduced by quality control of laboratory and clinical techniques. Male factor infertility has been dealt with by IVF in mild and moderate cases, but newer techniques will be required to deal with severe problems in the male. Most countries have accepted that the straightforward IVF pro­ cedure is ethical. Limitations concerning the use of donor oocytes and embryo experimentation exist in some religions and countries; legal control of the new reproductive technologies ranges from the passage of statutes to no control at all. Many countries are still considering the need for legislative control. The text endeavours to indicate new areas of importance and to guide those organizing services as to how to introduce newer technolo­ gies.

1 Selection and Preparation of Patients for In Vitro Fertilization.- 1.1 Introduction.- 1.2 The Waiting List.- 1.2.1 Patient Activation.- 1.3 Length of Menstrual Cycles — Confidence Limits.- 1.4 Hormonal Assessment.- 1.5 Assessment of Semen.- 1.5.1 Provision of Semen.- 1.5.2 Preliminary Sperm-wash Preparation.- 1.5.3 Immunological Studies.- 1.5.4 Microbiological Assessment of Semen.- 1.6 Serological Assessment.- 1.6.1 Female Partner.- 1.6.2 Male Partner.- 1.7 Bacteriological Assessment of the Cervix.- 1.8 Assessment of the Pelvis Prior to Treatment.- 1.9 Consent Forms.- 1.10 Psychological Preparation.- 1.11 Patient Support Group.- 2 Patient Management.- 2.1 Introduction.- 2.2 Natural Folliculogenesis.- 2.2.1 Luteinization and Ovulation.- 2.3 Stimulated Follicular Development.- 2.3.1 Hyperstimulation.- 2.3.2 Inadequate Stimulation.- 2.3.3 GnRH Agonists.- 2.4 Conclusion.- 3 Oocyte Pick-up.- 3.1 Introduction.- 3.2 Laparoscopic Method.- 3.3 Ultrasound-Guided Techniques.- 3.3.1 Transvesical Approach.- 3.3.2 Perurethral Approach.- 3.3.3 Transvaginal Approach.- 3.4 Ultrasound-Guided Technique Using a Combined Vaginal Needle and Transducer.- 3.4.1 Machines.- 3.4.2 Aspiration Needles.- 3.4.3 Sterilization of Transducers.- 3.4.4 Vaginal Preparation.- 3.4.5 Anaesthesia.- 3.4.6 Technique.- 3.4.7 Difficulties with Technique.- 3.5 Results.- 3.6 Conclusions.- 4 Fertilization and Embryo Culture.- 4.1 Introduction.- 4.2 Quality Control of Laboratory Procedures.- 4.2.1 Incubators.- 4.2.2 Glassware and Other Equipment.- 4.2.3 Water.- 4.2.4 Other Factors.- 4.2.5 Toxicity.- 4.3 Media for Insemination of Eggs and Culture of Embryos.- 4.3.1 Complex Media.- 4.3.2 Simple Balanced Salt Solutions.- 4.3.3 Serum Supplementation.- 4.3.4 Physiological Fluids.- 4.3.5 Choice of Culture Medium.- 4.4 Culture Conditions and Methods.- 4.5 Evaluation of Eggs.- 4.6 Insemination of Eggs.- 4.7 Microfertilization Techniques.- 4.8 Evaluation of the Fertilization Process.- 4.9 Evaluation of Embryos.- 4.10 Conclusions.- 5 Results from In Vitro Fertilization.- 5.1 The Evaluation of Results H. W. Jones Jr.- 5.1.1 Numerator Problems.- 5.1.2 Denominator Problems.- 5.2 Results P. A. W. Rogers.- 5.2.1 Ovulation Induction and Oocyte Retrieval.- 5.2.2 Fertilization and Embryo Transfer.- 5.2.3 Pregnancy.- 5.2.4 Gamete Intra-fallopian Transfer.- 5.2.5 Embryo Cryopreservation.- 6 Gamete Intra-fallopian Transfe.- 6.1 History.- 6.2 Gamete Preparation.- 6.2.1 Ovarian Stimulation and Laparoscopic Follicle Aspiration.- 6.2.2 Preparation of Spermatozoa.- 6.3 Gamete Transfer.- 6.3.1 Laparoscopy.- 6.3.2 Minilaparotomy.- 6.3.3 Transvaginal GIFT.- 6.4 Results.- 6.4.1 Pregnancies and Pregnancy Outcomes.- 6.4.2 Effect of Technical Factors.- 6.4.3 Effect of Oocyte Number.- 6.4.4 Effect of Clinical Variables.- 6.5 Complications.- 7 Outcome of Pregnancy.- 7.1 Introduction.- 7.2 Characteristics of Infertile Couples.- 7.3 Overall Results of IVF Pregnancies.- 7.4 Early Pregnancy Losses.- 7.4.1 Preclinical Abortion.- 7.4.2 Spontaneous Abortion.- 7.4.3 Ectopic Pregnancy.- 7.5 Viable Pregnancies.- 7.5.1 Duration of Pregnancy.- 7.5.2 Multiple Pregnancy.- 7.5.3 Obstetric Complications.- 7.5.4 Mode of Delivery.- 7.6 Infants Born after In Vitro Fertilization.- 7.6.1 Sex Ratio.- 7.6.2 Birthweight.- 7.6.3 Fetal Growth.- 7.6.4 Perinatal Mortality.- 7.6.5 Congenital Malformations.- 7.6.6 Follow-up Studies.- 7.7 Conclusions.- 8 Andrology, Male Factor Infertility and IVF.- 8.1 Introduction.- 8.2 Assessment of the Male.- 8.2.1 Semen Analysis.- 8.2.2 Advanced Semen Analysis.- 8.3 Separation of Motile Sperm.- 8.3.1 “Swim-up” Procedure.- 8.3.2 Albumin Columns.- 8.3.3 Glass Wool Columns.- 8.3.4 Sedimentation.- 8.3.5 Percoll Gradients.- 8.4 Male Factor Infertility.- 8.4.1 IVF and Male Factor Infertility.- 9 Oocyte Freezing.- 9.1 Introduction.- 9.2 The Human Oocyte.- 9.2.1 Oocyte Meiosis and Maturation.- 9.3 Feasibility of Oocyte Cryopreservation.- 9.3.1 Animal Evidence.- 9.3.2 Human Studies.- 9.4 Cryobiological Concepts in Oocyte Cryopreservation.- 9.4.1 Cryobiological Concepts.- 9.4.2 Cellular Events During Freezing and Thawing.- 9.5 Developing Oocyte Freezing Using an Animal Model.- 9.6 Establishing Human Oocyte Freezing.- 9.7 Factors Influencing Successful Freezing.- 9.7.1 Criteria for Oocyte Selection.- 9.7.2 Stage of Oocyte Maturation.- 9.7.3 Size of Oocyte-Cumulus Oophorus Complex.- 9.7.4 Volume of Medium for Freezing.- 9.7.5 Exposure to DMSO.- 9.7.6 Seeding.- 9.7.7 Rate of Freezing.- 9.7.8 Rate of Thawing.- 9.7.9 Assessment of the Oocyte.- 9.8 Results of Human Oocyte Cryopreservation.- 9.8.1 Clinical Studies.- 9.9 Discussion.- 9.9.1 Practical Applications of Human Oocyte Cryopreservation.- 9.9.2 Advantages of Human Oocyte Cryopreservation.- 9.9.3 Frozen Human Oocyte Pregnancies World-wide.- 10 Embryo Cryopreservation.- 10.1 Introduction.- 10.2 Requirements for Embryo Freezing.- 10.3 Development of Slow Cooling Methods for Cryopreserving Human Embryos.- 10.4 Methods of Cryopreservation by Slow Cooling.- 10.4.1 Slow Cooling in DMSO.- 10.4.2 Slow Cooling in 1,2-Propanediol.- 10.4.3 Slow Cooling in Glycerol.- 10.5 Success of Cryopreservation by Slow Cooling.- 10.6 The Development of Rapid Cooling Methods for Cryopreservation.- 10.6.1 Vitrification.- 10.6.2 Vapour Freezing.- 10.6.3 Ultrarapid Freezing.- 10.7 Use of Rapid Freezing Methods for Cryopreservation of Human Embryos.- 10.8 Cryopreservation of Embryos and Unfertilized Oocytes.- 10.9 Conclusion.- 11 Oocyte Donation.- 11.1 Introduction.- 11.2 Indications for Donor Oocytes.- 11.3 Clinical Management.- 11.3.1 Counselling.- 11.3.2 Synchronization.- 11.3.3 Embryo Transfer.- 11.4 Source of Donor Oocytes.- 11.4.1 IVF Patients.- 11.4.2 Known Donors.- 11.4.3 Volunteer Donors.- 11.4.4 Women Undergoing Sterilization.- 11.4.5 Donation of Oocytes Fertilized In Vivo.- 11.5 Steroid Replacement Therapy.- 11.6 Uterine Receptivity for Implantation.- 11.7 Endocrinology of Pregnancy.- 11.7.1 Luteo-placental Shift.- 11.7.2 Inhibin.- 11.7.3 Delivery.- 11.8 Legal Aspects.- 12 Infertility Counselling.- 12.1 Introduction.- 12.2 Why Would Anyone Seek or Need Specialised Infertility Counselling.- 12.3 Is Counselling Synonymous with “Assessment”.- 12.4 Who Does the Counselling.- 12.5 What Are Common Expressions Indicating Consideration of a Counselling Referral.- 12.6 When is Infertility Counselling Appropriate.- 12.6.1 Initial Diagnosis of Infertility.- 12.6.2 Waiting List.- 12.6.3 First Treatment Cycle.- 12.6.4 Pregnancy Test.- 12.6.5 Timing of Next Attempt.- 12.6.6 Deciding to Finish IVF Treatment.- 12.7 Should Counselling Be Compulsory for All Couples Seeking IVF.- 12.8 Are There Particular Treatment Options Necessitating Prior Counselling.- 12.9 What Are the Particular Issues a Counsellor Would Discuss with Couples Contemplating the Use of Donor Gametes.- 12.10 What is the Counselling Role of Support Groups.