What are the indications of artificial reproductive techniques (ART)?

  • Tubal factor

  • Severe male factor

  • Severe endometriosis

  • Unexplained infertility

  • Age >35 years

  • No pregnancy after 1 year of conventional ovulation induction treatment

What are the aims of the ART?

  • Achievement of oocyte from ovary with an artificial method.

What are the methods of the ART?

  • In vitro fertilization: Oocytes achieved from ovary and these oocytes and sperm put same media. After fertilization, embryo transfer is achieved.

  • Gamet intrafallopian transfer (GIFT): Oocyte and sperm are placed in the fallopian tube.

  • Zygote intrafallopian transfer (ZIFT): Zygote is placed in the fallopian tube.

  • Tubal embryo transfer.

  • Peritoneal oocyte and sperm transfer.

Which artificial reproductive techniques are used in male infertility?

  • Techniques of sperm achievement

    • Injection of one sperm to oocyte—Intracytoplasmic sperm injection (ICSI)

    • Testicular sperm extraction (TESE)

    • Microsurgical epididymal sperm aspiration (MESA)

    • Sperm aspiration from testis

Which screening tests are made before ART?

  • Hormone profile

  • HSG

  • Sperm test

  • Ultrasonography

  • HIV1 and HIV2

  • Hepatitis B and hepatitis C

  • Chlamydia, syphilis, gonorrhea, CMV, and rubella

What are the treatment alternatives of artificial reproductive techniques?

  • Spontaneous cycles (6% success)

  • GnRH analogues

  • GnRH antagonists

  • Human menopausal gonadotropin (HMG)

  • FSH

  • Clomiphene citrate

  • Metformin

  • Aromatase inhibitors—letrozole, anastrozole

How to determine treatment options of patients requiring ART?

  • Treatment is determined according to women age, and ovarian reserve.

  • GnRH analogues + FSH are preferred in young women.

  • Low-dose GnRH analogues + high-dose FSH ± combined oral contraceptives are preferred in advanced ages.

  • GnRH analogues + FSH (or HMG) + letrozole preferred in patients with poor ovarian reserve.

  • GnRH antagonist + low-dose FSH are used in PCOS.

  • GnRH analogues + FSH (Luteal long protocols) are preferred in endometriosis.

How would you follow up a patient when ART is applied?

  • Aim is controlled hyperstimulation.

  • For each follicle (>14 mm), estradiol level of at least 200 pg/mL is preferred.

  • Endometrial thickness in ultrasonography should be 7–12 mm; endometrial lining in ultrasonography should be triple line.

  • Oocyte pick-up (OPU) is made 34–39 h after hCG injection.

  • Embryo transfer is made 3–5 days later.

  • Generally progesterone is given after embryo transfer.

What is the basic technique of oocyte pick-up (OPU)?

  • Mild anesthesia and sedation is preferred.

  • Optimal monitoring is made.

  • Generally pick-up needle is inserted into an ovary once and oocytes are aspirated.

Describe the process of oocyte culture.

  • Oocytes are examined under a microscope.

  • Separated from the sheath (cumulus) around the oocyte after the egg collection.

  • After 4–6 h, the sperm is injected into the egg or leave to fertilization.

  • Sperm is separated by swim-up method (If IVF is done, 50,000–100,000 sperms are left per oocyte).

Describe the fertilization process.

  • Matured oocytes are fertilized at 65–80%.

  • Roughly 6% polyspermia-type 3 pronucleus cells are consisted.

  • If fertilization problem is present or if sperm count is too low, ICSI should be referred.

  • Surplus embryos are frozen.

Describe the embryo transfer process:

  • Generally 8-cell embryos after 72–80 h are transferred.

  • Or, if the quality embryo is high, embryo is transferred to the blastocyst stage after 5 days.

  • Depending on the age of the woman, the number of embryos may increase. Normally good quality 1–2 embryos are given.

  • Luteal phase support is needed.

  • After the transfer, hCG is measured on day 10–11.

  • Five weeks after last menstrual period, fetal heart activity is expected.

What are the pregnancy associated results of ART?

  • Abortion rate 20%.

  • It is stated that there may be minimal increase in congenital malformation because of increased multiple pregnancy.

  • Ectopic pregnancy is seen 3%.

  • Risk of multiple pregnancy 35%.

  • After three unsuccessful cycles, success rate is significantly decreased.

Describe male factor in fertility in artificial reproductive techniques.

  • Fertilization rate is low.

    • ICSI is recommended treatment.

    • All kinds of immature, immobile sperm can be used.

    • Morphological selection of sperm is recommended.

Describe genetic problems in male factor infertility

  • Infertile men have chromosomal anomaly in 5–7%.

  • There are high deletions in the Y chromosome in the presence of azoospermia.

  • 7–10% Y deletion in oligospermia.

  • 10% of sperms carry extra chromosomes.

  • There is 0.84% ​​sex chromosomal anomaly in ICSI pregnancies due to male infertility.

  • Genetic screening should be made to azoospermic men.

  • Klinefelter syndrome

    • LH β subunit mutation

  • There may be congenital absence of vas deferens. It is seen 1–2% in infertile men.

  • There may be cystic fibrosis mutation.

Describe oocyte donation.

  • Forbidden in some countries. Oocyte donation is the process in which a fertile woman’s several oocytes are aspirated, usually following ovarian stimulation, in order to be used in another patient (mostly infertile due to ovarian failure; Premature ovarian failure, Turner syndrome, Ovarian failure following chemotherapy or radiotherapy, IVF failure, genetic disorders).

  • It may be used in patients with premature ovarian failure.

  • Donor age 22–24 is preferred.

  • Success rate is approximately 50%.

In which patients, preimplantation genetic diagnosis (PGD) is preferred?

  • Cystic fibrosis

  • Duchenne muscular dystrophy

  • Sickle cell anemia

  • Hemophilia

  • Tay–Sachs disease

  • Lesch–Nyhan syndrome

  • Trisomy