Análisis Clínicos

Human Infertility

Low fertility or high infertility has become a common problem nowadays. A percentage of 15-20 of couples suffer from these problems. This may be caused by some different factors, such as high intake of alcohol, drugs, tobacco, or, due to professional reasons, the moment of having children is delayed, which is the reason for a lot of couples to have problems of infertility. The desire of having a baby is something natural, and couples plan to have children some moment in their common life; so we all assume having a baby is something natural. When problems arise, the couple could be affected by an emotional crisis. This crisis is caused by: physical conditions causing infertility, medical treatments and clinical operation to treat this, lack of information in our society, family and friends reaction and physiological characteristics of the patients. And because of that, it is essential that the couple have a correct diagnosis to their infertility problem, a correct analysis and treatment, together with detailed information about possibilities and techniques used in every step of the process. Nowadays, infertility is a problem that can be solved in the majority of the cases. But to reach this aim, a deep study must be held to know what is causing infertility and to indicate a correct diagnosis to solve the problem of the couple, reaching the final aim: to get pregnant and give birth to a healthy baby. A percentage of 80-95 of couples achieve a pregnancy after having the right diagnosis and waiting for the right period of time. This percentage can change depending on the causes producing infertility. There are a lot of different causes of infertility: a percentage of 40 is related to male problems; a percentage of 40 is related to female problems; a percentage of 15 is related to both partners problems. Finally, there is a 5% of unknown causes. Main causes of male infertility are those related with faulty sperm, such as: low number of spermatozoa, low or total lack of motility, a lot of abnormal forms, died spermatozoa, lack of acrosoma (vesicle having enzymes needed to get into the egg and fertilize it) or high levels of sperm DNA fragmentation. There are also another important causes of male infertility, such as varicocele, secretory azoospermia (lack of testicular sperm), obstructive azoospermia (lack of ejaculate sperm, not testicular sperm), and undescended testicle, a sexual dysfunction. Main causes of female infertility are: ovarian failure, fallopian tubes alterations, womb dysfunction, endometriosis, adhesions, high prolactin levels, cervical factor and others. In a lot of cases, male and female problems can be related, making it difficult for gametes to join and/ or get pregnant. Nowadays, woman’s age is a very important factor to take into account, because from 35 years on, ovaries begin to loose the capacity of producing good quality eggs. From 40 years on, the number of eggs slows down and do not have very good quality. This is the moment when reproductive problem appears. Women did not have a baby because of their work lifes or because they did not find the desired moment to get pregnant. These problems can be solved with assisted reproduction, using their own or donor eggs.

Sperm Analysis

There is a wide range of spermatic proofs that can help us to understand why a couple is suffering from infertility. Ejaculate analysis is divided into three parts: . Macroscopic exam: liquefaction time, colour, volume, viscosity and pH. . Microscopic exam: concentration, motility, viability, nuclear development, agglutination, morphology and MAR test. . Functional exam: Hypo-osmotic swelling test (HOS test), REM Training Test, Survival Test, acrosome reaction, sperm DNA fragmentation using the Tunel technique. If any other spermatic alteration is suspected, there are other complementary proofs such as: Biochemical analysis. . Prostate function markers: citrid acid, zinc, acid phosphatase. . Seminal vesicle markers: fructose and prostaglandins, alkaline phosphatase. . Epididymis markers: free L-Carnitine, glycerol phosphatidylcholine, alpha-glucosidase, maltase. Hormonal analysis. . Follicle-stimulating hormone (FSH): germinal epithelium function. . Luteinizing hormone (LH): testicular interstice and Leydig cells function. . Testosterone: testicular endocrine function. Germ immature cells identification. Spermatogonium. Spermatocyte, type.I and II. Round and long spermatids.

Azoospermia

There are some men suffering from sterility due to the lack of spermatozoa in the ejaculate. This is called azoospermia. There are two kinds of azoospermia: obstructive azoospermia or non-secretory, and non-obstructive azoospermia or secretory. Obstructive azoospermia: they are men having very injured seminal tract, with deferents agenesia and/or epididymis and epididymis obstructions. They do not have spermatozoa in the ejaculate, but these spermatozoa can be found in epididymis and testicle. The only treatment we can follow in this case is to make epididymis spermatozoa aspiration (MESA) or a testicular biopsy (TESE) to obtain spermatozoa and inject them inside the egg (ICSI). Non-obstructive or secretory azoospermia: they are men having problems with sperm production; there are spermatozoa neither in the ejaculate, nor in the testicles. Depending on which level the sperm development is blocked, we will find different germinal cells, spermatogonium, spermatocyte and spermatids, which are immature cells. In some cases there are not these immature cells, and there are only Sertoli cells. INDICATIONS Obstructive azoospermia. Non-obstructive azoospermia. METODOLOGY A testicular biopsy will be performed if testicular spermatozoa are needed to obtain fertilization (TESE). Only spermatids or immature sperm cells injection is performed in the egg (ROSI or ELSI) when there are spermatozoa neither in the ejaculate nor in the testicular biopsy. If that is the case, testicular biopsies will be treated in vitro culture inside the correct conditions, to obtain spermatozoa or sperm forms as much developed as possible. All this is known by the couple and they give their consent. You have at your disposal information sheets about all techniques. There are also sheets for the couple to give their consent and accept what they are asking for. The proofs show that secretory azoospermia is caused by the lack of spermatozoa production in the testicles. Nonetheless, sperm has live germ immature cells and with no apparent problems. So, it would be possible to obtain the development of these cells to spermatids state by cellular culture. These spermatids developed in the culture would be injected directly in the egg to fertilize it. A testicular biopsy is needed for this technique to success, because other types of testicular cells, absent in the ejaculate but present in the testicular tissue, are needed to help germ cells to develop into the in vitro culture. This technique has provided the birth of some babies with normal genes. Analysis and treatment to the patient will be the same as the ones followed to perform ICSI with spermatozoa in the ejaculate. The number of babies born by spermatids injection, mainly developed spermatids in vitro, is very low. So we advise you to ask for prenatal diagnosis, once the pregnancy has begun. You will need to perform an amniocentesis to analyze chromosomes and one ultrasound scan to study the foetus morphology. In vitro culture of testicular biopsy. Once the testicular tissue has been obtained following testicular biopsy and mechanical disintegration of seminiferous tubules, meiotic maturation of human germ cells is performed following in vitro culture in the presence of recombinant follicle stimulating hormone (rFSH) and testosterone, for 24 or 48 hours in 86 F (30 ºC) and 5% of CO2. Meiotic arrest (mainly inside primary spermatocyte phase) is the most common block kind in sperm maturation, in men with non-obstructive azoospermia. There is a recent new perspective due to the discovery to avoid meiotic arrest in vivo after in vitro maturation. Another treatment based on meiotic reduction of primary spermatocyte after egg microinjection (proved in mice) may cause a high risk of chromosome abnormalities due to premature segregation of sister chromatid. If post-meiotic maturity arrest appears, (spermiogenesis failure), in vitro culture may be beneficial, because elongated spermatids are formed with no apoptotic DNA damage, when compared with round spermatids before in vitro culture. This is important because germ cells apoptosis may be main obstacle to assisted reproduction using spermatids when there is a complete block of spermiogenesis. In fact, in vitro culture application provided first healthy babies births, when there was a total spermiogenesis failure. From the clinical point of view, a very important fact is reached following this technique: . The couple do not need to ask for at semen bank to have children. . To maintain the genes information of the patient, which would maintain genotype characteristics in the eventual embryo. FERTILIZATION Fertilization will be studied 24 hours after follicular puncture. At this moment, patients are informed about the number and quality of fertilized eggs (zygotes). Not all zygotes reach the pre-embryo stage, so this is just to inform the couple. 48 o 72 hours after follicular puncture, one or three obtained pre-embryos and best quality ones are transferred into the patient’s womb. It is demonstrated that this number of pre-embryos produces more possibilities of getting pregnant and less possibilities of multiple pregnancy. Non-transferred pre-embryos are frozen, after been accepted and known by the couple. These embryos can be stored for the couple for a maximum period of five years, and after that period the Clinic becomes the owner, in case the couple do not ask for them. Patients that do not need these embryos will donate them to the Clinic to the embryo donation protocol. This protocol is useful for couples with unsuccessful assisted reproduction tries due to bad quality male and female gametes producing non-evolutionary embryos. A big quantity of embryos can be obtained after fertilization drugs to ovarian stimulation. Eggs may be donated to women with problems to produce their own eggs when there is a high number of them. Nonetheless, donor maintains a number of her own eggs enough to be transferred, and to be frozen with her consent. Donation is unknown and free, an it is also beneficial both for recipients and donors, because putting together their eggs with different spermatozoa provide important information. . The problem is related with spermatozoa if fertilization fails with semen of her own partner but success with semen of another men. . The problem is in the eggs when fertilization fails in both cases. . If there is a good fertilization with different semen samples, as it is the rule, data about embryos quality, womb receptiveness, etc, are obtained. There is also a protocol of pure egg donor. Eggs are obtained from a woman donating her eggs to women suffering from infertility, due to lack or bad quality eggs, and who want to have children. If this is the case, there are two different protocols. If the patient is not capable of producing her own eggs, donor eggs will be fertilized with the semen of the male partner. Resulted embryos will be transferred to the patient, in a number assuring pregnancy. Non-transferred embryos will be frozen. In this case, obtained embryos have half the genetic information from the donor and half from the patient’s partner.

Preimplantory diagnosis

Preimplantation diagnosis is a very early prenatal diagnosis that allows eliminating embryos carrying genetic abnormalities before being transferred into the womb. INDICATIONS This will be performed both to fertile and infertile patients. Fertile patients: Patients having diseases related to gene mutations: . Beta-thalassemia.  . Cystic fibrosis.  . Hemophilia.  . Duchenne muscular dystrophy.  . Other. Infertile patients: . Aged patients and repeated failures when performing assisted fecundation (more risk of aneuploidy). . Embryo multi-nucleation. PROCEDURE If the embryo has been obtained by classic ICSI or FIV, two blastomeres from an embryo of eight cells are taken. After that, the genetic analysis of these blastomeres is made, following PCR (Polimerase Chain Reaction) or FISH (Fluorescent in situ hybridization).

Embryodon

In our Clinic we have an embryo donation program, that is to say, embryos donated by couples to patients with fertility problems. INDICATIONS . Bad or nil egg response and lack of spermatozoa in ejaculate and testicle. . Chromosome anomalies in both partners. Following the Spanish Law about assisted reproduction techniques, frozen embryos can be stored for a maximum period of three years, and after that period the Clinic becomes the owner. Patients that do not need these embryos will donate them to the Clinic, following a signed consent by both partners; this way, embryos can be transferred to other couples or used in investigation. It is possible that in the moment of the freezing (day 2 or 3 during fertilization), the couple decide not to frozen the spare embryos. Then, the embryos are donated by signed consent of both partners. Transferred embryos do not have the genes information of the couple. But the Clinic staff would try to find embryos with characteristic and ABO blood group as similar a possible to the recipient couple. Embryo donation is unknown, both for the couple and donor. The couple get the possible physical characteristics of received embryos.

Ovary stimulation

Patients visiting our centre may choose among: . Consultation to indicate the treatment and the way of controlling this treatment. Ultrasound scans and hormonal control are performed to know if it is possible to begin with the treatment, and which are the recommended dose. . Different visits from the 5th day of ovarian stimulation, to control the development of follicles and hormonal control, to choose the day to controlled ovulation. This cycle is monitored via vaginal ultrasounds in our Clinic. In the last visit, ovulation will be triggered with an injection of human Chorionic Gonadotrophin (hCG). . Medical control of complications that could arise in the process. Control of possible complications since the pregnancy is confirmed too. Risks: . Multiple pregnancy: due to multiple follicular development. This occurs because inseminations with four ovarian follicles are performed. Nonetheless, the risk is about 10-15 % for twins. The possibility of having more than two is less than 1%. This could be an important complication and the couple must evaluate to reduce the number of embryos. . Ovarian Hyperstimulation Syndrome: This is a complication of controlled ovarian stimulation arising in a very small proportion of women undergoing fertility treatment due to the soft hormonal treatment. It is due to the over-sensitivity of the ovaries to the fertility drugs in certain patients. If there is a high follicular development after ultrasound controls, the cycle will be cancelled. . In the other hand, this hyperstimulation appears in patients prepared for a In Vitro Fertilisation treatment o Intracytoplasmic Sperm Injection, the cycle is not cancelled and are required a lot of controls, because when conditions are serious, symptoms include swelling of abdomen and thorax, coagulation alterations, hepatic and renal failure. Then the patient may be admitted to the hospital for treatment, under the risk of having serious problems if do not go into. Mild cases of OHSS are treated by medical control and rest. . Anxiety or depressive symptoms in the couple may arise from these infertility treatments. Enough information and good professional advice is important to avoid this. Sometimes, problems may arise in their relation as a couple. In our Clinic, you have at your disposal the help of a psychology specialist if you would need help. High anxiety may arise in the waiting period from the beginning of the treatment to the confirmation of the pregnancy. Rarely you can suffer from genital infections, haemorrhages and torsion or torn ovaries.

Back down ejaculation

Retrograde ejaculation refers to the entry of semen into the bladder instead of going out through the urethra during ejaculation. It mixes with the urine, so spermatozoa are not in the ejaculate. This is not a common disease and may occur total or partially. Retrograde ejaculation may be caused by: . Prior prostate o urethra.surgery. . Diabetes. . Some medications, including some drugs used to treat hypertension and some mood-altering drugs. The presence of semen in the bladder is harmless. It mixes with the urine and leaves the body with normal urination. Men suffering from diabetes or after genitourinary tract surgery have more possibilities of suffering from this condition. Symptoms are mainly, little or no semen discharged from the urethra in conjunction with the male sexual climax (during ejaculation), possible infertility and cloudy urine after sexual climax. If retrograde ejaculation is caused by medications, discontinuation of the medication often restores normal ejaculation. If it is caused by surgery or diabetes, it is often not correctable. Couples with this kind of problem need a special treatment. A prior treatment of sodium bicarbonate is administered to the patient. After ejaculation, all the urine is collected, ad it is treated in the laboratory to obtain the maximum number of spermatozoa with good mobility and morphology. After that, artificial insemination, IVF or ICSI are performed, depending on sperm quality. Success percentage is similar to those treatments of assisted reproduction performed with sperm ejaculate.

FIV

Conventional In Vitro Fertilization treatment (IVF) is perhaps the easiest technique when talking about assisted reproduction. The first pregnancy was achieved in 1976 and the first birth in 1978. Normally, egg fertilization consists on the fertilization of this egg from the ovary, performed by a spermatozoon inside the fallopian tubes. But, IVF process is the joining of a woman’s egg and a man’s sperm in a laboratory dish. In vitro means “outside the body”. Obtained embryos are transferred to woman’s womb to continue the natural embryonic development. INDICATIONS . Damaged or blocked fallopian tubes. . Endometriosis. . Neck of the womb problems. . Artificial insemination failure. . Unexplained infertility. PROCEDURE Firstly, in conventional In Vitro Fertlization treatment (IVF), male and female eggs are obtained. Then, eggs are fertilized in the laboratory. Finally, prepared pre-embryos are transferred into the patient’s womb, to develop naturally. It is clinically demonstrated that there is more possibilities of gestation when several eggs are inseminated. This way several pre-embryos could be transferred. Ovarian stimulation with some drug support is performed to obtain a highest number of eggs. (See ovarian stimulation chapter). Rarely, this external stimulation can produce a highest response of the egg, causing symptoms of Ovarian Hyperstimulation Syndrome. This over-sensitivity of the ovaries is not advisable, and arises in a very small proportion of women. Follicular liquids are obtained by follicular puncture using ultrasound scan. This will be performed under general anaesthetic and will last 15 or 20 minutes. There is little possibility of problems arising from this intervention. The patient will go away within a few hours, after a little rest. Eggs are collected from follicular liquids and will be introduced in a correct culture at 98.6 F (37 ºC) and under CO2 atmosphere. Then, the male partner is asked for a semen sample. This sample is prepared in the laboratory to inseminate the eggs. Insemination is performed putting together correct spermatozoa with eggs. Fertilization will be studied 24 hours after follicular puncture. At this moment, patients are informed about the number and quality of fertilized eggs (zygotes). Not all zygotes reach the pre-embryo stage, so this is just to inform the couple. 48 o 72 hours after follicular puncture, one or three obtained pre-embryos and with the best quality ones are transferred into the patient’s womb. It is demonstrated that this number of pre-embryos produces more possibilities of getting pregnant and less possibilities of multiple pregnancy. Nonetheless, the number of eggs to be transferred will depend on the desires and possibilities of the couple. Transference procedure last just a few minutes, and is performed by ultrasound scan. A fine catheter is used to transfer the embryos into the woman’s womb, through the neck of the womb. After that, the patient will rest for two hours and then will go home. The procedure is similar to artificial insemination: easy, and with no pain. The patient will rest at home for a few days and will not have intercourse during 7 days, which is recommended. She will undergo her doctor’s treatment, which will mainly consists on progesterone, to improve the hormonal secretion during the lutea stage. This will improve also implantation possibilities and the eventual pregnancy. 14 days after the transfer is performed, a blood pregnancy test is made, which is measured following the presence of beta-human chorionic gonadotropin. The Clinic will be informed about the results. If the result is positive, an ultrasound scan will be performed in two or three weeks. Once the presence of an embryo sac with cardiac activity is confirmed, the doctor will inform the patient about the steps during her pregnancy. Non-transferred pre-embryos are frozen to improve the possibilities of getting pregnant again if the first embryo transference has been successful. If the result of this first transference is not positive, the couple may try again thanks to these frozen embryos. These embryos can be stored for the couple for a maximum period of five years, and after that period the Clinic becomes the owner, in case the couple do not ask for them. Patients that do not need these embryos will donate them to the Clinic to the embryo donation protocol. This protocol is useful for couples with unsuccessful assisted reproduction tries due to bad quality male and female gametes producing non-evolutionary embryos. All this is known by the couple and they give their consent. You have at your disposal information sheets about all techniques. There are also sheets for the couple to give their consent and accept what they are asking for. A big quantity of embryos can be obtained after fertilization drugs to ovarian stimulation. Eggs may be donated to women with problems to produce their own eggs when there is a big number of them. Nonetheless, donor maintains a number of her own eggs enough to be transferred, and frozen with her consent. Donation is unknown and free, an it is also good both for recipients and donors, because putting together their eggs with different spermatozoa give important information. The problem is related with spermatozoa if fertilization fails with semen of her own partner but success with semen of another men. The problem is in the eggs when fertilization fails in both cases. If there is a good fertilization with different semen samples, as it is the rule, data about embryos quality, womb receptiveness, etc, are obtained.

ICSI

This technique has achieved a lot of importance, mainly when referring to male infertility. More than 90% of fertilization is reached following this technique. INDICATIONS This procedure is performed when: . A few number of sperm with normal motility and morphology. . Problems when the spermatozoon is penetrating the egg. . Failure of conventional IVF. . Antisperm antibodies stopping fecundation. . Failure of acrosome response of spermatozoon. . A few number of eggs. . A big quantity of spermatozoa with no mobility or anomalous ones. PROCEDURE OVARIAN STIMULATION: To begin with this procedure, male and female gamete are collected. Ovarian stimulation with drug support is needed to obtain a big quantity of eggs, as it was said before when talking about ovarian stimulation. Ovarian Hyperstimulation Syndrome can arise in a very small proportion of women as a result of this external stimulation. It is due to the over-sensitivity of the ovaries to the fertility drugs in certain patients. In most cases the condition can be managed conservatively. FOLLICULAR PUNCTURE: Eggs are obtained by follicular puncture performing an ultrasound scan. This is performed under intravenous sedation and will last 15 or 20 minutes. Problems caused by this technique are very rare. LABORATOY TREATMENT: DAY 0 Following egg collection, mature eggs are specially treated to remove the cumulus cells surrounding them (cumulus ooephorus cells). This way, mature and quality of eggs is studied. Only mature eggs are injected. (Phase II). Inmature eggs will be treated in vitro following our own techniques. The male partner will be asked to provide a sperm sample; then, this sample is prepared in the laboratory to obtain a spermatozoon of the best quality. After that, it is injected directly into the egg under microscopic control (ICSI). One at a time. This technique is performed using one inverted microscope with micromanipulators which allows observing the spermatozoon 6,600 times bigger (IMSI). The egg is held by a microtitration diluter  whilst another one injects the spermatozoon inside the egg. All this is known by the couple and they give their consent. You have at your disposal information sheets about all techniques. There are also sheets for the couple to give their consent and accept what they are asking for. DAY 1 24 hours after follicular puncture, eggs are examined for signs of fertilisation. The couple is then informed about the number of obtained fertilised eggs or zygotes. This is just an informative point about the number of prepared pre-embryos for transfer after 24 or 48 hours, because it is possible than no all zygotes reach the pre-embryo stage. DAY 2 / DAY 3 (TRANSFERENCE) Viable obtained pre-embryos are deposited into the patient’s womb after 48 or 72 hours following follicular puncture. The pre-embryo is there to develop naturally. It is clinically proved that when 3 embryos are transferred the chances of achieving a pregnancy increase and multiple pregnancy risk lows. Our Clinic use to transfer between 1 and 3 enbryos. When transferring it is important to take into account some data for the number and embryos and pregnancy to be correct: patient age, quality of embryos and womb, patient diagnosis, possible risk between mother and baby and desires of the couple. EMBRYO FREEZING Excess pre-embryos are frozen. There is an informative and consent form for the couple. These frozen embryos belong to the couple for 5 years; after that period and if the couple does not ask for them, the Clinic can use these pre-embryos for embryo donation.

Artificial insemination

There are two possibilities when talking about artificial insemination: either the woman's husband's sperm, previously prepared in the laboratory (artificial insemination by husband, AIH), or a known or anonymous sperm donor, selected and prepared in the laboratory (artificial insemination by donor, AID) can be used. Indication: Indication of partner sperm or AIH: . Failure in obtaining a gestation performing arranged intercourses. . Ovulation alteration. . Anomalous interaction between spermatozoa and cervical mucus: positive antisperm antibody binding. . Low number, motility and spermatozoa anomalies. . Difficulties of spermatozoa entering the uterine cavity. . Ejaculation alterations. . Unexplained male unfertility. . Indication of donor sperm or AID: . Secretory azoospermia (nor spermatozoa neither sperm cells in testicle). . Bad sperm quality not allowing AIH (high number of spermatozoa with no motility, anomalous or died ones); those who failed when performing AIH or do not want to follow IVF. . Genetic or chromosome alterations of the couple. Procedure Before the partner or donor insemination is performed, ovulation will be triggered with an injection of human hormones (FSH y/o HMG). Administration of hCG is performed when the cycle is correct, that is to say, there is a good number of follicles in ovulation stage. One or two inseminations during each cycle can be performed after personal and cycle characteristics. In our Clinic, we perform two inseminations, because a highest number of pregnancies is reached, following published works. If more than four follicles are developed in ovulation stage, the cycle will be cancelled because of high risk of multiple pregnancy. Insemination allows best quality spermatozoa (by concentration and training developed in the laboratory) to be placed into the uterine cavity after the cervix, just near the fallopian tube. Ovulation induction normally produces more than one egg too; depending on pathology, we could be interested on achieving just one egg. All conditions are prepared for the fecundation to be performed inside the woman’s body. Intrauterine insemination advantages are: little invasive procedure, low emotional risk, with no pain, and where no anaesthetic is required because introduction of the spermatic sample is performed with a fine and flexible catheter. Normally, a treatment is indicated to the patient after insemination; progesterone is mainly administered to improve the development of the possible gestation. Succes possibilities Following scientific bibliography, success percentage depends on indications. But in general between 4 and 14% is reached when performing artificial insemination by husband in each cycle. Following our own statistic, a 20 % of pregnancies is reached in our Clinic in each patient and cycle, changing depending on indication. Success improves when talking about artificial insemination by donor, where between 20% and 40% in each cycle is reached. At MAR&Gen 38% is reached. Miscarriage possibilities once the pregnancy has begun are the same as in a natural cycle. There is not a bigger percentage of neither malformations nor genes alterations in babies conceived after that technique. Following our protocol, we perform 2 or 3 insemination cycles. Our won data and the studied bibliography show a slow down in success percentage in each cycle. In Vitro Fertilization will be advisable in these cases because, although a complete study of infertility is made, we do not know details about the joining of spermatozoon and egg. NOTE: Special circumstances when artificial insemination by donor is performed. . Gametes donation is unknown. This way, the recipient is not allowed to have her own donor. But the recipient is allowed to ask for a donor with some characteristics similar to those of her male partner, such as height, weight, eyes colour, hair colour, skin colour and blood group (following the Spanish Law). . Nonetheless, our team will take full responsibility about donor election. They must choose one donor as similar as possible to couple characteristics and woman’s family. Any case, the couple must give their consent. . Donors must be legally of age. Several exams about phenotype, immunological, genetic and hereditary characteristics, together with infectious and transmitted diseases, must be performed. . Following the Spanish Law, maximum of births after same donor is 6.

Attended laser

It is demonstrated that if Intracytoplasmic Sperm Injection (ICSI) injury egg cytoplasm, egg possibilities low and the percentage of fecundation falls down. It is true that in some eggs it is very difficult to perform ICSI because of different causes. INDICATIONS This procedure is performed when: . Hormonal treatment during stimulation may affect cytoplasm behaviour. . Cytoplasm may be damaged when performing ICSI by technical causes. . Zona pellucida thickness (egg shell) and its structure my be affected by hormonal treatment. PROCEDURE All these factors produce an injury when performing Intracytoplasmic Sperm Injection to the egg. There must be a deep pressure and the egg dye immediately, is not fertilized or my have abnormalities. This technique consists on opening a hole with by laser in the zona pellucida of the egg. Alter that, the Intracytoplasmic Sperm Injection needle with the spermatozoon is introduced into this hole. This technique is very successful, both in fecundation and pregnancy percentages.

Egg Donation

This protocol is one of the most asked for a big number of couples with female fertility problems. INDICATIONS This procedure is performed when there is: . Low egg response. . Bad quality of eggs. . Convencional FIV and/or ICSI failure. . Climacterium praecox.  . Aged women with climacterium or pre-menopausal syndrome. PROCEDURE Eggs are collected from an egg donor. This donor is previously selected by the Clinic staff and must have the physical characteristics asked by the patient. These donors help women with this kind of infertility to have children. Eggs’ donor will in this case be fertilized with the partner sperm, and embryos will be finally transferred to the patient. This number of embryos transferred must assure the pregnancy (normally between two or three embryos). Obtained embryos have half the genes information from the donor. The other half is obtained from the patient’s partner. Due to drugs administrated to produce ovarian stimulation, a big number of eggs’ donor can be obtained. Not transferred pre-embryos should be frozen for a second try of pregnancy or donated to other couples. Donation is unknown and free. All this is known by the couple and they give their consent. You have at your disposal information sheets about all techniques. There are also sheets for the couple and donor to give their consent and accept what they are asking for. OVARIAN ESTIMULATION Ovarian stimulation after administration of fertility drugs is performed to obtain a big number of eggs, as it as been explained in ovarian stimulation chapter. Ovarian Hyperstimulation Syndrome is a complication of controlled ovarian stimulation arising in a very small proportion of women undergoing fertility treatment. It is not advisable and may be prevented in most cases. FOLLICULAR PUNCTURE: Eggs are obtained by follicular puncture performing an ultrasound scan. This is performed under intravenous sedation and will last 15 or 20 minutes. Problems caused by this technique are very rare. LABORATOY TREATMENT: DAY 0 Following egg collection, mature eggs are specially treated to remove the cumulus cells surrounding them (cumulus ooephorus cells). This way, mature and quality of eggs is studied. Only mature eggs are injected. (Phase II). Inmature eggs will be treated in vitro following our own techniques. Male partner will be asked to provide a sperm sample; then, this sample is prepared in the laboratory to obtain a spermatozoon of the best quality. After that, it is injected directly into the egg under microscopic control (ICSI). One at a time. This technique is performed using one inverted microscope with micromanipulators which allows observing the spermatozoon 6,600 times bigger (IMSI). The egg is held by a microtitration diluter whilst another one injects the spermatozoon inside the egg. DAY 1 24 hours after follicular puncture, eggs are examined for signs of fertilisation. The couple is then informed about the number of obtained fertilised eggs or zygotes. This is just an informative point about the number of prepared pre-embryos for transfer after 24 or 48 hours, because it is possible than no all zygotes reach the pre-embryo stage. DAY 2 / DAY 3 (TRANSFERENCE) Viable obtained pre-embryos are deposited into the patient’s womb after 48 or 72 hours following follicular puncture. The pre-embryo is there to develop naturally. It is clinically proved that when 3 embryos are transferred, the chances of achieving a pregnancy increase and multiple pregnancy risk lows. Our Clinic use to transfer between 1 and 3 embryos. When transferring it is important to take into account some data for the number and embryos and pregnancy to be correct. Donor’s age is between 18 and 27, so multiple pregnancy is possible; quality of embryos and womb, patient diagnosis, possible risks between mother and baby and desires of the couple.

Egg Freezing

IMSI