Clinical services provided by Al-Amal ART unit 1- In vivo fertilization Ovulation Induction (O/I) and timing sexual intercourse (TSI). Intrauterine insemination (IUI) with superovulation Sex selection (X-Y Separation) with superovulation 2- Assisted conception techniques In vitro fertilization (IVF) - Conventional in vitro fertilization (C-IVF) - Intracytoplasmic sperm injection (ICSI) Preimplantation Genetic Diagnosis (PGD) Surgical sperm recovery - Percutaneous epididymal sperm aspiration (PESA) - Testicular sperm aspiration (TESA) - Testicular sperm extraction (TESE) Cryopreservation of embryos, sperm and testicular tissue Implantation enhancing techniques: - Assisted hatching (AH) - Blastocyst culture (BC) - Embryo glue 1- In vivo fertilization Ovulation induction (OI) and Timing Sexual Intercourse (TSI): - OI is used to increase the chance of conceiving through natural conception when male and female causes of infertility have been excluded or proved to be mild by investigations. More eggs (not more than three) are produced through oral tablets or hormonal injections according to the female age, duration of infertility and hormonal level. - Regular monitoring with vaginal ultrasound is needed to determine the patient ovarian response and dose modification. - When the follicles mature to the recommended size (16-18mm), we give an injection (hCG) to release the ova from the ovary, after which we ask the couple to time their intercourse within 24-36 hours. This method has a reasonable success rate. Fertility drugs for ovarian stimulation Intrauterine insemination(IUI) In this method, the female undergoes ovarian stimulation program, and the sperm are inseminated into the uterus after lab preparation. Ovarian stimulation is optimally achieved using gonadotropin injections with the aim of recreating 2-3 follicles, with this approach, the rate of conception is about 15-20%. The risk of twin is 20% and triplet less than 1%. Sperm can be prepared in several ways; the most common is simple sperm washing, swim up technique and gradient separation technique. Indications of IUI: - Male factor: Decreased sperm count (5-20 mill/ml) Poor sperm motility (fast forward motility not less than10%) Clumping or hyperviscosity (mild agglutination, liquefaction time> 60 min.) Defects of the penis e.g. hypospadias or severe penile curvature. Retrograde ejaculation or other forms of ejaculatory dysfunction. Female factor: Scanty unreceptive mucus (cervical hostility). Presence of antisperm antibodies Unexplained infertility. Intrauterine insemination procedure (IUI) Sex Selection (X-Y separation) Our ART lab provides the technique of separating X and Y sperms and inseminating the desired sample into the uterus at the time of ovulation. Several techniques have been used for separating X from Y-bearing sperm is used. At Al-Amal ART unit 70% of the children born after sperm separation using Double wash double swim up technique followed by IUI are males. 2- Assisted conception techniques - Assisted conception involves the lab preparation of sperm and eggs bringing them close together to enhance the chance of fertility and fecundity. - Prior to assisted therapies in Al-Amal ART unit and after baseline infertility investigations, couples are tested for HIV, hepatitis B and hepatitis C to avoid transmission from one partner to the other and to protect lab staff handling the fluids. Furthermore, cryopreserved gametes and embryos have the potential of cross –contamination through liquid nitrogen. In Vitro Fertilization (IVF) The term “in vitro” refers to any biological procedure that is performed outside the living organ it would normally be occurring in, to distinguish it from an “in vivo” procedure, where the tissue remains inside the organ within which it is normally found. IVF is a technique of assisted reproduction in which sperm and eggs are combined outside the body in a lab dish to give a chance for fertilization. Then the embryos are transferred into the uterus through the cervix and pregnancy is allowed to begin. At our unit, after diagnosis is established through male and female investigations and IVF is decided, a counselling session is carried out to explain all the steps of the program, success rates, side effects, time factor and cost. Then the couple are requested to sign a consent form to enter the IVF program and its related procedures. Procedures used in IVF - Conventional in vitro Fertilization (C-IVF) This involves ovarian hyperstimulation, then collection of eggs is performed. During this our lab team starts examining and treating the seminal fluid for the husband in order to choose the most active and best quality sperms (50-100 thousand fast, forward moving sperms for each retrieved egg are needed). Then the available eggs with the sperms are placed in special incubators with favourable environment for 24-72 hours in which fertilization takes place, division starts and embryos develop. The embryos are usually placed back into the uterus at day 2-3 after egg retrieval (2-8 cell stage). The technique of extended embryo culture (blastocyst) is also available where we keep the embryos in the IVF lab under favourable conditions for 5 days. This technique has the advantage of providing us with the best quality advanced embryos with higher implantation rates than the standard methods. Indications of C-IVF: 1. Infertility due to fallopian tube obstruction due to previous surgeries or pelvic infections. 2. Endometriosis or pelvic adhesions. 3. Mild seminal fluid weakness. 4. Unknown causes of infertility. - Intracytoplasmic sperm injection (ICSI) This is done by injecting a single sperm into a single egg using a special needle attached to a highly magnifying microscope after removing adhesive cells to the egg. In this method, we inject the sperm into the egg under a microscopic guidance while in the Classical method thousands of sperms are mixed with the egg waiting for one of them to fertilize it without any external help. At the time of egg retrieval, the husband gives the semen sample. After its treatment, we choose the best quality sperms to be injected. In cases where the ejaculated seminal fluid contains no sperms, we interfere surgically by extraction of the sperm from the testes or epididymis. ICSI technique has been known to have better fertilization rates than classical method (90% compared to 65% C-IVF). Indications of ICSI: 1. Failure of fertilization by C-IVF method. 2. Poor semen quality (count, motility, morphology) 3. Absence of sperm in seminal fluid (azoospermia) in which sperm are retrieved surgically from the epididymis or testicular tissue. 4. Infertility duration exceeding five year Basic steps in a IVF cycle 1. Ovarian stimulation 2. Egg retrieval 3. Insemination/microinjection 4. Fertilization 5. Embryo culture 6. Embryo transfer 7. Luteal phase support 1- Ovarian stimulation A corner stone step that precedes all IVF programs. During this, fertility drugs are used to stimulate sufficient number (more than four) and good quality eggs. To prevent premature ovulation (early release of the egg from the ovary). Drugs type and dose are defined according to the ovarian stimulation protocols and usually given over a period of 2-3 weeks. Ovarian response is evaluated with repeated vaginal ultrasound and hormonal testing (Estrogen which should increase as the follicles develop and Progesterone should be low until ovulation). When the follicles are ripe (>18mm in diameter), hCG is given 34-36 hours before egg collection. Our aim with ovarian stimulation for IVF is always to produce sufficient number of high quality embryos so as to enable two to three to be transferred to the uterus and to leave those that remain to be frozen for possible later use. In this way, the need for further stimulation cycles is reduced and the chance of success is maximized. Cycle cancellation may be decided when the ovarian response is poor and another ovarian stimulation strategy is attempted in the future. Sometimes cycle cancellation is decided for patients with severe ovarian hyperstimulation syndrome (OHSS). Ovarian hyperstimulation 2- Egg retrieval Is performed by transvaginal ultrasound aspiration under general anaesthesia. The probe is inserted into the vagina with ultrasound guided needle to aspirate the eggs from the follicles, this step usually needs 30 minutes. After 36 hours from taking HCG injection, the patient is timed for oocyte collection. When a patient is brought to the theatre for egg retrieval, the nurse with the embryologist who will do the oocyte collection will confirm that medical notes and patient information are for the same patient. Under ultrasound guidance, the oocytes will be aspirated and flushed into sterile tubes which will be then delivered to the embryologist to check it in Petri dishes under a stereomicroscope. These dishes will be scanned carefully in order to find the oocytes. When an oocyte-cumulus complex (OCC) is found, it will be picked up and all the blood and flushing media will be rinsed off by being washed with special media. At the end of oocyte collection, name of the patient and total number of oocytes will be announced and written on the petri dish containing the oocytes. 3- I n s e m ination/Micromanipulation - The eggs are examined in the IVF lab for quality and maturity, after retrieval they are placed in IVF culture medium, and kept in an incubator. - Sperm are obtained by ejaculation and separated from the semen through the step of “sperm preparation” - In Classical IVF, sperm are placed with the eggs in a dish in an incubator and fertilization is allowed to take place within 18-24 hours after insemination. - In ICSI which is the most commonly used method, a single sperm is directly injected into the egg in an attempt to achieve fertilization. - At Al-Amal, ICSI is performed in approximately 90% of ART cycles, C-IVF in 5% and both techniques are applied in the remaining. ClassicalIVF ICSI technique 4- Fertilization and embryo culture The following day, seeing two pronuclei confirm egg fertilization. The egg is responsible for one pronucleus and the sperm for the other. Around 60% of eggs are fertilized after CIVF and 90% after ICSI. In few cases no fertilization occurs at all. Two days after egg retrieval, 2-4 cell embryos are formed, and progress to 6-8 cells occurs on day 3. By the fifth day, the embryo is expanded and called blastocyst, when it is more than 100 cells with fluid cavity formation. Embryos could be transferred to the uterus at any time between day 2 and 5 after egg collection. Implantation into the endometrium (lining of the uterus) takes 4-7 days after embryo transfer. 2-cell stage embry o at 48 hours 4cellsta ge embry o at 48 hours 8-cell stage embryo at 72 hours 5- Embryo transfer Is a critical step in IVF. Embryos are loaded in a drop of culture media into a catheter which is connected to a syringe. Gently the tip is directed through the cervix and the fluid containing the embryo is injected in the uterine cavity. It is usually a painless procedure; patient may experience mild cramps following this step. Usually no anaesthesia is needed 6- Luteal phase support Luteal support regimens in IVF are important using progesterone. Various routes of administration have been tried. This can be oral, intra muscular and transvaginal. At AlAmal, we use oral and vaginal Progesterone. Oral Progesterone (Duphaston) is given in a dose of 40mg daily. Vaginal progesterone (Cyclogest, Utrogestan) is preferred as it offers several advantages over intramuscular. It is more convenient and acceptable to patients. It does not hurt and it rarely produces allergic reactions. Replacement begins one day after egg retrieval and continues until pregnancy testing (14 days after egg retrieval). If pregnancy is positive its continued for another 8 weeks (12-14 weeks pregnancy). Preimplantaion Genetic Diagnosis (PGD) PGD is a technique that was introduced originally as an alternative to prenatal testing in order to avoid pregnancy termination for couples who are at risk of transmitting some genetic diseases. Two techniques can be used for PGD. Fluorescent in situ hybridization (FISH) and polymerase chain reaction (PCR). Chromosomal abnormalities and genetic mutations which could be ruled out through PGD include trisomy 21 (Downs), balanced translocations, Xlinked diseases (Duchenn’s and Hemophilia) and single gene mutations (Cystic fibrosis, Thalassemia). At Al-Amal, we currently use FISH technique (which was first introduced in our unit in April 2005) for analysing chromosomal abnormalities and aneuploidy screening. This is recommended in couples with poor prognosis regarding ART as advanced maternal age (women over 38), recurrent miscarriages and multiple IVF-ET failure. Another benefit of PGD is identification of the sex of the embryo. This method is usually carried out on day 3 embryos (6-8 cell stage). A cell biopsy is performed (one or two blastomeres are removed), on which we apply the FISH technique. The top quality embryos of the desired sex are transferred back to the uterus. Using this technique, we have 98% accuracy in determining the gender before transfer; however the success rate for the patient to get pregnant remains the same as that of ICSI (35%). Sometimes we may not find any male embryos (XY), percentage of which in our statistical results shows 10% of total embryos. So few ladies may not have ET at the end of IVF-PGD cycle, in which case we advise to repeat the trial as results may differ from one cycle to another. Surgical sperm recovery - In obstructive azoospermia (OA) In OA, sperm retrieval usually succeeds. Facilities to cryopreserve sperm should be available after routine screening for hepatitis B, C and HIV. The procedure is minimally invasive using fine needle. Sperm recovery under local anaesthesia is associated with high patient satisfaction but some men may prefer general anaesthesia. The embryologist should be in the operating area to assess the recovered aspirate or biopsy and inform the surgeon when sufficient viable sperm are available. PESA can collect live sperm enough to cryopreserve in most cases. TESA is done if PESA fails to recover sperm. TESE might be needed if both didn't give enough yield. TESA procedure PESA procedure - In non obstructive azoospermia (NOA) In NOA, spermatogenesis is patchy in distribution and poor. So sperm recovery is uncertain. Sperm recovery should be offered in all cases even if the testes are very small or FSH levels are very high, since no test can confirm or exclude sperm within the testes. This should be clarified to the patient before attempting sperm recovery. Since TESA has 50% chance of recovering sperm in NOA so TESE is usually required. General anaesthesia is used because bilateral incisions and multiple biopsies might be taken. TESE suppresses spermatogenesis for 3-6 months. When ICSI cycles are to be done, TESE should be done after this time to allow the testes to recover. AZFa and AZFb Y-chromosome deletions are poor prognostic factors for successful sperm retrieved. Men with AZFc deletions are more likely to have sperm. The sperms are extracted from the testicular tissue by a surgical procedure under local or general anaesthesia 24 hours before egg retrieval to facilitate sperm recovery (immotile sperm may become active during incubation); however it could also be done on the same day. Multiple biopsies are taken from the testicular tissue which can reach up to 10 from testes. The sperm are extracted, treated in the lab and prepared to inject the eggs by ICSI technique. The remaining sperms will be frozen for further trials. The chance to get sperm in NOA ranges between 50 % depending on several factors like the size of the testes and the value of FSH hormone. TESE procedure - Regarding lab work In most cases of OA, abundant viable sperm are retrieved with enough extra sperm to freeze but in NOA identifying sperms in testicular tissue is a tedious process which might need several hours to find with no extra sperm to freeze. In NOA, post thawed sperm survival is low and the patient is often told to be ready to repeat TESE if necessary. TESE followed by ICSI procedure Freezing system at Al-Amal ART unit Freezing system is an integral part of our IVF programme as it avoids waste of embryos, maximizes the number of conception attempts per eggs retrieved, increases the cumulative pregnancy rate, and reduces the cost of treatment. In addition, it has its advantage in cycles with ovarian hyper stimulation syndrome (OHSS). Slow freezing methods previously used at Al-Amal were replaced by a rapid cooling technique (vitrification), being attractive in its simplicity and ability to eliminate cryoinjury from extra cellular ice formation. It was first introduced into our unit in April 2007 under guidance of Dr Safa Al-Hassani from Germany when a work shop was held at our hospital. It was a successful one with the contribution of most IVF centres in Jordan and others from abroad. Al-Amal results regarding this technique showed high (90%) post-thaw survival rate with successful pregnancies after thawing of vitrified embryos. This method significantly improved our pregnancy results. The first pregnancy achieved from vitrification was in Nov. 2007. Vitrification can be applied on day 2, 3 or 5 embryos. Regarding semen and testicular tissue freezing, we have an efficient Cryopreservation system which is used in different conditions like inability of the husband to be available on the day of egg retrieval, cancer patients where the man gives a sample to be frozen before starting chemotherapy and freezing of sperm retrieved through PESA, TESA, and TESE. Through cryopreservation technique we can keep sperm for many years for future use. Regarding oocyte freezing, it is not applied in our unit. International figures are not promising in this regard. For embryo transfer cycle, the patient is prepared by hormonal replacement protocol using Estradiol valerate starting day 2 of cycle with gradual increase of the dose. When endometrium is ≥ 8mm, Progesterone suppositories are given at 2-5 days (depending on the age of the frozen embryo) before warming of vitrified embryos. For transfer both Estrogen and Progesterone treatment should continue until 12 days after which pregnancy test is done. If negative to be discontinued, menses will follow in 2-3 days, and if positive to continue for another 8 weeks. Implantation enhancing techniques To enhance implantation rate of embryos in certain cases, our ART unit uses up to date techniques that have been effective world wide: - Assisted Hatching (AH) This technique could be done on 2-3 days (4-8 cell) embryos. The embryologist punctures the embryo envelope before transferring it back to the uterus using laser technique. To increase the implantation rate. AH is used in cases of repeated implantation failure, thick zona pellucida, it is also recommended in women above 38 years old. Monochorionic twining is seen more commonly with this technique. - Blastocyst culture (BC); Extended embryo culture was introduced to Al-Amal IVF unit in 1999, we were the first centre in Jordan to use this technique. To get a good success rate with this method, we need the development of a sufficient number of embryos (more than five). Embryos are cultured in favourable circumstances in an incubator until the embryos reach 100-200 cells (blastocyst stage) before transfer. Embryos at this stage have a high ability for implantation in the endometrium. Only one or two BC's should be transferred to avoid complications of multiple pregnancies. Our results showed that in 6% of the cases some embryos may lack the ability to divide (in vitro) with no embryos to transfer to the uterus then the case is cancelled. In a paper published by our team in the main American fertility journal "Fertility & Sterility", a significant increase in implantation rate with this technique was evident while multiple pregnancy rate was reduced. Day 5 embryo at blastocyst stage Complications of IVF 1. Multiple pregnancies; although many infertile couples are keen to have twins or high order pregnancy, we consider multiple pregnancy as a serious complication of IVF. This can be avoided by decreasing the no. of embryos transferred. Multiple pregnancy is highly related to increased pregnancy loss, obstetrical complications (pregnancy induced hypertension, abruptio placenta, gestational diabetes), pre-maturity, neonatal morbidity, also higher risk of congenital abnormalities. 2. Ovarian hyper stimulation syndrome occurs mostly in patients with high ovarian reserve like polycystic ovarian syndrome (PCOS).This condition is preventable by proper evaluation to predict high risk patients and accordingly modification of the stimulating drug doses. Answers to your questions How should the wife be prepared for egg collection? The female is advised to fast after midnight so that her safety is ensured when she goes under general anaesthesia the next day for oocyte retrieval. When can the wife leave the hospital? The wife can leave the hospital two hours after egg collection, the patient may complain of mild side effects like pelvic discomfort and mild bleeding from the vagina. After the procedure, the patient is given analgesic, antibiotic and luteal phase support. What is needed for follow up? The couple is asked to call the ART clinic the next morning after egg collection procedure to be informed about the fertilization results. If fertilization is successful and division starts, then the embryos are ready to be placed into the uterus (2-5 days after the oocyte retrieval procedure). What is the recommended number of embryos and when should we transfer the embryos into the uterus? This step is done after 2-3days or 5 days from oocyte pick up. In our ART unit we advise the return of 2-3 embryos depending upon various factors including patient's age, number of previous failed trials and quality of embryos. However, in case of optimal lab culture conditions, we advise the return of 1-2 embryos at advanced stage (BC). The remaining embryos that are not returned to the uterus and of good quality can be kept frozen according to the couple’s desire. What about embryo freezing? This could be done at any stage i.e. 48 hrs, 72 hrs, 5 day embryos. Freezing of extra good quality embryos is done through a technique called vitrification which has been recently introduced to Al-Amal IVF lab (April 2007). This procedure ensures a 90% survival rate of the embryos after re-warming. This gives the couple a chance of ET without having to go through controlled ovarian hyper stimulation (COH) and oocyte pick up (OPU); this approach is cost effective for the patient and increases cumulative pregnancy rate through a single controlled ovarian hyperstimulation program. How is embryo transfer (ET) done? ET to the uterus is a simple short procedure and the wife can leave the IVF the same day and resume to her normal daily activity. It is important to mention that this step is not painful and no anaesthesia is required. If the patient is living outside Jordan, she can travel the next day with no worries. Our only recommendation is that no intercourse occurs until pregnancy testing. When should the wife start hormonal supplement? From day 2 of egg retrieval, the wife is given hormonal medications (luteal phase support) that assist the implantation of the embryos in the uterus. The patient continues taking them until the date of the pregnancy test. If this showed positive outcome, then the wife will continue for another 6-8 weeks. What are the factors that increase the success rate? It depends mainly on the female age, number and quality of eggs, quality of sperms, number and quality of implanted embryos, health of the uterus, infertility duration and number of previous trials. The success rate can reach 40% for females under 35 years and within the first 3 trials of IVF; this rate decreases with advanced age. It is also evident that success rate starts to drop after the fourth trial. When does pregnancy occur? It needs 10-14 days to detect pregnancy after embryo transfer (ET) and this is according to the stage of implanted embryo. If the patient is in Jordan, she should visit our hospital for a blood pregnancy test, while if abroad, she is requested to inform our unit about the result. What is the rate of aborting or developing congenital anomalies? It is same rate as that of a normal pregnancy i.e. 15% and 1-2% respectively.