Assisted Reproductive Technologies:

Assisted reproductive technologies (ART) are medical techniques that help couples conceive. These procedures involve either:

• A coupleâ ' s own eggs or sperm
• Donor eggs, sperm, or embryos

Fertilization may occur either in the laboratory or in the uterus. In the U.S., the number of live birth deliveries from ART has dramatically increased in the last decade. Nearly 40,000 live births (deliveries of one or more infants) occur in the U.S. each year using assisted reproductive technologies.

Technically, the term ART refers only to fertility treatments, such as in vitro fertilization (IVF) and its variants, which handle both egg and sperm.

Intrauterine Insemination (IUI)

Artificial insemination (AI) is the least complex of fertility procedures and is often tried first in uncomplicated cases of infertility. AI either involves placing the sperm directly in the cervix (called intracervical insemination) or into the uterus (called intrauterine insemination, or IUI). IUI is the standard AI procedure. IUI is less expensive and poses less risk for multiple births than the more advanced assisted reproductive technologies (ART), such as in vitro fertilization.

It is useful under the following circumstances:

• When the woman's cervical mucus is unreceptive
• When donor sperm are required
• If the man's sperm count is very low
• When unexplained infertility exists in both partners

Those in whom IUI fails, couples with specific fertility defects, or older women may be candidates for more advanced reproductive technologies.

The Artificial Insemination Procedure. The IUI procedure is as follows:

• A woman usually (but not always) takes fertility drugs in advance.
• The man must produce sperm at the time the woman is ovulating.
• The sperm are subjected to certain so-called "washing" procedures. They are then inserted into the uterine cavity through a long, thin catheter.

The administration of fertility drugs and sperm retrieval is timed so that the process can coincide with ovulation.

In Vitro Fertilization (IVF)

Most assisted reproductive technologies procedures use in vitro fertilization (IVF). An in vitro procedure is one that is performed in the laboratory. Advances in these procedures have dramatically increased the rate of live births. IVF can be performed with a womanâ ' s own eggs and sperm, or with donor eggs and sperm.

In the past, IVF was used mainly to treat women with damaged fallopian tubes. It is now used as a fertility treatment for cases when the woman has endometriosis, the man has fertility problems, or the cause of a coupleâ ' s infertility is unexplained.

A standard IVF cycle is divided into the following steps:

• Ovarian Stimulation. Ovarian-stimulating drugs, such as clomiphene, are used to prompt the ovaries to produce multiple eggs. About 8-14 days later, another type of drug (usually human chorionic gonadotropin [hCG]) is given to foster egg maturation.
• Egg Retrieval. About 34 - 36 hours after the hCG injection, the eggs are retrieved before ovulation begins. A cycle may be canceled at this stage if not enough follicles are produced or if there is a risk of ovarian hyperstimulation syndrome (see Medications section).To retrieve the eggs, the doctor inserts an ultrasound-guided probe into the vagina. A needle is then used to drain the liquid from the follicles, and several eggs are retrieved.
• Fertilization and Embryo Culture. The doctor will examine the eggs to evaluate their quality and maturity. Selected eggs are placed in a culture in the laboratory and transferred to an incubator. They are then inseminated with sperm, either by placing sperm together with the egg or injecting a single sperm into the egg (see ICSI section below).
• Embryo Transfer and Cryopreservation. One or more embryos are implanted in the womanâ ' s uterus 1 - 6 days after egg retrieval. The doctor will discuss with the patient the appropriate number of embryos to be implanted. Excess embryos may be frozen and saved for future use. (The live birth rate is usually lower with cryopreserved embryos.) It takes about 2 weeks to determine if pregnancy has been achieved.

Other IVF Procedures. About 1 - 2% of IVF procedures use adaptations called gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT), which transfers the gametes (egg and sperm) into a womenâ ' s fallopian tube rather than her uterus.. In GIFT, the egg is harvested as with IVF and mixed with sperm, and is then injected into the womanâ ' s fallopian tube where fertilization occurs. In ZIFT, the egg is fertilized with sperm in the laboratory before being transferred to the fallopian tube. For GIFT and ZIFT a woman must have at least one functioning fallopian tube.

Success Rates. Not all IVF cycles result in pregnancy, and not all IVF-achieved pregnancies result in live births. According to the most recent statistics from the U.S. Centers for Disease Control (CDC), 34% of ART cycles (mostly IVF) led to pregnancy, but only 28% resulted in a live birth of one or more babies. Success rates provided by fertility clinics are not always a reliable indicator as they depend on many variables, including the age of the patients.

Data indicate that the chances of IVF resulting in live birth are about:

• 40% for women younger than age 35
• 30% for women ages 35 - 37
• 20% for women ages 38 - 40
• 10% for women ages 41 - 42

Some women try acupuncture during an IVF cycle to increase their chances for pregnancy success. While acupuncture is not harmful, there is no conclusive evidence that it boosts success rates.

Complications. Data have been conflicting on whether IVF increases the risk for genetic abnormalities and birth defects. In general, the overall risks for birth defects appear to be small.

The main risk of IVF is the consequences of multiple pregnancies. Multiple pregnancies increase the risks for a mother and her babies. In particular, there is increased risk for premature delivery and low birth weight. These factors can cause heart and lung problems and developmental disabilities in children.

Intracytoplasmic Sperm Injection (ICSI)

Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technology used for couples when male infertility is the main problem. It involves injecting a single sperm into an egg obtained from in vitro fertilization (IVF). The procedure is very simple:

• A tiny glass tube (called a holding pipet) stabilizes the egg.
• A second glass tube (called the injection pipet) is used to penetrate the egg's membrane and deposit a single sperm into the egg.
• The egg is released into a drop of cultured medium.
• If fertilized, the egg is allowed to develop for 1 - 2 days, then it is either frozen or implanted.

The greatest concern with this procedure has been whether it increases the risk for birth defects. Many, but not all, studies have reported no higher risks of birth defects in children born using ICSI procedures. However, if the fatherâ ' s infertility was due to genetic issues, this genetic defect may be passed on to male children conceived through ICSI.

Another concern has been whether the ICSI procedure is being overused. ICSI use has increased 5-fold over the past decade, even though the proportion of men receiving treatment for male infertility has remained the same. Some doctors recommend ICSI for women who have failed prior IVF attempts or who have few or poor-quality eggs, even if their male partners have normal semen measurements. According to the Society for Assisted Reproductive Technology, there is little evidence that ICSI helps improve pregnancy success for couples who do not have a problem with male factor infertility.