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Fertility Treatment Options

Fertility Treatment Options

Fertility Treatment Options: What Are Infertility Treatments?

 

 

Following detailed fertility investigation of the male tubal and ovarian factors, patient and her reproductive endocrinologist decide together on the optimal fertility treatment options.

Factors to consider in selecting the best fertility treatment options include:

Sperm source

  1. Is there a male partner: if so what is the ejaculate volume, sperm concentration, motility and shape? if >10 million moving sperm then pregnancy through intercourse or IUI is possible. Lower numbers indicates IVF or ICSI. If azospermia (no sperm in the ejaculate) then surgical sperm retrieval may be needed (TESE) or donor sperm can be used.
  2. If there is no male partner: anonymous or known donor sperm is used

Tubal Factor

  1. Open fallopian tubes allow for natural conception or IUI.
  2. Blocked fallopian tubes require IVF. Sometimes tubes can be fixed using tubal surgery.
  3. Blocked and dilated fallopian tubes (Hydrosalpinx) require surgical removal of the dilated tubes followed by IVF. Dilated tubes are very difficult to fix and can leak fluid into the uterine cavity and prevent implantation of the embryo.

Ovarian Factor

  1. Women who do not ovulate due to polycystic ovary syndrome  (PCOS): ovulation can be induced using oral medications (clomid or letrozole) or injection medications  (gonadotropins). This is usually combined with IUI.
  2. Women who do not ovulate due to defect in the master gland in the brain (Hypothalamic amenorrhea): ovulation can be induced using injection medications  (gonadotropins). This is usually combined with IUI.
  3. Women diminished ovarian reserve and unexplained (idiopathic) infertility commonly have lower quality eggs and may benefit from inducing multiple ovulation followed by IUI or IVF, to increase the chance that one of the eggs is healthy (chromosomally normal).

Donor Eggs

  1. Donor eggs are needed in women with low egg reserve that fail multiple IVF cycles after menopause or those who carry some genetic abnormalities.
  2. Donor eggs can enable same sex male couples parent a child (together with a gestational carrier).

Gestational carriers

  1. Gestational carriers enable women to parent a child if the uterus is absent or was removed due to a disease e.g endometrial cancer or if the lining of the uterus is damaged e.g intrauterine scarring due to prior scrapping.
  2. Gestational carrier enable women who cannot get pregnant to parent a child e.g history of breast cancer
  3. Gestational carriers enable same sex male couples to parent a child.

Genetic analysis of the eggs or embryos (PGD)

  1. Women and men with risk of conceiving a child with a specific genetic disorder e.g cystic fibrosis, sickle cell anemia should consider testing their embryos before transfer into the uterus (PGD)
  2. PGD can also be used for selecting the sex of the baby for family balancing.
  3. PGD can be used to test the chromosomes of the embryo to increase the chance for pregnancy in women select women but its efficacy for that purpose is still being investigated.

Fertility Preservation

  1. Women at risk for diminished fertility due to a medical problem or treatment e.g breast cancer can freeze their eggs or embryos to use later
  2. Men at risk for azospermia due to genetic factors, cancer and cancer treatment can freeze sperm for use later
  3. Many other techniques for fertility preservation can also be applied to adults and children to preserve reproductive organs and tissue.

 

Many fertility treatment choices exist to help women and men conceive a child. One or more of these methods can be tailored to each

i. individual circumstances:

singles women or men,

heterosexual couples or

same sex couples.

ii. reproductive aim:

wants to get pregnant now versus later,

wants one child only or accepts twins,

wants to conceive a child of certain sex,

will use own uterus or a gestational carrier,

will use own gametes- sperm or egg or donor gametes.

 

To learn more about  fertility treatment options please visit nycivf.org

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Gender Selection What you Need to Know

Gender Selection What you Need to Know

 Gender Selection what you need to know

A fascinating topic that stirs discussions on both sides. Selecting the sex of the baby, boy or girl, is an additional procedure that can be combined with IVF, for specific indications. A male baby is the result of fertilization of an egg (X chromosome) with a Y chromosome bearing sperm. Female baby results from fertilization of the egg with an X bearing sperm.

Indication for Gender (Sex) Selection

The World Health Organization defines the indication for sex selection into

  • Medical reasons—such as preventing the birth of children affected or at risk of X-linked disorders.
  • Family balancing—where couples choose to have a child of one sex because they already have one or more children of the other sex.
  • Gender preference— in favor of one sex often male offspring stemming from cultural, social, and economic bias in favor of male children and as a result of policies requiring couples to limit reproduction to one child. Biases vary among different communities e.g Germans has no preference, American men may prefer biological sons and American women has no preference (Gallup 2011) and both prefer adopted daughters.

Ethics of Gender Selection

Many European countries and Canada and Asian countries have banned sex selection in cases unrelated to any health purpose. The American Society of Reproductive Medicine (ASRM) has allowed pre-fertilization sex selection through sperm sorting and IUI and discouraged the use of IVF and PGD solely for sex selection. Sperm sorting is not available in the US as it is not approved by FDA.

The bio-ethical concerns related to sex selection include:

  1. Healthy fertile couples choosing IVF for the sole reason of sex selection. An alternative argument is that the risk of pregnancy outweighs the risk of IVF and this becomes relevant in women seeking to limit the number of pregnancies and babies to two of opposite sex.
  2. Future imbalance of population and changing the sex ratio. This is unlikely through IVF as only 1% of world population are born following assisted reproduction. Sex ratio imbalance does occur through sex-selective abortion.

Criteria to Consider Couples for Sex Selection Procedures

To address some ethical and safety concerns related to sex (gender) selection using IVF + PGD, couples requesting sex selection should fulfill minimal criteria

  1. IVF indicated for other fertility factors
  2. Not in the first cycle for the first baby except for genetic reason
  3. In subsequent cycles or selecting for the under-represented gender for family balancing only

Sperm sorting is not available in The US (not FDA approved).

Methods of Sex Selection

The choice of sex selection method is dependent on availability, cost and accuracy. The majority of couples do not merely prefer certain sex they specifically desire a boy or a girl. For couples interested in a certain sex only, methods of gender selection should be very accurate, close to 99%.

Pre-Fertilization

MicroSort

Not available for use in the US.  Sperm is sorted and used for intrauterine insemination (IUI). Sperm carrying an X chromosome have approximately 2.8% more DNA material than sperm carrying a Y chromosome. This is the basis of separating X and Y sperm. Microsort requires an excellent sperm sample of 140 million sperm and 50% motility for IUI and 70 million sperm and 50% motility for IVF. Studies reported that 91% of those attempting for a girl do conceive a girl, while the success rates for sex selection and boys using MicroSort® is lower at 74%. The pregnancy rate after ovarian stimulation and IUI is approximately 10%. Thus the success rate for getting pregnant with the desired sex using this method is 7.5 to 9% per attempt or less.

Other pre-fertilization methods

The Shettles Method is based on the fact that male and female sperm travel and survive in the reproductive tract for varying amounts of time. So you time intercourse about 12 hours prior to ovulation for a boy and several days before ovulation for a girl. There is no proof that this method is effective.

Ericsson Albumin Method. Sperm is filtered through albumin and used for IUI. In addition for a girl, Clomid is used since it has been shown to increase the number of girls. There is no scientific proof that this method is effective.

Post-Fertilization (Pre-embryo transfer)

IVF + Pre-Implantation Genetic Diagnosis (PGD). The ovary is stimulated and eggs are harvested using transvaginal ultrasound, under sedation. A sperm is injected in each egg. On day three, when the resulting embryos are about eight cell each, one cell is biopsied and tested to X and Y chromosome. Laser beam is sued to make a hole in the egg shell and one cell is sucked out. This can also accomplished after biopsy of blastocyst – trophoectoderm biopsy (day 5). The desired embryo(s) are transferred into the uterus. This method is over 99% accurate. We, in addition sort the sperm used for fertilization and freeze the desired sorted sperm and use it for fertilization of eggs. The aim is to enrich for the desired sperm (X or Y) to increase the chance of getting many embryos of the desired sex.

PGD can also be performed on frozen thawed embryos for couples that has frozen embryos and coming for frozen embryo transfer and desire sex selection for family balancing.

The biopsy material can also be tested for all the chromosomes or for certain gene. Imposing more criteria on the embryos will certainly make fewer embryos available for transfer.

If IVF cycle pregnancy rate is 35%, then the chance for achieving pregnancy with the desired sex is approximately 35% or less if that sex is found in the embryos

Considerations for sex selection using IVF + PGD

  1. Ovarian reserve: In gender selection cycles, the embryos available for transfer are fewer than in IVF cycles without sex selection. Each embryo has to be of good quality in addition to being of the desired sex to be considered for transfer onto the uterus. Women with diminished egg number and quality will have small number of embryos available for testing and are less likely to realize good quality embryos of the desired sex than women with good reserve and good egg quality. Ovarian reserve is directly related to the mother’s age.
  2. Inconclusive result. Sometimes, the embryo sex cannot be determined due to degeneration of DNA material in the cell. This minimized by appropriate fixation of the biopsy in expert hand.
  3. The desired sex could be under-represented in the embryos , by chance or due to other factors. One of the pre-fertilization methods can be used to enrich the sperm sample for the desired sex

How Do you Know if Gender Selection Worked?

After conception, there are many ways you can confirm success of gender selection 

  1. Non invasive perinatal testing (NIPT): a blood test that reports on chromosomes 21, 18, 13, X and Y using free fetal DNA floating in the mother circulation
  2. Ultrasound at 18 weeks or after can detect the external genitalia of the baby.
  3. CVS or amniocentesis these are invasive methods to test the chromosomes of the baby. They are the most accurate. Being invasive, they should only be used if indicated, not just to confirm sex.\

To learn more about gender selection please visit nycivf.org

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Sex Selection

Sex Selection

Sex selection is considered for one of three reasons:

1. Avoiding sex related genetic disorders. These are genes mostly carried on the X chromosomes and affect boys more than girls since they have one X chromosome e.g hemophilia

2. Family balancing: couples that have children of one sex and desire a child of the opposite sex

1941-2011 Trend: Suppose you could only have one child. Would you prefer that it be a boy or a girl?

Gender Selection, Boy or a Girl

3. Preference: some prefer a child of certain sex due to social factors. Recent poll in The UK  indicates that when 2,129 recently married couples were surveyed, found that 47% admitted that they would prefer to have a son first, with the majority citing practical reasons like boys being “less hard work”. Only 21% of respondents said they would like to have a daughter as their firstborn, and 32% reported having no preference either way. Couples who wanted to have a daughter first see older girls as ‘better role models’ to their younger siblings. In the US a Gallup poll yielded similar answers by American parents, especially men, since 1940s. American women do not have a proportionate preference for girls. American women show essentially no preference either way: 31% say they would prefer a boy and 33% would prefer a girl. More recent trends indicates that American couples prefer girls.

In contrast couples on a waiting list for adoption prefer girls both in the US and India. There is also some evidence that sexual orientation may influence that preference. Gay men are more likely to have a gender preference for their adopted child whereas heterosexual men are the least likely. Couples in heterosexual relationships are more likely to prefer girls than people in same-gender relationships.

The preference is also influenced by geography and politics. The official family planning policy in China, applied to large portions of Chinese, allow only for one child and does not allow sex selection. In the US many couples desire to limit the number of children to 2. If the first child is of one sex they desire the second child to be of the opposite sex

 

How is the sex of the embryo determined?

Older methods of selecting sex through change in the position or timing of intercourse or sperm sorting are not accurate and are not suitable for sex selection in modern couples seeking a specific sex (the other sex maybe conceived in 30% or more of couples). Modern sex selection depends on genetics. After stimulation of the ovaries, egg retrieval and fertilization, one or few cells from the embryo is obtained. The cells are analysed for each embryo for the X and Y chromosome. Results are obtained and are accurate >99% of the time.

After identification of the X and Y chromosomes, the desired embryo is transferred into the uterus. The embryo that carries the correct chromosome, should survive and be of good quality. Sex selection is more likely to succeed in women with good ovarian reserve, producing a good number of eggs. The larger the number of embryos available for testing, the more likely a healthy embryo of the desired sex is available for transfer.

Learn more about gender selection.

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