✓ First level medically assisted procreation techniques

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For some couples, finding a child can be a far from easy path and become a source of stress and frustration. If the pregnancy you want doesn't come later 12-24 months unprotected relationships are referred to as infertility. A problem that according to the World Health Organization concerns about the 15% of couples. When conception does not occur naturally, one can contact a medically assisted procreation center (PMA) to carry out checks and, if necessary, start a path of assisted procreation with first level techniques. The important thing is to try to remain calm and not wait too long before asking for a medical consultation and making all the necessary investigations.

First level medically assisted procreation techniques

Medically assisted procreation, also commonly called "artificial fertilization", is the set of techniques used to help procreation in a couple in which spontaneous conception is difficult or even impossible. MAP makes use of different techniques that are articulated on several levels (1st, 2nd and 3rd). "In the case of first-level techniques, it's about simple methods and not very invasive, characterized by the fact that fertilization takes place inside the female genital system - says the , Head of the Center for Medically Assisted Procreation at the Obstetric and Gynecological Clinic, University of Pavia - I am intracorporeal techniques where the physiology of reproduction is respected ".

Before embarking on a path of this type it is necessary to follow a diagnostic procedure first of all evaluating the clinical history of both partners and then investigating the causes of any infertility. In our country, the guidelines of law 40/2004 envisage the use primarily of the simpler and less invasive therapeutic options such as first-level MAP techniques which aim to bring together the spermatozoa and the oocyte in vivo.

With the term "first level techniques" we mean:

intrauterine insemination;
monitoring of ovulation;
induction of ovulation with or without intrauterine insemination.

Let's see what it is.

Monitoring of ovulation

Halfway between diagnosis and therapy, ovulation monitoring consists in following, through ultrasound scans, the growth of the follicle, that is the small chest in the ovaries inside which an egg matures every month that can be fertilized. It is used to check whether ovulation occurs or not, and also to direct the couple towards the best days (fertile period) in which to have sexual intercourse, thus increasing the likelihood of conceiving a child.

HOW TO DO IT

The woman undergoes transvaginal ultrasound scans within a few days of each other in order to identify the dominant follicle, that is, the one that will grow up to ovulation. The follicle is then measured and based on the size reached it is possible to predict when ovulation will occur and when it is therefore preferable to have sexual intercourse. In addition to ultrasounds, i hormone dosages, through blood sampling, to more accurately follow the follicular development.

Ovulation monitoring can also be accompanied by ovulation induction.

The induction of ovulation

Induction of ovulation is one of the most common pharmacological techniques in the treatment of infertility, particularly in cases where the woman has anovulatory cycles, that is, without ovulation, or with irregular ovulation. This practice can be considered only if there are no problems related to tubal closure, and in the absence of important factors of male infertility. The induction of ovulation allows the follicles to mature and ovulate regularly.

HOW TO DO IT

They are administered to the patient low doses of drugs such as Clomiphene citrate or Gonadotropins which stimulate the activity of the ovaries and the production of follicles. The drugs are selected and dosed on the basis of a series of parameters and their effect is controlled both through a series of ultrasound scans performed within a few days of each other, and with hormonal dosages (estradiol).

If the doses are too low there is a risk of not having any follicles, if too high there is a risk of multiple pregnancies, therefore during the treatment the follicular growth is followed carefully. "We try to make a stimulation as close as possible to what normally happens inside the body. Then this technique must be combined with targeted sexual intercourse or intrauterine insemination at the moment of ovulation which is induced with a specific trigger ", explains Prof. Nappi.

Read also: Superovulation: record mom gives birth to twins for the second time

Intrauterine Insemination - IUI

Intrauterine insemination consists in the introduction of seminal fluid inside the uterine cavity of the woman to facilitate the meeting between the spermatozoa and the oocyte. According to the guidelines of the Ministry of Health, this practice is indicated in cases of:

bad ovulation (endocrinological infertility);
unexplained infertility;
repeated pregnancy induction failures with stimulation of ovulation and targeted intercourse;
mild endometriosis, that is, when the disease has not affected the tubes;
problems during the passage of spermatozoa in the cervical mucus;
prevention of the risk of transmission of infectious diseases (HIV) in serodiscordant couples.

The path of insemination can also be considered in mild cases oligoasthenospermia (quantity, motility or shape of the spermatozoa below the norm) because before insemination the seminal fluid is treated in order to improve its quality.

HOW TO DO IT

Intrauterine insemination can be performed by exploiting the spontaneous ovulation of the woman or by inducing ovulation with drugs to obtain multiple follicular growth in order to increase the chances of conceiving a child. THE drugs the main ones that are used are Clomiphene citrate or injectable gonadotropins and their effect on follicular growth, as we have seen before, must be monitored through a series of ultrasounds and with hormonal dosages.

A few hours before insemination, the male partner must provide a semen sampleafter a minimum of two and a maximum of five days of sexual abstinence. The sample is collected in a sterile container and analyzed to ensure that there is an adequate number of motile spermatozoa among which to select the best ones. "At this point, with the help of a small catheter that is inserted inside the uterus, we introduce, thanks to a syringe, the seminal fluid of the partner or a donor" explains the gynecologist.

For intrauterine insemination, in fact, thanks to a revision of Law 40, which regulates the practices of medically assisted procreation in the country, it is now possible to use seminal fluid from a DONORS. In this case we speak of heterologous insemination, as opposed to the homologous one in which a sperm sample from the partner is used.

After insemination

Once the procedure is completed, the woman can safely return to her usual routine by resuming her normal activities. After intrauterine insemination, the following may occur:

leucorrhea, i.e. the loss of vaginal secretions due to the thinning of the cervical mucus;
abdominal cramps;
spotting or minor bleeding.

One may be prescribed to the woman in the following days hormone therapy to help implant the embryo and two weeks after intrauterine insemination, a pregnancy test must be performed. The success rates for this practice vary a lot.

Le complications they are rare, but they cannot be completely excluded and among these we find:

upper genital tract infection;
ectopic pregnancy;
ovarian hyperstimulation syndrome (in the case of pharmacological induction of ovulation);
multiple gestation.

The guidelines suggest a maximum of 3/6 cycles of intrauterine insemination after which it will be necessary to consider a second level medically assisted procreation technique.

Read also: IUI intrauterine insemination: what it is and how it works

What the law says in Del Paese

According to the guidelines of law 40/2004 "the use of medically assisted procreation techniques is allowed only when it is ascertained that it is impossible to otherwise remove the impeding causes of procreation and is in any case limited to documented cases of unexplained sterility or infertility from a medical document, as well as to cases of sterility or infertility from a cause ascertained and certified by a medical document ". Initially, as mentioned a few lines above, the law provides for the use in the first instance of the simpler and less invasive therapeutic options such as the first level MAP techniques to then move on to second or third level methods.

The guidelines also provide that before starting any treatment, aaccurate medical history and a proper physical examination of the infertile / sterile couple. The benefit-risk ratio with particular reference to obstetric complications, potential neonatological relapses and potential risks to women's health.

Finally, since 2022, some revisions have been made to the law on MAP and the Constitutional Court has revoked the ban on heterologous fertilization, i.e. fertilization in which one or both gametes come from a donor outside the couple.

Here is the list of all authorized centers that apply MAP techniques divided by region.

To conclude, as Prof. Nappi is keen to point out, "it is important not to be afraid and not to think" they will make me a test tube baby "because sometimes the appropriate treatments are enough to solve some problems related to fertility".

Read also: Heterologous fertilization: to be a father, it is not the genes that count, but love and closeness

Sources used:

Advice from, Head of the Center for Medically Assisted Procreation at the Obstetric and Gynecological Clinic, University of Pavia
Ministry of Health, Guidelines containing the indications of medically assisted procreation procedures and techniques, 2022
Ministry of Health, Regulations on medically assisted procreation (Law 19 February 2004, n.40) TAG: