✓ Second level medically assisted procreation techniques

SECOND LEVEL TECHNIQUES

- IVF

- ICSI

All second-level MAP techniques (the most used are Fivet, Icsi) include a series of preliminary tests to exclude diseases that may interfere: among others, blood group, karyotype, cystic fibrosis screening, hepatitis B and C, HIV ; for her also pelvic and breast ultrasound, hormonal assays, pap tests, vaginal swabs for the detection of chlamydia, mycoplasma and trichomonas, antibodies to rubella, toxoplasmosis, cytomegalovirus, herpes; for him spermiogram and urethral swab.

The woman may also be prescribed more invasive tests, such as laparoscopy and hysteroscopy. In Vitro Fertilization with Embryo Transfer (IVF)

For who. IVF is a very widespread technique, which allows to treat various dysfunctions both female and male: for example, endometriosis, bilateral tubal occlusion, lack or altered spermatozoa (low number, poor motility, morphological damage) or male genital alterations that prevent the sperm being emitted with the ejaculate; it is also indicated for idiopathic infertility that has not had results with first level MAP techniques.

An IVF is a complex procedure that lasts about four weeks, in various stages (some may vary according to the therapy established by the doctor.

Ovarian stimulation. Almost always the treatment begins with the intake of drugs (GnRh analogues or GnRh antagonists) that 'rest' the pituitary gland to prevent it from triggering ovulation at a certain point in the cycle, dispersing the follicles before collection.

The ovaries are stimulated (usually with gonadotropins) to produce more follicles at the same time to retrieve more eggs to fertilize. The drug and dose vary depending on how the patient is expected to react to treatment.

The development of the follicles is controlled by means of ultrasound scans and dosages of estradiol (the hormone that increases with the development of the follicles), also to avoid the danger of ovarian hyperstimulation (fortunately a very rare risk that causes enlargement of the ovaries, accumulation of fluid in the abdomen, and possible respiratory, cardiac, liver and kidney complications).

When the follicles are sufficiently developed, a dose of Hcg or Lh is administered to complete their maturation. After about 36 hours there is ovulation and then the egg retrieval.

The pick up. To collect the oocytes, a very thin needle is inserted into the wall of the vagina and, with the guidance of an ultrasound system, the liquid is sucked into the follicles. Only in very rare cases if the ovary cannot be reached otherwise - the pick-up is performed with a small incision in the abdomen (laparoscopy). The collection takes place under local or general anesthesia.

The preparation. The oocytes are examined under a microscope to check the stage of maturation, then placed in culture and incubated for a few hours. In the meantime, the man has to produce a seminal fluid sample: some centers have a semen sample delivered a few days before the pick-up and freeze it.

In cases of azoospermia it is possible to recover the spermatozoa directly from the testicles through surgery (Mesa, Tesa, Tese). The seminal fluid is also examined and subjected to a preparation to recover the most mobile and morphologically normal spermatozoa.

Fertilization. Oocytes and spermatozoa are brought into contact in the culture liquid. If the law does not establish a ceiling, it is possible to fertilize all the oocytes available and then decide how many embryos to transfer to the uterus and how many to freeze. After being fertilized the oocytes are put back into culture, and after about 20 hours it is checked whether there has been fertilization.

The transfer. Embryos can be transferred to the uterus at various stages of their development: usually on the second or third day after the pick-up. Beyond any legal limits, the choice of the number of embryos varies according to the case (state of health, age of the woman ...): most centers choose to transfer a maximum of 3 embryos, reducing them to 2 if the woman is very young or if the quality of the embryos is very good and increasing them to 4 if the woman is not young, the embryos are not of good quality, there have already been previous IVF failures. The embryos are transferred by means of a catheter inserted in the cervical canal up to the uterus.

If the law allows it, the frozen embryos can be used if the IVF cycle fails and the woman does not need to undergo further hormonal stimulation. Intracytoplasmic sperm injection (ICSI)

For who. Icsi is indicated in cases of severe male infertility, because it gives the possibility of obtaining fertilization with only one sperm for each oocyte (in IVF it takes at least 200 thousand): oligospermia (sperm concentration less than 5 million / ml), teratospermia ( with a percentage of spermatozoa with normal shape lower than 7-8 percent) and asthenospermia (sperm motility lower than 10 percent), and even if there are no spermatozoa in the seminal fluid and it is necessary to take them directly from the epididymis or the testicle (with called Mesa, Tesa and Tesi, see).

ICSI is also used when there are few oocytes or if IVF has not been successful. How. ICSI is identical to IVF, except in the way fertilization occurs: while in IVF the oocyte and the spermatozoa are brought into contact in the culture fluid and left to "do it all by themselves", in ICSI a single sperm is injected with a microinjection carried out with the help of a high-magnification microscope inside each oocyte.

How. In IVF there is ovarian stimulation, the use of mature oocytes and the preparation of seminal fluid before fertilization, to which only the morphologically best spermatozoa are destined.

(Scientific advice by, gynecologist and endocrinologist of the Maugeri Foundation -)