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Answers to doubts about assisted reproduction:

What is infertility and sterility?

Technically, these words are not synonymous as there is a difference between infertility and sterility depending on how the poblem arises.

Sterility:when a couple has maintained unprotected sexual intercourse for one year without getting pregnant.

Infertility: describes a situation where a couple achieves pregnancy, but it does not reach full term and a healthy baby.

Are fertility problems very frequent?

Approximately, one in ten couples during their fertile age have fertility problems. Nowadays, around 600.000 - 800.000 couples in Spain suffer fertility problems.

What can cause fertility problems?

Social problems, so called because they can arise from delaying maternity past the most fertile age or from the stress related to modern life. Of course, there is a wide variety of medical reasons, whether male or female related or due to a mixed factor (both members of the couple). Also, to this day, there is a 20% of fertility problems that are still undiagnosed.

Are there mental factors that trigger fertility problems?

The influence of emotional disorders on human fertility is still not clearly determined. It is true, though, that stress associated with reproduction must be treated because it affects the quality of life of the couple and in turn, their ability to face fertility treatments.

Can age affect a woman's fertility?

The ideal biological age for a woman to conceive is between twenty-five to thirty years. Today, however, women decide to have children past these ages due mostly to the insertion of the woman in the professional world. As from thirty-five years of age, female fertility decreases considerably and deteriorates because the ovarian reserve declines physiologically and runs out to the point that the possibilities of getting pregnant after 45 years of age are remote.

Do fertility problems have a male or female origin?

The studies on the population show that the responsibility for the fertility problems is shared between the sexes. Forty per cent are male related: (alterations in semen quality, genetic alterations, testicular alterations, seminal duct obstruction, prostatic problems, ejaculation or erection problems, etc.). On the other hand, another 40% are female related: low ovarian reserve, endometriosis, malformations in the fallopian tubes or the uterus, early menopause, endocrine disorders, etc.). The remaining 20% belongs to a mixed factor, that is, both members of the couple are responsible for the fertility problem they suffer.

Indepently of the origin of the problem (male or female), fertility must be treated jointly, without imputing blame and be tackled with the same interest by both members of the couple.

Is there a real decrease in fertility nowadays?

There are some studies that indicate that semen quality has worsened with lower sperm count and motility and attribute this problem to environmental contamination. However, it is also clear that women become interested in maternity at a more advanced age. On the other hand, fertility treatments are now requested to cater for the need of the new family models, like single mothers or same sex couples who also wish to experiment maternity or in cases where the couple wants to become parents again some years after surgical sterilization (vasectomy or fallopian tube ligation).

How do I calculate the fertile days in a menstrual cycle?

Ovulation or female fertile period in the woman occurs somewhere in the middle of each cycle, around the 14th day as long as the cycle is regular, that its, 28 days long. If the cycles are irregular, you should consult with your gynecologist to clarify which days are more fertile in each case.

How often should sexual intercourse be maintained to get pregnant?

Within the fertile period of the woman, 2-3 intercourses are advised or as many as desired by the couple without getting obsessed.

Is there a legal age limit to become parents?

There is no legal age limit for a couple to try to conceive naturally. But when it comes to fertility treatments, the law establishes in a not very clearly way that these techniques should be applied until the woman presents good psychological and physical health. However, the medical community sets this age at 50 years in the woman, considering this a reasonable limit after which it is not advisable to undergo pregnancy.

Is there a solution in most of the cases?

Thanks to the current techniques applied, we can offer a solution to 90% of couples that come to us for a solution to their fertility problem.

When should a consultation to the gynecologist specialized in fertility be made?

In general, more than one year maintaining unprotected sex without getting pregnant should be a hint of a possible problem and a professional consultation can help to determine the cause.

How is a semen sample obtained and subtmitted to the lab?

The semen sample should be obtained through masturbation and handed over in a sterile container. A 2 to 7-day sexual abstinence should be maintained. It is important that no more than one hour passes between producing the sample and handing it over to the lab for examination. To help in this aspect, Embriogyn has private facilities specially adapted to use when necessary.

Can a condom be used for sample collection?

No, because conventional condoms have spermicides. However, there are special condoms free from spermicides.

Is only one sperm analysis enough?

Normally, a minimum of two samples should be analyzed to confirm diagnosis because there are several factors with an impact on seminogram results: the inherent variation in sperm production, sexual abstinence period, fever, use of medication, etc.

Can male fertility be known through a sperm analysis?

A sperm analysis can reveal whether a possible cause of sterility is the male factor. However, this does not mean that a normal seminogram is a sure indicator of male fertility. Additionally, some fertility issues that are male related may not show in a sperm analysis.

What shall we do if we have a doubt or problem during treatment?

Embriogyn has an emergency telephone line for patients to call and speak directly to the doctors to address any doubt or problem that may arise.

Is the catheter test needed prior to beginning fertility treatment?

A catheter test is very important prior to insemination or embryo transfer procedures because it provides great help on the day the procedure is performed. It is necessary to be aware of possible difficulties that may come up during insemination or embryo transfer in advance. We have to know the direction and length of the cervical canal to choose the most adequate catheter for each patient.

Is it necessary to sign a consent prior to undergoing fertillity treatment?

Yes, it is. This is a legal requirement. It implies that information has been given regarding the medical, biologycal, legal, ethical and economic aspects and that this information has been understood and accepted before beginning the treatment in question.

What is a follicle?

It is a structure of the ovary where the female reproductive cell -the egg- develops. During the first days of the menstrual cycle, the follicle develops until the 14th day when the follicle ruptures causing the ococyte to be released into the fallopian tubes.

Can a fertility treatment be done without undergoing ovarian stimulation?

Yes, but the chances of getting pregnant are lower in comparison to stimulated cycles. These are the so called “natural cycles” which can be a good alternative for example for women undergoing artificial insemination who want to avoid the risk of a multiple pregnancy.

What is implantation?

It is the process by which the embryo adheres to the internal wall of the uterus (the endometrium) and penetrates inside this wall to continue its development. Implantantion occurs when the embryo is in the blastocyst stage, around 6 or 7 days after its formation, approximately on the 21st day of the menstrual cycle.

Do all the embryos implant?

No, they don’t. The human species is naturally subfertile. This means that a high proportion of the embryos produced are not endowed with the capacity to develop and produce pregnancy. Because of this aspect of nature, doubts may arise at the moment of deciding on the number of embryos to transfer in Invitro Fertilization treatment. A consensus should be reached between patients and doctors according to the characteristics of each particular case and the quality of the embryos attained whilst trying to minimize the risk of a multiple pregnancy and keeping the desired pregnancy rates.

Preliminary steps to assisted reproduction treatments

It is important to receive complete information related to the process. Our advise is:

A meeting with the gynecologist specialized in Sterility who will explain the process to follow, the medication plan, the days were rest is advised, the results and the possible risks derived from the application of the technique.

If the treatment to be done is In-vitro Fertilization, , we also advise a meeting with the biologysts who will describe and explain the work done in the IVF lab and the techniques that will be used in the consulted case, as well as legal information related to IVF.

What is a “blighted ovum”?

Abortion is the spontaneous termination of pregnancy before the foetus reaches viable gestational age (before 22 weeks or a weigh below 500 grams).

In the third part of the spontaneous abortions happening before the eighth week nor yok sac or embryo are visible. This is known as blighted ovum or anembryonic gestation.

Probably, the most frequent cause is a chromosomal abnormality. That is, an abnormal genetic load in the embryo deems it incompatible with life and in the case of a blighted ovum, this incompatibility stops the development of the embryo. There may be other causes of immunological or anatomic origin, thrombophilias, etc.

This is, after all, a process of natural selection relatively frequent both in human species as well as in many other animal species. Consequently, the occurence of an abortion (or blighted ovum) does not indicate a bad prognosis and it is not necessary to perform studies or additional tests, nor does it imply a possible repetition of an abortion. It therefore has relative importance.

However, things take a different turn after two or more abortions. This will represent a case of infertility, and you would be advised to undergo tests to rule out the most common causes and possibly find a solution.

Is it possible to become parents after a vasectomy?

Vasectomy is the male sterilization procedure consisting of cutting or blocking the vasa deferentia to avoid sperm release on ejaculation.

Infertility derived from previous vasectomy is a frequent problem in human assisted reproduction centers. This happens because some patients undergo vasectomy upon deciding they do not want to have more offspring. However, a subsequent change in personal circumstances (change of partner, new priorities, etc.) can rekindle the desire to have a baby.

There are currently two possible treatments to solve these cases:

1) Invitro fertilization (IVF) with intracytoplasmatic injection (ICSI) of sperm retrieved from the testicle, epididymus or vasa deferentia, and

2) Microsurgical repair of the seminal cord (epididymostomy and vasovasostomy).

The choice of any of these two options is determined by female age (over or under 35 years) and the prospect of more than one pregnancy in the future.

1) Invitro fertilization (IVF) with intracytoplasmatic injection (ICSI) of sperm retrieved from the testicle, epididymus or vasa deferentia.

Patients who prefer to avoid reconnection of the ducts can resort to assisted reproduction techniques (In Vitro Fertilization – ICSI). These cases entail the previous surgical recovery of sperm from the testicle, the epididymus or the vasa deferentia.

If female age exceeds 35 years or the couple wants to have a single child or if they want immediate pregnancy, the treatment of choice would still be the surgical recovery of sperm plus IVF-ICSI.

In these cases, men should undergo:

- Epididymal aspiration or testicular biopsy. It is a very simple procedure, generally requiring local anesthesia. Subsequently, the sperm are recovered in the lab and microinjected into the eggs, one spermatozoa per each oocyte, through ICSI. The viable embryos obtained can be transferred into the uterus (a maximum of 3 embryos).

This technique is the most widely used with a pregnancy rate that varies according to female age (between 33 – 50%). Additionally, it is worth pointing out that this technique is most useful for women of more advanced age due to the vital time gained.

2) Microsurgical repair of the seminal cord. (epididymostomy and vasovasostomy). There are important medical advances. However, although the reversal procedure may be successful, it does not ensure that the man will be able to have children. There are two surgical techniques to revert vasectomy: epididymostomy and vasovasostomy. The main aim of both techniques is that the ejaculate contains sperm again.

- Vasovasostomy is more frequently performed due to its higher success rate. Surgery consists of cutting and connecting the vasa deferentia and it lasts approximately two hours. Chances of achieving a spontneous pregnancy following vasovasostomy are around 64%. - Epididymostomy is more complicated. It is performed after falied vasovasostomy due to a potential blockage of the vasa deferentia. This surgery lasts longer, approximately five hours, and has a probability of around 40% of achieving spontaneous pregnancy.

Some months have to go by after surgery in order to assess the result, that is, the presence of enough sperm in the ejaculate. Although it is a simple solution, the real efficacy of such procedure presents different problems:

- Although surgery can be successful, there is no guarantee of good results because of the added objective sought: the capacity to transport seminal fluid which cannot be confirmed on surgery. The absence of sperm in the ejaculate can occur.

- Another possibility is that the volume of ejaculate or the concentration of sperm are insufficient to achieve spontaneous pregnancy, which, in turn, leads to the need of using reproductive techniques.

In view of the above, if a couple wants to have a child after vasecotmy, it is currently more advisable to go for ICSI-IVF. On the other hand, if the project is to form a new family and have more than one child, then vasovasostomy can be a good alternative, especially if the woman is young enough to expect her to be fertile for several years.