Assisted reproductive technology
Assisted reproductive technology (ART) is a general term referring to methods used to achieve pregnancy by artificial or partially artificial means. It is reproductive technology used in infertility treatment, which is the only application routinely used today of reproductive technology. However, there is yet no strict definition of the term.
Definitions
While there is no consensus on the definition, generally the process of intercourse is bypassed either by insemination (example IUI) or fertilization of the oocytes in the laboratory environment (i.e. in IVF).
- The Centers for Disease Control and Prevention(CDC) -- which is required as a result of the 1992 Fertility Clinic Success Rate and Certification Act to publish the annual ART success rates at U.S. fertility clinics -- defines ART to include "all fertility treatments in which both eggs and sperm are handled. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman." According to CDC, "they do not include treatments in which only sperm are handled (i.e., intrauterine—or artificial—insemination) or procedures in which a woman takes medicine only to stimulate egg production without the intention of having eggs retrieved."
Medical procedures
Most fertility medication are agents that stimulate the development of follicles in the ovary. Examples are gonadotropins and gonadotropin releasing hormone..
Manual procedures
To this category counts all forms of ART techniques that uses more substantial and forceful interventions than giving medication. In vitro fertilisation (IVF) and expansions of it (e.g. OCR, AZH, ICSI, ZIFT) are the most prevalent. However, there are also other manual ART, not necessarily dependent on IVF (e.g. PGD, GIFT, SSR).
In vitro fertilisation
In vitro fertilisation (IVF) is the technique of letting fertilisation of the male and female gametes (sperm and egg) occur outside the female body.
Expansions of IVF
The following are techniques that are involved in or requires in vitro fertilisation. On the other hand, in vitro fertilization doesn't necessarily involve each technique.
Transvaginal Ovum Retrieval (OCR)
This is the process whereby a small needle is inserted through the back of the vagina and guided via ultrasound into the ovarian follicles to collect the fluid that contains the eggs.
Assisted zona hatching (AZH)
Assisted zona hatching is performed shortly before the embryo is transferred to the uterus. A small opening is made in the outer layer surrounding the egg in order to help the embryo hatch out and aid in the implantation process of the growing embryo.
Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic sperm injection is beneficial in the case of male factor infertility where sperm counts are very low or failed fertilization occurred with previous IVF attempt(s). The ICSI procedure involves a single sperm carefully injected into the center of an egg using a microneedle.
Autologous Endometrial Coculture
Autologous endometrial coculture is a possible treatment for patients who have failed previous IVF attempts or who have poor embryo quality. The patient’s fertilized eggs are placed on top of a layer of cells from the patient’s own uterine lining, creating a more natural environment for embryo development.
Zygote intrafallopian transfer (ZIFT)
In zygote intrafallopian transfer egg cells are removed from the woman's ovaries and fertilized in the laboratory; the resulting zygote is then placed into the fallopian tube.
Egg Donor
Egg donors are resources for women with no eggs due to surgery, chemotherapy, or genetic causes; or with poor egg quality, previously unsuccessful IVF cycles or advanced maternal age. In the egg donor process, eggs are retrieved from a donor’s ovaries, fertilized in the laboratory with the sperm from the recipient’s partner, and the resulting healthy embryos are returned to the recipient’s uterus.
Gestational Carrier
A gestational carrier is an option when a patient’s medical condition prevents a safe pregnancy, when a patient has ovaries but no uterus due to congenital absence or previous surgical removal, and where a patient has no ovaries and is also unable to carry a pregnancy to full term.
Cryopreservation
Eggs, sperm and reproductive tissue can be preserved for later IVF.
Complementary or alternative medicine
Acupuncture, complementary medicines and hypnosis has shown positive with IVF in occasional studies, but no ones without subsequent criticism. There is no definitive positive effect of any complementary or alternative medicine on IVF.
Others
The following Assisted Reproduction techniques don't necessarily involve IVF.
Gamete intrafallopian transfer (GIFT)
In gamete intrafallopian transfer a mixture of sperm and eggs is placed directly into a woman’s fallopian tubes using laparoscopy following a transvaginal ovum retrieval.
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Preimplantation genetic diagnosis (PGD)
PGD involves the use of Fluorescent In Situ Hybridization (FISH) or Polymerase Chain Reaction (PCR) DNA amplification to help identify genetically abnormal embryos and improve healthy outcomes.
Sex selection
Sex selection is the attempt to control the sex of offspring to achieve a desired sex. It can be accomplished in several ways, both pre- and post-implantation of an embryo, as well as at birth. Pre-implantation techniques include PGD, but also sperm sorting.
Artificial insemination
Artificial insemination (AI) is when sperm is placed into a female's uterus (intrauterine) or cervix (intracervical) using artificial means rather than by natural copulation.
Therapeutic Donor Insemination
Therapeutic donor is an expansion of artificial insemination. It is also called artificial insemination by donor and is used in situations where the woman doesn't have a partner with functional sperm. Instead, a sperm donor supplies the sperm.
Surgical sperm retrieval (SSR)
The reproductive urologist may obtain sperm from the vas deferens, epididymis or directly from the testis in a short outpatient procedure.
Tuboplasty
Tuboplasty is a surgery to restore patency of obstructed fallopian tubes.
Frozen embryo transfer
A fertilized embryo can be cryopreserved. The latter insertion in he body is by the technique Frozen Embryo Transfer (FET).
Mind/Body Medicine
Mind/Body Medical approaches to infertility reduce psychological distress which often accompanies infertility. A reduction in distress (e.g., depression, anxiety) is found to be associated with improved fertility rates both with traditional medical procedures and without. These approaches typically focus on techniques such as relaxation, stress reduction, cognitive restructuring and mindfulness. New emerging treatments such as the Hunyuan fertility method and acupuncture for infertility have proven effective.
Risks
A 2008 study reported at the European Society for Human Reproduction and Embryology discovered that children born from frozen embryos did “better and had a higher birth weight” than children born from a fresh transfer. The study was conducted out of Copenhagen and evaluated babies born during the years 1995-2006. 1267 children born after Frozen Embryo Replacement (FER), via controlled rate freezers and storage in liquid nitrogen, were studied and categorised into three groups. 878 of them were born using frozen embryos that were created using standard in vitro fertilization in which the sperm were placed into a dish close to the egg but had to penetrate the egg on their own. 310 children were born with frozen embryos created using ICSI in which a single sperm was injected into a single egg, and 79 were born where the method of creation of the embryos was not known. 17,857 babies born after a normal IVF/ICSI with fresh embryos were also studied and used as a control group or reference group. Data on all of the children’s outcomes were taken regarding birth defects, birth weights, and length of pregnancy. The results of the study showed that the children who came from frozen embryos had higher birth weights, gave longer pregnancies and produced less “pre-term” births. There was no difference in the rate of birth defects whether the children came from frozen embryos or fresh embryos. In the FER group, the birth defect rate was 7.7% compared to the fresh transfer group which was slightly higher at 8.8%. The scientists also found that the risk for multiple pregnancies was increased in the fresh embryo transfers. Around 11.7% of the ICSI and 14.2% of the IVF frozen cases were multiple pregnancies. In the case of fresh embryos, 24.8% of the ICSI and 27.3% of the IVF were multiple pregnancies. It should also be noted that maternal age was significantly higher in the FER group. This is significant since based on age one would have expected a higher rate of problems and birth defects. The study adds to the body of knowledge suggesting that traditional embryo freezing is a safe procedure. It was unclear however why the frozen embryo children did better than their fresh embryo counterparts. Other studies have shown that the majority of IVF-conceived infants do not have birth defects.[1] However, some studies have suggested that assisted reproductive technology is associated with an increased risk of birth defects.[2][3] In the largest U.S. study, which used data from a statewide registry of birth defects,[4] 6.2% of IVF-conceived children had major defects, as compared with 4.4% of naturally conceived children matched for maternal age and other factors (odds ratio, 1.3; 95% confidence interval, 1.00 to 1.67).[1]
The main risks are:
- Genetic disorders. DNA damage increases in e.g. IVF and ICSI, which is reflected e.g. by upregulation of the gene expression of HNRNPC in the placenta.[5]
- Low birth weight. In IVF and ICSI, a risk factor is the decreased expression of proteins in energy metabolism; Ferritin light chain and ATP5A1.[5]
Other risk factors are:
- Membrane damage, which is contributed to or reflected by increased expression of the membrane fusion proteins NAPA and Annexin A3[5].
Costs
United States of America
Not everyone in the U.S. has insurance coverage for fertility investigations and treatments. Many states are starting to mandate coverage, and the rate of utilization is 277% higher in states with complete coverage. [6]
There are some health insurance companies that cover diagnosis of infertility but frequently once diagnosed will not cover any treatment costs.
2005 approximate treatment/diagnosis costs (United States, costs in US$):
- Initial workup: hysteroscopy, hysterosalpingogram, blood tests ~$2,000
- Intrauterine Insemination (IUI) fka Artificial insemination ~ $200- 900 per. trial
- Sonohysterogram (SHG) ~ $600 - 1,000
- Clomiphene citrate cycle ~ $ 200 - 500
- IVF cycle ~ $10,000 -30,000
- Use of a surrogate mother to carry the child - dependent on arrangements
Another way to look at costs is to determine the cost of establishing a pregnancy. Thus if a clomiphene treatment has a chance to establish a pregnancy in 8% of cycles and costs $500, it will cost ~ $6,000 to establish a pregnancy, compared to an IVF cycle (cycle fecundity 40%) with a corresponding cost of ($12,000/40%) $90,000
For the community as a whole, the cost of IVF on average pays back by 700% by tax from future employment by the conceived human being.[7]
United Kingdom
In the UK all patients have the right to preliminary testing, provided free of charge by the National Health Service. However, treatment is not widely available on the NHS and there can be long waiting lists. Many patients therefore pay for immediate treatment within the NHS or seek help from private clinics[8].
Sweden
In Sweden, official fertility clinics provide most necessary treatments and initial workup, but there are long waiting lists, especially for egg donations, since the donor gets just as low reward as the receiving couple are charged. However, there are private fertility clinics.
See also
- birth control
- Infertility
- Commercial surrogacy
References
- ↑ 1.0 1.1 Van Voorhis BJ (2007). "Clinical practice. In vitro fertilization". N Engl J Med 356 (4): 379–86. doi:. PMID 17251534.
- ↑ Kurinczuk JJ, Hansen M, Bower C (2004). "The risk of birth defects in children born after assisted reproductive technologies". Curr Opin Obstet Gynecol 16 (3): 201–9. doi:. PMID 15129049.
- ↑ Hansen M, Bower C, Milne E, de Klerk N, Kurinczuk JJ (2005). "Assisted reproductive technologies and the risk of birth defects--a systematic review". Hum Reprod 20 (2): 328–38. doi:. PMID 15567881. http://humrep.oxfordjournals.org/cgi/reprint/20/2/328.pdf.
- ↑ Olson CK, Keppler-Noreuil KM, Romitti PA, Budelier WT, Ryan G, Sparks AE, Van Voorhis BJ (2005). "In vitro fertilization is associated with an increase in major birth defects". Fertil Steril 84 (5): 1308–15. doi:. PMID 16275219.
- ↑ 5.0 5.1 5.2 Zhang Y, Zhang YL, Feng C, et al (September 2008). "Comparative proteomic analysis of human placenta derived from assisted reproductive technology". Proteomics. doi:. PMID 18792929.
- ↑ Jain T, Harlow BL, Hornstein MD. "Insurance coverage and outcome of in vitro fertilization." New England Journal of Medicine. 347(9):661-6.
- ↑ Long-term Economic Benefits Attributed to IVF-conceived Children: A Lifetime Tax Calculation by Mark P. Connolly, MHE; Michael S. Pollard, PhD; Stijn Hoorens, MSc; Brian R. Kaplan, MD; Selwyn P. Oskowitz, MD; and Sherman J. Silber, MD
- ↑ Infertility Treatment, NHS Direct Online (NHS Direct Online Health Enyclopaedia)
External links
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