Fertility Program

Age & fertility

The number of couples in their late 30s and 40s searching for pregnancy is constantly growing. Currently 25% of patients of the Mediterranean Fertility Center & Genetic Services are over 40. Nowadays it is common to delay starting a family for a number of reasons: second relationships, career and educational demands, desire for financial stability, waiting for a stable relationship; however it is important to understand that fertility in women declines as their age advances, particularly from late 30s onwards.
This is a normal consequence of the ageing process. The decline of fertility among married couples with advancing age has been repeatedly documented. It is enough to say that about one-third of women who defer pregnancy until the late 30s and at least half of women over the age of 40 will have infertility problems. In programs of assisted reproduction, successful delivery rates in women over 40 are one-third to one-half compared to those seen in younger women. And many of the assisted reproduction programs  rarely are successful  in women over 40.

As women age, their chance of successful pregnancy decreases as their chance of a miscarriage increases and also, there is an increased risk of a chromosomally abnormal pregnancy occuring.
In IVF, age affects the success of the treatment in a number of ways. As age anvances the number of eggs collected declines as weel as the quality of the embryos. For some women, donor egg treatment may be their best option in order to accomplish a successful pregnancy. Information about the Donor Egg Program at MFCGS, Chania is available from the patient coordinator, and the fertility specialist.

Sperm production, on the other hand, continues throughout a man's life, therefore, as men become older, the chances of achieving a pregnancy are lowered to a lesser degree compared to women. The changes in the male with aging are modest, but significant.

There are at least two reasons to believe that the quality of sperm decreases as age increases. Firstly, new autosomal disease can be attributed to an increase of the frequency of male gene mutations and secontly, paternal age is related to an increased risk of trisomies, indicating an increase in nondisjunction in  males.

Psychological impact

An IVF treatment can create additional stress to couples that may have already endured multiple disappointments. There is no question that IVF can be both physically and emotionally difficult for a number of reasons. For some, it may be the last step towards achieving a biological child. For others, an IVF cycle may disrupt work and daily schedules.
In the midst of this, couples want to realistically confront the odds for success while remaining optimistic enough to endure a regimented treatment program. Fortunately, there are ways to minimise these stresses and make the process a positive experience. Research studies have shown that couples that know what to expect can endure better these processes and use their own natural skills to their beσst advantage. Our centre collaborates with a specialised psychologist-psychotherapist that can help you cope with the difficulties of this special procedure.

The following strategies can assist you during this time period. 

• Become well informed about IVF. Understanding the process and knowing what to expect during each step will lessen your anxiety about the procedure.
• Be realistic about your expectations. 
• If pregnancy does not occur, a cycle will still contribute valuable information which can assist in planning a subsequent treatment.
• Set limitations and make decisions cooperatively with your partner.
• Make crucial decisions on time.
• Discuss your feelings about emotional issues such as cryopreservation, the use of donor semen or oocytes and the number of cycles you would consider, with friends or family members you wish to include in your confidence. Ask for emotional support from these friends or family members and talk about your feelings.
• Keep life simple. Plan activities that are entertaining and relaxing. 
• Bring familiar items from home if you are staying in a hotel.
• We strongly suggest you see a counsellor experienced in working with infertile couples prior to beginning this process. Our counsellors can talk with you about the stresses involved with infertility and treatment for fertility. They are able to suggest ways to cope with those stresses and are there for you during this stressful period.

Ovulation & Hormonal Disorders

Given the intricate interaction of the hormones necessary for ovulation, it is not surprising that about 33% of infertility cases can be traced back to ovulation and hormonal problems. They may result in the failure of the ovarian follicule to rupture an empty follicule or entrapment of the egg so that it isn't released.

Various medical conditions as well as lifestyle factors such as excessive exercise eating disorders smoking or stress can change normal hormonal rhythm. Even slight irregularities in the hormonal system can result in ovulation disorder.

Fibroid Tumors

Benign fibroid tumors in the uterus are extremely common in women over 30. In rare cases they can cause infertility by interfering with the uterine cavity blocking the fallopian tubes or altering the position of the cervix and preventing sperm from reaching the uterus. High levels of estrogen seem to stimulate the growth of fibroid tumors; heredity may also pay a role in their development.

Infertility over 40

As a woman ages, her reproductive capacity decreases. While the likelihood of naturally occurring pregnancy is about 20-25% per month for a woman in her twenties and thirties, that possibility has decreased to 5 % for a woman in her early forties. Increased reproductive age is also associated with increased miscarriage rate and increased risk of chromosomal abnormality such Down syndrome.

The decreased fertility and increased miscarriage and genetic abnormalities, all result from decreased quality of the eggs as the woman gets older. Even though women continue to ovulate into their fifties, very few women experience a successful pregnancy at that age. It is very important therefore for women older than forty to see a fertility specialist if not pregnant after three cycles of trying to conceive.

Two blood tests most commonly used to evaluate the woman's ability to produce good quality eggs are the FSH [Follicle Stimulating Hormone] In Inhibin and Estradiol performed on the third day of the menstrual cycle. Elevated levels suggest poor quality eggs and significant decrease in chances for pregnancy.

Another helpful test evaluate the quality of the eggs is Clomid Challenge Test . In this test, FSH level is measured on day 3 of the menstrual cycle and a repeat level is obtained after taking Clomid for 5 days. An abnormal test suggests a decreased likelihood of a successful pregnancy.

The decline in fertility is noted most acutely in IVF therapy. In fact, age is the most important factor in IVF rates. For women under 35, each fertilized embryo has a chance of implanting in the uterus. By the age of 43, that possibility has dropped to less than 5% per embryo. [Since generally more than one embryo is transferred per IVF cycle, the actual success rate can be higher than this].

The poorer IVF outcome is directly related to the decrease in egg quality. And while nothing can be done to improve the quality of the eggs, individualized ovarian stimulation may improve the ovarian response increasing the number of eggs available for fertilization. With more eggs, a greater number of embryos can be implanted, and the odds of pregnancy therefore increase.

Assisted hatching which involves microscopically removing part of the casing around the embryo just prior to transferring it to the uterus has not been shown unequivocally to improve pregnancy rates and is still under investigation.

For women whose ovaries are no longer producing good oocytes [eggs] , adoption, surrogacy or donor egg IVF using anonymous or known donor eggs often considered.

ICSI

ICSI may be useful in treating many aetiologies of infertility, including oligozoospermia [few sperm], asthenozoospermia [low motility], or antisperm antibodies. With ICSI very few sperm are necessary because only a single sperm is injected into the cytoplasm of each egg.

Intracytoplasmic Morphologically selected Sperm Injection (IMSI)

In Assisted reproductive technology many factors are affecting the fertilization and embryo development potential, the DNA integrity of the spermatozoon being one of the major factors. To minimise the paternal contribution in IVF failure, sperm selection based on morphological and nuclear aspects showed a clear benefit of intracytoplasmic morphologically selected sperm injection (IMSI), with high magnification in clinical pregnancies outcome.(Bartoov et al 2003, Berkovits et al 2005, Hazout et al 2006). IMSI is a method of spermatozoa selection based on high resolution microscopy which allows the enlargement (x 6000), thus a fine visualization of the head morphology of the spermatozoa. The evaluation of their degree of "vacuolization" allows a preselection of the spermatozoa before ICSI, so only the best sperm are injected.

Cryopreservation of Gametes and Embryos

 The majority of couples will elect to cryopreserve viable embryos that remain in unused after embryo transfer. In doing so they have another chance of trying again very shortly. This can be a wonderful opportunity for those couples that did not get pregnant during an initial cycle or even for those couples who do get pregnant but desire a second child in the future. About one-third of couples will have embryos frozen with an average of three to four embryos per couple.

The process of cryopreservation involves the freezing and storage of embryos at a very low temperature. After thawing about three quarters of the embryos usually survive and canl be transferred to the woman's uterus.

Cryopreservation of sperm for future use in reproductive medicine is known as sperm banking and it is advised:

To men before:

• chemotherapy and/or radiation treatment
• transurethral resection of the prostate
• vasectomy
• high occupational hazards (injury or exposure to toxic substances at work)

To couples undergoing IVF treatment and:

• sperm qyality is known to be variable
• sperm is of low qyality (OAT)
• the man may be absent during treatment (travels frequently or lives elsewhere)
• sperm has been retrieved surgically

For donation to an infertilie couple.

Gametes donation, Donor egg IVF

Sometimes [because of age, hereditary diseases, previous surgeries etc.] the ovary loses the capacity to produce the essential oocytes for conception. In these cases, the Program of Oocyte Donation, following the recommendations of the effective legislation, can resolve this problem.

The donation is an anonymous procedure in which the donor provides oocytes to the receiving couple. After an IVF process, the resulting embryos are transferred to the receiving patient who will hopefully develop a gestation.

After childbirth the new born is registered as the son of the couple like any other birth. The success rate by cycle is around 50%. In very infrequent cases it can happen that neither member of the couple have reproductive cells [oocytes and spermatozoa] being thus recommended the donation of embryos. These can come from donations made by couples that in the past have undergone IVF cycles and have decided to donate part of the obtained embryos, or from oocyte donation cycles.

The Egg Sharing Program

One of the ways of paying for your IVF or ICSI treatment is through our compensated egg sharing program. That means that if you wish to share your eggs with a woman who requires egg you will pay a reduced price for your treatment. All the details about the program will be explained to you and your husband and you will both be asked to sign a consent form. The women who you will share your eggs with, will remain anonymous to you and you will not be given any information about her treatment outcome. You will also remain anonymous to her.

You may participate in such a program if you produce 6 eggs or more. If this is the case you will share them equally with her. This will happen in any case you produce an even number of eggs greater than 6. If you produce an odd number of eggs you will receive the extra egg. She will never receive more eggs than you. If you produce 5 eggs or less you will keep all the eggs and continue with your treatment.

- Are you suitable?

- Are you under the age of 36?

- Are you generally fit and well with no personal or family history of inherited or congenital abnormalities?

If you are able to answer Yes to the above questions you may be referred to our Unit to be considered for this program. Initially you will meet a clinician for consultation. You may not be accepted if you have polycystic ovarian syndrome, have an elevated FSH or have had more than 2 cycles of unsuccessful infertility treatment. We would need to write to your GP, with your permission, to ask for details about family medical history.

Who is a candidate for the oocyte donation program?

You may want to consider oocyte donation program if you don't produce eggs on your own, if you carry a genetic disorder, or if your own ovaries have responded poorly to ovulation induction in the past. Previous chemotherapy, ovarian surgery, premature menopause, and absence of ovaries from birth are some of the common reasons why ovaries are absent or function poorly. To be considered as a recipient for donor oocytes, you must have a uterus and its shape should be relatively normal.

How do we select egg donors?

Egg donors are women between the ages of 21 and 30 years of age, who are screened to insure good general and reproductive health, genetic history and psychological stability. They are screened for hepatitis B and C, Cystic Fibrosis mutations, and sexually transmitted diseases [such as HIV, Chlamydia, Syphilis, Gonorrhoea and CMV].

Many of our potential donors have friends or relatives who have experienced infertility, and/or have children of their own and understand the significance of their gift. While similar in principle to sperm donation, egg donation is significantly more difficult. The egg donor will experience considerable inconvenience, discomfort, and risk. Egg donation involves the same steps required for in vitro fertilization. Donors will receive daily hormone injections, frequent ultrasounds and blood-work, and will undergo vaginal ultrasound guided egg retrieved.

Anonymous Recruited Donors:

We recruit a certain number of young healthy donors by advertisement and word of mouth. Some have called our Center without seeing any advertising to inquire if we have an egg donation program. The egg donor will not meet the recipient or know whether or not a pregnancy occurred from the recipient's cycle. We feel strongly that anonymous donors should be compensated financially for their time, discomfort, and risk.

What screening is involved for the recipient?

- Initial consultation with physician: At the initial consultation all aspects of egg donation will be discussed with you and your partner. If you have not been seen in our office before, you will need to send us your medical records in advance.

- Physical Exam: If you are 40 years old or older, a physical exam performed by your internist or family doctor is strongly recommended to ensure good general health. This should include tests to rule out diabetes and heart disease.

- Embryo Transfer: The embryo transfer is similar in discomfort to having a pap smear test. A small catheter is place into your uterus through the cervix and the embryos are passed through the catheter using gentle pressure. After the embryo transfer, we ask that you rest for one hour before going home. We require that someone else drive you home. When home, you will begin 48 hours of bed rest. You may return to your normal routine [excluding strenuous activities] after the two days of bed rest are over.

- Follow -up Care: Following the embryo transfer, you will remain on the estrogens and progesterone to sustain the early embryo. If you are definitely not pregnant, we will ask you to discontinue the medications. If your period starts before your scheduled blood pregnancy test is not evidence that you are not pregnant. Therefore regardless of whether you have started your period or not, a blood test is always required to confirm if there is a pregnancy.

Natural Cycle and Oocyte In Vitro Maturation

Natural cycle and in vitro maturation becomes an alternative tool to classical IVF for patient especially with PCO or high risk of hyper stimulation ovarian syndrome combined or not to poor ovarian reserve. More than clinical indication natural cycle and in vitro maturation can be considered as social and economic alternative to the classical ART based on the financial cost effective by excluding the medication.

Our in Vitro maturation programme is focused on patient with polycystic ovary syndrome and younger than 35 year olds with good sperm parameters of the partner.

IVF treatment lifecycle

IVF (In Vitro Fertilization) is the fertility treatment in which eggs are fertilized by sperm outside the woman’s womb. There are various stages involved in IVF treatment:

Boosting the woman’s egg supply

You will be prescribed drugs that will help control your egg production. You will also take drugs to increase the number of eggs you produce. This means that more eggs can be fertilised and the clinic will have a greater choice of fertilised eggs to use in treatment. In general, fertility medications improve or replace otherwise naturally occurring hormones.

Checking on progress

The clinic will carry out vaginal ultrasound scans to monitor your developing eggs. They will also do blood tests to chart the rising levels of estrogen produced by your ovaries. This helps monitor how your eggs are maturing. 34-38 hours before your eggs are due to be collected, you will be given a hormone injection to help your eggs fully mature.

Collecting the woman’s eggs

Egg retrieval is a minor surgical procedure that is performed in a sterile room (oocyte retrieval room) with the presence of an anaesthesiologist. It typically takes about an hour and requires mild anaesthesia. You are advised to be foodless since the previous night and avoid the ingestion of food, drink, water, sugar candy or chewing gum the morning before the egg retrieval. After the location of the ovarian follicles is successfully spotted, with the use of vaginal ultrasound, a needle is directed through the back wall of the vagina into the ovarian follicles and the eggs are carefully collected.

After the egg collection you can eat normally but you are advised to take a light meal and a lot of fluids. You can not drive or go to work at the same day. You are advised to rest at home.

Collecting the man’s sperm

Around the same time of egg collection, a sperm sample is given. The laboratory places the sperm sample at an incubator for a short period of time and a clarifying process referred to as “washing of the sperm” takes place in order to isolate the healthiest sperm. If donor sperm will be used, the donor sample will be prepared in the same way.

The interval between the last intercourse and the sperm collection should not be more than 3 days. Otherwise, the semen should be renewed before the abstinence period becomes longer.

Fertilization and Embryo Development

Immediately after egg collection, the eggs are carefully taken to the lab. To begin the fertilization process, the eggs are placed in a petri dish containing a solution rich in specialised egg nutrients for 2 to 3 hours. The washed sperm is incubated together with the eggs for 16-20 hours. They are then checked to see if fertilisation has taken place. The eggs that have been fertilised are now called embryos and are left for another 24-48 hours in special laboratory conditions before being checked again.

Alternatively, patients dealing with male infertility problems are offered the choice of Intra Cytoplasmic Sperm Injection (ICSI). ICSI is an in vitro fertilization procedure in which a single sperm is injected directly into an egg. The procedure is done under a microscope using micromanipulation devices (micromanipulators, microinjectors and micropipettes). A holding pipette stabilizes the mature oocyte. From the opposite site a thin, hollow needle is passed through the oolemma into the inner part of the oocyte and a single sperm is released into the oocyte.

Endometrium preparation

Estrogens and progesterone are prescribed in order to prepare the lining of the woman’s endometrium.

Embryo transfer

Embryo transfer is a simple procedure that does not require anaesthesia. Two to five days after eggs fertilization, the healthiest ones, according to morphological criteria, are selected in order to be placed into the woman’s womb. The selected embryos are inserted into a thin tube (catheter) and guided towards the woman’s uterus. One to four embryos can be transferred depending of the age and the medical record of the recipient. Rest is recommended for 24 to 48 hours after the embryo transfer. Any additional healthy fertilized embryos can be frozen at this point and used in a possible future IVF cycle.

While partners are encouraged to be present, their presence is not essential. However, you will need someone to drive you to and from the clinic.

It is not unusual to see vaginal blood spotting prior to the pregnancy test. Approximately 50% of our patients experience very mild bleeding (few blood spots) prior to the pregnancy test or even afterwards. THINK POSITIVE! You must do the pregnancy test even if you have seen a few spots of blood.

Pregnancy testing

Quantitative hCG pregnancy testing has to be done fourteen days after the embryo transfer. If, however, the day of the test falls on a weekend, a test that was supposed to be performed on Saturday should be done on Friday, and a Sunday test should be done on Monday. Most of the tests reveal either positive or negative results; however, occasionally there are “weakly positive” results. This situation is caused by one of the following four scenarios:

Further hCG monitoring is extremely important in any case. Two days after the first pregnancy test, you should repeat it. This blood work will enable us to determine if your pregnancy is beginning to progress along the normal course. The hCG level should double every two to three days.

An ultrasound examination will be performed approximately three to four weeks after your retrieval. This early ultrasound is critical to evaluate the possibility of miscarriage, ectopic pregnancy, and multiple pregnancies. An ectopic [tubal] pregnancy can occur in 2-4 % of IVF pregnancies. If diagnosed early, this unfortunate complication may be treated as an outpatient with medication. Once your gynaecologist determines the presence of foetal heartbeat, he will refer you to an obstetrician.

If both your pregnancy tests are negative you should contact us for further instructions on the medications. If we advise you to stop the treatment you will get a period within three to five days, if you have not already started bleeding. This period may not be different from your normal period (lighter, heavier, shorter, longer). If you do not get a period within one week, please call us and repeat the blood test.

After investing so much time and money for ART treatment, failure to have fertilized eggs or a negative pregnancy test can be an abrupt shock. You may wish to make an appointment to meet with your physician to review your treatment. All that it may take to achieve your IVF success is time and another attempt.

Embryo cumulus cells co-culture

This is a technique we have just introduced in our laboratory! Cumulus cells are cells that surround the woman’s eggs. They provide nutrients and growth factors to the egg and protect it during its journey from the ovaries to the uterus.

When collecting the eggs, automatically the cumulus cells are harvested, since they are connected tightly to the eggs. When ICSI is to be used for the fertilization of the eggs with the sperm, the cumulus cells are removed from the eggs. But, instead of discarding them, we wash and incubate them in nutritious culture medium to stimulate their proliferation. In that nutritious culture medium, the cumulus cells grow the so-called connexion dendrites, which connect with each other and form a lacelike layer at the bottom of the culture dish.

Embryos when placed to their own cumulus cells layer receive extra nutrients and growth factors, which are important to their development. Despite recent vast improvements that have been made in the embryo culture system, not all necessary nutrients for embryo development, like sugars, amino acids and growth factors, that are present during natural fertilization (in vivo) have been discovered. Therefore, by introducing this co-culture method into our program, we can give the embryos a little extra help, in a similar way that nature would do!