Chapter 10
Infertility
- Definition -
① Sterility : have some absolute factor preventing conception or impregnation,
even with Tx., with the implication that the condition is irreversible.
② Infertility : inability to achieve pregnancy within a stipulated period of time,
usually 1 yrs, or repeated failure to carry a pregnancy to term.
③ Fecundity : childbearing ability
④ Fertility : childbearing performance
⑤ primary infertility : term used to designate those couples who have never conceived
⑥ secondary infertility : indicates that at least one conception has occured for one or
both , but that the couple is currently not able to achieve preg.
- Medical Considerations -
* As the husband or wife, or both, may have factors contribuing to the infertility,
both must cooperate in the investigation. Although the woman is often the most interested
and aggresive in her desire for medical help, it is rarely satisfactory to initiate
an infertility investigation without the husband's cooperation.
1) Goals of an infertility evaluation
① to establish the etiology of infertility
② to give a prognosis for future fertility
⑴ three major areas must be considered in establishing the Dx. & Px.
- Basic Infertility Evaluation -
① age of the wife
② duration of the history
; unprotected intercourse를 1년동안 했음에도 불구하고 임신되지 않으면,
evaluation을 실시해야 한다.
③ medical factors responsible
; detail Hx,P/E,Pevic Exam이 필수적이다.
a) central or ovulation
b) male factor
c) mucus or cervical factor
d) endometrial or uterine factor
e) tubal factor
f) peritoneal factor
* a),b) 는 prognostic Ix of the seriousness of the problem
2) Initial interview
① past and present medical history
② social histroy of the couple
③ establish the motivation and interest of a couple
④ any previous infertility evalutaion
⑤ P/E ( to seeks ovarian or hormaonal dysfunction and physical or mechanical
problems within the pelvis )
3) Fundamental areas of investigation
⑴ central or ovulatory factor
( involving the physical act of ovulation and release of a mature oocyte )
; ovulation의 이상은 menstrual cycles과 관계있고, endocrinologic workup을 실시
⑵ male factor
( involving adequate production of normal sperm )
; STD는 epididymitis, blocked sperm ducts, varicocele, hormonal imbalance,
systemic ds,를 유발하여 sperm production에 이상을 초래할 수 있다.
⑶ mucus or cervical factor
( involving the presence of adequate cervical mucus which can act as a transport
medium and repository for sperm )
; ① mucus quantity → after cervical conization, endocervical gl.가 파괴되었을 때.
② mucus quality → infection , inadequate estrogen stimulation
③ mucus hostility → presence of antisperm antibody
⑷ endometrial or uterine factor
( involving the preparation of the endometrial implantation site that is dependent
on ovarian endocrine function and uterine end-organ normality and response )
; polyps , submucous myomas
⑸ tubal factor
( involving patency of tubes allowing transport of sperm and oocytes )
; end result of infection ( most frequent )
⑹ peritoneal factor
( involving the absence of any physical or mechanical barrier to fertility within
the peritoneal cavity )
; endometriosis , pelvic adhesion
- Infertility Evalution -
1) Central or ovulatory factor
- Diagnosis of ovulation -
Conclusive Pregnancy
Recovery of oocyte from tubal flushing
Recovery of oocyte or embryo from uterine flushing
Observation of ovulation via laparoscopy
Presumptive Biphasic basal temperature
Vaginal cytology
Vaginal pH
Cervical mucus change
Endometrial biopsy
Plasma progesterone
Urinary pregesterone
Plasma 17α-hydroxyprogesterone
Plasma estradiol
LH surge
Salivary glucose
Salivary esterase
Alkaline phosphatase
Premenstrual molimina
Regular cycles
Follicular collapse on U/S
Cul-de-sac fluid on U/S
Corpus luteum visualization via U/S , laparoscopy
- The most helpful change predictive of impedencing ovulation
→ cervical mucosal change under the influence of estrogen
: mucus ↑ in amount, fern formation(+)
→ under the influence of progesterone in the luteal phase
: mucus ↓ in amount, changes in character, fern formation(-)
- luteinized unruptured follicle(LUF) syndrome
→ because of failure of formation of the stigma
→ folliculogenesis and corpus luteum formation : nl
→ endocrine dynamics : nl
→ trapped within the follicle which does not rupture
→ 매우 드물기 때문에 presumptive criteria of ovulation가 유용하다.
- D/Dx of amenorrhea
① hypothalamic amenorrhea → excessive exercise,thinness,stress
② pituitary amenorrhea → prolactin-producing adenoma,panhypopituitarism
③ metabolic & endocrine ds → thyroid dysfunction
④ obesity and hyperandrogenism
⑤ polycystic ovarian, follicular exhaustion, premature menopause
- Treatment
① etiologic diagnosis : first step
② antiestrogen clomiphene citrate
→ correct dysfunction of feedback control mechanisms in pts
with an intact pituitary gland and normal ovaries
③ ② + hCG → cumulative 95% probability of ovulation
④ hMGs or pituitary gonadotropins → 99.9%
2) Male factor
⑴ initial assessment
- Semen analysis
① at least two times
② in the laboratory within 1 hr
③ prewarming the jar to body temperature
④ after a period of abstinence not less than 48 hrs
⑤ by induced ejaculation or by intercourse with withdrawal
- Criteria for a Normal Semen Anaysis -
① Count per mililiter
normal fertile : > 20 million
subfertile : 5 < count < 20
infertile : < 5
② Volume : 2.5 ml
③ Motility : 60% motile within 4 hr of collection
motility ↑ → fertility ↑
④ Differential : less than 25% abnormal forms
- survival time of sperm in the human female genital tract : 96 hrs
sperm can fertilize : 24-48 hrs
- freshly ejaculated spermatozoa는 oocyte를 둘러싼 cellular layers를 통과하지 못한다.
sperm이 ability to fertilize를 갖는 과정을 capitation이라한다.
- capitation
① occurs in the female reproductive tract
② removal of epididymal and seminal plasma proteins coating the sperm surface
③ acrosomal reaction ; activation of hydrolytic enz.(hyaluronidase in acrosome)
and acrosin
allow spermatozoa to digest the cumulus oophorus, the corona radiata,
the zona pellucida of the oocyte
allow fusion of the sperm with the vitelline menmbrane,the inner surface
of zona
⑵ semen abnormalities
* semen analysis → quantity and quality of the spermatozoa
secretory function of the accessory genital glands
등의 정보를 제공.
① seminal insufficiency (due to)
- defect in spermatogenesis, in sperm maturation,
- an abnormality in the components or constituents of the seminal ejaculate
② seminal plasma
- prostate(30%) + seminal vesicles(60%) + epididymis,ampullae,bulbourethral,
urethral gl (5-10%)
③ pH of seminal plasma ( normal semen = pH 7.2 -7.8 )
- prostatic fluid ; acidic and inhibitory to sperm → acid phosphatase
- vesicular secretion ; alkaline → fructose and prostaglandins
ex) acute or chronic vesiculitis, high fructolysis, androgen deficiency
→ low fructose levels → dysfuction of seminal vesicles
⑶ evaluation of the infertile male
- History
① cryptorchism,scrotal trauma,torsion
② recurrent episodes of prostatis,epididymitis,urethritis
③ occupational & environmental exposures to radiation,toxins,chemicals,pesticides
④ nonspecific factors : stress,anxiety,travel
⑤ over-the-counter medications taken,drug,alcohol use,abuse
⑥ potency,sexual techniques,frequency of intercourse
- Constitutional factors
① nutritional problem,acute or chronic illness,general metabolic ds
② Klinfelter's syndrome
③ Kartagener's syndrome
④ varicocele
- Drug history
① phenothiazine → retrograde ejaculation
② cardiovascular drug (adrenergic inhibitor,antihypertensives) → ejaculatory disturbance
③ furadantin → necrospermia
④ sulfasalazine → inhibits spermatogenesis
⑤ colchicine → transient inhibition of spermatogenesis,azoospermia
- P/E
① androgenization ( gynecomastia,beard & chest↓,eunuchoid proportions )
② intact sense of smell looks for a rare form of hypogonadism,Kallmann's syndrome
③ bimanual scrotal palpation ( testicular size,spermatocele,absent vas deference )
④ phimosis,meatal stenosis,hypospadias
⑤ valsalva maneuver ( varicocele )
- Laboratory evaluation of oligospermic male
⒜ pregerminal hypofertility
→ FSH(nl) , better prognosis
→ Tx : tamoxifen,clomiophene citrate,menopausal or chorionic gonadotropin,testosterone
⒝ primary germinal hypofertility
→ FSH(↑) , tubular damage , exogenous hormonal stimulation은 효과 없다.
⒞ postgerminal hypofertility
→ FSH(nl) ,anatomic obstruction of the reproductive tract,
history of infection(gonorrhea,epididymitis)
contrast vasography : preoperative diagnosis를 confirm하기위해
testicular biopsy
- Classification of Male infertility -
Ⅰ. Pretesticular or Pregerminal Causes
; oligospermia, azoospermia, FSH↓, LH↓, testosterone↓
Ⅱ. Testicular Causes
; azoospermia, oligospermia, FSH↑, LH & testosterone nl or ↓
Ⅲ. Posttesticular Causes
; azoospermia, FSH nl , LH & testosterone nl
- Penetration test
① Kremer test ( sperm-cervical mucus contact test,SCMCT )
→ phalanx formation가 즉시 일어나고,sperm이 mucus를 통과한다.(normal)
→ shivering-shaking phenomenon시에는 antisperm antibody test를 실시해야함.
② Sperm penetration assay(SPA) or cross-species penetration test
→ ability of sperm to penetrate an oocyte
-
abnormal inconclusive normal
semen analysis semen analysis semen anaysis
↓ ↓ ↓ ↓ ↓
repeat ↓ repeat ↓ ↓
↓ ↓ ↓ ↓ ↓
abnormal ↓ inclusive ↓ ↓
↓ ↓ ↓ ↓ ↓
↓ ↓
↓ sperm penetration assay ↓
↓ ↓
↓ ↑ 14-100% ↓
≤10%
male infertility ← → female infertility
evaluation evaluation
- Cause of Male Infertility -
Ⅰ. Pretesticular or Pregerminal Causes
Ａ. Central Gonadotropin Deficiensy
Hypothalamic → congenital GnRH deficiensy, tumor, infection, head trauma
Pituitary → congenital FSH/LH deficiency, tumor, infarction ,
infection, trauma
Other → sarcoidosis, hemachromatosis
Ｂ. Endocine Excess Syndrome
Estrogen → functional tumor of adrenal , cirrhosis
Androgen → congenital adrenal hyperplasia, androgen-producing tumor
Glucocorticoid → cushing's synd, steroid tx.( ulcerative colitis,asthma )
Ｃ. Other
Hypothyroidism , DM
Ⅱ. Testicular Causes
Ａ. Chromosomal abnormalities → Klinefelter' synd , 47-XXY
Ｂ. Cryptochidism,unilateral or bilateral
Ｃ. Radiation , chemotherapy
Ｄ. Mumps , viral orchitis
Ｅ. Trauma
Ｆ. Sertoli-cell-only synd
Ｇ. Idiopathic maturation arrest
Ｈ. Androgen receptor abnormality → androgen insensitivity synd
Ⅲ. Posttesticular Causes
Ａ. Congenital ductal obstruction → vas deferens , epididymis
Ｂ. Acquired ductal block → infection ( gonorrhea,Tbc ) , vas ligation
Ｃ. Impaired motility → Kartagener's synd , Immotile cilia synd ,
Enz. deficiency ( protein carboxymethylase )
- Treatment
① low dose testosterone → to increase sperm motility
② Cup insemination technique in wife → low semen volume with good quality sperm일때
③ split ejaculation → high semen vol일때,
→ artificial insemination using the initial part of ejaculation
→ concentrate sperm without the dilutional effect
④ intrauterine insemination → mucus hostility or absence일때
⑤ competent sexual therapist → impotence and psychosexual difficulty
⑥ therapy of varicocele
→ high ligation of the internal spermatic vein
→ HCG therapy after ligation
⑦ low dose continuous or cyclic clomiphene citrate → FSH,LH↑
→ men with pregerminal causes of oligospermia 에 유용
→ Cx : visual scotoma
⑧ tamoxiphen (estrogen antagonist similar to clomiphene but without its estrgen effect)
⑨ retrograde ejaculation시 ← sympathomimetic medication
⑩ dilute alkaline urine → sperm survival chance ↑
ⓐ limitation of smoking,excessive alcohol intake,attention to diet,adequate rest,
treatment of any chronic illness or metabolic disease
⑷ technique of insemination
a) Homologous Artificial Insemination (AIH)
< Indication >
① when potentially normal semen does not reach the cervix
→ hypospdias,spinal cord injury,psychogenic impotence,vaginismus,
local or anatomical problem
② retrograde ejaculation
→ after transurethral prostatectomy,in DM,
→ during phenothiazine(Thorazine,Mellaril) treatment,
catheterization of the bladder or postcoital voiding
③ impotence,premature ejaculation,anatomical abnormalities
b) Therapeutic Donor Insemination (TDI,AID)
< Selection of donor >
① proven fertility,healthy,physically fit,emotionally stable,intelligent,
free of any familial history of congenital,hereditary defects
② resemble the patient's husband in somatic type,hair,eye color
③ his blood type should be compatible with the wife
④ no history of vereneal disease,drug abuse,significant alcohol intake
< Donor screening >
; syphilis,hepatitis B,HIV,blood group,Rh,Tay-Sachs,Sickle cell anemia,thalassemia,
occupation,religion,ancestry
< Several rules of thumb >
① husband must have aware of his inadequacy
② husband has taken the initiative
③ no religious background in either partner
④ every reasonable medical investigation and aid must have been employed
to diagnosis and treat the cause of male infertility
⑤ normal fertility in the female ( The wife must be immune to rubella )
< Timing of insemination >
→ in the periovulatory
→ monitoring : history,BBt,cervical mucus evaluation,
use of Ovusticks(to indicate the timing of the LH surge),U/S
< Method >
① cervical cup,usually → vagina의 acid한 상태를 거치지 않으므로 sperm이 오래 생존.
② cervico-vaginal
③ fresh semen → usually used,but on occasion a frozen donor specimen is utilized
④ twice a cycle
** mixed the husband's sperm with that of the donor
→sperm agglutination between specimens
** intercourse prior to insemination or after the cup has been removed
→ more practice
c) Intrauterine Insemination
< Indication >
① male factor infertility → oligospermia,poor motility
② cervical factor infertility
→ hostility,antisperm Ab,inadequate or infected mucus,unexplained infertility,
conization pts without cervical mucus
< S/E >
; allergic rxn,fever,cramping,sever dysmenorrhea(PG와 연관),infection
< Method >
① direct transfer of sperm to the intrauterine cavity
② using a washed and concentrated specimen(PG 제거)
③ by using an angiocath,pediatric feeding tube,epidural cather
3) Cervical factor
- Cervical mucus function
① sperm penetrability
② sperm nutrition
③ sperm reservoir and survival
- Examination of the cervical mucus
① amount
② quality(viscosity,spinnbarkeit,crystallization,epithelial cell,bacteria),
③ presence or absence of infection
- Good estrogenic mucus
① in the preovulatory and periovulatory phase
② watery,copious,clear
③ acellular
④ excellent spinnbarkit ( 8cm or longer )
⑤ supoport motility of sperm
⑥ ferning
- Low estrogenic mucus
① in the luteal phase under progesterone influence
② in the postmenstrual phase
③ scanty,thick,cloudy
④ highly cellular
⑤ not ferning
⑥ not support sperm penetration
- Postcoital test ( PCT,Sims-Huhner test )
< Method >
① at periovulatory phase
② when the cervical mucus is well estrogenized
③ intercourse within 12-42 hrs of her visit
④ Tuberculin syringe
⑤ successful test → at least 5-10 actively motile sperm/HPF
< Normal PCT > implies
① satisfactory intercourse techniques
② normal mucus for the transport and preservation of sperm
③ adequate ovarian estrogenic function
④ at least the possibility of normal male fertility
→ one negative PCT has little clinical value and must be repeated.
< Abnormal PCT >
① inadequate amount of cervical mucus
# Cause → stenosis of endocervical canal,congenital
→ inadequate numbers or response of endocervical gl.
; secondary to acute or chronic cervitis or to conization
or cryosurgical therapy
# Treatment → low dose estrogen therapy
; ethinyl estradiol(EE2,10ug) or diethystilbestrol(DES,0.1mg)
→ daily from days 3 to 14 of the 28-day cycle
→ higher estrogen dose for a shorter time
; higher estrogen dose for a shorter time
→ EE2 ( 200ug daily for 5 days from day 8-12 of the cycle )
→ hMG(Pergonal) stimulation → endogenous estrogen output
② abnormal or hostile cervical mucus
; abnormal mucus quality usually implies an infected mucus.
# infected mucus ← vibramycin(100mg) for 10 days,from the 1st day of menses
# Chlamydia trachomatis,mycoplasma in the cevix → not related to infertility
# Chlamydial salpingitis → significant etiologic cause of infertility
# Chlamydia in the cervix ← tetracycline
③ faulty coital technique,oligospermia,lack of semen volume,vaginal factor,
poor sperm motility, sperm immobilization
④ failure of penetration of sperm into the cervical mucus
→ d/t a thick abnormal mucus or acrosomal defect in the sperm
⑴ antisperm antibodies
- sperm agglutinating activity in the cervical mucus → nonselective & nonspecific
- immobilization Ab : IgG,IgM,specific for sperm-coating proteins or acrosomeor midpiece
protein, complemen-dependent,correlate with female infertility
- secretory IgA → local Ab,capable of embryo toxicity
① Isojima sperm immobilization test
→ clinically reliable
→ its sensitivity has been increased by using washed spermatozoa
& an adequate amount of complement
→ test performed on the serum of husband and wife
② Gelatin agglutination test ( Kibrick method )
③ Tube-slide agglutination test ( Frankin-Dukes methods )
④ Sperm cervical mucus contact test,SCMCT ( Kremer test )
→ important screening test for the presence of antisperm Ab within cervical mucus
⑤ Slide test → sperm,mucus cross match test
⑵ treatment of immunologic infertility
① washing and concentration of sperm with intracervical or intrauterine insemination
② high dose steroid therapy as an immunosuppressant
→ methylprednisolone 32mg 3 days daily for 10 days.
starting at the wife's cycle day 21
→ agitation,emotional problem,bilateral aseptic necrosis of femoral head
③ condom contrception for 3 months
→ E.coli 에 의해 infection됬을때 reproductive tract에서 Ab가 형성되고, 이 Ab가
sperm과 cross-reaction한다.condom이 E.coli Ab형성을 감소시킨다.
4) Endometrial or uterine factor
# study of Premenstrual endometrium → information about ovarian luteal function and
the implantation site for the fertilized ovum.
# Endometrial biopsy
- with a Novak currete
- from high in the fundus
- according to the menstrual history & BBT chart
- within 1-2 days of menstruation
- Accurate endometrial dating by the criteria of Noyes et al is most satisfactory just
prior to the onset of menses and the biopsy serves as a bioassay of corpus luteum
progesterone output.
⑴ luteal phase inadequacy
< Definition >
- the histologic dating of the endometrium is 2 or more days behind the menstrual
dating in 2 or more cycles
- defective follicular development and inappropriate endometrial development
< Etiology >
a) insufficient progesterone exposure or inappropriate progesterone-estrogen ratio
→ defective progesterone output
- during the first ovulatory cycles following delivery or abortion
- in the over 35 year old woman
- in athletes undergoing strenuous training programs
- hyperprolactinemia
- unexplained infertility
- clomiphene-induced ovulations
b) inappropriately responded endometrium
→ inadequate numbers of endometrial progesterone cytosel receptors
< Clinical entities >
- early recurrent miscarriage
- primary infertility
- submucosal miscarrige
< Diagnosis >
- late luteal endometrial biopsy
- BBT
- serum prolactin , TSH ↓
- sge & nutritional status of the patient
< Treatment >
① correction of nutritional deficiencies,hypothyroidism,hyperprolactinemia
② progesterone vaginal suppositories
- 25mg twice daily
- begining 3 or 4 days into the luteal phase
- counting until the onset of menses
③ progesterone 12.5mg IM daily
④ hCG 2500IU daily
- luteotropic hormone
- stimulate the normal corpus luteum to synthesize an increased amount of progesterone
- unpredictable
< Ix of progesterone supplementation >
① regulatory ovulatory woman
② with cycle length less than 40 days
③ no another cause such as hyperprolactinemia,or hypothyroidism
④ under the age of 35
⑤ normal uterine cavity on hysterosalpingogram
< Prolonged follicular phase >
① d/t inadequacy of the intercycle FSH increase
② administration of clomiphene of gonadotropin
< Synthetic progestational agents >
- cIx in pregnancy
- ineffective → the effect on the endometrium is not equivalent to that of progesterone
- luteolytic effect → decreased progesterone output
⑵ Endometritis
- plasma cell → pathognomic
- lymphocytes & macrophages → ureaplasma endometritis
- doxycycline 200mg on the first day
100mg daily for 10 days
5) Tubal factor
- tubal function test → diagnostic & therapeutic
⑴ gas insufflation ( Rubin's test )
⑵ hysterosalpingography ( HSG )
< Time >
- after menstrual bleeding has ceased and prior to ovulation
→ radioresistant oocyte in prophase of meiosis I
< Finding >
- a collection of contrast → hydrosalpinx or peritubal adhesion
- nonvisualization of tubes → cornual obstruction or spasm
( atropin 0.5mg,glucagon 1mg IV )
< Oil-soluble media >
# disadvantage
; oil embolus,granuloma formation,remain longer in the pelvis
# advantage → water-soluble media 보다 좋다.
; greater therapeutic,
the incidence of conception increases during the 3-4 months after HSG,
clear image,
less pain with peritoneal spill
** The possibility of infection after HSG ( acute PID )
- patent dilated tubes on HSG
- doxycycline prophylaxis
6) Peritoneal factor
⑴ Definition
; those physical or mechanical barriers to infertility occuring within the pelvis
→ peritubal adhesions, endometriosis
⑵ Diagnosis
; diagnostic laparoscopy with instillation of indigo carmine or methylene blue dye
through the tubes
⑶ Tubal or Fimbrial occlusion
; result of adhesion from PID due to gonorrhea,Tbc,postabortal or postpartum infection
⑷ Adhesions
→ d/t endometriosis
→ other irritating reactions in the peritoneal cavity
( unrecognized ectopic pregnancy,ruptured corpus luteum cyst,bleeding from
the follicle at ovulation )
→ previous pelvis surgery ( ovarian wedge resection )
→ extrapelvic inflammation process
( regional enteritis,appendiceal abscess,IUD )
⑸ Treatment
① HSG → diagnosis & rupture minor adhesion
② lysis of adhesion,by laparoscopy or laparotomy
③ linear salpingostomy for removal of ectopic pregnancy
④ tuboplasty
- corneal implantation
- fimbrioplasty → delay in conception
- resection → anastomosis
⑤ prevention of peritoneal adhesion formation postoperatively
- high molecular weight dextran intraperitoneally
- hydrotubation with solutions of cortisone & antibiotics
7) Unexplained infertility
- fewer than 5% of infertile couples
- doxycycline treatment
- Other Consideration -
1) Psychogenic aspects of infertility
→ emotional tension
frustration tubal spasm
anger ovulatory defects
guilt decreased coital frequency
isolation pychogenic impotence
ejaculatory problem
infertility ←
- In Vitro Fertilization -
1) indications for IVF
① irreparably damaged or missing fallopian tubes
② abnormal cervical factor
③ oligospermia & male factor
④ immunologic infertility
⑤ unexplained infertility
⑥ endometriosis
⑦ EDS exposure
⑧ significant fimbrial disease
2) patient selection
; patient's age , weight , method used to aspirate oocytes 에 따라 성공률이 달라진다.
3) ovulation timing
; most important step of the process of IVF is to stimulate follicular development
and oocyte maturation.
; daily monitoring using serum estradiol and follicular diameter with U/S
; ovulation will occur over 36 hrs after the administration of IM hCG
; oocyte aspiration is timed to occur before spontaneous ovulation can happen.
4) stimulation protocols
- hMG alone
- hMG + clomophene
- hMG + pure FSH
- GnRH
5) aspiration of oocytes
- laparoscopy under local or general anesthesia
- transabdominal transvesicle U/S-guided approach
- transvaginal U/S-guided technique
6) fertilization in Vitro
⑴ Grading system for oocyte maturity
① size & expansion of the cumulus
② appearance of the corona radiata & ooplasm
③ the degree of darkness of the granulosa cells
⑵ Insemination
- 6-24 hrs later
⑶ Fertilization
- within 15-18 hrs of insemination
7) embryo transfer
- 2-8 cell stage
- 48-60 hrs after insemination
8) success of IVF/ET
⑴ Pregnancy rate
- transfer of one embryo, 10-15%
- transfer of two embryo, 20-25%
- 3 or more embryo, 30%
⑵ Multiple gestation → common
- Gamete Intrafallopian Transfer (GIFT) -
; The placement of gametes,sperm & oocytes,into the fallopian tube
through the laparoscopy or via a minilaparotomy
- 4 oocytes are removed from patient
- 2 per side or a total of 4 oocytes plus sperm are introduced into the tubes
- no incubation & culture procedures
- Nonsurgical Ovum Transfer -
⑴ Method
- wife : completely inaccesible ovary
- The donor is inseminated in a normal ovulatory cycle
- 4-5 days later,by uterine flushing technique
recovering the fertilized oocyte,now an embryo at the blastocyst stage.
- with proper synchronization,transfer of the embryo at the wife
with the hope of intrauterine pregnancy
⑵ Complication
- oocyte donor → the possibility of intrauterine or ectopic pregnancy and infection
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