Assisted Reproductive Technology (ART)

Intrauterine (pronounced IN-truh-YOO-tuh-rin) insemination (pronounced in-sem-uh-NAY-shun) is the placement of a man's sperm into a woman's uterus using a long, narrow tube similar to a thin straw.¹

More information on IUI includes the following:¹

• IUI is most effective for treating infertility in:
  • Women who have scarring or defects of the cervix
  • Men who have low sperm counts
  • Men who have sperm with low mobility
  • Men who cannot get erections
  • Men who have retrograde ejaculation, a condition in which sperm are ejaculated into the bladder instead of out of the penis
  • Couples who have difficulty having intercourse
• IUI can be used in combination with medications that stimulate ovulation. This combination can increase the chance of pregnancy in some cases.
• The success of IUI depends on the cause of the couple's infertility. If inseminations are performed monthly with fresh or frozen sperm, success rates can be as high as 20% per cycle. These outcomes depend on whether fertility medications are used, the age of the female partner, and the infertility diagnosis, as well as on other factors that could affect the success of the cycle.

During IVF, eggs and sperm from the couple are incubated together in a laboratory to produce an embryo. A health care provider then places the embryo into the woman's uterus, where it may implant and result in a successful pregnancy.

The steps of IVF are:²

• Superovulation
• Egg Retrieval
• Fertilization
• Embryo Transfer

Superovulation

In this process, also known as ovarian stimulation, ovulation induction, or stimulation of egg maturation, a woman takes medication to stimulate the ovaries to make many mature eggs at one time.

These medications are given by injection for 8 to 14 days. A health care provider closely monitors the development of the eggs using transvaginal ultrasound and blood tests to assess follicle growth and estrogen production by the ovaries. When the eggs are mature—as determined by the size of the ovarian follicles and the level of estrogen—an injection of the hormone hCG initiates the ovulation process. A health care provider takes out (egg retrieval) the eggs 34 to 36 hours after the hCG injection.

Egg Retrieval

This is the process used to remove the eggs from the ovaries so they can be fertilized. The procedure is performed in a physician's office as an outpatient procedure. A mild sedative and painkiller are often used during the procedure, and it normally takes about 30 minutes. The steps for egg retrieval are as follows:

• An ultrasound probe is inserted into the vagina to visualize the ovaries and the follicles, which contain the eggs.
• A needle is inserted through the wall of the vagina to the ovaries. Generally, ultrasound is used to guide the placement of the needle.
• Suction is used to pull the eggs from the ovaries into the needle.

Fertilization

A man provides a semen sample. If the sperm are healthy, they are centrifuged to concentrate them and reduce the volume, placed in a dish with the egg, and left overnight in an incubator. Fertilization usually occurs on its own. However, sometimes sperm are not able to fertilize the egg on their own. When this is the case, a single sperm is injected into an egg using a needle. This process is called intracytoplasmic (pronounced IN-truh-sahy-tuh-PLAZ-mick) sperm injection (ICSI). About 60% of IVF in the Unites States is performed with ICSI.³ The pregnancy rate is about the same for IVF using natural fertilization or ICSI.

If sperm cannot fertilize the egg without assistance, couples should consider genetic testing. This testing can determine whether the sperm have chromosome problems that might cause development problems in the resulting embryos.

Embryos that develop from IVF are placed into the uterus 1 to 6 days after retrieval.

Embryo Transfer

This procedure is performed in a physician's office. The procedure is normally painless, but some women may experience cramping.

A health care provider inserts a long, thin tube through the vagina and into the uterus and injects the embryo into the uterus. The embryo should implant into the lining of the uterus 6 to 10 days after retrieval.
Sometimes the embryos are frozen and thawed at a later date for embryo transfer. This is often done when fresh embryos fail to implant or when a woman wants to preserve her eggs in order to become pregnant years later. Women either time implantation with their ovulation cycle or receive estrogen and progesterone medications to prepare their uterine linings for implantation.

When couples do not achieve pregnancy from infertility treatments or traditional ART, they may choose to use a third party–assisted ART method to get pregnant.² Assistance can consist of:

• Sperm Donation
• Egg Donation
• Surrogates and Gestational Carriers
• Embryo Donation

Sperm Donation

Couples can opt for donated sperm if a man does not produce sperm, produces very low numbers of sperm, or has a genetic disease. Donated sperm can be used with IUI or with IVF.

Egg Donation

This process may be an option when a woman does not produce healthy eggs that can be fertilized. An egg donor undergoes the superovulation and egg retrieval steps of IVF. The donated egg can then be fertilized by sperm from the woman's partner. The resulting embryo is placed into the woman's uterus, which is receptive for implantation because of hormone treatments.

Egg donation may be particularly helpful² for women who:

• Have primary ovary insufficiency
• Have had chemotherapy or radiation therapy
• Have had surgical removal of the ovaries
• Were born without ovaries
• Are carriers of known genetic diseases
• Are infertile because of poor egg quality
• Are menopausal

Surrogates and Gestational Carriers

If a woman is unable to carry a pregnancy to term, she and her partner may choose a surrogate or gestational carrier.

A surrogate is a woman inseminated with sperm from the male partner of the couple. The resulting child will be biologically related to the surrogate and to the male partner. Surrogacy can be used when the female of the couple does not produce healthy eggs that can be fertilized.

A gestational carrier is implanted with an embryo that is not biologically related to her. This alternative can be used when a woman produces healthy eggs but is unable to carry a pregnancy to term. If needed, egg or sperm donation can also be used in this situation.

Embryo Donation

Embryo donation, sometimes called embryo adoption, allows the recipient mother to experience pregnancy and give birth to her adopted child. Couples who have undergone IVF and completed their families sometimes choose to donate their remaining embryos. An embryo donation agency, such as the National Embryo Donation Center, stores these frozen embryos and mediates adoption with the recipient woman or couple.Communication between the donating and adoptive couple can range from anonymous to a fully open relationship.

Reasons a woman may choose embryo adoption include:

• She or her partner is infertile and looking for alternatives to other ART.
• IVF has repeatedly failed.
• She or her partner is concerned about or at high risk for passing on genetic disorders.

The donated embryo is transferred to the recipient's uterus. According to CDC, 50% of transfers with donated frozen embryos result in pregnancy, and 40% result in a live birth.⁴