Assisted Fertilization: What is it? Procedures, Risks, Use, Ethics and Costs

It is a reproductive technology used mainly for infertility treatments, it is also known as fertility treatment.

Assisted reproduction technology (ART) is the technology used to achieve pregnancy in procedures such as fertility medication, in vitro fertilization and surrogacy.

It mainly belongs to the field of reproductive endocrinology and infertility, and may also include intracytoplasmic sperm injection (ICSI) and cryopreservation.

Some forms of assisted reproduction technology are also used with respect to fertile couples for genetic reasons (genetic diagnosis prior to implantation).

Assisted reproduction technology is also used for couples who are discordant for certain contagious diseases; for example, HIV to reduce the risk of infection when a pregnancy is desired.

Procedures

General

With assisted reproduction technology, the process of sexual intercourse is overlooked and fertilization of the oocytes occurs in the laboratory environment (ie, in vitro fertilization).

In the USA UU., Centers for Disease Control and Prevention (CDC), which is required as a result of the 1992 Fertility Clinic Success and Certification Rate Act to publish annual success rates of Assisted Reproduction Technology in US Fertility Clinics UU

According to the Centers for Disease Control and Prevention, “they do not include treatments in which only sperm are handled (ie, artificial or intrauterine insemination) or procedures in which a woman takes medication only to stimulate egg production without the intention to have recovered ovules. ”

In Europe, assisted reproduction technology also excludes artificial insemination and includes only procedures where oocytes are manipulated.

The World Health Organization also defines assisted reproduction technology in this way.

Fertility medication

Most fertility medications are agents that stimulate the development of follicles in the ovary. Some examples are gonadotropins and gonadotropin-releasing hormone .

In vitro fertilization

In vitro fertilization is the technique that allows the fertilization of male and female gametes (spermatozoa and ovules) outside the female body. The techniques generally used in in vitro fertilization include:

Transvaginal egg retrieval (OVR) is the process by which a small needle is inserted through the back of the vagina and guided by ultrasound to the ovarian follicles to collect the fluid contained in the ovary. ovules

Embryo transfer is the step in the process whereby one or more embryos are placed in a woman’s uterus with the intention of establishing a pregnancy. The less used techniques in in vitro fertilization are:

Assisted hatching of the area (AZH) is done shortly before the embryo is transferred to the uterus. A small opening is made in the outer layer that surrounds the egg to help the embryo out and help in the process of implantation of the growing embryo.

Intracytoplasmic sperm injection (ICSI) is beneficial in the case of male factor infertility, in which sperm counts are very low or failed fertilization occurred with previous attempts at in vitro fertilization.

The intracytoplasmic sperm injection procedure involves the administration of a sperm carefully injected into the center of an egg with a microneedle.

With intracytoplasmic sperm injection, only one sperm per egg is needed. Without intracytoplasmic sperm injection, you need between 50,000 and 100,000. This method is also sometimes used when using donor sperm.

Autologous endometrial coculture is a possible treatment for patients who have failed previous attempts at in vitro fertilization or who have poor embryo quality.

The patient’s fertilized eggs are placed on a layer of cells from the patient’s own uterine lining, creating a more natural environment for the development of the embryo.

In the zygote intrafallopian transfer (ZIFT), the ovules are extracted from the woman’s ovaries and fertilized in the laboratory; The resulting zygote is then placed in the fallopian tube.

Cytoplasmic transfer is the technique in which the contents of a fertile egg from a donor are injected into the patient’s infertile ovule along with the sperm.

Egg donors are resources for women without ovules due to surgery, chemotherapy or genetic causes; or with poor egg quality, in vitro fertilization cycles or advanced maternal age previously failed.

In the process of egg donation, the ovules are recovered from the ovaries of a donor, fertilized in the laboratory with the sperm of the recipient’s partner and the resulting healthy embryos are returned to the recipient’s uterus.

Sperm donation can provide the source of sperm used in in vitro fertilization procedures, in which the partner does not produce sperm or has a hereditary disease, or when the woman being treated does not have a male partner.

Preimplantation genetic diagnosis (PGD) involves the use of genetic detection mechanisms such as fluorescent in situ hybridization (FISH) or comparative genomic hybridization (CGH) to help identify embryos genetically abnormal and improve healthy results.

Embryo division can be used for twinning to increase the number of available embryos.

Others

Other techniques of assisted reproduction include:

In the intrafallopian transfer of gametes (GIFT), a mixture of sperm and eggs is placed directly into the fallopian tubes of a woman by laparoscopy after the extraction of a transvaginal ovum.

The selection of sex is the attempt to control the sex of the offspring to achieve a desired sex. It can be achieved in several ways, both before and after the implantation of an embryo, as well as at the time of birth.

Preimplantation techniques include genetic diagnosis prior to implantation, but also sperm classification.

Reproductive surgery, treat, for example, the obstruction of the fallopian tube and the obstruction of the vas deferens, or reverse a vasectomy through a reverse vasectomy.

In the recovery of surgical sperm (SSR), the reproductive urologist obtains the sperm from the vas deferens, the epididymis or directly from the testicle in a brief outpatient procedure.

By cryopreservation, the ovules, sperm and reproductive tissue can be preserved for subsequent in vitro fertilization.

Risks of assisted fertilization

Most babies conceived for in vitro fertilization do not have birth defects. However, some studies have suggested that assisted reproductive technology is associated with an increased risk of birth defects.

Artificial reproductive technology is increasingly available. Early studies suggest that there may be an increased risk of medical complications with the mother and the baby.

Some of these include low birth weight, placental insufficiency, chromosomal disorders, premature births, gestational diabetes and preeclampsia (Aiken and Brockelsby). In the largest study in the US UU., Which used data from a state registry of birth defects.

6.2% of children conceived with in vitro fertilization had significant defects, compared to 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).

Assisted reproduction technology carries a risk of heterotopic pregnancy (simultaneous intrauterine and extrauterine pregnancy). The main risks are:

Genetic disorders, in vitro fertilization and intracytoplasmic sperm injection, a risk factor is the decrease of protein expression in energy metabolism; Light chain of ferritin and the enzyme ATP5A1.

Preterm birth, low birth weight and premature births are strongly associated with many health problems, such as visual impairment and cerebral palsy, and children born after in vitro fertilization are approximately twice as likely to suffer from cerebral palsy .

Other risk factors are:

Damage to the membrane, which can be reflected by an increased expression of the membrane fusion proteins of the NAPA and Annexin A3 gene.

Sperm donation is an exception, with a birth defect rate of almost one fifth compared to the general population. It can be explained by the fact that sperm banks only accept people with a high sperm count.

Current data indicate little or no risk of postpartum depression among women using assisted reproductive technology.

The use of assisted reproductive technology, including ovarian stimulation and in vitro fertilization, has been associated with an increased overall risk of childhood cancer in the offspring, which may be caused by the same disease or original condition that caused infertility or subfertility. in the mother or the father.

That said, in a historical document by Jacques Balayla et al. It was determined that babies born after assisted reproductive technology have a neurological development similar to that of babies born after natural conception.

Use

Assisted reproduction technology procedures performed in the USA UU They have more than doubled in the last 10 years, with 140,000 procedures in 2006, which has resulted in 55,000 births.

In Australia, 3.1% of births are the result of assisted reproductive technology.

In case of interruption of fertility treatment, the most common reasons have been estimated:

  • Postponement of treatment (39%).
  • Physical and psychological burden (19%, psychological burden of 14%, physical burden of 6.32%).
  • Relational and personal problems (17%, personal reasons 9%, relational problems 9%).
  • Refusal of treatment (13%).
  • Organizational problems (12%)
  • Clinical problems (8%).

ethic

Some couples find it difficult to stop treatment despite a poor prognosis, resulting in useless therapies. This can give providers of assisted reproductive technology the difficult decision to continue or refuse treatment.

Some technologies of assisted reproduction can, in fact, be harmful for both the mother and the child.

Presenting a psychological and physical health risk, which may affect the continued use of these treatments. Adverse effects can cause alarm and should be strictly regulated to ensure that candidates are not only prepared mentally but physically.

Fictitious representation

Films and other works of fiction that represent the emotional struggles of assisted reproductive technology have seen an upturn in the latter part of the 2000s, although techniques have been available for decades.

However, the amount of people who can relate to her from personal experience in one way or another is growing, and the variety of trials and struggles are huge.

For specific examples, see fiction sections in individual sub-items, for example subrogation, sperm donation and fertility clinic.

In addition, reproduction and pregnancy in speculative fiction has been present for many decades.

Costs

U.S

Many Americans do not have insurance coverage for research and fertility treatments. Many states are beginning to demand coverage, and the usage rate is 278% higher in states with full coverage.

There are some health insurance companies that cover the diagnosis of infertility, but often once diagnosed they will not cover the costs of treatment.

2005: approximate costs of treatment / diagnosis (United States, costs in US $):

  • Initial treatment, hysteroscopy, hysterosalpingogram, blood analysis ~ $ 2,000.
  • Sonohisterograma (SHG) ~ $ 600 – $ 1,000.
  • Clomiphene citrate cycle ~ $ 200 – $ 500.
  • Fertilization cycle in vitro ~ $ 10,000 – $ 30,000.

The use of a surrogate mother to take the child depends on the arrangements

Another way to see the costs is to determine the expected cost of establishing a pregnancy. Therefore, if a treatment with clomiphene has the possibility of establishing a pregnancy in 8% of the cycles and costs $ 500.

The expected cost is $ 6,000 to establish a pregnancy, compared to an in vitro fertilization cycle (fertility cycle of 40%) with the corresponding expected cost of $ 30,000 ($ 12,000 / .4).

For the community as a whole, the cost of in vitro fertilization on average pays 700% for taxes on the future employment of the conceived human being.

United Kingdom

In the United Kingdom, all patients are entitled to preliminary tests, provided free of charge by the National Health Service. However, treatment is not widely available in the National Health Service and there may be long waiting lists.

Therefore, many patients pay for immediate treatment within the National Health Service or seek help in private clinics.

In 2013, the National Institute of Excellence in Health and Care published new guidelines on who should have access to in vitro fertilization treatment at the National Health Service in England and Wales.

The guidelines also say that women between 40 and 42 years old should be offered an in vitro fertilization cycle at the National Health Service if all of the following additional criteria are met.

They have never before received in vitro fertilization treatment, have no evidence of low ovarian reserve (this is when eggs in the ovary are low in number or of low quality) and have been informed of the additional implications of in vitro fertilization and pregnancy at this age.

However, if tests show that in vitro fertilization is the only treatment likely to help them become pregnant, women should be referred for in vitro fertilization immediately.

This policy is often modified by local clinical commissioning groups, in a fairly flagrant violation of the Constitution of the National Health Service for England.

That states that patients have the right to medications and treatments that have been recommended by the National Institute of Excellence in Health and Care for use in the National Health Service.

For example, the Clinical Commissioning Group of Cheshire, Merseyside and West Lancashire insists on additional conditions:

The person who undergoes the treatment must have begun the treatment before turning 40 years old. The person undergoing treatment must have a body mass index between 19 and 29. None of the members must have living children, either from the current or previous relationship. This includes adopted and biological children.

Subfertility should not be the direct result of a sterilization procedure in any of the parties (this does not include conditions in which sterilization occurs as a result of another medical problem).

Couples who have reversed their sterilization procedure are not eligible for treatment.

Sweden

In Sweden, official fertility clinics provide most of the necessary treatments and initial treatment, but there are long waiting lists, especially for egg donations, since the donor receives a reward as low as the one the couple receives.

However, there are private fertility clinics.

Canada

Some treatments are covered by OHIP (public health insurance) in Ontario and others are not. Those with bilaterally blocked fallopian tubes and those under 40 have the covered treatment, but are still required to pay the lab fees (about $ 3,000 – $ 4,000).

Coverage varies in other provinces. Most other patients must pay for the treatments themselves.

Israel

Israel’s national health insurance, which is mandatory for all Israeli citizens, covers almost all fertility treatments.

The costs of in vitro fertilization are fully subsidized until the birth of two children for all Israeli women, including single women and lesbian couples.

Embryo transfers for purposes of gestational surrogacy are also covered.

New Zealand

The National Public Health System of New Zealand covers in vitro fertilization treatment only in specific circumstances, based on an equation of “points for conception challenges”.

Publicly funded in vitro fertilization treatments are limited (between one and three treatments depend on the criteria) and are subject to substantial waiting lists, which depend on the local health financing region, which increases the potential inequity of health care support. assisted reproductive technology throughout the country.

Infertility tests through blood tests can be covered with public funds, however, in the absence of explicit gynecological complications, additional investigations may not be covered publicly.

Research such as a hysterosalpingogram may be covered, but the waiting list may exceed six weeks, while a private-source sonohysterogram may cost $ NZ900 but is available.

Many New Zealanders select self-funded in vitro fertilization cycles, at approximately $ NZ10,000 per cycle, and other forms of assisted reproductive technology.

Like intrauterine insemination, at approximately $ NZ1200, using the services of private fertility clinics, which in itself is a growing local industry.

People who use private services are generally not covered by personal health insurance policies in New Zealand.

Germany

On January 27, 2009, the Federal Constitutional Court ruled that it is unconstitutional, that health insurance companies must pay only 50% of the cost of in vitro fertilization.

On March 2, 2012, the Federal Council approved a bill of some federal states, which states that the federal government grants a subsidy of 25% of the cost. Therefore, the proportion of the costs generated by the pair would be reduced to only 25%.

Jordan

In Jordan, not everyone has insurance coverage for research and treatment of fertility. The army forces cover the members of the army for all the investigations and treatments of infertility. It also covers three trials of in vitro fertilization in cases of primary infertility.

Some insurance companies cover the diagnosis and treatment of infertility for people with government health insurance, but will not cover any of the techniques of assisted reproduction.

In the private sector, there are many centers offering private treatment for infertility, including assisted reproduction techniques. Conventional cost of in vitro fertilization 1170JD = 1654 US $, ICSI costs 1270 JD = 1797 US $ Both prices include assisted hatching.

But it does not include the cost of the medication, which averages between 500-700 JD, which is equivalent to between 700-1000 USD.