Sterility is the inability of an individual or a couple to conceive naturally.
Infertility and Sterility
What is infertility?
Infertility is the inability of a couple to get pregnant and take that pregnancy to term with a healthy live born child.
What kinds of sterility can we encounter?
Primary sterility
When a couple has had relations for one year without getting pregnant.
Secondary sterility
When a couple, after having had their first child, cannot get pregnant in the subsequent two to three years.
What kinds of infertility can we encounter?
Primary infertility
When a couple gets pregnant but cannot carry out the pregnancy to term with a healthy live born child.
Infertilidad secundaria
When a couple, after having had a previous pregnancy and birth, is unable to get pregnant and carry out that pregnancy to term with a healthy live born child.
Causes of Infertility
How does age influence a woman’s fertility?
It is a fact that a woman is less fertile with the passing of time. Several reasons exist that explain this:
— The age of a woman’s eggs. Women are born with a set number of oocytes that do not divide. Therefore, with the passing of time there exists the real possibility that the oocytes have poor quality. This can lead to embryos that do not develop correctly.
— The probability of embryos that will lead to errors in implantation and subsequent spontaneous abortions increases.
— The number of follicles and oocytes diminishes progressively.
— There is a greater chance of developing endometriosis and fibroids which are two of the leading causes of infertility.
How does a man´s age influence fertility?
The male also becomes less fertile with time. However, the incidence is less and generally occurs after the age of 50.
What are polycystic ovaries?
This pathology is defined as an endocrinological dysfunction that is characterized by irregular menstrual periods or even an absence of periods, an increase in facial and body hair and characteristic images of the ovaries on ultrasound.
What is anovulation?
An anovulatory cycle occurs when an oocyte is not expelled by the ovary because it has not developed or it has not reached maturity. Therefore, ovulation is not produced and subsequently neither is a pregnancy. Approximately 35% of women at some point in their life present with anovulation. The origin of this hormonal alteration can be produced by the hypothalamus, the pituitary or the ovary itself.
Factors that influence fertility
How does weight affect male fertility?
Men who have a body mass index (BMI) of less than 20 are at an increased risk of lower sperm production. A BMI greater than the recommended 28 can also harm male fertility and can cause a 22% reduction in sperm count. A low sperm count is one of the main factors of infertility in the male.
How does weight affect female fertility?
Women who have a low BMI are likely to experiment pauses in their menstrual cycles or irregular cycles that can cause female infertility. Gaining weight to a normal BMI will regulate the cycles in the majority of women.
A BMI that is high can cause harm to fertility as well. Women with an increased BMI frequently experiment changes in their cycle. The percentage of women with an increased body mass index who have problems ovulating reaches 30 – 40%.
How does tobacco affect fertility?
Studies have shown that when it comes to female fertility, smoking has adverse effects. When smokers versus nonsmokers are compared, smokers have more infertility and take longer to conceive. Smoking by either member of the couple has adverse effects. The impact on fertility to the exposure of secondhand smoke is slightly less than active smoking. Smoking seems to accelerate the loss of oocytes and reproductive function. This can cause early menopause.
Men present with a lower sperm count, lower motility and worse anomalies in the morphology and function of sperm. The effect of smoking on male fertility is harder to discern because it is difficult to set up research studies to address this issue. Although the effects of smoking on male fertility are not conclusive, the damaging effects on fertility of secondhand smoking to the partner and the negative quality of sperm acquired suggest that smoking by the male should be considered a negative risk factor on fertility.
How does alcohol affect fertility?
In the male, the considerable consumption of alcohol, according to different studies, can cause a lower sperm count, lower testosterone levels and an increase in estrogen levels. Women who drink alcohol can have irregular menstrual cycles and can also have anovulatory cycles (periods without ovulation).
What tests does the infertility work up include?
In order to study your case, our doctors begin with a thorough clinical history and complete physical exam. Generally the tests will include the following:
– In the case of the female patient: blood tests, hormone levels, vaginal ultrasound, a trial transfer and a hysterosalpingogram.
– In the case of the male patient: blood tests, semen analysis where the number, activity and morphology of the semen are studied.
What is a semen analysis?
This analysis consists of obtaining a semen sample, preferably through masturbation, so that it can be evaluated by our laboratory for quantity and quality. There needs to be a 3-5 day abstinence period prior to obtaining the sample.
What is a hysterosalpingogram?
This technique consists of a contrast being injected into the uterus that subsequently passes through the fallopian tubes. An X-ray is taken and we are able to visualize if the tubes are obstructed by the inability of the contrast to flow through them. The radiation necessary for this test is minimal and does not pose any risk. Anesthesia is not necessary. The procedure may produce discomfort but the patient is able to resume normal daily activity.
Initial visit
When should I make an appointment for an initial visit?
There is no established recommendation as to when one should undergo reproductive treatment as there is no age limit either. However, the average monthly pregnancy rate for a couple is 25%. More than half of these couples will become pregnant in six months and the majority of these couples will become pregnant within the first year. Therefore, it seems reasonable to recommend an initial appointment after several months of trying with a maximum of one year.
The goal of the initial visit is to find out the current state of the couple as well as their history. We also carry out a full physical examination and recommend the diagnostic testing necessary. We do this so we can have all the data to begin studying each individual case. After this visit, we assign the couple to a working group made up of different specialists based on the characteristics of the case. This group of specialists will be the couple´s guide during the entire process and will be available to answer any questions or doubts that arise during the study and throughout the treatment.
What type of documentation do I need to bring to my initial visit?
During your initial visit at Bionac, you will need to bring all your blood work and medical reports regarding any fertility work up you may have undergone. This includes treatment cycles in other centers. You will also need your National Identity card. In the case of the male patient, we will need to order another semen analysis regardless of already having had one.
Treatments
Do I have to sign a document before I undergo treatment?
Yes, it is required by law that patients sign an informed consent specific to the the reproductive assisted technique applied. This is also true for some of the diagnostic procedures. Having signed these documents, you state that you have been correctly informed of the medical, biological and judicial aspects of these treatments, that you understand and accept the conditions.
Likewise, prior to your specific treatment, you will have the budget for the treatment including all the phases explained to you. The budget proposal will also have to be signed and turned in.
What are the risks to patients that undergo a reproductive assisted treatment?
In general, the risks to patients are very low. Nevertheless, it is necessary to let you know the major risks:
Ovarian hyperstimulation syndrome. This syndrome is produced due to the reaction the patient has to the treatments. The hormones produce an excessive number of eggs. This generates abdominal discomfort for several days. Our gynecologists will inform you if you are at risk for this syndrome during the hormone monitoring. In the worst case scenario, the gynecologist will cancel the treatment.
The other risk worth mentioning is multiple gestations. With assisted reproductive techniques, if 3 embryos are transferred, the percentage of twins is 20%-25% and the percentage of triplets is 4%. If the patients do not want to expose themselves to this possibility, they can tell their gynecologist before deciding on the number of embryos to transfer. In those cases in which a multiple gestation occurs and the pregnancy poses a risk to the patient, an embryo reduction can be performed.
What is ovarian stimulation?
It consists of inducing multiple ovulation in a patient by means of hormones with the objective of obtaining more than one egg per cycle. This makes the transfer of more than one embryo possible. Furthermore, it permits us to guarantee and anticipate the maturity of the eggs and the exact moment of ovulation. This phase usually lasts an average of 12 -14 days.
What does the hormone monitoring phase consist of?
During ovarian stimulation the patient will need to come to our center daily or every other day to check estradiol levels through a blood test. Estradiol is the hormone that is produced by the growing follicle. A transvaginal ultrasound will also be performed to see how many follicles are developing and to determine their size. Depending on these results, that same day our gynecologists will evaluate the cycle and adjust the dose of the hormones needed to obtain the best possible results for your follicles.
Will the same gynecologist see me throughout my treatment?
Our medical team is truly a cohesive group and even though we will always try to have you see the same gynecologist, there are times that this is simply not convenient for the patient. One of our objectives is to not waste your time by having you wait. Having said this, our medical team has a daily meeting where they evaluate every cycle of every patient so that all our gynecologists are up to date on each patient.
When do I know how many oocytes have been extracted?
After the egg retrieval, the oocytes are taken to the lab to be analyzed and counted. The patient will have this information before they are discharged home.
Do all oocytes have the same quality?
Not all oocytes obtained have the same quality and this can be seen by the fact that not all follicles will develop in the same way during ovarian stimulation. After the egg retrieval, the mature, immature and the morphologically abnormal oocytes can be distinguished. The immature and the morphologically abnormal oocytes cannot be used for treatment.
How is a semen sample obtained?
The sample is generally obtained by masturbation in a sterile recipient. Our biologists will transfer the sample and it will be tagged and treated for optimal results. Normally, the sample is obtained in our clinic, but for those patients with difficulties, we offer the option of bringing the sample from home. This can only be done if the sample is brought to our clinic within 45 minutes of producing the sample.
What happens if the patient cannot produce a semen sample?
When patients have difficulty obtaining a sample, they can bring it to the clinic from home within 45 minutes of producing the sample. In some cases, cryopreservation of semen will be recommended if there is an abnormality diagnosed by the semen analysis or if the patient is unavailable on the days indicated for treatment.
How many eggs are usually extracted during an oocyte retrieval?
Not all follicles aspirated will have an oocyte inside. The lab will see if the oocytes retrieved are suitable for fertilization. The number of oocytes obtained will depend on different factors such as age, pathology and the response to treatment the patient has. The average number of oocytes obtained is 5 to 10 in a 35 year old woman . The average number of embryos fertilized is 3 to 6 in a 35 year old woman. A single embryo is sufficient for there to be a possibility of a pregnancy. Therefore, you should not be worried if the number of oocytes obtained or the number of embryos fertilized is low.
Which embryos are selected for transfer?
As expected, the embryos having the best quality are transferred. The number of embryos transferred will depend on the age and clinical history of the patient as well as the quality of the embryos. The final decision regarding the number of embryos transferred is made by the patients with 3 being the legal maximum.
What is the outcome of the embryos not transferred?
Good quality embryos not transferred or those that are maintained in culture and develop into blastocysts will be cryopreserved for future treatments.
What are the scheduling demands for these treatments?
Artificial Insemination
During the cycle, the patient will need to come to the clinic an average of 4 to 5 times to undergo monitoring. The duration of each visit is approximately 10 minutes.
The actual insemination is a process that requires another 10 minutes. The patient will need to rest for 15 minutes after the procedure and then will be able to resume normal daily activity.
In vitro fertilization
During the cycle the patient will need to be monitored an average of 10 to 12 days approximately every 48 hours. The duration of each visit is 10 minutes.
The egg retrieval itself takes about 30 minutes. The postoperative time that the patient will stay in one of our hospital rooms is an average of 3-4 hours before they are able to go home.
Within days 3 and 5 post egg retrieval, the patient will need to return to our clinic for the embryo transfer. This process lasts 30 minutes. Then the patient will have to be at rest for another 15 minutes before they can go home and resume normal daily activities.
Egg donation
During the cycle the patient will need to come to the clinic for monitoring with the objective of making sure that the endometrium is developing correctly. The patient will need to come for an average of three visits once a week with the first visit being the initiation of treatment.
Within the 3 to 5 days after the last ultrasound appointment, the patient will need to return to the clinic to undergo the embryo transfer. This procedure lasts 30 minutes. The patient will then need to rest for 15 minutes before she is able to go home and resume normal daily activity.
If the patient does not live in Seville or it is impossible for the patient to come to the routine appointments in our clinic, these visits can be carried out by another gynecologist closer to where the patient resides. However, this needs to be set up prior to the cycle. This would include our clinic coming in contact with the other clinic and sending them all the pertinent information. This way the patient would only need to come to our clinic the day of the egg retrieval and the embryo transfer.
When do I know if I´m pregnant?
We will do a blood test to check the pregnancy hormone (Beta hCG) 11 days after the embryo transfer. If it is positive, you are pregnant and you will be informed immediately.
Are there any differences between a pregnancy that is achieved spontaneously and one that is achieved through assisted reproductive techniques?
No. There are no differences. The development of a pregnancy by assisted reproductive techniques is the same as the development that occurs with a spontaneous pregnancy. The weeks of embryo development correspond to the same weeks in a spontaneous pregnancy. There are no delays or advances in the growth of the baby that has been achieved through assisted reproductive techniques.
Egg donation (recipient)
What does the Spanish law say regarding the donation of eggs or semen?
Oocyte donation is regulated by the 1988 Spanish legislation. This guarantees that the medical and biological processes involved concerning the donor and embryo´s health are at all times ethical. Oocyte donation is a voluntary, altruistic and anonymous act. Oocyte donors have to be between 18 and 35 years of age.
The commerce for profit of oocytes, sperm and embryos is prohibited by Spanish law. Oocytes will be used exclusively to help a woman have a desired child. The Human Assisted Reproduction National Commission, an organization created to give counsel on the development of this law, advises that the donors will receive an economic compensation for their dedication and time necessary to carry out the full treatment.
Also the law specifies that there must be strict anonymity between recipient and donor at the time of donation and in the future. This implies that the donor can never know, see or choose the recipient of their gametes. The recipient will also not be allowed to know, see or choose the donor. This ensures total anonymity in the donation process.
The different tests that are necessary for donors to undergo can be found regulated by the human assisted reproduction technology law 14/2006 and the Royal Decrees 412/1996 and 1301/2006.
Who selects the oocyte donor?
The egg donor selection is the responsibility of the medical team in our clinic along with our nursing staff. When making this decision our team takes into account all the phenotypical characteristics such as their build, eye color, skin color and type of hair as well as their blood type and Rh group.
Do egg donors have to undergo certain tests to make sure they are healthy
Yes, and we also have to study their family history. Before a person is able to enter our donation program, they have to pass a series of strict evaluations and exams which include the following:
Informative interview where they will understand their rights and duties as a donor.
Psychological evaluation
Medical interview that will allow us to rule out genetic disorders by family and personal history.
Blood analysis
Serologies (hepatitis B and C, HIV, syphilis, rubella)
Blood type
Karyotype to rule out chromosomal abnormalities
Genetic analysis to rule out Cystic Fibrosis carrier and hemoglobin electrophoresis
to rule out some genetic anemias
Additional genetic evaluation in certain cases
Gynecological exam
Pap smear
Cervical cultures
Transvaginal ultrasound
Interview with the nursing staff to make sure the donor understands how to carry out the treatment
Is this treatment painful?
No, the recipient only receives treatment with transdermal estrogen patches and vaginal progesterone ovules that will allow us to synchronize the cycle until the embryo transfer.