Treatment Approaches
- Treatment Introduction
- Intrauterine Insemination (IUI)
- Hysteroscopy
- Laparoscopy
- In Vitro Fertilization & Embryo Transfer
- Intracytoplasmic Sperm Injection (ICSI)
- Embryo Cryopreservation
- Assisted Hatching
- Ovulation Induction
- Preimplantation Genetic Diagnosis (PGD)
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In Vitro Fertilization & Embryo Transfer
In vitro fertilization is the process where sperm are allowed to fertilize the eggs in a petri dish with a micro-culture environment in a technologically highly advanced laboratory. The fertilized eggs are then grown for 2 to 6 days in sophisticated embryo incubators before transfer to the mother’s uterus. This allows correction and bypassing of certain causes of infertility such as blocked fallopian tubes or severe endometriosis. Many IVF laboratories do not have the equipment or scientific expertise to support the early embryo until the blastocyst stage (day 5) when it usually arrives in the uterus from the fallopian tube. The science of simulating the functions of the human fallopian tube inside of an incubator has been a work in progress for more than thirty years.
Dr. Marius Meintjes has a well earned reputation as an innovator and international authority concerning laboratory methods associated with high IVF/ET success rates. He has been a leader in the advancement of the use of sequential media since it became clear that the normal fallopian tube support a developing embryo’s changing metabolic requirements during the tubal sojourn. He has designed and published the studies indicating that the oxygen concentrations in room air are detrimental to embryonic development and that certain proteins, when added to culture media, favor improved pregnancy outcomes.
Fallopian tube vs. incubator
As seen in a drawing published in a work by Dr. Papanicolaou (the originator of the Pap smear) sixty years ago, the fallopian tube at the time of ovulation has two conspicuous cell types. Cilia (green arrow) move the egg to the rendezvous with sperm and then retain the fertilized egg in the tube for 3-5 days awaiting the optimal development of the uterine lining (endometrium). Secretory cells (red arrow) are responsible for achieving a tubal environment that not only fosters fertilization but also the development of the embryo over the first several days of its existence.
Most IVF programs in this country and abroad have laboratory equipment and techniques that will only support the development of a human embryo until the 8-cell stage. Below (A), an 8-cell embryo that is three days post fertilization appears to have some promise with respect to becoming a baby. However the unequal size of the cells (blastomeres) increases the likelihood that the embryo could be unhealthy and will shortly self-destruct. If a laboratory cannot sustain embryonic development for an additional two days there will be the inclination to transfer this embryo and typically two others in the hope that one will become a healthy baby and those embryos that are unhealthy will simply fade away. This is a classic circumstance leading to a triplet (occasionally more should an embryo split and become two) pregnancy. Whether high-order multiple gestations lead to increased health risks for mother and babies is not debatable (see Risks of twins and Complications of multiple births-ASRM).
An ideal would be to allow two days of additional development in the incubator. Over those 48 hours an embryo is expected to demonstrate considerable advancement (B). The zona pellucida (ZP), the membrane that surrounds the embryo, has become very thin relative to the 8-cell stage indicating that “hatching” is imminent. The inner cell mass (double green arrows) which represents the baby to be and the trophectoderm (red arrow) which will become the placenta are now clearly discernable. Because there is a near 80% likelihood that this embryo will become a baby it is reasonable to transfer a single blastocyst and cryopreserve others that have advanced to this stage.