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1. Medical Treatment: with medications to correct hormonal imbalance that harms fertility (hormones).

2. Surgical Treatment: correction of anatomical abnormalities affecting the reproductive organs by microsurgery, video hysteroscopy, and/or video laparoscopy (including endometriosis).

3. Assisted Reproduction: ovulation induction (programmed intercourse), artificial insemination, and in vitro fertilization (ICSI or IMSI (Intracytoplasmic Morfologically Select Sperm Injection) – Hight Magnification Morfological Selection).

4. Egg Donation: if the woman cannot produce eggs.

5. Sperm Bank: if the man cannot produce spermatozoa.
Although all these treatments are important, ASSISTED FERTILIZATION TREATMENTS will be the main emphasis.

Assisted Fertilization Treatments

Assisted fertilization consists of lab techniques utilized by doctors and embryologists, in order to stimulate the fertilization of the egg by the sperm when it does not run its natural course. The medical procedures in assisted fertilization use rigorous techniques, require modern high precision technology, and use a specialized team.

Assisted reproductive technology can be classified according to the complexity:

A. Low Complexity
– Ovulation Induction – Programmed Intercourse.

B. Medium Complexity
– Artificial Insemination (AI) – Intrauterine Insemination (IUI)

C. High Complexity
– IVF (In Vitro Fertilization; Test Tube Baby IVF-ET)
– ICSI (Intracytoplasmic Sperm Injection)
– IMSI (Intracytoplasmic Morfologically Select Sperm Injection) – Hight Magnification Morfological Selection.

Ovulation Induction (Low Complexity)

Having all normal lab exams, the patient could have her ovulation induced by medications, in order to produce a large number of eggs during that month. The development is monitored by a series of transvaginal ultrasounds until the follicles reach an ideal size (synchronized with the development of the endometrium – which is the membrane that lines the interior of the uterus, where the implantation of the embryo happens). By hormone stimulation, the eggs must have a progressive development and reach an approximate size of 18 mm, and the endometrium, a thickness above 7 mm. Once reaching this ideal size (generally around the 12th to 14th day of the cycle), the ovulation occurs 24 to 36 hours after the injection of the appropriate medication (hCG). Starting from this moment, the doctor will give instructions as to the best time for intercourse. By having a large number of available eggs and the right time of ovulation, the chances of pregnancy are substantially greater when compared to a spontaneous cycle (without medication). The success rate for this method is around 12 to 15% per cycle. Although this rate is lower than the 20% determined for spontaneous pregnancy, as described in the first chapter, remember that the couples under treatment already have some difficulty in conceiving. Therefore, this success rate is lower than expected when the pregnancy is obtained naturally by couples without problems.
Artificial Insemination (AI) – Intrauterine Insemination (IUI) (Medium Complexity)

Artificial insemination, known since ancient times, is a therapeutic remedy of great value in the treatment of an infertile couple. Recommending this option is based on the impossibility or difficulty of the semen reaching the egg in the woman’s reproductive system (tubes), therefore, obstructing fertilization. The candidates of this therapeutic procedure are patients who present the following symptoms:

a) Poor or insufficient cervical mucus.
b) Sterility without Apparent Cause (SWAC), Unexplained Infertility.
c) Husbands with abnormal semen analysis (oligospermia, asthenospermia, or anatomical problems).
Important: Fertilization occurs in its natural environment, that is, in the tubes which have to be permeable.
Ovulation Induction, Technique and Day of Insemination

In the same manner as programmed intercourse, the ovaries are stimulated by hormones with the objective of obtaining a large number of eggs. The growth of these eggs is monitored by ultrasound until they reach a diameter of approximately 18 mm, and the endometrium, a thickness above 7 mm. Ovulation also occurs at the right moment by medication. The differences consist of the medication dosages used for ovarian stimulation and that the spermatozoa are placed inside the uterus, rather than by sexual intercourse.

Artificial insemination is a relatively simple procedure. It is performed in the doctor’s office, without anesthesia; it is painless; and it does not take more than a few minutes. With the patient in a gynecological position, the sperm is placed inside the uterus, near the inner openings of the tubes, by a catheter that passes delicately through the vagina and the cervical canal. After the insemination, the patient should remain lying down for around 20 minutes, in order for the semen to reach the interior of the tubes and for fertilization to occur. After this period, she can return to her daily activities. The success rate of IUI, following ovarian stimulation (super ovulation), is around 18 to 25% per cycle, but can reach to 50% after a few attempts. In cases where the male partner is a carrier of serious sperm disorders (azoospermia – lacking spermatozoa), frozen sperm can be used from an anonymous donor, through a Sperm Bank (see details described below).