Assisted reproductive technology - AbsoluteAstronomy.com

Assisted reproductive technology (ART) is a general term referring to methods used to achieve pregnancy

Pregnancy

Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

by artificial or partially artificial means. It is reproductive technology

Reproductive technology

Reproductive technology encompasses all current and anticipated uses of technology in human and animal reproduction, including assisted reproductive technology, contraception and others.-Assisted reproductive technology:...

used primarily in infertility

Infertility

Infertility primarily refers to the biological inability of a person to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term...

treatments. Some forms of ART are also used in fertile couples for genetic reasons

Preimplantation genetic diagnosis

In medicine and genetics pre-implantation genetic diagnosis refers to procedures that are performed on embryos prior to implantation, sometimes even on oocytes prior to fertilization. PGD is considered another way to prenatal diagnosis...

. ART is also used in couples who are discordant for certain communicable diseases, e.g. AIDS

AIDS

Acquired immune deficiency syndrome or acquired immunodeficiency syndrome is a disease of the human immune system caused by the human immunodeficiency virus...

, to reduce the risk of infection when a pregnancy is desired. The term includes any reproductive technique involving a third party e.g. a sperm donor. Examples of ART include in vitro fertilisation

In vitro fertilisation

In vitro fertilisation is a process by which egg cells are fertilised by sperm outside the body: in vitro. IVF is a major treatment in infertility when other methods of assisted reproductive technology have failed...

, intracytoplasmic sperm injection

Intracytoplasmic sperm injection

Intracytoplasmic sperm injection is an in vitro fertilization procedure in which a single sperm is injected directly into an egg.-Indications:...

(ICSI), cryopreservation

Cryopreservation

Cryopreservation is a process where cells or whole tissues are preserved by cooling to low sub-zero temperatures, such as 77 K or −196 °C . At these low temperatures, any biological activity, including the biochemical reactions that would lead to cell death, is effectively stopped...

, and intrauterine insemination (IUI). There is yet no strict definition of the term. Usage of the ART mainly belongs in the field of reproductive endocrinology and infertility

Reproductive endocrinology and infertility

Reproductive endocrinology and infertility is a surgical subspecialty of obstetrics and gynecology that trains physicians in reproductive medicine addressing hormonal functioning as it pertains to reproduction as well as the issue of infertility...

Definitions

While there is no consensus on the definition, generally the process of intercourse is bypassed either by insemination

Insemination

Insemination is the deliberate introduction of sperm into the uterus of a mammal or the oviduct of an oviparous animal for the objective of impregnating a female for reproduction...

(for example, artificial insemination

Artificial insemination

Artificial insemination, or AI, is the process by which sperm is placed into the reproductive tract of a female for the purpose of impregnating the female by using means other than sexual intercourse or natural insemination...

) or fertilization of the oocyte

Oocyte

An oocyte, ovocyte, or rarely ocyte, is a female gametocyte or germ cell involved in reproduction. In other words, it is an immature ovum, or egg cell. An oocyte is produced in the ovary during female gametogenesis. The female germ cells produce a primordial germ cell which undergoes a mitotic...

s in the laboratory environment (i.e., in vitro fertilization).

The Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...

(CDC)—which is required as a result of the 1992 Fertility Clinic Success Rate and Certification Act to publish the annual ART success rates at U.S. fertility clinics—defines ART to include "all fertility treatments in which both eggs and sperm are handled. In general, ART procedures involve surgically removing eggs from a woman's ovaries, combining them with sperm in the laboratory, and returning them to the woman's body or donating them to another woman." According to CDC, "they do not include treatments in which only sperm are handled (i.e., intrauterine—or artificial—insemination) or procedures in which a woman takes medicine only to stimulate egg production without the intention of having eggs retrieved."

Procedures

Procedures are mainly fertility medication

Fertility medication

Fertility medication are drugs which enhance reproductive fertility. For women, fertility medication is used to stimulate follicle development of the ovary...

, as well as ART techniques that use more substantial and forceful interventions, of which in vitro fertilization (IVF) and expansions of it (e.g. OCR, AZH, ICSI, ZIFT) are the most prevalent. However, there are also other manual ART, not necessarily dependent on IVF (e.g. PGD, GIFT, SSR).

Medication

Most fertility medication are agents that stimulate the development of follicles in the ovary. Examples are gonadotropins and gonadotropin releasing hormone.

In vitro fertilization

In vitro fertilization (IVF) is the technique of letting fertilization of the male and female gametes (sperm and egg) occur outside the female body.

Techniques usually used in in vitro fertilization include:

Transvaginal ovum retrieval (OCR) is the process whereby a small needle is inserted through the back of the vagina and guided via ultrasound into the ovarian follicles to collect the fluid that contains the eggs.
Embryo transfer
Embryo transfer
Embryo transfer refers to a step in the process of assisted reproduction in which embryos are placed into the uterus of a female with the intent to establish a pregnancy...

is the step in the process whereby one or several embryos are placed into the uterus of the female with the intent to establish a pregnancy.

Expansions of IVF

The following are techniques generally requires methods of in vitro fertilisation. In vitro fertilization, however, usually does not require these techniques.

Assisted zona hatching
Assisted zona hatching
Assisted zona hatching is a procedure of assisted reproductive technology in which a small hole is made in the zona pellucida, using a micromanipulation, thereby facilitating for zona hatching to occur.....

(AZH) is performed shortly before the embryo is transferred to the uterus. A small opening is made in the outer layer surrounding the egg in order to help the embryo hatch out and aid in the implantation process of the growing embryo.
Intracytoplasmic sperm injection
Intracytoplasmic sperm injection
Intracytoplasmic sperm injection is an in vitro fertilization procedure in which a single sperm is injected directly into an egg.-Indications:...

(ICSI) is beneficial in the case of male factor infertility where sperm counts are very low or failed fertilization occurred with previous IVF attempt(s). The ICSI procedure involves a single sperm carefully injected into the center of an egg using a microneedle. This method is also sometimes employed when donor sperm is used.
Autologous endometrial coculture
Autologous endometrial coculture
Autologous Endometrial Coculture is a technique of assisted reproductive technology. It involves placing a patient’s fertilized eggs on top of a layer of cells from her own uterine lining, creating a more natural environment for embryo development and maximizing the chance for an in vitro...

is a possible treatment for patients who have failed previous IVF attempts or who have poor embryo quality. The patient's fertilized eggs are placed on top of a layer of cells from the patient's own uterine lining, creating a more natural environment for embryo development.
In zygote intrafallopian transfer
Zygote intrafallopian transfer
Zygote intrafallopian transfer is an infertility treatment where a blockage in the fallopian tubes prevents the normal binding of sperm to the egg. Egg cells are removed from a woman's ovaries, and in vitro fertilised. The resulting zygote is placed into the fallopian tube by the use of laparoscopy...

(ZIFT), egg cells are removed from the woman's ovaries and fertilized in the laboratory; the resulting zygote is then placed into the fallopian tube.
Cytoplasmic transfer
Cytoplasmic transfer
Cytoplasmic transfer is an assisted reproductive technology , fertility technique whereby cytoplasm from a donor egg is injected into an egg with compromised mitochondria...

is the technique in which the contents of a fertile egg from a donor are injected into the infertile egg of the patient along with the sperm.
Egg donor
Egg donor
Egg donation is the process by which a woman provides one or several eggs for purposes of assisted reproduction or biomedical research. For assisted reproduction purposes, egg donation involves the process of in vitro fertilization as the eggs are fertilized in the laboratory. After the eggs...

s are resources for women with no eggs due to surgery, chemotherapy, or genetic causes; or with poor egg quality, previously unsuccessful IVF cycles or advanced maternal age
Advanced maternal age
Advanced maternal age is defined as an increase in the age at which women give birth to their first child, is now a widespread, and indeed near universal, phenomenon across the OECD countries....

. In the egg donor process, eggs are retrieved from a donor's ovaries, fertilized in the laboratory with the sperm from the recipient's partner, and the resulting healthy embryos are returned to the recipient's uterus.
Sperm donation
Sperm donation
Sperm donation is the provision by a man, , of his sperm, with the intention that it be used to impregnate a woman who is not usually the man's sexual partner, in order to produce a child....

may provide the source for the sperm used in IVF procedures where the male partner produces no sperm or has an inheritable disease, or where the woman being treated has no male partner.
A gestational carrier is an option when a patient's medical condition prevents a safe pregnancy, when a patient has ovaries but no uterus due to congenital absence or previous surgical removal, and where a patient has no ovaries and is also unable to carry a pregnancy to full term.
Preimplantation genetic diagnosis
Preimplantation genetic diagnosis
In medicine and genetics pre-implantation genetic diagnosis refers to procedures that are performed on embryos prior to implantation, sometimes even on oocytes prior to fertilization. PGD is considered another way to prenatal diagnosis...

(PGD) involves the use of genetic screening mechanisms such as Fluorescent In Situ Hybridization (FISH) or Comparative Genomic Hybridization (CGH) to help identify genetically abnormal embryos and improve healthy outcomes.
Embryo splitting can be used for twinning to increase the number of available embryos.

Others

The following Assisted Reproduction techniques don't necessarily involve IVF.

In gamete intrafallopian transfer
Gamete intrafallopian transfer
Gamete intrafallopian transfer is a tool of assisted reproductive technology against infertility. Eggs are removed from a woman's ovaries, and placed in one of the Fallopian tubes, along with the man's sperm...

(GIFT) a mixture of sperm and eggs is placed directly into a woman's fallopian tubes using laparoscopy following a transvaginal ovum retrieval.
Sex selection
Sex selection
Sex selection is the attempt to control the sex of the offspring to achieve a desired sex. It can be accomplished in several ways, both pre- and post-implantation of an embryo, as well as at birth...

is the attempt to control the sex of offspring to achieve a desired sex. It can be accomplished in several ways, both pre- and post-implantation of an embryo, as well as at birth. Pre-implantation techniques include PGD, but also sperm sorting
Sperm sorting
Sperm sorting is a means of choosing what type of sperm cell is to fertilize the egg cell. It can be used to sort out sperm that are most healthy, as well as determination of more specific traits, such as sex selection in which spermatozoa are separated into X- and Y- chromosome bearing...

.
Artificial insemination
Artificial insemination
Artificial insemination, or AI, is the process by which sperm is placed into the reproductive tract of a female for the purpose of impregnating the female by using means other than sexual intercourse or natural insemination...

(AI) is when sperm is placed into a female's uterus (intrauterine) or cervix (intracervical) using artificial means rather than by natural copulation. N.B. This can be a very low-tech process, performed at home by the woman alone or with her partner.
- Conception device
  Conception device
  A conception device is a medical device which is used to assist in the achievement of a pregnancy, often, but not always, by means other than sexual intercourse or NI...
  
  s, such as a conception cap are used to aid conception by enhancing the natural process. Conception caps are used by placing semen
  Semen
  Semen is an organic fluid, also known as seminal fluid, that may contain spermatozoa. It is secreted by the gonads and other sexual organs of male or hermaphroditic animals and can fertilize female ova...
  
  into a small conception cap, then placing the cap onto the cervix
  Cervix
  The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
  
  . This holds the semen at the cervical os, protecting the semen from the acidic vaginal secretions and keeping it in contact with the cervical mucus.
- Artificial insemination by donor is used in situations where the woman doesn't have a partner with functional sperm. Instead, a sperm donor supplies the sperm.
Surrogacy
Surrogacy
Surrogacy is an arrangement in which a woman carries and delivers a child for another couple or person. This woman may be the child's genetic mother , or she may carry the pregnancy to delivery after having an embryo, to which she has no genetic relationship whatsoever, transferred to her uterus...

, where a woman agrees to become pregnant and deliver a child for a contracted party. It may be her own genetic child, or a child conceived through in vitro fertilization or embryo transfer
Embryo transfer
Embryo transfer refers to a step in the process of assisted reproduction in which embryos are placed into the uterus of a female with the intent to establish a pregnancy...

using another woman's ova
Ovum
An ovum is a haploid female reproductive cell or gamete. Both animals and embryophytes have ova. The term ovule is used for the young ovum of an animal, as well as the plant structure that carries the female gametophyte and egg cell and develops into a seed after fertilization...

.
Reproductive surgery
Reproductive surgery
Reproductive surgery is using surgery in the field of reproductive medicine. It can be used for contraception, e.g. in vasectomy, wherein the vasa deferentia of a man are severed, but is also used plentifully in assisted reproductive technology....

, treating e.g. fallopian tube obstruction
Fallopian tube obstruction
Fallopian tube obstruction is a major cause of female infertility. Blocked fallopian tubes are unable to let the ovum and the sperm converge, thus making fertilization impossible. Fallopian Tubes are also known as oviducts, uterine tubes, and salpinges .-Types:About 20% of female infertility can be...

and vas deferens obstruction, or reversing a vasectomy
Vasectomy
Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed in a manner such to prevent sperm from entering into the seminal stream...

by a reverse vasectomy
Reverse vasectomy
Vasectomy reversal is a term used for surgical procedures that reconnect the male reproductive tract after interruption by a vasectomy. Two procedures are possible at the time of vasectomy reversal: vasovasostomy and vasoepididymostomy...

.
- In surgical sperm retrieval (SSR) the reproductive urologist obtains sperm from the vas deferens, epididymis or directly from the testis in a short outpatient procedure.
By cryopreservation
Cryopreservation
Cryopreservation is a process where cells or whole tissues are preserved by cooling to low sub-zero temperatures, such as 77 K or −196 °C . At these low temperatures, any biological activity, including the biochemical reactions that would lead to cell death, is effectively stopped...

, eggs, sperm and reproductive tissue can be preserved for later IVF.

Risks

The majority of IVF-conceived infants do not have birth defect

Congenital disorder

A congenital disorder, or congenital disease, is a condition existing at birth and often before birth, or that develops during the first month of life , regardless of causation...

s.
However, some studies have suggested that assisted reproductive technology is associated with an increased risk of birth defects.
In the largest U.S. study, which used data from a statewide registry of birth defects,
6.2% of IVF-conceived children had major defects, as compared with 4.4% of naturally conceived children matched for maternal age and other factors (odds ratio

Odds ratio

The odds ratio is a measure of effect size, describing the strength of association or non-independence between two binary data values. It is used as a descriptive statistic, and plays an important role in logistic regression...

, 1.3; 95% confidence interval

Confidence interval

In statistics, a confidence interval is a particular kind of interval estimate of a population parameter and is used to indicate the reliability of an estimate. It is an observed interval , in principle different from sample to sample, that frequently includes the parameter of interest, if the...

, 1.00 to 1.67).

The main risks are:

Genetic disorder
Genetic disorder
A genetic disorder is an illness caused by abnormalities in genes or chromosomes, especially a condition that is present from before birth. Most genetic disorders are quite rare and affect one person in every several thousands or millions....

s. DNA damage increases in e.g. IVF and ICSI, which is reflected e.g. by upregulation of the gene expression
Gene expression
Gene expression is the process by which information from a gene is used in the synthesis of a functional gene product. These products are often proteins, but in non-protein coding genes such as ribosomal RNA , transfer RNA or small nuclear RNA genes, the product is a functional RNA...

of HNRNPC
HNRNPC
Heterogeneous nuclear ribonucleoproteins C1/C2 is a protein that in humans is encoded by the HNRNPC gene.It is abnormally expressed in fetuses of both IVF and ICSI, which may contribute to the increase risk of birth defects in these ART.-Function:...

in the placenta.
Low birth weight
Low birth weight
Low birth weight is defined as a birth weight of a liveborn infant of less than 2,500 g. regardless of gestational age-Causes:LBW is either the result of preterm birth or of the infant being small for gestational age , or a combination of...

. In IVF and ICSI, a risk factor is the decreased expression of proteins in energy metabolism; Ferritin light chain
Ferritin light chain
Ferritin light chain is a protein that in humans is encoded by the FTL gene.It is abnormally expressed in fetuses of both IVF and ICSI, which may contribute to the increase risk of birth defects in these ART....

and ATP5A1
ATP5A1
ATP synthase subunit alpha, mitochondrial is an enzyme that in humans is encoded by the ATP5A1 gene.-Further reading:...

.
Preterm birth. Low birth weight and preterm birth are strongly associated with many health problems, such as visual impairment
Visual impairment
Visual impairment is vision loss to such a degree as to qualify as an additional support need through a significant limitation of visual capability resulting from either disease, trauma, or congenital or degenerative conditions that cannot be corrected by conventional means, such as refractive...

and cerebral palsy
Cerebral palsy
Cerebral palsy is an umbrella term encompassing a group of non-progressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement....

, and children born after IVF are roughly twice as likely to have cerebral palsy.

Other risk factors are:

Membrane damage, which is contributed to or reflected by increased expression of the membrane fusion protein
Membrane fusion protein
Membrane fusion proteins are membrane proteins which cause more than one membrane to combine.Examples include:* SNARE , such as VAMP* Gp41...

s NAPA
NAPA (gene)
N-ethylmaleimide-sensitive factor attachment protein, alpha, also known as NAPA or alpha-SNAP, is a human gene.It is abnormally expressed in fetuses of both IVF and ICSI, which may contribute to the increase risk of birth defects in these ART....

and Annexin A3
Annexin A3
Annexin A3 is a protein that in humans is encoded by the ANXA3 gene.It is abnormally expressed in fetuses of both IVF and ICSI, which may contribute to the increase risk of birth defects in these ART.-Further reading:...

.

Sperm donation

Sperm donation is the provision by a man, , of his sperm, with the intention that it be used to impregnate a woman who is not usually the man's sexual partner, in order to produce a child....

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

Current data indicate little or no increased risk for postpartum depression

Postpartum depression

Postpartum depression , also called postnatal depression, is a form of clinical depression which can affect women, and less frequently men, typically after childbirth. Studies report prevalence rates among women from 5% to 25%, but methodological differences among the studies make the actual...

among women who use ART.

Usage

Assisted reproductive technology procedures performed in the U.S. has more than doubled since 10 years ago, with 140.000 procedures in 2006, resulting in 55.000 infants born.

In Australia

Australia

Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...

, 3.1 percent of babies now born are a result of ART.

United States of America

Not everyone in the U.S. has insurance

Health insurance

Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...

coverage for fertility investigations and treatments. Many states are starting to mandate coverage, and the rate of utilization is 277% higher in states with complete coverage.

There are some health insurance companies that cover diagnosis of infertility but frequently once diagnosed will not cover any treatment costs.

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

Initial workup: hysteroscopy
Hysteroscopy
Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention .-Method:...

, hysterosalpingogram, blood test
Blood test
A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick....

s ~$2,000
Intrauterine Insemination (IUI) aka Artificial insemination ~ $200– 900 per. trial
Sonohysterogram (SHG) ~ $600 – 1,000
Clomiphene citrate cycle ~ $ 200 – 500
IVF cycle ~ $10,000 -30,000
Use of a surrogate mother to carry the child – dependent on arrangements

Another way to look at costs is to determine the expected cost of establishing a pregnancy. Thus if a clomiphene treatment has a chance to establish a pregnancy in 8% of cycles and costs $500, the expected cost is $6,000 to establish a pregnancy, compared to an IVF cycle (cycle fecundity 40%) with a corresponding expected cost of $30,000 ($12,000/.4).

For the community as a whole, the cost of IVF on average pays back by 700% by tax from future employment by the conceived human being.

United Kingdom

In the UK all patients have the right to preliminary testing, provided free of charge by the National Health Service

National Health Service

The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...

. However, treatment is not widely available on the NHS and there can be long waiting lists. Many patients therefore pay for immediate treatment within the NHS or seek help from private clinics.

Sweden

In Sweden, official fertility clinics provide most necessary treatments and initial workup, but there are long waiting lists, especially for egg donations, since the donor gets just as low reward as the receiving couple are charged. However, there are private fertility clinics.

Canada

Some treatments are covered by OHIP (public health insurance) in Ontario and others are not. Those undergoing artificial insemination or with bilaterally blocked fallopian tubes and under 40 have treatment is covered but are still required to pay lab fees (around $3,000–4,000). Coverage veries in other provinces. Most other patients are required to pay for treatments themselves.

Israel

Israel's National Health Insurance, which is mandatory for all Israeli citizens, covers nearly all fertility treatments. In-Vitro-Fertilization costs are fully subsidized up to 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 IVF treatment in specific circumstances only, based on a 'points for conception challenges' equation. Publicly funded IVF treatments are limited (between one and three treatments dependent on criteria) and are subject to substantial wait-lists, dependent on local health funding region, which raises potential inequity of ART support across the country. Infertility testing through blood tests can be covered by public funding, however in the absence of explicit gynecological complications, additional investigations are may not be covered publicly. Investigation such as a hysterosalpingogram may be covered, but the wait-list could be in excess of six weeks, whereas a privately sourced HSG can cost $NZ900 but is readily available. Many New Zealanders select self-funded IVF cycles, at approximately $NZ10,000 per cycle, and other forms of ART, such as IUI, at approximately $NZ1200, using the services of private fertility clinics, which in itself is a growing local industry. Individuals using private services are generally not covered under personal health insurance policies in New Zealand.

Ethics

Some couples find it difficult to stop treatment despite very bad prognosis, resulting in futile therapies. This may give ART providers a difficult decision of whether to continue or refuse treatment.

For treatment-specific ethical considerations, see entries in individual subarticles, e.g. In vitro fertilisation, Surrogacy and Sperm donation

Fictional representation

Films and other fiction depicting emotional struggles of assisted reproductive technology have had an upswing in the latter part of the 2000s decade, although the techniques have been available for decades. Yet, the amount of people that can relate to it by personal experience in one way or another is ever growing, and the variety of trials and struggles are huge.

For specific examples, refer to the fiction sections in individual subarticles, e.g. surrogacy, sperm donation and fertility clinic

Fertility clinic

Fertility clinics are staffed medical clinics that assist couples, and sometimes individuals, who want to become parents but for medical reasons have been unable to achieve this goal via the natural course...

.

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

External links

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