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Before you begin your fertility treatment, bear in mind that there is no such thing as a standard course of treatment. There's no point in comparing your pregnancy plans with those of other couples. Your fertility program will be personalised according to your own history: your medical and family history, your clinical characteristics, your age, etc.
According to the World Health Organisation, infertility is defined as 'the inability of a couple to conceive a child after more than twelve months of regular sexual intercourse without operating contraception'. It is, therefore, necessary to consult a gynaecologist after this period. If the woman is over 35, it is recommended that this consultation takes place within six months of unsuccessful attempts.
It is essential that both members of the couple are present at this consultation. During the consultation, the gynaecologist will talk to the couple about their desire to have a child. The medical, surgical, and family history of each couple will be discussed. This interview is followed by a gynaecological examination, to which additional tests are added for both men and women. The aim of these tests is to identify potential infertility in either men or women.
Fertility tests performed on women
Hormone check-up
The purpose of this blood test is to analyse the functioning of a woman's endocrine system: abnormalities in hormone secretion that may impair female reproductive function. More specifically, FSH, LH, AMH, 17β-estradiol, and progesterone are measured.
Pelvic ultrasound
It is used to assess the AFC (antral follicle count). Combined with the AMH assay, this indicator makes it possible to estimate the ovarian reserve, i.e. the number of follicles capable of developing with a view to ovulation. The thickness of the endometrium is also measured.
Hysterosalpingography
This is an X-ray examination that uses a contrast medium to analyse the uterus and fallopian tubes. This examination can detect various uterine pathologies that may be responsible for infertility (fibroids, endometriosis, polyps, blocked tubes, etc...).
Fertility tests performed on men
Spermogram
The spermogram is used to identify male infertility. The aim of this examination is to study the composition and appearance of the sperm (volume ejaculated, pH, viscosity of the ejaculate, number, mobility, morphology, and viability of the spermatozoa).
Spermocytogram
A complement to the spermogram, the spermocytogram consists of studying the quality of the sperm after staining the spermatozoa. In particular, it is used to detect morphological abnormalities in spermatozoa (abnormalities of the head, intermediate piece, and flagellum).
Sperm culture
This test looks for the presence of bacterial infections in the sperm. These are totally abnormal and can be the cause of male infertility. If the sperm culture is positive, antibiotics will be prescribed.
This consultation with the gynaecologist takes place after both members of the couple have undergone the prescribed fertility tests. The results are explained to the patients, and the causes of the infertility (male, female, or mixed) can then be determined. In some cases, however, the causes may remain unexplained, as no abnormality or pathology was detected during the fertility test. This is known as idiopathic infertility.
At this stage, infertility has been diagnosed and the causes are known. You will then be referred for fertility care. You will then be shown all the techniques and protocols operated, as well as the success rates.
This meeting takes place in the absence of patients. It brings together the entire medical team (gynaecologists and biologists). During this meeting, the clinicians decide which technique will be most suitable for the couple's medically assisted reproduction care.
This decision is based on the results of the fertility test (hormonal assessment, hysterosalpingography, ultrasound, sperm analysis) and your patient characteristics (family history, age, diagnosed pathologies).
This meeting is the opportunity to complete the administrative file (identity documents, birth certificate, procedure for requesting reimbursement for medical acts). Consents are signed at this meeting. In this way, the couple validates their chosen fertility program. Patients may also consent to the freezing of potential embryos (this consent is not obligatory; the couple may refuse to freeze).
In some centres, this meeting may be followed by an interview during which the medical team will tell you exactly what type of fertility pathway will be operated during your infertility treatment. This is also an opportunity to ask any questions you may have and to discuss any issues that are of concern to you.
Your file has been created: you can start your MAP program!
It takes place between the first and third days of your period. The aim of this consultation is to obtain a prescription for ovarian stimulation treatment. Each fertility protocol is based on an ovarian stimulation phase, during which the patient self-administers a hormonal treatment (in the form of medication and injections).
Successful ovarian stimulation is crucial for the rest of the fertility process. The chances of success depend largely on this phase. Treatment errors are common! Make sure you understand all the instructions and tell your gynaecologist about any hesitations, questions, or doubts you may have during this consultation.
The ovarian stimulation phase lasts an average of 2 to 3 weeks. There is no precise duration of treatment, which essentially depends on the patient's response to the hormones. The progress of this phase is checked by the gynaecologist every 48 hours from the tenth day onwards. This is known as ovarian monitoring.
Monitoring the ovaries during ovarian stimulation :
Ultrasound
Ultrasound can quantify the number of follicles growing in the ovary. Each follicle contains an oocyte that can be fertilised by a spermatozoon. Ovulation will be triggered when several follicles have reached a size of 17 to 18 millimetres.
Hormone levels
LH levels are measured to ensure that ovulation has not occurred spontaneously. 17β-estradiol is also measured: this ovarian hormone reflects the maturation of the follicles. Progesterone is used to identify whether the follicles have begun to transform into corpus luteum.
Your gynaecologist will adjust your treatment according to the results of your ovarian monitoring. Injection doses may therefore change frequently: it is vital that you remain available to the medical team to be informed of the results of the monitoring and the continuation of the treatment.
Wistim offers you daily support during the ovarian stimulation phase, reducing the risk of treatment errors!
When the ovarian follicles have reached a sufficient size and hormone levels are deemed optimal, ovulation is induced. The patient will be given a precise time by the medical team. Ovulation is triggered by an injection of a gonadotropin (recombinant β-hCG or GnRH analog) which artificially reproduces the ovulatory LH peak.
It is very important that you adhere precisely to the time indicated by your doctor for triggering ovulation. This takes place 36 to 40 hours after your injection. Sperm insemination (in the case of an intrauterine insemination protocol) or oocyte puncture (in the case of an in vitro fertilisation protocol) will take place 36 hours after induction. If you have missed the exact time for your injection, be sure to tell your gynaecologist.
In France, intrauterine insemination is the first-line treatment. It is therefore the most commonly operated technique in medically assisted procreation, accounting for 43% of attempts in 2017. Artificial insemination involves placing sperm directly into the patient's uterus to maximise the chances of fertilisation.
Ovarian stimulation
As part of an IUI protocol, ovarian stimulation is used to improve ovulation and control its timing. The hormonal treatment induces the maturation of up to three ovarian follicles.
Inducing ovulation
The aim of intrauterine insemination (IUI) is to facilitate the meeting between the oocyte and the spermatozoon. Inducing ovulation allows the oocyte to mature and be released by the ovary into the Fallopian tubes (where fertilisation will take place).
94% of IUI artificial inseminations are carried out with the spouse's sperm and 6% with donor sperm!
Sperm preparation
On the day of intrauterine insemination, sperm is collected by masturbation after 2 to 5 days of sexual abstinence. The sperm is prepared in the laboratory and the most mobile spermatozoa are selected for artificial insemination. This requires a minimum of one million sperm cells.
Intrauterine insemination with the spouse's sperm is recommended in cases of moderate sperm abnormalities (with at least one million motile spermatozoa). It will also be prescribed for couples with idiopathic infertility and in cases of ovarian insufficiency, mild endometriosis, or cervical abnormality.
Artificial insemination using donor sperm is used in cases of male infertility (azoospermia: total absence of spermatozoa in the partner's sperm or severe teratospermia: numerous spermatozoa abnormalities). Sperm donation may also be considered when the spouse presents a high risk of transmitting a genetic disease to his or her offspring.
Insemination
Insemination takes place at the fertility centre 36 hours after ovulation is triggered. It takes place in the gynaecological position: the selected spermatozoa are placed in a flexible tube (a catheter). The catheter is used to deposit the sperm in the uterine cavity.
Although the most commonly operated technique in France, intrauterine insemination is far from being the most effective! Only 5,868 babies were born as a result of the 49,367 artificial inseminations carried out in 2017. This type of medically assisted procreation, therefore, has a success rate of around 12%. It is important to note that artificial insemination using donor sperm (a man with no sperm abnormalities) has a birth rate of 21%.
Following several failed attempts at artificial intrauterine insemination, the couple will be referred to an in vitro fertilisation protocol. Unlike intrauterine insemination, here the meeting will take place outside the woman's body. IVF may be proposed as a first-line treatment when the infertility assessment of the woman or the man recommends it: for example, in the case of numerous sperm abnormalities (in terms of quantity, mobility, viability, and morphology of the spermatozoa) or an abnormality of the fallopian tubes.
In cases of very severe male infertility, the IVF-ICSI protocol is preferred!
Ovarian stimulation
The success of an IVF or IVF-ICSI protocol depends essentially on the effectiveness of ovarian stimulation. The aim here is to stimulate the ovaries as much as possible so that they produce as many oocytes as possible.
Inducing ovulation
With IVF or IVF-ICSI, ovulation is only triggered to allow the oocytes to mature. Only mature oocytes can be fertilised by a spermatozoon.
During an IVF or IVF-ICSI procedure, the oocytes are not released into the fallopian tubes; they are retrieved during the puncture to be fertilised in the laboratory!
Oocyte puncture
This takes place in the operating theatre, under local or general anaesthetic. The puncture is carried out transvaginally under ultrasound control. The follicular fluid in which the oocytes are immersed is removed using a probe. The oocytes are counted under a microscope.
The oocytes are too small to be visible during puncture. You will have to wait for the laboratory analysis before you can find out the exact number of oocytes collected. This number often does not correspond exactly to the number of follicles visible on ultrasound. The average number of oocytes per puncture is 10.
Sperm preparation
While the patient undergoes the oocyte puncture, her partner collects the sperm. This is done by masturbation after 2 to 5 days of sexual abstinence. The sperm is prepared in the laboratory and the spermatozoa are selected for in vitro fertilisation.
Fertilisation
This is the only difference between IVF and IVF-ICSI. With IVF, 50,000 sperm are placed in contact with an oocyte: fertilisation is spontaneous. In IVF-ICSI, a single sperm is injected directly into the oocyte to maximise the chances of fertilisation.
Embryonic development
Over the next five days, the development of the embryos resulting from fertilisation is monitored. Each embryo is given a score based on its morphology. The embryo with the best implantation potential is selected for transfer.
Embryo transfer
The transfer takes place at the medically assisted reproduction centre. It takes place in the gynaecological position: the embryo(s) selected for transfer are placed in a flexible tube (a catheter). The catheter is used to deposit the embryos in the uterine cavity.
The embryo(s) may be transferred two or five days after fertilisation. More and more frequently, a single embryo is transferred in order to reduce the risk of multiple pregnancies. However, depending on the characteristics of the couple (age, previous history, pathologies, etc.), it is possible that two embryos may be transferred. The decision will be taken by the gynaecologist in agreement with the patients.
By maximising the chances of fertilisation, IVF and IVF-ICSI have a higher success rate than intrauterine insemination. In fact, 18% of attempts result in a birth! These two protocols also allow recourse to sperm or egg donation in cases of severe infertility of one of the two partners. In these cases, the success rates are relatively equivalent (18% for egg donation and 21% for sperm donation).
Following IVF or IVF-ICSI, it is not uncommon for several embryos to be considered as having a high implantation potential. One of these embryos is therefore chosen for transfer: this is known as a fresh embryo transfer. Embryos that have not been transferred may be frozen with a view to a future transfer (in the event of a new attempt after failure or after a first pregnancy): this is known as a frozen embryo transfer.
Freezing supernumerary embryos
Embryos with a high implantation potential that are not selected for embryo transfer are frozen in liquid nitrogen (-196°C). Cryoprotective agents are used to protect the embryo from the formation of ice crystals that could be detrimental to its survival.
The law on bioethics sets a maximum storage period of 5 years for frozen embryos!
Defrosting the embryos
During defrosting, the cryoprotective agents are gradually replaced by water. The embryos are then placed at 37°C and observed under the microscope. This ensures that the embryos are alive and have withstood the freezing-thawing process.
Frozen embryo transfer is a less cumbersome protocol than fresh embryo transfer. TEC avoids a new phase of ovarian stimulation and oocyte puncture for the patient. This transfer can take place during a natural cycle or an artificial cycle.
For a frozen embryo transfer during a natural cycle, the patient is monitored by her gynaecologist, who carries out ultrasound scans and hormone measurements. The aim is to carry out the frozen embryo transfer during the implantation window when the endometrium has reached an optimal thickness for the future implantation of the embryo...
During a frozen embryo transfer on an artificial cycle, the gynaecologist prescribes a hormone treatment based on oestrogens from the start of the menstrual cycle. Around the fourteenth day, an ultrasound scan is scheduled to measure the thickness of the endometrium. Double treatment (oestrogen + progesterone) then begins, until the frozen embryo is transferred.
Embryo transfer
Frozen embryo transfer takes place at the MAP centre. It is carried out in the same way as a fresh embryo transfer. It takes place in the gynaecological position, using a flexible catheter to deposit the embryos in the uterine cavity.
Whether it is a fresh embryo transfer or a frozen embryo transfer, you can return to a completely normal life. At the time of implantation, the embryo has reached the blastocyst stage and measures less than one millimetre. Shocks, therefore, have no impact on it. You can work, travel, drive, and do sport, while you wait for the rest of the journey, which promises to be much calmer from a medical point of view...
Following intrauterine insemination or frozen embryo transfer, the gynaecologist prescribes hormone treatment for around ten days. This progesterone-based treatment optimises the luteal phase and therefore improves the quality of the endometrium. The implantation of the embryo depends largely on the capacity of the endometrium to support a pregnancy.
After undergoing ovarian stimulation, ovarian monitoring, intrauterine insemination, oocyte puncture, in vitro embryo development, and frozen embryo transfer, you may feel alone during the post-treatment period. You will have very little contact with the medical team. Don't hesitate to stay active and clear your head during this period!
WiStim, the fertility monitoring specialist, will provide you with day-to-day support during the post-treatment period, in the same way as during ovarian stimulation. Follow your treatment easily on the Wistim fertility application.
If a blastocyst has implanted in the endometrium, the embryonic cells begin to multiply intensely. These contribute to the formation of the future placenta: a key organ in pregnancy that produces the main hormones. Among these hormones, ß-hCG is synthesised in increasing quantities after embryonic implantation.
Blood sampling
Depending on the protocol, the ß-hCG test may be taken sooner or later. To avoid false negatives, it is advisable to wait 14 days after artificial insemination or frozen embryo transfer and repeat the test a few days later.
A result of more than 50 mIU/ml is a sign of pregnancy. A rapid rise in ß-hCG levels is a sign that the early stages of pregnancy are proceeding normally!
Ultrasound
This first ultrasound examination enables the pregnancy to be dated accurately and any abnormalities, such as ectopic pregnancies, to be ruled out. This ultrasound should be carried out between the eleventh and thirteenth week of amenorrhoea.
Congratulations, you're pregnant! Your pregnancy will be monitored in a similar way to a spontaneous pregnancy. Bear in mind that miscarriages are common during the first trimester: 15-20% of pregnancies are affected. However, at this stage, a pregnancy resulting from a fertility treatment has the same chances of reaching term as a natural pregnancy.
If the pregnancy test is negative or if the pregnancy is terminated (ectopic pregnancy, miscarriage, etc.), the medical team will decide how to proceed. The decision will then be proposed to you (change of technique, recourse to donation): a new consent form will have to be signed before starting any new medically assisted procreation protocol.
