Newer Indications for In Vitro Fertilization (IVF)

In vitro fertilization (IVF) is now a fairly commonly used procedure and has resulted in the birth of tens of thousands of babies every year. According to the latest statistics available (2015, www.sart.org) there were 209,336 IVF cycles performed in the U.S. alone. This is an increase from 154,412 IVF cycles being performed in 2011.

In addition, the success rates with IVF have been steadily increasing with fewer embryos being transferred (details once again at www.sart.org). Initially, IVF was devised as a treatment for patients with diseased fallopian tubes (tubal factor). There have since been several other indications for IVF and a couple of brand new ones, which will be discussed in this blog.

Indications for IVF

1. Tubal disease. In women with blocked fallopian tubes, IVF has largely replaced surgery as the treatment of choice. In patients with hydrosalpinx, the tubes may have to be surgically removed (or interrupted) to maximize IVF success rates.
2. Male factor. In cases with male infertility, where there is a defect in sperm quality, sperm have difficulty penetrating the egg. IVF with intracytoplasmic sperm injection (ICSI) may be used in such cases. With ICSI, a sperm cell is injected directly into the egg cell. ICSI can be used when sperm numbers are very low. In patients with no sperm in the ejaculate (azoospermia), it is possible to do ICSI with sperm aspirated directly from the testis (TESA).
3. Endometriosis. Patients with endometriosis, often have tubal involvement and ovarian cysts (endometrioma) and will benefit from IVF.
4. Ovulatory dysfunction. In patients with polycystic ovarian disease (PCOS) and other ovulatory problems, IVF can be used when other methods have failed.
5. Unexplained infertility. Patients with no obvious cause for their infertility (normal work up) can benefit from IVF. Due to the costs of the procedure, IVF is generally attempted only after less expensive options have failed.

For IVF to be successful it typically requires a healthy egg, sperm that can fertilize, and a uterus that can carry a pregnancy. But, what can be done in patients where this is not the case? This is where newer techniques such as preimplantation genetic diagnosis (PGD) to rule out presence of genetic disorders, as well as egg donation or surrogacy (where the woman providing the egg isn’t the same who will carry the pregnancy to term) can be used. Read on.

Preimplantation genetic screening or diagnosis (PGS or PGD)

It is now possible to screen embryos for genetic or chromosomal abnormalities prior to transfer. PGD is indicated in:

• Couples who have a family history of inherited disease
• Couples who want to use gender selection to prevent a gender-linked disease
• Couples who already have a child with an incurable disease and need compatible cells from a second healthy child to cure the first, resulting in a “savior sibling” that matches the sick child in HLA type.

There will be a series of blogs discussing these issues in further detail in the immediate future.

Fertility preservation

Egg freezing or embryo freezing can be offered to patients with cancer that may require surgery, chemotherapy or radiotherapy. In these cases, the cancer treatment can have a adverse impact on their fertility. By preserving eggs (or embryos), patients can potentially preserve their fertility and pursue pregnancy when ready.

Egg or embryo donation

In egg donation or embryo donation, the resultant embryo is transferred in another woman than the one providing the eggs. This is an excellent option 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.

Surrogacy

In women who are not able to carry a baby, gestational surrogacy is an option. Women without a uterus (hysterectomy) or with uterine factors (multiple fibroids, abnormal uterine cavity (severe adhesions) or who are not able to carry a baby for other medical conditions are candidates for surrogacy. This is also an excellent option for gay couples (male) who wish to have a child.

Illinois is one of the few states with specific laws that make it possible for couples to use a surrogate to deliver the baby but have the genetic parents' name(s) on the birth certificate.

As you can see, it is now very common for couples to use IVF to have a baby. The pregnancy rates have been improving steadily. The procedure itself is getting to be less complex and has brought hope to thousands of couples who would otherwise be infertile.