Many are trying to fulfill their dream of parenting. In the past, the natural spontaneous way was the only one to fulfill this dream. With time and the development of science, reproductive medicine had developed treatments for all the aspects of infertility in order to fulfill the parenting whish. Surrogacy is one those treatments,. To simplify the process and facilitate the delivery of information, in this article we will answer the common questions about surrogacy.

What is surrogacy?

Surrogacy is a process in which the female partner’s egg is fertilized with the male partner’s sperm in a laboratory (in vitro fertilization). The fertilized egg develops to an embryo, biologically belonging to the intended parents. This embryo is transferred to the surrogate woman’s womb. The surrogate will carry the pregnancy , give birth to the baby and deliver him to the intended parents, immediately after the delivery.

When surrogacy is needed?

When carrying a pregnancy is impossible as a result of health problems of the female partner, irreparable womb problems, after womb resection or recurrent failure of fertility treatments referred to a uterine or endometrial unsolvable problem.

Who is the surrogate?

A surrogate is a woman who will carry the intended couple embryo in her womb on a volunteer basis or for a fee. The woman can be an acquaintance of the intended parents or, alternatively, a stranger. Anyway, the surrogate’s status, rights, and obligations are enshrined in a legal agreement before the surrogacy process begins.

What is a surrogacy agreement?

Because this is a complex process, which involves many emotions, stress, anxiety, anticipation, sometimes involving people who do not know each other at all, the legislature requires that even before the process begins, a risk-taking process is carried out between the parties involved: the surrogate mother and the intended parent or parents. The content of the agreement and its reservations will be personalized on a case-by-case basis, however, there are issues that are essential to be signed in the beginning, such as, who’s subject and costs, parental responsibility for the newborn to come and more.

The surrogacy process, how is it actually done?

Once the agreement is approved and signed by the parts, reproductive medical clinics will manage the process. The medical team will accompany, conduct and synchronize the treatments, for the surrogate mother and the intended parents: from initial medical tests and examination of the surrogate mother and intended parents, through the in vitro fertilization process and embryo transfer to the surrogate womb, follow-up of pregnancy, to the long-awaited delivery of a  healthy baby. At the last stage of the process, the baby will be handed over to his parents and will be registered as the intended parent/s baby.

What are the types of surrogacy available?

“Partial surrogacy” or by its accompanying name “Traditional surrogacy” is surrogacy in which the pregnancy result from the sperm of the male intended partner and the surrogate mother’s egg. This method is not legal in everywhere. Sometimes a parentship agreement which ensure the new born transfer to the intended father, may bypass the legal problem.

“Full surrogacy” or its accompanying name “surrogate pregnancy” is surrogacy as described above.

Each state whether and when the surrogacy process is approved has a constitutional process that the process seeks.

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It is IVF the last treatment to be applied after a series of frustrating fertility treatments, when the couple is broken and discouraged?

The in vitro fertilization process has two purposes, one diagnostic and the other therapeutic. For some couples, the diagnostic in vitro fertilization will be the beginning of the treatments journey, others will be treated with IVF following a diagnosis such as fallopian tube obstruction or very low sperm quality.

What is IVF ?

We know the term in vitro fertilization as a test tube baby. The female partner eggs are picked up from the overstimulated ovaries and the fertilization process takes place in the laboratory instead of the fallopian tubes. The fertilized eggs begin to divide in the laboratory and the resulting embryos are transferred to the womb 3 or 5 days later.

This technique was developed in the UK in the 1980s. and quickly has spread all over the world. Initially, the treatment was designed for patients with obstructed fallopian tubes. Subsequently, egg fertilization techniques have been developed for sperm unable to fertilize on its own. Now is possible to test the future embryo genome and avoid a variety of genetic diseases to be inherited or prevent spontaneous abortion at the beginning of pregnancy. In the foreseeable future, damaged genes will be repaired ensuring genetic disease-free lives for future generations.

Almost 3% of all births in the Western world are by IVF. Due to the success and effectiveness of the method, many are applying for IVF, give birth to a baby of their own avoiding the need for adoption or surrogacy.

In vitro fertilization is now used even when there is no fertility problem, as a diagnostic tool such as the need to prevent the transmission of genetic diseases to the fetus, choice of newborn sex or fertility preservation.

Hyper-ovulation towards the Eggs pick-up.

The purpose of this treatment is to create about 10-15 mature follicles, in both ovaries, containing 10-15 eggs (unlike a natural ovulation cycle in which only one follicle develops in one ovary).

During hyper-ovulation treatment, the female partner will be required to inject artificial hormones similar to those secreted by the hypophyseal gland to induce follicular development and ovulation (gonadotropins): one type is designed to induce hyperovulation and the other type is for the final maturation of the eggs and timing of the ovulation.

During this treatment, the ovarian response is monitored by blood tests to determine hormone levels and transvaginal ultrasound scans of the small pelvis, to determine the number and size of the ovarian follicles, and endometrial thickness. When this monitor indicates that the follicles are mature, the ovulation hormone is administrated. 36 hours later the ovulation    follicular rupture and egg expulsion) is expected. 34 hours after ovulation hormone administration, the eggs will be picked up by transvaginal guided follicular fluid aspiration, under general anesthesia. The content of the follicles is transferred to the laboratory for the identification of the oocytes.

Fertilization phase: The normal and moving sperm are isolated from the male partner ejaculate, by a laboratory process, in parallel with the oocytes pick up. Later, the eggs and sperm are brought together for fertilization, which is a pairing of one set of 23 chromosomes from the egg with a parallel set from the sperm cell. The fertilized egg now contains 46 chromosomes (two pairs of 23, one from each parent). The fertilized egg will undergo cell division process: on day 3 after fertilization, the embryo will have 6-8 identic cells; by day five after fertilization, the embryo will containing 150-250 cells differentiated in three kinds, and ready for implantation in the womb.

When the sperm is unable to fertilize by himself the eggs (due to sperm cell anomaly), injecting the genetic material of the sperm into the egg is performed Intracytoplasmic Sperm Injection (ICSI): using a micromanipulator, under the microscope, a single sperm is aspirated into a needle and injected directly into the egg.

Embryo Transfer is performed on the third day or the fifth day after the oocyte pick-up and fertilization; Using a very thin plastic tube,1-2 embryos are transferred to the womb, through the uterine cervix, without anesthesia (no pain or discomfort is involved in this procedure)

Freezing of embryos and cryopreservation

When, after embryo transfer, one or more embryos are left, they can be frozen in a special process and kept at a very low temperature (-196 Celsius degrees below zero). If no pregnancy results in the actual treatment, the frozen embryos can be thawed in the subsequent cycle, without the need to undergo hormonal therapy. If the treatment results in a viable pregnancy, the cryopreserved embryos can be preserved for many years so that a new pregnancy can be created even long after the birth of the baby, even when the advanced maternal age does not permit a new pregnancy. The maternal age of the embryos is the age of the female partner at ovum pick-up time. You may create healthy embryos at age 25 and use them age 40 plus. This is  the most effective method of Fertility Preservation.

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Gens guide our body to grow and develop, our organs to function and repair themselves when needed. When there is a malfunction (mutation) in the encoding areas of these genes, inherited diseases may occur (eg: cancer, heart disease, etc.). A high percentage of humans are carriers of affected gens, but the individual is free of the disease because every gen has twin, and if the twin gen is healthy, no disease or malformations will happen. These mutations are transmitted to the future child by the female egg and \or sperm cell. If the child will inherit the same mutant gen from both parents he will suffer from a genetic syndrome or severe disease. Some diseases (especially cancer) will appear if only one parent passes the affected gen.

How, in the biotech era, we mobilize knowledge for our benefit?

If you plan a family or plan to extend the family, the first step is a

Broad genetic screening tests for both partners, even when there is no family history of genetic diseases. Eighty percent of children born with a genetic problem has no family history of the same disease. An extensive genetic survey is a simple way to detect defects in the DNA. That does not cause disease in the parent (autosomal recessive), but if a similar defect exists in the other parent, the child is at a remarkably high risk of being born ill or affected.

An oncogenic genetic screening test is recommended in case of a family history of malignant disease. Discovering a carcinogenic gene mutation that causes a malignant disease will help in the early detection and saving of the carrier parent life and will not allow the gene to be transmitted to the child.

Example: 1 out of 7 women are expected to have breast cancer in their span life. Some of the patients carry a genetic defect in one or more of the genes encoding for tumor suppression or tumor growth. For a woman who is not carrying an oncogenetic mutation, the risk of illness is about 1.5% while an oncogenetic carrier has a 47% risk to be ill. Knowledge of carrier status for both partners allows early detection and preventative care. If you are a carrier, the defective gene may be allocated in the fetus before his implantation in the womb ensuring a healthy baby.

The onco-genetic panel assembly is customized for an individual, couple or family and is based on detailed medical questioning.

Before Pregnancy: Pre-implantation genetic testing (PGT) of the embryo and implantation of a non-carrier embryo.

If the pregnancy is already running: Placental (chorionic villi sampling-CVS) or amniotic fluid genetic test (Amniocentesis).

Supplemental genetic counseling

Are given by the genetic companies that carry out genetic sequencing tests and if there are clinically significant findings you will be referred to genetic counseling or/and onco-geneticist.

What to do with the findings of carrier status?

1. For mutations that affect the function and health of the carrier: build a customized plan for early detection / preventive care/ change nutrition habits and physical exercise.
2. For mutations that do not affect the function and health of the carrier: Testing for the spouse to avoid disease (for a recessive autosomal gene) of the offspring.

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Unlike all other medical areas where the disease is diagnosed first, and the treatment is matched to the diagnoses, in the reproductive medicine field, the common practice is “trial and error,” meaning trying light therapy, first several cycles, if fails, trying more aggressive treatment … and so on.

Our’s work-up method is the opposite of the trial and error method.

The guiding principle is: highly accurate diagnoses for both partners enables the most appropriate treatment choice.

Step one, non-invasive investigation of the reproductive system (for both partners)

The work-up is conducted over monthly menstrual cycle. In this context, the following  are tested:

1. The ovulation process
2. Hormonal system (both partners)
3. Basic sperm test.
4. The female partner mechanical reproductive system (uterus and fallopian tubes) evaluation.
5. Structure and quality of the internal coating of the womb (endometrium) who is responsible for the embryo implantation.
6. The genetic screening, for both partners, based on a medical personal and familiar questionnaire.
7. Breast examination
8. Uterine cervix swab (PAP or HPV)
9. General blood tests (including infectious and immunological diseases)

In each of the tests mentioned, dozens of parameters are tested and their meaning is analyzed by an expert system computer program that helps to make correct diagnoses. If this work-up does not produce working diagnoses,the next step:

Stage two: embryological evaluation (of the fertilized egg and pre-implantation embryo)

Diagnostic in vitro fertilization is especially necessary when there is no clear diagnosis at the initial stage, or the diagnosis requires in vitro fertilization treatment (such as obstruction of the fallopian tubes or severe sperm condition). This process may end in a pregnancy, having the value of treatment as well.

1. Egg Assessment.
2. Sperm ability to fertilize the egg.
3. The morphologic quality of the embryo and his capability of reaching the implantation stage.
4. Genetic testing of the embryos on the day of implantation, giving the opportunity to appreciate the chances of a viable pregnancy and a healthy baby.

The initial consultation, with the couple, is recommended “On-Line” after fulfilling the forms.

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Intrauterine insemination(IUI): This treatment is intended to increase the chances of the female partner egg fertilization after ovulation had occurred. This procedure is indicated when a low sperm count and/or motility is diagnosed. The female partner is monitored by a transvaginal ultrasound scan of the small pelvis for the identification and timing of ovulation

The purpose of intrauterine insemination is to significantly increase the number of sperm cells that will reach the fallopian tube area (the place where the egg is picked up during ovulation). The semen undergoes a laboratory process in which the good moving sperm cells are isolated from the others.  The solution containing a high concentration of semen is injected, with a thin tube, directly into the womb, close to the tube that has picked up the egg, so that within a few seconds the semen will reach the egg. Artificial insemination is a simple procedure that does not involve pain and is performed in the clinic.

Controlled Ovarian Stimulation and Intrauterine Insemination (COS&IUI):

When previously diagnosed, in the female partner, ovulatory or hormonal disorders this treatment is performed to induce ovulation and to schedule intrauterine insemination. During ovulation treatment, the partner will be required to inject artificial hormones similar to those secreted by the hypophyseal gland to induce follicular development and ovulation (gonadotropins): one type is designed to induce ovulation and the other type is for the final maturation of the egg and timing of the ovulation.

During this treatment, the ovarian response is monitored by blood tests to determine hormone levels and transvaginal ultrasound scans of the small pelvis, to determine the number and size of the ovarian follicles, and endometrial thickness. When this monitor indicates that one or two follicles are mature, the ovulation hormone is administrated which causes the follicular ruption and egg expulsion. 36 hours later, the egg will be picked up by the tube and be ready for fertilization. The couple is invited to the clinic, 36-40 hours later, for insemination.

Sperm Donation Treatment:

When using sperm from a donor, from the Sperm Bank, because the sample is frozen, the amount and quality of sperm cells are slightly impaired. In this situation, it is recommended to perform intrauterine insemination with or without ovulation induction, according to the female diagnoses.

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Designated for women whose eggs are abnormal, early ovarian failure, carriers of certain genetic diseases or are at advanced age for pregnancy.

Women at an advanced age for natural reproduction, where the genetic quality of the eggs is poor and does not allow viable pregnancy are the largest group for this treatment. In most cases, these are women aged 40-45 years and older. With age, a decline in ovarian function and egg genetic quality occurs and the female partner is no longer able to conceive or obtain a viable pregnancy, even by in vitro fertilization (IVF). Sometimes a similar phenomenon is found in young women when their ovaries do not contain oocytes for different reasons, or the ovaries cease to function early in their lives: Premature Ovarian Failure. Some genetic defect carriers (detected in a survey or/and genetic tests before conception) are candidates to replace their eggs with donated eggs.

Whose child is this?

The embryo is the result of the female partner egg fertilization by the male partner sperm. The egg inherits the one pair (23 chromosomes) and the sperm inherits the second pair of chromosomes, thus creating the future child’s genetic genome (46 chromosomes). Beginning from the moment of embryo implantation (day 5 after fertilization), the mother carrying the pregnancy changes and stabilizes the genetic expression of the future baby (phenotype). This process is called Epigenetics.  The mother’s role in epigenetics is huge and she is responsible for most of the neonate’s properties and not the egg donor. The eggs are obtained from young women, which will be fertilized with the sperm (male partner’s or donor sperm) in the process of IVF.

The treatment is performed to the Egg Donor, and the recipient’s womb is synchronized with the donor IVF treatment, so that embryo transfer will be performed to the recipient.

Egg Donor selection and treatment:

Donors undergo rigorous screening, which focuses on the donor’s general health and family genetic history. Also, the donor undergoes a series of tests that will ensure that they do not carry infectious diseases such as AIDS, hepatitis, sexually transmitted diseases and some genetic test. It is strongly recommended to perform a family genetic screen to the egg donor and the male partner to ensure that the donor and male partner are not carriers of a similar genetic mutation (that has 25% risk of a genetic affected baby).

Donor egg fertilization and fertilization is done similarly as described in “In vitro fertilization”. After the egg is picked up, it is fertilized by the male partner’s sperm (or donor sperm from the sperm bank). It should be noted that one egg donor may donate oocytes to more than one recipient. Fertilizing the eggs in different sperm samples will create genetically different embryos that will be implanted in different wombs (different epigenetic influences).The embryos may checked genetically before implantation, ensuring a healthy baby and permitting even sex selection.

Preparation of the recipient’s uterus for embryo transfer:

If there is no ovarian hormone activity (menopause, no ovaries or Turner’s syndrome) endometrium (internal layer of the womb) is built by using estrogen (pills) and progesterone suppositories (vaginal) and/or progesterone by injections, while monitoring blood hormone levels and endometrial

Thickness (by transvaginal ultrasound scan).

Embryo Transfer.

To implant, the embryo in the womb, a very thin plastic tube is passed through the uterine cervix, under ultrasound guidance. This procedure does not include pain or discomfort.

The transplant is done on the third or fifth day after Egg pick-up from the donor’s ovaries. Subsequently, hormone levels are monitored and treatment guidelines are provided as needed.

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