Oocytes used in both GIFT and IVF are not required to be from the wife of the infertile couple. Indeed, these procedures allowed women to utilize donor gametes as their male counterparts have been doing for over a century. A fertile woman who agrees to donate her oocytes anonymously or to a known couple, undergoes ovulation induction, and the retrieved oocytes are fertilized. Of course, the sperm may also be from a sperm donor. After embryonic development, the embryos are replaced into the wife of the infertile couple. She is treated with exogenous hormones to synchronize her cycle with the donor.
Indications:Ooctyes obtained from a donor are indicated for patients with medical or surgical menopause or genetic disorders that may impact offspring. Oocyte donors must be physically and mentally healthy and without major genetic diseases in the family, have attained the state's age of legal majority, and preferably be within 21-34 years of age. The donor must be screened for HIV, hepatitis B surface antigen, hepatitis C antibody, syphilis, chlamydia, gonorrhea and CMV (IgM and IgG) (American Society of Reproductive Medicine Practice Committee Report: Guidelines and Minimum Standards for Gamate Donation, revised 1997).
Procedure:Both oocyte donors and recipients are carefully selected, counseled and screened before being accepted into the program. Donors may be known to the patient, a volunteer that altruistically donates to an anonymous recipient (usually reimbursed for missed work and effort), or an individual that is undergoing IVF and donates her spare oocytes. Stimulation and transfer are performed as with routine IVF.
Contraindications:Any contraindication to pregnancy, spontaneous or induced ovulation would preclude either donation of oocytes or use in an IVF cycle.
Outcome:In 2004 8,420 fresh donor oocyte cycles resulted in a delivery rate of 50.4% per transfer (SART). Previously, Paulson and associates reported an overall delivery rate of 29.3% per cycle and cumulative delivery rates after four cycles of 86.1%. Furthermore, they found that neither recipient age nor diagnosis played a substantial role in the success of oocyte donation (53).
Advancements in IVF promulgated its extension to couples with male factor infertility since in vitro fertilization required fewer moving sperm than in vivo fertilization, even after IUI. Furthermore, in the early 1990's the zona pellucida was incised (zona slitting) or treated with hyaluronic acid (zona drilling) to facilitate sperm transgression across it in cases of male factor infertility. Another technique injected sperm under the zona pellucida (SZI). Indeed, inadvertent penetration of the cytoplasm and injection of a sperm during a SZI procedure resulted in a pregnancy and sired the best treatment of male factor infertility since donor sperm: Intracytoplasmic Sperm Injection (ICSI) (54).
Indications:ICSI is indicated for male factor infertility in which the count, motility, or strict morphology is low. The definite parameters will depend upon each program; in general, a sperm density <5 x 106, motility <20% and strict morphology <5% are indications. In addition, patients with antisperm antibodies may be best treated with ICSI.
ICSI also enabled men without sperm in their ejaculate to sire a pregnancy. Sperm aspirated from the epididymis (MESA) and from the testicle (TESE) may be used for injection. It is important, however, to realize that men with azoospermia may have a genetic defect which may possibly be inherited and result in infertility in subsequent male offspring. Similarly men with at least one vas deferens congenitally absent, may be carriers of cystic fibrosis. Wives of such men should be screened for cystic fibrosis mutations to assure that they, too, are not carriers, lest they have a child affected with the disease.
Procedure:Patients treated with ICSI undergo the same procedures as with IVF except that 5 hours after aspiration, one sperm is injected into each oocyte. The sperm is pretreated to remove it from the seminal plasma and placed in poly vinyl propylpyrrhidol (PVPP) which slows its movement and allows a single sperm to be aspirated into a glass micropipette. The tail of the sperm is frequently broken off to prevent migration from the cytoplasm after injection.
Contraindications:Contraindications to ICSI are the same as those to IVF.
Outcome:ICSI requires IVF and Federal law requires that the outcome of all IVF cycles be reported to the national database kept by the CDC and ASRM/SART.
Overall, ICSI outcome in the United States for aspirations performed in 1999 is 32.9% per aspiration and 32.3% per embryo transfer (SART data, 1999). The results from 2004 cases are not yet published.