Assisted reproductive technology ( ART) includes medical procedures used primarily to address infertility. This subject involves procedures such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and cryopreservation of gametes and embryos, and the use of fertility medication. When used to address infertility, ART may also be referred to as fertility treatment. ART mainly belongs to the field of reproductive endocrinology and infertility. Some forms of ART may be used with regard to fertile couples for genetic purpose (see preimplantation genetic diagnosis). ART may also be used in surrogacy arrangements, although not all surrogacy arrangements involve ART. The existence of sterility will not always require ART to be the first option to consider, as there are occasions when its cause is a mild disorder that can be solved with more conventional treatments or with behaviors based on promoting health and reproductive habits.
Procedures
General
In the US, the Centers for Disease Control and Prevention (CDC) 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."
In Europe, ART also excludes artificial insemination and includes only procedures where oocytes are handled.
The World Health Organization (WHO), also defines ART this way.
Ovulation induction
In vitro fertilization
Techniques usually used in in vitro fertilization include:
- Transvaginal ovum retrieval (OVR) 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 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.
- Assisted zona hatching (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 (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. With ICSI, only one sperm per egg is needed. Without ICSI, you need between 50,000 and 100,000. This method is also sometimes employed when donor sperm is used.
- Autologous endometrial coculture 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 (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 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.
- 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. 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 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.
- Preimplantation genetic 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.
Pre-implantation genetic diagnosis
Others
- Mitochondrial replacement therapy (MRT, sometimes called mitochondrial donation) is the replacement of mitochondria in one or more cells to prevent or ameliorate disease. MRT originated as a special form of IVF in which some or all of the future baby's mitochondrial DNA comes from a third party. This technique is used in cases when mothers carry genes for mitochondrial diseases. The therapy is approved for use in the United Kingdom. Index page with links to summaries including one page summary flyer .
- In gamete intrafallopian transfer (GIFT), a mixture of sperm and eggs is placed directly into a woman's fallopian tubes using laparoscopy following a transvaginal ovum retrieval.
- Reproductive surgery, treating e.g. fallopian tube obstruction and vas deferens obstruction, or reversing a vasectomy by a reverse vasectomy. 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, eggs, sperm and reproductive tissue can be preserved for later IVF.
Risks
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, 1.3; 95% confidence interval, 1.00 to 1.67). ART carries with it a risk for heterotopic pregnancy (simultaneous intrauterine and extrauterine pregnancy). The main risks are:
- Low birth weight. In IVF and ICSI, a risk factor is the decreased expression of proteins in energy metabolism; Ferritin light chain and ATP5A1.
- Preterm birth. Low birth weight and preterm birth are strongly associated with many health problems, such as visual impairment and cerebral palsy. Children born after IVF are roughly twice as likely to have cerebral palsy.
Sperm donation 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.
of the mouse normally have a frequency of spontaneous point that is 5 to 10-fold lower than that in from the same individual.McCarrey JR. Maintenance of genetic integrity during natural and assisted reproduction. Reprod Biomed Online. 2009;18 Suppl 2:51-5. doi: 10.1016/s1472-6483(10)60449-x. PMID 19406032 This low frequency in the germline leads to that have a low frequency of point mutations in the next generation. No significant differences were observed in the frequency or spectrum of mutations between naturally conceived fetuses and assisted-conception fetuses. This suggests that with respect to the maintenance of genetic integrity assisted conception is safe.
Current data indicate little or no increased risk for postpartum depression among women who use ART.
Study results indicate that ART can affect both women and men's sexual health negatively.
Usage of assisted reproductive technology including ovarian stimulation and in vitro fertilization have been associated with an increased overall risk of childhood cancer in the offspring, which may be caused by the same original disease or condition that caused the infertility or subfertility in the mother or father.
That said, In a landmark paper by Jacques Balayla et al. it was determined that infants born after ART have similar neurodevelopment than infants born after natural conception.Balayla, Jacques, Odile Sheehy, William D. Fraser, Jean R. Séguin, Jacquetta Trasler, Patricia Monnier, Andrea A. MacLeod, Marie-Noëlle Simard, Gina Muckle, and Anick Bérard. "Neurodevelopmental Outcomes After Assisted Reproductive Technologies." Obstetrics & Gynecology (2017).
ART may also pose risks to the mother. A large US database study compared pregnancy outcomes among 106,000 assisted conception pregnancies with 34 million natural conception pregnancies. It found that assisted conception pregnancies were associated with an increased risk of cardiovascular diseases, including acute kidney injury and arrhythmia. Assisted conception pregnancies were also associated with a higher risk of caesarean delivery and Preterm birth.
In theory, ART can solve almost all reproductive problems, except for severe pathology or the absence of a uterus (or womb), using specific gamete or embryo donation techniques. However, this does not mean that all women can be treated with assisted reproductive techniques, or that all women who are treated will achieve pregnancy.
In Australia, 3.1% of births in the late 2000's are a result of ART. 'More IVF babies but less multiple births' THE AUSTRALIAN. September 24, 2009
The most common reasons for discontinuation of fertility treatment have been estimated to be: postponement of treatment (39%), physical and psychological burden (19%), psychological burden (14%), physical burden (6.32%), relational and personal problems (17%), personal reasons (9%), relational problems (9%), treatment rejection (13%) and organizational (12%) and clinic (8%) problems.
There are some health insurance companies that cover diagnosis of infertility, but frequently once diagnosed will not cover any treatment costs.
Approximate treatment/diagnosis costs in the United States, with inflation, as of (US$):
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 $, the expected cost is $ to establish a pregnancy, compared to an IVF cycle (cycle fecundity 40%) with a corresponding expected cost of $ ($ × 40%).
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.
[[File:Assisted reproductive technology across Europe.svg|left|thumb|Conditions of assisted reproductive technology in different European countries:
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Across Europe, the legal criteria per availability vary somewhat. In 11 countries all women may benefit; in 8 others only heterosexual couples are concerned; in 7 only single women; and in 2 (Austria and Germany) only lesbian couples.
Spain was the first European country to open ART to all women, in 1977, the year the first sperm bank was opened there. In France, the right to ART is accorded to all women since 2019. In the last 15 years, legislation has evolved quickly. For example, Portugal made ART available in 2006 with conditions very similar to those in France, before amending the law in 2016 to allow lesbian couples and single women to benefit. Italy clarified its uncertain legal situation in 2004 by adopting Europe's strictest laws: ART is only available to heterosexual couples, married or otherwise, and sperm donation is prohibited.
Today, 21 countries provide partial public funding for ART treatment. The seven others, which do not, are Ireland, Cyprus, Estonia, Latvia, Luxembourg, Malta, and Romania.
Such subsidies are subject to conditions, however. In Belgium, a fixed payment of €1,073 is made for each full cycle of the IVF process. The woman must be aged under 43 and may not carry out more than six cycles of ART. There is also a limit on the number of transferable embryos, which varies according to age and the number of cycles completed.
In France, ART is subsidized in full by national health insurance for women up to age 43, with limits of 4 attempts at IVF and 6 at artificial insemination.
Germany tightened its conditions for public funding in 2004, which caused a sharp drop in the number of ART cycles carried out, from more than 102,000 in 2003 to fewer than 57,000 the following year. Since then the figure has remained stable.
17 countries limit access to ART according to the age of the woman. 10 countries have established an upper age limit, varying from 40 (Finland, Netherlands) to 50 (including Spain, Greece and Estonia).
Since 1994, France is one of a number of countries (including Germany, Spain, and the UK) which use the somewhat vague notion of "natural age of procreation". In 2017, the steering council of France's Agency of Biomedicine established an age limit of 43 for women using ART.
10 countries have no age limit for ART. These include Austria, Hungary, Italy and Poland.
Most European countries allow donations of gametes by third parties. But the situations vary depending on whether sperm or eggs are concerned. Sperm donations are authorized in 20 EU member states; in 11 of them anonymity is allowed. Egg donations are possible in 17 states, including 8 under anonymous conditions.
On 12 April, the Council of Europe adopted a recommendation which encourages an end to anonymity. In the UK, anonymous sperm donations ended in 2005 and children have access to the identity of the donor when they reach adulthood.
In France, the principle of anonymous donations of sperm or embryos is maintained in the law of bioethics of 2011, but a new bill under discussion may change the situation.
In 2013, the National Institute for Health and Care Excellence (NICE) published new guidelines about who should have access to IVF treatment on the NHS in England and Wales.
The guidelines say women aged between 40 and 42 should be offered one cycle of IVF on the NHS if they have never had IVF treatment before, have no evidence of low ovarian reserve (this is when eggs in the ovary are low in number, or low in quality), and have been informed of the additional implications of IVF and pregnancy at this age. However, if tests show IVF is the only treatment likely to help them get pregnant, women should be referred for IVF straight away.
This policy is often modified by local Clinical Commissioning Groups, in a fairly blatant breach of the NHS Constitution for England which provides that patients have the right to drugs and treatments that have been recommended by NICE for use in the NHS. For example, the Cheshire, Merseyside and West Lancashire Clinical Commissioning Group insists on additional conditions:
Some assisted reproductive technologies have the potential to be harmful to both the mother and the child, posing a psychological or physical health risk, which may affect the ongoing use of these treatments.
In Israel, there is research supporting using ART, including recycled lab materials from the IVF process, to help women work through some of these mixed emotions.Article link: Dr. Katan, Seven news, 14.1.2022, Hebrew See section on Artistic conception הפריה אומנותית.
Gilat Kupietzky-Sacks, IVF Embryologist and initiator of the project and Miriam Kupietzky, Art Therapist run a women's workshop using recycled lab material. about workshopWorkshop on the Use of Life Cycle Concepts about workshop in the USA and other countriesAngela Savage. "Works of ART: on creativity, infertility and Assisted Reproductive Technology." In Art, 25.7.2016. Article on art produced in response to IVF treatment [15]
For specific examples, refer to the fiction sections in individual subarticles, e.g. surrogacy, sperm donation and fertility clinic.
In addition, reproduction and pregnancy in speculative fiction has been present for many decades.
The first successful birth by ICSI (intracytoplasmic sperm injection) took place on 14 January 1992. The technique was developed by Gianpiero D. Palermo at the Vrije Universiteit Brussel, in the Center for Reproductive Medicine in Brussels. Actually, the discovery was made by a mistake when a spermatozoid was put into the cytoplasm.
Usage
By country
United States
European Union
United Kingdom
Canada
Germany
France
Cuba
India
Society and culture
Ethics
Fictional representation
Historical facts
See also
External links
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