Treatments

Ovulation Induction and Programmed Sexual Intercourse (OI)

In its simplest form of assisted reproduction, this approach aims to help couples to achieve a pregnancy without any advanced clinical or laboratory intervention. This option is advised when the male partner’s sperm parameters are normal and the female spouse has not been diagnosed of any significant ovarian dysfunction and with patent fallopian tubes. A minor stimulation protocol most usually associated with the administration of pills and a low dosage of hormone injections is used to induce the maturation of one or a small number of follicles assumed each to contain an egg. Ultra sound scans are performed for monitoring the response of the ovaries to this medication. Ovulation is triggered by the use of a single injection once the ultra sound findings confirm optimal egg maturation. The couple is advised to have intercourse approximately 36 hours post the administration of this injection. A pregnancy test is advised two weeks later.

Intrauterine Insemination (IUI)

The procedure entails that a semen specimen produced by the male partner is processed for separating and activating the motile spermatozoa from the rest constituents of the ejaculate (seminal plasma). The final preparation usually concentrated to a small volume of 0.5 ml is released inside the uterine cavity with the aid of a fine canula (catheter) which is threaded through the cervical canal. The procedure which is relatively quick and most usually painless aims that the motile sperm swim into the fallopian tubes in search for the egg(s). IUI can be performed using mild ovarian stimulation or during the natural cycle of the female partner. In those cases where controlled stimulation (using tablets and/or low dose hormonal injections) is implemented the possibility of a positive outcome is enhanced due to multiple follicular development, however, this is also associated with a higher risk of multiple pregnancy.

In Vitro Fertilisation (IVF)

This is the commonest procedure in assisted reproduction treatments and involves 5 consecutive steps;

Controlled Ovarian Stimulation
The aim of this phase is to induce the ovaries to respond to hormonal medication so that a satisfactory number of follicles can develop. A collection of different ovarian stimulation protocols exist and each patient receives an individualized regimen. This is prescribed after careful consideration of several parameters including the baseline characteristics, the hormonal profile, the fertility manifestation and previous clinical history of the female partner. The duration of the injection administration can vary between patients. Usually it lasts 10 days and is associated with minor side effects.

Monitoring of Ovarian Response
It is imperative that the dosage administration of the hormonal injections produces neither an exuberant nor an inert response. The monitoring phase which can be commenced as early as from the 4th day of stimulation aims to the subsequent harvest of a satisfactory number of mature eggs at retrieval. Along with the ultra sound scan monitoring it is advised that blood tests are performed so that the findings of the ultra sound are consistent with the number and maturity of the follicles growing. According to the findings of the monitoring scans and blood tests the initial dosage of hormonal injections may be amended. Once the follicles had reached a satisfactory size a final injection is administered to induce final maturation and the time of the egg collection is scheduled to approximately 34-36 hours thereafter.

Egg Retrieval
The egg collection is undertaken in a surgical suite under light general anaesthesia and therefore the patient is advised to fast previously for at least 6 hours. Eggs are aspirated from their follicles with the aid of a very fine needle under ultrasound guidance. The follicular fluids are immediately screened for the presence of an egg by the scientist in the adjacent to the theater embryology lab. Once retrieved, the eggs are washed several times and stored in specially defined culture media in incubators.

Egg Fertilisation and Embryo Culture
Following their retrieval the eggs are left in incubation for approximately 4 hours at optimal conditions (36.8 °C, 6% Carbon Dioxide in air and absolute humidity).

Each egg is mixed with a specific number of motile sperm and let to fertilise back in the incubator. Normally the fertilisation process is complete within 16 hours post insemination and after inspection the fertilized eggs (zygotes) are placed in fresh culture media. Embryo development is inspected every 24 hours post egg fertilisation. Assessment is performed according to the capacity of each embryo to divide consistently with its time in culture, the relative size and shape of the constituting cells and the degree of fragmentation observed within each cell (intracellular) and between the cells (extracellular).

Intra Cytoplasmic Sperm Injection (ICSI)

In certain cases where the semen specimen of the male partner has been found to be abnormal due to the spermatozoa being too few or suboptimal in their morphology or with poor motility, the fertilisation of the eggs is managed mechanically. The ICSI method makes use of special micro-instruments which enable the immobilisation, aspiration and subsequent injection of a single sperm into the centre (cytoplasm) of each egg.

Epididymal Sperm Aspiration/ Testicular Sperm Extraction (PESA/TESE)

Those men whose sperm is not produced into the ejaculate due to an obstruction of the spermatic cord for example or due to a congenital dysfunction or irreversal vasectomy, spermatozoa are retrieved from the testes either by the use of a very fine aspiration needle guided into the epididymis or by minor testicular incision followed by a open biopsy. Although the spermatozoa recovered are usually short populated, the quality is good enough to secure equally good fertilisation rates when compared with the conventional approaches.

Frozen Embryo Replacement

Patients who had been successful in their initial attempt with IVF and who also had a number of their embryos frozen at the time can aim for a sibling using this procedure. Alternatively those who unfortunately failed to achieve a maintained pregnancy previously but had surplus embryos frozen can subsequently make use of the FER in their endeavor for a positive result. The benefits of this procedure is that the patient does not need to go through the steps for controlled ovarian stimulation using drug administration and egg collection procedures. Rather, the female partner is prepared for endometrial receptivity using estrogen tablets and the frozen embryo(s) are thawed and replaced similarly to a natural cycle. The couple incurs less expense and inconvenience by pursuing this procedure. The novel method of embryo cryo preservation namely vitrification, secures a superior embryo survival rate than its alternative slow cooling approach. Vitrified embryos can be left in liquid nitrogen storage for a considerable time period.

Egg Donation

Egg donation at Genesis is possibly the most organised and successful program worldwide. Genesis receives patient requests directly or from referral sources mainly established in the United Kingdom, the Arab countries and Canada. The demand for this treatment modality is high and Genesis has a dedicated team comprised of accredited individuals who consistently provide individualized care to patient/couples.

Egg donation provides the only means of conception for women who produce very poor quality eggs, too few eggs, no eggs or eggs which are abnormal due to genetic reasons. There is currently no restriction as to an age limit for potential recipients although Genesis believes that an upper limit of 55 years should be set. Egg donation at Genesis is anonymous. Egg donors receive no financial compensation for their contribution and renounce liability of the eggs donated in written consent forms witnessed by a member of Genesis medical staff.

The mean age of egg donor candidates is 25. All donors must have proven fertility potential prior to their enrolment to this program. Furthermore, candidates receive extensive clinical and psychological evaluation, laboratory screening and counseling to determine their suitability. Donors are screened not only for routine tests such as HIV 1 & 2 , Hepatitis B & C, VDRL, CMV, Chlamydia etc but for their chromosomal constitution through karyotyping and other single gene defects mainly conveyed from the female partner to the male offspring. Such analyses include all known mutations of cystic fibrosis, fragile X-syndrome and muscular dystrophy. Egg donors of Mediterranean origin are also screened for thalassaemia trait whereas Afro-Caribbean candidates are also screened for Sickle cell anaemia. Most of the candidates are of Eastern European decent and are university graduates. Recipient couples who enroll for treatment will liaise directly with Genesis for their treatment synchronisation. Genesis will forward a list of potential donor candidates for their review and once a decision of choice has been made, a synchronisation regime will be prescribed. Normally a physician will be assigned to consult with the recipient couple and answer questions regarding their treatment. In the event that the involvement of a physician has not been made possible in the city of the recipient residence, Genesis will provide in a satellite fashion the relevant assistance. It is the policy of the institution to only provide egg donation treatments at a single scheme basis. The recipient benefits from the whole cohort of eggs harvested from a single donor rather than sharing this number with a second or even third recipient, an approach which is adopted by almost all other clinics offering this service. The single scheme almost always allows for embryo cryo-preservation. In the event that the couple has been successful with the fresh embryo replacement, the embryo freezing provides a good possibility for the couple to achieve a sibling at a subsequent stage. There are no restrictions as to how long embryos can be retained in the frozen state. Following treatment completion, the Genesis’ egg donation staff provides continuous care and support to both the donor and the recipient. Genesis will liaise with the clinic assigned to monitor a successful pregnancy and disclose all information requested for the best possible monitoring and care. The written consent of the recipient couple is a prerequisite for Genesis to disclose such information to third parties. Similarly, Genesis looks after the donor candidate and makes sure of her well being. Genesis is very pedantic over the issue of biological family. Donors who have successfully assisted in the establishment of more than 4 to term pregnancies are not being recruited in the program thereafter.

Sperm Donation

Sperm donation is advised to couples unable to achieve a pregnancy due to the incapacity of the male partner to produce spermatozoa. Sperm donation is also increasingly being used to assist single women and single or coupled lesbians to have children.

Sperm donor applicants are subjected to a rigorous screening process before they are cleared to donate sperm. This, apart from the clinical assessment, consists of questionnaires, blood screening, specimen screening, genetic analysis and a physical evaluation. The questionnaire process involves comprehensive interviews mainly related to sexual behaviour, family background and reasons for participating in the donation program. Laboratory screening includes a collection of different analyses such as HIV 1 and 2 antibodies, Hepatitis B and C, all sexually transmitted diseases, blood group and Rh factor and a chromosomal profile. The semen is analyzed for sperm cell count, forward sperm cell motility, and normal sperm morphology. The age of semen donors ranges between 20 and 45. Once a candidate has been accepted for donation, his specimen will be cryo-preserved and retained in the deep freeze (-196 ºC) for a period of at least 6 months by which time a repeat HIV screening is performed. Specimens donated by a candidate can only be used once the second HIV test has been found negative.

The Genesis sperm cryo-bank has more than 75 sperm donors in its pool. The donor candidates are mainly of Eastern European decent but a large number is of Mediterranean origin as well. Genesis receives requests from several clinics worldwide regarding the acquisition of frozen donor semen specimens. Genesis has adopted a very effective transportation system to assist in the provision of such requests. Furthermore, Genesis has always a limited number of frozen semen specimens which have been donated or are being donated by highly intellectual and accredited individuals. Such candidates include academic scholars and successful entrepreneurs whom achievements have been documented in literature.

Similarly to egg donation, sperm donation is strictly anonymous and no information can be disclosed to potential recipients regarding the identity of the donor candidates without obtaining a written consent in advance.

Egg/ Sperm Freezing

Sperm Cryopreservation
The freezing of semen and its storage at very low temperature for future attempts at conception using one of the available assisted reproductive technologies is considered for a collection of different reasons.

• Men who opt to receive reversal or irreversal vasectomy are advised to store their semen in view of preserving their fertility potential pending circumstantial changes during their lifetime.
• Treatment against testicular cancer or lymphomas using surgery, radiation or chemotherapy may have a detrimental effect on sperm production. Patients scheduled for such treatments are advised to retain a number of semen frozen specimens insuring their fertility potential in the future.
• Men can freeze their sperm prior to an artificial reproduction treatment cycle as a back up. Occasionally, men face difficulties in producing a fresh semen specimen on the day that this is required or the sample they produce is of poor or inadequate quality mainly due to stress related reasons.
• Couples pursuing artificial reproduction treatments may find themselves limited by the male partner’s time schedule which may be rendering him unavailable to produce a fresh semen specimen on the critical day. Previously cryopreserved semen alleviates the couple from the frustration and stress of such circumstances.
• Patients who receive testicular sperm extraction during IVF related treatments are advised to consent to sperm freezing in view of retaining their gametes for possible future attempts.

Oocyte (Egg) Cryopreservation
Oocyte cryopreservation provides the opportunity to conserve patient's eggs or oocytes at very low temperatures for future attempts at conception using fertility treatment. Unlike sperm cryopreservation, egg freezing has a very short history. Between 100 and 200 children have been born worldwide following egg freezing Although these children do not appear to exhibit unusual health problems, there is not enough data to conclude that this method is safe. Therefore egg freezing is considered experimental and patients who request oocyte cryopreservation will be offered the procedure as part of a research protocol.

Egg freezing requires that the patient undergo ovarian stimulation and surgical procedures to acquire the oocytes. The oocytes are frozen by a ultra-rapid freezing method (vitrification).

Oocyte cryopreservation is most appropriate for women under 30 years of age who wish to defer family building into later years when the ovarian reserve has been deplenished, for couples who wish to limit the number of embryos created by assisted reproduction, or for women facing treatment such as cancer therapy that may diminish ovarian function.

Pre-implantation Genetic Screening

Pre-implantation genetic testing (PGS) is the technique employed to investigate and identify genetic abnormalities in embryos which have resulted from in vitro fertilization undertaken by presumed normal genetic parents. Pre-implantation genetic diagnosis (PGD) is a laboratory procedure designed to identify a known genetic predisposition curried by either of the two or both parents. The genetic screening which is made possible at the pre-implantation stage using PGS/PGD substitutes the alternative post-conception diagnostic interventions such as amniocentesis and chorionic villus sampling. This powerful tool of laboratory science provides the only means towards preventing heritable genetic disorders from being conveyed to the offspring.

There are three different laboratory approaches to screening embryos before their replacement into the uterus of a recipient patient. PCR (Polymerase Chain Reaction), FISH (In Situ Hybridisation) and CGH (Comparative Genome Hybridisation). Prior to enrolling in this treatment modality, potential candidates should seek advice from a qualified geneticist or a genetic counselor in view of assessing the risk of conveying the genetic aberration to their children. A number of tests will be requested to confirm the presence of the abnormality to the parent and to identify accurately the genetic derangement(s) which cause the manifestation.

A prerequisite to all three approaches is the incorporation of embryo biopsy during the IVF/ICSI cycle. Biopsies are normally being performed on the 3rd day of embryonic development and by which time the embryo should have reached the 8 cell stage. Alternatively, embryos can be treated with biopsy at the blastocyst stage (64 cells). Embryos which have received biopsy remain unaffected with regards to their developmental potential thereafter unless these are currying major chromosomal derangements such as monosomies (presence of one rather than two chromosomes for a particular set).

PCR is used for diagnosing single gene defects. The basis of the technique resides on the million fold amplification of a particular DNA sequence related to the gene in question. Following this step the products of the reaction are ran onto a gel through electrophoresis and subsequently inspected using UV lighting. The technique which is relatively fast suffers from the pitfall that subtle contamination in the reaction will produce a misdiagnosis in the final result.

FISH is a chromosome enumeration method where embryos can be screened in view of identifying whether they are currying a normal complement for a particular set of chromosomes. The basis of this technique is the hybridization of a particular chromosomal region with synthetic DNA which will fluoresce under a certain light band. In this way the absence or presence of the chromosome in question can be identified. A disadvantage of the technique is the risk associated with mosaicism, a phenomenon often observed in pre-implantation embryos. The chromosomal constitution of the cell biopsied may be found to be normal whereas the rest of the embryo cells were abnormal and vice versa.

In CGH, the nucleus of a cell recovered from the embryo is labeled with a fluorescent dye (green) whereas another cell used as a control is labeled using a different colour (red). The two cells are then co-hybridised and the ratio between the 2 colour intensities is compared. According to the higher or lower intensity exhibited the nucleus of the cell can be diagnosed to contain additional or less chromosomes. The technique takes 72 hours suggesting that the embryos will have to be frozen since there is a limited duration of an embryo which can be maintained in vitro culture.

Genesis has performed more than 25000 embryo biopsies and subsequent diagnoses to date rendering the centre one of the most experienced in the field of pre-implantation genetic diagnosis worldwide.