REPRODUCTIVE MEDICINE

 The first successful IVF attempt in Manchester in 1978 was by the natural cycle method. Although over the years the use of ovarian stimulation medications has changed a lot, in recent years the natural cycle method has become increasingly used as an alternative to medication use.

The natural cycle is the method in which we do not administer drugs to stimulate the ovaries and obtain many eggs, as is done in classical IVF. On the contrary, we are watching the ovary which the woman normally produces herself during the cycle.

Monitoring is done by vaginal ultrasound as well as hormone measurement in the blood. When the follicle is large enough, at about 16-17 mm, then a gonadotropin injection is made for its final maturation (Pregnyl, Ovitrelle) and, after 36-38 hours, the egg is taken. Once the egg is harvested and fertilized, the resulting embryo is placed in the uterus using the classic method of embryo transfer, 2-3 days after egg collection.

The advantage of the natural cycle is that we do not administer any medication to stimulate the ovaries. Although in-person medications have been used for 25 years and do not appear to be responsible for health effects, many women appear reluctant to take injectable hormones. By the natural cycle method, the stage of stimulation is bypassed, and the only drugs used are non-injectable post-ovulation drugs, which aim to improve the chances of embryo implantation in the uterus and achieve pregnancy.

In addition, the main complications of classical IVF are avoided: Ovarian Overstimulation Syndrome and Multiple Pregnancy.

This method is used in women who either cannot take medicines for various medical reasons or have poor response (Poor responders). It can also be used in women who have made multiple failed attempts with poor quality embryos.

The disadvantage of the physical cycle is that the success rates of the method are significantly lower than that of classical IVF using drugs. The chance of finding a good egg during ovulation, fertilizing and developing a good quality embryo in the laboratory is about 50-60%. Once a good quality embryo is transferred, the chance of pregnancy can be as high as 35%, depending on the age of the woman.

In summary, the natural cycle method can be used with quite good success rates either in women who do not wish to take medications to stimulate their ovaries or in women whose response to medication is poor.

For many couples with fertility problems, in vitro fertilization (IVF) is the best solution for achieving pregnancy. It can be used to treat a variety of causes of infertility, such as mild sperm problems, endometriosis, fallopian tubes, or unexplained infertility. In the process of classical IVF, the eggs are fertilized by the sperm in the laboratory environment (instead of the female tubes). Fertilization can be achieved either by the classical IVF procedure or by the method of Intra-cytoplasmic sperm injection (ICSI).

The story of IVF

Robert G. Edwards was to become the most famous biologist of his day when he announced, on July 25, 1978, the birth of Louise Brown, the first "tube child" in England, together with obstetric surgeon Patrick Steptoe and midwife Jane Purdie. Since then, developments have been rapid: There has been a revolution in the announcement of successful intramuscular sperm injection (ICSI) in 1992 (Palermo) and its variants, MESA (Silber & Asch, 1992) and TESE (SchES). , 1993). The male infertility factor is considered to have been virtually eliminated. In Greece, the first child by in vitro fertilization was born on January 20, 1982 and was the 13th child of the tube worldwide.

The stages of IVF - Procedure

The IVF cycle includes the following stages:

Investigation and diagnosis of infertility

Preliminary examinations

Ovarian stimulation with medication (12-14 days), with the aim of developing many follicles. We select the type of protocol based on the specifics of each woman's cycle, age, previous efforts and other factors that we evaluate

Monitoring with a series of ultrasound and hormonal determinations. Monitoring is done every two to three days to optimize your daily dosage of medication and to optimize your effort.

Induction of final maturation of ova (single evening injection). On the day that the follicles have matured sufficiently, the last injection is given, which will schedule the final maturation of the eggs and follicular function.

Ovulation (Egg collection). Eggs are taken intermittently by puncture and continuous ultrasound guidance. The ovulation is short in duration (10-30 minutes) and practically painless because it is performed under drunkenness.

Seeding (Collection of sperm). In cases of azoospermia, testicular biopsy (TESE) is suggested

Egg fertilization by the sperm. At this laboratory stage, the eggs come in contact with the sperm. When the semen has normal parameters, the classical IVF is chosen as the method of fertilization. There is no intervention in the classical method. For many couples with poor sperm quality, where the sperm is unable to fertilize the egg itself, ICSI-Intracytoplasmic Sperm Injection is the method of treatment that allows successful egg fertilization even in severe cases. The next day, the embryologist checks and records the percentage of normal fertilized eggs

Embryo culture After fertilization the embryos are cultured in the laboratory for 2 - 6 days, until the blastocyst stage. Proper cell division is a key criterion for their quality

Embryo transfer Select the best embryos and transfer them to the uterine cavity. Two to six days after ovulation the embryos are transferred to the uterus. It is a painless process that does not require drunkenness. With the help of a thin catheter, the embryos are transferred to the endometrial cavity

Pregnancy check (13 days after embryo transfer with blood sampling to determine gonadotropin beta-hormone)

Interventional ultrasound clinical pregnancy screening (4 weeks after embryo transfer).

Control of progressive pregnancy at 12 weeks gestation in 10 weeks after embryo transfer.

Optional procedures (depending on history)

Freezing of embryos or ova. Freezing allows the eggs, sperm and embryos to be maintained for an extended period of time (for a period of five years or more). By applying the new method of vitrification, vitrification, it seems that survival and pregnancy rates are higher than progressive controlled freezing.

Assisted Hatching is a laboratory technique that facilitates embryo hatching. Recommended when the fetal translucent zone is thick or hard, in cryopreserved embryos, in women with previous failed attempts

Preimplantation genetic diagnosis (PGD) for the detection of genetic abnormalities and Preimplantation Testing (PGS) with the new CGH array method, in cases of patients deemed necessary.

For many years, couples undergoing IVF treatment have been able to freeze and cryopreserve non-transferable embryos at the end of treatment. The embryos are stored in liquid nitrogen and can be used at a later date.

Embryo cryopreservation is performed with the new method of vitrification, after embryos reach the blastocyst stage (day 5 or 6), to ensure that only embryos with good growth potential are stored. When decided to use, these embryos are thawed, and at the appropriate stage of the woman's cycle are transferred to the endometrium.

Sperm Surgery (TESE)

Sperm surgery is recommended in case of azoospermia, ejaculation failure or induced ejaculation failure. The procedure is performed with intravenous or local analgesia. The testicular tissue obtained is specially processed by the Embryologist for the purpose of finding sperm. After isolation of spermatozoa, the ova are fertilized by the method of micro-fertilization. Excess sperm may be frozen for future use. There are various methods of sperm surgery, either by the epididymis or the testes.

Obtaining sperm from the epididymis

• Microsurgical epididymal sperm aspiration (MESA): Recommended in cases of obstructive azoospermia with normal spermatogenesis. It involves surgical excision of the epididymis using a microscope and suction of the epididymal fluid to find spermatozoa.
• Percutaneous epididymal sperm aspiration (PESA): Recommended in cases of obstructive azoospermia with normal spermatogenesis. It is performed by puncturing the epididymis using a 19-21G needle.

Taking sperm from testicles

• Fine needle aspiration (FNA): Recommended in cases of obstructive azoospermia with normal spermatogenesis. The testis is punctured using a 21G thin needle.
• Testicular sperm aspiration (TESA): Recommended in cases of obstructive azoospermia with normal spermatogenesis.
• Testicular biopsy (testicular sperm extraction - TESE): Recommended in cases of obstructive and non-obstructive azoospermia and involves open biopsy and collection of small pieces of testicular tissue.

Methods of suctioning the epidermis from the epididymis (MESA, PESA) or the testes (TESA) are simpler, but are largely "blind", causing damage to the testicular tissue, such as hematoma, fibrosis and testicular atrophy. Testicular biopsy (TESE) is suggested by international literature as the most effective method of finding sperm and is associated with a lower rate of complications.

Historical data

The first mention of the possibility of freezing semen was made in 1776 by Spallanzani after successful experiments with freezing - thawing human semen in the snow. But in fact, the first semen freeze occurred in 1949 when Polge and his colleagues observed the cryoprotectant effect of glycerol on avian semen that was frozen at -76 degrees Celsius. It was followed in 1953 by Sherman and Bunge who first frozen human sperm in a 10% solution of glycerol and dry ice. The first pregnancy from sperm that had been frozen in glycerol solution and liquid nitrogen was achieved by the same research team a few years later. The first human semen cryopreservation banks were created in the 1970s, and the birth of the first infant with Louis Brown in 1979 gave new impetus to the improvement of semen freezing techniques.

How to freeze - freeze sperm?

The semen can be frozen through a suitable procedure and stored in nitrogen-containing containers at -196 degrees Celsius. The most commonly used method involves adding to the sperm a suitable volume of cryoprotectant such as glycerol at a concentration of 5-10% and then freezing the sample with or without the use of a cooling gradient. Although no significant changes in results have been made in recent years to improve the cryopreservation method, more complex solutions containing other non-glycerol substances such as egg yolk, soy lecithin and citric acid have also been used. Frozen semen can be preserved without losing its properties and fertility for many years or even decades.

Indications - Advantages of Freezing - Sperm Cryopreservation.

• In men who are going to undergo chemotherapy or radiation due to cancer, this is expected to significantly affect their fertility. In men who are about to undergo orchectomy or prostatectomy due to benign or malignant tumor in order to maintain their fertility in the future.
• In men who are about to undergo neutering (vasectomy - ligation of the semen) so that their fertility can be reversible.
• In males with poor quality of life such as excessive smoking, high and daily alcohol consumption, daily exposure to occupational risk factors (chemicals, radiation, excessive heat) that they wish to maintain through sperm cryopreservation in their distant future.
• Couples following extracurricular cycles but not being able to physically present their spouse on the day of vaccination (long business trips, unforeseen events at work), etc.
• In men who have an erection defect and cannot ejaculate or have a complete lack of spermatozoa, sperm can be directly collected from the epididymis and testis and the collected spermatozoa to be frozen for use.
• In men who have had an accident (spinal cord injury) and cannot often ejaculate, the amount and quality of sperm decreases over time. In these cases, storing - preserving sperm as early as possible can greatly protect their fertility.
• In men who wish to give birth at a later time and want to secure their reproductive potential, as a foreshadowing move.
• In men who have been successfully treated for improved sperm quality but are less likely to maintain this effect, they can freeze sufficiently at this time in their quantity and quality of sperm.
• In men with severe oligoasthenia when multiple ectopic material is required to be concentrated.

The possibility of establishing semen banks and using semen donation at any time for couples facing severe azoospermia problem was provided.

In vitro fertilization since its inception in 1978 has been the most important scientific breakthrough in the treatment of infertility. Developments since then have eased the effectiveness of the method to very high levels. An important role in this direction has been the development of a new innovative method of embryo cryopreservation, vitrification. The vitrification method allows for safe preservation of embryos, achieving survival rates exceeding 98% after thawing!

The high efficacy of the new cryopreservation method has enabled experts to adopt new more effective practices in the implementation of IVF.

One such emerging and important practice, which in recent years has been gaining ground more and more internationally, is the planned embryo cryopreservation and transfer to the next cycle.

In some cases during an IVF cycle it may be found that the endometrium does not have the ideal conditions for implantation. Factors that may affect the function of the endometrium and therefore the implantation process may be the medication itself used during IVF, ovarian hyperstimulation syndrome, as well as pathological findings that may be found during treatment such as endometrial polyps, very thin endometrial etc. Today and thanks to the vitrification method it is possible to cryopreserve all the embryos for as long as needed until they are secured. the ideal conditions in the endometrium before embryo transfer of valuable embryos. Scheduled embryo cryopreservation and embryo transfer in the next cycle is a new modern approach that allows us to deliver embryos only when endometrial conditions are ideal, thereby maximizing the likelihood of pregnancy.

The maintenance of the resulting excess embryos, in a cycle of IVF, has been a well-known and recognized method for many years. But thanks to the vitrification method the efficiency of embryo maintenance has been maximized! Nearly 100% of embryos survive after thawing and remain as capable of pregnancy as fresh embryos. This new advanced feature allows the couple to complete their family without the need for repetitive therapeutic procedures and implements the plan: "a Stimulation Therapy - a Family"!

Experience so far has shown that the results of implantation of embryos that have been cryopreserved by vitrification are as good as those obtained from embryo transfer of fresh embryos, and in some cases even better, because of the ideal endometrial conditions that we guarantee! Both redundant embryo cryopreservation and planned embryo cryopreservation and subsequent embryo transfer are powerful tools for the individual treatment of each couple.

Cryopreservation of egg-laying eggs is a method that has recently begun to be implemented in the field of assisted reproduction and is applied in cases such as:

• Women with early ovarian failure
• Women who are going to undergo oncology treatment and there is an increased risk of losing fertility
•  Women who want to maintain their fertility and postpone the birth of a family
•  Couples wishing to avoid embryo freezing for ethical or religious reasons

The first pregnancy report from frozen eggs was obtained by Chen in 1986. Since then, few children have been born worldwide because the process of freezing eggs by the freezing method did not have high success rates. The main reason was the difficulty in cryopreservation of cells with high water content, such as eggs.

On the contrary, the recently used vitrification method, according to the international literature, seems to be successfully used for cryopreservation of anoxic eggs. The survival rate of eggs after thawing is over 90%, the fertilization rate is about 70% and the pregnancy rate is more than 40%. In order to collect the eggs for cryopreservation, the woman undergoes hormonal ovarian stimulation, as in the case of IVF. The procedure takes approximately 9-12 days during which it is subjected to ultrasound and blood sampling for analysis, at regular intervals. Once the eggs have matured sufficiently, they are removed with a thin needle placed through the vagina under ultrasound guidance. The procedure is not painful, it takes a while and the woman is intoxicated, a form of narcolepsy. The eggs collected are frozen immediately to -196 degrees Celsius and remain stored until the woman thinks it's time to become a mother. "

Cryopreservation of egg-laying eggs is a promising method that touches on the modern living conditions of Greek women and seems to offer much in the field of assisted reproduction.

In vitro fertilization using Danish eggs concerns women who:

• They treat early menopause
• They have a history of repeated failed IVF attempts
• History of recurrent miscarriages
• History of low quality eggs
• History of hereditary disease

It is a well-documented scientific process with excellent results that in specialized units the success rates are over 50%.

This unit has been working in this unit for over 15 years with excellent results and within the framework of responsibility and application of particularly stringent scientific and ethical criteria.

According to the Greek Legislation in force since 2005, donors are healthy Greek women under the age of 35 who, on their own initiative and voluntarily donating or eggsharing, anonymously consent to the offer of a specific number of eggs.

Donors give a detailed individual and family history and are screened for

• communicable diseases (hepatitis, AIDS, syphilis etc.),
• hematological diseases (Mediterranean anemia, cystic fibrosis),
• chromosomal abnormalities with karyotype.

Exterior features are also simulated between the two women.

The recipient of the ova should be screened for the well-being of its uterus and appropriate hormonal preparation of the uterus for embryo reception. The waiting time for finding eggs is between 5-6 months.

Women that turn to surrogacy are usually those who had their uterus removed for medical reasons – yet they retain their ovaries - or whose uterus is not functional or there is another reason that makes it impossible for them to conceive. In these cases, a surrogate mother provides her womb, where the doctor places the embryo or embryos that have emerged from the fertilized egg of the first woman with the sperm of her partner. The main role in this process is held by the two women, the biological mother and the surrogate mother or otherwise " birth mother", who carries the fetus and then gives birth to the child.

There are a variety of genetic or acquired diseases and disorders that can make pregnancy impossible and lead to the choice of surrogate uterus. Typical examples are:

• Hysterectomy (surgical removal of the uterus for medical reasons) • Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) • Previous injuries and scars on the uterus • Multiple fibroids tumours of the uterus • Medical conditions that make a pregnancy risky (heart disease, kidney disease, etc.) • Cases of multiple miscarriages • Multiple failures in IVF attempts • Dangerous complications in a previous pregnancy • Asherman Syndrome (multiple endometrial adhesions)

Legislation and surrogacy

According to current law concerning assisted reproduction in our country, the process of surrogacy is allowed only by court decision. The petitioner is solely the woman who wishes to have a child and is unable to conceive, provided she is not over 50 years old. In addition, specific medical documents that clearly demonstrate the reasons of her inability are required.

Similar conditions apply to the surrogate mother, ranging in age from 25 to 45 years, having at least one child of her own and not having undergone more than two caesareans. Also, in order to make sure that it is suitable, diagnostic tests and psychological evaluation are performed. A common condition for both women is to live in Greece. It is vital to stress that any financial consideration is expressly prohibited.

In summary, the legislation in our country is very specific, yet quite favourable. Legal guidance is necessary in order to avoid any complications during the process. Also, a private agreement must be concluded between the couple, the centre and the surrogate, so that all parties are protected.

Choosing this path can really be a life-changing event. We can help you to achieve this every step of the way