Processing Sperm and Oocytes
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Processing Sperm and Oocytes

Counselling
Counselling is a very important aspect of ART and is required by law before, during and after treatment, since undergoing fertility treatment can be emotionally and physically stressful. It provides the opportunity for one to explore feelings, beliefs and thoughts to enable informed decisions.

At each step of the process (counselling, before and after treatment) can contribute to enable an assessment between benefit and risks. If a risk is higher than the procedure of IVF, then, the process can be stopped and the reasons will be given. Couples will be informed on such situations at the beginning of the process. (Further information is found in ARTF168-Infertility Counselling Service, provided in this pack).

Consent
All activities within the process of ART treatment can only be performed after the prospective parent / donor has given a free (without undue influence) and informed consent. The decision to proceed with ART treatment can have life changing implications on the prospective parent / donor, child born from ART treatment and immediate family members. Services of an interpreter may be arranged depending on availability of language.

Recommendations:
- Read this Information Sheet carefully.
- Seek clarification of any queries that may arise from our team of experts.
- Take time to reflect - this can be as long as required but not shorter than fifteen (15) days before you proceed to the next step.

Genetic Counselling and Testing
Genetic counselling is the process of helping people understand and adapt to the medical, psychological, and familial implications of the genetic contributions to disease. Within the Artificial Reproductive Technology field, this is required to assess the risk of transmission of inherited conditions known to be prevalent, according to international scientific evidence, in ethnic backgrounds and family history. In addition, genetic counsellors can be involved in other ways, including preconception family history evaluation, investigating possible genetic causes for infertility or miscarriage and gamete donor screening.

Fertility Assessment
The Clinician responsible must determine and document, based on the medical history and therapeutic indications, the justification of treatment/donation and its safety for the recipient, donor and any children that may be born. This assessment may include, imaging tests (e.g. ultrasound); laboratory tests involving cervical smear, blood samples and semen analysis; and certain procedures (e.g. laparoscopy). These decisions will be discussed with the prospective parent.

Screening
Biological tests for the following infectious markers are performed to assess the risk of cross-contamination: HIV type I & II, Hepatitis B, Hepatitis C, Syphilis and Chlamydia infections.

Additional markers may be required depending on exposure and travel history.
- Occasionally there may be the need for certain tests to be repeated. This does not mean that the result is positive.
- Positive results will be communicated at the earliest and guidance for follow up will be provided.

Semen Collection
1) By Ejaculation
After seeking approval from the Embryo Protection Authority, a semen specimen is collected by ejaculation, usually by manual stimulation. This sample is collected at the clinic, to prevent any loss in viability due to delays in transportation and ensure identification. A private room is provided for this purpose. In “partner donation” this sample is collected on the day of oocyte (egg) retrieval. There are occasions when this is performed days before oocyte retrieval, and cryopreserved, for best possible chances of success. Semen collection is usually a one-time procedure however there are instances when a second sample is requested.

Recommendations:
- No ejaculation for 2 - 4 days before semen sample collection to favour sufficient number or function of sperm in specimen
- Hands to be washed with soapy water and dried well. No gels or lubricants are to be used.
- Instances of serious infections or illness with high temperature, occurring for up to 3 months before the start of ART treatment needs to be reported, since these may reduce sperm production.

2) Surgical Recovery
In these cases, the male is referred to a Urologist (a specialist in male infertility). After seeking authorisation from the Embryo Protection Authority, the procedures may include any one of the following; Percutaneous Epidydimal Sperm Aspiration (PESA) whereby fluid containing sperm is aspirated from the epididymis; Testicular Sperm Aspiration (TESA), whereby fluid containing sperm is aspirated from the testis; and Testicular Sperm Extraction (TESE) involving extraction of testicular tissue biopsies. This procedure is a minor operation under general anaesthetic. It is treated as a day case surgery, however the male needs to stay overnight at the hospital for further observation after the operation.

3) Retrograde Collection
Sperm can be collected from a urine sample. This occurs in cases when semen enters the urinary bladder instead of ejaculated through the penis.

Controlled Ovarian Stimulation
This procedure can only be done after approval by the ART Prioritisation Committee. The ovaries are stimulated by means of medications, in order to produce the maximum amount of mature oocytes (eggs). During this period an ultrasound is done on regular basis to measure the size of the follicles, which contains the oocyte (eggs). This treatment might take from 8 and up to 14 days.

Side effects which may arise from the medications:
- Tenderness, swelling or bruising at the injection site.
- Hot flushes, blurred vision, nausea, bloating and headaches
- Irritability and restlessness.
- Breast tenderness or swelling
- Ovarian hyperstimulation

Intra Uterine Insemination (IUI)
This is a fertility treatment that involves placing sperm inside a women’s uterus to facilitate fertilisation. The procedure can be carried out after prior authorisation by EPA. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilisation. This procedure is performed following Controlled Ovarian Stimulation. In this procedure freshly collected or thawed sperm can be used.

Oocyte Collection (pick-up)
Once approval by EPA is sought, this procedure is carried out under general anaesthesia, whereby oocytes (eggs) are collected. This is done through the vagina using ultrasound guidance in an operating theatre. The woman should not wear any perfume on day of egg collection. The vaginal ultrasound probe has a fine needle attached to it. The tip of the needle is pushed into the ovaries and the fluid from each follicle is drained into test tubes that are handed to the embryologist in the adjoining laboratory. There is considerable variability in the number of eggs collected and number of follicles. Not every follicle will yield an oocyte (egg). Some follicles may contain either immature eggs or deteriorating eggs rendering these eggs unsuitable for insemination. On very rare occasions no eggs are found.

On the day of oocytes (eggs) retrieval, the prospective parent is admitted as a day case in a surgical ward at MDH and prepared for general anaesthesia hence needs to be starved and blood tests will be collected. At the ward the nurses will prepare for transfer to the operating theatre. After the egg collection the prospective parent will be transferred back to the ward until she is well enough to go home on the same day. All treatment given will be explained before discharge and a written prescription will be given for the purchase of the treatment. Information will be given to prepare the couple for the day of the transfer of the embryos. The male partner is to accompany the woman on this day, in order to provide a fresh sperm ejaculate for fertilisation.

Note: Oocytes retrieval is a very safe procedure. However, all surgical procedures carry some element of mild vaginal bleeding and infections.

1) Processing
- Sperm from a semen sample/surgical sperm recovery/retrograde ejaculate is prepared in the laboratory so that the most motile sperm are harvested and placed in a special fluid awaiting oocyte (egg) insemination.
- Oocytes - The fluid drained from ovarian follicles is carefully examined under the microscope for the presence of oocytes (eggs). Every oocyte (egg) is retrieved and placed in a uniquely labelled dish with culture fluid and placed in an incubator.

2) Insemination
These procedures are performed in the Laboratory.

- Intracytoplasmic sperm injection (ICSI): A highly specialised technique which increases the possibility of fertilization since a single sperm is injected directly into each oocyte (egg), using a specifically designed glass needle. Fresh or thawed gametes can be used.
- IVF (In-vitro insemination): In this technique a small volume of processed sperm is added to the egg in culture fluid. IVF is carried out in our laboratory, in cases where only one or two oocytes (eggs) are collected and they do not look mature. In this procedure freshly collected oocytes are used while sperm can be freshly collected or thawed

Notes:
- A maximum of five (5) oocytes (eggs) are allowed to be inseminated in one treatment cycle when prospective parent/s consent for embryo storage and potential embryo donation. This option has to be approved by The Embryo Protection Authority EPA). If approval is not granted only two (2) oocytes (eggs) will be allowed to be inseminated.
- A maximum of two (2) eggs are allowed to be inseminated in one treatment cycle when prospective parent/s do not consent for embryo storage and potential embryo donation.
 
An image of microscope inspection 
 
Fertilisation
16-20 hours after ICSI /IVF the embryologist checks the injected eggs for fertilisation. Eggs showing early signs of fertilisation are checked again during the day. By the following day the fertilised eggs are expected to divide to form an embryo consisting of 2 to 6 cells which are generally clearly visible and regularly shaped. However, there will usually be some embryos in which a cell/s has broken into small fragments. This is quite common, and does not appear to affect pregnancy rates. Healthy pregnancies have developed from embryos with even significant fragmentation.

Notes:
- There is no guarantee that the eggs will fertilize.
- Quality of oocytes(eggs) and sperms collected play an important role in rate of fertilization.
- Normally most fertilized oocytes (eggs) will divide, however a small percentage may not and the development of others might arrest at any stage.
- Occasionally an egg will fertilise abnormally, not fertilise at all or show early signs of fertilisation.
- Unfertilised and /or abnormally fertilised eggs are discarded.
- Information on the number and quality of eggs collected, number of eggs frozen and number of eggs fertilised are conveyed to the couple/patient by the embryologist after fertilisation has been checked.
 
An image showing the fertilisation process 
 
Embryo Transfer
Embryo transfer takes place in the same operating theatre where egg collections are performed. A maximum of two (2) embryos are allowed to be transferred in any one cycle of treatment, in terms of the Embryo Protection Act. The embryos are transferred into the uterine cavity via a catheter passed through the cervix. This may cause some cramping, discomfort and possibly a small amount of bleeding. Infection is exceedingly rare but possible and may require antibiotic treatment.

Note: No perfume is allowed to be worn on day of embryo transfer.

- Prospective Parents who consent for embryo storage and potential embryo donation and for whom EPA consents.The day of embryo transfer depends on the rate of development of their embryos and is decided on Day Three (3) after oocyte (egg) collection, whereby potential of extending culture to blastocyst stage is assessed. Thus embryo transfer can occur on any day between Day Three (3) and Day Five (5). Embryo transfer day for these couples will be communicated by phone on Day Three (3). The prospective parent must be ready to come to hospital for their embryo transfer as guided.
- Prospective Parents who do not consent for embryo storage and potential donation. Embryo transfer will usually take place on Day Two (2) or Day Three (3). Extended embryo culture and blastocyst transfer for this prospective parent/s is not advisable due to the small number of embryos.

Cryopreservation
This is the process of preserving embryos and gametes (sperm & oocytes) for future use by cooling in very low temperatures while minimising the risk of cellular damage.

- Sperm Cells: These may be cryo-preserved and kept at ART Clinic - MDH during the lifetime of the person from whom they originate.
- Oocytes: These may be cryo-preserved and kept at ART Clinic - MDH for future own use. These will be stored up till the permissible age for the fertilization and for all procedures, including embryo transfer, after which they may be donated in terms of the Embryo Protection Amendment Act. Consent for donation will have to be signed before specifying if they wish to donate after death as well.

Note: Unfortunately, not all cryopreserved oocytes (eggs) will necessarily survive the thawing process or give rise to embryos after ICSI.

- Embryos: Those embryos which cannot be transferred into the prospective parent within a treatment cycle shall be cryo-preserved for future own use. This shall be regulated by an agreement and requires authorization from the Embryo Protection Authority. This agreement is renewable every five (5) years up till the maximum permissible age of embryo transfer into the prospective parent. After which the Embryo Protection Authority shall authorize donation of the embryo.In the rare occasions where the prospective parent/s do not consent for Cryopreservation of Embryos, and embryo transfer will not be possible due to grave and certified force majeure not predictable at the moment of fertilization, embryos will be cryo-preserved up to the date of transfer which shall take place as soon as possible.

Risks of ART
- Multiple pregnancy: There is an increasing risk of this pregnancy resulting in twins or pregnancies of a higher number of babies.
- Prematurity: There is an increasing risk of babies being born prematurely (i.e before 37 weeks of gestation).
- Miscarriage: As in all pregnancies, there is a risk that the pregnancy may result in miscarriage. IVF does not contribute to miscarriages. Like spontaneous pregnancies, it is the chromosomal abnormalities of the embryo which may lead to 80% of early miscarriages.
- Ectopic pregnancy: There is an increasing risk of pregnancy implanting itself outside the uterus (e.g in the Fallopian tubes). This is a medical emergency and such pregnancies are not viable.
- Ovarian Hyperstimulation: The process of assisted fertility requires that the ovaries be stimulated using certain medicines. Sometimes this can result in hyperstimulation, which is a condition whereby ovaries may swell up temporarily and cause pain and bloating, as well was excessive fluid in the abdomen. In some extreme cases, this may require admission to hospital for treatment.
- High risk pregnancy: This pregnancy is considered a high risk pregnancy in that complications which may arise during any pregnancy are more common and can be more severe in pregnancies arising from assisted fertility.
- Termination of process: This process may be terminated at any stage for whatever reason, including ovarian hyperstimulation or lack of response to treatment. There is the possibility of not proceeding to embryo transfer and in that eventuality all oocytes and/or embryos will have to be cryopreserved.
- Failure: There is a risk that the process of assisted fertility does not succeed and pregnancy will not occur.

Access to Treatment
- Access to ART Treatment is provided to all those entitled by law irrespective of colour, disability, gender, marriage, civil partnership, race, religion or belief, sexual orientation, nationality, politics or social status.
- Adequate and timely Access to ART Treatment is provided according to one’s needs based on medical history and clinical judgement guided by clinical criteria to maintain safety and equity while avoiding discrimination. A Prioritization Committee is set up for this purpose.

Privacy, Confidentiality and Data Protection
- The ART Clinic Team is committed to respect your privacy and safeguard your confidentiality.
- Medical records and personal data are maintained and processed to ensure traceability which is fundamental for the safety of services and treatment provided. The ART Clinic –MDH is bound to keep this data for thirty (30) years as per the Human Transplant Act, and refer data in a timely manner to the Embryo Protection Authority to be kept for the rest of the years making up one hundred and ten years (110 yrs) as per The Embryo Protection Act.
- Health information is stored and processed in accordance to General Data Protection Regulations (GDPR).
- You have the right to access and modify your personal data.
- Your anonymized data can be used for epidemiologic studies if you provide consent.

Your Responsibilities
- To attend for a scheduled appointment
- To be on time for scheduled appointments.
- To inform the ART Clinic - MDH Team of any changes in name, address, phone number or other details.
- To provide correct and accurate information on one’s medical history, exposure to infections and travel history.
- To provide us with feedback by filling up the “Patient Feedback Questionnaire” to help us improve our services.