In vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) is also known colloquially as artificial insemination (assisted reproduction).
In IVF and ICSI, fertilization does not take place in the woman's body, but artificially in the laboratory. Both techniques are part of reproductive medicine.
For some couples, artificial insemination is the only way to have a child after an infertility diagnosis.
While IVF was mainly used at the beginning of reproductive medicine, 75 percent of doctors now use ICSI.
In IVF, egg and sperm cells are brought together in a laboratory glass. There they have to find each other.
In vitro fertilization (IVF) is a form of assisted fertilization @ phonlamaiphoto /AdobeStock
In ICSI, on the other hand, doctors inject a single sperm cell directly into an egg cell. This is done with a very fine needle. Doctors usually use ICSI if the man's sperm quality is not optimal.
Intracytoplasmic sperm injection (ICSI) is suitable for men with severely impaired sperm quality @ Tatiana Shepeleva /AdobeStock
In both procedures, the woman receives hormone treatment as a first step. The aim of hormone treatment is to remove as many eggs as possible from the woman's ovaries.
Doctors then bring the eggs and sperm together. After successful fertilization and if the fertilized egg develops, doctors transfer it to the uterus.
Couples who wish to undergo fertility treatment must have a number of tests carried out beforehand.
First and foremost, the focus is on investigating the causes and the question of why a fertility disorder has occurred.
Both the woman and the man must be examined for this.
Preliminary examinations for the woman
- Taking a detailed medical history
- A thorough physical examination
- An ultrasound examination
- Observation of the menstrual cycle
- Hormone tests from the blood and
- Uterine or laparoscopy
Preliminary examinations for men
- Taking a detailed medical history
- A thorough physical examination
- Spermiogram
- Hormone tests from the blood
- Ultrasound of the testicles
- Under certain circumstances, it may also be useful to take a tissue sample from the testicles and epididymis.
Information on artificial insemination
In any case, couples should take enough time to think about it after the fertility tests and the information provided by the doctor. After all, artificial insemination is a massive intervention in the female body.
Further examinations before artificial insemination
In any case, both partners should have an HIV and hepatitis (B and C) test carried out before artificial insemination.
The woman should also be tested for rubella. Other tests that may be useful before artificial insemination are tests for toxoplasmosis and chlamydia.
ICSI is also suitable if the sperm quality is low, as only one sperm cell is required per egg cell.
In vitro fertilization, on the other hand, requires several sperm cells to find their way into the egg. The man's spermiogram is therefore decisive in determining whether IVF or ICSI is used.
The spermiogram contains values and information on
- Number of sperm in the seminal fluid
- Shape and motility
- The pH value of the seminal fluid and
- Numerous other characteristics
Doctors now use ICSI not only for male fertility problems, but also after unsuccessful IVF attempts.
Hormone treatment and egg retrieval
For artificial insemination (IVF and ICSI), the woman is given hormone preparations to stimulate the ovaries. This allows the ovaries to mature several follicles. This increases the chances of obtaining several fertilizable eggs for artificial insemination.
The womaninjects the hormones under her skin using a thin pen or a normal syringe @ Suzi Media /AdobeStock
To prevent premature ovulation during hormonal stimulation, the woman is given medication to slow down the body's own hormone release. This procedure is also known as the agonist protocol with downregulation.
During the stimulation treatment, check-ups are carried out in which the doctor checks whether one or more eggs are present.
If sufficiently large eggs are present, the woman takes special medication to trigger ovulation. 36 hours later, the doctors remove the eggs from the ovaries.
This is done under light anesthesia or analgosedation. This is an outpatient procedure and the woman can return home after around two hours.
Provision of sperm for artificial insemination
One or more sperm cells are required for the artificial insemination itself. These should be as fresh as possible, which means that the man delivers his sperm on the day of egg fertilization.
He can do this either at the clinic itself or at home. If he brings the sperm sample from home, he must use a special container for transportation. He must also ensure that the sperm is at body temperature.
If neither IVF nor ICSI is an option, you will need to find another solution together with the doctor.
After the man has donated the sperm sample, the seminal fluid is processed in the laboratory to increase the fertilization capacity.
Sperm donation for artificial insemination
If the man is infertile or has limited fertility after unsuccessful artificial insemination, the couple can consider sperm donation.
Both procedures (IVF, ICSI) can also be carried out with donor sperm. Sperm donation also makes sense if the man has a hereditary disease that he does not wish to pass on to the child.
In Germany, only men between the ages of eighteen and forty who are physically and mentally healthy are accepted as sperm donors. All donors are tested for infectious diseases (e.g. HIV, hepatitis, chlamydia).
Sperm donation is also possible with intrauterine insemination. With intrauterine insemination, doctors insert a catheter into the woman's uterus. The donor sperm then enters the woman's body.
The use of donor sperm for artificial insemination can be very stressful for the couple. Therefore, in addition to medical advice, psychological counseling is also advisable. You should also consult a lawyer to ensure that you are legally protected. It is advisable to conclude a treatment contract.
Artificial insemination in the laboratory
After doctors have retrieved the eggs and processed the sperm, artificial insemination takes place. Doctors bring egg and sperm cells together by injection (ICSI) or fill both into a laboratory container, where they have to find their own way to each other (IVF).
Laboratory staff then cultivate the treated egg cells in the incubator. The conditions there are optimal. 24 hours later, the experts examine the egg cells under a microscope and check whether fertilization has taken place.
If fertilization was successful, the woman receives the fertilized egg back into the uterus after around 2-5 days.
The doctor will explain the following to the couple on the day of egg retrieval:
- The duration of cultivation in the incubator (up to 5 days is possible)
- The number of eggs that will be returned to the woman
After two to five days, the doctor inserts the fertilized eggs into the uterus using a thin catheter. This is a painless procedure. Experts also call it embryo transfer.
If fertilized eggs are left over, they can be frozen (cryopreserved). If the treatment does not work, they can be thawed and used the next time. The advantage: a cryopreservation attempt is much gentler because the woman does not have to repeat the whole procedure.
Pregnancy test and ultrasound examination
About a fortnight after the embryo transfer, a blood test is carried out to determine whether the woman is pregnant. The pregnancy hormone (HCG) in the blood is important here. A further two weeks later, an ultrasound scan will show how many children there actually are.
The chances of success of artificial insemination depend on various factors:
- Type of fertility disorder
- Duration of involuntary childlessness
- Age of the woman
- Age of the man
- Number of fertilized eggs and
- Psychological stress before and during the treatment itself and
- Existing illnesses of the man or woman.
The average birth rate per embryo transfer for IVF and ICSI is between 22-24%.
The birth rate per treatment cycle is around 20%, as every tenth treatment does not result in successful fertilization.
- After artificial insemination, every twelfth pregnancy results in a foetal malformation. In a normal pregnancy, this is the case in every fifteenth pregnancy. The reason for this may be artificial insemination or it may be due to the parents' risk factors.
- The risk of malformation is slightly lower with IVF than with ICSI. Possible malformations can include cleft lip and palate, heart defects and malformations of the stomach and intestinal tract.
- The frequency of multiple pregnancies also increases with IVF and ICSI. Children who are born in the early weeks of pregnancy have a very high risk of physical and mental impairments.
It should be borne in mind that the chances are not exactly high at fifteen to twenty percent per attempt. It may therefore take several cycles before artificial insemination is successful.
As each attempt is a great strain, the couple needs a certain amount of stamina. Sometimes it can be helpful to take a break after a few unsuccessful attempts in order to recover.
For successful implantation of the embryo in the uterine lining, the embryo must hatch from its protective envelope membrane (vitreous membrane).
This implantation process can be facilitated in reproductive medicine by assisted hatching. It is a kind of hatching aid for the embryo.
During artificial insemination, it is made easier for the embryo to leave the zona pellucida by thinning it out or perforating it. Assisted hatching is performed using a laser, a glass needle or enzymatic thinning of the vitreous membrane. Laser technology is the method of choice in modern reproductive medicine.
A careful risk-benefit assessment is necessary despite the low risk of injury to the embryo through precise laser technology.
Assisted hatching makes sense for couples who have already undergone several unsuccessful treatment cycles with IVF or ICSI.
Due to the hormonal treatment during artificial insemination, it is possible for several follicles to mature.
After follicular puncture, all the eggs retrieved are then used for sperm injections (ICSI) or egg cell insemination (IVF).
If more eggs are fertilized than are intended for transfer, there is the option of cryopreservation. This means that the patient does not have to undergo further stimulation and egg retrieval (follicular puncture).