Infertility is typically defined as a condition in which a healthy couple of childbearing age cannot conceive after more than a year of unprotected sexual intercourse. In women over 35 years of age, the time frame may be shortened to six months. Infertility categories are further subdivided into primary infertility - patients without any prior pregnancies, and secondary infertility - couples who are experiencing infertility after having had previous conceptions.

 Every year, millions of couples try to conceive a child; unfortunately, many find that they cannot. Before July 25, 1978, the world's first successful "test-tube" baby was born in Great Britain, those women who were found to have Fallopian tube blockages (approximately 20% of infertile women) had no hope of becoming pregnant. Usually, conception occurs when an egg cell (ovum) in a woman is released from an ovary, travels through a Fallopian tube, and is fertilized by the man's sperm. The fertilized egg continues to travel while it undergoes numerous cell divisions. It then rests in the uterus to grow.
 Based on the last statistics and literature within the kingdom, Infertility has raised up to reach 15% of the population. 50% of which are female infertility, 40 % are male infertility and 10% both. 

 Infertility may be caused by disruption in any of these processes. Egg development and ovulation are under the control of complex hormonal interactions including FSH, LH, estradiol, progesterone, and others. Diseases of the thyroid, adrenal, pituitary, or hypothalamus glands can lead to adulatory dysfunction. Certain conditions, such as polycystic ovarian syndrome, cause irregular or absent ovulation that leads to infertility.
 

ART
Ovulation Induction (OI) 

Simply, the main objective through Ovulation Induction is to produce one mature Ovum ready to be fertilized by one sperm to produce an embryo.
Ovulation induction refers to the administration of medications to stimulate ovulation. These medications range from oral Clomid to FSH (gonadotropins) or combinations of the two. Gonadotropins are injected, ovulation stimulating hormones (FSH) that are replicas of the hormones produced by the body.
During 2007, Dallah Fertility Unit has treated 980 infertility cases with Ovulation Induction. 
 

 Intrauterine Insemination (IUI)
Intrauterine insemination (IUI) using the partner's sperm is often a viable option for couples experiencing infertility. IUI requires that the female produce and ovulate viable eggs that travel unimpeded through the fallopian tubes and are capable of being fertilized by sperm. IUI is sometimes used as a "first line" infertility treatment in combination with ovulation inducing medications.
Indications for IUI include:

Low sperm count. Decreased sperm motility. Increased numbers of abnormal sperm (abnormal morphology). Poor cervical mucus with a poor post coital test. Anti sperm antibodies in male or female, and / or unexplained infertility.

IUI is a painless procedure that requires only a few minutes to perform. If the partner's count is low, his sperm can be collected, specially prepared, washed, concentrated, and placed into the uterine cavity. (Unwashed sperm should never be placed directly into the uterus as fatal allergic reactions can occur). In cases of moderate to severe male factor infertility, in vitro fertilization (IVF) is the first treatment of choice.
Per cycle, success rates with IVF are usually higher than IUI, and many patients are directed for IVF as the first line treatment. IUI is less expensive per cycle than IVF, meaning some patients can afford more attempts; however, statistically the chance of conception from two IVF attempts is significantly higher than three to four IUI cycles.
During 2007, Dallah Fertility Unit has treated more than 200 infertility cases with Intrauterine Insemination with success rate around 29%.

 In Vitro Fertilization (IVF)
The First IVF cycle at Dallah Fertility Unit was performed successfully in 1996. Our specialized IVF team includes Consultant IVF specialists, IVF nurse coordinators, IVF laboratory specialists, and Urologists. The combined efforts of these individuals are responsible for our superior results and success rates.
In vitro fertilization (IVF) is a process that involves the use of medications (FSH), to stimulate the development, growth, and maturation of eggs to be fertilized in laboratory. 
Preparatory period for patients undergoing IVF is performed by using certain medications called Gonadotropins analogues which either GnRh protagonists or GnRh antagonists following different protocols assigned based on the patient history and infertility case. FSH or HMG dosages are individualized for each patient; responses are carefully monitored using ultrasound and estradiol measurements. 
IVF bypasses the fallopian tubes and is therefore the first treatment of choice for most patients with damaged or absent fallopian tubes. IVF also has been instrumental in helping patients with endometriosis, moderate to severe male factor infertility, infertility of unknown causes, and many other infertility disorders. 
Success with IVF increases with the number of cycles attempted up to four cycles.
 

Steps of IVF Treatment
Stage 1 Preparation and Activation of Ovary

Preparation Injections are given in the beginning.  Then, activation of the ovary is performed using fertility drugs to allow many eggs to mature at the same time. More mature eggs mean more chances of fertilization and eventually of pregnancy.
During treatment, the response of ovaries is carefully monitored by USS and hormonal blood tests to minimize the risk of over stimulation
 

Stage 2 Egg Collection
When the eggs mature to the optimal size, they are aspirated from the ovaries. This is done via a fine needle introduced through the vagina under USS guidance. The eggs are examined by the embryologist to choose the healthy ones for fertilization.
 

Stage 3 Fertilization of the Oocytes
At this stage, the mature eggs are exposed to the active sperm obtained from the husband to allow fertilization and development. This process takes a maximum of 50 hours.
You can be assured that the highest level of caution is taken within DFU laboratory to ensure that the work is done accurately, efficiently and to preclude any mistakes inside the lab. This is achieved via special monitoring procedures for each case in isolation from others.
 

Stage 4 Embryo Transfer
This is usually the simplest part of the procedure. Two to three embryos could be loaded into a fine transfer catheter which is passed through the cervix. The embryos are deposited inside the wife’s uterus for potential implantation.
 

Follow up
Two weeks after the transfer of embryos, a pregnancy test is performed. If the pregnancy test is positive, an USS examination is done after 35 days to confirm a normal pregnancy and to hear the heartbeat of the fetus. Subsequently, during the pregnancy, the lady remains under the care of the Dallah Fertility Unit Team.
 

 IntraCytoplasmic Sperm Injection (ICSI)

Although cases diagnosed with mild sperm abnormalities can be successfully treated by "classical" IVF, today Intra-Cytoplasmic Sperm Injection (ICSI) offers a new dimension of therapy for all the moderate and more severe forms of male infertility.
 
Indications for ICSI include:

Men diagnosed with low sperm concentration, motility and / or morphology ( irrespective of the degree of these abnormalities ), antisperm antibodies, or with poor scores in the functional bioassays Cases of partial or total fertilization failure in a previous IVF attempt ( with overt or more subtle sperm deficiencies or even with normal semen analysis ) Men diagnosed with absence of sperm in the ejaculate ( azoospermia ). These challenging cases include two main types of problems: • obstructive lesions of the male genital tract ( such as congenital bilateral absence of the vas deferens, inflammatory occlusions, previous vasectomy, and others ) • Patients diagnosed with different degrees of testicular insufficiency ( hypospermatogenesis or poor sperm production of testicular origin ). The former cases can be successfully treated by new techniques of sperm aspiration from the epididymis or the vas deferens followed by ICSI. In the latter cases, sperm can be obtained from the testes by performing an open testicular biopsy or by needle aspiration, also followed by ICSI.

In all these cases, the possibility of freezing "extra" sperm obtained at the time of the urological intervention (prior to or at the time of IVF / ICSI) should always be considered. Frozen - thawed sperm may maintain viability and therefore can be used in future ICSI cycles. Sperm freezing is a mandatory and efficient means of maintaining the reproductive potential of men who will have radical therapies in cases of curable cancer.
 

EGG RETRIEVAL
In the vast majority of cases, egg retrieval is performed transvaginally with ultrasound guidance. This usually is performed under intravenous sedation with local anesthesia, but general anesthesia may be given.
 The eggs are then combined with sperm in culture dishes; the resulting embryos are placed in an incubator where they are nourished until they are ready for transfer usually in 3 - 5 days. The IVF incubator is a highly controlled environment that maintains precise temperatures, gas concentrations, and uses highly filtered purified air.
 

IMMATURE EGGS
On average, approximately 80% of the eggs collected are mature. Thus, 20% of the eggs are immature at the time of egg retrieval. Although approximately 60% of the immature eggs will mature with overnight incubation of an in vitro culture, a pregnancy rarely occurs (< 2%) from the transfer of only embryos that originate from immature eggs
EMBRYO TRANSFER
Once mature, the embryos are removed from the incubator and placed into the uterus where they are allowed to continue normal fetal development (transfer). Embryo transfer is usually performed under no anesthesia and lasts only a few minutes.
On occasion, dilatation of the cervical canal may be required at the time of transfer in order to facilitate the procedure. Minor side effects include mild cramping and minimal bleeding, mostly from the use of a cervical tenaculum to straighten the cervical canal. 

 

EMBRYO CRYOPRESERVATION
Embryo cryopreservation has revolutionized the process of IVF and positively affected success rates. The advantages include inseminating all of the available oocytes, limiting the number of pre - embryos transferred to reduce the incidence of multiple pregnancy, and giving patients an added chance of achieving a pregnancy without having to undergo a complete stimulated IVF cycle (which offers tremendous cost and time advantages).
 Cryopreservation is performed on fertilized pre - embryos with a slow freezing protocol using a cryoprotectant. Thawing and transfer of the pre - embryos is performed in a natural cycle following ovulation, or in a programmed cycle that includes exogenous administration of estrogen and progesterone.
 To illustrate the effect of cryopreservation on success rates, the total reproductive potential (TRP: the chances of a live birth from either fresh or cry preserved embryos from the same stimulated cycle) is calculated. Based on data from our program, the TRP is greater than 45% for patients under 35 years of age.
 

Assisted Hatching
Assisted hatching (AH) is a micromanipulative procedure that involves the placement of a small opening in the membrane ( zona pellucida ) that surrounds the dividing human embryo.
The AH procedure is performed about 18 hours before the embryo/s are transferred back to the uterus when they are between the four - to - ten cell stage of development. Some investigators have reported in scientific literature that performing AH increases the rate of implantation and possibly the pregnancy rate for certain patients undergoing in vitro fertilization. Types of patients who may request / require the AH procedure include:

Patients of advanced maternal age (40 years) Patients who have frequently failed to achieve a pregnancy following IVF Patients with embryos who have thick zona pellucidae.

Blastocyst Transfer
A blastocyst is an embryo that has developed for five days after fertilization and has divided into two different cell types. A healthy blastocyst should hatch from its "shell" (zona pellucida) by the end of six days, and within 24 hours after hatching, should begin to implant within the lining of the uterus.
Most of our embryo transfers are performed on day two or three. However, recently, improvement in embryo culture conditions have allowed sustained embryo development to the blastocyst stage (the stage at which the embryo naturally arrives to the uterine cavity and implantation occurs). Candidates for blastocyst transfer are patients with at least six embryos and under the age of 40. However, as in the other areas of IVF treatment, the day of transfer and number of embryos to be transferred is discussed with the patient.
 

Male Infertility
Male infertility is present in 30% - 45% of infertile couples. This high frequency seems to be increasing in parallel with a possible overall decline of sperm numbers and function worldwide.
 Therefore, Dallah Fertility Unit, has the highest rate of these cases in the Kingdom, and was the first to enroll the newly advanced technique of PESA on routine base for azoospermic cases.
 Hormonal evaluation and urologic consultation may be indicated in many cases. We have developed a close relationship with our urology department in order to better understand and treat male infertility.

 

Rectal ElectroEjaculation (REE)
The rectal electroejaculation (REE) technique is used to collect semen from men who are unable to ejaculate. The technique has been used in animals since 1930s and in humans since 1948 onwards. In Dallah Fertility Unit, it has been used since 1997
The aim of rectal electroejaculation (REE) is to directly stimulate the seminal vesicles.
 

What is IVM treatment involves?
Immature eggs are collected from unstimulated or minimally stimulated ovaries under ultrasound scan guidance. The immature eggs are then matured in the laboratory for 24-48 hours using specific culture medium with added small quantities of hormones. Intracytoplasmic sperm injection (ICSI) is used for fertilization of the matured eggs. The resulting embryos are transferred to the women's wombs.
 

How does IVM differ from IVF?
Stimulated IVF is associated with the risk of developing ovarian hyperstimulation syndrome (OHSS) which is a potentially fatal condition and IVM eliminates this risk because it does not involve ovarian stimulation. Also, IVM is less expensive than IVF because it does not involve taking costly gonadotropin injections and involve less monitoring. Moreover, IVM is a shorter treatment regimen compared with in vitro fertilization.
Who would benefit from IVM treatment?
A number of people may benefit from IVM treatment:

• As an alternative to IVF for women with PCOS; these patients are at significant risk of OHSS
• As an alternative to IVF for younger women with normal menstrual cycles, IVM being less costly and safer
• Fertility preservation in young cancer women who are going to receive chemotherapy or radiotherapy
• Salvaging immature eggs collected during a standard IVF/ICSI (when unexpectedly a significant number of eggs collected are immature)

How effective treatment IVM compared with IVF?
About 400 babies have been born worldwide through IVM treatment; so far IVM seems to be safe. However, long-term safety records are lacking. Over a million children have already been born after IVF treatment and over 100,000 children have been born after ICSI and long-term data on safety and efficacy are available. Clinical pregnancy rates of 38% for women aged 35 years or under having IVM has been reported which compares favorably with that of conventional IVF.
 

How is PGD performed?
Standard IVF technique is used when the procedure requires FISH analysis. ICSI is used when there is abnormal semen or PCR analysis is required. This is to reduce the risk of contamination with sperm DNA. The eggs are retrieved and fertilized with the partner's sperm, often utilizing intracytoplasmic sperm injection (ICSI). Once the embryo reaches the six to eight cell stages, one or two cells are removed (biopsied) from an 8-cell embryo through an opening in the outer protective coat. The procedure is carried out under the microscope without damaging its ability to continue to develop normally (because at this stage of development, none of the embryo cells have become specialized). The cell is then analyzed for the presence of genetic disorders.
Patients who might benefit from PGD include:

• Carriers of known genetic diseases,
• Women over the age of 38,
• Women who have had recurrent miscarriages,
• Couples who have had previous aneuploid conceptions, or
• Couples who have had more than three IVF failures.

Clinical experience remains limited and the test is not 100% reliable, as sometimes the analyzed cell does not represent the rest of the embryo. To date, about 1000 babies have already been born worldwide using PGD. There are no reports of increased fetal abnormalities following PGD. However, long-term consequences on the fetus are unknown at present