Assuming that the chocolate-and-flowers technique has failed or is impractical, a number of methodologies and approaches can be used to help interested persons achieve pregnancy.
This writeup attempts to summarize techniques in the assisted reproduction of human beings that were current at time of writing (2006). Further details on most can be found in their individual nodes.*
- Cycle monitoring — Sometimes all that is required for successful conception is knowing when to make the attempt. Cycle monitoring may be performed at home by tracking basal body temperature and using an Ovulation Predictor Kit (OPK). Clinical cycle monitoring uses a combination of blood testing and ultrasound examination to predict ovulation more precisely. When the presence of a luteinizing hormone (LH) surge in the blood indicates that ovulation is imminent, sexual intercourse (at home, not in the clinic!) may be attempted. One of the following techniques may also be employed if attempts using cycle monitoring alone fail.
anthropod notes that Cycle monitoring is discussed in fertility awareness, albeit from a different perspective.
- Intravaginal insemination (IVI) — IVI may be used if there are no suspected problems with the female partner, but a male factor issue exists or the sperm donor is not physically intimate with the gestational carrier. IVI is simply the collection of a sperm sample into a sterile container, and its subsequent introduction directly into the vagina. Cycle monitoring is used to time the sperm transfer to just before ovulation. This "turkey baster" approach may be used by couples at home, if the pressures of infertility and performing "on the clock" have rendered the male partner unable to hit his mark. If performed in a clinic, a sperm wash will often be used to ensure that the best sperm are transferred.
- Intracervical insemination (ICI) — In cases where there is no tubal blockage or suspected egg/sperm quality issues, the problem may simply be that the sperm are not getting to the cervix and then into the uterus. Male infertility factors such as ejaculation problems, or conditions requiring the use of a sperm donor, may be indicators for ICI. Cycle monitoring is performed to track the day of ovulation. A sperm sample collected from the male is injected via catheter and deposited just outside the cervix. A 'sperm wash' is often done first, to separate the 'wheat from the chaff' in the sperm sample, so that only the best sperm are used. From there the sperm pass through the cervical mucus into the uterus and rendezvous with the released egg, where conception hopefully occurs.
- Cervical cap insemination — Basically the same as Intracervical insemination, with the addition of a cervical cap — a small, plastic dome — which is placed against the cervix. The sperm sample is injected into the dome through a one-way barrier. This cervical cap holds the sperm sample against the cervix, increasing the chances that the sperm will cross into the uterus.
- Intrauterine insemination (IUI) - In order to prevent infection, the cervix is protected by a mucus plug. At the time of ovulation, this mucus barrier normally thins in order to allow access to the male's "germ cells" — that is, his sperm. In some cases, dubbed 'hostile mucus', this mucus barrier may not thin normally, and thus will not allow sperm to pass into the uterus. IUI bypasses this mucus barrier entirely. Again, cycle monitoring is performed. Just prior to ovulation, the male's sperm is collected. Here the 'sperm wash' is mandatory, to remove most of the seminal fluid, dead sperm, and other unwanted material which would irritate the uterus. The most motile sperm are selected and injected directly into the uterus via a small catheter. Here they hang out for up to 24 hours, awaiting the arrival of the released egg and destiny.
- Intratubal Insemination (ITI) — This approach, and its related procedures Sperm Intrafallopian Transfer (SIFT), Gamete Intrafallopian Transfer (GIFT), and Zygote Intrafallopian Transfer (ZIFT) are relatively rare. They are much more invasive, and expensive, than the techniques described above. Each involves a transfer of genetic material directly into the fallopian tubes. This approach is contraindicated for couples with a history or risk of ectopic pregnancy.
- 'Stimulated' IUI — Before resorting to a complete IVF procedure, an intermediate step may be tried. If decreased egg quality is suspected, but the tubes are intact, a drug and hormone protocol may be used to stimulate several eggs to mature simultaneously, in the hopes that one or more will be viable. Unlike an IVF, surgical extraction of the eggs is not performed. IUI is used to make sure that sperm are on hand when the eggs arrive in the uterus.
- In vitro fertilization (IVF) — In today's IVF programmes, the female partner or egg donor is given a multi-week drug and hormone protocol which overrides and controls the body's natural cycle of egg production. Multiple eggs are brought to maturity and harvested surgically. The eggs are placed in a growth medium, and fertilized by the male partner or sperm donor's sperm. The resultant embryos are cultured for three to five days. The strongest embryos that develop are transferred into the female partner or surrogate's uterus.
- Natural 'IVF' — Instead of pulling out the full drug and hormone arsenal of a complete IVF procedure, an intermediate step may be tried. The egg (or eggs, if this procedure follows a failed hormone stimulation cycle) are allowed to mature without hormone therapy, and cycle monitoring is performed. When ovulation nears, the egg or eggs are extracted via laparoscopy, and the normal IVF process proceeds as described above.
- Intracytoplasmic sperm injection (ICSI) — Usually part of a full IVF cycle with drug protocol cycle, ICSI may also be used in a natural cycle. A mature egg is extracted via laparoscopy. A single healthy sperm from the male donor is injected directly into the egg. The embryo is developed in culture for a few days, and then transferred to the uterus.
- In vitro maturation (IVM) — A relatively new, even more experimental technique which replaces traditional IVF. Instead of subjecting the egg donor's body to weeks of drug therapy, immature eggs are retrieved from the woman's ovaries and are grown to maturity in the lab. The drug protocols are applied directly to the eggs, rather than injected into the woman's body. This technique is currently being used on patients with a high risk of Ovarian Hyperstimulation Syndrome (OHSS) from traditional IVF. A few successes have been reported, but the complexities of human folliculogenesis have prevented widespread adoption of the technique. Nonetheless, the potential benefits of this approach are numerous, most importantly that it is both less intrusive and less expensive than IVF.
* - Or will be, in due time.
Please note that I am not a medical specialist. My expertise is that of personal experience. As always, nothing on Everything2 should be considered medical advice. Consult with your own medical doctor before making any decisions about your health. See also the Everything2 medical disclaimer.