Techniques and
Treatments

Intrauterine insemination consists of introducing selected and treated spermatozoa, previously prepared in the laboratory, into the uterus through a catheter (flexible and thin tube) that is placed in the cervix after the speculum insertion. The scope of the sperm laboratory treatment is to increase its potential and the possibility of fertilization occur.
It is a painless process that lasts a few minutes.
After the insemination, the woman can resume her normal life.
Depending on the indications and the cause of infertility, intrauterine insemination can be carried out with sperm of the male element of the couple or with donor sperm.
Ovarian stimulation and ovulation induction
Follicular development is induced with gonadotropins administered daily from the 2nd to 3rd day of menstruation. This is controlled echo graphically with the aim of leading to the growth of one or two follicles, monitor their evolution and schedule the intrauterine insemination when the follicles reach the appropriate size. The IUI is scheduled 36 hours after a final injection that will induce the release of the oocytes from the ovary (s).

In cases of IUI with the sperm of the couple’s male element:
- Dysovulation as cause of infertility
- Unexplained cause of infertility
- Slight changes on the semen of the couple’s male element
- Female element shows changes in the cervix that prevent the sperm from ascending from the vagina to the tubes
In cases of IUI with donor sperm:
- Male element has no sperm in the ejaculate (azoospermia)
- Male element at high risk of transmitting disease, infectious or genetic, to offspring
- Women without male partner
- Women couples
The success rate of IUI depends, fundamentally, on the cause of infertility and the woman's age, but generally does not exceed 10 to 12%.
If, after 3 IUI cycles pregnancy does not occur, it is necessary to reassess the couple / patient and eventually propose a new course of therapy with progression to IVF / ICSI. Naturally, depending on the response to a previous IUI cycle, it may, or not, make sense to anticipate, or delay, the progression to an IVF / ICSI technique, depending on the clinical assessment of each specific situation.

IVF is a Medically Assisted Reproduction technique that consists on the union of the oocyte with the sperm in laboratory environment (therefore, outside the woman's body) in order to obtain embryos that will later be transferred into the uterus and, ideally, originate a pregnancy. For the oocytes’ fertilization, there are two possible laboratory techniques to be applied, IVF (in vitro fertilization) and ICSI (intracytoplasmic sperm microinjection); ICSI technique, differently from IVF, consists of the injection of a single spermatozoa into the oocyte and is indicated in cases of infertility due to severe male factor, situations of failed fertilization in IVF or, possibly, in cases of poor oocyte quality.
In IVF / ICSI homologous gametes (oocytes and sperm from the two members of the couple) or heterologous gametes (using donated gametes) can be used.
This technique can also be used in the treatment of women couples by the method of reciprocal fertilization or shared maternity (in which a woman receives the embryo created from her partner's oocytes and sperm from a donor).

IVF / ICSI involves several steps:
- Ovarian stimulation
- Follicular puncture
- Laboratory technique
- Embryo culture
- Embryo transfer

- Failure in previous treatments such as ovulation induction or IUI
- Tubal’ obstruction or pathology, or absence of tubes
- Moderate to severe male factor
- Moderate to severe endometriosis
- Treatment using pre-implantation genetic tests
- Treatment using oocyte donation
The average success rate for IVF / ICSI treatments is around 35-40%. This percentage varies a lot according to the woman's age, with groups of patients with excellent prognosis and in which the probability of becoming pregnant in a first treatment cycle exceeds 50% (as is the case of women under 35), and others in that the probability of pregnancy is particularly low, as is the case of women over the age of 42, where the percentage of success in treatments with their own oocytes will be less than 10%.

The IVF / ICSI technique using oocytes from a donor consists of fertilizing these oocytes with sperm of the couple´s male element, or of a donor (in the case of women without a male partner, couples of women and situations of heterosexual couples with serious male factor), leading to obtain embryos in the laboratory, which will later be transferred into the beneficiary's uterus.

- Donor selection
Treatments with oocyte donation have been authorized in Portugal since 2006 (Law n. º 32/2006, of July 26th). Since April 24th 2018, and in accordance with the guidelines of the Constitutional Court, gamete donations in Portugal are made on a non-anonymous basis for the child born. So, when becoming adults, children born from donation treatments are entitled to ask, to the Portuguese authority that regulates the treatments of Medically Assisted Procreation (National Council for Medically Assisted Procreation - CNPMA), information on the identity of the donor(s) whose gametes were used in the treatment that originated them.
This is a right only for people born from these techniques, who are allowed to request, or not, this information – meaning that there is no obligation to consult this data.
In selecting the most appropriate donor for each couple or beneficiary, aspects such as ethnic origin, blood group and phenotypic characteristics of each person (skin colour, eye colour, hair, height, etc.) are taken into account.
- Donor stimulation
- Treatment of the receiver
- IVF / ICSI with donated oocytes
- Embryo transfer

- Premature ovarian failure (natural or iatrogenic)
- Gonadal dysgenesis
- Ovarian reserve significantly decreased
- Hereditary diseases that make it impossible for women to use their own gametes
- Repeated failures in previous IVF / ICSI treatments
- Embryos with chromosomal changes in previous treatments

It is the procedure by which previously cryopreserved embryos are transferred into the uterus. These embryos may be the result of treatments with own gametes or using donation.
CET is also the technique applied in situations of embryo donation and treatments using pre-implantation genetic tests (pre-implantation genetic diagnosis - PGT-M / SR or pre-implantation aneuploidy screening - PGT-A)
Cryopreserved embryos should always be transferred before starting a new IVF / ICSI treatment.
CET is a simple procedure, which does not involve ovarian stimulation or follicular puncture, only endometrial preparation for the embryo implantation. The embryos survival rates of to the freeze and thaw processes are over 90%, and the probability of pregnancy after CET is similar to that obtained with the transfer of fresh embryos.

- Endometrial preparation
- Thawing of cryopreserved embryos
- Embryo transfer

- Situations in which a pregnancy has not been achieved, in a previous cycle, from which cryopreserved embryos remain
- Cases in which a new pregnancy is intended
- Transfer of donated embryos
- Treatments with pre-implantation genetic tests (pre-implantation genetic diagnosis - PGT-M / SR or pre-implantation aneuploidy screening - PGT-A)
- Treatments in which, for clinical reasons, all available embryos are frozen (freeze all)
Treatment with cryopreserved embryos is also a way to prevent the risks of multiple pregnancy. In fact, the great effectiveness of the embryo freezing techniques currently available, makes it possible to transfer one embryo at a time and, consequently, avoid complications that could arise as a result of a multiple pregnancy.

IVF / ICSI technique using donor oocytes and donor sperm, in order to obtain embryos that will later be transferred into the beneficiary's uterus.

- The same as for treatment with oocyte donation and, simultaneously, a serious male factor, such as the total absence of sperm;
- Risk of genetic diseases transmission to offspring
- Woman without male partner or women couple, with indication for oocyte donation

It is the procedure by which donated embryos, previously cryopreserved, are transferred into the receiver's uterus.

- Endometrial preparation
- Thawing of cryopreserved embryos
- Embryo transfer

- Couples with mixed problems: women without the possibility of using their own gametes and a partner with a serious male factor, without the possibility of obtaining their own sperm
- Couples with previous IVF / ICSI cycles resulted in poor quality embryos
- Couples with repeated implantation failures
- Woman without male partner or women couples

Women are born with millions of oocytes (eggs) inside their ovaries, and this number decreases with age. These oocytes are not all ready to be fertilized: initially, they are only immature oocytes which, after puberty, enter a process of cyclic ripening, in which women's ovaries release one oocyte at a time.
Additionally, to this quantity reduction, the oocyte’ quality will also decrease over the years, as the process of maturation and release of the oocytes begins to occur with failures. These changes can lead to an increase number of spontaneous abortions in women of older age, as well as a higher risk of children birth with chromosomal changes (being the most frequent the trisomies 13, 18 and 21), especially as of 35 years.
On the other hand, nowadays, more and more women are postponing their desire for motherhood and starting a family, whether for social or professional reasons or because they have not yet found the ideal partner for this project, losing their ideal time to get pregnant (before the age of 28) that would correspond to the maximum peak of the fertility.
Surely and undeniable the ideal will be that each woman has children as soon as possible, but sometimes the circumstances of life make it not feasible. In these cases, there is the possibility, through the cryopreservation of oocytes, to preserve the woman's fertility potential. This way, if the woman faces, at an older age, infertility, she will always have the possibility to try to get pregnant with her own oocytes (which she cryopreserved at a younger age), with no need to resort to oocytes donated by another woman.
So, oocytes cryopreserved maintain their properties for years, which means that a woman can, for example, become pregnant at 40 with the oocytes that she cryopreserved at 32 - in this case the likelihood of pregnancy and the risk of chromosomal changes will be those that the same woman had at 32 and not those that she will have at 40 years old.

The woman must be carefully studied in a consultation prior to carrying out the fertility preservation procedure.
The treatment consists of an hormonal stimulation that is done in the most appropriate way for each woman and her characteristics, namely age, ovarian reserve and hormonal profile.

With the development of vitrification techniques, it became possible to cryopreserve oocytes in a safe way. The survival rates of oocytes to the cryopreservation / thawing process are already above 90%.

The woman's age at the time of the oocyte cryopreservation is the decisive factor in the probability of obtaining a pregnancy after the ICSI treatment with cryopreserved oocytes. The younger the woman is, at the time of the cryopreservation, the greater the probability of success. It is usually considered that the ideal age, to conserve oocytes, is before 38.

There are countless cases of women of reproductive age, but still without children, in whom an oncological disease is diagnosed with an urgent need for chemotherapy and / or radiotherapy treatment. Chemo and radiotherapy accelerate ovarian aging leading to a sharp decrease in the number of oocytes, which in most cases results in premature ovarian failure.
All of these situations, properly studied and in collaboration with the oncology specialist, can be directed to our clinic, with the objective of cryopreserve the oocytes prior to the start of the chemotherapy. The final decision to proceed will be made by the patient after counselling with her oncologist and the infertility specialist.

During Medically Assisted Reproduction treatments, or before, it may be necessary to cryopreserve and store sperm or testicular tissue.

- Use of donor sperm (is always cryopreserved)
- When is expected that the partner cannot be present at the time of the follicular puncture or IUI
- Serious male factor, with risk of worsening in the future
- Oncological situations, prior to the start of chemotherapy or radiotherapy
- Preservation of fertility from non-cancer causes, for example before a vasectomy

Testicular tissue (also called testicular pulp) is obtained from the Testicular Biopsy: surgical procedure, carried out under local anaesthesia (or general, if the patient so prefers or there is a clinical indication in that sense), in which a portion of testicular tissue / pulp containing sperm is extracted from the testicle. This material can be used fresh, in an ICSI cycle, or cryopreserved and stored for use in future treatments.
Indications for Testicular Biopsy:
- Diagnosis of azoospermia
- Obstructive azoospermia (absence of sperm in the ejaculate due to an obstructive reason)
- Very serious male factor; to improve ICSI success probability - better fertilization rate and better embryonic quality with the use of sperm extracted from testicular tissue.
In Portugal, the conservation period for cryopreserved sperm / testicular tissue is 5 years, which can be renewed for another 5 years.

It is a technique that allows a couple of women, who wish to have a child together, to share the process of motherhood. In essence, the oocytes of one of the partners are fertilized, with the sperm from a donor, and the resulting embryo is transferred into the uterus of the other partner, enabling pregnancy in this partner. That is why it is called Reciprocal Fertilization, a form of Shared Motherhood. Sometimes this technique is also called the “ROPA technique” (as it involves the PArtner's Oocyte Recovery).

The couple of women must be properly studied, taking into account the characteristics of each element, including a complete gynaecological evaluation of both. It is essential to decide jointly what will be the role of each in the process, the donor of the oocytes and the receiver of the embryo.
- Ovarian stimulation
- Follicular puncture
- Embryo transfer

- Female couple who wishes to share motherhood.

It is a state-of-the-art incubator created to optimize the conditions of embryonic culture and to enable the observation and evaluation of embryos round the clock.

Right after fertilization, the embryos are placed inside the EmbryoScope® incubator, in a controlled environment without external manipulation, and continuously monitored (9 image plans, obtained every 15 minutes).
The images are then compiled using specific software that creates a sequence of these photographs originating a film of the embryonic development.
This way is possible to record all the detailed and objective information of each embryo, which until now was not possible to be observed.
With EmbryoScope®, every day we learn things about embryonic development, several of which were just unimaginable a few years ago.
This information is used by embryologists to select the embryos most likely to generate a pregnancy, through the application of previously validated algorithms that allow the identification of embryos with the greatest potential for implantation.
At the end of the process, the couple / woman receives a report with a video of the complete evolution of their embryo(s). If all goes well, these will the baby's first pictures.