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SCOPE OF FERTILITY CHALLENGES WORLDWIDE

Fertility problems are found in both males and females and affect one in six couples worldwide at least once in their lives, with cases linked to physiological causes as well as lifestyle factors. Many couples seek resolution in Assisted Reproductive Technology as a final attempt to become parents.

GOAL:

It is our vision to provide Assisted Conception Technology (ART) to those infertile couples who have failed conventional treatments to achieve pregnancy and are considering overseas In-Vitro Fertilization treatment options. By offering this program locally, it is very convenient and reasonably cost effective and eliminate taking away family/work time, the enormous expense and the inconveniences involved in air travel, lodging, medical treatment, foreign environment, and time constraint which are usually encountered when such treatments are undertaken abroad. The fertility centre is designed to serve primarily the entire Nigerian people and other nationals are encouraged to utilize the services.

OVERVIEW OF ASSISTED CONCEPTION

In order for pregnancy to occur, an egg has to be released from the ovary of the woman following follicular rupture at ovulation. The egg then unites with the man’s sperm ejaculated during normal intercourse. Normally this union, called fertilization, occurs within the fallopian tube which joins the uterus (womb) to the ovary. The fertilized egg (zygote) then slowly moves to the uterus where it implants and develop into a baby.

Diagramatic represention of the events from Ovulation to implantation of the human blastocyst.

What is in vitro fertilization (called IVF for short)?



IVF involves taking EGGS from the woman, fertilizing them in the LABORATORY with her partner's sperm and transferring the resulting embryos back to her uterus 2-6 days later.

The first IVF baby in the world was born in July of 1978 in England. Today, thousands of children are born annually as a result of this technique.

INDICATIONS FOR IVF

IVF is of demonstrated value for Women with absence of both fallopian tubes and irreversible tubal blockage (where corrective surgery has either failed or is inadvisable). Males with infertility related to low sperm counts or poor sperm motility usually have ICSI. Other causes of infertility treated with IVF include endometriosis, ovulatory dysfunction, genetic disorders and unexplained infertility.


AGE, FERTILITY AND IVF : There is no specific age limit for couples who may be considered for IVF in our Fertility Hospital. However, Older women –age 40 years and above must understand that they have lower pregnancy rates, increased incidence of miscarriages and medical complications when they become pregnant than younger women . Older women have higher cancellation rates and decreased response to ovarian stimulation. They will need more drugs, and therefore may pay more for their treatments. Some older women may need a third party arrangement in form of egg donor or surrogate motherhood. Prospective patients should undergo thorough medical and psychological evaluation and counseled about any increased medical risks of conception and pregnancy associated with advancing age. Bottom line: A woman's age and health status, her endometrial environment, her husband's age and sperm quality and the appearance of the developing embryo have the greatest influences on pregnancy outcome.

ART: Step-by-Step Guide

Every cycle of ART involves multiple steps, and each occurs at a specific time during a four to six-week period. The following is an overview of the IVF procedure. The procedure begins in the month proceeding the actual ART cycle. An IVF cycle typically includes the following steps or procedures:

  • Medications to grow multiple eggs
  • Retrieval of eggs from the ovary or ovaries
  • Insemination of eggs with sperm
  • Culture of any resulting fertilized eggs (embryos)
  • Placement ("transfer") of one or more embryo(s) into the uterus
  • Support of the uterine lining with hormones to permit and sustain pregnancy


  • In certain cases, these additional procedures can be employed:

  • Intracytoplasmic sperm injection (ICSI) to increase the chance for fertilization
  • Assisted hatching of embryos to potentially increase the chance of embryo attachment ("implantation")
  • Embryo cryopreservation (freezing)
  • The success of IVF largely depends on growing multiple eggs at once
  • Injections of the natural hormones FSH and/or LH (gonadotropins) are used for this purpose
  • Additional medications are used to prevent premature ovulation
  • An overly vigorous ovarian response can occur, or conversely an inadequate response

Cycle Preceding ART Cycle

  1. Sometimes oral contraceptives are begun.
  2. Sometimes a GnRH agonist (e.g. Lupron®) is initiated.
  3. Sometimes a mock transfer is performed to identify potential problems in embryo transfer.
  4. Occasionally, an IVF cycle starts with a cycle day of the menstrual period without other medications.

ART Cycle

  1. Prestimulation treatment
  2. Ovarian stimulation with gonadotropins (e.g. Bravelle®, Menopur®, Follistim®, Repronex®, Gonal-F®, Follistim AQ pen, and/or Gonal-F RFF Pen)
  3. Monitoring follicle development with ultrasound and serum hormone levels
  4. Final oocytes maturation and hCG administration (Profasi®, Pregnyl®, Novarel® or Ovidrel®)
  5. Transvaginal oocyte retrieval
  6. Insemination
  7. Embryo transfer
  8. Progesterone supplementation
  9. Pregnancy test
  10. Early pregnancy follow-up

Step 1 – Prestimulation Treatment

Initiation of Oral Contraceptives



Some patients will receive oral contraceptives in the cycle prior to the ART cycle. This ensures that GnRH analog therapy will start at the proper time if you have irregular cycles. There is also evidence that oral contraceptives can help prevent ovarian cysts, which sometimes develop during GnRH analog therapy. Provera® or progesterone may be prescribed for patients who ovulate irregularly or not at all.

Suppression of Ovulation



There are two principle ways that physicians ensure ovulation does not occur before egg retrieval. One involves pre-treatment of a patient with a GnRH agonist. The other involves treatment after six or so days of stimulation with a GnRH antagonist.

GnRH Agonist Administration



GnRH agonist (Lupron®): This medication is taken by injection. There are two forms of the medication: A short acting medication requiring daily injections and a long-acting preparation lasting for 1-3 months. The primary role of this medication is to prevent a premature LH surge, which could result in the release of eggs before they are ready to be retrieved. Since GnRH-agonists initially cause a release of FSH and LH from the pituitary, they can also be used to start the growth of the follicles or initiate the final stages of egg maturation.

A GnRH agonist might be prescribed sometime after taking oral contraceptive pills. This dose may be reduced when ovarian stimulation is begun. Agonist is often discontinued on the day of hCG (human chorionic gonadotropin) administration.

Some protocols also might begin GnRH agonist sometime after ovulation in the cycle preceding stimulation in the "mid-luteal" protocol, after the start of menses in the "flare" or "micro-flare" protocol.

GnRH-antagonists (ganirelix acetate or cetrorelix acetate)



(Antagon®, Cetrotide®): These are other classes of medications used to prevent premature ovulation. They are typically administered several days after stimulation and require fewer injections.

Baseline Pelvic Ultrasound



Around the time of your expected period, we will perform an ultrasound scan to examine the ovaries. If we detect a cyst, we may withhold further therapy until the cysts resolve spontaneously (usually in about a week). Occasionally, we recommend cyst aspiration (drainage). This is a procedure in which your doctor inserts a fine needle connected to a syringe, guided by ultrasound, into the cyst. We may also perform a blood test (serum estradiol measurement) to confirm that the ovaries are properly suppressed.

Step 2 - Ovarian Stimulation

In general, ovarian stimulation begins after menstrual bleeding starts. To control the timing of egg ripening and to increase the chance of collecting a substantial number of eggs, fertility drugs selected for the woman's individual situation are prescribed. Several similar medications may be used to stimulate follicle development: Bravelle®, Repronex®, Lupron®, Gonal-F®, Repronex® Follistim® Follistim AQ pen and Gonal-F RFF Pen. GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®) are another class of medications used to prevent premature ovulation and, in combination with an antagonist trigger, they may offer protection from severe ovarian hyperstimulation syndrome. They tend to be used for short periods of time in the late stages of ovarian stimulation. There are several different types of stimulation protocols. Although all protocols more-or-less employ the same types of medications, specific protocols may help certain types of patients to have a better response than other types. It is, however, unrealistic to think that switching from one protocol to another will dramatically change a poorly responding patient to a highly responding patient.

Step 3 - Monitoring of Follicle Development

Follicular development is monitored with a combination of vaginal ultrasound and hormone measurements (blood tests).

To check that egg development is satisfactory,IVF@ M&M utilizes trans-vaginal ultrasound examinations of the ovaries (a painless method of seeing the image of the enlarging follicles containing the eggs).

TRANSVAGINAL SONOGRAM (TVS) OF OVARIES SHOWING FOLLICLES UNDER HORMONAL STIMULATION

These tests are performed frequently during the ART cycle, and the dose of medication might be adjusted in an effort to improve follicular development. The amount of medication prescribed also depends upon the results of the blood tests and ultrasound exams. Using the above information, the physicians determine when to administer an injection to cause final ripening of the eggs and when to schedule egg retrieval.

Step 4 - Final Oocyte Maturation and hCG Administration

Human chorionic gonadotropin (hCG) (IVf-C, Profasi®, Novarel®, Pregnyl®, Ovidrel®) is a hormonal drug that stimulates the final maturation of the oocytes. Determining the proper day for hCG administration is critical. The leading follicular diameter should be above 18mm. The time of the injection determines when the egg retrieval will be scheduled. Some protocols using GnRH antagonists use GnRH agonists to trigger the final maturation of oocytes.

Step 5 - Transvaginal Oocyte Retrieval

The retrieval procedure to obtain the eggs is performed trans-vaginally using a hollow needle guided by the ultrasound image (this is completely comfortable under adequate sedation and local anesthesia). Eggs are gently removed from the ovaries using the needle. This is called "follicular aspiration or oocyte retrieval" Its timing is crucial because the egg will not develop properly if it is collected too early or too late. The eggs also may develop poorly or may have already been released from the ovary and lost.

Oocyte retrieval is performed about 34-36 hours after hCG has been administered. A transvaginal ultrasound probe is used to visualize the ovaries and the egg-containing follicles within the ovaries. A long needle, which can be seen on ultrasound, can be guided into each follicle and the contents aspirated. The aspirated material includes follicular fluid, oocytes (eggs) and granulosa (egg-supporting) cells. The physician will collect the oocytes and follicular fluid into a test tube and this is immediately sent to the embryologist who will search the follicular fluid, locate and pick up the oocytes using a microscope.

  • Injury and infection are rare during the procedure if you are under the care of an experienced IVF specialist.


After the retrieval, patients recover from anesthesia in an adjacent recovery room where they will be observed while the intravenous medications wear off. It is not uncommon to have some vaginal spotting and lower abdominal discomfort for several days following this procedure. Generally, patients feel completely recovered within 1 to 2 days.

The number of oocytes retrieved is related to the number of follicles in the ovaries, their accessibility, and the number of follicles that develop in response to stimulation. Sometimes a follicle may be not contain any egg, or harbor immature or post mature egg. Ultrasound provides only an approximation of the number of oocytes that one can expect to recover. On the average, 8 to 10 oocytes are retrieved per patient.

Step 6 - Insemination of Oocytes and Embryo Culture

  • Sperm and eggs are placed together in specialized conditions (culture media, controlled temperature, humidity and light) in hopes of fertilization
  • Culture medium is designed to permit normal fertilization and early embryo development, but the content of the medium is not standardized.
  • Embryo development in the lab helps distinguish embryos with more potential from those with less or none.


a Semen is usually collected by masturbation the morning of the retrieval and the sperm are removed from the semen through special processing in the andrology laboratory. On rare occasions, a second semen sample may be necessary. If a patient might have some anxiety regarding semen collection, he may elect to freeze semen before oocyte retrieval as a backup or sometimes as the primary sperm source.

After eggs are retrieved, they are transferred to the embryology laboratory where they are kept in conditions that support their needs and growth. The embryos are placed in small dishes or tubes containing "culture medium," which is special fluid developed to support development of the embryos made to resemble that found in the fallopian tube or uterus. The dishes containing the embryos are then placed into incubators, which control the temperature and atmospheric gasses - Co2' Oxygen and nitrogen that the embryos need for development and growth.

A few hours after eggs are retrieved, sperm are placed in the culture medium with the eggs, or individual sperm are injected into each mature egg in a technique called intracytoplasmic sperm injection (ICSI) (see below). The eggs are then returned to the incubator, where they remain to develop. Periodically, over the next few days, the dishes are inspected so the development of the embryos can be assessed.

The following day after eggs have been inseminated or injected with a single sperm (ICSI), they are examined for signs that the process of fertilization is underway. At this stage, normal development is evident by the still single cell having two nuclei; this stage is called a zygote. Two days after insemination or ICSI, normal embryos have divided into about four cells. Three days after insemination or ICSI, normally developing embryos contain about eight cells or more. Five days after insemination or ICSI, normally developing embryos have developed to the blastocyst stage, which is typified by an embryo that now has 80 or more cells, an inner fluid-filled cavity, and a small cluster of cells called the inner cell mass.

It is important to note that since many eggs and embryos are abnormal, it is expected that not all eggs will fertilize and not all embryos will divide at a normal rate. The chance that a developing embryo will produce a pregnancy is related to whether its development in the lab is normal, but this correlation is not perfect. This means that not all embryos developing at the normal rate are in fact also genetically normal, and not all poorly developing embryos are genetically abnormal. Nonetheless, their visual appearance is the most common and useful guide in the selection of the best embryo(s) for transfer.

In spite of reasonable precautions, any of the following may occur in the lab that would prevent the establishment of a pregnancy:

  • Fertilization of the egg(s) may fail to occur.
  • One or more eggs may be fertilized abnormally, resulting in an abnormal number of chromosomes in the embryo; these abnormal embryos will not be transferred.
  • The fertilized eggs may degenerate before dividing into embryos, or adequate embryonic development may fail to occur.
  • Bacterial contamination or a laboratory accident may result in loss or damage to some or all of the eggs or embryos.
  • Laboratory equipment may fail, and/or extended power losses can occur which could lead to the destruction of eggs, sperm and embryos.
  • Other unforeseen circumstances may prevent any step of the procedure to be performed or prevent the establishment of a pregnancy.

Step 7 - Embryo Transfer

  • After a few days of development, the best appearing embryos are selected for transfer.
  • The number chosen influences the pregnancy rate and the multiple pregnancy rate.
  • ,li>A woman’s age, her endometrial environment and the appearance of the developing embryo have the greatest influences on pregnancy outcome.
  • Embryos are placed in the uterine cavity with a thin tube.
  • Excess embryos of sufficient quality that are not transferred can be frozen.


The embryo transfer procedure is usually performed three to five days after oocyte retrieval. The physician will pass a catheter gently through the cervix into the uterus and deposit the embryos into the uterine cavity along with an extremely small amount of fluid. This procedure usually does not require anesthesia, and the patient usually leaves the office after a brief recovery period.

Step 8 – Hormonal Support of the Uterine Lining (Progesterone Supplements)

  • Successful attachment of embryo(s) to the uterine lining depends on adequate hormonal support.
  • Progesterone, given by the intramuscular or vaginal route, is routinely given for this purpose.

Progesterone supplementation can occur using vaginal, oral or injectable progestreone, and in some cases, a combination of methods. Supplementation usually begins on the day of or the day after oocyte retrieval. Usually, cells in the follicle will produce progesterone following aspiration. During oocyte retrieval, some of these cells may be removed along with the oocyte. Supplemental progesterone helps prepare the uterine lining for implantation.

This daily medication will continue until your pregnancy test. If the test is positive, you may be advised to continue to take progesterone for several more weeks.

Step 9 - Pregnancy Test

A pregnancy test is necessary regardless of vaginal spotting or bleeding: It determines if pregnancy has occurred and is done 9-12 days after the embryo transfer. This test is usually repeated 2 days later if positive. If the test is negative, the doctor may instruct you to stop the progesterone and any other medications.

Step 10 - Early Pregnancy Follow-up

Close scrutiny or follow up of a pregnancy is necessary to try to identify early miscarriages or ectopic or heterotopic pregnancies and to help counsel the patient regarding the status and treatment of multiple gestations. Patients are generally released to their obstetrician after they are confirmed pregnant.

SUMMARY OF THE MAJOR IVF STEPS

There are five major steps in the IVF and embryo transfer sequence:

  1. Stimulation and development of FOLLICLES in the ovaries.
  2. Collect eggs from the follicles.
  3. Obtain and process sperm.
  4. Put eggs and sperm together in the laboratory, and provide correct

    environment for fertilization and early embryo growth.

  5. Transfer embryos into the uterus (womb).

The eggs are immediately identified by the embryologists in the directly adjacent IVF laboratory.

IVF WORK STATION AND IVF CHAMBER

The retrieved eggs can be inseminated with sperm, which have been obtained by masturbation and carefully processed. Sometimes the partner’s sperm is so low that a different method called Intra Cytoplasmic Sperm Injection (ICSI) is used to ensure union of sperm and egg.

INTRA-CYTOPLASMIC SPERM INJECTION (ICSI)



The sperm and eggs are then placed in incubators to allow fertilization to take place.

The eggs are examined carefully at intervals to ensure that fertilization and cell division have taken place. The fertilized eggs are now called embryos.

EGG DONATION

Egg donor programs are offered in almost all IVF centres worldwide. We offer a complete, sophisticated, compassionate and comprehensive program here at M&MFertility Hospital. This is so because majority of our patients are beyond the age of forty.

  • Egg donors in our program are:
  • Between the ages of 21 to 30
  • Bright and mature
  • Likely an undergraduate or graduate of a university
  • In excellent health and has been screened for routine infections and Genotype

The typical Egg Donor can be described as a caring, altruistic person who welcomes the opportunity to help an infertile couple have a child. Often times she has personally known couples who have had difficulties conceiving and therefore is particularly sensitive and empathetic to the inevitable hardships of the infertile couple. For all these reasons, she wants to help a couple enjoy the joy of parenthood.

Egg Donation process:

This process involves the stimulation of the egg donor woman with fertility drugs and the retrieval of her eggs. The donor's eggs are then fertilized with sperm and then the resultant embryos are transferred to the uterus of the recipient that is adequately prepared.

Why does someone need donor eggs?

There can be many reasons why someone may need the help of an egg donor in order to become pregnant and carry a baby. Listed below are some of the more common problems that are encountered in infertility:

Age is a very important factor. The older the woman, the more likely she may need egg donation especially beyond forty years of age. However, it is known that some women who are older than forty have conceived and delivered normal babies using their own eggs.

The recipient's ovaries are no longer functioning, i.e., there is no follicular development (menopause or premature menopause from any cause).

The recipient may be a carrier of a genetic disease and does not want to pass the disease on to her children

The recipient may not be able to produce a sufficient number of eggs and/or the eggs may not fertilize with IVF treatment

The recipient may have a history of repetitive pregnancy loss (miscarriage)

INFORMED CONSENT PROCESS

Guidelines from M&M FERTILITY HOSPITAL 

Obtaining and recording informed consent before major diagnostic, therapeutic, and invasive procedures is OUR STANDARD PRACTICE HERE . It is a physician’s professional and legal obligation to our patients. Patients have the legal right to grant or withhold informed consent, either personally or through lawful representatives. While not all physicians and not all patients desire to be involved in a shared decision making process, prevailing negligence law and the legal right to self-determination now require some documentation of informed consent for most major treatments and procedures. Physicians therefore have a legal motivation for obtaining and recording informed consent for major treatments and procedures, subject to recognized legal exceptions such as in providing emergency medical care to incapacitated patients. 

In addition to this legal motivation, M&M Hospital believes physicians ought to be motivated by a commitment to the ethical value of patient self-determination, or personal autonomy. The Goal is for M&M doctors to go beyond a limited consent model that emphasizes primarily the physician's legal obligation We involve the patient from the beginning through communication and encourages a certain kind of transaction between patient and physician.

The norms that govern such transactions are clarity, relevance, accuracy, and sincerity. There is an underlying ethical obligation to make it possible for the patient and the physician to participate together in a transaction that takes into account the norms of clarity, relevance, accuracy, and sincerity. In certain cases, physicians may simply explain that they see many people with a particular problem and regularly with success treat the problem in a particular way, then ask if the patient has any questions about the problem or the treatment. In these cases, if the patient makes statements or asks questions indicating discomfort, lack of understanding, or continuing uncertainty, then the following guidelines apply. 

Shared Decision Making.

The primary value of documented informed consent is that it represents the existence of a relationship between physician and patient that is based upon, or at least includes, an element of shared decision making. Shared decision making for the patient is not the same as mere acquiescence, or compliance based on partial or slanted information, or indifference due to habit or apathy, nor is it the same as conformity to custom – such as the custom of “following doctor’s orders.” Shared decision making is a process for reaching a shared conclusion through informed judgment. Such a process is an educational ideal in the field of medical care, as it is throughout most institutions in a democratic society. The heart of the matter is the control of information: to the extent information about a problem can be shared, decisions about potential solutions can be shared. 

Physicians have privileged access to medical information through their education, experience, and expertise. This privilege carries with it the duty to disclose clearly such information as is relevant and is supported by accurate scientific information in a sincere manner for consideration by the patient. Furthermore, this duty is itself governed by the physician’s fiduciary obligation to protect the patient’s best interests. Generally, physicians control the medically relevant information patients need in order to ask the questions they may want to ask but might not be able to formulate on their own. Successfully sharing that information is a matter of 1) the physician’s willingness to do so, and 2) the physician’s ability to apply the skills of communication required to do so. It is also a matter of 3) the patient’s willingness to participate in the process, and 4) the patient’s ability to understand the information, apply it to his or her situation, and then express a reasoned judgment based on the relevant medical information as well as on personal values, wishes, and goals. 

The physician personally initiates the process of informing the patient by presenting the medically reasonable options relevant to the patient’s condition. The medical reasonableness of these options is tied to the available and reliable evidence base of expected benefit and risk for each alternative. The physician’s judgment about these options should be free of personal self-interest, and religious, political, racial, and gender bias. M&M HOSPITAL encourages our patients to have someone with them (an advocate of some kind) during these discussions, as patients can be overwhelmed, frightened, and confused when confronting an important medical decision.


Skills for Eliciting Informed Consent 

By far the most important skill is empathetic listening, which is the capacity for acquiring objective knowledge about the perspective taken by another person. It is a way of listening that requires temporary suspension of one’s personal point of view while trying to assume another’s point of view. It is a means for gathering data. It is not synonymous with being compassionate or sympathetic, even though its mere presence can have a beneficial effect. The primary purpose of empathy in this sense is to become well informed about the patient’s point of view. It is important for the physician to find out what and how much the patient already knows and what more the patient wishes or needs to know, and to what extent the patient desires to participate in the decision making process. 

In disclosing medical information the physician can err in two ways – excess and deficiency. Empathetic understanding can help guard against going wrong in either of these ways. Next is skill in disclosing and explaining. In trying to establish the basis for shared decision making, the physician discloses medical information relevant to the case at hand, and provides explanations of what that information means, in language that is intelligible to the patient. It is important to distinguish between two useful but distinct kinds of explanation. The first is scientific explanation, which is making a case for why certain events are the way they are and for predicting future events. The second is semantic explanation, which by contrast is making the meaning of something clear to the listener. Semantic explanation is like translation or paraphrase, using different words and terms until the intended meaning is revealed and understood. An explanation can be satisfactory from a formal (scientific) point of view, while at the same time failing to be satisfying from the patient’s point of view. Another way to put this point is that while a medical explanation of risks and benefits associated with treatment options can be scientifically sound, the listener may find it to be unintelligible, and therefore not useful as information upon which to grant or withhold consent. Informed consent depends on the physician’s success in providing both kinds of explanation.

Definition of Informed Consent

Informed consent for treatment has been obtained when: 1) the physician has disclosed and explained to the patient’s satisfaction the process used to arrive at the medically reasonable and recommended intervention(s), which is based on reliable evidence of expected benefit and risk of each alternative, and which is free of any impermissible bias; 2) the patient, who has demonstrated capacity, has been given ample opportunity to ask questions about the process and the recommended intervention(s), to the extent the patient wishes, all questions then having been answered to the patient’s satisfaction; and 3) the patient gives consent in writing to major intervention(s) agreed to jointly with the physician.


COST OF INFERTILITY TREATMENT

Most infertility couples are young and structured infertility evaluation and treatment are expensive. Most times, their little life savings are engulfed by infertility treatments such as surgery, stimulation medications and constant changes of care associated with visiting different unqualified physicians, local herbalists, prayer houses and infertility consultants. Each unsuccessful treatment adds cost, delay, stress and frustration to the couple. 

Each couple’s problems are unique to them and themselves alone. Some couples may have simple problems that may require simple solutions at minimal expense, while other couples may have multiple complex problems involving one or both partners. The more complex the problems are, the more expensive the treatments will be. This does not translate into more successful pregnancy outcome. 

There are no guarantees in all infertility treatments and every couple must understand this. There is always anger, frustration and disappointments among couples who fail to achieve the expected success following various infertility treatments. 

The physicians should endeavour to be honest with their patients from the start, guiding and counselling them as to their various options and prognosis. Each couple must then weigh their individual financial circumstance and make informed decision based on their options. For example- a couple with both male factor infertility such as severe oligozoospermia and female factor infertility of bilateral tubal blockade will benefit most from assisted conception via in vitro fertilization and icsi method. This is the most expensive method of achieving conception and may place a heavy financial burden on the couple. They may consider adoption as an alternative option, but must consider how adoption is viewed in their respective societies and cultures with respect to inheritance and acceptability. 

In cases of severe oligo or azoospermia of the male partner, and the woman is normal with at least one functional fallopian tube, it may be prudent and cost effective for the couple to request Donor intrauterine insemination.