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.

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.

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.

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

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

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.

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

Initiation of Oral Contraceptives

Suppression of Ovulation

GnRH Agonist Administration

GnRH-antagonists (ganirelix acetate or cetrorelix acetate)

Baseline Pelvic Ultrasound

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.

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

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.

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.

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.

• 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.

• 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.

• 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.

• 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.

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.

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.

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 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.

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.

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)

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.

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.