Reproductive ladder: treatment protocole that brings the best results in infertile couples The specific treatment for each couple is chosen once the infertility diagnosis is done. To choose the treatment or assisted reproduction technique, we use what is called the Reproductive ladder. The objective is to start with the first simplest treatment that offers real possibilities to succeed with a pregnancy. From this treatment, or step, we go up the ladder. This makes us choose the right treatment for each case avoiding treatments that are more complex or more expensive than what is needed. The reproductive ladder is divided in low and high complexity treatments. Each treatment is considered a step. a) Low complexity Sexual intercourse Programmed intercourse Intrauterine insemination (IUI, with couple or donors sample) b) High complexity In vitro fertilization (IVF) / Intracytoplasmatic sperm injection (ICSI) ICSI + Pre-implantation genetic diagnosis (PGD) Egg donation (Ovodonación) Egg donation + semen donation Embryo donation When do we suggest low complexity? When the values in the semen analysis are higher than the stablished standard by the WHO. When women are younger than 39 years old (depending the case). When the couple has been trying to have a baby for less than 2 to 3 years (depending the case). Permeable Fallopian tubes, with no myomas, polyps or endometriosis. When do we suggest high complexity? When the values in the semen analysis are lower than the stablished standard by the WHO. When the couple has been trying to have a baby for more than 2 to 3 years (depending the case). Women older than 39 years old. Bilateral tubal oclussion. Any other factor (uterus, endometrial, embryonary). Womens age is a basic factor to consider for the selection of the complexity, as the egg reserve can diminish if the treatments take long. Click here for more information. It is well known that, the success rates of having a baby dimish from age 35. As well, from this age, the chromosomic abnormalities increase in the fetus. There are some stablished studies that assign a percentage of this risk according to the patients age (from 38). This is why, it is recommended to perform a pre-implantation genetic diagnosis (PGD) from this age, to know if the embryo is healthy so it can be transfered to the patient. Nowadays, this practice has increased the pregnancy rates, as placing a healthy embryo diminishes the possibility of an abortion. Show more For the cases of any familiar sickness, an embryo biopsy is indicated in order to place a healthy one inside the patient. Other consideration for the embryo biopsy is the sex selection. This is a delicate subject as it can be used in an indiscriminatory way. There is no legislation about this in Mexico so, in Centro FiVER no sex selection is done, unless it is mandatory due to healthy reasons. When the possibilities of success for a couple with their own eggs is very low, it is moment to go up the ladder. As well, if the male also has any sperm abnormality blocking the pregnancy, a semen donor should be considered. There are semen banks in the reproduction clinics as well as women donating eggs or donated embryos. The embryo donation is less expensive than the creation of a new embryo. Sexual intercourse 85% of couples succeed in a pregnancy within the first year of having regular sexual intercourse with no protection (every 2 to 3 days) and up to 9% will succeed in the first 2 years. These rates drop significantly when women are older than 35. The effect of age in mens fertility is less clear. Timed intercourse This is the 2nd step in the reproductive ladder and the 1st to be done together with a reproduction specialist. It consists in the orientation of the couple to have sexual intercourse in the best moment of the womans cycle. It can be done with or without stimulation with medicines. Up to 6 cycles can be tried (depending the case). Click here to read more. Intrauterine insemination This is the 3rd step in the reproductive ladder. Must be done in assisted reproduction centers. It consists in placing the capacitated semen (best selected semen) directly inside the womans uterus. This way, the sperm and egg do what they are supposed to do naturally, fertilizing and resulting in an embryo that should stay there during 9 months. The successful rate is limited. Normally, the rate is 88% after 3 cycles. This is why, in assisted reproduction centers, no more than 4 cycles are recommended. It should be considered to go up the reproductive ladder if the specialist recommends it. Click here for more information. In vitro Fertilization (IVF) / Intracytoplasmatic sperm injection (ICSI) This is the 4th step in the reproductive ladder. Due to its complexity, must be done in a reproduction center. It consists in the obtention of the sperm and eggs to do a fertilization in the lab, transferring afterwards the embryo inside the uterus. The successful rate is 45-60% per cycle and it will vary depending on the couple and on the infertility causes. Click here for more information. ICSI + Pre-implantation genetic diagnosis (PGD) This is the 5th step in the reproductive ladder and it can only be done in reproduction centers. Once the embryo are created in the lab, a hole is done in the external wall of the embryo to extract a cell and analyse all its chromosomes. This way, a healthy embryo can be transfered to the patient. If no healthy embryo is obtained, no transfer is done. The success rate is 50-70%, with variations depending on the infertility causes and the percentage of health corresponding to the age. For example, at age 38, there is a 26% possibilities of a healthy embryo, if the healthy embryo is obtainted, then the rate of success is 50-70%. A 4-8% of error should be considered. Show more This should be done between day 3 and 5 of the life cycle of the embryo, when, if a cell is removed, the embryo can build all the organs with the remaining cells. Nowadays, the precise indication to have an embryo biopsy is for genetic sicknesses that are in a specific gene and that can be found in the embryo, in order to transfer a healty one. Controversial indications and good practice indications: Advanced female age IVF failure with no apparent reason. Repeated abortion. Semen count lower than 5 million sperm (severe male factor). The embryo biopsy is used for the sex selection of the baby. Due to internal policies, this is not performed in Centro FiVER unless, there is a specific genetic sickness that could affect either the male or female embryo. Egg donation This is the 6th step in the reproduction ladder, only done in assisted reproduction centers. This step is used when the patient has low possibilities of conceiving with own eggs. The ovaries stimulation and the egg extraction are then done to the donor: once the eggs are in the lab, they are fertilized with the sperm. Once the embryos are formed, the most viable one is placed inside the patients uterus. The success rate is 50-70%, depending on each case. Click here for more information. As women grow older, the eggs reserve and their quality decrease, which increases the possibilities of abnormalities in the embryo. This is when the use of donors eggs is considered. The percentage of success would then be the one corresponding to the donors age, which is always under the age of 30. This is an anonymous procedure, niether the donor nor the future mom will know about each others identity. Each donor has gone through extensive tests: genetic, physical, psycological, allowing us to know if there is any risk of transmitting a decease. Egg donation + Semen donation This is the 7th step in the reproductive ladder, done only in assisted reproduction centers. It is the creation of embryos from donated eggs and donated semen. Once the embryo is created, it will be placed inside the patients uterus. This procedure is very important at a reproduction center. The physical characteristics of both patients and donors should match. These characteristics can be: blood type, eye color, hair color, etc. All donors are younger than 30 years old and have gone through physical tests, psycological tests and blood analysis, to make sure that the donors are healthy. Embryo donation This is the last step in the reproductive ladder. This step is only done in assisted reproduction centers. Those couples that accomplished their dream of having a baby through assisted reproduction techniques and have extra frozen embryos, can donate them to other couples. One cycle of donated embryos is less expensive than a cycle of egg donation / semen donation, as the cost of selection of donors, medicaments and IVF procedure has already been done by the couple donating the embryos. Important considerations in the reproduction ladder It is important to highlight that, we cannot say that by doing more cycles of a treatment, the possibilities of success will increase. The possibilities are always the same for each cycle, but it is true that the doctors will have more knowledge of the couple each time, allowing them to consider different actions around the medicaments to increase the success of having a baby home. There are endometrial factors that wont result in 100% in reproduction techniques as, even if the best embryo, the healthier one, the one that has more pregnancy possibilities in the lab is used, the endometrium and the embryo should match so the embryo can stay there during the necessary 9 months. Nowadays, the endometrial factor is studied when some cases of failure of treatments repeat and have no clear explanation. Though, It is not a rutine study as the % of patients suffering from it is not high (5-8%).