The Department of assisted reproductive technologies is equipped with the newest high quality equipment, which allows to provide all contemporary types of treatment of sterility. Doctors of the Department have many years of experience in the field of sterility treatment and they constantly co-operate with the leading clinics of France and Israel. All the doctors are members of the European Society of Human Reproduction and Embryology.

The basic directions of scientifically-practical work:

• In vitro fertilization and transfer of embryos (IVF+TE)
• In vitro fertilization by the method of ICSI
• In vitro fertilization by the method of ТЕSЕ (spermatozoa are taken immediately from testicles) or МЕSЕ + РЕSА
• (reception of spermatozoa from epididimus at the heaviest forms of man's sterility).

And also:

• Auxiliary hatching.
• Cryopreservation and embryo storage.
• Оocyte donor service.
• Surrogate motherhood (surrogacy).
• Preimplantation genetic diagnostics.
• Artificial insemination by husband's sperm (AIH).
• Artificial insemination by donor's sperm (AID).
• Cryopreservation and storage of donor sperm (bank of donor sperm).

Indications for IVF:

1. Tubo-peritoneal sterility factor.
2. Endocrine infringements.
3. Endometriosis.
4. Syndrome of polycyst ovaries.
5. Sterility of not clear genesis.
6. The male factor (decrease of mobility of spermatozoa and their quantities, up to full absence of spermatozoa in ejaculate).
7. Immunological factors of sterility.
8. Inefficient treatment of long existing sterility.

Method of IVF consists of the following stages:

1. Carrying out stimulation of superovulation with various medicaments, under the influence of which not just one-two oocytes ripenin woman's ovaries as during a natural menstrual cycle, but 5-10-15 at once.
2. A puncture of follicules and fence of oocytes by transvaginal way under ultrasound control is performed. The puncture lasts 5-10 minutes under intravenous anesthesia and is an absolutely painless procedure.
3. Fertilization of oocytes with sperm occurs in the first days in a special thermostat in special conditions (temperature, gas structure, sterility). At low concentration of spermatozoa the injection is made, an intracytoplasmic sperm injection of chosen spermatozoa of high quality to cytoplasm of oocytes by means of special manipulator (ICSI).
4. On the 3rd day, the best embryos are selected and transferred to woman's uterine cavity by means of special very thin and flexible catheter under ultrasound control. This manipulation is safe and painless.
5. Within 14-16 days a supporting therapy is recommended, after which a test for pregnancy (urine and/or level definition β-HCG in blood).
6. Further methods of treatment should always be discussed with the treating doctor, both in cases of positive and negative results.

Before providing treatment of sterility through IVF, we first examine the patients.

Pre-IVF examination program includes:

1. Hormones in blood:
   On 2nd/3rd day of menstrual cycle:
   - LH, FSH, estradiole (E2), prolactine, TSH, ТT4, DHEA-S, testosterone
2. Test for chronic infections:
   - Chlamidiosis, mycoplasmosis, ureaplasmosis, cytomegalovirus, herpes, toxoplasmosis, measles
3. Vaginal smear on the degree of cleanliness
4. Bacterial swab from vagina and uterine cervix
5. Colposcopy, dab on oncocytology smear
6. Ultrasound on 5th/8th day of the menstrual cycle, folliculogenesis
7. Thyroid gland ultrasound (upon indications)
8. Mammography or ultrasound of mammary glands (upon indications)
9. Blood analysis on RW, HIV, HBV and HCV
10. Blood group and Rh factor
11. The clinical analysis of blood
12. The biochemical analysis of blood:
    - Glucose, cholesterol, total protein, creatinine, total bilirubin
13. Coagulogram
14. The general analysis of urine
15. An electrocardiogram
16. X-ray examination of chest
17. Consultation of the doctor-therapist
18. Consultation of the genetics (under indications)
19. Spermogram of the spouse.

Patients should not consider IVF as a one time course of treatment which guarantees 100 % efficiency. Unfortunately, even in the best clinics of the world productivity of this method does not exceed 40-45% for one attempt.

The success of IVF depends on a set of factors: the patient's age, the condition of uterus, the general condition of organism, and the reason of sterility. Thus, it is difficult to estimate the exact chances of a positive result. Besides, the success of the IVF procedure depends on doctors' skills, equipment of the clinic, and selection of medicines for the therapy. The effectiveness of IVF in RCMCHP is around 35-40%.

A special role in the department of ART is given to the Laboratory of Embryology. The equipment of the Laboratory, the level of preparedness and the experience of the embryologist in many respects define the result of work of the whole department. Our embryologist, Karen Jinanyan, has been working in the Department of IVF from the first stages of its formation and has a wide professional experience. He has repeatedly participated in trainings in France.

The conditions of performing ICSI are as follows:

1. Azoospermia - full absence of sperm because of a severe disease of testicles and also blockade or absence of deferent ducts;
2. Oligozoospermia - decrease of concentration of spermatozoa less than 2 million/ml;
3. Asthenozoospermia - the presence of less than 1 million active-mobile spermatozoids in 1ml ejaculation;
4. Teratozoospermia - less than 5 % spermatozoa of normal structure;
5. The varicocele expansion of veins of seed scrotum;
6. The combination of sperm pathology (various combination of changes in concentration is possible, in mobility and structure of spermatozoa which considerably reduces fertilizing ability of sperm);
7. Presence of antispermal antibodies in ejaculate (the MAR-test more than 50 %).
8. Unsatisfactory effect or complete absence of fertilization of oocyte in previous attempt of IVF.

Qualitative performance of procedure of ICSI in our laboratory is promoted by fitting out of modern equipment. The procedure is carried out on microscope firms "Leica" (Germany) by means of micromanipulators by "Narishige" (Japan). Due to presence of video equipment, we have possibility of video and computer recording of all manipulations.

Auxiliary Hatching (processing of the cover of embryo): is a new method which facilitates embryo implantation in uterus. This method consists in easing of brilliant cover of embryo that promotes its stronger fastening at nidation.

Indications to the carrying out of the auxiliary hatching:

1. Woman's age is over 38 years;
2. Previous unsuccessful attempts of implantation;
3. Presence of embryos with bad morphological indicators;
4. Raised level of follicle-stimulating hormone (FSH) in blood;
5. Carrying over of refrozen embryos;

Auxiliary hatching can be done in 3 ways: chemical, mechanical and laser. In our laboratory, mechanical auxiliary hatching is performed through micro tools.

Crioconservation of embryos: if after carrying out of program of IVF and transfer of embryos to a uterine cavity, there is a remainder of "superfluous" embryos of high quality, a couple is offered to freeze them. Storage of frozen embryos is carried out in special marked plastic straws which are placed in liquid nitrogen. The period of storage of embryos is not limited.

Cryopreservation of embryos is done only in high quality and at certain stage of development. Embryos of bad quality are not subject of freezing as during defrosting they will be destroyed. We do cryopreservation of embryos only when it is necessary for patients, and they have agreed to this procedure.

Our Center also successfully performs programs of "Oocytes Donor Services" and "Surrogacy".
The use of donor's oocyte is recommended when a woman has poor quality oocytes or when oocytes cannot be obtained through stimulation of ovaries.


Program stages "Oocytes Donor Services" (EGG donor):

1. A woman - the donor of oocyte, chosen by the infertile couple, is exposed to careful comprehensive examination on the possible infectious and genetic diseases.
2. An agreement between all participating parties is executed.
3. The infertile woman-recipient takes special medicine pills which will prepare endometrium to accept the germ.
4. Mature donor's oocytes are taken from ovaries and in laboratory conditions are impregnated with spermatozoa, received from spouse of infertile woman.
5. Within three days embryos are developed "in the test tube", then they are transferred to infertile woman's uterus.

Requirements for donors of oocytes:

• Age from 20 till 35 years
• Presence of own healthy child
• Absence of bright phenotypic features
• Absence of contra-indications to an induction of superovulation and punctions of follicules.

The surrogate motherhood (surrogacy)-a way of overcoming infertility for a woman, who cannot carry and give birth to a child herself (in connection with absence of uterus, habitual miscarriage or somatic pathology).

In this case the infertile woman's oocyte, impregnated by her husband's sperm, is entered into the uterus of another woman, capable to carry and give birth to a child. Biological parents of the child are the couple that gives the oocyte and the sperm for the formation of the embryo, and the woman who carries their child, is called the surrogate ("auxiliary", "replacing mother").

Originally, the relatives of the childless couples were often the surrogate mothers, but recently surrogacy became a profession - biological parents pay money to healthy women who agree to the implantation and carrying of their children.

Surrogate motherhood is the most difficult and, naturally, expensive program in the structure of IVF. Involvement of a third person in the process of child birth became possible as a result of almost fantastic progress of the medical science. It gave a chance to experience the joy of motherhood to many women, whose sterility was insuperable before.

At surrogate motherhood a legal agreement is executed between the parties.

Requirements for surrogacy:

• Age from 20 till 35 years
• Presence of own healthy child
• Absence of contra-indications to competent pregnancy.

Preimplantational genetic diagnostics (PGD) is applied to revealing of chromosomal defects at embryo and discovering of hereditary diseases linked to sex. Preimplantational genetic diagnostics is done with adult parents (age more than 37 years), at repeated spontaneous abortions and implantational infringements. Essence of PGD consists of the fact that we have a possibility to define the genetic status of embryo before its carrying over to the uterine cavity, to choose the most viable embryos, and, thus, not only to exclude heavy chromosomal pathology, but also to raise probability of implantation and approach of pregnancy.

Artificial Insemination of husband's sperm ("AIH") and the donor's sperm (AID).

In a case of AIH, husband's sperm is preliminary processed in embryological laboratories and is entered into woman's internal uterine. Insemination can be spent both in natural cycle, and after stimulation of ovulation. In any case at carrying out AID the permeability of uterine tubes should be checked, as during the insemination, as well as during pregnancy through natural method, fertilization occurs in the fallopian tubes.

Indications for AIH:

• Erectile dysfunction.
• Developmental anomalies of genitals of a man at whom sexual life is either impossible, or ejaculation occurs not in the vagina (for example, hypospadias, retrograde ejaculation).
• Vaginism.
• Cervical factor of sterility i.e. inability of spermatozoa to get through of uterine cervix.
• Insemination with cryopreserved sperm of spouse, for example, in case of advanced frozen sperm, in case of detection of the oncological disease at spouse demanding chemotherapy, sharply worsening quality of sperm.

The sperm donor service: is a program, allowing to have children in cases of male's absolute sterility or in cases of single women without sexual partners. Healthy men at the age of 20-40 years with fertile sperm can be donors of sperm.

The volume of obligatory inspection of donors of the sperm includes:

• Urologist's survey and conclusion.
• Inspection of possible infection: gonorrhoea, clamidiosis, genital herpes, ureaplasmosis, mycoplasmosis, cytomegalovirus.
• Blood analysis on RW, HIV, HBV, HCV.
• Blood group, Rh factor.
• Psychiatrist's survey and conclusion.
• Therapist's survey and conclusion.

Crioconservation of sperm. Our clinic has the ability to freeze the donors' and the spouses' sperm for their subsequent use in programs of treatment of fertility by means of methods of auxiliary reproductive technology. Freezing of sperm is done in liquid nitrogen with use of special equipment. Sperm can be stored in frozen condition for some years. It is necessary to consider three years as an optimum period of storage of sperm because after this period the impregnating ability of spermatozoa is reduced.

Georgi G. Okoev

մանկաբարձ-գինեկոլոգ
բ․գ․դ․, պրոֆեսոր

Angela P. Harutyunyan

էմբրիոլոգ

Lusine Z. Balayan

մանկաբարձ-գինեկոլոգ, ռեպրոդուկտոլոգ