There are two key factors that regulate
the behavior of doctors and consequently also patients
with assisted reproduction in Italy.
First of all law 40.
Law 40 essentially, in a quite simple way,
for us to understand better,
essentially bans the donation of oocytes,
and the donation of sperm,
and requires the transfer of all embryos that were
produced, and limits said transportation to three embryos at a time,
by banning their preservation, their freezing.
Since that time, Italy has quickly developed
a method of freezing oocytes with positive results,
a method that rivals all others in the world.
Then a few months ago, sentence 151 was passed
by the Constitutional Court that has partially liberalized the process, i.e.
allowed the doctor to agree with the patient, judging case by case,
where there are good reasons of a medical nature
to justify the fertilization of more than one oocyte and the production of more than one embryo,
and if not possible, because it creates different embryos,
you can re-freeze again and preserve embryos
beyond the first transfer,
thus allowing would-be the parents the opportunity to try
multiple attempts with a single earlier stimulation.
This puts us on par with all European countries and honestly makes
foreign trips less justifiable for our patients.
Now going abroad is justified only for patients
that really need donations of eggs or
patients who need a preimplantation diagnosis.
There are first, second and third level techniques
that we will explain now.
The first level techniques we say are the simplest
and are those that use
methods to
select the best sperm, we say,
concentrate them into the smallest amount of liquid culture medium possible
to then send them inside the female genital system,
more specifically the uterus,
as close as possible to the tube, in order to
optimize and maximize your chances of uniting two gametes,
in other words, oocyte and sperm.
This can be done either by stimulation of the ovaries
or just through the natural physiological cycle of the woman, the patient.
And this is the first level.
The second level is--
That's when we say just use in vitro fertilization.
IVF is usually synthesized
both by doctors and patients.
It's designed to stimulate the ovaries,
obtaining a greater quantity of follicles and then oocytes
than what the woman normally obtains in her spontaneous cycle.
Obviously, this stimulation must absolutely be carefully controlled
to avoid potentially dangerous excesses
known as hyperstimulation.
Or to stave off the need for unnecessary treatments if the stimulation is too low.
We say that the treatment should be modulated
depending on the response of the individual patient.
Then a sample is made
from the oocytes, under control of an ultrasound guide,
always we say, from the vagina,
i.e., from the bottom, not from the abdominal.
This is done generally in the vast majority of cases
under general anesthesia, very routine, very fast so
we say that the patient is asleep for only a few minutes
in the healthcare protected environment
as we say we doctors.
And then the laboratory
puts 50 to 100 thousand counted motile sperm around each egg
expecting fertilization to occur
i.e., the sperm must be able to get inside the oocyte
and there is a special sign when this has happened.
After waiting for two more days generally,
two or three days,
the first cell divisions of the embryo are expected to begin
and after that the embryo is moved back with a very soft catheter
inside the uterus of the patient.
At this point we have to wait 14 days and see whether the patient is really
pregnant or not.
One clarification:
The dimensions we're talking about.
An embryo is a tenth of a millimeter in diameter.
That means it's smaller than a speck of dust
and all of these operations must therefore be performed under a microscope.
This is not visible to the naked eye.
This is one of the difficulties of our work.
The last method is perhaps the most important:
There are many, especially at the first level, but
the procedure we perform most often
is what we call the IXI,
which is the injection into the cytoplasm of the egg
of a single sperm.
This is a method that is added to in vitro fertilization, which I just described
and allows the achievement of fertilization
with very few sperm,
two, three, five sperm,
providing a solution to very serious male factors,
even patients who have absolutely no sperm in the semen
may be treated
by taking those three or four sperm that we need
directly from the testicle, using a little bit of anesthesia.
I would say that these are the fundamental methods.
I would say that there are several critical factors involved.
Firstly this is a
team effort and therefore
it's very important that in the group of practitioners available to the patient
there be a great sense of harmony between them,
the biologist who oversees the growth of the embryo by fertilization
before it is transferred into the uterus of the patient,
the future and possible mother,
must coordinate with the gynecologist
the urologist
and also I would say with the paramedics.
Let me also repeat that the work in the operating room is extremely important
because it must be done under sterile conditions and then
I think that coordination of everyone's work is very important
if there is to be a chance of success.
Another critical factor is the quality of the laboratory.
There can be the best gynecologist in the world
but if he is not accompanied by an excellent biologist, embryologist,
or a group of them, teams of biologists, embryologists, which, as I've said, have a system of in vitro culture
that is highly effective with these embryos,
then all the work fails.
And lastly I would say, quality control
is essential in the context of this group,
there must be ongoing monitoring of the results
which are obtained as you work
and if these results are lowered
the cause of this variation must be sought out immediately
which can sometimes be caused by the material from the culture media.
The continuous control of quality and results is a very important goal
of the work group.
This is an extremely important subject.
Time is already limited,
and unfortunately today, couples decide to try to become pregnant later and later in life.
Ten years ago the average age of our patients was about 34.
Today the average age is about 38.
And this has influenced a number of factors
that now seem unnecessary to argue about, but
the fact of the matter is,
when a couple has difficulty
becoming pregnant, we must act quickly
both in the diagnostic phase, that is, in our attempts to determine specifically
what is delaying the pregnancy
and then eventually in our efforts to implement appropriate therapies.
So I'm not saying that we must immediately reach the third level
for all couples, not at all.
But we have to be pretty quick to diagnose and try to understand
what the problem is. Sometimes we see couples who take
a very long time, years, to come to an understanding
of what the problem actually is.
And there is little doubt that psychological problems between the couple
can be a factor,
but for this to work, we must be able to help the patient quickly.
I believe that to offer a practical schedule,
within six months to one year maximum
we should be able to diagnose the couple
and then begin the appropriate treatment if necessary.
I think that the couple should become pregnant quickly enough.
If not, third level therapies should be attempted
within a couple of years,
if more time is spent it means that somewhere time was wasted.
I think a center for assisted reproduction
must be a place that brings together the work of several specialists,
all of whom must together in the service of the couple both in the diagnostic stage,
that is, when trying to understand the problem that's preventing pregnancy, and
over the course of therapy.
The center must utilize gynecologists
urologists, psychologists and excellent biologists.
Even the law itself tells us to make available to patients
experts on any legal problems the couple might face,
and I think this is crucial.
The center must be able to help the couple quickly
and must be able to face any situation, even health-related.
Fortunately it is very rare, but our work can be
dangerous, can have side effects,
and therefore must be performed in a healthcare environment
that is prepared to face any risk
or any side effect or complication.
But the main advice is to
try to overcome some psychological difficulty,
a shyness that the couple may have about asking for help
in this very intimate matter.
And definitely turn to health care early in the process
because, failing that, once you want to become pregnant,
if you're not able to obtain a pregnancy within a year
a year and a half, two years, after two years it comes to infertility reports.
This also depends on the woman's age,
two years for a 38 year-old patient could be too long.
So my first advice is to try to
seek the advice of experts, quickly bypass any shyness,
and my next advice is to work with only qualified centers,
don't be forced to wander from place to place
in search of individual specialists
that may not be related
to the urologist or the gynecologist.
I believe that at the present time
in Italy, indeed particularly in Italy,
these centers are evolving
to be able to offer all options of diagnosis and treatment of infertility
and then to be able to provide maximum assistance to this type of couple.
This advice is difficult.
First you should try to understand.
In medicine in general when you can make a diagnosis
this often results in providing appropriate therapy
which then ends in success.
The biggest problem is trying to solve a problem you don't understand.
So on the one hand, always search for a diagnosis.
Nowadays there are many details you want to keep in mind
We're beginning to know certain things about implantation
that need to be taken into account, for example
there may be immunological problems
that could hinder implantation and
in case of pregnancy, increase the risk of miscarriage,
and that on the one hand, then,
rather than continuing to make attempts at in vitro fertilization
one after another
blindly, at some point
it makes sense to pause to try to deepen
an eventual diagnosis
over and above the diagnosis of infertility which could eventually
understand why these embryos that are transferred
to the uterus then fail to take root.
On the other hand, perhaps, my last piece of advice
is to try not to only use stimulation.
Nowadays we are getting big results
performing in vitro fertilization on the spontaneous cycle
without necessarily needing to stimulate
the growth of many follicles.
And if several attempts at stimulation have already failed, for example,
one alternative that might
help the rooting of that single embryo
is forgoing stimulation to focus on the natural follicles, which therefore have more vitality and a higher capacity for rooting
and thus giving rise to pregnancy.
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