Infertility - Assisted Reproductive Technology (ART)

Azoospermia is defined as the absence of spermatozoa in the ejaculate semen on atleast two occasions and is observed approximately in 1% of the population.

Assisted Reproductive Technology (ART) refers to a set of special medical and laboratory techniques used to help infertile couples achieve pregnancy when natural conception has failed or is not possible.

ART is recommended after conventional infertility treatments have been tried and have not succeeded.

Classification of ART:

Fertilisation of egg (ovum) and sperm is carried out outside the body in simulated conditions (culture medium similar to the female reproductive tract).

Process:

1. Ovarian hyperstimulation with hormones to produce multiple eggs
2. Egg retrieval via minor surgery (transvaginal aspiration)
3. Fertilisation with selected healthy sperm in culture media in lab
4. Embryo cultured for 3–5 days to blastocyst stage
5. Transfer of embryo into the uterus (Embryo Transfer / ET)

Indication: Women with blocked or damaged fallopian tubes.

Zygote Intra Fallopian Transfer is also known as Tubal Embryo Transfer (TET)

• Fertilisation occurs in vitro (in the lab). The resulting zygote (not an older embryo) is then transferred to the fallopian tube using laparoscopy.
• ZIFT is not suitable for women with abnormal or blocked fallopian tubes.
• Difference from IVF: In IVF, the embryo is placed in the uterus. In ZIFT, the zygote is placed in the fallopian tube.

Both eggs and sperm (gametes) are collected and transferred directly into the fallopian tube via laparoscopy, where fertilisation occurs naturally (in vivo).

• Condition: Requires at least one healthy, functional fallopian tube.
• Key Distinction: GIFT involves in-vivo fertilisation (inside the body). IVF and ZIFT involve in-vitro fertilisation (outside the body).

A single, selected sperm is injected directly into the cytoplasm of the egg under a high-powered microscope.

• Indication: Severe male infertility - very low sperm count, poor motility, or when sperm are retrieved via TESE.
• Combined with TESE: When a man has azoospermia (no sperm in ejaculate), sperm are surgically extracted from the testes (TESE) and then injected via ICSI.

Intra Uterine Insemination is also called Artificial Insemination (AI)

• Semen (collected from the husband or a donor) is processed and introduced directly into the uterus near the time of ovulation.
• Indication: Used when the male partner cannot inseminate naturally, or has low sperm count but the female reproductive tract is functional.​

Note: In IUI, fertilisation occurs in vivo - inside the fallopian tube, just as in natural conception.

A surgical procedure where sperm are directly extracted from testicular tissue in men with azoospermia (no sperm in ejaculate).​

Used with: ICSI - the retrieved sperm are injected into eggs via ICSI.

Cryopreservation is the technique of preserving biological materials (sperm, eggs, embryos) at sub-zero temperatures (typically −196°C in liquid nitrogen) to halt all biological activity.

Process:

1. Sperm/eggs/embryos are collected
2. Cryoprotectant agents (e.g., glycerol) added to prevent ice crystal damage
3. Stored at −196°C in liquid nitrogen

Frozen Embryo Transfer (FET): Cryopreserved embryos are thawed at a later date and transferred into the uterus.

Advantage: Allows fertility preservation before chemotherapy, radiation, or for later family planning.

A woman (the surrogate mother) carries and delivers a baby for another couple (commissioning couple) when the intended mother cannot carry a pregnancy.​

Types:

• Traditional Surrogacy: Surrogate's own egg used - she is the genetic mother
• Gestational Surrogacy: Embryo from the commissioning couple's gametes is implanted in a surrogate - the surrogate has no genetic link to the baby.

Legal Note (India): The Surrogacy (Regulation) Act, 2021, regulates surrogacy in India. It permits only altruistic surrogacy (no commercial payment) and only for eligible couples.​

Ethical Issue: Exploitation of economically disadvantaged women as surrogates is a major concern.

• High Cost: Expensive equipment and specialist needs make procedures inaccessible for many in India.
• Low Success Rates: Average success ranges from 15% to 40%, often requiring multiple attempts.
• Emotional Burden: Repeated cycles and clinical failures cause significant psychological stress.
• Multiple Pregnancies: Treatments increase the risk of multiple births and associated obstetric complications.
• Ethical & Religious Objections: Many communities oppose external fertilisation or embryo selection.
• Exploitation in Surrogacy: Commercial practices risk the exploitation of economically vulnerable women.
• Legal Gaps: Current laws (ART Act 2021) exclude same-sex couples, unmarried men, and cohabiting partners.