Interview with the geneticist in order to define the need for targeted investigations to search for genetic abnormalities related to infertility or for familiarity for diseases transmissible to offspring.

Causes of female infertility can be: ovulatory defect, tubal occlusion, uterine fibroids, congenital malformations of the uterus, endometriosis, clinical history of pelvic infections, previous pelvic surgery, chemotherapy, etc.
Casa di Cura San Rossore performs the following diagnoses for the female partner:
– Hormone Tests – Allows assessment of FSH, AMH, LH and estrogen levels, in combination with other hormones such as prolactin, thyroid hormones and androgens, which may affect ovarian function.
– Vaginal swabs – Qualitative and quantitative assessment of the main populations of microorganisms (bacteria and mycetes) that can colonize the female genital tract.
– Pap test
– Cervical cancer screening
– Transvaginal pelvic ultrasound with antral follicle count – Ultrasound in the early follicular phase of the cycle that not only excludes uterine and ovarian pathologies, but also allows the assessment of the number of antral follicles present (AFC). AFC in association with hormone assays allows the patient’s ovarian reserve to be defined and allows ovarian response to drug stimulation to be estimated.
– Echographic cycle monitoring – Provides for a series of trans-vaginal ultrasound scans performed regularly with the goal of assessing endometrial growth and follicular development. It can be performed for diagnostic purposes and possibly combined with hormone assays or for therapeutic purposes (targeted reports, timing for transfer of cryopreserved embryos or obtained from vitrified oocytes).
– Sonohysterosalpingography – Ultrasound method that by intrauterine injection of sterile saline and air allows visualization of the uterine cavity (uterine malformations, synechiae, polyps and fibroids) and tubal patency.
– Diagnostic and operative hysteroscopy – Allows the study of the uterine cavity and involves passing a small fiber-optic instrument called a hysteroscope through the cervical duct until the entire cavity is visualized. In case of endocavitary abnormalities (polyps, submucosal myomas, uterine septa), it allows treatment of them.
– Diagnostic and operative laparoscopy – Visual examination of the anatomy of the pelvis (uterus, tubes, ovaries) that allows the diagnosis and treatment of morpho-functional alterations (e.g. adhesions, endometriosis, fibromatosis, uterine abnormalities) that could cause female infertility. A contrast agent can be injected through the cervical duct to visualize whether or not it passes through the tubes.
– ERA test – This is a diagnostic test patented by IGENOMIX in 2009, which helps assess a woman’s endometrial receptivity. ERA detects each patient’s specific “implantation window,” allowing for personalized embryo transfer (pET).

Causes of male infertility can be: reproductive tract diseases (cryptorchidism, hypospadias, testicular cancer); infections (orchitis, epididymitis, prostatitis, etc.); testicular trauma; torsion of the spermatic funiculus; diabetes mellitus; hepatopathies; nephropathies; neuropathies; varicocele; genetic factors. Sterility from combined factors: immunological infertility, female and/or male psychosomatic infertility.
Casa di Cura San Rossore performs the following diagnoses for the male partner:
– Spermyogram – Evaluation of chemical and physical properties (volume, pH, fluidization and viscosity), concentration, motility and morphology of spermatozoa in the specimen according to WHO (World Health Organization) criteria.
– Capacitation test – Allows selection of sperm with better motility and morphology and reproduces in vitro the changes they undergo in the female genital tract to acquire the ability to penetrate the oocyte (“capacitation”). The test, therefore, is used as a diagnostic investigation in choosing the most suitable IVF treatment for a couple.
– Spermiculture – Qualitative and quantitative assessment of the main populations of microorganisms (bacteria and mycetes) that can colonize the male genital tract.
– Hormone dosages – Luteinizing (LH), follicle-stimulating (FSH), prolactin (PRL), and testosterone (T), the altered levels of which can affect the process of sperm production.
– Testicular Doppler ultrasound – Highlights any anatomic-functional abnormalities and presence of varicocele.
– Sperm DNA Fragmentation Test -The test analyzes the percentage of damaged sperm DNA and provides a tool in the study of idiopathic infertility or in selected cases by providing additional information to the standard seminal fluid examination especially where no sperm abnormalities are evident to justify male infertility itself.

Casa di Cura San Rossore provides the following course of treatment:

Ultrasound monitoring for timing spontaneous reports
Indications: unexplained infertility, mild male factor.
Procedure: involves ultrasound monitoring of the cycle so as to detect the ovulatory phase in order to schedule intercourse. It can be combined with the administration of a drug to induce ovulation and/or progesterone to support the postovulatory phase.

Intrauterine insemination (IUI) on spontaneous or stimulated cycle
Indications: unexplained infertility, mild-to-moderate male factor, moderate endometriosis without established tubal compromise, and difficulty in sexual intercourse (impotence, vaginismus).
Procedure: this is an outpatient and painless technique involving the deposition of semen, after laboratory preparation (capacitation), inside the uterine cavity at the time of ovulation. It can be practiced either on spontaneous cycle or in combination with multiple ovarian stimulation in order to increase the chances of success. Needs ultrasound monitoring to detect ovulatory phase.

IVF
Indications: tubal factor, moderate grade male factor, endometriosis and multiple failures of Level I techniques (IUI).
Procedure: is a test tube technique involving multiple ovarian stimulation by subcutaneous injection drugs to increase oocyte production. Ultrasound monitoring and hormonal evaluation on blood samples should be combined to assess the response pattern and proper follicular growth and maturation. Once good follicular development is obtained, oocytes are harvested transvaginally under ultrasound control under sedation. On the same day as the pick-up, the partner performs semen sample collection, which is capacitated and used to inseminate the oocytes. The transfer of the obtained embryos takes place 2-5 days after insemination and is a quick and painless procedure.

ICSI
Indications: severe male infertility; obstructive and secretory azoospermia (absence of spermatozoa in seminal fluid) (testicular or epididymal spermatozoa); failed or reduced fertilization in previous in vitro fertilization (IVF) cycles; cryopreserved oocytes.
Procedure: technique involving ovarian stimulation and monitoring similar to IVF. It differs from the latter only in its laboratory procedures: in this case, a single sperm is injected into the cytoplasm of the oocyte and then, after fertilization has occurred, the embryos are transferred into the uterus.

Testicular Goaspirate (TeFNA) or testicular biopsy – Technique used for surgical sperm retrieval.
Indications: absence of spermatozoa in seminal fluid (azoospermia)
Procedure: is a technique involving direct aspiration from the testis of spermatozoa under local anesthesia. If the procedure fails in recovery, an open biopsy i.e., by incision of the testis can be performed. The isolated spermatozoa are then usable for the ICSI technique.

Sperm storage (from ejaculate or needle aspiration)
Indications: diseases requiring therapies inducing damage to spermatogenesis (neoplastic diseases, autoimmune diseases, etc.), pathologies requiring urogenital surgery that may impair ejaculatory function or undergoing vasectomy occupational exposure to potentially genotoxic substances OATs (oligoastonoteratospermic) presenting transient improvements in semen quality severe and progressive worsening of semen quality cryptozoospermic (very small number of spermatozoa in the ejaculate) difficulty collecting semen on the day of PMA (psychological or logistical difficulties)

Oocyte Cryopreservation – Procedure that finds indication in in vitro fertilization programs if:
– the number of oocytes available is more than strictly necessary to obtain a suitable number of embryos for the patient in accordance with Law 40/2004 and Constitutional Court Ruling No. 151/2009;
– the patient undergoing egg retrieval presents a high risk to develop ovarian hyperstimulation syndrome;
– fertility preservation in patients who have to undergo gonadotoxic treatments such as chemotherapy or radiotherapy.

Embryo cryopreservation (Constitutional Court Ruling No. 151/2009)
The 2009 Judgment made it possible to inseminate more than 3 oocytes. The number of oocytes to be used is determined by the gynecologist considering not only the patient’s age but also the causes of infertility. The evolving embryos can be cryopreserved to be used later for further attempts or a second pregnancy.

Endometrial scratching
This is the so-called “endometrial scratch,” which is a microtrauma of the endometrium prior to IVF/ICSI treatment that aims to activate endometrial growth factors in order to promote embryo attachment.

IUI with donor sperm
Indications: severe male factor
Procedure: the procedure does not differ from homologous IUI, except that a cryopreserved semen sample obtained from a selected donor is used.

Heterologous ICSI
Indications: all situations of proven infertility of either or both partners in which one or both cannot have their own competent gametes or if the female partner is Rh-negative and severely isoimmunized and the male partner is Rh-positive.
Procedure: an ICSI procedure is performed using oocytes from a selected donor with semen from the couple’s male partner or a donor. The obtained embryos are subsequently transferred into the uterus after appropriate preparatory treatment. The timing of the transfer is customized by seriate ultrasounds.

Gynecology
Dr. Vito Cela
Dr. Maria Ruggiero
Dr. Olga di Berardino

Biology
Dr. Elena Carletti
Dr. Giovanni Paolo Artini