INTRODUCTION

What Is ART?
Assisted reproductive technology (ART) is used to treat infertility. It
includes fertility treatments that handle both eggs and sperm. It
works by removing eggs from the ovaries. The eggs are then mixed
with sperm to make embryos.
The embryos are then put back in the parent's body. In vitro
fertilization (IVF) is the most common and effective type of ART.

ART procedures sometimes use donor eggs, donor sperm, or

previously frozen embryos. It may also involve a surrogate or
gestational carrier. A surrogate is a person who becomes pregnant
with sperm from one partner of the couple. A gestational carrier
becomes pregnant with an egg from one partner and sperm from
the other partner.

The most common complication of ART is a multiple pregnancy. It

can be prevented or minimized by limiting the number of embryos
that are put into the parent's body.
In general, ART procedures involve surgically removing eggs from a
woman’s ovaries, combining them with sperm in the laboratory, and
returning them to the woman’s body or donating them to another
woman. They do NOT include treatments in which only sperm are
handled (i.e., intrauterine—or artificial—insemination) or procedures
in which a woman takes medicine only to stimulate egg production
without the intention of having eggs retrieved. ART can alleviate the
burden of infertility on individuals and families, but it can also
present challenges to public health as evidenced by the high rates

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Of multiple delivery, preterm delivery, and low birth-weight delivery
experienced with ART. Monitoring the outcomes of technologies
that affect reproduction, such as contraception ART, has become an
important public health activity.

CDC’s Division of Reproductive Health has a long history of

surveillance and research in women's health and fertility, adolescent
reproductive health, and safe motherhood.
In 1997, CDC submitted to Congress the first annual report, titled
Assisted Reproductive Technology Success Rates: National
Summary and Fertility Clinic Reports. This report gained a wide
audience, including potential ART patients and their families, policy
makers, researchers and health care providers. Maternal and child
health professionals, as well as state and local public health
departments, also began requesting data on birth outcomes among
infants born using ART technologies in their localities. In 2002, CDC
prepared the first ART surveillance report on ART use and
outcomes by state.
The National ART Surveillance System (NASS) does not contain
information on long-term outcomes of ART. This information can be
obtained by linking ART surveillance data with other surveillance
systems and registries, while paying close attention to confidentiality
protection. Since 2001, CDC has collaborated with health
departments of three states (Massachusetts, and later Michigan and
Florida), to link NASS with vital records, hospital discharge data,
birth defects registries, cancer registries, and other surveillance
systems of these states. This project, called States Monitoring ART
(SMART) Collaborative, provides a unique opportunity for federal
and state public health agencies to work together on establishing
state-based public health surveillance of ART, infertility and related
issues.

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OBJECTIVES OF ASSISTED REPRODUCTIVE
TECHNIQUE

● Review indications and relative contraindications of ART.

● Identify relevant female pelvic anatomy for ART.
● Discuss evidence-based techniques for in vitro fertilization
and associated procedures.
● Outline complications of ART and subsequent management.

EQUIPMENTS OF ARTs

Based on American Society of Reproductive Medicine (ASRM)

guidelines for embryology labs, the following basic equipment is
required for the management of oocytes and embryos:
● Incubator
● Microscope suitable for handling and micromanipulation of
oocytes and embryos
● pH and temperature monitoring and maintenance devices
● Warming blocks
● Laser for biopsy of embryos
● Cryopreservation equipment (liquid nitrogen tanks)
● Laboratory centrifuge
● Laminar flow hood
● Culture media
● Refrigerator
● Air filtration system

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PREPARATION FOR ART

Preparation for ART procedures largely involves the evaluation

and workup for etiologies of infertility. Infertility is defined as
failure to achieve pregnancy after at least one year of unprotected
intercourse. Infertility evaluation can also be initiated at six
months of failure to achieve pregnancy in women over 35 or in
cases where there are known possible barriers, such as known
uterine or tubal disease or male infertility. Initial comprehensive
history taking includes menstrual history, pregnancy history,
infertility duration, prior infertility treatments, past medical and
surgical history, family history, and social and environmental
exposures/habits. The physical exam includes evaluating basic
vital signs, body mass index, thyroid evaluation, excess
androgen, and pelvic examination.
For the female evaluation, day 3 follicle-stimulating hormone
(FSH), estradiol (E2), antral follicle count, and Anti Mullerian
Hormone (AMH) are determined via blood work and baseline
transvaginal ultrasound to evaluate ovarian reserve. Further
medical evaluation in patients with ovulatory dysfunction includes
collections of thyroid-stimulating hormone (TSH), prolactin,
DHEAS, testosterone, and 17 hydroxyl-progesterone. The above
hormonal assessment helps determine the etiology of
anovulation. In addition, the uterine and pelvic cavity is also
typically evaluated with a baseline transvaginal ultrasound, often
in conjunction with a hysterosalpingogram or sonohysterogram.
The ultrasound evaluation helps to identify any uterine factors
affecting fertility and pregnancy maintenance, such as the

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presence of polyps, submucosal fibroids, and/or uterine
malformations such as uterine septums.
Ultrasound evaluation can also determine other causes of
subfertility, such as hydro salpinx or endometriosis. Male infertility
workup includes a semen analysis. Both male and female
evaluation usually involves a basic infectious disease workup,
including syphilis, a hepatitis panel, and human immunodeficiency
virus (HIV).

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TYPES OF ARTs
There are several types of ART procedures that involve different
techniques and reproductive cells. A doctor can advise which
ART will be most suitable depending on the circumstances. The
most common type is in vitro fertilization (IVF).

1.IVF
IVF involves extracting eggs and fertilizing them in a special
lab. Specialists can combine this with an embryo transfer
(IVF-ET) and transfer the resulting embryos into a person’s
uterus. The Society for Assisted Reproductive Technology
states that IVF-ET accounts for 99% of ART procedures.
The centers for disease control and prevention (CDC) lists
the 2018 success rate of IVF treatment for one oocyte
retrieval from people using their own eggs as:

● 47.2% for people aged 35 or younger

● 34.6% for people aged 35–37

● 22.1% for people aged 38–40

● 7.2% for those over the age of 40

A person may also use a tool called an IVF success

estimator Trusted Source to estimate their chance of having

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 a baby using IV .It may take more than one IVF cycle to
result in pregnancy, and some people may not conceive with
IVF at all. The benefits of IVF are an increased chance of
fertilization and pregnancy. Potential complications may
include:

● Multiple pregnancy, or two or more embryos implanting

at a time.
● Side effects from fertility drugs, such as ovarian hyper
stimulation syndrome
● Ectopic pregnancy, where the embryo settles outside
the womb

2.INTRAFALLOPIAN TRANSFER

Some methods of ART are similar to IVF but use

laparoscopic surgery to deliver the gametes directly into the
fallopian tube. Some people may choose this method for
religious reasons, or their insurance may only cover this type
of ART.

Similar to other forms of ART, there is an increased chance

of multiple pregnancy. Additionally, due to the laparoscopy,
there is a risk of complications from the surgery, such as
infection, organ puncture, or side effects from anesthesia.
Intra fallopian transfers are typically more expensive than
IVF.

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 Due to the higher costs and risks of this type of ART,
specialists rarely use these procedures.

3.EMBRYO TRANSFER

The embryo transfer process is similar to the process for a

pap smear. The doctor will insert a speculum into the
woman’s vagina to keep the vaginal walls open. Using
ultrasound for accuracy, the doctor will then pass a catheter
through the cervix and into the womb. From there, the
embryos are passed through the tube and into the womb.

The process is usually pain free and rarely requires any

sedatives. Some women may feel discomfort as a result of
having the speculum inserted or from having a full bladder,
which is required for ultrasound. The process is short, and
the bladder can be emptied immediately after

TYPES OF EMBRYO TRANSFER

● FRESH EMBRYO TRANSFER:-Once eggs have been

fertilized, they are cultured for 1-2 days. The best embryos
are chosen to transfer directly to the woman’s uterus.

● FROZEN EMBRYO TRANSFER:- Any healthy embryos that

were not used in the first transfer can be frozen and stored
for future use. These can be thawed and transferred to the
uterus.

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● BLASTOCYST EMBRYO TRANSFER:-If many healthy
embryos develop after the fertilization, it is common to wait
to see if the embryos develop into blastocysts. According to
a study in the Indian Journal of Clinical Practice, blastocyst
embryo transfer has a higher success rate than the standard
embryo transfer.

RISKS AND PRECAUTIONS OF EMBRYO TRANSFERS

The risks of embryo transfers themselves are very low.

These risks are mostly related to increased hormonal
stimulation, causing an increased risk such as a blood clot
blocking a blood vessel.

The woman can also experience bleeding, changes in her

vaginal discharge, infections, and complications of
anesthesia if it is used. The risk of a miscarriage is about the
same as in natural conception.

The greatest risk of embryo transfer is the chance of multiple

pregnancies. This occurs when multiple separate embryos
attach to the uterus. This may increase the risk of stillbirth
and children born with disabilities, and is more common in
pregnancies due to IVF than natural conception.

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4. INTRACYTOPLASMIC SPERM INJECTION

Intracytoplasmic sperm injection (ICSI) is a procedure that

specialists can perform alongside IVF to help fertilize an egg.
An embryologist, or embryo specialist, uses a tiny needle to
inject a single sperm directly into the center of an egg.

ICSI fertilizes between 50–80% of eggs. The success rate of

ICSI is similar to those of IVF, and it may be an effective
method of ART for people with sperm-related infertility. ICSI
is typically an add-on procedure to IVF, so it will be more
costly than IVF alone.

PROCEDURE FOR SUCCESSFUL ICSI

Step 1: Retrieval. The man will have to produce a sperm

sample ejaculating into a cup or the sperm will have to be
surgically retrieved.

Step 2: Injection of Sperm into Egg.

Step 3: Monitoring the Embryo.

Step 4: Transfer of Embryos.

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5.THIRD-PARTY ART

Third-party ART Trusted Source is when another individual

donates eggs, sperm, or embryos to an individual or couple. It can
also include surrogate and gestational carriers. These refer to
when another person is either inseminated with sperm from the
couple using ART or implanted with an embryo from those using
ART.

Evidence suggests that 50%Trusted Source of transfers with

donated frozen embryos result in pregnancy, and 40% result in a
live birth. Other benefits of third-party ART include the following:

● It may work when IVF has repeatedly failed.

● It may help to avoid passing on specific conditions.
● It can help a person who produces healthy eggs but has had
difficulty carrying a pregnancy to term.
● It can help those who have difficulty producing an egg or
sperm.

6.ZYGOTE INTRAFALLOPIAN TRANSFER

(ZIFT)

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Zygote intra fallopian transfer (ZIFT) is an assisted reproductive
procedure similar to in vitro fertilization and embryo transfer, the
difference being that the fertilized embryo is transferred into the
fallopian tube instead of the uterus. Because the fertilized egg is
transferred directly into the tubes, the procedure is also referred
to as tubal embryo transfer (TET).
This procedure can be more successful than gamete intra
fallopian transfer (GIFT) because your physician has a greater
chance of ensuring that the egg is fertilized. The woman must
have healthy tubes for ZIFT to work.

7.GAMETE INTRAFALLOPIAN
TRANSFER (GIFT)

● Gamete intra fallopian transfer (GIFT) is a three-step

procedure that involves removing the eggs, combining them
with sperm, and immediately placing them in the fallopian
tubes, where the egg is fertilized.
● The woman is given follicle-stimulating drugs to increase her
chances of producing multiple eggs. The eggs are collected
via aspiration and mixed with sperm.
● Using laparoscopy, the combined egg and sperm mixture is
placed in the fallopian tubes.
● GIFT is an option only if the woman has a healthy uterus and
fallopian tubes.

8.INTRAUTERINE TRANSFER (IUT)

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The zygote or the early embryo up to 8 blastomeres (cells that are
produced during cleavage of a zygote) is transferred into the
fallopian tube in zygote intra fallopian transfer (ZIFT) technique. If
an embryo contains more than 8 blastomeres and it is transferred
into the uterus then it is called intra uterine transfer (IUT).

9.ARTIFICIAL INSEMINATION (AI)

In artificial insemination, a doctor inserts sperm directly into a

woman's cervix, fallopian tubes, or uterus. The most common
method is called "intrauterine insemination (IUI)," when a doctor
places the sperm in the uterus.

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Risks of ARTs

Perinatal risks that may be associated with assisted reproductive

technology (ART) and ovulation induction include multifetal
gestations, prematurity, low birth weight, and small for gestational
age, perinatal mortality, cesarean delivery, placenta Previa,
abruption placentae, preeclampsia, and birth defects.

With ART and ovulation induction, higher-order multifetal

pregnancy may occur. Multifetal pregnancy and its associated
outcomes is the greatest risk of ART and ovulation induction and,
consequently, every effort should be made to achieve a singleton
gestation.

Before initiating ART or ovulation induction procedures,

obstetricians–gynecologists and other health care providers
should complete a thorough medical evaluation to ensure that
patients are in good health and should counsel these women
about the risks associated with treatment.

Couples at risk of passing genetic conditions on to their offspring,

including those due to infertility-associated conditions.

When a higher-order (triplet or more) multifetal pregnancy is

encountered, the option of multifetal reduction should be

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discussed. In the case of a continuing higher-order multifetal
pregnancy, ongoing obstetric care should be with an obstetrician–
gynecologist or other obstetric care provider and at a facility
capable of managing anticipated risks and outcomes.

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CLINICAL SIGNIFICANCE

ART allows individuals and couples to achieve pregnancy in

situations that might not otherwise be possible, such as those with
infertility, a history of gonadotropic therapies, or those with
deleterious genetic conditions.

According to the Center for Disease Control, as of 2017, 1.9% of

United States-born infants are conceived with ART. In 2017,
approximately 200,000 ART cycles with an embryo transfer were
performed, with 78,052 live births in that year. As access, rates of
delayed childbearing, and insurance coverage for ART increase,
these numbers will likely increase. As such, women’s health and
reproductive health providers need to have a basic functioning

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knowledge of indications and appropriate timing for referral to a
reproductive endocrinologist and infertility specialist.

THE CONCLUSION

As studied earlier in this article, numerous techniques are

available for conceiving a child, but all these techniques
necessitate extreme handling precisions. These techniques can
be only performed by specialized medical professionals and
expensive laboratory equipment, making them outrageous for
most couples. As a result, these services are only available in a
few locations across the country. And clearly, their benefits are
only affordable to a small number of couples.

In general, ART has the potential to have a life‐changing impact

for people who are otherwise unable to conceive; however,

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parents should be counseled on the risks and benefits. In
concordance with advanced medical technology, the benefits of
ART are also associated with risks. Although the primary risks are
more strongly associated with multiple births, even in singleton
pregnancies there is an increase for specific birth defects,
imprinting disorders, preterm birth, and low birthweight, small for
gestational age, stillbirth, and perinatal mortality.

In the end, we conclude that ART is a relatively safe procedure,

with single embryo implantation maximizing outcome. However,
informed consent, including both risks and benefits, as well as
ongoing longitudinal studies are required to fully understand ART
outcomes

BIBLIOGRAPHY

https://pubmed.ncbi.nlm.nih.gov/79723

https://pubmed.ncbi.nlm.nih.gov/19208787

https://pubmed.ncbi.nlm.nih.gov/19007646

https://pubmed.ncbi.nlm.nih.gov/32115183

https://pubmed.ncbi.nlm.nih.gov/27357126

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