Fertility, Infertility, and

Treatment Options
Fertility, Infertility, and
Treatment Options

Ronnee Yashon and Michael R. Cummings

MOMENTUM PRESS, LLC, NEW YORK

Fertility, Infertility, and Treatment Options

Copyright Momentum Press, LLC, 2017.

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First published in 2017 by

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ISBN-13: 978-1-94664-642-2 (paperback)

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 Abstract
It seems simple to create a baby, after all everyone does it. Even simpler is
the definition of fertility. For a successful conception, you need only three
things: egg, sperm, and uterus. However, all of these components have to
work together to produce a healthy baby, but what happens if one of these
parts is not working properly, or is missing altogether?
In this book, we will be discussing normal fertility, infertility, and
treatment developed in the last 30 years to help with a problem that is
almost an epidemic in some countries.
Often, treatment for infertility has led scientists to find ways to place
the sperm and egg as close together as possible so that they fuse and begin
development of an embryo. Some of these methods are quite remark-
able. You are sure to know someone who has used one form or another
of methods that are called assisted reproductive technologies (ART) and
had success. Most specialists think that the age of the mother is one of
the biggest stumbling blocks in conceiving a child. The older the mother,
the more difficult it becomes. This is because as a woman grows older, her
hormones decrease and her eggs might be damaged.
We are learning more about using these procedures, and the birth
rate from ART is going up. In the United States, about 1 percent of all
births result from the use of ART. This book will answer questions you
might have about methods such as in vitro fertilization (IVF) and other
commonly used forms of ART.

Keywords
ART, artificial uterus, assisted reproduction, egg, embryo, gastrula, genet-
ics, ICSI, infertility, meiosis, mitosis, sperm, surrogacy, uterus
 Contents
Introductionix

Chapter 1 Fertilization.....................................................................1
Chapter 2 Infertility.........................................................................9
Chapter 3 Treatment for Infertility.................................................15
Chapter 4 Sperm and Egg Donation..............................................21
Chapter 5 Surrogacy.......................................................................25
Chapter 6 In Vitro Fertilization (IVF)............................................27
Chapter 7 Problems with ART.......................................................31
Chapter 8 The Future of ART........................................................33
Chapter 9 Landmark Cases............................................................37
Chapter 10 What Would You Do?....................................................43

References45
Index47
 Introduction
To begin with, we will discuss a little bit about the biology of cells, sperm,
and eggs.
The average human body contains about 37 trillion cells. Each is sur-
rounded by a membrane, and inside, contains a semi-liquid cytoplasm
and a nucleus (red blood cells are the exception here; they do not have a
nucleus). Within the nucleus are 46 chromosomes. Following is a d rawing
of a cell for you to review (Figure I.1).
The relevant parts of a cell are indicated in this drawing. Chromo-
somes and the nucleus containing them are the most relevant to the topic
of this book.
DNA is one of the basic components of a chromosome (see F igureI.2)
and carries the cells genetic information. Chromosomes carry many
genes, which create proteins that work within our bodies, having many
functions. Each cell has the same number of chromosomes and the same
gene set (check) as every other cell, but genes are turned on only when
they are needed.
Parts of a chromosome are indicated here. Arms (3 and 4) and
centromere (2).

CHROMOSOME

NUCLEUS

HUMAN CELL
MITOCHONDRIA

Figure I.1 Cell

x Introduction

Figure I.2 Human chromosome

An example might be stomach acid. This chemical is made by up of

proteins in the cells lining the stomach and breaks down foods for diges-
tion. The stomach acid is very acidic.

What might happen if this gene became active in the eye?

Now that we have introduced cells, lets look at the gametes, the repro-
ductive cells produced by mature men and women. Beginning at puberty,
males form sperm from special cells in the testes. These cells are called
spermatogonia and contain a complete set of chromosomes (in humans,
this means 46 chromosomes). First, spermatogonia undergo a type of cell
division called meiosis or reduction division and end up with 23 chro-
mosomes. Then, over a period of days, these cells gradually transform into
sperm, complete with a tail (for movement). Eggs are formed by females
before birth within the ovaries from cells called oogonia. The oogonia
also undergo meiosis, and in the end, contain 23 chromosomes, similar
to the sperm.
 Introduction xi

Normally, if all goes well, after intercourse, sperm and egg fuse to
form a single cell called a zygote, which now contains 46 chromosomes
(23 from the sperm and 23 from the egg). Mitotic divisions in the zygote
begin almost immediately, and continue until birth.

Can you guess the number of divisions between fusion of sperm

and egg and birth?

In the chapters that follow, we will explore the details of mitosis and
meiosis, how the sex of a baby is determined, and what is needed for a
successful pregnancy.
 CHAPTER 1

Fertilization
Questions (in italics) are scattered throughout this chapter and the fol-
lowing chapters. Watch for them and think about how they may apply to
you and the case in Chapter 2.

Cell Division
Mitosis is a form of cell division that produces two daughter cells that are
genetically identical to the parent cell. Since each daughter cell carries the
same genetic information as the parent cell, the chromosomes are copied
before mitosis begins. The process of mitosis is divided into stages defined
by the processes completed in each stage. These stages are prophase, pro-
metaphase, metaphase, anaphase, and telophase. During mitosis, the
chromosomes coil tightly and become visible. They attach to fibers in the
cytoplasm that pull and guide one copy of each chromosome to opposite
sides of the cell. After the cell membrane pinches inward, the cytoplasm
divides, the nucleus re-forms, and the chromosomes uncoil. The result is
two genetically identical daughter cells. A simplified illustration is shown
in Figure 1.1.
In the embryo and fetus, mitosis creates new cells that form all the
organs and body parts before birth. During infancy and childhood, mito-
sis produces the cells that contribute to the growth, maturation, and
transformation of the child into an adult. In adults, growth takes place,
and mitosis is mainly responsible for replacing dead and worn-out cells.
In a normal adult, mitosis produces over 200 billion cells every day to
maintain the body.
We all begin life as a single cell, the zygote, which results from the
fusion of a sperm and egg, an event called fertilization. Gametes, the
cells involved with reproduction, are formed in the testes (sperm) and
the ovaries (eggs). Cells in the testes and ovaries undergo another form
2 FERTILITY, INFERTILITY, AND TREATMENT OPTIONS

Figure 1.1 Mitosis. #1: mother cell; #2: duplication of chromosomes;

#3: 2 daughter cells. The stages of mitosis are shown: 1. mother cell;
2. chromosome duplicate; 3. daughter cells exact copies of #1.

of cell division called meiosis, which reduces the number of chromo-

somes in the parent cell by half. At the start of meiosis, cells contain
two copies of each chromosome, for a total of 46 chromosomes. During
meiosis, members of a chromosome pair separate from each other and
end up in different cells, resulting in cells with 23 chromosomes. This
process involves two rounds of cell division, and is necessary to produce
sperm and egg cells for reproduction. Figure 1.2 shows how meiosis
occurs.
Reduction division with #1 being the original cell with 46 chromo-
somes. And #4 being the gametes with 23 chromosomes each.
When the sperm and egg, each carrying 23 chromosomes, fuse
together at fertilization, the zygote ends up with a full complement of
chromosomes (46). If chromosomes fail to separate properly during mei-
osis, the gametes can contain too few or too many chromosomes, result-
ing in an abnormal number of chromosomes in the zygote and the child
that develops from this zygote, as shown in Figure 1.3.
 Fertilization 3

Figure 1.2 Cells undergoing meiosis

To join

Figure 1.3 Sperm nucleus (#1) and egg nucleus (#2) are about to join

Formation and Early Development of the Embryo

In the laboratory, we can see how fertilization takes place by adding sperm
to a small dish containing an egg. Responding to chemical signals, hun-
dreds of sperm surround the egg, but only one sperm enters the egg. As
it does so, its tail remains behind, so only the sperm head containing the
chromosomes enters, and all other sperm are chemically blocked from
entry and fall away. Inside the egg, the sperm head fuses with the nucleus
4 FERTILITY, INFERTILITY, AND TREATMENT OPTIONS

of the egg, creating a zygote carrying 46 chromosomes. Shortly thereafter,

mitosis begins, and the embryo begins to grow.
Fertilization occurs in the fallopian tube (oviduct), and over the next
few days, the developing embryo travels down the oviduct to the uterus.
Once it reaches the uterus, the embryo nestles into the wall of the uterus,
and sends out projections that attach it to the uterus and begin formation
of the placenta, through which nutrients are received, and waste materials
are exported.

Sex Determination
At this point, lets pause and talk about how sex is determined in a devel-
oping embryo. As we mentioned earlier, cells in humans carry 46 chro-
mosomes, organized into 23 pairs (one member of each pair was donated
by the mother, and the other by the father). One of these pairs is called
the sex chromosomes (identified as X and Y). Females have two X chro-
mosomes as their sex chromosome pair, and males have an X and a Y
chromosome as their pair. These sex chromosomes partially determine the
sex of the baby. Follow along with the illustration in Figure 1.4. Females
have two X chromosomes, and so after meiosis, each egg contains one X
(but which one?). Sperm, however, can have either an X or a Y chromo-
some, but because during meiosis, only one of chromosomes ends up
in each sperm. So that means that sperm can carry either an X or a Y.
About half of all sperm created in the testes have an X chromosome, and
half have a Y. It doesnt take a lot of math to realize that this means that
the SPERM determines the sex of a baby; an egg can contribute only an

Figure 1.4 Sperm surrounds egg

 Fertilization 5

Egg with X

Fertilized by sperm Fertilized by sperm

with Y with X

XY XX

Gonads become
Due to no Y
testes and
gonads become
secrete
ovaries
testosterone

Testosterone causes External genitalia

development becomes female
of male external sex
organs

Figure 1.5 This chart shows the sequence of sex determination

Xchromosome, while the sperm can contribute either an X or a Y chro-

mosome. For each fertilization, there is a 50 percent chance the zygote
will have an XX sex chromosome pair, setting the chromosomal sex of
the embryo as female. Of course, there is also a 50percent chance that
the zygote will be XY, making the chromosomal sex of the zygote male
(Figure 1.5).
When a baby is born no one looks at the chromosomes but they
look at the baby itself and say congratulations you have a fill in the
blank.

What if we want to have a boy? Can we do this?

6 FERTILITY, INFERTILITY, AND TREATMENT OPTIONS

Formation of the embryos sex organs begins in about the 7th week of
development. The sex chromosomes control development of the inter-
nal and external sex organs. If a Y chromosome is present, the action of
genes on this chromosome stimulates the cells of the embryos gonads
to make testosterone and development follows the male pathway. If two
XX chromosomes are present, development proceeds along the female
pathway, via estrogen secretion. At puberty and beyond, these hormones
work to control the maturation of the sex organs and the development of
secondary sex characteristics such as breast development and distribution
of body hair and body fat. In addition, these and other hormones control
many aspects of fertility and pregnancy.

Uterus
Ovary

Female reproductive system

II

Testes

Male reproductive system

Figure 1.6 These are drawings of both male and female reproductive
organs. The most important parts are highlighted. Ovary and testes
 Fertilization 7

As you can see, there are many moving parts to fertility, and problems
can arise at any of these steps, from the production of sperm and eggs to
implantation and normal development. In the following chapter we will
discuss forms of infertility, how they are diagnosed, and in later chapters,
what treatments are available for different fertility problems.
 Index
ACLU. See American Civil Liberties Female reproductive system, 6
Union Fertilization, 17
ACOG. See American College
of Obstetricians and Gestational surrogacy, 25
Gynecologists
American Civil Liberties Union Human chromosome, x
(ACLU), 40
American College of Obstetricians
ICSI. See Intracytoplasmic sperm
and Gynecologists (ACOG), 9
injection
American Society for Reproductive
Infertility
Medicine (ASRM), 9
ASRM definition of, 9
ART. See Assisted reproductive
causes of, 10
techniques
in men, 1213
Artificial uterus, 25, 35
in women, 1012
ASRM. See American Society for
Insurance coverage, 41
Reproductive Medicine
Intracytoplasmic sperm injection
Assisted reproductive techniques
(ICSI), 33
(ART), 1516
In vitro fertilization (IVF), 2730
first level of treatment, 18
IVF. See In vitro fertilization
future of, 3335
legal decision questions, 31
list of treatment, 1819 Johnson v. Calvert, 3940
male treatments, 1617
Male reproductive system, 6
California Cryobank, 22 Meiosis, x, 2
Cell, ix Men
Cell division, 13 ART treatment, 1617
Cells undergoing meiosis, 3 fertility problems, 16
Chromosome infertility in, 1213
human, x Misuse of gametes case, 4041
parts of, ix
National Institutes of Health (NIH),
Davis v. Davis, 3738 10
NIH. See National Institutes of
Health
Egg donation, 2123
Egg nucleus, 3
Embryo, formation and development Obesity, in infertility, 12
of, 34 Oogonia, x
Embryologists, 27
Embryos Implanted case, 41 Reduction division, x, 2
48 Index

Sex determination, 47 Trial court, 40

Spermatogonia, x
Sperm donation, 2123
Sperm Donor SUES for Custody Women
case, 41 fertility problems, 16
Sperm nucleus, 3 infertility in, 1012
Supreme Court of California, 40
Supreme Court of Tennessee, 38
Surrogacy, 2526 Zygote, xi, 1