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Débauches anales alternative title for Débauches anales pour jeunes pucelles débutantes Notes available Débauches anales pour jeunes pucelles débutantes 1985, Dir. Alain Payet as John Love Notes available Déchirure anale alternative title for Les Petites filles sodomisées Notes available (in masked orgy scene) Donne bestiali alternative title for Débauches anales pour jeunes pucelles débutantes Notes available L'Éducation à la soumission alternative title for Outrages transsexuels des petites filles violées et sodomisées Notes available (plays Muriel) Enfer anal alternative title for Petits trous déchirés, salopes par derrière Notes available Étudiantes à sodomiser 1984, Dir. Alain Payet as John Love Notes available Étudiantes à sodomiser sans limites alternative title for Étudiantes à sodomiser Notes available Geil versaute Sekretärinnen alternative title for Les Petites filles sodomisées Notes available (in masked orgy scene) Initiation d'une petite garce alternative title for Étudiantes à sodomiser Notes available Jeux spéciaux pour petites filles à sodomiser alternative title for Les Petites filles sodomisées Notes available (in masked orgy scene) Jouissances très spéciales alternative title for Prouesses anales pour top modèles de luxe Notes available
Ogni volta di più alternative title for Les Petites filles sodomisées Notes available (in masked orgy scene) Outrages transsexuels des petites filles violées et sodomisées 1985, Dir. Pierre B. Reinhard Notes available (plays Muriel) Petites filles à sodomiser alternative title for Les Petites filles sodomisées Notes available (in masked orgy scene) Les Petites filles sodomisées 1985, Dir. Joe de Palmer Notes available (in masked orgy scene) Petits trous déchirés, salopes par derrière 1985, Dir. Pierre B. Reinhard Notes available Prouesses anales pour top modèles de luxe 1985, Dir. Pierre B. Reinhard Notes available Le Secret de la pierre phallique alternative title for Étudiantes à sodomiser Notes available Sex-exzesse intim alternative title for Étudiantes à sodomiser Notes available Soumissions alternative title for Trois petits c... en chaleur Notes available (plays Dany?) Trois petits c... en chaleur 1983, Dir. Pierre Unia as Reine Pirau Notes available (plays Dany?)



The eggs are retrieved from the patient using a transvaginal technique called transvaginal oocyte retrieval, involving an ultrasound-guided needle piercing the vaginal wall to reach the ovaries. Through this needle follicles can be aspirated, and the follicular fluid is passed to an embryologist to identify ova. It is common to remove between ten and thirty eggs. The retrieval procedure usually takes between 20 and 40 minutes, depending on the number of mature follicles, and is usually done under conscious sedation or general anaesthesia. Egg and sperm preparation In the laboratory, for ICSI treatments, the identified eggs are stripped of surrounding cells (also known as cumulus cells) and prepared for fertilisation. An oocyte selection may be performed prior to fertilisation to select eggs that can be fertilized, as it is required they are in metaphase II. There are cases in which if oocytes are in the metaphase I stage, they can be kept being cultured so as to undergo a posterior sperm injection. In the meantime, semen is prepared for fertilisation by removing inactive cells and seminal fluid in a process called sperm washing. If semen is being provided by a sperm donor, it will usually have been prepared for treatment before being frozen and quarantined, and it will be thawed ready for use. Co-incubation Demonstration of IVF The sperm and the egg are incubated together at a ratio of about 75,000:1 in a culture media in order for the actual fertilisation to take place. A review in 2013 came to the result that a duration of this co-incubation of about 1 to 4 hours results in significantly higher pregnancy rates than 16 to 24 hours.[70] In most cases, the egg will be fertilised during co-incubation and will show two pronuclei. In certain situations, such as low sperm count or motility, a single sperm may be injected directly into the egg using intracytoplasmic sperm injection (ICSI). The fertilised egg is passed to a special growth medium and left for about 48 hours until the egg consists of six to eight cells. In gamete intrafallopian transfer, eggs are removed from the woman and placed in one of the fallopian tubes, along with the man's sperm. This allows fertilisation to take place inside the woman's body. Therefore, this variation is actually an in vivo fertilisation, not in vitro. Embryo culture Main article: Embryo culture The main durations of embryo culture are until cleavage stage (day two to four after co-incubation) or the blastocyst stage (day five or six after co-incubation).[71] Embryo culture until the blastocyst stage confers a significant increase in live birth rate per embryo transfer, but also confers a decreased number of embryos available for transfer and embryo cryopreservation, so the cumulative clinical pregnancy rates are increased with cleavage stage transfer.[30] Transfer day two instead of day three after fertilisation has no differences in live birth rate.[30] There are significantly higher odds of preterm birth (odds ratio 1.3) and congenital anomalies (odds ratio 1.3) among births having from embryos cultured until the blastocyst stage compared with cleavage stage.[71] Embryo selection Further information: Embryo quality Laboratories have developed grading methods to judge ovocyte and embryo quality. In order to optimise pregnancy rates, there is significant evidence that a morphological scoring system is the best strategy for the selection of embryos.[72] Since 2009 where the first time-lapse microscopy system for IVF was approved for clinical use,[73] morphokinetic scoring systems has shown to improve to pregnancy rates further.[74] However, when all different types of time-lapse embryo imaging devices, with or without morphokinetic scoring systems, are compared against conventional embryo assessment for IVF, there is insufficient evidence of a difference in live-birth, pregnancy, stillbirth or miscarriage to choose between them.[75]. Active efforts to develop a more accurate embryo selection analysis based on Artificial Intelligence and Deep Learning are underway. Embryo Ranking Intelligent Classification Assistant (ERICA),[76] is a clear example. This Deep Learning software substitutes manual classifications with a ranking system based on an individual embryo's predicted genetic status in a non-invasive fashion.[77] Studies on this area are still pending and current feasibility studies support its potential.[78] Embryo transfer Main article: Embryo transfer The number to be transferred depends on the number available, the age of the woman and other health and diagnostic factors. In countries such as Canada, the UK, Australia and New Zealand, a maximum of two embryos are transferred except in unusual circumstances. In the UK and according to HFEA regulations, a woman over 40 may have up to three embryos transferred, whereas in the US, there is no legal limit on the number of embryos which may be transferred, although medical associations have provided practice guidelines. Most clinics and country regulatory bodies seek to minimise the risk of multiple pregnancy, as it is not uncommon for multiple embryos to implant if multiple embryos are transferred. Embryos are transferred to the patient's uterus through a thin, plastic catheter, which goes through her vagina and cervix. Several embryos may be passed into the uterus to improve chances of implantation and pregnancy. Luteal support Main article: Luteal support Luteal support is the administration of medication, generally progesterone, progestins, hCG, or GnRH agonists, and often accompanied by estradiol, to increase the success rate of implantation and early embryogenesis, thereby complementing and/or supporting the function of the corpus luteum. A Cochrane review found that hCG or progesterone given during the luteal phase may be associated with higher rates of live birth or ongoing pregnancy, but that the evidence is not conclusive.[79] Co-treatment with GnRH agonists appears to improve outcomes,[79] by a live birth rate RD of +16% (95% confidence interval +10 to +22%).[80] On the other hand, growth hormone or aspirin as adjunctive medication in IVF have no evidence of overall benefit.[30] Expansions There are various expansions or additional techniques that can be applied in IVF, which are usually not necessary for the IVF procedure itself, but would be virtually impossible or technically difficult to perform without concomitantly performing methods of IVF. Preimplantation genetic screening or diagnosis Main article: Preimplantation genetic diagnosis Preimplantation genetic screening (PGS) or preimplantation genetic diagnosis (PGD) has been suggested to be able to be used in IVF to select an embryo that appears to have the greatest chances for successful pregnancy. However, a systematic review and meta-analysis of existing randomised controlled trials came to the result that there is no evidence of a beneficial effect of PGS with cleavage-stage biopsy as measured by live birth rate.[81] On the contrary, for women of advanced maternal age, PGS with cleavage-stage biopsy significantly lowers the live birth rate.[81] Technical drawbacks, such as the invasiveness of the biopsy, and non-representative samples because of mosaicism are the major underlying factors for inefficacy of PGS.[81] Still, as an expansion of IVF, patients who can benefit from PGS/PGD include: Couples who have a family history of inherited disease Couples who want prenatal sex discernment. This can be used to diagnose monogenic disorders with sex linkage. It can potentially be used for sex selection, wherein a fetus is aborted if having an undesired sex. Couples who already have a child with an incurable disease and need compatible cells from a second healthy child to cure the first, resulting in a "saviour sibling" that matches the sick child in HLA type.[82] PGS screens for numeral chromosomal abnormalities while PGD diagnosis the specific molecular defect of the inherited disease. In both PGS and PGD, individual cells from a pre-embryo, or preferably trophectoderm cells biopsied from a blastocyst, are analysed during the IVF process. Before the transfer of a pre-embryo back to a woman's uterus, one or two cells are removed from the pre-embryos (8-cell stage), or preferably from a blastocyst. These cells are then evaluated for normality. Typically within one to two days, following completion of the evaluation, only the normal pre-embryos are transferred back to the woman's uterus. Alternatively, a blastocyst can be cryopreserved via vitrification and transferred at a later date to the uterus. In addition, PGS can significantly reduce the risk of multiple pregnancies because fewer embryos, ideally just one, are needed for implantation. Cryopreservation Main articles: Oocyte cryopreservation and Embryo cryopreservation Cryopreservation can be performed as oocyte cryopreservation before fertilisation, or as embryo cryopreservation after fertilisation. The Rand Consulting Group has estimated there to be 400,000 frozen embryos in the United States in 2006.[83] The advantage is that patients who fail to conceive may become pregnant using such embryos without having to go through a full IVF cycle. Or, if pregnancy occurred, they could return later for another pregnancy. Spare oocytes or embryos resulting from fertility treatments may be used for oocyte donation or embryo donation to another woman or couple, and embryos may be created, frozen and stored specifically for transfer and donation by using donor eggs and sperm. Also, oocyte cryopreservation can be used for women who are likely to lose their ovarian reserve due to undergoing chemotherapy.[84] By 2017, many centers have adopted embryo cryopreservation as their primary IVF therapy, and perform few or no fresh embryo transfers. The two main reasons for this have been better endometrial receptivity when embryos are transferred in cycles without exposure to ovarian stimulation and also the ability to store the embryos while awaiting the results of pre-implantation genetic testing. The outcome from using cryopreserved embryos has uniformly been positive with no increase in birth defects or development abnormalities.[85] Other expansions Intracytoplasmic sperm injection (ICSI) is where a single sperm is injected directly into an egg. Its main usage as an expansion of IVF is to overcome male infertility problems, although it may also be used where eggs cannot easily be penetrated by sperm, and occasionally in conjunction with sperm donation. It can be used in teratozoospermia, since once the egg is fertilised abnormal sperm morphology does not appear to influence blastocyst development or blastocyst morphology.[86] Additional methods of embryo profiling. For example, methods are emerging in making comprehensive analyses of up to entire genomes, transcriptomes, proteomes and metabolomes which may be used to score embryos by comparing the patterns with ones that have previously been found among embryos in successful versus unsuccessful pregnancies.[87] Assisted zona hatching (AZH) can be performed shortly before the embryo is transferred to the uterus. A small opening is made in the outer layer surrounding the egg in order to help the embryo hatch out and aid in the implantation process of the growing embryo. In egg donation and embryo donation, the resultant embryo after fertilisation is inserted in another woman than the one providing the eggs. These are resources for women with no eggs due to surgery, chemotherapy, or genetic causes; or with poor egg quality, previously unsuccessful IVF cycles or advanced maternal age. In the egg donor process, eggs are retrieved from a donor's ovaries, fertilised in the laboratory with the sperm from the recipient's partner, and the resulting healthy embryos are returned to the recipient's uterus. In oocyte selection, the oocytes with optimal chances of live birth can be chosen. It can also be used as a means of preimplantation genetic screening. Embryo splitting can be used for twinning to increase the number of available embryos.[88] Cytoplasmic transfer is where the cytoplasm from a donor egg is injected into an egg with compromised mitochondria. The resulting egg is then fertilised with sperm and implanted in a womb, usually that of the woman who provided the recipient egg and nuclear DNA. Cytoplasmic transfer was created to aid women who experience infertility due to deficient or damaged mitochondria, contained within an egg's cytoplasm. Leftover embryos or eggs Further information: Embryo donation and Egg donor There may be leftover embryos or eggs from IVF procedures if the woman for whom they were originally created has successfully carried one or more pregnancies to term. With the woman's or couple's permission, these may be donated to help other women or couples as a means of third party reproduction. In embryo donation, these extra embryos are given to other couples or women for transfer with the goal of producing a successful pregnancy. The resulting child is considered the child of the woman who carries it and gives birth, and not the child of the donor, the same as occurs with egg donation or sperm donation. Typically, genetic parents donate the eggs to a fertility clinic or where they are preserved by oocyte cryopreservation or embryo cryopreservation until a carrier is found for them. Typically the process of matching the embryo(s) with the prospective parents is conducted by the agency itself, at which time the clinic transfers ownership of the embryos to the prospective parents.[89] In the United States, women seeking to be an embryo recipient undergo infectious disease screening required by the U.S. Food and Drug Administration (FDA), and reproductive tests to determine the best placement location and cycle timing before the actual Embryo Transfer occurs. The amount of screening the embryo has already undergone is largely dependent on the genetic parents' own IVF clinic and process. The embryo recipient may elect to have her own embryologist conduct further testing. Alternatives to donating unused embryos are destroying them (or having them implanted at a time where pregnancy is very unlikely),[90] keeping them frozen indefinitely, or donating them for use in research (which results in their unviability).[91] Individual moral views on disposing leftover embryos may depend on personal views on the beginning of human personhood and definition and/or value of potential future persons and on the value that is given to fundamental research questions. Some people believe donation of leftover embryos for research is a good alternative to discarding the embryos when patients receive proper, honest and clear information about the research project, the procedures and the scientific values.[92] History Main article: History of in vitro fertilisation The first successful birth of a child after IVF treatment, Louise Brown, occurred in 1978. Louise Brown was born as a result of natural cycle IVF where no stimulation was made. The procedure took place at Dr Kershaw's Cottage Hospital (now Dr Kershaw's Hospice) in Royton, Oldham, England. Robert G. Edwards was awarded the Nobel Prize in Physiology or Medicine in 2010, the physiologist who co-developed the treatment together with Patrick Steptoe and embryologist Jean Purdy; Steptoe and Purdy were not eligible for consideration as the Nobel Prize is not awarded posthumously.[1][2] The second successful birth of a test tube baby occurred in India just 67 days after Louise Brown was born.[93] The girl, named Durga conceived in vitro using a method developed independently by Dr. Subhash Mukhopadhyay, a physician and researcher from Kolkata, India. With egg donation and IVF, women who are past their reproductive years, have infertile male partners, have idiopathic female-fertility issues, or have reached menopause can still become pregnant. Adriana Iliescu held the record as the oldest woman to give birth using IVF and a donor egg, when she gave birth in 2004 at the age of 66, a record passed in 2006. After the IVF treatment some couples are able to get pregnant without any fertility treatments.[3] In 2018 it was estimated that eight million children had been born worldwide using IVF and other assisted reproduction techniques.[4] Ethics Mix-ups In some cases, laboratory mix-ups (misidentified gametes, transfer of wrong embryos) have occurred, leading to legal action against the IVF provider and complex paternity suits. An example is the case of a woman in California who received the embryo of another couple and was notified of this mistake after the birth of her son.[94] This has led to many authorities and individual clinics implementing procedures to minimise the risk of such mix-ups. The HFEA, for example, requires clinics to use a double witnessing system, the identity of specimens is checked by two people at each point at which specimens are transferred. Alternatively, technological solutions are gaining favour, to reduce the manpower cost of manual double witnessing, and to further reduce risks with uniquely numbered RFID tags which can be identified by readers connected to a computer. The computer tracks specimens throughout the process and alerts the embryologist if non-matching specimens are identified. Although the use of RFID tracking has expanded in the US,[95] it is still not widely adopted.[96] Preimplantation genetic diagnosis or screening While PGD was originally designed to screen for embryos carrying hereditary genetic diseases, the method has been applied to select features that are unrelated to diseases, thus raising ethical questions. Examples of such cases include the selection of embryos based on histocompatibility (HLA) for the donation of tissues to a sick family member, the diagnosis of genetic susceptibility to disease, and sex selection.[97] These examples raise ethical issues because of the morality of eugenics. It becomes frowned upon because of the advantage of being able to eliminate unwanted traits and selecting desired traits. By using PGD, individuals are given the opportunity to create a human life unethically and rely on science and not by natural selection.[98] For example, a deaf British couple, Tom and Paula Lichy, have petitioned to create a deaf baby using IVF.[99] Some medical ethicists have been very critical of this approach. Jacob M. Appel wrote that "intentionally culling out blind or deaf embryos might prevent considerable future suffering, while a policy that allowed deaf or blind parents to select for such traits intentionally would be far more troublesome."[100] Profit desire of the industry In 2008, a California physician transferred 12 embryos to a woman who gave birth to octuplets (Suleman octuplets). This led to accusations that a doctor is willing to endanger the health and even life of women in order to gain money. Robert Winston, professor of fertility studies at Imperial College London, had called the industry "corrupt" and "greedy" stating that "one of the major problems facing us in healthcare is that IVF has become a massive commercial industry," and that "what has happened, of course, is that money is corrupting this whole technology", and accused authorities of failing to protect couples from exploitation: "The regulatory authority has done a consistently bad job. It's not prevented the exploitation of women, it's not put out very good information to couples, it's not limited the number of unscientific treatments people have access to".[101] The IVF industry has been described as a market-driven construction of health, medicine and the human body.[102] In the US, the Copyright Clause provides innovators with a temporary monopoly over their respective work. As a result, IVF is prohibitively expensive for patients as providers have to also cover the costs of patents. For example, 23andMe has patented a process used to calculate the probability of gene inheritance.[103] The industry has been accused of making unscientific claims, and distorting facts relating to infertility, in particular through widely exaggerated claims about how common infertility is in society, in an attempt to get as many couples as possible and as soon as possible to try treatments (rather than trying to conceive naturally for a longer time). This risks removing infertility from its social context and reducing the experience to a simple biological malfunction, which not only can be treated through bio-medical procedures, but should be treated by them.[104][105] Indeed, there are serious concerns about the overuse of treatments, for instance Dr Sami David, a fertility specialist, has expressed disappointment over the current state of the industry, and said many procedures are unnecessary; he said: "It's being the first choice of treatment rather than the last choice. When it was first opening up in late 1970s, early 80s, it was meant to be the last resort. Now it's a first resort. I think that it can harm women in the long run."[106] IVF thus raises ethical issues concerning the abuse of bio-medical facts to 'sell' corrective procedures and treatments for conditions that deviate from a constructed ideal of the 'healthy' or 'normal' body i.e., fertile females and males with reproductive systems capable of co-producing offspring. IVF over age 40 All pregnancies can be risky, but there are greater risk for women who are older and are over the age of 40. The older the women the riskier the pregnancy. As women get older, they are more likely to suffer from conditions such as gestational diabetes and pre-eclampsia. If older women do conceive over the age of 40, their offspring may be of lower birth weight, and more likely to requires intensive care. Because of this, the increased risk is a sufficient cause for concern. The high incidence of caesarean in older mothers is commonly regarded as a risk. Though there are some risk with older women pregnancies, there are some benefits associated with caesareans. A study has shown that births over 40 have a lower rate of birth trauma due to increased delivery by caesarean. Though caesarean is seen to benefit mothers over 40, there are still many risk factors to consider. Caesarean section may be a risk in the same way that gestational diabetes is. Women conceiving at 40 have a greater risk of gestational hypertension and premature birth. The offspring is at risk when being born from older mothers, and the risks associated with being conceived through IVF.[107] Normal Vaginal Canal Vs Menopause Adriana Iliescu held the record for a while as the oldest woman to give birth using IVF and a donor egg, when she gave birth in 2004 at the age of 66. In September 2019, a 74-year-old woman became the oldest-ever to give birth after she delivered


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