WHAT IS IVF?
IVF is commonly referred to as "test tube baby" treatment. IVF stands for “In Vitro Fertilization”. The procedure involves removing a number of mature eggs from the ovary, fertilizing them outside the body with the husband's sperm in the laboratory and transferring the resultant embryos (fertilized eggs) back into the patient's uterus.
WHAT ARE THE INDICATIONS FOR IVF?
- Blocked Fallopian tubes
- Unexplained infertility-where routine tests do not indicate any abnormality in the couple
- Male factor-Severe abnormalities in the sperm parameters –very low sperm count/ motility
- Endometriosis-moderate/severe
- Advanced female age
WHAT DOES THE TREATMENT PROCESS INVOLVE?
There are several steps which include
Ovarian stimulation
In a normal menstrual cycle only one follicle (sac containing egg) usually reaches maturity and releases an egg each month. However in an IVF cycle, we aim to stimulate growth of several follicles so that many eggs are available for fertilization so that the chance of success is increased.
Injections called gonadotrophins are the most commonly used injections to develop a good number of follicles in the ovary. They are given daily till the follicles reach a diameter of 18 mm or more. The stimulation injections are usually given for between 10 to 14 days. Some of the injections are given subcutaneously which means it is injected under the skin and other injections into the muscle.
The most common side effects noted are a little inflammation at the injection site, transient fever and joint pains.
Monitoring the growth of the follicles
On an average, 3-4 scans will be carried out while you are taking the stimulation injections to monitor the growth and number of follicles in the ovaries. When at least 3 follicles reach 18mm in size, the egg collection procedure can be planned.
Monitoring the follicle growth is very important to adjust the dose of medication and also to identify excessive stimulation of ovaries which may result in potentially serious side effect known as ovarian hyper stimulation syndrome (OHSS). Hormonal assays in the blood might be performed if there is evidence of excessive response to guide management.
Ovulation trigger
A drug called Human Chorionic Gonadotropin or HCG is given once the follicles reach the desired size, which is necessary for final maturation of the egg prior to ovulation. This injection will trigger the process of ovulation and the next step i.e. oocyte retrieval is then scheduled at 36 hours after administration of HCG. This injection is given late in the evening 2 days before the day of egg collection.
Egg collection procedure
This procedure is usually done under intravenous sedation. Since the procedure is performed under sedation, overnight fasting is advised. The procedure is performed in a dedicated theatre adjacent to the embryology laboratory. A fine needle is inserted through the wall of the vagina and into the ovaries using ultrasound guidance. Through the needle, fluid from the follicles are drained and collected in a test tube which is checked under the microscope by the embryologist for the presence of eggs.
The collected eggs are kept in special culture media in the incubator in the laboratory. The incubator mirrors as closely as possible the body environment in terms of temperature and pH.
Most women find the process of egg collection uncomfortable rather than painful. There may be mild cramp like pain or slight bleeding from the vagina which usually subsides in a few hours. Oral antibiotics are given to the woman as prophylaxis against infection. The woman goes home 2-3 hours after the procedure.
Fertilization of the eggs in the laboratory
Sperm preparation
On the day of egg collection, the husband is required to produce a semen sample by masturbation in a clean wide mouthed container supplied by the lab. Though a fresh sample of semen is ideal, if the husband cannot be present at the scheduled time a semen sample can be collected in advance and the semen frozen for use during the IVF treatment. The semen sample is processed to obtain a clean concentrated highly motile sperm which is used to inseminate the eggs.
- Insemination - We aim to add sperm to eggs a few hours after the egg collection. It is only necessary to add a relatively small number of sperm to inseminate the eggs. Fertilization of the eggs by the sperm will normally occur during the evening of the collection day.
- Fertilization check- The following day the dish is checked for fertilized eggs. We are looking for 2 pronuclei within the egg that is the genetic material from the egg and sperm. It is not usual for all eggs to fertilize. On an average, 60-70% of collected eggs show signs of fertilization. The embryo (fertilized egg) is then placed in fresh dishes of culture medium and replaced in the incubator.
Embryo transfer (ET)
ET is carried out on any one day, between the 2nd day and 5th day after oocyte retrieval. On the 2nd day after egg collection, the embryo cleaves to form a 2-4 cell stage embryo and if further cultured in the lab forms an 8 cell embryo on day 3 and around 50% of embryos with further culture become blastocysts. The stages at which the embryos are transferred are based on the number and quality of embryos. The embryos are graded according to their appearance.
The embryo transfer is a simple procedure and does not need an anesthetic. The embryos are deposited in the upper part of the uterine cavity (womb) by means of a soft plastic catheter traumatically.
Outcome
A blood test indicating HCG levels to confirm pregnancy is done 12 days after the embryo transfer. In order to support a conception the woman is advised to continue with progesterone supplementation till 12 weeks of pregnancy or stopped when the first pregnancy test is negative.
In cases of a failed outcome, normal menses usually resumes within 2 weeks.
Risks of fertility treatment
As with all medical treatments, there might be some complications which occur after IVF.
Ovarian Hyper stimulation Syndrome (OHSS)
This is a medical condition that arises when the ovaries overreact to the stimulation injections.
Pelvic Infection
The risk of pelvic infection following the egg collection is extremely low. A short course of antibiotics is prescribed following the egg collection procedure to minimize the chances of infection.
Multiple pregnancies
This is a potential risk of all forms of fertility treatment. The overall chances of multiple pregnancies occurring after IVF are 25% when 2 or 3 embryos are transferred. The main complication with multiple pregnancies is the high risk of preterm delivery and subsequent morbidity to the babies. If a triplet or higher order pregnancy results selective reduction is discussed.
Miscarriage
On an average, one in four of all pregnancies results in a miscarriage whether it results from natural conception or as a result of fertility treatment.
Ectopic Pregnancy
An ectopic pregnancy is one where the pregnancy develops outside the womb mostly in the fallopian tubes. For this reason it is always important to perform an ultrasound scan on all pregnant women at about 6 weeks gestation to confirm that the pregnancy is developing inside the womb.
Success of IVF treatment
With IVF, each cycle gives a take home baby rate of around 30-35%.
DR.S.VYJAYANTHI, MD, DGO, DNB, MRCOG (London), MSc (Embryology) (UK)
Head of Department and Consultant in Infertility, Reproductive Medicine and Surgery
Krishna Institute of Medical Science
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