IVF

What is in vitro fertilization?

Follicles are retrieved from the woman and fertilized with the husbands semen in a petridish simulating a natural fertilization process.

The IVF process involves:

  • Stimulating multiple follicles and eggs to develop
  • Egg retrieval to get the eggs
  • Fertilizing the eggs in the laboratory
  • Embryo transfer to the uterus

Who should undergo treatment with IVF?

  • Blocked or damaged fallopian tubes.
  • Low sperm count for the husband.
  • Poorspermmotility .
  • Several failed IUIs (intra uterine inseminations) .
  • Advanced maternal age above 35 years
  • Reduced ovarian reserve.
  • Unexplained infertility ,where no actual cause of infertility has been diagnosed.

How does IVF improve fertility?

In essence we are compressing several months of “natural” attempts into one cycle . By transferring fertilized embryos directly into the cavity we are bypassing cervical and tubal factors responsible for infertility.

A normal woman only produces one egg per cycle, in an IVF cycle we are able to produce several eggs per cycle.

The best quality embryos are fertilized with the best quality sperm. Depending on the age of the patient we transfer 2-4 embryos per cycle.

All remaining embryos are frozen for the next cycle.

Effectively bypassing all cervical factors of infertility and directly implanting the embryos into the uterine cavity.

How is IVFperformed?

Fertility drugs are given to stimulate ovaries to develop several mature follicles.There are several protocols followed for ovarian stimulation , the most commonly used ones are mentioned below.

In order to maximize success rates with in IVF we want a good number of high quality eggs from the woman. We generally try to get about 10-18 eggs at the egg retrieval procedure.

Long protocol:

GnRH agonists are started from day 21 of previous menstrual cycle. Gonadotropins are started from day 3 of current cycle.Gonadotropin dosage is altered depending on the growth of the follicles. Once enough follicles have reached 18-20 mm in size, a HCG injection is administered to mature the follicles.

Flexible Protocol:

Gonadotropin stimulation is started from day 3 of cycle.GnRH antagonists are started after the dominant follicle reaches 14 mm in size and continued until the dominant follicle reaches to 18-20 mm in size. At this point a HCG injection is administered to mature the follicles.

Short Protocol:

GnRH agonists are started on the 1st day of the cycle followed with gonadotropin stimulation on day 3.

Egg Collection:

As soon as the follicles are deemed ready for collection, a HCG injection is given.The eggs are collected in the operation theatre under anaesthesia .This complete process takes about 15 – 30 minutes depending on the number of follicles.You will be able to go back home the same day.

The sperm sample is obtained either on the same day or a frozen sample (collected earlier) is thawed and utilized.

Embryology Lab:

We mix the collected oocytes and the sperm in a petridish in culture media. The eggs are checked the next morning for evidence of fertilization.

The embryos thus formed are incubated for 3 or 5 days depending on the type of embryo transfer.During this time, the patient is started on progesterone therapy to ready the endometrium for implantation. Once the endometrium is ready for implantation (confirmed by ultrasound) , the embryo transfer is performed .

A brief idea about embryo grading:

Most clinics “grade” each embryo using one of many scoring systems. Unfortunately, there is no agreement at all as to which system to use.

Children born from low grade embryos are just as competent as those born from high grade embryos. The only difference seems to be with the chance for the embryo(s) to result in a pregnancy.

  • Cell number
    • Embryos should be at 2 to 4 cells at 48 hours after egg retrieval and preferably about 7 to 10 cells by 72 hours.
  • Cell regularity
    • The cells within the embryo should be relatively regular in shape and size.
  • Fragmentation
    • Here , the embryo’s cells have broken off and are now separate from a portion of the cell. It is preferable to have little or no fragmentation.

Other aspects of the microscopic appearance of the embryos are also noted including the presence of vacuoles, granularity, thickness of the outer shell, etc.

In an ideal scenario :

By 48 hours (“day 2”), the embryos must be to at least 2 cells. We prefer that at least some of them are at the 3 or 4 cell stage by then.

By 72 hours (“day 3”), we like to see at least 6 cells – and preferably some at about 8 cells. We have seen babies that came from 4 cell embryos on day 3, but chances for pregnancy increase significantly with increasing cell number.

Embryos with higher cell numbers, regular appearing cells and little or no fragmentation have a higher overall chance of implanting than do other embryos with less cells, more irregularity and significant fragmentation.

Embryo quality as we see it under the microscope in the IVF lab gives us some reasonable ability to predict the chances for pregnancy after the embryo transfer procedure. However, because there are many other contributing factors involved that we can not see or measure, the generalizations about “quality” made from grading embryos are often inaccurate.

Ultimately, the true test of embryo quality is whether it implants and develops normally and eventually goes home from the hospital with mom and dad. In other words, embryo grading systems are imperfect, and we always need the pregnancy test, and the final pregnancy outcome, to tell us more about “embryo quality” than a microscope could ever reveal.

The true genetic potential of the embryo to continue normal development is very difficult to measure accurately unless we utilize pre-implantation genetic screening (PGS) to select chromosomally normal embryos for transfer.

Embryo Transfer :

Embryo transfer is the most important step in the IVF procedure, it requires expertise and sufficient skill. Depending on the age of the patient 1-3 embryos are transferred into the uterine cavity using special catheters. The embryo transfer is performed under ultrasound guidance. This is a completely painless procedure and does not require any anesthesia.

After this procedure you will be asked to lie down for about 2 hours.

After embryo transfer you will be prescribed medications to maintain the pregnancy growth .After 3 days of rest , you can go back to your normal routine ,although strenuous workouts , sexual intercourse should be avoided.

When do I take a pregnancy test?

A pregnancy test can be done 2 weeks after the procedure. We recommend a b- HCG blood test as it is more sensitive and gives a more accurate result than a urine pregnancy test.

What happens to the remaining embryos?

All viable embryos will be frozen.

If embryo transfer is not possible in the current cycle or embryo transfer is unsuccessful, the frozen embryos will be transferred the next cycle.

If implantation is successful, the choice of what happens to the remaining embryos is at you and your partner’s discretion.