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In Vitro Fertilization (IVF)

What is IVF?

In vitro fertilization also called test-tube fertilization and often shortened to IVF, is a treatment that has helped several thousand couples achieve parenthood. 'In vitro' simply means in glass, and refers to the fact that all test tubes were once glass.

'In vitro fertilization' means fertilization outside the body. It is a method, which has helped many women to have babies since 1978 when it was first used successfully. IVF is a method of assisted reproduction in which a man's sperm and a woman's eggs are combined in a culture dish. Once fertilisation is established, the resulting embryos are left for 1-4 days to check that they are growing and then transferred into the woman's womb. If the treatment has been successful, one or more embryos will implant in the lining of the uterus and each embryo will develop into a fetus and placenta.

The first thing to mention is that IVF does not work every time. In every unit in the world, IVF fails more than it succeeds.

Indication For IVF- ET or ICSI

  • Tubal disease
  • Endometriosis
  • Cervical factor
  • Male factor
  • Anovulatory infertility
  • Unexplained infertility
  • Immunological infertility
  • Donor eggs & Donor embryo

IVF using donated eggs may be offered to women suffering premature menopause, those whose eggs will not fertilize, those whose ovaries have been removed or older women.

Chances of success

The average success rate for IVF is about 17% per treatment cycle, and slightly less (about 12 %) for frozen embryo transfer. However, your chances will very much depend on your own individual circumstances.

Before starting treatment

The first step before you start IVF is to discuss your fertility problem, and talk over everything you are concerned about with the team who will be treating you. Before IVF, tests are needed. Sometimes the clinic may repeat the tests you have already had. Mostly, a semen analysis, and most will perform blood tests to look for signs of the hepatitis virus in you both and rubella.

There are many considerations to be taken into account when deciding on fertility treatment, and the doctor will offer you an opportunity to talk through any issues and concerns either of you may have

Written consent must be given before treatment begins. You should only give your consent once you are satisfied that you understand what you are agreeing to. Because the issues can be particularly personal and far-reaching. You should feel that you have had the opportunity to consider the implications of what it is you are being asked to agree to.

What does IVF involve?

Every month women develop several eggs from one of their ovaries, but usually only one is chosen by the body to be released into the fallopian tubes. Most IVF units make women produce more that one egg, so that they have a greater chance of collecting at least one which is healthy. There are several ways egg production is stimulated. GMRH agonist can be given either as a series of injections or by nasal spray. Gonadotropin will act on the ovary to make it produce more eggs than it would normally. They need to be given every day for about eleven days. Many women prefer to give their own injections, or ask their partners to give the, they find going to the IVF unit or seeing their own doctor every day very stressful.

Egg development and drugs:

Normally, every month a woman's ovaries begin to develop several eggs but only one of these becomes fully mature. This egg is released into the fallopian tube where it may be fertilised following intercourse. IVF involves a small operation to collect eggs, and clinics prefer to try to give the woman hormones ('stimulated cycle'). These generally cause the ovaries to mature several eggs in one monthly cycle, which can then be collected.

Drugs containing hormones usually be of 3 types:

  • A nasal spray or an injection given every day throughout the 28-day cycle. These drugs suppress the hormones produced by a woman in a normal menstrual cycle and enable greater control over when the eggs are produced. These are GnRH agonists or antagonists which your doctor will discuss with you.
  • Injections or tablets, which stimulates the ovaries. These are given so that more than one egg develops, and are known as superovulatory drugs. These drugs are gonadotropins, which will act on the ovary to make it produce more eggs than it would normally. They need to be given every day for about eleven days.
  • Final hormone injection is given which completes the maturing process.

Do the drugs have side effects?

No drug is absolutely safe and completely free of side-effects but with the doses of drugs you are likely to notice few. With all fertility drugs the biggest worries are that they will do their job too well and produce an enormous response. This is called ovarian hyperstimulation syndrome which is rarely the cause of anything more than some pain and discomfort in the abdomen. However, in rare cases, it can become more serious, and in some cases this may mean abandoning the treatment for that cycle.

Egg collection:

  • Ultrasound guided egg collection: The most common technique, this may be done under a mild sedative or general anesthetic, and this is usually a day-care procedure. A fine hollow needle is passed under ultrasound guidance via the vagina and each egg is removed in turn. The fluid from each follicle is sucked into tubes and examined by an embryologist who looks for eggs. Each portion of fluid is examined in turn and this is continued until every possible egg has been collected.
  • Laparoscopy: This technique is rarely used nowadays but was the original method of egg collection.

Fertilization:

The eggs are also prepared and placed in an incubator. After about 3-6 hours, depending upon their maturity, the eggs and sperm will be placed together in a specially prepared culture medium. It is inspected the following day to see whether the sperm have fertilized the eggs. The day after egg collection the embryologists can often tell if fertilization has happened by examining the eggs. Not all eggs fertilize properly, but only the healthy ones are used.

If they have, the resulting embryos will be left to grow for a day or two longer and some clinics also offer blastocyst culture and transfer the embryos after 4-5 days.

Embryo transfer:

The embryologist will check that the embryos are developing satisfactorily and may be transferred into the uterus by using a fine plastic tube (a catheter).

This procedure is quick, easy and simple. A fine plastic tube is passed through the cervix, and the embryos put as high in the uterus as possible. Since most embryos do not turn into babies, most IVF units put more than one embryo into the womb. Putting three embryos into the womb gives a better chance of a baby than one does but it also gives a chance of more than one baby developing.

The clinic will advise whether any remaining embryos are suitable for freezing for treatment at a later date. Not all clinics are able to offer freezing facilities.

What happens next?

Usually the clinician will prescribe further hormone injections or vaginal pessaries to assist implantation. This will depend upon the levels of hormones already in the blood and the type of drugs that have already been given. Advice will also be given as to lifestyle pending a pregnancy test will generally be performed two weeks after embryo transfer.

If the patient has become pregnant, the pregnancy test is normally positive 15 days following egg collection. If the test is positive, an ultrasound scan is performed three weeks later to assess the status of the pregnancy.

Follow up

If the treatment is unsuccessful, the couple is encouraged to attend for a follow-up consultation and they are offered counseling. At this stage, the patients are usually aware that failure is more common than success but nevertheless this is a very difficult fact to accept and counselling is always available at this time.

Risks of IVF

Some women experience mild unpleasant symptoms as a reaction to the drugs, but these are normally short-lived and are no cause for concern. They may include hot flushes, feelings of depression and irritability, headaches and restlessness at night.

Despite careful monitoring, a small number of women may develop "Ovarian Hyperstimulation Syndrome (OHSS). The majority of these women have a mild or moderate form of over- response to the drugs, and complain of pain and mild abdominal swelling. A fertility specialist should monitor the condition, and in some cases the cycle may have to be abandoned.

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