In Vitro Fertilization (IVF)
What is IVF?
In vitro fertilization also called test-tube baby 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 kept in an incubator for 3-5 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 does not have a hundred percent guarantee of working in the very first attempt itself.
Indication For IVF- ET or ICSI
- Tubal disease
- Endometriosis
- Cervical factor
- Male factor
- Anovulatory infertility
- Unexplained infertility
- Immunological infertility
- Donor eggs & Donor embryo
ICSI (intracytoplasmic sperm injection) involves picking up each sperm and injecting it directly into each egg under the microscope. It is especially useful for couples with severe male factor or previous failed fertilisation with conventional IVF.
Chances of success
The average success rate for IVF is about 25-30% per treatment cycle (higher or lower depending on the age of the woman). Also, 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, certain preliminary tests are required for both partners. These include a hormonal profile for the wife, a semen analysis for the husband and infectious disease screen for both partners.
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 their ovaries, but usually only one is chosen by the body to be released into the fallopian tubes. To undergo an IVF cycle, you will be stimulated to produce multiple eggs instead of just one, thereby increasing your chances of obtaining one or more healthy embryos for transfer. To achieve this, you will be given a gonadotropin (FSH or hMG) injection daily from Day1 or 2 of your period for about 10-11 days. Serial ultrasound scans will be performed during this time to monitor the growth of your follicles. A GnRH antagonist injection will be added once your follicles have reached 14 mm (or from Day6 onwards) to prevent them from rupturing on their own. In place of this, a GnRH agonist or nasal spray may be used right from the start of the cycle too.
Egg development and drugs:
Each month the ovaries recruit several follicles for growth, out of which one follicle finally grows and releases a mature egg during ovulation, whereas the rest of the follicles undergo atresia or die. IVF stimulation ensures these other eggs will grow too, instead of dying. It does not cause your ovarian reserve to decline faster or your menopause to approach sooner as it does not pull out extra eggs from your ovaries that would have otherwise not been recruited.
Three types of injections are usually used, as follows:
1. Gonadotropin injections such as FSH or hMG to stimulate the growth of the follicles
2. GnRH antagonist or agonist to prevent premature rupture of the follicles
3. hCG or GnRH agonist trigger to cause final maturation of the oocytes
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, which 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 two to 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 success may not be achieved in the first attempt 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 OHSS (Ovarian Hyperstimulation Syndrome). 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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