Fertility Treatments

IVF

In-vitro Fertilization, or IVF, is a type of assisted reproductive technology (ART) that is frequently used to aid couples who are having difficulty conceiving.

In Vitro Fertilisation (IVF) – An Overview

In Vitro Fertilisation (IVF) or Intra Cytoplasmic Sperm Injection (ICSI) is a medical procedure aimed at helping couples to conceive a child who were otherwise finding it difficult to do so naturally. IVF and ICSI are commonly known as test-tube baby treatment.

The treatment starts on the second or third day of the menstrual cycle. Your IVF Specialist will perform transvaginal ultrasound sonography to check the viability of starting an IVF treatment. If he finds everything alright, he will start stimulation of the ovaries. Your first prescription of injections will be ideally for 5 to 6 days. On the 5th or 6th day of your treatment, you will be called for a follow-up scan to check the response of the stimulation injections. If needed your doctor may adjust the dose a little bit. You will be prescribed injections for three more days and will be called for a follow-up scan again on the 8th or 9th day of your menstrual cycle. If everything is good, your doctor will prescribe a trigger injection, preparing you for an Ovum Pick-Up [OPU] procedure scheduled between 34 to 36 hours after the trigger injection. In an OPU procedure, a doctor retrieves or collects matured eggs from ovaries and fertilizes them with sperm in an embryology lab. After that, they transfer the fertilized embryo(s) into the uterus. It may take around four weeks for one cycle of IVF-ICSI to complete.

IVF-ICSI is one of the most effective techniques for assisted reproduction. One of the key reasons behind its acceptance among the masses is that this technique uses the husband and wife’s sperm and eggs, respectively. But in some cases, the eggs, embryos, and sperm may also come from an anonymous donor. Also, in rare cases, the doctor may recommend a gestational carrier (Surrogate), a woman who has an embryo implanted in her uterus.

However, the success of IVF-ICSI, as with any other medical procedure, depends on several factors, natural and otherwise. Primary factors that may affect the results of IVF are the cause of infertility and the woman’s age.

Now, although IVF can be quite beneficial for you if you are unable to conceive, it can be a little expensive, invasive, and may take a little time to complete and show favourable results. Also, as more than one embryo is transferred into the uterus, it can result in multiple pregnancies, which means the patient will be pregnant with more than one foetus.

Who Needs An IVF?

IVF-ICSI is a procedure aimed at providing treatment for genetic issues and fertility problems. If you as a couple are looking to opt for IVF as a solution to your fertility issues, you may first want to go through other options like IUI (intrauterine insemination), in which the doctor places the semen directly in the uterus when you are close to ovulation. Another option is fertility drugs, which can help you increase the production of eggs.

Often, the fertility doctor recommends IVF as a primary treatment option for women in their 30s who have infertility. The IVF procedure may also be suggested if either of the partners suffers from a medical condition or issues, like:

  • Ovulation disorders:  Inadequate number of eggs will be available for fertilization if a woman’s ovulation is infrequent or not present altogether.
  • Uterine fibroids: Fibroids are a few small, tender, and harmless tumours present in a uterus, which are quite common for women in their 30s and 40s. They can make the fertilized eggs implanting inside the uterus more difficult and may interfere with the whole process.
  • Weakened sperm function and production: A few factors that may make it difficult for the sperm to fertilize the eggs are poor mobility of sperm, weaker sperm production, and concentration, along with abnormal sperm morphology (shape and size). If you have been diagnosed with any of these issues, you may want to visit a fertility doctor to check if there is a treatment or if this issue may be due to other medical conditions.
  • Genetic issues: You may want to consider preimplantation genetic testing (before going forward with IVF) if you have been diagnosed with a possibility of inflicting a genetic condition onto your forthcoming child. After the doctor harvests your fertilized eggs, they will look for any genetic problems that may cause concern. Even though not every genetic issue can be determined with this analysis, it may help decrease the risk. The doctor will transfer only those embryos that the doctor doesn’t spot a problem with.
  • Damage or blockage in the fallopian tube: A damaged or blocked fallopian tube can make fertilizing an egg quite tricky. Moreover, it can block the fertilized embryo from reaching the uterus.
  • Tubal ligation: It is a medical procedure, also known as tubal sterilisation, or removal, in which the fallopian tubes are cut or blocked permanently to ensure a nil chance of pregnancy. If you wish to have a child after tubal ligation, you may opt for IVF-ICSI rather than the tubal ligation reversal procedure. 
  • Fertility preservation: If you are diagnosed with a condition like cancer, you may need to undergo treatments like radiation therapy, immunotherapy, chemotherapy, etc., which may affect your fertility. In that case, you may consider having IVF-ICSI for fertility preservation. The doctor can harvest and collect the eggs from your ovaries and freeze them to be used later. They can also first fertilize the eggs and then freeze them as embryos so that, if needed, they can help you with your pregnancy in the future.
  • Endometriosis: It is a medical condition that occurs when the tissues like your uterine lining implant grow outside the uterus. The issue often influences the functional abilities of your uterus, ovaries, and fallopian tubes.
  • Unexplained infertility: Sometimes, the doctor may not be able to determine the root cause of your infertility despite going through the process for all the common causes. In that case, IVF can be quite beneficial.

Sometimes it happens that the functional ability of a woman’s uterus gets severely affected, or pregnancy in their case may be a severe health risk. If that’s the case with you, IVF with a gestational carrier (Surrogate) carrying the child for you with your embryos may be the best solution. In this procedure, a woman’s eggs are fertilized with the husband’s or donor’s sperm, and the fertilized embryos are placed in the uterus of the surrogate mother (a woman more suitable for carrying the baby).

What Are The Risks Of The IVF Procedure?

Here are a few risks associated with fertilisation IVF-ICSI:

  • Premature weight and delivery: According to a few pieces of research, children born with fertilization using IVF-ICSI are more prone to being premature and with a lower than usual birth weight.
  • Miscarriage: The rate of miscarriage for women giving birth via IVF is similar to the women giving birth naturally, roughly between 10% and 15%. But this rate may increase quite significantly with the age of the woman.
  • Ectopic pregnancy: Ectopic pregnancy is a condition in which the fertilized egg accidentally implants outside the uterine lining, usually in the fallopian tubes. Since the egg won’t be able to survive out of the uterus, you may not be able to continue with the pregnancy. Women who opt for pregnancy with fertilisation by IVF-ICSI will have a 2% to 5% chance of experiencing an ectopic pregnancy.
  • Multiple births: Transferring more than one embryo in the uterus may increase the risk of multiple births. Multiple foetuses may increase the risk of a mother going into early labor, low birth weight, and even babies born prematurely.
  • Ovarian hyperstimulation syndrome (OHS): If fertility drugs like human chorionic gonadotropin or HCG have been injected for stimulating ovulation, it may result in a condition called ovarian hyperstimulation syndrome. The syndrome may cause your ovaries to become painful and swollen. The symptoms of this syndrome may last for around a week and cause you to have bloating, vomiting, abdominal pain, diarrhoea, and nausea. If you get pregnant after being afflicted with this issue, the symptoms may go on for a few weeks. Rarely, a patient may have more severe ovarian hyperstimulation syndrome, which may cause breathlessness and rapid weight gain.
  • Congenital disabilities: One of the most significant risk factors in developing congenital disabilities is the mother’s age. It usually doesn’t matter if the child was conceived naturally or via an artificial technique like IVF. However, there is not enough research to conclude if the babies born with In-Vitro fertilisation (IVF-ICSI) are more vulnerable to birth defects.
  • Stress: One of the most apparent risks in artificial fertility techniques like IVF is stress. It can drain a person physically, emotionally, and financially. That’s why you may want to get help and support from your family and friends, as well as professional counsellors.

 

During the initial consultation, the doctor will make you aware of these risks and determine if you are suitable for this procedure.

Diagnostics & Medical Examination Before IVF

The success rate for IVF depends on several factors, including the patient’s age and any medical afflictions they may be suffering from, along with the treatment selected and the clinic’s treatment population.

Here are a few steps and screenings you may need to undergo during the preparation for an IVF:

  • Semen analysis: The fertility doctor will conduct a semen analysis before the start of the IVF cycles. The doctor may even conduct this test during your initial fertility evaluation.
  • Ovarian reserve testing: To ensure good quality and quantity of eggs, the doctor may conduct a test to check the follicle-stimulating hormone or FSH, oestrogen (Estradiol), and Anti-Mullerian hormone (AMH) during the initial phase of your menstrual cycle. These tests may be combined with an ultrasound sonography (USG) to determine how your ovaries will respond to fertility drugs.
  • Screening for infectious diseases: Both the man and the woman will be screened carefully to check the presence of any contagious disease such as HIV.

Few Important Queries To Ask Your Doctor Before / During IVF

Before the start of the initial phase of IVF, you may want to ensure that you have a proper understanding of the following questions:

  • How many embryos will be transferred into your uterus?

The number of embryos transferred will depend on the eggs retrieved by the doctor and the woman’s age. That is because the rate of implantation usually decreases with age. But the doctor will follow strict guidelines while inserting embryos to prevent multiple pregnancies. Therefore, you may want to ensure that you and your doctor have a mutual understanding about the number of embryos to be placed into the uterus.

  • How will you take care of yourself during multiple pregnancies?

Transferring more than one embryo into the uterus with the hope of increasing the chances of pregnancy through IVF may sometimes result in multiple pregnancies. 

  • What Will Happen to The Extra Embryos?

You may choose to freeze the extra embryos for future. But you must understand that not all embryos may survive after being frozen. So, you may also choose to discard the unused embryos.

  • What About the Potential Complications with Donor Sperm, Eggs, Embryos, or Gestational Carrier?

A designated clinic representative as per the prevalent laws, applicable to your country will help you file the documents for becoming the legal parent of an embryo and also try to answer all your concerns regarding the same.

Make sure you ask any other questions regarding the IVF process during the initial consultation to prevent any later issues.

Let’s look at the different steps of IVF.

In vitro fertilisation is a complicated sequence of medical procedures, including ovarian stimulation or ovulation induction, sperm retrieval, egg retrieval, fertilisation and embryo transfer. One cycle consisting of all these steps may take anywhere between 2 and 3 weeks. Therefore, you may require more than one cycle for successful results.

Let’s look at the different steps of IVF.

Step 1

Ovarian Stimulation

First off, the doctor will use synthetic hormones to stimulate the production of multiple eggs. Multiple eggs are required as not every one of them will develop after fertilisation. A few of the medications that may be used are as follows:

  • Ovarian stimulation medication: Follicle-stimulating hormone (FSH), luteinizing hormone (LH), or their combination may be injected to stimulate your ovaries for increased egg production.
  • Oocyte maturation medications: After 8 to 14 days, when the eggs are ready for retrieval, the doctor will give you HCG or other medications to mature the eggs.
  • Medications for preventing premature ovulation: These medications prevent the release of still-developing eggs.
  • Medications for preparation of uterine lining: The doctor may give you progesterone supplements to make your uterus more receptive and habitable for the embryos being transferred.

The doctor will provide you with adequate information to understand when you are supposed to take these medications.

The ovarian stimulation process goes on for one to two weeks. After that, the following tests will be conducted to check if your eggs are ready for retrieval:

  • Blood tests: These tests will check how your body is responding to ovarian stimulation medications. Your oestrogen levels will go up with the development of follicles. Also, the progesterone levels will be low till ovulation.
  • Vaginal ultrasound: The doctor will conduct a vaginal ultrasound to monitor the fluid-filled sacs containing maturing eggs.

The doctor may have to cancel the IVF cycles before egg retrieval due to premature ovulation, development of inadequate follicles, development of too many follicles, or other medical issues.

Step 2

Egg Retrieval

Egg retrieval is conducted in the doctor’s clinic around 34 to 36 hours after the trigger injection. The doctor may put you under pain medicines and anaesthesia during the egg retrieval, and a transvaginal ultrasound aspiration may be used. A thin needle goes and an ultrasound guide go into the follicles through the vagina for egg retrieval.

In case the ovaries aren’t accessible through typical methods, an abdominal ultrasound may be used. Then, the eggs are retrieved through a suction device connected to a needle in around 20 minutes. Following that, you may have a feeling of fullness and cramping. After they are collected, the eggs are placed in incubation. But not all eggs will fertilise with sperm.

Step 3

Sperm Collection

In the case of a couple, the husband provides a semen sample at the doctor’s office around the same time eggs are being retrieved. Other than masturbation, the doctor may go for testicular aspiration (TESA), which directly extracts the sperm from the testicles.

The andrology team will clean and concentrate the sperm from the bigger sample of semen once it arrives at the lab. The sperm are washed and suspended in a solution that simulates the environment of the Fallopian tubes in the female reproductive system after this first step of isolation.

The concentrated motile sperm will be delivered to the embryology lab when this process is completed, where fertilisation fertilization will take place.

Step 4

Fertilisation

The doctor will initiate fertilization with either of the two methods:

  • Intracytoplasmic sperm injection (ICSI): In this method, the egg is fertilised fertilized with a sperm cell directly injected into it. This method may be used when semen quantity or quality is not up to the mark.
  • Conventional insemination: Mature eggs are mixed with healthy sperm and then incubated overnight.

In some cases, other procedures may be recommended just before the embryo transfer:

  • Assisted hatching: If the woman is older or has had failed IVF before, the doctor may suggest assisted hatching for fertilized eggs. This technique helps hatch the embryos before implantation.
  • Preimplantation genetic testing (PGT): The procedure is used to test the baby for any genetic diseases and ensure there is an appropriate number of chromosomes. Only those embryos will be transferred to the uterus that has no issues.

The doctor may recommend these procedures depending on the woman’s age and overall condition.

Step 5

Embryo Transfer

The doctor will perform this procedure right at the clinic. It is usually done 2 to 5 days after the eggs are retrieved. Again, you may be put under a sedative to ensure a painless experience. A long, thin, and flexible catheter will be inserted into your uterus through the cervix and vagina during this procedure. Then, the doctor will place the embryo inside the uterus using a syringe. The embryo will implant around 3 to 4 days after the retrieval.

You may be able to resume your daily routine shortly after the procedure is completed. However, your ovaries may still be a little enlarged, so one must stay off the rigorous activities you usually perform. A few of the side effects that you may encounter are:

  • High oestrogen levels may result in tender breasts
  • Mild cramping
  • Small amounts of bodily fluids, including blood, may pass after the procedure
  • Constipation
  • Mild bloating

If you experience pain or develop any of the complications mentioned above, you may want to consult with the doctor. They will diagnose the situation correctly and come up with a solution. A pregnancy blood test known as Beta HcG is performed 14 days after the embryo transfer (ET) to find out the successful implantation of the embryos. Home urine test 14 days after the embryo transfer can also be carried out but pregnancy can only be confirmed by your fertility doctor 7 days after the positive Beta HcG test. Do not stop any medicines without confirmation with your fertility doctor. Also, do not take any medicines on your own without confirmation with your fertility doctor. If you are pregnant, you can reveal your pregnancy once 12 weeks are passed by.

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Dr. Dipesh Sorathiya

M.S. (Obs & Gyn)
DIP. in Gynec Endoscopy (CICE)

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