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InVitro Fertilization (IVF)

InVitro Fertilization (IVF)

 

InVitro Fertilization (IVF) popularly known as “test tube baby”

 

It is the process in which fertilization of the female egg by male sperm happens outside the body in special petridishes under very special environment.

Instead of growth of one follicle producing one egg, the goal is to stimulate multiple follicles in both ovaries, thereby producing multiple eggs.
 

Indications of IVF

 

Tubal pathology


Natural fertilization takes place in fallopian tube followed by transport of the embryos towards uterine cavity for implantation. Hence tubal pathologies leading to damage or blockage or its absence (Congenital or surgical) makes conception difficult or impossible.

 

IVF bypasses the work of fallopian tube as fertilization happens outside the body and prepared and divided embryos are transferred back directly to the uterine cavity.
 

Endometriosis


It is a condition characterised by presence of endometrial tissue outside the endometrial cavity of uterus. During each menstrual cycle, it bleeds with the shedding of endometrial linings causing accumulation of old blood (chocolate colored fluid) in the ovarian tissue leading to chocolate cyst formation, peritoneal scarring leading to appearance of powder puff burns and adhesions of pelvic organs to each other and bowel distorting its relationship. Due to varied reasons it contributes to infertility. If conventional surgical and medical methods fail, IVF is the treatment of choice.
 

Pelvic adhesions


Pelvic adhesions form due to inflammation or infection in the pelvis or post surgically. As it disturbs tubo ovarian relationship, it hampers transport of the egg following ovulation.
 

Male infertility


In the process of IVF, 50,000 to 100,000 Normal motile sperms are left surrounding an egg in a petridish containing culture media so that the sperm can fertilize the egg by its own. It is the method of choice in patients with mild to moderate oligospermia. ICSI is the method of choice in cases of severe oligospermia (Total motile sperms < 1 million).
 

Unexplained infertility


The clear diagnosis of the couples regarding explanation of their decreased or absent fertility can not be established. Reports of female and male partner are within normal limits. IVF is best option if couple is unable to conceive following ovulation induction and Intrauterine inseminations.
 

Anovulatory infertility


Anovulatory cycle abnormalities are an indication of IVF if 12 cycles of treatment with ovulation induction and 3-4 cycles of Intrauterine inseminations have been unsucceeded.

 

Advanced age of the female partner: female fertility declines with increasing age. It declines steeply after the age of 35. IVF treatment should be considered sooner in cases with low ovarian reserve.
 

Recurrent IUI failure


IVF should be considered in the patients with 3-4 failed cycle of Intrauterine insemination.

 

Intracytoplasmic Sperm Injection (ICSI)


It is a higher scale assistance designed to overcome poor performance of spermatozoa. It involves the injection of a single sperm cell intracytoplasmically directly into cytoplasm of an oocyte, thus bypassing the zona pellucida and oolemma. It is a highly specialized procedure that is performed by an expert embryologist under magnification with micromanipulator.

 

Indications:

  • very low sperm count& motility
  • faulty sperm egg interaction
  • low number of oocyte retrieved
  • previous IVF failure
  • when PGD on oocyte or embryo is required
  • sperm retrieval is done surgically

Pre IVF counselling


Counseling is an integral part of the treatment cycle. The couple is explained in detail about the schedule of the treatment, actual procedure, expense as well as chance of success in their particular case. The couple may have numbers of misconception and stress related to the infertility treatment. We make sure that all their doubts and confusions are attended. Psychologist support may require in many patient as they may be highly stressed because of the social taboos associated with Infertility.
 

Pre IVF investigations


Basic reports are done to confirm patient’s medical and gynaecological fitness to carry the pregnancy till term.

 

Ultrasonography and endocrinological evaluation is needed to decide the protocol and dosage of the drugs.
 

Stimulation protocols

 
  • Long protocol
its aim is to achieve pituitary down regulation with suppression of endogenous gonadotropin secretion before stimulation with exogenous gonadotropins. Inj lupreolide acetate is started from 21st day of previous cycle to achieve baseline status and drugs for ovarian started from 2nd or 3rd day of treatment cycle along with.
  • Antagonist protocol
it is based on principle of maximizing potential endogenous pituitary stimulation. Drugs for ovarian stimulation started directly from 2nd or 3rd day of treatment cycle and later on GnRh antagonist injection is added to prevent the LH surge.
 

IVF step by Step

 

Cycle regulation and down regulation


During previous cycle, birth control pills are given to regularize and programme the cycle. In case of long protocol, Inj lupreolide acetate is started from 21st day of previous cycle to achieve downregulation. Stimulating drugs can be started after confirming downregulation.
 

Ovarian stimulation


In order to increase chances of success of an IVF cycle, ovarian stimulation with gonadotrophins is done to ensure the formation of maximum number of follicles within patient’s safety limit. Patient is instructed to take daily injection of the gonadotropin along with GnRh agonist or antagonist as per protocol. Patient can take injection by herself or or her husband or family member can assist her. However, we are always happy to welcome to clinic for injections. These injections are to be taken as per the timings given in the prescription.

 

We will instruct you regarding your next appointment for cycle monitoring.
 

Cycle monitoring


It is done using transvaginal ultrasonography to monitor the growth of follicles and endometrium. In some cases hormonal level is checked as a part of cycle monitoring. It is started usually 5-6 days after starting the drugs for ovarian stimulation and then every 2-3 days. Depending upon the findings of the scan, the dosage of the stimulating drug is altered or antagonist injection is added.

 

Cycle cancellation may be warranted in hyperresponsive cases which endangers the life of patient or in hyporesponsive patients where only one or two follicle grows which decreases chances of pregnancy significantly.
 

hCG injection


once the follicles attain a specific size, hCG injection is given in order to final maturation of the follicles. The ova resume its arrested meiosis process and reach upto the stage of metaphase II. The procedure of egg collection is planned 35-36 hours after the hCG injection.

 

We will inform you regarding time of hCG injection, time of egg retrieval and admission instructions for the procedure of egg retrieval.
 

Egg Retrieval


we prefer to do the egg retrieval under short General anesthesia where you are sedated and sleeping comfortably. Using an ultrasound-guided needle, the content of all the follicles is sucked out and collected in test tubes. The fluid is passed to the embryologist, who then examines to identify and separate the eggs from it. The procedure takes around 30 minutes. You can go home about 2-3 hours after the procedure.

 

By the time you leave the clinic that day, we will let you know how many eggs were retrieved. In the days that follow we will monitor those embryos to see if they continue to divide and grow.

Very few special cases require laparoscopic ovum aspiration.

Vaginal bleeding through the vaginal punctures made by needle and mild to moderate lower abdominal pain or discomfort due to ovarian capsule stretching are the common complains after the procedure of egg retrieval. No need to panic for this as it does not affect chances of conception and Paracetamol tablet can be taken safely to relieve the discomfort.

important note: During ultrasonography for the cycle monitoring we can count the number of follicles but we can not see the eggs inside.
Although we hope that each follicle contains an egg, we know that this is not the case. Not every follicle has an egg, not every egg is alive, and not every live egg is mature, not every mature egg fertilizes and not every fertilized egg (embryo) continues to cleave until the day of embryo transfer.
 

Semen collection


A fresh semen sample is collected on the day of egg retrieval. We prefer to cryopreserve one semen sample in advance to have backup if male partner is not able to produce semen on that day. It is advisable not to ejaculate 2-5 days before the day of egg retrieval. Otherwise there is no restriction on regular sexual activity during the phase of ovarian stimulation.

 

If surgical extraction of sperm is needed, it is to be performed on the day of egg retrieval. It is done under local anesthesia or light sedation and patient can go home 2-3 hours after procedure with prescription for antibiotics and painkiller.
 

Emryology procedure



The oocytes identified from the follicular fluid, separated and put in a special nunc cell dish containing the culture media and then kept under incubator care. Processing of the husband semen sample done and 50,000 to 1,00,000 highly motile sperms are inseminted with oocytes in each well of nunc cell dish.

 

After 16-18 hours of insemination, oocytes are examined under microscope to confirm fertilization. Embryo cleavage starts after fertilization. It will divide into two and later on 4 & 8 cell stage. We prefer to do the embryo transfer procedure at 4 to 8 cell stage.

Embryo transfer


It is the procedure in which embryos are put back into the uterus after 2-3 days of egg retrieval. . You have to come with partially filled bladder to enhance the sonographic visualization. 2-3 good embryos selected and mounted in transfer catheter and transferred transcervically under ultrasonography guidance. This procedure is similar to IUI and as it is painless, anesthesia is not recommended. You will be advised to rest for 30 minutes after transfer.
 

Post IVF

 
  • Post transfer counselling
patient may have many misconceptions regarding post transfer phase. They are instructed properly regarding do’s and dont’s after Embryo transfer and prescribed medicines for luteal support and follow up visit.
  • Pregnancy test

Blood pregnancy test is to be performed 15 days after the procedure of Embryo Transfer. Ultrasonography is followed after a week of positive blood pregnancy test to confirm the presence and number of gestational sacs. We may need to repeat the blood test after 2-4 days.

 

You may not feel the symptoms of pregnancy this early, so don’t be alarmed. Spotting or bleeding can occur even if you are pregnant.

The progesterone suppositories that you are taking for luteal support is very vital for pregnancy. Please do not interrupt it or stop it without doctor’s instructions. It is to be continued till negative pregnancy test or till completion of first 3 months of pregnancy as later on placenta will take the function of production of progesterone.
 

Laser Assisted Hatching


Zona pellucida is the cover of the oocyte that hardens after fertilization and prevents polyspermic fertilization and later on protects the embryo and helps it in maintaining its integrity. Once in the uterus, the zona has to dissolve to get the blastocysts out, so that they can interact with the endometrial cells for implantation. The process of Zona dissolution is known as hatching.

 

Laser is accurately controlled system by which precise zona pellucida openings can be made without thermal or mutagenic effects. Embryos at 6-8 cell stage, at day 3 after insemination, or at the blastocyst stage, at day 5 after insemination can be manipulated with assisted hatching techniques. It can be used on freshly prepared or frozen embryo. It improves the implantation rate of embryos in cases of previous implantation failure.

It is indicated in patients with advanced age, elevated FSH level, previous implantation failures or embryos with thick zona.
 

Preimplantation Genetic Diagnosis (PGD)


The chromosomal make up of an embryo can be revealed before implantation. First polar body and Day 3 single cell embryo biopsy are the most common cells for assessment of chromosomal number & pattern. The use of this technology helps in selecting chromosomally normal embryos for replacement.

 

It improves implantation rate, reduce spontaneous abortion rate, reduce aneuploid conception and improve delivery rates in ART cycle. It is specially indicated in patients with idiopathic repeated miscarriages and patients with repeated miscarriages due to chromosome translocation.

Currently, numerical errors of chromosome 13, 18, 21, x & y can be detected with PGD technique in India.

Dr. Nimisha Pandya
M.D.(OB&GY)
nimisha.pandya@shalby.org
Designation :   
Infertility Specialist
Department :   
Obstetrics and Gynaecology
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