BIOMATERNITY Fertility Specialsts-IN VITRO FERTILIZATION (IVF)-Microscope

In Vitro Fertilization (IVF)

In Vitro Fertilization (IVF) refers to the fertilization of a woman’s egg outside of her body.

The procedure involves ovarian stimulation, removing a mature egg or eggs from the woman’s ovary, fertilizing it with semen (in vitro: outside the body), incubating the dividing cells in the laboratory and then transferring the developing embryo in the mother’s uterus at the appropriate time. The fertilization of the eggs can be carried out by means of the conventional IVF technique or by Intracytoplasmic Sperm Injection (ICSI).

IVF is an established treatment for a wide variety of infertility diagnoses including unexplained infertility.

 

 

The ovaries are stimulated by daily injections of gonadotropins to optimize follicular development, which is monitored by means of transvaginal ultrasonography.
Ultra- sonography of an unstimulated ovary shows a small antral follicle (Panel A, arrow).
The same ovary has multiple growing follicles after gonadotropin stimulation. One follicle is shown with measurements in two dimensions (Panel B).
After ovarian stimulation, eggs are retrieved by means of ultrasound-guided transvaginal aspiration of follicular fluid (Panel C).
A mature human egg is recovered from the aspirated fluid (Panel D).
Recovered eggs are often fertilized in vitro by culturing eggs with many motile sperm (Panel E); in this image, multiple sperm are attached to the egg’s zona pellucida (arrows point to three of the sperm).
Eggs can also be fertilized by means of intracytoplasmic sperm injection, a technique in which a single sperm is injected into the egg with the use of a thin glass pipette (Panel F). This technique was developed to facilitate fertilization in cases of male-factor infertility but is now used in a majority of IVF cycles.
Multiple embryos are cultured, often for 3 days (an eight-cell embryo, shown in Panel G) or
5 days (a blastocyst embryo, shown in Panel H, with the inner cell mass indicated by the arrow)
before selected embryos are transferred back to the uterus (Panel I).
Good-quality, excess embryos are often cryopreserved.

THE PROCESS OF IVF

BIOMATERNITY Fertility Specialsts-IN VITRO FERTILIZATION (IVF)-The Process of IVF

IVF Cycle

Step 1 - Prestimulation treatment
  • Initiation of Oral Contraceptives
    Some patients will receive oral contraceptives in the cycle prior to the ART cycle. This ensures that GnRH analog therapy will start at the proper time if you have irregular cycles. There is also evidence that oral contraceptives can help prevent ovarian cysts, which sometimes develop during GnRH analog therapy. Provera® or progesterone may be prescribed for patients who ovulate irregularly or not at all.
  • Suppression of Ovulation
    There are two principle ways that physicians ensure ovulation does not occur before egg retrieval. One involves pre-treatment of a patient with a GnRH agonist. The other involves treatment after six or so days of stimulation with a GnRH antagonist.
  • GnRH Agonist Administration
    GnRH agonist: (This medication is taken by injection. There are two forms of the medication: A short acting medication requiring daily injections and a long-acting preparation lasting for 1 month. The primary role of this medication is to prevent a premature LH surge, which could result in the release of eggs before they are ready to be retrieved. Since GnRH-agonists initially cause a release of FSH and LH from the pituitary, they can also be used to start the growth of the follicles or initiate the final stages of egg maturation.A GnRH agonist might be prescribed sometime after taking oral contraceptive pills. This dose may be reduced when ovarian stimulation is begun. Agonist is often discontinued on the day of hCG (human chorionic gonadotropin) administration.

Some protocols also might begin GnRH agonist sometime after ovulation in the cycle preceding stimulation in the “mid-luteal” protocol, after the start of menses in the “flare” or “micro-flare” protocol.

  • GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®):
    These are other classes of medications used to prevent premature ovulation. They are typically administered several days after stimulation and require fewer injections.
  • Baseline Pelvic Ultrasound
    Around the time of your expected period, your physician will perform an ultrasound scan to examine the ovaries. If your physician detects a cyst, they may withhold further therapy until the cysts resolve spontaneously (usually in about a week). Occasionally, cyst aspiration (drainage) is recommended. This is a procedure in which your doctor inserts a fine needle connected to a syringe, guided by ultrasound, into the cyst. They may also perform a blood test (serum estradiol measurement) to confirm that the ovaries are properly suppressed.
Step 2 – Ovarian Stimulation

In general, ovarian stimulation begins after menstrual bleeding starts. Several similar medications may be used to stimulate follicle development: Bravelle®, Repronex®, Lupron®, Gonal-F®, Repronex® Follistim® Follistim AQ pen and Gonal-F RFF Pen. GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®) are another class of medications used to prevent premature ovulation and, in combination with an antagonist trigger, they may offer protection from severe ovarian hyperstimulation syndrome. They tend to be used for short periods of time in the late stages of ovarian stimulation. There are several different types of stimulation protocols. Although all protocols more-or-less employ the same types of medications, specific protocols may help certain types of patients to have a better response than other types. It is, however, unrealistic to think that switching from one protocol to another will dramatically change a poorly responding patient to a highly responding patient.

Step 3 – Monitoring of Follicle Development

Follicular development is monitored with the combination of vaginal ultrasound and hormone measurements (blood tests). These tests are performed frequently during the ART cycle, and the dose of medication might be adjusted in an effort to improve follicular development. The amount of medication prescribed also depends upon the results of the blood tests and ultrasound exams.

Step 4 – Final Oocyte Maturation and hCG Administration

Human chorionic gonadotropin (hCG) (Profasi®, Novarel®, Pregnyl®, Ovidrel®) is a hormonal drug that stimulates the final maturation of the oocytes. Determining the proper day for hCG administration is critical. The time of the injection determines when the egg retrieval will be scheduled. Some protocols using GnRH antagonists use GnRH agonists to trigger the final maturation of oocytes.

Step 5 – Transvaginal Oocyte Retrieval
  • Eggs are removed from the ovary with a needle under ultrasound guidance.
  • Anesthesia is provided to make this comfortable.
  • Injury and infection are rare.

Oocyte retrieval is performed about 34-36 hours after hCG has been administered. An anesthesiologist usually administers intravenous medications (sedatives and pain relievers) in order to minimize the discomfort that may occur during the procedure. Most patients sleep through the procedure. A transvaginal ultrasound probe is used to visualize the ovaries and the egg-containing follicles within the ovaries. A long needle, which can be seen on ultrasound, can be guided into each follicle and the contents are aspirated. The aspirated material includes follicular fluid, oocytes (eggs) and granulosa (egg-supporting) cells. The physician will collect the oocytes and follicular fluid into a test tube and the embryologist will search the follicular fluid and locate the oocytes using a microscope.

After the retrieval, patients recover from anesthesia where they will be observed while the intravenous medication wears off. It is not uncommon to have some vaginal spotting and lower abdominal discomfort for several days following this procedure. Generally, patients feel completely recovered within 1 to 2 days.

The number of oocytes retrieved is related to the number of ovaries, their accessibility, and the number of follicles that develop in response to stimulation. Ultrasound provides only an approximation of the number of oocytes that one can expect to recover. On the average, 8 to 15 oocytes are retrieved per patient.

Step 6 – Semen Collection

In order to obtain sperm of optimal quality, it is important that patients follow clinic instructions for semen collection. Common instructions include:

  1. Do not ejaculation for at least two days but not more than five days before obtaining the semen sample.
  2. Semen should be collected in a sterile, non-toxic plastic jar provided by the laboratory. Other containers are not acceptable.
  3. Most clinics prefer that the specimen be collected in the office, if possible. Private collection rooms are usually available. Wash and dry your hands prior to collecting the specimen. Some programs also recommended cleansing the penis followed with rinsing and drying to remove any soap or water.
  4. Your physician should be notified if there are any problems in collecting. An alternative collection method could be provided, including the use of a special nontoxic condom for collection by sexual intercourse or the use of a vibrator. Commercial condoms cannot be used because they kill the sperm.
  5. Lubricants should not be used unless directed by a physician.
  6. Follow the clinic instructions for labeling and transporting the specimen. It is critical to follow these instructions carefully. Keep the jar closed tightly to prevent leakage. Let the lab know if any of the speciment was lost or spilled and whether you have been taking any medications, including herbal remedies.

Masturbation is the most frequent method used to produce a sperm sample on the day of oocyte retrieval. Occasionally, intercourse using a special condom or electroejaculation is required for successful collection. Some men are unable to ejaculate or have no sperm in their semen. In these special cases, urologists can often obtain usable sperm from the testicle or the epididymis utilizing a minor surgical procedure.

Some physicians recommend freezing a sample as a “back-up” if problems arise in the production or quality of the sperm on the day of egg retrieval.

If a patient is using donor sperm, it will be thawed at the time of the egg retrieval. The donor sperm must be collected and used in accordance with regulatory guidelines.

Step 7- Embryology Lab Procedures

After eggs are retrieved, they are transferred to the embryology laboratory where they are kept in conditions that support their needs and growth. The embryos are placed in small dishes or tubes containing “culture medium,” which is a special fluid developed to support development of the embryos made to resemble that found in the fallopian tube or uterus. The dishes containing the embryos are then placed into incubators, which control the temperature and atmospheric gasses the embryos experience.

A few hours after eggs are retrieved, sperm is placed in the culture medium with the eggs, or individual spermatozoa are injected into each mature egg in a technique called IntraCytoplasmic Sperm Injection (ICSI).

The ICSI technique

IntraCytoplasmic Sperm Injection (ICSI) involves use of the micropipette to inject a single spermatozoon into the ooplasm.
For more details visit the ICSI section.

Preimplantation Genetic Diagnosis (PGD) and Preimplantation Genetic Screening (PGS)

Preimplantation Genetic Diagnosis (PGD) and Preimplantation Genetic Screening (PGS)

are two techniques that can be used during in vitro fertilization (IVF) procedures to test embryos for genetic disorders prior to their transfer to the uterus. PGD and PGS make it possible for couples or individuals with serious inherited disorders to decrease the risk of having a child who is affected by the same problem. Both of these techniques involve the use of the micromanipulator to remove a cell from an embryo. This cell is then sent to a diagnostic lab to determine the embryo’s normalcy. Acceptable embryos can then be transferred into the patient, decreasing her odds of having an affected child. PGS has also been reported to increase the pregnancy rates of some women with chromosomal disorders that result in either lower implantation rates of embryos or higher miscarriage rates.

Step 8 – Embryo Transfer
  • After a few days of development, the best appearing embryos are selected for transfer.
  • The number chosen influences the pregnancy rate and the multiple pregnancy rate.
  • A woman’s age and the appearance of the developing embryo have the greatest influences on pregnancy outcome.
  • Embryos are placed in the uterine cavity with a thin tube.
  • Excess embryos of sufficient quality that are not transferred can be frozen.

The embryo transfer procedure is usually performed three to five days after oocyte retrieval. The physician will pass a catheter gently through the cervix into the uterus and deposit the embryos into the uterine cavity along with an extremely small amount of fluid. This procedure usually does not require anesthesia, and the patient usually leaves the office after a brief recovery period. SART has specific guidelines on the number of embryos to transfer – see below. Remaining embryos can be frozen for a future frozen embryo transfer cycle.

Cryopreservation of Embryos

Embryo freezing is an important part of the IVF process. Patients who have additional good quality embryos can freeze them for future use. These embryos provide a second or even a third opportunity for pregnancy without undergoing another ovarian stimulation and retrieval.

Embryos that meet developmental criteria for appearance and rate of growth can be frozen at any of several stages of development. There are 2 ways to freeze embryos. One is called slow cooling. With this method embryos are placed into special freezing solutions, and using a computer, the temperature of the embryos is slowly decreased. Frozen embryos are then stored in liquid nitrogen (at -196°C or approximately -400°F), or sometimes, in liquid nitrogen vapor.

Another technique for freezing embryos is called vitrification. In this ultra-rapid freezing method, embryos are placed into special solutions and then placed immediately into liquid nitrogen. Embryos are stored same as in slow cooling. The method used to freeze embryos dictates how the embryos must be warmed or thawed. Not all embryos survive the freezing/thawing procedure and sometimes an embryo cannot be found after freezing.

Embryos can be transferred into patients whose cycle has been synchronized with that of the stage of the frozen embryo. Alternatively, embryos can be transferred during a “natural” cycle. Embryos can be stored indefinitely without a compromise in their quality.

Step 9 – Hormonal Support of the Uterine Lining (Progesterone Supplements)
  • Successful attachment of embryo(s) to the uterine lining depends on adequate hormonal support.
  • Progesterone, given by the intramuscular or vaginal route, is routinely given for this purpose.

Progesterone supplementation can occur using vaginal, oral or injectable progesterone, and in some cases, a combination of methods. Supplementation usually begins on the day of or the day after oocyte retrieval. Usually, cells in the follicle will produce progesterone following aspiration. During oocyte retrieval, some of these cells may be removed along with the oocyte. Supplemental progesterone helps prepare the uterine lining for implantation.

This daily medication will continue until your pregnancy test. If the test is positive, you may be advised to continue to take progesterone for several more weeks.

Step 10 – Pregnancy Test

A pregnancy test is necessary regardless of vaginal spotting or bleeding. It determines if pregnancy has occurred and is done 9-12 days after the embryo transfer. This test is usually repeated 2 days later if positive. If the test is negative, the doctor may instruct you to stop the progesterone.

Early Pregnancy Follow-up

Close scrutiny of a pregnancy is necessary to try to identify miscarriages or ectopic pregnancies and to help counsel regarding the status and treatment of multiple gestations. Patients are generally released to their obstetrician at 8-10 weeks gestation.

IVF Risks

Like all medical treatments, fertility treatment carries some risks and your clinic should discuss these with you before you go ahead. Risks can include reactions to fertility drugs that may be prescribed, and also the risks associated with any pregnancy. Other risks, of which some are not yet fully understood, relate to the children born as a result of the treatment.

Drug Reaction

A mild reaction to fertility drugs may involve hot flushes, feeling down or irritable, headaches and restlessness. Symptoms usually disappear after a short time but if they do not, you should see a doctor as soon as possible.

Ovarian Hyper-Stimulation Syndrome (OHSS)

OHSS can be a potentially dangerous over-reaction to fertility drugs used to stimulate egg production. It is very rare for this complication to occur with mild fertility drugs such as clomifene/clomiphene.  Even with the powerful gonadotrophin drugs used in some cases, OHSS symptoms are mild. In IVF and ICSI cases,  where a larger cluster of eggs are being stimulated to grow, 5% of patients develop some symptoms. The serial scanning of the ovaries means that the clinic staff will be aware if you may be at risk of OHSS. It can cause symptoms such as swollen stomach and stomach pains. In severe cases, nausea and vomiting, severe stomach pains and swelling, shortness of breath, faintness and reduced urine output. Patients who develop strong OHSS symptoms generally do so during the week after egg retrieval.  Cysts develop on the ovaries and fluid collects in the abdomen. In severe cases (about 1%-2%) your ovaries become very swollen and fluid may distend the abdomen and (rarely) enter the chest cavity. On occasion, OHSS can be life-threatening.

If you start to experience any of the above symptoms you must contact your clinic immediately. Never feel you are wasting the clinic’s time. If you are badly affected you may have to be admitted into hospital as an emergency.

Miscarriage

Although the risk of a miscarriage after IVF is no higher than after a natural conception, nor is the risk lower. An early pregnancy ultrasound scan is arranged if you conceive after IVF. This is to check that the pregnancy is not likely to miscarry. The scan is usually done about two weeks after the positive pregnancy test.

Ectopic Pregnancy

When an embryo implants outside the uterus, the pregnancy is said to be ectopic. The most common site is in the fallopian tube. Occasionally an ectopic pregnancy can develop in the ovary. The chances of an ectopic pregnancy seem to be higher in women having IVF, especially if they already have problems affecting their tubes. The first symptom is usually a one-sided low abdominal pain, followed by vaginal bleeding or dark brown or red vaginal discharge. As the pregnancy continues, the pain increases. The major risk is that the ectopic pregnancy will rupture through the tube causing internal bleeding. Hormone tests and scans are used to detect ectopic pregnancies; a pregnancy blood test is arranged to check for the pregnancy hormone, hCG. A scan is also arranged at six weeks to check for the baby’s heartbeat and to make sure it is growing properly in the uterus.

Contact your doctor straight away if you have any stomach pain or vaginal bleeding in early pregnancy.

Multiple Births

Having a multiple birth (twins, triplets or more) is the single greatest health risk associated with fertility treatment. Multiple births carry risks to the health of the mother and the unborn babies. The babies are more likely to be premature and to have a below-normal birth weight. Studies show that the risk of death before birth, or within the first week of life, is more than four times greater for twins than for a single baby. For triplets, the risk is seven times greater than for a single baby. The risk of cerebral palsy is five times higher for twins and 18 times higher for triplets than for a single baby. These risks are always discussed with you when deciding how many embryos to transfer in your treatment; one way to greatly reduce the risks associated with multiple births is to use single embryo transfer, so make sure you speak to your clinician about this option.

Birth Defects

The risk of birth defects in the general population is low: two per cent (2%) of children in Europe are born with birth defects. Although some research suggests that fertility treatment may be associated with an increased incidence of birth defects, this risk remains low. Some research suggests that ART techniques are associated with longer-term health issues in the children born. Whether there is a direct link is yet to be conclusively agreed, as it is possible that the association is due to other factors. These could relate to underlying subfertility in the patients. Research into the area is ongoing; a key recent study of 106,013 children born after assisted conception, one of the largest of its kind, found no increased risk of cancer in ART children. Patients should be aware that where studies report, for example, a doubling of risk or cases of a health complication (eg, from 0.1 to 0.2%) this may not necessarily equate to a significant clinical risk, and they should discuss any concerns with their clinician.

BIOMATERNITY Fertility Specialsts-IN VITRO FERTILIZATION (IVF)-Microscope

In Vitro Fertilization (IVF)

In Vitro Fertilization (IVF) refers to the fertilization of a woman’s egg outside of her body.

The procedure involves ovarian stimulation, removing a mature egg or eggs from the woman’s ovary, fertilizing it with semen (in vitro: outside the body), incubating the dividing cells in the laboratory and then transferring the developing embryo in the mother’s uterus at the appropriate time. The fertilization of the eggs can be carried out by means of the conventional IVF technique or by Intracytoplasmic Sperm Injection (ICSI).

IVF is an established treatment for a wide variety of infertility diagnoses including unexplained infertility.

 

 

THE PROCESS OF IVF

BIOMATERNITY Fertility Specialsts-IN VITRO FERTILIZATION (IVF)-The Process of IVF

The ovaries are stimulated by daily injections of gonadotropins to optimize follicular development, which is monitored by means of transvaginal ultrasonography.
Ultra- sonography of an unstimulated ovary shows a small antral follicle (Panel A, arrow).
The same ovary has multiple growing follicles after gonadotropin stimulation. One follicle is shown with measurements in two dimensions (Panel B).
After ovarian stimulation, eggs are retrieved by means of ultrasound-guided transvaginal aspiration of follicular fluid (Panel C).
A mature human egg is recovered from the aspirated fluid (Panel D).
Recovered eggs are often fertilized in vitro by culturing eggs with many motile sperm (Panel E); in this image, multiple sperm are attached to the egg’s zona pellucida (arrows point to three of the sperm).
Eggs can also be fertilized by means of intracytoplasmic sperm injection, a technique in which a single sperm is injected into the egg with the use of a thin glass pipette (Panel F). This technique was developed to facilitate fertilization in cases of male-factor infertility but is now used in a majority of IVF cycles.
Multiple embryos are cultured, often for 3 days (an eight-cell embryo, shown in Panel G) or
5 days (a blastocyst embryo, shown in Panel H, with the inner cell mass indicated by the arrow)
before selected embryos are transferred back to the uterus (Panel I).
Good-quality, excess embryos are often cryopreserved.

IVF Cycle

Step 1 - Prestimulation treatment
  • Initiation of Oral Contraceptives
    Some patients will receive oral contraceptives in the cycle prior to the ART cycle. This ensures that GnRH analog therapy will start at the proper time if you have irregular cycles. There is also evidence that oral contraceptives can help prevent ovarian cysts, which sometimes develop during GnRH analog therapy. Provera® or progesterone may be prescribed for patients who ovulate irregularly or not at all.
  • Suppression of Ovulation
    There are two principle ways that physicians ensure ovulation does not occur before egg retrieval. One involves pre-treatment of a patient with a GnRH agonist. The other involves treatment after six or so days of stimulation with a GnRH antagonist.
  • GnRH Agonist Administration
    GnRH agonist: (This medication is taken by injection. There are two forms of the medication: A short acting medication requiring daily injections and a long-acting preparation lasting for 1 month. The primary role of this medication is to prevent a premature LH surge, which could result in the release of eggs before they are ready to be retrieved. Since GnRH-agonists initially cause a release of FSH and LH from the pituitary, they can also be used to start the growth of the follicles or initiate the final stages of egg maturation.A GnRH agonist might be prescribed sometime after taking oral contraceptive pills. This dose may be reduced when ovarian stimulation is begun. Agonist is often discontinued on the day of hCG (human chorionic gonadotropin) administration.

Some protocols also might begin GnRH agonist sometime after ovulation in the cycle preceding stimulation in the “mid-luteal” protocol, after the start of menses in the “flare” or “micro-flare” protocol.

  • GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®):
    These are other classes of medications used to prevent premature ovulation. They are typically administered several days after stimulation and require fewer injections.
  • Baseline Pelvic Ultrasound
    Around the time of your expected period, your physician will perform an ultrasound scan to examine the ovaries. If your physician detects a cyst, they may withhold further therapy until the cysts resolve spontaneously (usually in about a week). Occasionally, cyst aspiration (drainage) is recommended. This is a procedure in which your doctor inserts a fine needle connected to a syringe, guided by ultrasound, into the cyst. They may also perform a blood test (serum estradiol measurement) to confirm that the ovaries are properly suppressed.
Step 2 – Ovarian Stimulation

In general, ovarian stimulation begins after menstrual bleeding starts. Several similar medications may be used to stimulate follicle development: Bravelle®, Repronex®, Lupron®, Gonal-F®, Repronex® Follistim® Follistim AQ pen and Gonal-F RFF Pen. GnRH-antagonists (ganirelix acetate or cetrorelix acetate) (Antagon®, Cetrotide®) are another class of medications used to prevent premature ovulation and, in combination with an antagonist trigger, they may offer protection from severe ovarian hyperstimulation syndrome. They tend to be used for short periods of time in the late stages of ovarian stimulation. There are several different types of stimulation protocols. Although all protocols more-or-less employ the same types of medications, specific protocols may help certain types of patients to have a better response than other types. It is, however, unrealistic to think that switching from one protocol to another will dramatically change a poorly responding patient to a highly responding patient.

Step 3 – Monitoring of Follicle Development

Follicular development is monitored with the combination of vaginal ultrasound and hormone measurements (blood tests). These tests are performed frequently during the ART cycle, and the dose of medication might be adjusted in an effort to improve follicular development. The amount of medication prescribed also depends upon the results of the blood tests and ultrasound exams.

Step 4 – Final Oocyte Maturation and hCG Administration

Human chorionic gonadotropin (hCG) (Profasi®, Novarel®, Pregnyl®, Ovidrel®) is a hormonal drug that stimulates the final maturation of the oocytes. Determining the proper day for hCG administration is critical. The time of the injection determines when the egg retrieval will be scheduled. Some protocols using GnRH antagonists use GnRH agonists to trigger the final maturation of oocytes.

Step 5 – Transvaginal Oocyte Retrieval
  • Eggs are removed from the ovary with a needle under ultrasound guidance.
  • Anesthesia is provided to make this comfortable.
  • Injury and infection are rare.

Oocyte retrieval is performed about 34-36 hours after hCG has been administered. An anesthesiologist usually administers intravenous medications (sedatives and pain relievers) in order to minimize the discomfort that may occur during the procedure. Most patients sleep through the procedure. A transvaginal ultrasound probe is used to visualize the ovaries and the egg-containing follicles within the ovaries. A long needle, which can be seen on ultrasound, can be guided into each follicle and the contents are aspirated. The aspirated material includes follicular fluid, oocytes (eggs) and granulosa (egg-supporting) cells. The physician will collect the oocytes and follicular fluid into a test tube and the embryologist will search the follicular fluid and locate the oocytes using a microscope.

After the retrieval, patients recover from anesthesia where they will be observed while the intravenous medication wears off. It is not uncommon to have some vaginal spotting and lower abdominal discomfort for several days following this procedure. Generally, patients feel completely recovered within 1 to 2 days.

The number of oocytes retrieved is related to the number of ovaries, their accessibility, and the number of follicles that develop in response to stimulation. Ultrasound provides only an approximation of the number of oocytes that one can expect to recover. On the average, 8 to 15 oocytes are retrieved per patient.

Step 6 – Semen Collection

In order to obtain sperm of optimal quality, it is important that patients follow clinic instructions for semen collection. Common instructions include:

  1. Do not ejaculation for at least two days but not more than five days before obtaining the semen sample.
  2. Semen should be collected in a sterile, non-toxic plastic jar provided by the laboratory. Other containers are not acceptable.
  3. Most clinics prefer that the specimen be collected in the office, if possible. Private collection rooms are usually available. Wash and dry your hands prior to collecting the specimen. Some programs also recommended cleansing the penis followed with rinsing and drying to remove any soap or water.
  4. Your physician should be notified if there are any problems in collecting. An alternative collection method could be provided, including the use of a special nontoxic condom for collection by sexual intercourse or the use of a vibrator. Commercial condoms cannot be used because they kill the sperm.
  5. Lubricants should not be used unless directed by a physician.
  6. Follow the clinic instructions for labeling and transporting the specimen. It is critical to follow these instructions carefully. Keep the jar closed tightly to prevent leakage. Let the lab know if any of the speciment was lost or spilled and whether you have been taking any medications, including herbal remedies.

Masturbation is the most frequent method used to produce a sperm sample on the day of oocyte retrieval. Occasionally, intercourse using a special condom or electroejaculation is required for successful collection. Some men are unable to ejaculate or have no sperm in their semen. In these special cases, urologists can often obtain usable sperm from the testicle or the epididymis utilizing a minor surgical procedure.

Some physicians recommend freezing a sample as a “back-up” if problems arise in the production or quality of the sperm on the day of egg retrieval.

If a patient is using donor sperm, it will be thawed at the time of the egg retrieval. The donor sperm must be collected and used in accordance with regulatory guidelines.

Step 7- Embryology Lab Procedures

After eggs are retrieved, they are transferred to the embryology laboratory where they are kept in conditions that support their needs and growth. The embryos are placed in small dishes or tubes containing “culture medium,” which is a special fluid developed to support development of the embryos made to resemble that found in the fallopian tube or uterus. The dishes containing the embryos are then placed into incubators, which control the temperature and atmospheric gasses the embryos experience.

A few hours after eggs are retrieved, sperm is placed in the culture medium with the eggs, or individual spermatozoa are injected into each mature egg in a technique called IntraCytoplasmic Sperm Injection (ICSI).

The ICSI technique

IntraCytoplasmic Sperm Injection (ICSI) involves use of the micropipette to inject a single spermatozoon into the ooplasm.
For more details visit the ICSI section.

Preimplantation Genetic Diagnosis (PGD) and Preimplantation Genetic Screening (PGS)

Preimplantation Genetic Diagnosis (PGD) and Preimplantation Genetic Screening (PGS)

are two techniques that can be used during in vitro fertilization (IVF) procedures to test embryos for genetic disorders prior to their transfer to the uterus. PGD and PGS make it possible for couples or individuals with serious inherited disorders to decrease the risk of having a child who is affected by the same problem. Both of these techniques involve the use of the micromanipulator to remove a cell from an embryo. This cell is then sent to a diagnostic lab to determine the embryo’s normalcy. Acceptable embryos can then be transferred into the patient, decreasing her odds of having an affected child. PGS has also been reported to increase the pregnancy rates of some women with chromosomal disorders that result in either lower implantation rates of embryos or higher miscarriage rates.

Step 8 – Embryo Transfer
  • After a few days of development, the best appearing embryos are selected for transfer.
  • The number chosen influences the pregnancy rate and the multiple pregnancy rate.
  • A woman’s age and the appearance of the developing embryo have the greatest influences on pregnancy outcome.
  • Embryos are placed in the uterine cavity with a thin tube.
  • Excess embryos of sufficient quality that are not transferred can be frozen.

The embryo transfer procedure is usually performed three to five days after oocyte retrieval. The physician will pass a catheter gently through the cervix into the uterus and deposit the embryos into the uterine cavity along with an extremely small amount of fluid. This procedure usually does not require anesthesia, and the patient usually leaves the office after a brief recovery period. SART has specific guidelines on the number of embryos to transfer – see below. Remaining embryos can be frozen for a future frozen embryo transfer cycle.

Cryopreservation of Embryos

Embryo freezing is an important part of the IVF process. Patients who have additional good quality embryos can freeze them for future use. These embryos provide a second or even a third opportunity for pregnancy without undergoing another ovarian stimulation and retrieval.

Embryos that meet developmental criteria for appearance and rate of growth can be frozen at any of several stages of development. There are 2 ways to freeze embryos. One is called slow cooling. With this method embryos are placed into special freezing solutions, and using a computer, the temperature of the embryos is slowly decreased. Frozen embryos are then stored in liquid nitrogen (at -196°C or approximately -400°F), or sometimes, in liquid nitrogen vapor.

Another technique for freezing embryos is called vitrification. In this ultra-rapid freezing method, embryos are placed into special solutions and then placed immediately into liquid nitrogen. Embryos are stored same as in slow cooling. The method used to freeze embryos dictates how the embryos must be warmed or thawed. Not all embryos survive the freezing/thawing procedure and sometimes an embryo cannot be found after freezing.

Embryos can be transferred into patients whose cycle has been synchronized with that of the stage of the frozen embryo. Alternatively, embryos can be transferred during a “natural” cycle. Embryos can be stored indefinitely without a compromise in their quality.

Step 9 – Hormonal Support of the Uterine Lining (Progesterone Supplements)
  • Successful attachment of embryo(s) to the uterine lining depends on adequate hormonal support.
  • Progesterone, given by the intramuscular or vaginal route, is routinely given for this purpose.

Progesterone supplementation can occur using vaginal, oral or injectable progesterone, and in some cases, a combination of methods. Supplementation usually begins on the day of or the day after oocyte retrieval. Usually, cells in the follicle will produce progesterone following aspiration. During oocyte retrieval, some of these cells may be removed along with the oocyte. Supplemental progesterone helps prepare the uterine lining for implantation.

This daily medication will continue until your pregnancy test. If the test is positive, you may be advised to continue to take progesterone for several more weeks.

Step 10 – Pregnancy Test

A pregnancy test is necessary regardless of vaginal spotting or bleeding. It determines if pregnancy has occurred and is done 9-12 days after the embryo transfer. This test is usually repeated 2 days later if positive. If the test is negative, the doctor may instruct you to stop the progesterone.

Early Pregnancy Follow-up

Close scrutiny of a pregnancy is necessary to try to identify miscarriages or ectopic pregnancies and to help counsel regarding the status and treatment of multiple gestations. Patients are generally released to their obstetrician at 8-10 weeks gestation.

IVF Risks

Like all medical treatments, fertility treatment carries some risks and your clinic should discuss these with you before you go ahead. Risks can include reactions to fertility drugs that may be prescribed, and also the risks associated with any pregnancy. Other risks, of which some are not yet fully understood, relate to the children born as a result of the treatment.

Drug Reaction

A mild reaction to fertility drugs may involve hot flushes, feeling down or irritable, headaches and restlessness. Symptoms usually disappear after a short time but if they do not, you should see a doctor as soon as possible.

Ovarian Hyper-Stimulation Syndrome (OHSS)

OHSS can be a potentially dangerous over-reaction to fertility drugs used to stimulate egg production. It is very rare for this complication to occur with mild fertility drugs such as clomifene/clomiphene.  Even with the powerful gonadotrophin drugs used in some cases, OHSS symptoms are mild. In IVF and ICSI cases,  where a larger cluster of eggs are being stimulated to grow, 5% of patients develop some symptoms. The serial scanning of the ovaries means that the clinic staff will be aware if you may be at risk of OHSS. It can cause symptoms such as swollen stomach and stomach pains. In severe cases, nausea and vomiting, severe stomach pains and swelling, shortness of breath, faintness and reduced urine output. Patients who develop strong OHSS symptoms generally do so during the week after egg retrieval.  Cysts develop on the ovaries and fluid collects in the abdomen. In severe cases (about 1%-2%) your ovaries become very swollen and fluid may distend the abdomen and (rarely) enter the chest cavity. On occasion, OHSS can be life-threatening.

If you start to experience any of the above symptoms you must contact your clinic immediately. Never feel you are wasting the clinic’s time. If you are badly affected you may have to be admitted into hospital as an emergency.

Miscarriage

Although the risk of a miscarriage after IVF is no higher than after a natural conception, nor is the risk lower. An early pregnancy ultrasound scan is arranged if you conceive after IVF. This is to check that the pregnancy is not likely to miscarry. The scan is usually done about two weeks after the positive pregnancy test.

Ectopic Pregnancy

When an embryo implants outside the uterus, the pregnancy is said to be ectopic. The most common site is in the fallopian tube. Occasionally an ectopic pregnancy can develop in the ovary. The chances of an ectopic pregnancy seem to be higher in women having IVF, especially if they already have problems affecting their tubes. The first symptom is usually a one-sided low abdominal pain, followed by vaginal bleeding or dark brown or red vaginal discharge. As the pregnancy continues, the pain increases. The major risk is that the ectopic pregnancy will rupture through the tube causing internal bleeding. Hormone tests and scans are used to detect ectopic pregnancies; a pregnancy blood test is arranged to check for the pregnancy hormone, hCG. A scan is also arranged at six weeks to check for the baby’s heartbeat and to make sure it is growing properly in the uterus.

Contact your doctor straight away if you have any stomach pain or vaginal bleeding in early pregnancy.

Multiple Births

Having a multiple birth (twins, triplets or more) is the single greatest health risk associated with fertility treatment. Multiple births carry risks to the health of the mother and the unborn babies. The babies are more likely to be premature and to have a below-normal birth weight. Studies show that the risk of death before birth, or within the first week of life, is more than four times greater for twins than for a single baby. For triplets, the risk is seven times greater than for a single baby. The risk of cerebral palsy is five times higher for twins and 18 times higher for triplets than for a single baby. These risks are always discussed with you when deciding how many embryos to transfer in your treatment; one way to greatly reduce the risks associated with multiple births is to use single embryo transfer, so make sure you speak to your clinician about this option.

Birth Defects

The risk of birth defects in the general population is low: two per cent (2%) of children in Europe are born with birth defects. Although some research suggests that fertility treatment may be associated with an increased incidence of birth defects, this risk remains low. Some research suggests that ART techniques are associated with longer-term health issues in the children born. Whether there is a direct link is yet to be conclusively agreed, as it is possible that the association is due to other factors. These could relate to underlying subfertility in the patients. Research into the area is ongoing; a key recent study of 106,013 children born after assisted conception, one of the largest of its kind, found no increased risk of cancer in ART children. Patients should be aware that where studies report, for example, a doubling of risk or cases of a health complication (eg, from 0.1 to 0.2%) this may not necessarily equate to a significant clinical risk, and they should discuss any concerns with their clinician.

FREE
CONSULTATION

CONSULT FOR FREE OUR FERTILITY SPECIALISTS

*Any and all information will be kept completely private.