The main strategy in IVF treatment is to stimulate the ovaries with hormones to produce multiple follicles containing eggs. These eggs are retrieved and mixed with sperm and embryos are generated.
- The first step is the shutting down of the pituitary-ovarian hormones called down regulation. This is done with a drug known as Gonadotrophin releasing hormone agonist (GnRHa). This is available in the form of a nasal spray, daily subcutaneous injections or depot injections (the effect of one injection lasts for 4-6 weeks). This suppression can be started on day two or day 21 of a period depending on the type of protocol (long or short). Please see protocols. It takes approximately two weeks for complete suppression. This is confirmed by an ultrasound scan which will show a thin uterine lining and quiescent ovaries without any cyst. A blood test is also performed to check the hormonal level (Oestradiol) for the confirmation of down regulation or suppression.
- Once down regulation is confirmed the daily injections of FSH or menotrophin will be started to stimulate the ovaries. These injections need to be administered daily for 12-16 days. The GnRH agonist is also continued during this period of ovarian stimulation.
Monitoring the cycle
The ovarian response to the stimulation is monitored by serial ultrasound scanning and blood test. Usually, three to four scans are necessary during this two week period of injections. In addition, blood tests are carried out to check the level of Oestradiol along with scans in all patients. The scans are usually internal scans which give a better picture of the uterus and the ovaries. During the scans the number and the size of the follicles are measured and the thickness and the texture of the lining of the womb are assessed. When the leading follicles reach a diameter of 18 mm or over, the lining of the womb is at least 8 mm in thickness and the Oestradiol levels correspond to the number of growing follicles, it is time to give the trigger injection (HCG injection). At this stage, the GnRH agonist and FSH or menotrophin injections will be stopped. The trigger injection is the Human Chorionic Gonadotrophin (HCG) which starts the maturation process of the eggs. This is usually given in the late evening and the egg collection will be performed 36 hours later.
Natural cycle IVF
This term refers to IVF treatment using one’s natural cycle i.e. without any stimulation with drugs. Normally, only one egg is produced and released every month. This egg is collected and mixed with sperm. If fertilization takes place, there is one embryo which is replaced after 48 hours.
The main advantage is that there is no injection or use of any other drugs. This means there are no side effects of drugs. Usually, the injections used in the treatment of IVF are expensive. Hence, natural cycle IVF is also cheaper.
The main disadvantage is that the chance of success is rather low because there is only one egg and one embryo.
Egg collection procedure
Egg collection is usually performed in the morning, approximately 36 hours after the HCG injection.
Route: the egg collection is performed vaginally under ultrasound guidance. When IVF was started the egg collection was routinely done laparoscopically. Because of the invasive nature of this method, it is used only in selected cases. For example, if one or both ovaries are not accessible vaginally, laparoscopic egg collection is performed.
Anaesthesia: the vaginal egg collection is done under intravenous sedation (conscious sedation). Some centres use general anaesthesia for this procedure.
Procedure: a needle is attached to the vaginal probe of the ultrasound. Under ultrasound guidance, the needle is passed through vagina and into the ovary, as shown in the diagram above. The fluid from an ovarian follicle is aspirated and the fluid is passed to the embryologist who identifies the egg in this fluid under a microscope. If there is no egg, in the aspirated fluid the follicle is flushed with culture medium and sucked out. Once the egg is identified, the needle is moved to the next follicle and the procedure is repeated. Once all the follicles are emptied, the needle is taken out of the ovary and passed into the other ovary and the same procedure is carried out.
The number of follicles does not correspond to the number of eggs collected. Some follicles may not contain an egg.
After the procedure
Trans-vaginal egg collection is a relatively safe procedure. It takes an average of 20-30 minutes. The woman is allowed to go home after two hours. She must be taken home by her partner or friend. She should not drive a vehicle for 24 hours.
After the egg collection procedure, there may be some discomfort or soreness in the tummy. This might be more if the number of eggs collected is more (more than 12). Pain-killers can be used to control the symptom. This will not interfere with the fertility treatment.
There may be some spotting. This is usually minimal and dark brown in colour. This may be due to the oozing from the needle puncture site in the vagina.
There may be nausea and vomiting. This can be due to the anaesthetic drugs or mild hyper-stimulation. When the number of eggs is more than 15, there may the bloating of the abdomen.
If any of the symptoms becomes severe, one should consult the doctor.
The husband or the patient’s partner is required to produce a semen sample on the day of egg collection. The man is advised to abstain for 2-3 days prior to producing sample. If the period of abstinence is more than 7-10 days, the quality of the semen sample may become poor.
The semen sample is generally produced by masturbation. It is recommended that the man washes his hands and genitals with soap, rinses with clean water and dries with a clean towel. No lubricant such as petroleum jelly, should be used during masturbation to avoid problems of toxicity to sperms. The sample is collected into sterile plastic containers which are non-toxic to the sperm.
The partner usually produces the sample in a separate room in the clinic. This is to ensure that the sample is as fresh as possible. If some men find it difficult to produce samples in the clinic’s environment, they can produce sample at home and bring it to the clinic, provided it is delivered within one hour. Also, it is important to keep the sample warm by carrying it in the inner pocket of the jacket. If some men find it difficult to produce into a small plastic container, they can use a special condom provided by the clinic. This condom is a special one and does not have the spermicidal agents present in the normal condoms.
If the partner is not going to be available on the day of egg collection, he could produce a sample before and have it frozen. The frozen sample can be thawed and used for the treatment.
If a partner has or is likely to have difficulty in producing a sample, it is better for him to produce a sample before the commencement of the treatment and freeze it as a backup arrangement.
After the egg collection, the patient is advised to take the hormone progesterone as a support for the implantation. This is usually given in the form of a pessary or suppository. It is given in the dose of 400 mg twice daily rectally until embryo transfer and rectally or vaginally after embryo transfer. This is continued until the day of pregnancy test which is performed 12 days from the embryo transfer. In the pleasant event of the test being positive, it is continued for another two months (till 12 weeks of gestation). If the pregnancy test is negative, the medication is stopped on that day.
- The eggs and the prepared sperm are mixed in a cultured medium in the laboratory. This is kept in a labelled dish in an incubator.
- The dish is checked next morning for fertilization. The sign of fertilization is the presence of two pronuclei (one from the sperm and one from the egg), as shown in the picture on the right. Normally about 60% of the eggs fertilise.
- The embryos are checked for further cell division the next day. There should be 2-4 cells the next day (day 2) and 6-8 cells on the third day, as shown in the pictures on the right. Sometimes the embryos may be rather slow in their division. The embryos which have divided and show regular outline and minimal or no fragments are usually transferred. The grading of the embryos is based on the regularity of cellular outline and the presence of fragment.
- The number of embryos to be transferred will be discussed with the patient/couple. In general, it is recommended to have one embryo transferred if the patient is under 35years of age. This is to reduce the risk of twin pregnancy. In the UK, the HFEA allows clinics to transfer a maximum of two embryos in women under the age of 40 years and 3 embryos in women of 40 years and above.
- Depending on the number of embryos available, after choosing the best embryo for transfer, the other embryos will be frozen for future use if they are of good quality.
The embryo transfer is a simple procedure. Normally no anaesthesia is used for this procedure. However, in some difficult cases, mild sedation may be used. The couple may be able to see the embryos through a monitor before the procedure.
Procedure: The woman lies on the couch with her legs in stirrups. The doctor introduces a speculum to visualise the cervix and then cleans the cervix. Meanwhile, the embryos are loaded on to a catheter by the embryologist. Finally, the doctor introduces the catheter gently into the uterine cavity and deposits the embryos.
Embryo transfer is carried out under ultrasound guidance with a full bladder. This is to visualise the position of the catheter and the placement of the embryos. This is reassuring to the doctor and the patient. In addition the full bladder may correct the angle between the cervix and the body of the uterus and make the transfer easier. This is to reduce the trauma to the embryos during the procedure. After transferring the embryos, the catheter is withdrawn slowly and handed over to the embryologist. The embryologist checks the catheter to make sure that no embryo is left in the catheter. If one or more embryos are retained in the catheter, they are loaded again and replaced. This does not reduce the chance of success.
If the transfer is difficult, a tenaculum is applied to the cervix and a different catheter which would negotiate the angle between the cervix and the uterus is used.
After the embryo transfer, the patient is advised to lie down for 15 minutes. She is then allowed to get up and empty her bladder.
The question that is present in every patients mind: “Will the embryos fall out when I get up?” Luckily, the answer is: no.
Dos and don’ts after embryo transfer:
- Take it easy for the next few days. This does not mean bed rest. One can take leisurely walks.
- It is better to avoid strenuous activities, lifting heavy weights, jogging, riding and gym activities.
- Avoid swimming.
During IVF treatment, a blood test is performed 14 days after the egg collection. This period of waiting is very stressful for couples. This is said to be the longest two weeks in one’s life. There is nothing one can do to improve the chances.
The pregnancy test is a quick test and the result should be ready in one or two hours. If the test is positive it is usually repeated within 2-5days to check the rising level of the hormone β-HCG.
If the hormone level does not rise in the usual pattern, it indicates problems with the pregnancy, such as miscarriage or ectopic pregnancy. This is followed up with serial blood test. Some women may start spotting or bleeding before the pregnancy test is due. They may assume that they have started period and not attend the hospital for the blood test. It is important that a blood test is carried out even under these circumstances to establish whether there is a pregnancy or not.
- Positive outcome: if the pregnancy test is positive, the woman is advised to continue with the progesterone supplementation. An ultrasound scan is arranged 2-3 weeks after the test. This is to confirm that the pregnancy is in the right place (uterus), check the number of pregnancy sacs and viability of foetuses. If the findings are normal the progesterone is continued for another 5-6 weeks (until 12 weeks of pregnancy).
- Negative outcome: this is the worst fear of every woman who goes through IVF treatment. If the pregnancy test is negative, the progesterone supplementation is stopped. The negative pregnancy test is very upsetting to the couple. Some couples may benefit from seeing a counsellor. They need time to recover from the shock. When they are in a position to discuss the matter they can make an appointment to see the doctor in hospital/clinic to plan for future treatment.
- IUI (INSEMİNATİON)
IUI method is an assisted reproductive method performed on patients who could not become pregnant despite regular sexual relationship for a year and received the diagnosis of infertile. Insemination can be performed, as a result if 1 year has passed and couples have not fallen pregnant. Insemination method is quite simple and is almost painless application compared to other methods. Sperm with available to be processed feature in male and no problem in the development of the eggs in female is required for the implementation of insemination method.
- IVF (İN VİTRO FERTİLİSATİON- CONVENTİONAL IVF)
IVF is the procedure of creating an embryo in laboratory conditions and transferring the embryo to the uterus. In the conventional IVF method the egg collected from the female is brought together with an adequate quantity of sperm from the male in special laboratory conditions allowing the fastest and most fertile sperm to enter the egg naturally. About 16-18 hours will be allowed for fertilisation and then the situation will be evaluated under microscope. However this treatment method requires an adequate quantity of sperm and eggs. The method may fail if sperm quality or quantity is poor or if egg quantity is inadequate
- ICSI (INTRA CYTOPLASMİC SPERM INJECTİON-MİCROİNJECTİON)
In the ICSI method the only difference from conventional IVF is the method of fertilisation. In this method an embryologist uses specialised needles to inject only a single sperm into each egg. The fertilised egg is put into a special culture environment and will be examined about 16-18 hours later to see if fertilisation has been achieved. The procedure increases the chances of fertilisation and therefore conception especially in couples with male side factors (poor sperm count and motility) or inadequate egg quantity.
- IMSI (INTRACYTOPLASMİC SPERM INJECTİON)
The IMSI method allows a more accurate sperm selection by examining the sperm under considerably greater magnification (x6000-x8000). By doing this IMSI increased chances of success for couples suffering especially from sperm defects. Remaining IVF stages and microinjection procedures are exactly the same.