What is In-Vitro Fertilisation (IVF)?
In vitro fertilisation treatment is when the follicles in the ovaries that develop in the body are monitored via an ultrasound, when the follicles are ready, an egg collection takes place and in the laboratory fertilisation (injecting the sperm of the patient’s partner) takes place. The embryos prepared in the laboratory are then transferred to the mother’s womb at the appropriate time.
Who should seek IVF treatment?
Couples looking to undergo IVF treatment will either have reasons concerning the female or the male-related infertility (50%):
Egg reserve (capacity) decrease (due to age, genetic reasons, chocolate cysts, past surgeries, etc.);
Couples who want to have children at a more mature age;
Couples who require genetic analysis in the embryo due to the genetic disease they have or are known carriers of;
The Fallopian tubes are damaged and that does not allow normal pregnancy to occur and as a result cannot be repaired;
Advanced adhesion in the abdomen (due to past operations, endometriosis etc.);
A low sperm count or no sperm at all (Azoospermia);
Couples with high risk of producing genetically abnormal embryos;
Couples who cannot achieve pregnancy despite the fact that their tests are normal and have been diagnosed with unexplained infertility;
In cases where either of the couple have an illness or condition and need to begin treatment which can potentially harm the ovaries or sperm due to the disease (for example to protect the fertility in couples that are due to undergo chemotherapy or radiotherapy).
What are the causes of infertility in women?
Ovulation problems, the most common cause that can be seen is when the number of eggs is high, such as hormonal causes such as Polycystic Ovaries (PCOS) or it may be due to decrease in egg reserve;
Presence of defects such as complete Fallopian tube blockage or enlargement (hydrosalpinx) in the tubes;
The womb contains certain factors to prevent a natural pregnancy (polyps, myoma or adhesion);
Situations in which sexual intercourse cannot be carried out (such as vaginismus)
What are the causes of infertility in men?
Azoospermia (no sperm is present due to congenital disease or an illness such as mumps when younger)
Sperm production is further affected (number-mobility in the sperm and progressive decrease in structural format) due to unknown reasons;
Sexual dysfunctions (psychological or any medical discomfort / problems associated with ejaculation or failure to achieve erection due to drug side-effects).
What are the stages involved in IVF treatment?
1. Couple Assessment: The female and male should be assessed by a medical professional. Certain blood tests are needed to assess fertility levels in a couple. Examples of blood tests for the female are Anti Mullerian Hormone (AMH), TSH, Prolactin etc. as well as gynaecological examinations, a trans-vaginal scan to monitor the egg reserve and a Hysterosalpingogram (HSG) to check the fallopian tubes and uterus. Males require blood tests but most importantly a Semen analysis. After the tests, if there is a problem then this will be corrected and then we look to begin stimulation.
2. Ovarian Stimulation is based on the results from the blood test assessment and scans, a medication protocol is designed for the female, this will be daily hormonal injections with a combination of vitamins to stimulate the antral follicles and enable the follicles to grow. There are two types of stimulation protocols, Long and Short, the preferred protocol is generally the Short protocol (Antagonist) as stimulation will begin on day two or three of the menstrual cycle and will last between 11-13 days. Ultrasounds and blood tests will be needed at certain stages of the stimulation, so the female will be closely monitored to check follicle development. The hormone stimulation is a series of hormone daily subcutaneous injections (GnRH) and these encourage the eggs in your body to grow but the dose of the medication is also dependent on factors such as how may potential antral follicles are present, as well as height and weight of the patient.
3. Trigger Injection ready for Egg collection Once the stimulation process is completed and the follicles are of a certain size to be triggered, the last injections are applied and these are to invoke ovulation and also help to increase the number of mature eggs collected. There are two different types of trigger injections that can be used individually or in combination (containing hCG / containing GnRH analogue) Based on your follicle development, your doctor will determine which trigger injections should be used. Egg collection (OPU) is performed, 34-36 hours after the trigger injection is administered at a certain time. The egg collection itself is a very straight forward procedure, and anaesthesia is used to sedate the female, to make the egg collection less stressful. Prior to the egg collection we need the female to be nil by mouth (no food or water) for 4-6 hours because anaesthesia will be administered intravenously. On the day of the egg collection, the sperm sample will also be needed, we recommend a minimum of 2-3 days abstinence. The sperm sample will then be processed within the laboratory and then the one best-looking and high-quality sperm will be injected into each mature egg. After the egg collection procedure, a new medication protocol will begin (e.g. Progesterone) to prepare the body for the transfer of the embryos to maximise the chances of pregnancy.
4. Fertilisation The fertilisation of bringing the egg and sperm together is carried out by the embryologists within the laboratory, there are different techniques that can be carried out:
In Vitro Fertilisation Method: The mature egg is placed in a laboratory dish with some of the sperm sample, they are left for 16-18 hours within the incubator and then monitored under a microscope to see if fertilisation has taken place.
Intra Cytoplasmic Sperm Injection (ICSI) Method: In this method, once the eggs are removed, each egg is placed under the microscope and a single sperm selected is microinjected by the embryologist into the mature egg. Nowadays this is the preferred technique as it maximises the chances of fertilisation. The eggs are left within the incubator and 16-18 hours after the microinjection, the eggs are monitored to see if fertilisation has taken place.
IMSI (Highly Powered Microscope to Select Sperm for Microinjection): The IMSI method is a technique used for selecting sperm in couples who have poor quality sperm, allowing more detailed evaluation of sperm the microscope magnifies the sample to enable the best-looking sperm to be selected for microinjection. With this method, the anomalies of the head, tail etc. of the sperm cell are individually assessed, as they are magnified 6000-8000-fold, this means that sperm can be detected more precisely.
5. Embryo Monitoring After Microinjection, the dishes are labelled and stored within special incubators with the patient’s ID and 16-18 hours after injection they are monitored to determine whether fertilisation has taken place.
6. Embryo Transfer Your doctor will advise you (based on embryo development) which day the transfer will be best to be carried out. Depending on egg count or endometrium thickness, your doctor may decide to freeze the embryos for transfer at a later stage.
The Transfer procedure is a straight forward and painless procedure, it does not require any anaesthesia or sedation. Patients who are sensitive may be sedated for the transfer if needed. The transfer is carried out with a full bladder, so you are required to drink plenty of water before the procedure. Once the bladder is full the endometrium can be clearly identified with the aid of ultrasound guidance. The embryologist draws the embryo into a catheter and passes it to the doctor and with the aid of the ultrasound the catheter is guided by a nurse and the catheter is placed into the endometrium and the embryo(s) are released. After the transfer, you are taken to your room and are asked to rest for approximately 1 hour. After the transfer, and resting for one hour, the medication protocol will be adjusted and you will be discharged from the Centre as you will be in treatment as an outpatient.
7. Post Transfer On the transfer day, the date of when the pregnancy test should be carried out will be advised, it is usually 12 days post transfer when a beta HcG blood test is advised to be carried out.