In vitro fertilization (IVF)

In Vitro Fertilization is a one assisted reproductive technology (ART) commonly referred to as IVF. IVF is the process of fertilization by manually combining an egg and sperm in a laboratory dish, and then transferring the embryo to the uterus. Other forms of ART include gamete intra fallopian transfer (GIFT) and zygote intra fallopian transfer (ZIFT).

In IVF, this process of fertilization happens outside woman’s body. A woman’s eggs are retrieved by needle suction under ultrasound guidance. Eggs are made to meet  Sperms in a Petri-dish in the laboratory under strict environmental control. The process is known as IVF (In-Vitro Fertilization). Fertilized egg is called embryo. This embryo can be easily transferred to women’s womb, the process being known as Embryo Transfer (ET). This completes IVF Cycle. Typically, one IVF cycle takes between four and seven weeks.

Why is IVF used?

IVF can be used to treat infertility with the following patients:

  • Blocked or damaged fallopian tubes
  • Male factor infertility including decreased sperm count or sperm motility
  • Women with ovulation disorders, premature ovarian failure, uterine fibroids
  • Women who have had their fallopian tubes removed
  • Individuals with a genetic disorder
  • Unexplained infertility
  • Transvaginal UltrasoundMeasures the growth of the egg follicles and the thickness of the uterine lining, both of which should be increasing as you take the injectable medications.
  • BloodworkMeasures the estrogen level. The levels of estrogen in the blood are another indicator of the growth and maturation of the eggs – rising as the follicles grow.

After each monitoring appointment, you will receive a phone call from our team of doctors, usually in the afternoon. It is extremely useful to be available to speak with the nurse when she calls to make sure you receive the important instructions and clarify any aspects of your care. During the update your doctor will inform you of the progress of your cycle, medication modifications, and when you should return for the next monitoring appointment. This is also an opportunity for you to ask any questions about your cycle, test results and any side effects that you may be having.

Inside the Lab: Embryo Development: 

After collecting husband’s semen and wife’s eggs, these genetic materials are handed over to the embryology team for the process of fertilization. There are two ways by which fertilization can be made to occur:

  • Conventional Fertilization:Is frequently used in cases such as blocked fallopian tubes or unexplained infertility. The embryologist isolates the healthy sperms which are then exposed to each egg inside the embryology laboratory where fertilization occurs naturally.
  • Intracytoplasmic Sperm Injection (ICSI):Is used in cases when the quantity or quality of sperms is poor and therefore sperm is unable to effectively penetrate the egg on its own. The embryologist selects a single healthy sperm and injects it directly into the center of each egg. Since fertilization only requires one healthy sperm, ICSI has become one of the most incredible advances in treating severe male factor infertility.

The decision about which method to use is based on the quality of the sperm. To test sperm, an analysis is completed as part of the initial basic fertility work-up for diagnosis before treatment and then again when the semen sample is provided on the day of the egg retrieval. If the results from this analysis do not meet the parameters required for conventional fertilization, the embryologist will make the decision to switch to ICSI so that the cycle can still produce embryos and increase your chances of success. The clinical team will let you know if an unplanned ICSI procedure is recommended.

Once fertilization occurs, the embryos begin to develop. Every morning for the next 3 to 7 days, embryologist examines the developing embryos and adds notes in your record regarding each individual embryo. Your doctor will follow-up daily with your fertilization report updating you on the status of each growing embryo and the recommendations for either a day 3 or a day 5 embryo transfer.

Embryo Transfer

The embryo transfer (ET) is a simple procedure that takes about 10 minutes to complete. There’s no anesthesia, and hence no recovery time. When your transfer is scheduled, nurse will notify you, and provide specific instructions on when to arrive and how to prepare. On the morning of transfer, embryologist will make a final assessment of your embryos and provide a recommendation on the number of embryos to be transferred. These recommendations are based on overall embryo quality and age of embryos, day 3 or day 5-7 blastocyst stage embryos. Your IVF specialist will use the information provided by the embryologist and other factors related to your case such as your age and history of previous treatments to make a final call on embryo transfer.

At times, when patients meet specific criteria, IVF Specialist suggest Single Elective Embryo Transfer (eSET). eSET is the transfer of a single embryo, usually at blastocyst stage, despite having many available. Transferring one high quality embryo is found to reduce the risk of multiple pregnancies while maintaining a similar chance of successful IVF cycle. Patient criteria for eSET:

  • The female partner is 37 or younger in age
  • It is her first cycle of IVF or she has had a previous successful IVF cycle
  • Quality of blastocyst is good.

Prior to start of embryo transfer, patient reviews her cycle with the IVF Specialist and a final decision regarding the appropriate number of embryos to be transferred is made along with what to do with remaining embryos, if any. Once the number of embryos to be transferred is determined, inside the laboratory, embryologist will verify all identifiers, such as your name, identification number, and compare them to the embryo culture dish and corresponding egg data-sheet. Then, transfer catheter is loaded with the appropriate number of embryos. Upon entering the transfer room, the embryologist will state your name along with your husband’s name and the number of embryos in the catheter for repeat confirmation to avoid remote possibility of error.

During transfer, IVF specialist will insert the loaded catheter and push the plunger to place the embryos into the uterus with a small puff of air. The procedure is visually guided on a monitor with abdominal ultrasound. Once transferred, doctor will slowly remove the catheter to eliminate or decrease any uterine contractions. Since embryo is invisible to naked eye, embryologist will then check the catheter under microscope to make sure that the embryo was released. You will be asked to lie quietly for 5 minutes after ET. Then, you’ll be advised instructions for the coming 2 weeks until it’s time for pregnancy test.

Side effect of In Vitro Fertilization:

Although you may need to take it easy after the procedure, most women can resume normal activities the following day.

Some side effects after IVF may include:

  • Passing a small amount of fluid (may be clear or blood- tinged) after the procedure
  • Mild cramping
  • Mild bloating
  • Constipation
  • Breast tenderness

Severe cases may involve:

  • Heavy vaginal bleeding
  • Pelvic pain
  • Blood in the urine
  • A fever over 100.5 ºF (38 ºC)

How successful is in vitro fertilization?

The success rate of IVF clinics depends on a number of factors including reproductive history, maternal age, cause of infertility, and lifestyle factors. It is also important to understand that pregnancy rates are not the same as live birth rates.

Steps of IVF: Demystifying the Process

While most of us have heard about IVF, not many people know exactly how the process works. IVF can be broken down into few parts from pre-cycle appointments and preparations through the pregnancy test making understanding the process just a little bit easier. Whether you’re just starting to search fertility treatments or are already a patient planning to begin IVF, knowing more about the treatment can reduce your anxiety and make your journey feel less complicated.

Appointments and Preparing the Ovaries for Stimulation:

In preparation for an IVF cycle, you will undergo a Mock Embryo Transfer. This procedure is a “practice run” for the embryo transfer and allows the doctor to test the size and placement of the catheter with your particular anatomy before the big day. During the procedure an ultra-thin catheter is inserted into the uterus while a sonogram guides the process on a monitor. Many patient compare the Mock Embryo Transfer to a pap smear, it is relatively painless and takes only a few minutes.

Following the completion of the pre-cycle testing, you will meet with your doctor to review the results and plan their protocol for treatment. The protocol is like a blueprint that is used by you and your medical team. It is important to remember this plan which provides tentative dates; frequently, treatment timelines will need to be adjusted based on how you respond to medication; you should anticipate changes and block time as needed in your work and travel schedules.

Many women start an IVF cycle by taking birth control pills for a set number of days, to help:

  • Decrease the chances of creating cysts that could interfere with the cycle start.
  • Synchronize the egg follicles so they all start at the same stage, on the date collectively chosen by the doctor and patient.
  • Allow the physician and patient to control the timing of the cycle.

Ovarian Stimulation and Monitoring:

In a normal ovulation cycle, one egg usually matures per month. In an IVF cycle, the goal is to have as many mature eggs as possible, as this will increase your odds of success with treatment. In the stimulation phase of the IVF cycle, injectable medications are used for approximately 8-14 days to stimulate the ovaries and produce more eggs. Stimulation medications are derivatives from the hormones FSH and LH, which are the natural hormones involved in the natural ovulation process. Some protocols use one or the other of these hormones exclusively and many use a combination. During the ovarian stimulation phase, you will come to our centre approximately 7-8 times for morning monitoring appointments. Monitoring appointments consists of:

The Trigger Shot and Egg Retrieval:

The stimulation phase ends with a trigger shot. The trigger shot provides final maturation to the developing follicles and sets ovulation in motion. Timing is crucial in this phase because the egg retrieval must be performed prior to the expected time of ovulation. The doctor decides when you are ready for trigger based on the two key factors that have been monitored during the stimulation phase:

  • Size of the Follicles – The goal is to have as many follicles as possible, be 18mm or larger since these are the most likely to contain mature eggs.
  • Level of Estrogen (Estradiol)While there is no specific number the physicians are looking for, your estrogen level should not be too high or too low. The level directly correlates with the number of follicles in the ovaries. The cells inside each follicle produce estrogen so a patient with 8 follicles will generally have a blood estrogen level that is lower than a patient with 16 follicles.

At our center, egg retrieval is done approximately 36 hours after the trigger shot. Husband’s semen is collected on the day of egg retrieval or if he is unlikely to be available on the suitable date (out-of-state or international patients) previously frozen sample will be used.

On the day of egg retrieval, you will meet the anesthetist at our center, who will review your medical history and do a general physical examination. An intra-venous line will be started that will deliver the anesthesia medication. Only very short acting drugs are used for this purpose so that you are awake by the time procedure is over. After 4 hours’ of observation, you are fit to go home.

The egg retrieval itself takes only about 20-30 minutes. During the procedure, ultrasound is used to guide a needle into each ovary and remove the follicular fluid containing eggs.

At Urogyn, we understand the delicacy of emotional aspect between husband and wife. Hence, we have completely segregated IVF lab from the clinic area by dedicating a separate floor to it. Attendants are not allowed entry to the IVF laboratory floor, thus, making young ladies feel more comfortable. We have taken special precautions in employing only female staff for IVF lab floor as for as possible.

The Pregnancy Test

Pregnancy test is done at around 14 days after the embryo transfer (ET). Unlike a home pregnancy test, blood is drawn and beta-hCG level is measured. A beta-hCG level of over 100 is considered to be positive although many on-going pregnancies start out with a beta-hCG level below 100. You may be asked to repeat the test in 2-3 days. Under normal circumstances, we expect beta-hCG to double every 2 days. If it does, another beta-hCG may be ordered. If all 3 tests are favorable, then a trans-vaginal ultrasound will be scheduled between 6th and 8th weeks of pregnancy. By this time, your doctor will be looking for heart-beat in a gestational sac to confirm healthy pregnancy. Once healthy pregnancy is confirmed, the patient is considered “graduated” and she is subjected to continuing obstetric care.

If the cycle results in a negative pregnancy test, it’s very disappointing. It is important to remember, you have a treatment plan with options for trying again. Your doctor will start by instructing you to stop medications and offer you to plan for a repeat cycle. At that time, you’ll discuss what happened during the cycle; any changes you might make to your protocol, and ultimately how you want to proceed.

What is involved with in vitro fertilization?

There are five basics step in the IVF and embryo transfer process:

Step 1: Fertility medications are prescribed to stimulate egg production. Multiple eggs are desired because some eggs will not develop or fertilize after retrieval. Transvaginal ultrasound is used to examine the ovaries, and blood test samples are taken to check hormone levels.

Step 2:  Eggs are retrieved through a minor surgical procedure that uses ultrasound imaging to guide a hollow needle through the pelvic cavity to remove the eggs. Medication is provided to reduce and remove potential discomfort.

Step 3: The male is asked to produce a sample of sperm, which is prepared for combining with the eggs.

Step 4: In a process called insemination, the sperm and eggs are mixed together and stored in laboratory to encourage fertilization. In some cases where there is a lower probability of fertilization, intracytoplasmic sperm injection (ICSI) may be used. Through this procedure, a single sperm is injected directly into the egg in an attempt to achieve fertilization. The eggs are monitored to confirm that fertilization and cell division are taking place. Once this occurs, the fertilized eggs are considered embryos.

Step 5: The embryos are usually transferred into the woman’s uterus three to five days following egg retrieval and fertilization. A catheter or small tube is inserted into the uterus to transfer the embryos. This procedure is painless for most women, although some may experience mild cramping. If the procedure is successful, implantation typically occurs around six to ten days following egg retrieval.

What are the risks associated with in vitro fertilization?

As with most medical procedures, there are potential risks. Fertility medications can have various side effects including headache, mood swings, abdominal pain, hot flashes, and bloating, amongst other side effects. Although it is rare, fertility medications may cause ovarian hyper-stimulation syndrome (OHSS). Symptoms of OHSS may include abdominal pain or a feeling of being bloated. More severe symptoms include the following:

  • Nausea or vomiting
  • Decreased urinary frequency
  • Shortness of breath
  • Faintness
  • Severe stomach pain and bloating
  • Ten pound weight gain within three to five days