In Vitro Fertilization

WHAT IS IVF OR ICSI?

IVF or In vitro fertilization is a procedure where the eggs of the female partner are incubated with the sperm sample in a laboratory dish and fertilization is allowed to happen.

ICSI or Intracytoplasmic sperm injection is a procedure where each egg is injected with one sperm individually, with the help of special instruments called micromanipulators.

Both procedures differ only in the method of fertilization, other steps remaining the same.

IVF or In vitro fertilization

WHAT DOES THE IVF/ICSI PROCEDURE INVOLVE?

COUNSELING:

Before you are enrolled in the IVF cycle, you will undergo a detailed counseling session about the procedure with one of our doctors where the steps, medications used; case specific success rates and costs are elaborated. Any queries or doubts the couple may have are also cleared.

PRE TREATMENT CYCLE:

In the cycle or month preceeding the intended IVF cycle, we do a set of basic investigations in the male and female partner.

  •  Tests for ovarian reserve like the FSH, LH, AMH and routine blood investigations will betaken in the female partner.
  • AFC count on a transvaginal ultrasound may be taken.
  • 3-D ultrasound or Diagnostic hysteroscopy may be advised to assess the uterine cavity.
  • Husband’s semen analysis and C&S will be taken along with basic blood investigations.
  • You will then be started on a course of OCP for suppression and will be asked to contact the IVF sister on day 1 of your withdrawal bleeding.
  • These steps may be omitted in case you happen to have all therelevant reports ready with you (taken within the past 6 months) or may be done in your own country and mailed to us in case you are from out of India.
  • 3-D ultrasound or Diagnostic hysteroscopy may be advised to assess the uterine cavity.
  • Husband’s semen analysis and C&S will be taken along with basic blood investigations.

TREATMENT CYCLE:

There are 6 steps involved in the process

  • Ovarian stimulation and monitoring
  • Ovum pick up
  • Process of fertilization
  • Development of the embryos in the incubator
  • Embryo transfer
  • Luteal phase support

STEP 1 - Ovarian stimulation and monitoring

  • Our aim in IVF is to promote the development of multiple eggs in both ovaries by the administration of hormone injections, a process known as COH or controlled ovarian hyper stimulation
  • We usually in almost all cases follow the Antagonist protocol for its relatively shorter duration as compared to the long protocol with no compromise in success rates.
  • The patient reports on day 2 of the cycle and is asked to give blood to test her LH and estradiol levels. We do a basal scan to rule out any cysts and also count the AFC.
  • The dose and type of gonadotrophin injection selected by the reproductive medicine specialist is then administered by the IVF sister from day 2 to day 3.
  • The patient is asked to come to the clinic at the same time everyday to take her shots which will be administered by the subcutaneous route over her tummy. We do not send the injections home with the patient usually as in a hot tropical country like ours with frequent power cuts, the quality of injections may be compromised if they are not stored at a certain temperature.
IVF Treatment
In vitro fertilization Treatment
  • Starting on day 5 of stimulation (giving injections), we begin monitoring by transvaginal ultrasound, the number of follicles developing on each side and their sizes are noted on a chart along with the endometrial thickness.
  • The dose of medication may be altered depending on the growth and an additional injection called Gnrh antagonist is started to prevent the follicles from releasing the eggs earlier.
  • Blood tests to check for the Estradiol level may also be done on day 7 and day of trigger.
  • Once the eggs reach a certain size and are considered to contain mature eggs, the trigger

Day 1

Inform the IVF sister about start of periods

Day 2

Report to clinic for blood tests and basal scan

Day 3

Start taking the hormone injections everyday

Day 5 or 7 of stimulation

report for follicular scans on alternate days or as advised. Start antagonist as advised.

Day 7 or 9 of stimulation

give serum estradiol

Day 9 or 11 of stimulation

take the trigger injection at the specified time punctually

Injections commonly used in a IVF cycle

  • FSH-contains only follicular stimulating hormone. mostly recombinant versions may be used depending upon the case.
  • HMG-Human menopausal gonadotrophins are preparations containing both FSH and LH in equal parts.
  • LH-contains only Luteinizing hormone in it’s pure form.
  • Cetrorelix-It is a Gnrh antagonist given to prevent the premature release of eggs.
  • Hcg-Human chorionic gonadotrophin is one of the injections commonly used to trigger the release of eggs from the follicles.
  • Leuprolide acetate-It is a Gnrh agonist injection which may alternately be used as a trigger where OHSS is anticipated.

What is OHSS ?

OHSS or ovarian hyper stimulation syndrome is a potentially serious condition where the ovaries have been overly stimulated by fertility medications. The ovaries may increase in size and produce large amounts of fluid which then leads to pain and bloating of the abdomen.

When there is a strong possibility of OHSS as evidenced by the number of follicles or very high levels of serum estradiol, we may decide to adopt a policy of “Freeze all” and avoid fresh transfer to prevent serious OHSS.

STEP 2 - Ovum pick up

OPU (ovum pickup) or oocyte retrieval is an outpatient procedure where the follicles are aspirated transvaginally under ultrasound guidance in the operation theatre, under IV sedation given by an anesthetist.

The embryologist examines the collected follicular fluid under the microscope and separates the eggs from it. They will inform us about the number of mature oocytes aspirated at the end of the procedure. The retrieved eggs are then placed in the incubator. It is important to remember that not every follicle may contain an egg and that some may contain immature eggs which are not capable of fertilization. Hence, the total number of eggs obtained may be lower than the number of follicles documented on ultrasound.

STEP 3 – Fertilisation

  • In our hospital, we usually follow ICSI as the method of fertilization in most of the cases.
  • Here, each of the retrieved eggs are prepared and then injected with a single sperm with the help of a micromanipulator.
  • Fertilization will be observed after 20 to 24 hours.
Fertilisation

STEP 4 - Incubation of the Embryos

Embryo culture is the process following fertilization where the developing embryos are observed for subsequent development on a daily basis.

  • Day 1 post OPU-the formation of 2 PN (pro nuclei) denotes fertilization success and formation of a zygote
  • Day 2 post OPU- The developing embryos should be at the 3 or 4 cell stage
  • Day 3 post OPU-The healthy embryos should be at the 7 or 8 cell stage of division.
  • In case we are doing day 3 transfers, we will decide on which embryos to transfer freeze or discard at this stage depending on the number, quality of embryos and the endometrial thickness of the patient. This is a decision taken after counseling the couple.
  • In case of Blastocyst transfer, we will culture the embryos till day 5 posts OPU and transfer or freeze them.
  •  use in subsequent frozen embryo transfer (FET) cycles should the current one fail.
  • The frozen embryos will remain unchanged over long periods of time, years also and most healthy embryos will survive the thawing process.

Cryopresevation of Embryos

  • The number of embryos to transfer per cycle will depend primarily upon the age of the mother and the quality of the formed embryos. There are strict guidelines internationally to guide this.
  • When the number of embryos is more, they are then cryopreserved or frozen in liquid nitrogen by a process known as vitrification. These will then be available for use in subsequent frozen embryo transfer (FET) cycles should the current one fail.
  • The frozen embryos will remain unchanged over long periods of time, years also and most healthy embryos will survive the thawing process.

STEP 5 - Embryo Transfer

  • This is the simplest process in the whole procedure but also one of the most important where the selected embryos are placed into the endometrial cavity of the patient under ultrasound guidance.
  • This will not require anesthesia in the majority of cases.
  • In patients who have undergone prior IUI cycles, this process is something almost similar.

STEP 6 - Luteal phase support

  • This is the two week phase after ET and is usually a period of mental stress and anticipation for the couple.
  • It is important to maintain a positive outlook and carry on with regular routine activities at this stage with only few restrictions.
  • IT IS NOT NECESSARY TO TAKE BED REST post ET as it does not improve pregnancy rates in any manner.
  • Our body is not capable of producing adequate quantities of estradiol and progesterone to prepare the uterus for implantation and sustain a growing pregnancy here, as would happen in a natural cycle Hence,we supplement the requirements by giving support in the form of injections, vaginalgels, vaginal tablets or oral tablets.
  • After 14 days post transfer, we will perform the all important beta hcg blood test to detect an ongoing pregnancy.

Success Rates

Success rates in an IVF cycle cannot be generalized as they are case specific and influenced by many factors such as :

  • Age of the couple
  • Number of eggs obtained
  • Quality and number of embryos transferred
  • Presence of endometriosis
  • Quality of the sperm
  • Fresh or frozen cycle

Worldwide the success rates are given as 30 to 40 % per cycle.

When trying for 2- 3 cycles with cryopreserved embryos, this would then give us a cumulative pregnancy rate of 70 to 80%

PREGNANCY CALCULATOR

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Enter the date of the first day of your last menstrual period (LMP):

DUE DATE RESULT

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Probable date of conception:

 

Foetal Age Today:

 

Best date range for NT scan:

 

(12 weeks 3 days to 13 weeks 3 days)

Morphology Scan Date:

 

(19 weeks)

First Heart Tones by Doppler:

 

(11 to 12 weeks)

Best time to evaluate cervical length in patient with risk factors:

 

Best time for routine anatomy ultrasound:

 

(18 to 20 weeks)

Estimated Due Date: