Indications for IVF
The treatment of IVF was introduced to deal with the female infertility causes, specially the tubal diseases. Fallopian tube is the only place in female reproductive system where normal fertilization occurs and if due to infection, inflammation or endometriosis irreparable damage has occurred to the tubes and the tubes become blocked, then pregnancy becomes difficult or impossible. Tubes can be unilaterally or bilaterally blocked which can be assessed by hysterosalpingography. Tubal reconciliation may be helpful in some cases.
The abnormal growth of endometrial cells outside the uterus is known as endometriosis and is one of the main causes of infertility in almost 20-48% of women. Endometriosis may involve masses of tissue within the pelvis that may distort fallopian tubes and ovaries and effect fertility through the production of hormones and other substances that have adverse effect on ovulation, fertilization or implantation of embryo.
Premature Ovarian Failure
Also known as premature ovarian insufficiency or premature menopause is the loss of the function of ovaries before age 40. POF may be due to genetic disorders, chemotherapy, endometriosis and surgery. This is assessed by Antimullerian hormone test which is done irrespective of the day of menstrual cycle.
Polycystic ovary syndrome
PCOS is a common hormonal disorder in women of reproductive age. It causes irregular menstrual cycles, clusters of pearl sized cysts in the ovaries which contain immature eggs. Two third of the women with PCOS will not ovulate on regular basis and hence seek treatment for ovulation induction. Medication for stimulation in PCOS is done with great care in order to avoid hyper stimulation. Use of GnRH agonist instead of HCG for inducing final oocyte maturation eliminates the risk of OHSS.
Infertility is said to be unexplained when all the tests of both the partners are normal, yet the couple is not able to conceive. When unexplained infertility does not respond to fertility medications along with artificial insemination IVF is the option.
Low sperm count is the main cause of male infertility. Because IVF allows us to take refined sperm for fertilization this problem is over ruled. In cases of severe male infertility, a procedure called ICSI enables us to fertilize the eggs and give desirable results.
IVF – GETTING STARTED
The stimulatory phase of IVf cycle must begin on the second day of stimulation. In patients with polycystic ovarian syndromeor those who respond to stimulation very vigorously in order to minimize the risk of hyperstimulation and improve egg quality, we put these patients on birth control pills and add Lupron injection on daily basis starting approximately 10 days before the anticipated start of stimulation.
The oocyte retrieval is the day when the follicle sizes measures between 18 mm or more. Patients arrive at the IVf centreapproximately one to two hours before the scheduled time of retrieval. Intravenous general anesthesia is given and the process is almost painless. Retrieval is performed by inserting a needle through the vagina directly into the ovary under ultrasound guidance. The needle enters the follicle and aspirate the fluid and egg which is collected in a test tube. Patients are retrieved after one hour of the procedure. The embryologist receives the content of the test tube and examines the recovery of the immature eggs. The semen sample of the male partner is collected the same day.
Embryo transfer is done on day 3 or day 5. The procedure takes about 10-15 minutes and the patient requires no anesthesia.The embryos are transferred through a fine catheter under pelvic ultrasound guidance. The patients are allowed to rest for 30 minutes and then leave the clinic with instructions, progesterone injections and some medicines. Heavy exercise and sexual intercourse should be avoided for few days. Pregnancy test is conducted after 14-15 days of transfer.
During stimulation, the patients are given injections of gonadotropins, which stimulate the ovaries to produce multipleeggs. The stimulation phase lasts for about 7-10 days, but can vary according to the size of progressing follicles. At each visit, which is usually after two to three days a vaginal ultrasound is performed to make a note of the size and numbers of the follicles. When follicle size reaches 17-18 mm a final shot of HCG trigger is given prior to 36-40 hours of oocyte retrieval. This helps the larger eggs to go through their maturation process which is essential for fertilization.
FERTILIZATION AND EMBRYO FORMATION
After retrieval, fertilization is done either with traditional IVF or ICSI. In IVF high concentration of sperms is placed with eachegg in a Petri dish and left overnight to allow fertilization to take place. In ICSI a single sperm is injected in the cytoplasm of single egg hence leading to a better fertilization rate. After 48 hours, the fertilized eggs are called embryos and kept in the incubator for 3- 5 days. Embryo transfer may be done either on day 3 or day 5 (blastocyst transfer).