IVF - In
IVF was originally introduced for
women with irreparably damaged tubes. Today, it is
a first line therapy for a variety of problems such
as endometriosis, tubo-peritoneal disturbances, pelvic
adhesions, PCOD and cases of unexplained infertility.
Also, patients who have had repeated failures of IUI
or simple treatment methods in the past qualify for
In vitro fertilization (IVF) literally
means "fertilization outside the human body"
or, in broader terms, in the laboratory. This term
applies to any form of assisted conception where fertilization
takes place outside the body, such as ICSI or ZIFT.
You would require an initial screening
and evaluation for sexually transmitted disease and
a semen analysis with a trial wash to categorize you
for either IVF or ICSI. Next, we would decide upon
a suitable protocol for stimulating your wife's ovaries
in order to get a good harvest of eggs.
Controlled ovarian stimulation
This involves a series of hormone
injections to encourage your ovaries to produce more
eggs than usual. You can have these injections either
at our clinic if you stay in the vicinity or from
your general practitioner or you could have a nurse
or clinic assistant to come and inject you at home
or we could teach your husband how to give the injections
OR YOU COULD SELF INJECT.
The common drugs which would
be prescribed to you are as follows
- GnRH-agonist (gonadotropin releasing hormone agonist)
or a GnRH-antagonist (e.g. Antagon) to suppress
the LH surge and ovulation until the follicles are
- FSH product (follicle stimulating hormone) or
hMG to stimulate development of multiple follicles.
- HCG (human chorionic gonadotropin) to cause final
maturation of the eggs in the follicles.
The purpose of the GnRH-agonist
(or antagonist) is to suppress release of LH (luteinizing
hormone) from the woman's pituitary gland during the
ovarian stimulation process. LH surges would cause
premature ovulation (release) of the eggs.
The purpose of the FSH product is
to stimulate development of multiple follicles (structures
that contain eggs) in the ovaries.
Every month, as you approach ovulation,
a number of follicles begin to mature (exactly how
many varies, and depends on your age). Usually, the
follicle that is mature first is ovulated, and all
the other developing follicles shrink away and are
lost in a process call Artesia. When you are on the
hormone treatment, most or all these developing eggs
are allowed to continue growing until a number of
them have reached maturity. In this way, we can make
use of eggs that would have otherwise been wasted,
without using up your egg total any faster. Throughout
the stimulation period, you will need to visit either
one of our clinics or suburban centers for ultrasound
monitoring and sometimes blood hormone levels. This
will help us know when there are enough follicles
that are mature enough for us to go ahead with the
Collecting the eggs
Usually, the egg pick-up is performed
through the wall of the vagina, guided by ultrasound.
We prefer a short acting propofol anesthesia to help
you recover immediately after the procedure. The ovaries
are scanned through the vagina, in the same way that
they were during your monitoring. A needle is placed
through the wall of the vagina and into the ovary,
where the follicles are emptied of their fluids and
their eggs. You will feel some pressure on the ovaries
during the procedure and there is often a small amount
of bleeding from the wall of the vagina.
Simultaneously, an embryologist
is present at the time of the procedure, looking through
the follicular fluid, finding the eggs, and scoring
them according to their maturity and quality. All
this is done in a special controlled environment in
what is called the culture room.
Collecting the sperm
To ensure that we have an adequate
quantity of sperm for IVF, 2 days abstinence is required
before giving the semen sample. However, the sperm
also need to be quite fresh, so you should not abstain
for more than 4 days beforehand. (We recommend that
you ejaculate on the day of the trigger injection.)
Sperm collection can be done in one of our special,
very private collection rooms . You may do this alone
or together with your wife, whichever you prefer.
If you anticipate that you will have any trouble providing
a sample on the day of the egg pick-up procedure,
we can arrange for you to collect ahead of time and
have the sperm frozen. We can also provide special
non-sperm-toxic condoms if you wish to collect at
home instead. If you choose this option though, you
do need to get the sample to us as quickly as possible
afterwards. In the laboratory, the sperm will be washed
and specially prepared for IVF.
Your eggs and sperm will be taken
to our embryology lab, which is on the same floor
as the day surgery where you will have had the procedure.
Once in the lab, the eggs are isolated from the fluid
and other cells, and prepared for IVF. The prepared
sperm and eggs are combined in a glass dish filled
with a nutritive medium. The eggs are then left in
an incubator overnight. The next day, the eggs are
checked for signs of fertilization. You can tell the
difference between a fertilized egg and an unfertilized
egg by two faint spheres visible in an egg after fertilization.
These two spheres (pronuclei) hold
the DNA of the sperm and the egg, and will fuse to
form the nucleus of the embryo (called syngamy). The
fertilized eggs will be left to grow for several days
in the laboratory. The embryos grow in the special
mini-incubators that hold only 4 culture dishes, so
that your embryos are not disturbed every time someone
else's embryos are checked on, as they would be in
the traditional bigger incubators. The embryologist
will record how many eggs are successfully developing,
and two or three of the embryos will be chosen for
the embryo transfer. Any remaining good quality embryos
can be 'frozen' for future use if you wish.
By the time the embryo is transferred,
it consists of at least 2 to 8 cells, surrounded by
a soft "shell" (the zona pellucida). After
the transfer, the growing embryo will need to hatch
out of the zona pellucida to implant in the lining
of the uterus. On the day after the egg pick-up procedure,
please call us to find out if the eggs have been fertilized.
If at least one embryo is available for transfer back
to your uterus an appointment will be made for the
embryo transfer procedure.
The embryo transfer itself is a
very simple procedure, usually taking just a few minutes,
and requiring no anaesthesia or sedation. The embryos
are kept in the laboratory until you are ready for
the procedure. A scientist brings them to the day
surgery in the special controlled-environment chamber,
so that they are kept in optimum conditions right
up until they are transferred to your uterus. The
embryos are picked up with special two-part catheter
(a bit like a very thin syringe ). This is carefully
guided through the cervix, and a thin soft tube that
will not damage the lining of the uterus is advanced
out to reach the middle of the uterus, and the embryos
are deposited there. The front and back of the uterus
are normally touching, and this holds the embryo in
place - so you can get up straight away.
After the transfer
To make sure the lining of your
uterus (the endometrium) is ready for the embryo to
implant, you will need to have two injections of hCG
(human chorionic gonadotropin) or better still, daily
injections of progesterone in oil (Inj Gestone / Puregest
/ Susten). This helps the endometrium swell up and
envelop the embryo so it has the best chance to implant.
If your hormone levels are high, we many recommend
progesterone pessaries instead of further Profasi
From this point, it is a matter
of waiting to see if an embryo implants successfully
and begins to develop. A pregnancy test can be performed
about 16 days after the egg pick-up and the nurse
co-ordinators will have the results for you.
A Blastocyst transfer is the transfer
of an embryo from the laboratory to the uterus at
Day 5 of development, instead of Day 3. it is one
way of selecting the embryo or embryos most likely
to survive and implant, giving a better chance of
pregnancy. To appreciate the difference two extra
days can make to an embryo, first you need to understand
a little about early embryo development.
The first week.
After the sperm enters the ovum,
the sperm head enlarges to form the male pronucleus.
Within 24 hours, two small spheres, called the pronuclei,
can be seen in the cytoplasm of the egg. These contain
the genetic material from the mother and the father.
When the two pronuclei fuse, joining the DNA from
both parents together, fertilization is complete.
As the pre-embryo grows, it undergoes cleavage, where
the cell divides into smaller cells call blastomeres.
After 2 days, the embryo will consist of 4-8 blastomeres.
At this point it is impossible to tell which embryos
are most likely to survive and develop normally. After
about 3 days, when the embryo consists of 12-16 blastomeres,
the cells begin to compact, forming a morula. This
is the stage at which the embryo would normally enter
the uterus, where it floats for a day or two before
attaching to the lining of the uterus.
During those two days, huge changes
in the embryo's appearance can be seen, as the cells
begin to differentiate into those that will become
the fetus, and those forming the amniotic sac and
placenta. These changes are characterized by the formation
of a cavity in the morula, to create a blastocyst.
After 4 or 5 days the embryo "hatches"
out of the outer shell of the egg, the zona pellucida,
and the blastocyst is able to attach to the endometrium.
By Day 7, the embryo has completely implanted in the
lining of the uterus.
Why have a blastocyst transfer?
By watching the embryo develop to
the blastocyst stage, the embryologists can have a
better idea of which embryos are most likely to be
healthy and continue to develop. One of the factors
that decides an embryo's fate is whether or not it
has enough energy for the first week of development,
hatching and implantation. Of course, there are still
many stages of development that the embryo must pass
through to create a successful pregnancy, but choosing
the healthiest 5-day-old embryos and transferring
them just before they would normally implant has given
us the best success rates yet. Ultimately, our goal
is to have such high success rates that only one blastocyst
will need to be transferred in each cycle for a good
chance at pregnancy.
We often recommend blastocyst transfers
for couples who have had a number of unsuccessful
attempts at routine IVF. Whether you have your embryos
transferred at Day 2-3 or Day 5 is your decision.
Some patients prefer to have the embryos put back
earlier rather than risk there not being any still
developing on Day 5, while others would prefer not
to have the transfer if the embryos do not survive
to Day 5.
Normally "spare" embryos
are frozen at the 4-8 cell stage, and provide good
results when transferred after thawing. We are now
able to successfully freeze and thaw blastocysts.
The limited number of cases so far mean that we don't
yet have reliable data on success rates for transfer
after blastocyst freezing.
What does a blastocyst transfer mean
Essentially, a blastocyst transfer
means that your transfer will be one or two days later
than it would have been otherwise. There are no different
medications or extra procedures, although it does
incur an additional charge. Having a blastocyst transfer
can also mean that by Day 5 you might have fewer embryos
than at Day 3, but that those embryos lost along the
way would not have created a pregnancy anyway.
How is assisted hatching performed?
The embryo is held with a specialized
A very delicate, hollow needle is used to expel an
acidic solution against the outer "shell"
(zona pellucida) of the embryo.
A small hole is made in the shell by digesting it
with the acidic solution.
The embryo is then washed and put back in culture
in the incubator.
The embryo transfer procedure is
done shortly after the hatching procedure. Embryo
transfer places the embryos in the woman's uterus
where they will hopefully implant and develop to result
in a live birth.