By Dr. Vanadana Bhatia
We all know that IVF stands for In vitro fertilisation. The procedure was pioneered by Sir Robert Edwards and Patrick Steptoe in 1978 and since then IVF has helped millions of people become parents. While there are treatment options other than IVF, such as ovulation induction and intrauterine insemination, IVF is certainly the most talked-about of these treatment options. Though there has been a constant development of new medications and refined techniques to increase the success rate of IVF, at the same time care is being taken to minimize the risks associated with the procedure. Before embarking upon their IVF journey, couples need to understand the pros and cons of the procedure and they should know what to expect while undergoing this treatment. For this, they need to see a fertility specialist who can explain the entire process to them on an individual basis so that informed decisions can be made.
IVF usually involves the following steps though there are many protocols which can be decided for a patient keeping in mind their medical history, cause of fertility, results of investigations and financial constraints. The patient is recruited for IVF once all prerequisites are fulfilled.
At the beginning of the menstrual cycle on day 2 /3, blood work is done, along with a baseline ultrasound. If everything is normal, the woman receives a hormonal injection ( FSH/HMG gonadotropins ), usually in the form of a daily injection for about 9 - 11 days. This is to coax your ovaries into producing surplus eggs. The patient is called after 4 days and transvaginal ultrasound is done to monitor the developing follicles. Depending upon the ultrasound findings, the injections and dosage remain the same or may be changed and the patient is again called after 2 or 3 days for serial follicular monitoring. Once 3 to 4 follicles reach a size of 18 mm, final injection for the maturity of eggs is given. The patient is given all the instructions regarding the egg pick up which is done 34 to 35 hours after the last injection.
2. Retrieving the eggs
The eggs are collected through a minor surgical procedure known as --- ovum pick up or follicular aspiration. This is done under general anaesthesia. A thin needle is inserted through the vagina and into an ovary. The needle is connected to a suction device whichsucks the eggs out. This process is done for both the ovaries. The procedure usually takes less than a half-hour.
3. Insemination and fertilization
Semen from the male partner is collected from the male partner on the day of ovum pick up. The eggs that are collected are placed together with male sperm for IVF so that after a few hours, the sperm enter the egg and fertilizes it.If there is male factor infertility, the sperm is directly injected into the egg. This is known as an intracytoplasmic sperm injection (ICSI).Frozen sperm, retrieved through testicular biopsy, can also be used. The eggs are checked for fertilization status 18 - 22-hour post-IVF/ICSI. The fertilized egg divides and becomes an embryo. In case there is an indication for a patient, pre-implantation genetic diagnosis (PGD) can be done at a blastocyst stage to screen the embryo for genetic disorder or aneuploidy in case of recurrent miscarriages/ recurrent implantation failure or elderly patients. One or two of the best embryos are selected for transfer.
4. Embryo transfer
The transfer of the embryo is done using an embryo transfer catheter. It is generally done without anaesthesia unless and until it is technically difficult. It can be done on day 3 ( cleavage stage ) or day 5 ( blastocyst ). Usually on day 5 single blastocyst is transferred while 2 to 3 embryos may be transferred if it is a day 2/ 3 transfer. This is done after a detailed discussion with the couple wishing to have a child. If there are no viable embryos available for transfer, the procedure stands cancelled.
5. Luteal Phase Support
Once embryo transfer is done, the patient is advised to take vaginal/oral progesterone tablets for 14 days along with multivitamins and a serum beta HCG is done for confirmation of pregnancy.
If pregnancy is confirmed, the patient is asked to continue with medication and ultrasound is advised for location of gestational sac depending on beta HCG levels. If unfortunately, the pregnancy test is negative the patient is asked to stop all medication and she gets her period 3 to 4 days after stopping all the medication.
Advantages of IVF
Successful pregnancy: The ultimate advantage of IVF is achieving a successful pregnancy and a healthy baby for patients who would otherwise be unable to have children following the conventional path--- like in patients with :
a) Blocked tubes: For women with blocked or damaged fallopian tubes, IVF provides the best opportunity of having a child using their eggs. In fact IVF was first pioneered for this very reason so that women who had tubal damage or blockage could still have children of their own.
b) Older patients/ patients with a low ovarian reserve: IVF can be used to increase the chance of older patients or even a young patient with poor ovarian reserve conceive timely.
c) Male infertility: Couples with a male infertility problem( problems with semen parameters ) will have a much higher chance of conceiving with the help of intra-cytoplasmic sperm injection (ICSI).
d) Unexplained infertility: 1 in 6 couples suffer from fertility problems and sometimes these remain undiagnosed even after investigation. IVF in these cases can help to diagnosefertilisation problems. These cases remain undiagnosed until fertilisation is attempted in the laboratory. For example, where sperm and egg do not interact, this is called “failed fertilization “.Though this can be very devastating for the couple, it can provide some answers as to why a successful conception has not been achieved in the past. In such cases, a second attempt can be tried using an ICSI or other advanced technologies.
e) PCOS: Polycystic ovary syndrome is a common condition in which there is a hormone imbalance leading to irregular menstrual cycles, obesity and hirsutism. IVF has proved very successful in patients with PCOS, who do not conceive with simple ovulation induction.
f) Endometriosis: Patients with endometriosis (especially grade III or IV ), should try IVF, as it has proved successful in this group.
g) Use donated eggs and/or sperm. Women with premature ovarian failure or menopause can try IVF using donor eggs, which has high success rates. This gives them a chance to experience pregnancy and motherhood. Similarly, men with testicular failure can take the help of donor semen.
Increase your chances of having a healthy baby. For individuals who are known carriers of genetic disorders such as Cystic fibrosis, Sickle cell anaemia, Tay Sachs disease, Huntington’s disease and Muscular dystrophy, going for IVF with pre-implantation genetic diagnosis (PGD) of the embryos can be a reliable method to ensure that a child conceived will not suffer from the disorder and is born healthy. Previous history of aneuploidy: Pre-implantation genetic screening (PGS) screens embryos for aneuploidies and chromosomal disorders such as Down’s syndrome. In some instances where couples having recurrent miscarriages or who are at risk of having children born with conditions like Down’s Syndrome --- using IVF with pre-implantation genetic screening and diagnosis (PGS/ PGD) or comparative genomic hybridization (CGH), the incidences of these conditions can be reduced dramatically.
Embryo donation: Unused embryos can be donated to another childless couple or even for research. This can only be done with due permission of the biological parents.
It can be used by anybody: In-vitro fertilization isn’t restricted to the biological mother. It can also be used by surrogate or gestational carriers to help people become parents. This includes same-sex couples, single women or women who are physically unable to carry a baby because of some medical problems or congenital malformation of the uterus.
Cryopreservation of gametes in cancer patients: The fertility preservation options, which include sperm, oocyte, ovarian tissue and embryo cryopreservation should be given to all such affected patients who wish to have a family later on . These methods will permit boys, girls and young women to become parents in the future even after exposure to chemotherapy or to other agents that might cause infertility.
Control over timing:This specially goes for the young generation who are focused on their careers and they want their baby to be born at a specified time period . They have have option of cryopreserving their eggs or embryos for future use. This can also help with spacing children in a way that works best for your personal situation.
Risks Associated With IVF:
The success of IVF is not guaranteed, and patients often have to undergo more than one cycle of treatment .However, the outcome is not going to be the same for everyone who goes through IVF and unfortunately, IVF is not the answer for everyone. In fact, less than 50 percent of all couples starting an IVF cycle will achieve a pregnancy. Of those who do become pregnant, not all of the pregnancies will result in a baby. Only about 30 percent of IVF cycles started, result in a live birth. It is important to be realistic but positive about the chances of success.
Anaesthetic and operative risks:Another disadvantage of IVF is because the process involves an operative procedure, there are the associated risks of anaesthesia , infection and haemorrhage.
Ovarian Hyperstimulation Syndrome is a risk that is associated with treatment when the ovaries are stimulated through the use of medications, to make multiple eggs. This is what happens in IVF and OHSS becomes a risk for patients undergoing this treatment. Fortunately, the use of fewer or no drugs in natural and mild IVF cycles or safer protocols means that the likelihood of developing unwanted risk of OHSS is dramatically decreased or eliminated. The aiim for every IVF unit is to have OHSS free clinic.
Higher Chance Of Ectopic Pregnancy: Despite all best efforts, embryos can implant in the wrong place (i.e. the fallopian tubes), which results in an ectopic pregnancy. This can become a life threatening situation requiring urgent surgery. With IVF treatment, the risk of an ectopic pregnancy doubles, to 1-3%, particularly in women with damaged fallopian tubes.
Multiple pregnancies :Many people would not consider the prospect of multiple pregnancies as a disadvantage of IVF. However, many couples are unaware of the the risks of multiple pregnancy, and the frequency with which these complications can occur. If more than one embryoius transferred, there is a chance that all of the embryos may implant, leading to multiple pregnancies. Around 20-30% of IVF pregnancies can result in multiple pregnancies. Multiple pregnancies do carry associated health risks to the mother and baby --- there is an increased chance of miscarriage, premature labour, need for caesarean, stillbirth and infant health problems.
IVF treatment can be expensive. IVF treatment is not cheap. It is good to have a clear idea of the costs involved and to have your finances in order before starting the process .In India, private health insurance do not cover IVF procedures. There are lower cost option available for IVF that one might consider exploring.
Stressful experience: For patients undergoing treatment, it can be physically and emotionally demanding. It is important to prioritise your psychological health which is good for the mother and the baby.
Ethical concerns : The idea of selecting some embryos and potentially discarding others may not go well with everyone. Before starting treatment, consider you would be comfortable with. If one is uncomfortable with the creation of multiple embryos and cryopreservation , one can opt for minimal stimulation protocols.
Premature and low birth weight babies :There is a concern that IVF increases the risk of prematurity and low birth weight in babies. This has been linked to long-term health problems for the child. But at present there is no clear cut evidence to support this .
So basically ,it is always advisable to have a detailed discussion with your treating doctor , clear all your doubts and get a fair idea about the benefits and drawbacks of IVF treatment, before you start the process of IVF , to make it more comfortable , stress free and more successful.