What is IVF?

IVF or In Vitro Fertilization is a complex of procedures when the eggs of a woman’s and sperms of a man’s are manipulated outside of the female body in a test tube (Test Tube Baby). Following the hormonal stimulation leading towards a higher number of mature eggs these are retrieved straight from ovaries and brought in to a special cultivation solution together with selected sperm. After the fertilization eggs are cultivated in to embryos in special mediums completely naturally without any other intervention. The fertilized egg (embryo) is then inserted in the uterine cavity of the women’s body.

Who needs IVF?

For normal conception to happen a healthy sperm with good motility should pass through cervical mucus, swim through uterus and reach fallopian tube to meet egg around the time of ovulation (when the egg is released in the body). Eggs and sperms meeting in the fallopian tube form an embryo which goes to uterine lining and implants there. It means for normal conception to happen there is a need for healthy motile sperms, open fallopian tubes, good eggs, ovulation happening on its own and good uterine lining. If there is an issue with any of them, then there might need to think about assisted reproduction.

One might need IVF if one is suffering from:

• Male Infertility: Sperms less in number (oligospermia), sperms not motile (asthenospermia), sperms abnormal in shape (teratospermia), or all three issues (Oligoasthenoteratospermia or OATS). It might also be possible there are no sperms seen in the routine analysis (Azoospermia)

• Female Infertility: A female might be sub-fertile due to number of reasons like issues with blocked fallopian tubes, fluid in tubes (hydrosalpinx), adhesions, issues with egg polycystic ovarian syndrome (PCOS) - no egg releasing or anovulation; low number of eggs – advanced age, low AMH; endometriosis-cyst in ovary issues with uterus – fibroid, adenomyosis, poor endometrial lining or thin ET (endometrial thickness), adhesions in uterus (Ashermann syndrome).

Who does IVF?

IVF is done by only trained IVF treatment specialists, who have worked in the field of Reproductive Endocrinology. It is very important to choose the right doctor with impeccable qualifications.

Are there any investigations required before IVF?

Besides routine investigations and viral serology, the treating IVF doctor needs to do a transvaginal ultrasound to look at the uterus and ovaries. The doctor will have a look at an endometrial thickness (ET) as well as the number of eggs in Ovary (Antral follicle count or AFC) Also, hormonal investigations including AMH (Anti Mullerian Hormone) will be done Hysteroscopy might be required prior to IVF if there are issues with the uterine lining.

How much time does the process of IVF take?

If the process is started from Day 2 of the cycle, the whole treatment till embryo transfer is completed in a duration of 15-20 days.

What are the steps involved in the process of IVF treatment?

• Initial Consult: In the first consult, a detailed history, examination & have a thorough look at the patient’s old records and investigations are needed. Also, a Transvaginal examination will be undertaken. It is always a good idea to bring all the old records including any Hystero-salpingogram (HSG) X-ray if any. A follow-up detailed plan will be accordingly made on the patient’s first visit.

• Ovarian Stimulation: For an IVF cycle to succeed, there is a need to get more eggs, to have more good quality embryos and to increase the chances of success. This is done by taking hormonal injections. These are pen-style injections and can be self- administered by the patient.

• Hormonal stimulation: Multiple growth of follicles increases the chances for achieving a bigger amount of quality eggs and consequently more embryos suitable for transfer. This is achieved by hormonal stimulation under constant doctor’s control.

• Ultrasound Monitoring: To see the response of hormonal injections, transvaginal ultrasound (TVS), is done at an interval of 2-4 days.

• Egg retrieval: After the follicles are ready, the egg retrieval is performed under short general anesthesia guided by trans-vaginal ultrasound and it takes about 5-10 minutes. The procedure is done with a special thin needle, which goes via vaginal whole straight to an ovary. From there are the eggs suctioned. The patient is discharged about 2 hours post procedure. So, there is no incision, no mark. This surgery is quite safe.

• The sperm collection and preparation: A sperm sample is collected from a partner on the day of egg retrieval in special room. Sexual abstinence is recommended 2-5 days prior the collection in aim to get the best possible quality sample. Following its laboratory preparation eggs are fertilized by partner’s sperm in a special solution. Fertilization happens spontaneously, the sperm moves towards the egg and penetrates its shell. The common cultivation of eggs and sperm lasts 16-20 hours. After this time the embryologist finds out about the success of fertilization which is proved by the presence of two pronucleus. If the man is in any doubt about the ability to give a sample in the day of egg retrieval, he can use the option of cryopreservation in advance. For men who have no sperm in the ejaculate is MESA/TESE one of the options to get the sperm in IVF cycle.

• Embryo cultivation: The day the patient’s eggs are taken; the same day the patient’s husband’s sperm sample is taken. Eggs are then fertilized by sperms using conventional IVF or advanced techniques like ICSI (Intracytoplasmic Sperm Injections), IMSI, PICSI, etc. The next day the number of eggs fertilized is seen under a microscope or embryo scope. Embryos are then developed to day 2, day 3 or day 5 (Blastocyst) stage. The lab keeps the patient updated about the progress and accordingly plans for embryo transfer.

Cultivation to the state of blastocyst/ Blastocyst Culture

Blastocysts are embryos which have grown till day 5 or 6 after fertilization. By using the special solutions, it is possible to extend the time of cultivation of embryos for up to 5 or 6 days (state of a blastocyst). The benefit of this procedure is the option to choose the best quality embryos for transfer and increase the chances for pregnancy. Use of the long cultivation is suitable especially when the number of mature eggs is sufficient (6 and more). Determination of an optimum date for ET is very individual and can be different in repeated cycles. Normally in an IVF cycle on the day of egg pick up, sperms are injected into eggs through the process of ICSI. Next day fertilization check is done and embryos are cultured in the incubator. Blastocyst or extended culture as we say it is taking the embryos till day 5 of culture to select the best embryo available for freezing or transfer.

Are Day 3 embryos better or day 5?

As we do extended culture of embryos, only those embryos which have the potential to implant inside uterus will go on to form blastocysts. Hence a natural selection helps us in selecting the best embryos to transfer. As there are embryonic activation blastocysts can result in better pregnancy rates. So, it does improve pregnancy rates.

When should you go for blastocysts in IVF?

It is always a better idea to go for blastocysts than day 3 embryos. However, in patients at higher age or in patients with repeated IVF failures, it is always a good idea to opt for blastocyst culture. Also, in patients trying to avoid multiple pregnancy in IVF blastocyst culture is a good idea.

Are there any drawbacks of blastocyst culture?

For extended culture it is imperative that embryology lab conditions are strictly maintained. Also, there is 1-2 percent risk of no blast forming in a cycle which should be taken into account.