In vitro fertilization (IVF) is one of the most successful techniques available for improving your chances for a pregnancy. This reproductive journey is exhaustive and needs your involvement, but when you are guided properly, it will ease as many of the complexities that may occur along the way.
In this technique, since fertilization occurs in the laboratory rather than in the woman’s body, this procedure is called “in vitro”. The eggs and sperm are maintained in a special culture medium within a controlled environment. After fertilization is complete, if the fertilized egg is developing well, it will consist of 6-8 cells on Day 3 after egg retrieval. If an embryo is progressing appropriately, it will form a blastocyst by Day 5-6. Among the best embryos, one or more are selected for transfer into your uterus and the rest may be frozen to be transferred at a future time, if unfortunately the first attempt fails.
The Journey of IVF
Though the steps of each individual cycle vary, most of the assisted reproductive technologies have similar steps.
1. EVALUATION AND PREPARATION PHASE
A detailed schedule of the protocol will be handed over to you for your reference. In many cases, oral contraceptive pills (OCPs) will be prescribed to regulate you for the procedure. The reason for prescribing the OCP is to lessen the chances of you developing an ovarian cyst during the treatment and to have flexibility in the timing of the cycle.
Uterine Assessment: If your uterus was not assessed within the last year, your fertility expert may suggest a screening test as a hysteroscopy or a diagnostic laparoscopy before the IVF cycle. A complete assessment and rectification of any complications will be done, if present during the procedure.
2. OVULATION INDUCTION / STIMULATION PROTOCOL
Any assisted reproductive technology (ART) procedure has better success and improved results if multiple mature oocytes are available for retrieval. To achieve good number of matured eggs, systematic stimulation of the ovaries is performed by the fertility expert by administering hormone injection on a daily basis. The medications are in a class called gonadotropins. Some of the most common and most preferred gonadotropins are Follistim, Gonal-F, Menopur and Repronex.
Baseline Ultrasound: Before starting the stimulation protocol, your consultant will start with the baseline ultrasound. If the ultrasound is normal, you will begin gonadrotropin injections. This medication will support a group of several follicles to develop together. Most of them ideally develop about 10-12 follicles, but the response is quite variable and there are ample chances that you may develop only 2-3 follicles, or as many as 20-30. The dosage of medication you will receive is based on a calculation of how your ovaries will respond based on your age, your baseline FSH and estradiol (E2) levels, and any previous ovulation induction output.
When you begin the gonadotropin medication, it is important to avoid intense physical exercises because such activity could be of hindrance to the follicles development. The majority of women taking hormone injections for IVF will experience a sense of fullness in their ovaries. Risks include Ovarian Hyperstimulation Syndrome (OHSS) and multiple births.
hCG Timing: During the follicular monitoring, your consultant will closely monitor the follicle development and when the lead follicle reaches to a size of about 18mm in diameter, you will be administered with Human Chorionic Gonadotropin (hCG) injection. The timing at which the hCG is given is critical, so you need to take it precisely at the given time. The Egg/Oocyte retrieval will follow after 35 hours.
3. EGG / OOCYTE RETRIEVAL
The egg retrieval will be scheduled approximately 35 hours after the hCG injection. The retrieval will be performed in our IVF theatre under sedation. You will be given prior instructions for preparing yourselves for the retrieval. Usually you will be asked not to have anything to eat or drink before the egg retrieval. The procedure is done by inserting a needle through your vagina and into the ovary, under ultrasound guidance. Since you are under sedation, mostly you will not feel this procedure at all. The follicles which contain the eggs are precisely ruptured and the fluid is collected in test tubes and quickly passed to the embryologists in the IVF laboratory. The egg retrieval takes approximately 30-40 minutes.
After the procedure is completed, you will be allowed to rest under supervision and then transferred to the room after an hour. The chances of risks or serious problems are extremely small as the whole procedure is done under the guidance of highly effective ultrasound machines.
You should avoid any work on the day your egg retrieval is scheduled. Many of them do return to work the next day, while others also rest the day following the retrieval. You may feel some pelvic heaviness or soreness and cramping. Often there is a small amount of spotting. Your bleeding should be less than a normal period. Avoid vaginal intercourse from the day of the retrieval for several days to allow the vagina to heal.
Semen Sample: Your partner will be asked to give his semen sample on the day of the egg retrieval. It is recommended that he abstain from ejaculation for 2 to 5 days before the scheduled day of retrieval.
4. FERTILIZATION OF RETRIEVED EGGS
Once the eggs are retrieved, they are safely placed in special culture medium and put inside the incubators for few hours. By then the given semen sample is prepared for fertilization. The highly efficient sperms are then inseminated to allow them to fertilize the eggs in the petridish. Fertilization can also be accomplished by directly injecting the sperm into the oocyte by performing ICSI (Intra-Cytoplasmatic Sperm Injection). ICSI is highly recommended if the fertility expert suspects that there will be a considerable chance of no fertilization or a low rate of fertilization with usual insemination of the oocytes in the laboratory.
It is essential to understand that all the embryos may not continue to grow. Normally an embryo begins to cleave, first into two cells, then into four after 36-48 hours. After 3 days, an healthy embryo which is growing properly will have 6-8 cells. An embryo should reach a blastocyst stage at 5-6 days after retrieval. The best embryos are transferred either on third day or fifth day according to the fertility expert’s suggestion.
5. EMBRYO TRANSFER
Three to five days after the oocyte retrieval you will be scheduled for your embryo transfer. Your consultant will recommend which day is most appropriate for you. In general, blastocyst transfer is recommended when there are a large number of embryos of good quality. Your consultant will recommend the number of embryos to be transferred based on your age, your previous IVF history if you have had performed in the past, and the quality of the available embryos.
Your fertility expert will perform the transfer under the guidance of a highly efficient ultrasound. The embryologist will load the embryos into a small catheter and your physician will ease the tip of the catheter through the cervix into the uterus and the embryos are transferred. If there are any good quality embryos that are in excess, they are can be frozen for future use, if unfortunately the current cycle fails or if you want to have another baby in future. To know more about freezing your embryos, please refer freezing at Srushti.
On the day of your transfer wear comfortable clothing and socks to keep your feet warm. Your bladder should feel full, but not very uncomfortable. A partially full bladder often will allow the transfer to be completed more easily and will allow a better picture on the abdominal ultrasound.
We suggest that you rest the day after the transfer, to allow yourself time to relax as much as possible. However, it is important to know that nothing you will do, such as walking or going to the bathroom will cause the embryos to dislodge from the uterine wall. The main factors that determine whether an embryo will implant are the viability of the embryo and the quality of the uterine lining. Healthy embryos will be much more likely to implant and develop than embryos which are not viable.
6. LUTEAL SUPPORT PHASE
You will be asked to take progesterone as it increases your chances for a successful IVF. Progesterone is the natural hormone that your body produces to support the uterine lining and maintain an early pregnancy.
It is common to have a sensation of heaviness or cramping in your pelvis 5-8 days after egg retrieval. Your ovaries frequently enlarge at this time. Light bleeding sometimes occurs in the weeks following egg retrieval, even if there is a normally developing pregnancy.
A pregnancy test will be performed approximately two weeks after your egg retrieval. Waiting for your pregnancy test is not an easy task. It is usual to have symptoms of pregnancy that frequent due to the hormonal changes. Spotting or bleeding may occur even if a pregnancy is developing normally. Please do not discontinue your progesterone intake that is prescribed until your pregnancy test, even if you think you may not be pregnant. Avoid guessing or doing home pregnancy tests before the scheduled blood test. They may not be accurate.
On the day of your pregnancy test, if the test is positive, you will be asked to return for a follow-up test 2-3 days later to check if your Beta hCG level is increasing appropriately. Hopefully we will have good news to know that pregnancy test is positive and have follow-up as recommended by your physician. If unfortunately you are not pregnant, you will be instructed to stop the progesterone and expect to see your period within 2-5 days. If the cycle was unsuccessful, you may find it supportive to schedule a follow-up visit with the physician, so we can counsel you concerning your next steps. Another cycle of treatment can begin as soon as one month after a failed cycle.
Do’s and Donts after completing the IVF cycle: