What is the Procedure of IVF with Donor Embryos?

IVF WITH DONOR EMBRYO:

The transfer of an embryo resulting from male and female gamete, not taken from the recipient and/or her partner is known as IVF with embryo donation. It is also referred to as a type of third party reproduction.

INDICATIONS FOR DONOR EMBRYO:

1. Gonadal dysgenesis (Defective embryonic development of gonad in male or female).
2. Women with premature ovarian failure or iatrogenic ovarian failure( due to ovarian surgery or radiation ) or is a poor responder to ovarian stimulation and the man suffers from a severe disturbance in gamete production.
3. Couple who are carriers of a hereditary disease which may cause significant morbidity in the newborn.
4. Women who have attained menopause with male factor infertility.

PROCEDURE

The procedure enables either cryopreserved embryos previously created by donors /couples undergoing fertility treatment OR fresh embryos that were created from donor sperm and donor eggs specifically for the purpose of donation are transferred to recipient in order to achieve pregnancy.

It involves the following steps

1. Evaluation of the recipient
2. Evaluation and selection of donor
3. Counseling of recipient couple and donor
4. Consents of recipient couple and donor
5. Controlled ovarian stimulation of egg donor
6. Oocyte retrieval of egg donor
7. Endometrial preparation of the recipient
8. Invitro fertilisation and embryo development
9. Embryo transfer to the recipient
10. Pregnancy test

1. EVALUATION OF RECIPIENT

• Thorough medical and reproductive history of couple should be evaluated
• Complete general physical examination including pelvic examination should be performed to rule out any abnormalities which can affect pregnancy outcome
• Endocrinological investigations that can affect fertility potential and subsequent pregnancy prognosis like thyroid function tests, serum prolactin, blood glucose levels etc. should be evauated.
• Relevant serological screening tests like HIV, Hepatitis,syphilis and investigations for other reproductive tract infections such as chlamydia and tuberculosis should be done if necessary.
• Relevant laboratory tests including blood type and rh type , hemoglobin etc. and pap smear for cervical screening should be done.
• Evaluation of uterine cavity.A good two dimensional ultrasonography to rule out the presence of any uterine or ovarian pathology like fibroids, polyps, hydrosalpinx, ovarian cyst, uterine malformations should be done and confirmed by three-dimensional ultrasound if needed. Hysteroscopy is indicated in case of suspicion of any abnormality.
• Endometrial biopsy for histopathological examination, TB-PCR and culture may be done if there is any previous history or recurrent implantation failure or persistently thin endometrium or any suspicion on hysteroscopy.
• If female age is more than 40 assessment of cardiac function should be done. Risk of hypertension during pregnancy and gestational diabetes should be considered.couple should be counseled regarding impact of advanced maternal age of pregnancy as well as any medical illness that may affect pregnancy.
• Rubella and varicella screening can be done and non immune recipients may be immunised.
• Genetic testing depending on history, ethnicity and current recommendations
• Special tests like karyotyping and autoimmune screening if needed. Cardiac evaluation if recipient is a known case of Turners syndrome
• Psychological evaluation of the couple

2. EVALUATION AND SELECTION OF DONOR:

• Anonymous donor is selected and Screening of gamete donors should be done as per most recent guidelines.relevant investigations should be done.
• Egg donors should be legal adults and preferably between 21 to 34 years age and with one living child of minimum 3years age preferably. if donor is more than 34 years it should be revealed to the recipient and explained about effect of donor age on pregnancy.
• Evaluation of personal and medical history.detailed sexual history, substance abuse, history of family disease and psychological history
• Donors should be screened for sexually transmitted diseases or any communicable diseases that can endanger health of the recepient
• Genetic testing if indicated
• Once donor is fit and all relevant compatibility tests are done ,donor is assigned to the specific recipient depending on some phenotypic and blood characteristics etc.

3) COUNSELING OF RECIPIENT COUPLE AND DONOR:

• Recepient Couple should be counseled regarding benefits and risks of the procedure,laws related to the procedure. couple should be reassured that process of gamete donation shall be kept confidential in accordance with national ART bill.
• Donors should be counseled regarding laws related to the procedure, details of the procedure ,need for regular visits and risk of complications due to ovarian stimulation.

4) CONSENTS OF RECIPIENT COUPLE AND DONOR:

Informed Consents should be taken from recipient couple and gamete donors as per the recent guidelines

5) OVARIAN STIMULATION OF DONOR:

Egg donor undergoes ovarian stimulation with hormonal treatment as per the Standard protocol.

6) OOCYTE RETRIEVAL OF THE DONOR:

Once ovarian follicles have reached the appropriate size, trigger medication is given to attain final oocyte maturation and ovulation. After trigger oocyte retrieval is done at appropriate time under anaesthesia to obtain oocytes.

ENDOMETRIAL PREPARATION OF THE RECIPIENT:

This procedure involves hormonal treatment that prepares the endometrium (inner lining of uterine cavity where embryo gets implanted)of the recipient to favor embryo implantation.

8) INVITRO FERTILISATION AND EMBRYO DEVELOPMENT:

Semen sample is obtained from sperm donor. for fresh embryo formation best sperm is selected from the sample and is injected in to the oocyte( obtained from oocyte retrieval of egg donor)through the technique of ICSI (intra cytoplasmic sperm injection) .embryo is grown upto blastocyst stage to attain maximal implantation and pregnancy rates.

9) EMBRYO TRANSFER TO THE RECIPIENT:

• For this Either fresh embryos created from donor egg and donor sperm can be utilised or cryopreserved embryos previously created from donors or from couple undergoing infertility treatment who fulfil the criteria can be utilised.

• Embryos are loaded into a catheter and transferred into the uterus of the recipient under ultrasound guidance.

10). PREGNANCY TEST:

• A Blood pregnancy test is performed few days after transfer to measure HCG levels in the blood to determine if the pregnancy result is positive or negative.
• Depending on the value of HCG it might be repeated after two days and patient is then scheduled for an ultrasound at five or six weeks to date and evaluate pregnancy.
• The recipient continues to take hormonal supplements as directed by her specialist often until 12th week of pregnancy.

FACTORS FOR PROCEDURAL SUCCESS

RECEPIENT FACTORS

A. AGE – Women younger than 40 years had higher implantation and pregnancy rates.
B. ENDOMETRIAL THICKNESS – Endometrial thickness greater than 7mm favors better implantation and success rates.
C. QUALITY OF EMBRYO – High grade embryos evidently increase the chances of pregnancy rates.
D. HIGH BMI – Higher BMI might have negative impact.
E. UTERINE PATHOLOGY– Presence of any uterine pathology like myoma ,polyp etc inhibiting Implantation might have negative effect.
F. DIFFICULT EMBRYO TRANSFER-might have negative impact

DONOR FACTORS

A. AGE – 21-34year age group has higher success rates.
B. NUMBER OF MATURE OOCYTES (M2) RETRIEVED – Higher live birth rate with higher number of mature oocytes retrieved.

IMPLICATIONS OF EMBRYO DONATION:

ON RECIPIENT –
1. Good obstetric outcome except for an increase in hypertensive disorders and caesarian section rates.
2. No added risk of congenital malformations.

ON DONOR –

1. Short term risks of egg donation include ovarian hyperstimulation syndrome, Intra abdominal bleeding, Infection, Ovarian torsion and short term subfertility. Serious complications are rare.
2. Psychological distress and long term risks are rare.