Steps involved in the process of In Vitro Fertilisation (IVF) cycle

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Steps involved in the process of In Vitro Fertilisation (IVF) cycle

In Vitro Fertilisation (IVF) cycle

In Vitro Fertilisation (IVF)

Dr.Alka (Infertility &IVF specialist, INDIRA IVF, UDAIPUR) explained thesteps involved in In-vitro fertilization (IVF) in detail.Every couple that visits our clinic will initially be given an educational lecture highlighting the causes of infertility and the basis of how we individualize our plans. This is followed by a one on one meeting with each couple to discuss their case.

After this we carry outbasic blood tests for the couple, an Anti- Mullerian hormone test for the female partner and a semen analysis of the male partner. The female partner then gets a baseline ultrasound done.

  • After the couple has finished their screening, an individualized treatment plan will be developed. They will follow their plan until pregnancy is achieved. Since each case is different, each treatment plan will be different.

An example of an IVF treatment plan

  • Baseline ultrasound
  • Initiation of hormonalpills if required
  • Ovarian stimulation and monitoring
  • Trigger shot for maturation, rupture of follicleand oocyte retrieval
  • Fertilization
  • Embryo transfer (3, 5, or 6 days after retrieval)
  • Pregnancy test (15 days after transfer)
  • Early OB ultrasound (4-5 weeks gestation)

Baseline ultrasound

Whenever the patient visits our centre, we will perform a transvaginal ultrasound scan to examine their ovaries and take an antral follicular count which gives an idea of the patient’s ovarian reserve.We also look at the uterus, if endometrial thickness is appropriate for that phase of the menstrual cycle and if any pathologies of the Fallopian tube are visible. This procedure is used to ensure that the ovaries are not producing eggs at the moment (are suppressed).  In some cases, women may develop uterine fibroids, infections of the fallopian tubes orovarian cysts or endometriomas. If we detect a cyst, we may not continue therapy until the cysts resolve on their own or advise the right surgical treatment as deemed necessary. If the baseline ultrasound is normal, we will begin stimulatory medication.

Initiation of hormonal medication

Some patients will receive hormonal medication at the start of their IVF cycle. The possible benefits include:

  • Shortened use of ovarian suppressive drugs such as GnRH-agonists
  • Decreased chance of developing ovarian cysts prior to starting gonadotropins.
  • Improved ovarian response during ovarian stimulation resulting in better egg recovery.

It is important to suppress the ovaries before starting stimulation medications. This helps to optimize the chances of uniform or synchronous follicle growth which in turn leads to better retrieval rates at the time of egg pick up.

Ovarian stimulation

The specific stimulatory medication depends on an individual protocol (procedure). It may include any or all of the following medications:

  • GnRH-AGONISTS (e.g. Lupron,Triptorelin) – The desired effect is to prevent premature release of the developing eggs. This medication suppresses the pituitary gland. This, in turn improves the recruitment of multiple follicles which leads to a better oocyte or egg retrieval.
  • GnRH ANTAGONISTS (e.g. Ganirelix, Cetrotide) – This medication has similar effects asAgonists but works in a different way. It can also improve ovarian response.
  • Gonadotropins (e.g. follistim, Gonal-f, menopur, repronex, bravelle) – This medication includes Recombinant FSH and LH or HCG and helps to stimulate follicle development and egg maturation. Recombinant injections provide the benefit of minimal side effects with a better response to stimulation.

The medicines are injected just underneath the surface of the skin that is subcutaneously.

Follicular monitoring

Along with the stimulatory injections, we will monitor the patient in the clinic using ultrasounds and if required hormonal measurements.  Patients are usually seen every one to three days depending on follicle growth. This frequency allows us to adjust the dose of medication in an effort to improve follicular development and decide when to add medications as well as when to give the trigger injection to rupture the follicles.

Final maturation / Trigger injection

Oocyte retrieval

Trigger injections include HCG or Gnrh Agonist. Thirty-six hours after the trigger injection, our team will perform an oocyte retrieval or ovum pick-up procedure, which involves removing eggs from the ovary.During the retrieval, we will use general anaesthesia. An anaesthesiologist will monitor the patient.

A very thin needle attached to a transvaginal ultrasound probe is inserted into the vagina and into the ovary. The contents from each follicle will be drawn into a test tube. The contents will be immediately delivered to our embryo laboratory and examined to find oocytes or eggs. The egg retrieval takes approximately 10-15 minutes.

The patient will be able to return home after a brief recovery from the procedure. Because of the powerful narcotics and effects of the anaesthesia, they must have someone else drive them home.  Most patients continue to rest at home for the remainder of the day. Soreness, cramping and mild vaginal bleeding is common on the night of retrieval. We will prescribe pain medication before the patient leaves the clinic. They should feel back to normal by the following day.  After the retrieval, the ovaries remain enlarged for the next several weeks. There may be side effects such as mild bloating, abdominal pain or spotting per vaginum which disappear in a few days after the ovum pick up.

Fertilization and Blastocyst Culture

A semen sample is generally collected on the day of retrieval and processed by the laboratory for the IVF procedure. In some cases, a frozen sample can be used, particularly when a sample from a sperm donor is necessary. Eggs are then inseminated with the sperm sample. On the day five after the retrieval, we will call the patient and let them know the number of eggs that fertilized and developed into Day Five embryos or blastocysts.

Embryo transfer-fresh or frozen

If fresh embryo transfer is advised then the procedure will happen three to six days after the oocyte retrieval. The timeline is based on what the doctor and embryologist determines will be most successful.

However we prefer frozen embryo transfer as it provides better results so the patient is called after giving medications for endometrial preparation either in the next menstrual cycleor as per their convenience

A catheter (tube) will be inserted into the uterine cavity to place the embryos chosen for transfer.  In this case, as well, we will use an abdominal ultrasound to watch and guide what is happening inside.  This procedure requires a full bladder. That permits our staff to best see the uterus, and allow for the best possible placement of the embryo(s).

The team of doctors and embryologists will work with the patient to decide on the number of embryos to transfer.  A number of factors will be looked at in making this decision:

  • Quality and number of embryos retrieved.
  • Age of the patient
  • Previous pregnancies.
  • Whether they have had a previous transfer

At one time we advise either a two embryo transfer or a single embryo transfer in some cases.

Embryos that are not chosen for transfer and that meet freeze criteria will be frozen and stored for later use, if desired by the patient.

On the day of the transfer, we provide the patient with specific instructions. The information whether bed rest is necessary, medications and other important directions to follow until the day of their pregnancy test.

Luteal phase

Progesterone (a hormone naturally made by the ovary) helps to support the uterine lining. It’s important in helping a healthy pregnancy develop. Progesterone supplementation increases the chance of success with IVF.  For this reason, we prescribe progesterone injections around the time the embryo transfer is planned and after the transfer they will take it either by injection and/or vaginal suppository. Progesterone supplementation is used worldwide for IVF and other infertility treatments. It is the same natural hormone the ovaries produce and is used in a dose that is not excessive. Progesterone will be continued at least until the pregnancy test and longer once the patient is confirmed to be pregnant.

Pregnancy

Pregnancy test

A pregnancy test is performed approximately two weeks after the egg retrieval. In this period the patient is advised to continue with their normal routine.Pregnancy symptoms are not a reliable sign of pregnancy success or failure, because symptoms may come and go. Bleeding is also more common following IVF.

Vaginal bleeding after the transferdoes not means that the procedure was unsuccessful. A blood pregnancy test (hCG level), approximately 15 days after embryo transfer confirms the pregnancy. If the hCG level is borderline we may ask the patient to repeat the test after 48 hours.

Early obstetric ultrasound

Fifteen days after a positive pregnancy test, an early antenatal ultrasound will be scheduled. This will be about one month following the embryo transfer.  This ultrasound is done transvaginally (as opposed to abdominally). We will look for an early fetal heartbeat, a yolk sac and gestational sac.  If the ultrasound shows all of these elements, and is determined to be normal, we will start medications to support the pregnancy and those recommended in early pregnancy.Since these pregnancies are precious, we ask the patient to follow up with us in the antenatal period and we look after each case carefully till term.

 

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