In-Vitro Fertilization & Embryo Transfer


The birth of Louise browne in 1978 marked the evolution of a new era in the treatment of infertility. For the first time scientists (Dr Patrick Steptoe and Robert Edwards) were able to retrieve a human egg, fertilize it in vitro with the husband's sperm and replace the embryo into the womb of the uterus to produce the world's first IVF (test-tube) baby. Within a few months, India reported the second IVF success in the world from Kolkata.

IVF was originally introduced for women with irrepairably damaged tubes. Today, it is a first line therapy for a variety of problems such as endometriosis, tubo-peritoneal disturbances, pelvic adhesions, PCOD and cases of unexplained infertility. Also, patients who have had repeated failures of IUI or simple treatment methods in the past qualify for IVF.

In vitro fertilization (IVF) literally means "fertilization outside the human body" or, in broader terms, in the laboratory. This term applies to any form of assisted conception where fertilization takes place outside the body

In-Vitro Fertilization & Embryo Transfer
The initial screening would cover
  1. Hormone estimations such as a serum AMH (can be done anytime during the menstrual cycle), FSH (to be done on 2nd day of menstruation), LH (to be done on 2nd day of menstruation), Prolactin and TSH (early morning fasting on any day)
  2. Transvaginal ultrasound to diagnose any ovarian cysts, submucous fibroids, endometrial polyps, chocolate cysts and hydrosalpinges which would require a surgical correction prior to IVF.
  3. Routine hematological investigations such as CBC, fasting and post prandial blood Sugar, HIV, Hepatitis B & C, VDRL, Hemoglobin electrophoresis for thalassemia or sickle cell anemia, G-6PD and other tests as applicable (for eg – sickle cell for African patients, etc)
  4. A semen analysis to diagnose any problem with the male partner and take a decision between IVF & ICSI (the latter being preferred in the presence of low sperm counts or poor sperm motility & also in case of unexplained infertility)
  5. Diagnostic or operative laparoscopy or hysteroscopy or both to ensure that the uterus is in top form for receiving an embryo and also to enhance the patients fertility

The next basic step after recruitment would be selection of the ideal ovarian stimulation protocol.

Controlled Ovarian Stimulation

  • GnRH-agonist (gonadotropin releasing hormone agonist) or a GnRH-antagonist (e.g. Cetrotide / Ganirelix) to prevent release of the eggs before doctor can retrieve them
  • FSH (Follicle stimulating hormone) or hMG (Human menopausal gonadotropin) to stimulate development of multiple follicles and ensure a cohort of good quality and mature eggs
  • HCG (Human chorionic gonadotropin) to cause final maturation of the eggs in the follicles

The purpose of the GnRH-agonist / antagonist is to suppress release of LH (luteinizing hormone) from the woman's pituitary gland during the ovarian stimulation process. In simpler terms, they prevent premature rupture of the follicles and eggs before they can be retrieved for the IVF process.

The purpose of the FSH product is to stimulate development of multiple follicles (structures that contain eggs) in the ovaries.

Every month, as you approach ovulation, a number of follicles begin to mature (exactly how many varies, and depends on your age). Usually, the follicle that is mature first is ovulated, and all the other developing follicles shrink away and are lost in a process call atresia. When you are on the hormone treatment, most or all these developing eggs are allowed to continue growing until a number of them have reached maturity. In this way, we can make use of eggs that would have otherwise been wasted, without using up your egg reserve any faster. Thus, there is no need to fear early menopause because of these treatments. Throughout the stimulation period, you will need to visit us for ultrasound monitoring and sometimes blood hormone levels. This will help us know when there are enough follicles that are mature enough for us to go "egg pick-up".

How to minimize your stay in Mumbai?

Please enquire about availability of injections/tablets as follows – Leuprolide acetate (brands – Lupride, lupron, luprdex, lupronin), Busaralin acetate (brands – Suprefact, Busarlin), Triptorelin acetate (brands – Decapeptyl) or any other GnRH agonist. Also, enquire for availability of oral contraceptive (birth control) pills (common brands – ovral L, novelon, femilon, triquilar, duoluton-L, ovral G, diane) Depending upon whether injections or tablets are available you can inform us and we may ask you to follow one of the following protocols.

  1. Long protocol – Begin Inj Lupride / Busarlin 0.5 ml subcut once daily from 21st day of periods (counting from 1st day of periods) – take for 15-20 days – to be continued until arrival in Mumbai after a minimum of 15 injections (arrival on the first Friday after 15th injection). To be continued during (menstruation) periods. Procedure would be completed in 20 days after arrival
  2. Short protocol – Begin one tablet of any birth control / contraceptive pill packet – from the 2nd day of your periods (in the month preceding the month of arrival) – take one tablet daily and inform the clinic about the date of starting the pill. We would ask you to take the last tablet on any Sunday and arrive on the following Friday after that. Stay would be for 20 days after arrival.
  3. Alternative short protocol - If flight (Visa) / train bookings are possible at short notice: Begin tab progynova (estradiol valerate) 2mg twice a day from the 25th day of the periods – Then wait for your next period. Arrive in Mumbai on the 2nd, 3rd, 4th, 5th or latest 6th day of periods. Make sure that you keep taking the pills even during your menstruation and until you meet dr jatin. This kind of programming helps us to begin injections for IVF as soon as you arrive without having to waste time waiting for periods to start.
Sample long agonist protocol Prescription

Inj Progesterone 100 mg deep IM on 21st day of periods (if Polycystic ovaries with irregular periods). This would help you to get a period on time.

Inj Busarlin / Leuprolide 0.5 ml subcut once daily from 22nd day of periods to be continued until arrival in Mumbai. Arrival is after 15-20 days of injections

Arrival can be timed for the first Friday after a minimum of 15 injections – injections have to be continued until the day you see dr jatin. You can postpone your visit by a week or two if you have flight ticket problems. Just make sure that you keep taking the injections (even if you arrive on the 10th or 15th day of periods the remainder of the treatment will be unaffected)

Sample short protocol discription

Begin Tab Ovral L (Birth control pill) from the 2nd day of your periods (for eg: say that is 4th of January). You still have to apply for VISA and book your flight ticket. Once that is done, you communicate to the clinic that you are for the short protocol and would like to arrive in the third week of February. We would then ask you to keep taking the pill until 16th of February (a Sunday- last pill on Sunday night) and arrive on the morning of 20th February (a Friday – that would be the 2nd day of your period). Do not stop the pill after 21 days. Just get another pack and keep taking as per instructed dates.

Ovarian stimulation after arrival at the clinic

After a Transvaginal ultrasound to confirm that all criteria are fulfilled you would be asked to begin injections of Follicle stimulating hormone to produce multiple eggs. The dose would be decided by Dr Jatin based upon your age, weight, serum FSH and AMH levels, previous IVF treatment records (if any), and other clinical criteria. The follicles would be monitored several times thereafter until the leading follicles reach a size of 18 mm. At this time the night trigger (injection hCG – 10000 IU) is administered and the egg retrieval is performed after 36 hours in the morning hours.

CAUTION

  • If you are on long agonist protocol and there are more than 20 eggs (and serum estradiol is > 5000 mIU/ml) we might cancel the cycle to avoid the complication of ovarian hyperstimulation which can sometimes cause lot of discomfort and pain.
  • If there are too many eggs but serum estradiol is < 5000 miu/ml, we would pick up all the eggs, fertilize them and cryofreeze all the embryos (no fresh embryo transfer in that cycle). This would reduce the severity of any pain or discomfort that follows (severe if you get pregnant in that cycle)
  • If there are very few eggs and embryos OR if you have a history of a biochemical / ectopic pregnancy in a previous IVF cycle OR if the lining of the uterus is < 8mm in thickness, the clinic would rather freeze the embryos and transfer them in the next cycle. These modifications have been introduced since the past year in view of very high pregnancy rates with a "freeze-all" approach and transfer in the next month when due attention can be paid to proper development of the lining of the uterus
IMPORTANT NOTES ABOUT INJECTIONS
  1. Most of the injections need refrigeration. An uninterrupted cold chain is important right from the factory to the patient's home. The clinic takes all due precautions to ensure that this is complied with
  2. Your injections need to be packed with coolant packs for transportation to and from the clinic to your home
  3. Please ensure that the person administering the injection is also conscious of this fact

Collection of Eggs

Usually, the egg pick-up is performed through the wall of the vagina, guided by ultrasound. We prefer a short acting anesthesia to help you remain pain free. You will recover within half an hour of the procedure. The ovaries are scanned through the vagina, in the same way that they were during your monitoring. A needle is placed through the wall of the vagina and into the ovary, where the follicles are emptied of their fluids and their eggs. Normal operating time is about 5 to 10 minutes. We have some very nice and well designed rooms / deluxe suites for your quick post operative recovery. Most rooms have an attached toilet, television, seating arrangements for your husband / relatives, electronic safe for your valuables and some great décor.

Simultaneously, an embryologist is present at the time of the procedure in the embryo culture laboratory, looking through the follicular fluid, finding the eggs, and scoring them according to their maturity and quality. Precautions are taken to maintain the eggs at body temperature at all times. The key to higher success rates is speed in the embryo laboratory and this is one area where our clinic is very fast. The average ovary to incubator time of the egg is usually less than one minute owing to the proximity of the lab to the operation theater in compliance with international standards.

Collection of Sperms

To ensure that we have an adequate quantity of sperm for IVF, abstinence for more than 2 days is recommended before giving the semen sample. However, in the light of new research in this area it now seems that even just one hour of abstinence is enough and this may in fact give better quality (fresh) of sperm for IVF.

Sperm collection can be done in one of our special, very private collection rooms. You may do this alone or together with your wife, whichever you prefer. We also have a specially designed masturbatorium with a nice automatic recliner, television, visual aids if you would prefer that. This is as per international norms for IVF clinics.

Sperm freezing in advance / as a back-up / in cases with very low sperm counts

If you anticipate that you will have any trouble providing a sample on the day of the egg pick-up procedure, please inform any of the staff and we can arrange to have the sperm frozen anytime before the day of the actual procedure. This would help in avoiding.

Fertilization

The semen sample (in a beaker marked with your name) will be taken to our embryology lab, which is adjoining the operation theatre where you will have had the egg retrieval procedure. Once in the lab, the eggs are isolated from the fluid and other cells, and prepared for IVF. The prepared sperm and eggs are cultured in a glass dish filled with a nutritive medium. The eggs are then left in an incubator overnight. The next day, the eggs are checked for signs of fertilization. You can tell the difference between a fertilized egg and an unfertilized egg by two faint spheres visible in an egg after fertilization (2-pronucleur stage)

These two spheres (pronuclei) hold the DNA of the sperm and the egg, and will fuse to form the nucleus of the embryo (called syngamy). The fertilized eggs will be left to grow for several days in the laboratory. The embryos grow in the special mini-incubators (Minc, Cook, Australia) that hold only 8 culture dishes, so that your embryos are not disturbed every time someone else's embryos are checked on, as they would be in the traditional bigger incubators. The embryologist will record how many eggs are successfully developing, and two or three of the embryos will be chosen for the embryo transfer. Any remaining good quality embryos wil be 'frozen' for future use (in the next month if the fresh cycle fails or for your second or third pregnancy if the first one is successful)

By the time the embryo is transferred, it consists of at least 2 to 8 cells, surrounded by a soft "shell" (the zona pellucida). After the transfer, the growing embryo will need to hatch out of the zona pellucida to implant in the lining of the uterus. On the day of embryo transfer you would be provided all details about number of eggs, number of mature eggs, number of fertilized eggs, number of embryos, the quality of the embryos, number of embryos being transferred (not more than 2-3) and number of good quality embryos being vitrified (cryo-frozen)

Embryo Transfer

The embryo transfer itself is a very simple procedure, usually taking just about half a minute, and requiring no anaesthesia or sedation. You could, however, request an anesthetic if you are unduly nervous or uncomfortable with vaginal manipulations. An ultrasound machine is kept handy in every room just in case your embryo transfer is anticipated to be difficult and we need ultrasound guidance.

A small speculum is introduced in the vagina to expose the mouth of the uterus (cervix). The outer sheath of the embryo transfer catheter is then negotiated through the cervix. Dr Jatin then returns to the lab, loads the best two embryos into the inner sheath and comes back to guide this through the outer sheath into the uterine cavity. Very gently, the embryos are then injected into the top part of the uterus. This may be confirmed by ultrasound if required. The catheter is withdrawn and you will be asked to rest for ten minutes.

The front and back of the uterus are normally touching, and this holds the embryo in place so do not worry about them being displaced or "falling out" if you happen to make any untoward movements or cough/sneeze. One of the greatest myths is that you have to take compete bed rest after the procedure. Please remember that it has been proven that more than 10 minutes of rest in fact reduces the success rate of IVF. Please remember this and communicate the same to your friends or relatives who are undergoing IVF.

After the Transfer

To make sure the lining of your uterus (the endometrium) is ready for the embryo to implant, you will need to have daily injections of progesterone in oil OR if you find this painful we have vaginal gel preparations of progesterone OR even effervescent tablets or capsules. More recently, we have available aqeous based progesterone injections for subcutaneous injections which are painless and devoid of side effects.

This helps the endometrium swell up and envelop the embryo so it has the best chance to implant.

From this point, it is a matter of waiting to see if an embryo implants successfully and begins to develop. A pregnancy test can be performed about 14 days after the embryo transfer and the IVF specialists or nurses or counselor will have the dates and discharge card ready for you when you exit the clinic.

Blastocyst Transfer

A blastocyst transfer is the transfer of an embryo from the laboratory to the uterus at day 5 of development, instead of day 2 or day 3. It is one way of selecting the embryo or embryos most likely to survive and implant, giving a better chance of pregnancy. However, every clinic has their own methodologies and experience with success with different days of transfer. Our clinic performs most transfers (especially egg or embryo donation) on day 2. Sometimes we do day 3. For patients who insist that they want a single embryo transfer (SET) OR do not want multiple pregnancies OR have high progesterone levels on the day of the trigger (and do not have the time to stay on for embryo transfer in the next cycle) we sometimes perform a blastocyst transfer.

To summarize, Blastocyst transfer might be recommended in any of the following situations:

  • Repeated unexplained IVF implantation failures
  • High serum progesterone on the day of the trigger (if freezing and transfer in the next month are not options in view of limited duration of stay in Mumbai)
  • To eliminate the risk of multiple pregnancy (single blastocyst transfer)

This does not have much advantage in first cycle patients or those who are undergoing egg or embryo donation cycles

Freezing Blastocysts

Normally "spare" embryos are frozen at the 4-8 cell stage, and provide good results when transferred after thawing. Of late, we have had excellent results with frozen and thawed blastocysts too

Assisted Hatching

May be required if the egg has a very thick outer coat

How is Assisted Hatching Performed ?

This is usually done with a laser unit which is attached to the ICSI microscope and ready at all times

BED REST

Research has shown that extended bed rest has very few benefits. In fact, some studies have shown that patients who have 24 hours of bed rest as compared to patients who have just 1 hour of bed rest have 7-13% lower pregnancy rate. We do not recommend any bed rest. You can have light activities for 3 - 4 days following which you can resume your daily chores as long as they do not involve lifting heavy weights or strenuous exercise.

What about sexual intercourse following Embryo Transfer ?

At the current moment, we ask couples to abstain from sexual intercourse for 15 days after embryo transfer. However, in view of current research findings that seminal fluid might also contain implantation factors besides sperm, sexual intercourse might in fact prove to be beneficial after embryo transfer. Further studies and research is required before this becomes routineadvise.

What should I expect from IVF cycle?

Please remember that IVF success rates even in the best centers in the world rarely exceed 30 - 40% per cycle. Persistence and faith are important. It is important to remember that the cumulative pregnancy rate after 3 cycles is close to 60 - 70%. With current embryo freezing and vitrification techniques, our cumulative pregnancy rate with one fresh and one frozen attempt is more than 60% which is heartening news for a lot of patients

COMPLICATIONS OF IVF

  • Ovarian hyperstimulaton syndrome (OHSS): This is a dreaded complication which can sometimes take a serious turn. Most modern clinics aim to achieve “OHSS-free clinic” status and ours has been extremely successful to that end. OHSS occurs due to abnormal response of the ovaries to the FSH injections (too many eggs). With serum AMH tests and DrJatin personally deciding your protocol and dose, the incidence of this complication now stands at < 3%. Patients who are very young, with polycystic ovaries and very slim are at high risk for this complication. So are patients with very high AMH levels. Most of these high risk patients are now advised the short antagonist protocol so that in the event that there is an excessive response we can change the night trigger (give leuprolide or decapeptyl instead of hCG), remove all the eggs, fertilize them and vitrify (freeze) all embryos. With this approach we ensure that there is no cycle cancellation and the success rate remains intact. If at all, for some reason, there are two many eggs with the long agonist procotol, we freeze all embryos, do not perform fresh embryo transfer (as the complication worsens only if pregnancy occurs in the same month) and give the patient tablets of cabergolin to ensure that the ovaries return to normal size at the earliest
  • Multiple pregnancy. Since 2013, the clinic transfers only 2 embryos in the first cycle and 3 if there are more than 2 failed cycles in the past. Under no circumstances do we transfer more than 3 embryos. For this reason, triplets or higher order multiple pregnancies have practically been eliminated. Even the incidence of twin pregnancy is < 20%. Multiple pregnancies are often complicated and can sometimes end in premature delivery and loss of the babies. For this reason, we prefer that the patient has one child at a time (like nature).

Embryo Freezing During IVF or ICSI Cycles

A new technique of embryo freezing was introduced two years ago (VITRIFICATION). Currently, success rates with embryo freezing and transfer in the next cycle (not the cycle in which eggs are retrieved) are in the range of 50-60% (10% more than with fresh embryo transfer). In view of this technology advance, the clinic might decide to freeze all your embryos and transfer them in the next cycle in the following situations:

  • Less eggs and embryos (less than 3 of grade 1).
  • Patients with low AMH and poor responders (pooling of embryos).
  • History of previous miscarriage.
  • History of previous ectopic pregnancy.
  • More than 20 eggs (hyperstimulation).
  • Endometrium (uterus lining) thin or < 7 mm in thickness.
  • Previous failed IVF cycles
  • Any other indication at the discretion of Dr Jatin.

The decision to freeze all and transfer in the next month might be taken during your IVF cycle and even as a last minute call – it is purely to give you a better chance and entirely in your own interest. More and more international clinics are moving towards frozen embryo transfers to:

  • Enhance pregnancy rates.
  • Avoid complications such as ovarian hyperstimulation.
  • Focus more on implantation from the point of view of the uterus and its lining (endometrium).
  • Avoid high order multiple pregnancies (triplets or more).
  • Make treatment simple and relatively painless.

Failed IVF / ICSI Cycle

Please remember that pregnancy rates with IVF/ICSI are in the range of 40-50% per cycle. After making provisions for early or late miscarriages, pregnancy losses, ectopic pregnancies, the net live birth rate is in the range of 37% per cycle. This means that 63% of treatments would fail. The common causes of failure are:

  • Suboptimal sperm quality (especially ICSI patients with sperm problems)
  • Suboptimal egg quality (patients > 35 years of age or low AMH levels, Polycystic ovaries and endometriosis)
  • Thin lining of the uterus (endometrium) or insufficient blood supply in the uterus
  • Hormonal imbalances created by the injections given to produce good eggs which might put the uterus out of phase for receiving the embryo
  • Improper response of the ovaries to the ovarian stimulation protocol used (short antagonist or long agonist)
  • Most importantly, the CHANCE (only 37% at best) per cycle. This implies that even if all goes well, failure might be unexplained and implies the necessity for more cycles or attempts
Measures might be suggested
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