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 irreversibly damaged tubes. Today, it is a first line therapy for a variety of problems such as endometriosis, tubo-peritoneal disturbances, pelvic adhesions, PCOS and cases of unexplained infertility. Also, patients who have had repeated failures of IUI or simple treatment methods in the past qualify for IVF. Another indication is patients with poor ovarian reserve and low AMH who wish to preserve enough embryos for a complete family (2-3 children). Also, more and more young girls who wish to delay child bearing owing to career or personal reasons are opting to freeze their eggs at a young age for use later in life. Elective or social egg freezing is the new norm for our young generation and immensely growing in popularity.
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.
The initial screening would cover
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).
Transvaginal ultrasound to diagnose any ovarian cysts, submucous fibroids, endometrial
polyps, chocolate cysts and hydrosalpinges which would require a surgical correction
prior to IVF.
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).
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). More recently we are also advising the sperm DNA fragmentation test (SDF or DFI) to ensure that the sperms are of optimal quality. Y chromosome deletions and sperm aneuploidy studies might be required in select cases.
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 fertility (for cases of hydrosalpinx, endometrial polyps, septum, intrauterine adhesions and other conditions)
For patients with recurrent miscarriages we often advise genetic testing (karyotype for both partners), APLA, ACLA, ANA, sperm DNA fragmentation and some other tests as indicated. For patients with hereditary conditions or history of an abnormal child we need to do a whole genome sequencing followed by IVF and PGT (preimplantation genetic testing) to ensure that a normal embryo is transferred.
Controlled Ovarian Stimulation
1 GnRH-agonist (gonadotropin releasing hormone agonist) or a GnRH-antagonist (e.g. Cetrotide / Ganirelix) to prevent release of the eggs and spontaneous ovulation. These are mandatory so that eggs can be retrieved and follicles do not rupture on their own.
2 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.
3 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.
Long protocol – Begin InjLupride / 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.
Short protocol – Begin tablets of Norethisterone
acetate 5 mg twice a day from day 20 of your menstrual cycle. This has to be continued
for a minimum of 7 and maximum of 14 days. We would ask you to take the last tablet
on any Sunday and arrive on the following Friday after that. This way, you would
arrive exactly on day 2 of your menses and we can begin the injections immediately.
Your stay in Mumbai would be for 20 days after arrival.
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 against 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.Alternatively, you can take tablets of primolut N or medroxyprogesterone as advised by the clinic
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 description
Tab Norethisterone 5mg twice a day from day 20 of your cycle (minimum 7 to maximum
of 14 days). We will tell you the date for stopping the pill and arrival into Mumbai.
Ovarian stimulation would begin 5 days after the last tablet (which would usually
be day 2 of menses as well)
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. This no longer happens as our selection
of protocol is tailored to your age, body weight, presence of PCOS, serum AMH levels
and past response.Our clinic has been free of this complication called ovarian hyperstimulation syndrome since the past 10 years.
• If there are too many eggs (with the long agonist protocol) 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). Things are easier with the short antagonist protocol (even if there are more than 20 eggs) where we just substitute the hCG injection with the agonist (decapeptyl) to negate the risk of ovarian hyperstimulation.
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 five years 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.
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 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.
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 undue stress or 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 a few days before the day of the actual procedure.
This would help in avoiding undue stress for our team as well as yourselves. In
the rare event of this happening we can still freeze the eggs and fertilise them
at a later date with the same outcome and results. Sometimes, we could also do an
emergency retrieval of sperm from the testes (for severe cases of “performance anxiety”).
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 will 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). We generally prefer freezing
of embryos at the 4 or 8 cell stage (and do not perform blastocyst cultures routinely).
Recent research has shown that cleavage stage embryo transfer might have better
outcomes than blastocyst transfer in a lot of patients. This decision would be at
the clinics discretion and always in your best interest. We routinely do blastocyst
transfers if the first cleavage stage transfer fails or if you are undergoing preimplantation
genetic testing for hereditary disease of other indications. Also, we perform single
blastocyst transfer if the patient already has a child and is very clear that she
does not want twins in the second round.
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 for successful and
correct placement of the embryos
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. DrJatin 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. Ultrasound guidance is not a mandatory requirement
if the uterus is of normal size and often adds to the discomfort of the patient
as it requires a full urinary bladder.
The front and back walls of the uterus lining 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.
To make sure the lining of your uterus (the endometrium) is ready for the embryo
to implant, you will need to insert vaginal gel preparations of progesterone OR
even effervescent tablets or capsules. More recently, we have available aqueous
based progesterone injections for subcutaneous injections which are painless and
devoid of side effects. For some indications, we might advise the progesterone in
oil injections as well. You would also be on oral estrogen tablets if you are undergoing
a frozen embryo transfer. In addition, supplements such as coenzyme Q, L-Arginine,
Vaginal tablets of sildenafil, low dose aspirin and blood thinners like LMWH (Heparin)
might also be required for some patients.
This helps the endometrium swell up and envelop the embryo so it has the best chance
to implant.
Once embryo transfer is done, 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 on day 3 or day 5 (Blastocyst). 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 perform a blastocyst transfer.
To summarize, Blastocyst transfer might be recommended in any of the following situations:
1 IVF implantation failures with day 2 or 3 stage embryos
2 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)
3 To eliminate the risk of multiple pregnancies (single blastocyst
transfer)
This does not have much advantage in first cycle patients or those who are undergoing
egg or embryo donation cycles.
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 routine advise.
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 hyper stimulation 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 too 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 pregnancies. 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
As per current guidelines, fresh and frozen embryo transfer have the same results and outcome if the endometrium is triple line and > 8mm, the serum Progesterone on the day of the hCG trigger is normal and the number of eggs retrieved are less than 10-15.
Freezing all the embryos and transferring them in the next month (Freeze-all) is recommended for the following conditions:
- Less eggs and embryos (less than
2 embryos of grade 1)
- Patients with low AMH and poor responders undergoing pooling of embryos.
- History of previous miscarriage.
- History of previous ectopic pregnancy.
- More than 10-15 eggs.
- 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
hyper stimulation.
- 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 50-60% per cycle. After making provisions for early or late miscarriages, pregnancy losses, ectopic pregnancies, the net live birth rate is in the range of 50% per cycle. This means that 50% of treatments would fail. The common causes of failure are:
- Suboptimal sperm quality (especially
ICSI patients with poor quality sperm or high DNA fragmentation indices)
- 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
50% 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.
SUGGESTIONS LIKELY TO GIVE A BETTER OUTCOME IN THE SECOND OR THIRD CYCLE:
- Repeat cycle,
maybe with a change in dosage or protocol. Switching from antagonist (short) to agonist (long) protocol, use of RFSH VS HMG VS COMBINATION VS HP-HMG, use of the dual trigger, fresh vs frozen transfer, day 3 or day 5 embryo transfer and addition of aspirin or LMWH (heparin) and other adjuvants might be recommended .
- Freeze-all : especially in patients with early miscarriages, low AMH, less embryos, thin endometrium or too many eggs (hyper stimulation.)
- Higher dose of
injections (FSH) to get more eggs and embryos (for freezing).
- 2-3 rounds of ovarian stimulation to pool more good quality embryos (in patients with low AMH and very poor egg reserve)
- Hysteroscopy for uterine enhancement
- Use of endometrial scratching or intrauterine instillation of G-CSF / intrauterine platelet rich plasma (PRP) to improve the receptivity of the uterus and implantation chances.
- Use of donor eggs (in case of repeated failures owing to poor egg quality, age more than 38, low AMH or recurrent miscarriages).
- Use of donor sperm (in case of repeated failures of ICSI or very poor sperm quality).
- Use of donor embryos (in case of both eggs and sperms being of poor quality OR when cost is an issue)
- Use of surrogacy (repeated unexplained or explained implantation failures owing to poor endometrium or problems in the uterus).