IVF treatment in India

What is IVF and how does it work

IVF or In Vitro Fertilization is one of the more widely known types of Assisted Reproductive Techniques (ART). IVF works by using a combination of medicines and surgical procedures, to help the sperm fertilize an egg. Here the eggs are fertilized outside the human body and implanted in the uterus.These procedures can be used to help couples struggling with infertility and also in prevention of genetic problems.

A pregnancy starts with fertilization – when a woman’s egg joins with a man’s sperm. Fertilization usually takes place in the fallopian tube within the woman, which is a tube like organ that joins an ovary to the uterus. If the fertilized egg ( which is now called an embryo)successfully travels down the fallopian tube and implants in the uterus, an embryo starts growing on the endometrial wall, in the uterus

When this normal process of fertilization does not take place in couples who are planning to have a baby, advanced techniques of Assisted Reproductive Techniques (ART)are utilized to increase the chances of conceiving a healthy baby.

In an IVF cycle, eggs are retrieved from the ovaries and sperms are collected from the ejaculate (or surgically retrieved from the husband’s testes if ejaculation is not possible or if ejaculate has no viable sperms). These sperms are then allowed to fertilize the egg outside the body, in the laboratory. This fertilization can happen if the sperms and eggs are kept in close proximity to each other (called as conventional IVF) or is forced by pushing the sperm into the egg (through a process called as ICSI). The fertilized eggs are then cultured and ‘grown’ in the lab in conditions that mimic the woman’s uterus. The fertilized egg gets all nourishment from the culture media that it is kept in. An embryologist monitors the growth of the embryo. When the embryo has grown sufficiently, it is either transferred into the uterus of the woman (called fresh embryo transfer) or is frozen for a future transfer (called as frozen embryo transfer).

One full IVF cycle takes about three weeks but sometimes the procedure is split into parts, to manage certain challenges in the couples. This may delay the process.

IVF can be done using the woman’s own eggs and the male partner’s sperms or it may involve sperms, eggs or embryos from anonymous donors. Sometimes a gestational carrier (a woman who has an embryo implanted in her uterus) might be used. Such a carrier is called a surrogate mother and the process is called a surrogacy.

When is IVF advised?

There are various reasons where a couple may be advised IUI, to attain the joy of parenthood. IUI is recommended in the following situations:

Fertilization normally occurs in the fallopian tube and then the embryo travels down to the uterus where it gets implanted. Blocked or defects in fallopian tubes hinders the fertilization and movement of the embryo to the uterus .

If ovulation is not regular or absent then fewer eggs are available for fertilization.

A woman normally goes into menopause between the age of 42-56, but in premature ovarian failure her ovaries stop working normally much earlier

Endometriosis occurs when the uterine tissue implants and grows outside of the uterus and causes inflammatory changes in the pelvis. It often affects the function of the ovaries, uterus and fallopian tubes preventing the implantation of the embryo on the uterine wall. Endometriosis is one of the major cause for infertility.

Uterine Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s and 40s. Uterine fibroidscan interfere in the fertilization process where the egg and sperm are unable to meet, or the implantation process of the embryo,it can also affect the growth and positioning of the baby.

It occurs when a woman’s ovaries loses its reproductive potential, which can cause infertility. In Poor ovarian reserve the quality and quantity of the woman’s eggs are diminished and usually occurs around menopause.Aging is the primary cause of poor ovarian reserve.

The peak reproductive years of a woman is in her 20s. Fertility (the ability to get pregnant) starts to decline in her 30s, once you reach your mid 30s there is a rapid decline in fertility, getting pregnant naturally is unlikely for most women by age45.

Certain genetic factors affect fertility. Genetic abnormalities are of two types – single gene defects and chromosomal abnormalities. After the eggs are retrieved and fertilized, they’re screened for certain genetic problems though not all the genetic problems can be found. Embryos that don’t contain the identified problems can be transferred to the uterus.

IVF is advised in women who have had their fallopian tubes removed surgically either due to blocked tubes or a past ectopic pregnancy or tumor.

In Unexplained infertility the cause of infertility is not known despite evaluation for common causes.

IUI or intrauterine insemination is a relatively simple treatment for infertility, it may be done with or without fertility drugs. The procedure involves – transferring semen that has been washed in a special way directly into the uterus with a thin catheter. IVF is advised when repeated IUI procedures fail. The possible reasons why IUI fails might depend on age, egg quality , the sperm quality, the timing and endometriosis.

Maleinfertility refers to a male’s inability to cause pregnancy in a fertile female. Male infertility is commonly due to deficiencies in the semen and semen quality. Low sperm counts are often associated with decreased sperm motility and abnormal morphology,

This happens when the veins on a man’s testicle(s) are too large. This heats up the testicles. The heat can affect the number or shape of the sperm.

The factors that cause a man to make too few sperm or none at all may be advised for IVF

Poor motility of the sperm may be caused by the shape and size of the sperm which makes it difficult for the sperm to fertilize the egg. Sometimes injuries or other damage to the reproductive system block the sperm or changes the shape of the sperm .

Cancer treatment, such as radiation and chemotherapy, could harm your fertility, If you’re about to start treatment for cancer, you can opt IVF for fertility preservation . Women can have eggs harvested from their ovaries and frozen in an unfertilized state for later use. Or the eggs can be fertilized and frozen as embryos for future use.

Women who don’t have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF using another person to carry the pregnancy (gestational carrier). In this case, the woman’s eggs are fertilized with sperm, but the resulting embryos are placed in the gestational carrier’s (or surrogate mother’s)

IUI is a non-invasive and a painless procedure and can be done with your natural cycle with minimal medication. During ovulation, sperm cells are collected from the male partner and used in IUI. The chances of conception can increase with a combination of IUI and ovarian stimulation. The ovarian stimulation to produce multiple eggs could be achieved with specific medications that stimulate the growth of eggs in the ovaries.

How do you prepare for IVF ?

Various screening procedures have to be done before beginning an IVF cycle

  • Ovarian reserve testing – The concentration of follicle-stimulating hormone (FSH), estradiol (estrogen) and anti-mullerian hormone in your blood during the first few days of your menstrual cycle are done to determine the quantity and quality of the eggs. Test results along with an ultrasound of your ovaries help  the doctor to predict how your ovaries will respond to fertility medication.
  • Semen analysis – Semen analysis is done as a part of fertility evaluation before starting the IVF cycle
  • Infectious disease screeningBoth the partners are screened for infectious diseases, including HIV.
  • Uterine exam -The inside lining of the uterus will be examined before you start IVF .This might involve a sonohysterography an ultrasound to create images of your uterine cavity.

Procedure of IVF

 IVF involves several steps like ovarian stimulation, egg retrieval, sperm retrieval, fertilization and embryo transfer. One cycle of IVF can take about two to three weeks sometimes several cycles may be required.

Ovulation induction

The process of IVF begins with fertility medications and hormones, which are given to the woman for about 10 – 12 days to stimulate the growth of multiple eggs in the ovary.  Transvaginal ultrasound scans and hormone analysis is done to know the status of growing eggs.

One may need several different medications, such as

  • Medications for ovarian stimulation  follicle-stimulating hormone (FSH) or luteinizing hormone (LH) or a combination of both are injected to stimulate the ovaries. These medications stimulate more than one egg to develop at a time.
  • Medications for egg (oocyte) maturation –Specific medicinescalled triggers, like Lupride or HCG, are given to help maturation of the eggs when the follicles are ready for egg retrieval.
  • Medications to prevent premature ovulation These medications are given to prevent your body from releasing the developing eggs too soon.
  • Medications to prepare the lining of your uterus– Progesterone supplements may be given on the day of embryo transfer to make your uterus more receptive for implantation.
  • One to two weeks of ovarian stimulation will be needed before the eggs are ready for retrieval

To know the status of  the eggs  your doctor will perform:

  • Vaginal ultrasound- an imaging of your ovaries to monitor the development of follicles (fluid-filled ovarian sacs where eggs mature)
  • Blood tests-  are done to see your  response to  the medications given for ovarian stimulation. For example, estrogen levels increase as follicles develop, and progesterone levels remain low till ovulation. These will give an indication on how the woman’s body is responding to the hormones being injected.

Egg retrieval

Egg retrieval is done  34 to 36 hours after the final trigger injection and before ovulation. Once eggs are grown sufficiently and matured with the administration of the trigger injections, eggs are extracted through a minor surgical procedure called follicular aspiration that uses ultrasound to guide a hollow needle through the pelvic cavity to extract the eggs.  Patient is given general anaesthesia to decrease or eliminate potential discomfort.

Egg retrieval is done by a method called Transvaginal ultrasound aspiration. An ultrasound probe is inserted into your vagina to identify follicles and then a thin needle is inserted into an ultrasound guide to go through the vagina and into the follicles to retrieve the eggs.An abdominal ultrasound may be used to guide the needle if the ovaries are not accessible through a Transvaginal scan. Multiple eggs are removed from the follicles through a needle connected to a suction device. You may experience cramping and feeling of fullness or pressure after egg retrieval. Mature eggs are placed in a nutritive liquid (culture medium) and incubated. Healthy and mature eggs will be mixed with sperm to attempt to create embryos or ICSI procedure will be done to fertilize the eggs.

Fertilization

The male counterpart is asked to produce a sample of semen by ejaculating. The sperms and eggs are put together in a dish and stored in laboratory in a controlled environment to encourage fertilization.  In certain cases, a process called ICSI is undertaken where the sperms are pushed into the egg, without damaging the eggs. This will ensure fertilization.

The fertilized egg is stored in a special growth medium for about 48 hours until it divides and becomes an embryo containing 6-8 cells. At the same time, the woman is given supplements of progesterone hormone to prepare the uterus lining for implantation of the embryo.

Conventional insemination– Healthy sperm and mature eggs are mixed and incubated overnight.

Intracytoplasmic  sperm injection (ICSI) – In ICSI, a single healthy sperm is injected directly into each mature egg. ICSI is often used if fertilization attempts during prior IVF cycles failed.

Embryo Transfer

The embryos are usually transferred into the woman’s uterus three to five days after egg retrieval and fertilization.  A catheter or small tube is used to transfer the embryos into the uterus.  This procedure is usually painless for most women, although some women may experience mild cramping.  After successful transfer of embryos, implantation takes place inside the uterus resulting in pregnancy which can be detected by blood tests after 16 days of embryo transfer. If the test turns out to be positive, you go through the pregnancy phase as a regular pregnancy. a healthy and successful pregnancy happens through IVF treatment.

Fertilization is attempted using two common methods:

Frozen Embryo transfer

In an IVF cycle, one or more embryos develop and these embryos are usually frozen for later use. Usually, only one or two embryos are transferred into the women’s uterus during an IVF cycle as there are more chances of multiple pregnancies. The remaining embryos are frozen for future use. A fresh embryo transfer is done after two to five days after egg retrieval. A frozen embryo transfer is a procedure where a frozen embryo is retrieved from the cryo preservation tanks (filled with liquid nitrogen), it is thawed to normal room temperature, brought back to life and is then transferred into the woman’s uterus. The process of transferring into the uterus is the same as in a fresh transfer.

After the Embryo Transfer procedure

There may be a slight discomfort after the embryo transfer, normal daily activities can be resumed.Vigorous activity should be avoided. Breast tenderness due to high estrogen levels, mild bloating, cramping, constipation are some of the side effects seen after embryo transfer.

Results

Doctor will test a sample of the woman’s blood after about 12 days after embryo transfer, to detect whether it is a successful pregnancy.

  • If pregnant, the doctor, in most cases, will handle the case until three months – high risk period. Subsequently, the doctor may refer the woman to an obstetrician or other pregnancy specialist for prenatal care.
  • If not pregnant, the doctor will ask the woman to stop taking progesterone and the woman is likely get her period within a week.
The chances of giving birth to a healthy baby after using IVF depend on various factors:

Younger women are more likely to get pregnant and give birth to a healthy baby using their own eggs during IVF. To increase the chances of success, donor eggs are considered during IVF for women over 41 years or in cases where the egg quality or egg reserve is not sufficient.

Pregnancy rates  depends on the stage of the embryo, embryos that are more developed (blastocyst) is associated with higher pregnancy rates compared with less-developed embryos (day two or three).

Women who have previously given birth are more likely to be able to get pregnant using IVF than women who have never given birth.

Women who have severe endometriosis are less likely to be able to get pregnant using IVF than women who have unexplained infertility. Normal supply of eggs increases the chance of infertility

Obesity can decrease the chances of getting pregnant and having a baby. Use of alcohol, recreational drugs, excessive caffeine and certain medications also can be harmful. Women who smoke have fewer eggs retrieved during IVF and may miscarry more often.

What are the potential risks of IVF
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IVF slightly increases the risk of babies born early with a low birth weight.

In ovarian hyperstimulation syndrome (OHSS), ovaries become swollen and painful due to the use of fertility injections like HCG. Symptoms normally last a week and include mild abdominal pain, bloating, nausea, vomiting and diarrhea. However, your symptoms might last several weeks if you become pregnant. In some rare cases, a woman may develop a more severe form of ovarian hyperstimulation syndrome and in such cases, the women tends to gain weight and experience shortness of breath because of excess fluid in the chest, pelvic region and in the ovaries.

The rate of miscarriage for women who conceive using IVF with fresh embryos is similar to that of women who conceive naturally,but the rate increases with maternal age.

Rarely bleeding, infection, damage to the bowel, bladder, blood vessels can occur due to the use of aspirating needle to retrieve eggs. Sedation and general anaesthesia has its own risks.

when the fertilized egg implants outside the uterus, usually in a fallopian tube, it is called ectopic pregnancy. The fertilized egg can’t survive outside the uterus therefore it is not possible to continue the pregnancy.

The age of the mother is the primary risk factor in the development of birth defects, no matter how the child is conceived. So, babies conceived through IVF do not have any higher risk of birth defects. In fact, IVF babies are screened more diligently in the double marker, triple marker and anomaly examinations, thereby giving an opportunity to handle birth defects much earlier.

IVF or test tube baby is a blessing to every couple who cannot conceive. Millions of couples worldwide have benefitted from IVF, over the last few decades. These IVF babies are leading a healthy and normal life, like any other normally conceived child. Couples aspiring to have a baby of their own need not have to be lose hope. They just have to visit a good IVF centre and get the right advice