All About IVF

All About IVF

All About IVFBy Dr. Rajeev Agarwal

WHAT IS IVF or THE TEST-TUBE BABY TECHNIQUE? Test-tube baby treatment is the popular name for in vitro fertilization, usually shortened to IVF. It is the process by which egg and sperm are mixed outside the body and then returned to the uterus after fertilization. It involves the removal of an egg from the woman''s ovary, the collection and purification of sperm from her partner, the mixing of sperm and egg in laboratory and, if fertilization occurs, the insertion of the developing fertilised egg - the embryo - into the uterus.

The embryo, still quite invisible to the naked eye, is placed in its mother''s uterus usually two days after fertilisation, while it still consists of only a few cells and long before any organs have formed. WHEN SHOULD IVF BE CONSIDERED? The main situations when IVF may be worth considering are: * When the tubes are badly damaged and tubal surgery has less chance of success than IVF or in most cases where tubal surgery has already been unsuccessful. IVF should be considered because it bypasses the tubes.

* When the man''s sperm count is on the low side or abnormal, yet potentially capable of fertilizing an egg. Here IVF may be useful because fertilization can possible be manipulated and observed by the scientific team. This does not necessarily require sperm injection, or zona drilling, but simply very careful preparation of the sperm in suitable laboratory solutions.

* For certain women who have problems with the cervix perhaps ''hostile'' mucus, IVF bypasses the cervix and its mucus.

* For women who are not ovulating spontaneously, but who produce eggs on fertility drugs without conceiving. In this situation, the ability to force the ovary to produce many eggs and then select the best ones for fertilization and transfer means that IVF may be suitable option.

* For some women with endometriosis or with very carefully investigated infertility which remains unexplained. We think that endometriosis is an excellent indication for IVF and have had particular success.

* For couples who have several factors together which are causing infertility; commonly a combination of poor male fertility and tubal disease are the most usual indications.

* Most recently, for certain couples who are at high risk of having genetically abnormal babies.

1. TESTING A COUPLE''S SUITABILITY BEFORE TREATMENT

Preliminary preparation for an ART procedure may be as important as the procedure itself.

* Testing for ovarian reserve may be recommended in order to predict how the ovaries will respond to fertility medication.

* Blood Tests to assess the general health of the couple (ask the clinic for a complete list)

* Hysteroscopy to assess the inside of the uterus to look for problems like fibroids, polyps, or a septum may need to be corrected before IVF.

* Laparoscopy may be required to assess problems like endometriosis and to treat problems like hydrosalpinx; a fluid-filled, blocked fallopian tube which reduces IVF success should be removed prior to IVF.

* Lifestyle issues should be addressed before ART. Smoking, for example, may lower a woman''s chance of success by as much as 50%. All medications, including over-the-counter supplements, should be reviewed since some may have detrimental effects. Alcohol and drugs may be harmful, and excessive caffeine consumption should be avoided. Some vitamins especially folic acid is started.

The process of stimulating the ovaries to produce eggs is a controlled one and requires that the body''s own internal capacity to regulate that growth be stopped. Otherwise the eggs may mature early and their collection may not be possible. For this purpose an injection is started usually in the previous cycle (D21) or sometimes even in the same cycle. At a particular time, (usually D2) blood levels of Estradiol (E2) and LH are tested to confirm the down regulation before starting stimulation.

The best chance of successful pregnancy is obtained when more than one embryo is placed in the uterus at the same time. This is because so many early human embryos, normally fertilised, are lost or do not develop into babies. Consequently, one way of overcoming this natural loss is to put back several embryos simultaneously during IVF. During ovarian stimulation, also known as ovulation induction, ovulation drugs, or "fertility drugs," are used to stimulate the ovaries to produce multiple eggs rather than the single egg that normally develops each month. Multiple eggs are needed because some eggs will not fertilize or develop normally after egg retrieval. Drug type and dosage vary depending on the program and the patient. Most often, ovulation drugs are given over a period of eight to 14 days. Ovulation drugs include clomiphene citrate, human menopausal gonadotrophins (hMG), follicle stimulating hormone (FSH), recombinant FSH and LH, and human chorionic gonadotrophin (hCG). Gonadotropin releasing hormone (GnRH) agonists or GnRH antagonists are used in conjunction with these medications to prevent premature ovulation.

4. ASSESSING THE DEVELOPMENT OF THE EGGS

Egg collection is generally timed to within a few hours of when the woman is expected to ovulate. If eggs are not collected very close to this time, they may not fertilise properly. This is the main reason why so many tests are often done to confirm the status of the woman''s hormones and, thus, development of her eggs.

* Hormone tests: As the follicle swells, the hormone oestrogen (Estradiol or E2) is produced in increasing amount. Regular blood test can detect this increase.

* Ultrasound: The swelling follicle can be directly measures using Trans vaginal ultrasound. This is usually done daily. We know from experience that, when the follicle is about 20 mm across, ovulation is imminent.

Using ultrasound examinations and blood testing, the physician can determine when the follicles are appropriate for egg retrieval. Generally, eight to 14 days of FSH and/or HMG injections are required.

When the ovaries are ready, hCG or other medications are given. The hCG replaces the woman''s natural LH surge and helps the eggs to mature so they may be capable of being fertilized. The eggs are retrieved before ovulation occurs, usually 34 to 36 hours after the hCG injection is given. However, 10% to 20% of cycles are cancelled prior to the hCG injection.

Egg retrieval is usually accomplished by transvaginal ultrasound aspiration, a minor surgical procedure. Some form of anaesthesia is generally administered. An ultrasound probe is inserted into the vagina to identify the mature follicles, and a needle is guided through the vagina and into the follicles. The eggs are aspirated (removed) from the follicles through the needle connected to a suction device. The egg retrieval is usually completed within 30 minutes. Some women experience cramping on the day of the retrieval, but this sensation usually subsides by the next day. Feelings of fullness and/or pressure may last for several weeks following the procedure because the ovaries remain enlarged.

After the eggs are retrieved, they are examined in the laboratory The best quality, mature eggs are placed in IVF culture medium and transferred to an incubator to await fertilization by the sperm. Sperm, obtained by ejaculation or a special condom used during intercourse, are separated from the semen in a process known as sperm preparation. Motile sperm are then placed together with the eggs, in a process called insemination, and stored in an incubator. Fertilization occurs in the laboratory when the sperm cell penetrates the egg, usually within hours after insemination.

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