IVF ( In- vitro fertilization), commonly known as test-tube baby, is a procedure in which fertilization of egg with sperms happen outside of the human body. During this procedure, the eggs are removed from the woman’s ovaries and they are fertilized by the husband’s sperms. The resultant embryos are allowed to grow in the incubators for 3-5 days after which they are transferred in the mother ‘s womb. if the implantation is successful, the embryos grow as a foetus and finally the baby.
Indications or IVF
IVF has proved to be a boon for millions of childless couples and is used to treat infertility arising from a variety of causes. The most common indications for IVF include:
- Blocked Fallopian Tubes.
- Male factor infertility.
- Disorders in Ovulation.
- Unexplained infertility.
- Age-related infertility.
The IVF Treatment
All patients need to undergo a detailed workup before starting the IVF treatment. This includes blood investigations, a transvaginal ultrasound, and hysteroscopy or hysterolaparoscopy.
- Blood Investigations includes complete blood counts, rubella immunisation status, check for infectious diseases including HIV, HBsAg, HCV and VDRL; and thalassemia screening. In addition, thyroid and prolactin hormones and the hormonal assays to assess the ovarian reserve- AMH, Day-2 FSH & LH are also done.
- Transvaginal Ultrasound is done to assess the anatomy of ovaries and uterus and to rule out any major abnormalities like fibroids, polyps, ovarian cysts etc. If any abnormality is detected these may need to be tackled before the IVF cycle begins. TVS scan also helps to assess the ovarian reserve and the endometrium.
- Hysteroscopy is performed to find defects in the uterine cavity like polyps, fibroids, septum or adhesions. These abnormalities can prevent the implantation of embryos and can thus decrease the IVF success. Hysteroscopy is performed as a day care procedure under brief general anaesthesia. A Hysteroscope is a very thin telescope which can be passed into the uterus through the vagina and helps us study the structure of uterus from its inside. Any abnormalities detected can be corrected at the same sitting.
Ovarian Stimulation and Follicular Monitoring
It’s the process in which multiple hormonal injections are given to produce multiple eggs in the ovary. It is important to understand while only one egg is needed to have a successful pregnancy, not all eggs are good enough to yield pregnancy, and so gonadotropin injections are given to produce multiple eggs in the same cycle. Different protocols are used for ovarian stimulation and depend on the age, BMI and ovarian reserve of the patient. It is a controlled process in which injections are given not only to produce eggs but also to prevent premature ovulation. Usually a woman requires injections for 10-12 days. Serial transvaginal scans are done during this period to assess the growth of follicles and to titrate the dose of injections. Once the follicles are ready (majority of follicles reach the size of 16-18mm), a final injection trigger (HCG or GnRH Agonist) is given which prompts the egg to mature and be ready to ovulate. The egg retrieval is usually scheduled after 34-35 hours of final injection.
Egg Retrieval/ Oocyte Pick-up
The procedure is usually scheduled after 34-35 hours of final injection. The procedure is done under short general anaesthesia and requires admission for few hours. The procedure is done through vagina and doesn’t involve any incisions on the body. The patient is asked to remain fasting for 6-8 hours prior to the procedure. During the procedure, the vagina is thoroughly washed with sterile water. A needle is introduced under ultrasound guidance through the vagina into the ovary and all the follicles are aspirated one after the other. The procedure is then repeated on the other ovary. The aspirated fluid is collected in test tubes which are immediately transferred to the IVF lab where it is scanned to find the eggs/oocytes. The whole procedure takes around 20-30 mins. The recovery from anaesthesia takes approximately 3-4 hours after which the woman is discharged.
Before fertilisation, the husband semen sample is prepared and washed to remove all the dead sperms, debris and liquid from the semen and then good quality sperms selected for fertilizing the eggs. The eggs that have been retrieved from ovaries are then overlaid with 50,000 to 100,000 sperms from the partner.
The fertilized eggs called the embryos start dividing and become 4 celled by 2nd day, progressing to 8 cells by 3rd day and up to 100 cells by 5th day. The embryologist and the clinician keep a check on the growth and quality of the embryos. The final decision of embryo transfer and timing of the same is based on the embryo status & quality and the clinical details of the patient.
The embryos can be transferred to the womb either on Day 2, Day 3 or Day 5 following the egg retrieval. Usually 1-3 good grade embryos are transferred. The decision about the day of transfer and the number of embryos to be transferred is generally based on the number and quality of embryos formed, patient’s age and clinical indication of IVF. Any additional embryos are generally frozen and can be used in future, if required.The procedure is done as outpatient procedure and does not require anaesthesia. The patient is asked to report to the clinic with full bladder as it allows us to visualise the uterus using abdominal ultrasound. The embryos are transferred to the uterus using a thin catheter. After appropriate patient and embryo verification, the required number of embryos are loaded in the catheter which is passed in the uterus through the cervix. The exact location of catheter is checked by abdominal ultrasound and the embryos are then deposited in the uterus. The procedure is usually over in few minutes and is painless. After the procedure, the woman is asked to rest on the table for 15-20 mins after which she is allowed to go home.
Post Embryo Transfer
After the procedure, the woman is usually prescribed some medicines to support the pregnancy. The patients are advised to avoid any stress and vigorous activities like running, strenuous exercises or swimming. They are also asked to avoid any vaginal intercourse or orgasm and vaginal lubricants. There are no dietary restrictions. There is no need of complete bed rest. They are advised to keep themselves well hydrated and to drink plenty of clear fluids.
A pregnancy test is usually advised 2 weeks after the embryo transfer. If the test is positive the women is asked to continue the medicines. A repeat test is usually advised after 2 days to reconfirm the pregnancy. If the test is negative the women is asked to stop the medicines.An ultrasound scan to confirm the pregnancy is performed 3-4 weeks after the first positive pregnancy test.