In Vitro Fertilization (IVF) is the treatment of choice for couples with non - repairable tubal disease or severe male factor infertility as well as for all other causes, including unexplained infertility, when conventional treatment has not been successful. During the IVF process, the ovaries are stimulated with injectable fertility medications to mature multiple eggs. Once monitoring with ultrasound and blood tests indicate that the eggs are ready, they are collected nonsurgically with an ultrasound-guided needle under deep sedation. The procedure takes about 20 minutes and is painless. Fertilization is accomplished by exposing the eggs to sperm in a culture dish, or by directly injecting a single sperm into each mature egg (intracytoplasmic sperm injection - ICSI). After fertilization, embryo development is monitored over the next 3-5 days at which time usually 2 or 3 embryos are placed into the uterus with a small catheter through the cervix. Excess embryos may be frozen for future use. For future details read IVF cycle. For patient with abnormalities in semen a single sperm is injected (ICSI) in the egg to assist fertilization.

In this procedure an extremely sharp needle is used to inject a single sperm into the center of the cytoplasm of each egg under microscopic guidance. This technique has been used in humans since the early 1990s. ICSI has dramatically changed the treatment of male factor infertility. The fertilization rates with sperm injection average 70% regardless of the severity of the male factor. This technique is used for men with severely depressed sperm parameters, men with absent or blacked has deferens, in cases where sperm is aspirated directly from the epididymas or testicle, and in cases with history of failed fertilization with IVF. The pregnancy rates with IVF/ICSI are the equivalent of those couples without male factor infertility who have standard IVF. F or patients whose condition requires the surgical extraction of sperm urologists trained in infertility perform the procedure of TESA/MEAS in our surgical OT

A full evaluation is needed for patients undergoing the IVF cycle which includes extensive patient education and a few diagnostic tests. This preparation may take 1 - 2 months.

In order for pregnancy to occur an egg has to be released from the ovary and unite with the sperm in the fallopian tube. This process is called fertilization. However in IVF the union occurs in the laboratory after the eggs and sperms have been mixed in a culture dish. The embryos so formed are then transferred into the uterus for further growth.

Which patients require IVF:

	Woman with blocked / damaged fallopian tubes.
	Male partner with sub fertile seminal parameters.
	Unexplained infertility
	Endometriosis
	Multiple failed IUI
	Patients with ovarian failure who option for egg donation.

Steps of IVF / ICSI cycle:

	Down regulation.
	Controlled ovarian hyper stimulation.
	Ovum pick up.
	Fertilization.
	Embryo transfer.
	Luteal phase monitoring.
	Implantation.

In a natural cycle, due to the control of the pituitary gland the ovary produces 1 - 2, eggs only. In order to remove the control of the pituitary and to eliminate the possibility of premature LH surge, most of the cycles of IVF / ICSI are down regulated. This is done with the use of GnRh agonist i.e. Lupreolid / buserelin.

There are various ways of down regulating and the most common method used, is the long protocol. Here 0.5cc of the GnRh agonist in injected subcutaneously starting from day 20 of the previous cycle. The patient is also given progesterone tab 10mg daily for 5 - 7 days. Adequacy of the down regulation is confirmed when LH is below 2, E2 below 20 and endometrial thickness below 4mm.

The other protocol using GnRh is agonist is the short protocol where in the agonist is added from the first day of menstrual flow.

This can be done using urinary gonadotropins or recombinant FSH. At the onset of menses HMG or r-FSH is started in the doss of 2 - 8 ampoules (75IU each) and the GnRH agonist continued in the dose of 0.2ml. On the fifth day of the treatment transvaginal sonography is done to assess the adequacy of the stimulation. Ideally the patient should have at least 5 - 10 follicles developing in both the ovaries and there should be no dominant follicle. If no follicles develop the dose of HMG/r-FSH is increased and serum prolactin level done. Sonography is generally repeated 3 days later. The follicles normally develop at the rate of 2mm/day. HMG/r-FSH with GnRh agonist is continued until the leading follicle reaches 18 - 20mm and or 2 follicles are 17mm and endometrium atleast 8mm thick and E2 level should be 150 pgm / follicle of 15mm size. Once these criteria are met the patient is give HCG 10,000 iu or LH (ovidril) one ampoule.

Flare up and stimulation: In patients with poor ovarian response the GnRh agonist is not used to suppress the pituitary but is used to cause a flare up action. It is given in the dose of 0.5ml subcutaneously twice a day for the first three days followed by the HMG / r-FSH injection.

GnRh antagonist: With the advent of GnRh antagonist, and down regulation step in IVF cycle is not done. GnRh antagonist cause immediate suppression of the pituitary gonadotropins i.e. FSH + LH. Thus the premature LH surge is prevented. HMG / r-FSH is started on day 2 or 3 of the cycle and when the lead follicle reaches 14mm i.e. usually day 6-7, GnRH antagonist is given subcutaneously until the day of HCG injection.

Depending on the quality of the developing embryos, a decision is jointly taken by the doctor and patient, as to how many embryos are to be transferred into the uterus. Usually 2 - 4 embryos are transferred. The procedure is done without anesthesia where in an atraumatic catheter is passed through the cervix into the womb under sonographic guidance. The embryos are then injected into the womb. To reduce the risk of multiple pregnancies we only transfer an appropriate no of embryos into the uterus. As a result, you may have additional embryos that we can freeze (cryopreserve) and store for transfer in a future cycle. Embryo freezing may then provide you with more than one opportunity to conceive from a single egg recovery cycle. However, it is your choice to select this option or not.

Embryo freezing involves laboratory techniques that allow us to store the embryos in liquid nitrogen at -192^oC for potentially very long period of time. Studies have not shown any increased risk of birth defects from babies born after embryo freezing when compared with those born from maternal age-matched naturally conceived pregnancies. Further more, the age-related pregnancy success rates and risk of birth defects corresponds to your age when the eggs were fertilized, not your age at the time you transfer them to your uterus. Preparation for the transfer of your frozen embryos involves the use of estrogen and progesterone in sequence to create a suitable “lining” layer in the uterus to allow the embryo to implant. Only the strongest appearing embryos are suitable for freezing, but even with this pre-selection, it is possible that some will not survive the freezing and thawing process. Only at the time of expected embryo transfer can we tell you how many embryos have survived the thawing process. Pregnancy rates following the transfer of frozen embryos are lower to those following the transfer of fresh embryo.

Successful implantation marks the beginning of a 9 - month gestation. The mother-to-be will return to her personal physician for prenatal care. If an embryo did not implant, the patient can use the frozen embryos or begin a new treatment cycle. Implantation of the embryo is the attachment of the embryo to the lining of the uterus until about 7 days after fertilization when the process of implantation starts. By this time the embryo, now known as the blastocyst, will have two distinct types of cells. One type will form the afterbirth (known as the placenta) and the other will form the fetus. The embryo begins burrowing into the endometrium and to secrets a hormone-BhCG which can be detected on the blood to confirm pregnancy. This HCG will continue to stimulate the corpus luteum so that progesterone production is maintained and the pregnancy can continue. The corpus luteum is so functional for the first 10 weeks of pregnancy then the progesterone production is taken over by the placenta. The most common place for the blastocyst to implant is at the top and back of the womb. Not all embryos implant and not all implanted embryos will further develop to fetuses, and not all fetuses end in healthy babies. Sometimes adverse outcomes can result, such as miscarriages and ectopic pregnancy. However, the majority of couples will end in having healthy babies. In vitro fertilization may not be successful in the first cycle and patients are encouraged to talk to their physician and to actively participate in planning for future treatments. The treatment cycle allows us to gather an enormous amount of information that is frequently beneficial to tailor a patient's future treatments.

Successful conception childbirth for any specific couple cannot be a guaranteed program, even if the couple under goes multiple cycles. The probability of success has many factors, including patients age the cause of infertility and the talent and experience of the IVF team. No centre can guarantee result but we try to minimize the stress by offering all facilities under one roof.

Copyright 2009 | Dr. Hitesh Parikh | Latest in IVF | Bandra, Mumbai - India