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Edited by:
Dr Poonam Goyal | Dr Bhavana Mittal | Dr Sowjanya Aggarwal
Information Booklet for Public
WHAT IS IVF
Crosslay Society for Promotion of Medical Education & Research
W-3, Sec-1, Vaishali, Ghaziabad-201012, NCR-DelhiTel.: 0120-4173000, 4188000 Fax: 0120-4188199E-mail: [email protected] Website: www.pch.co.in
What is IVF?
Information Booklet for Public
Edited by:Dr Poonam GoyalDr Bhavana Mittal
Dr Sowjanya Aggarwal
“At 11.47 pm on 25 July 1978, the world's first IVF baby was born in the United Kingdom. Thirty four years later, many thousands of infertile couples have been blessed with a baby worldwide.
How many of us know that an average couple's chance of conception is only 20 %? Modern medicine has increased
this possibility to about 50% after decades of research. However, this 50% is not applicable for everyone; it changes from patient to patient and also to a certain extent, from centre to centre.
Though IVF does hold a lot of hope for couples, it is important to know all about it – the pros and cons, as well as the realistic possibilities before opting for the treatment. Couples who approach an “IVF” centre come with a lot of emotional and psychological stress, which can be addressed with the information and knowledge this guide provides.
This useful guide edited by Dr Poonam Goyal, Dr Bhavana Mittal, and
Dr Sowjanya Aggarwal has explained the process of fertilization, infertility and the treatment options available in very simple language, without compromising on the quality of the matter. This guide will be a very useful resource for all couples and their families.
Dr K K Gopinathan
HOD (Dept of OBG) & Unit Director - CIMAR
Centre for Infertility Management & Assisted Reproduction
A Unit of Edappal Hospital Pvt Ltd
Edappal Kochi, Coimbatore
Foreword
iii
The number of people with infertility has been gradually increasing over the
years and it is estimated that one in every eight suffers from this disorder.
Changes in lifestyle, social values and career goals have had an immense
impact on the progression of this problem. However, since infertility is
curable, an awareness of the causes and related treatment options is vital for
any infertile couple.
Pushpanjali Institute of IVF and Infertility is a modern Assisted Reproductive
Technology (ART) centre with the latest technology in the field dedicated to
helping couples with infertility. Our dedicated team of super specialist
doctors, trained laboratory technicians, staff nurses and administrative staff
provide holistic support to couples who come to us for solutions.
This Guide “What is IVF” will be useful for such patients and their families.
We hope that the guide will serve as a ready reckoner for all those seeking
information regarding infertility disorders. In addition, it will also be of
educational importance for all those individuals who value knowledge.
We are grateful to Dr Vinay Aggarwal and Dr Vijay Agarwal for their guidance
and unstinted support. Dr Gaurav Aggarwal needs a special mention for his
continuous and valuable inputs. We are also thankful to Dr Madhumita Puri
for her help and support in the compilation and editing of this Guide. Equally
invaluable are the services rendered by Ms Tabassum in designing the book for
which we are indebted; and also Ms Sini for her contribution.
Editors
Dr Poonam Goyal Dr Bhavana Mittal Dr Sowjanya Aggarwal
Preface
v
Introduction 1
1. Help your treatment succeed 2
2. Basics of human fertility - Ovulation, 3
fertilization and implantation
3. Intrauterine insemination (IUI) 4
4. Fertility enhancing endoscopic surgery 5
5. In-vitro fertilization (IVF) / 6
Intracytoplasmic sperm injection (ICSI)
Indications
Egg production
Egg recovery
Insemination
Embryo transfer
6. Outcome of IVF treatment 10
7. Percutaneous epididymal sperm aspiration (PESA) 11
and Testicular sperm extraction (TESE)
8. Some common issues of concern 12
9. Other treatments 14
Egg, Sperm and Embryo donation
Sperm donation
Egg donation
Embryo donation
Surrogacy
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Contents
Page No.
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Welcome to Pushpanjali Crosslay Hospital; and the Pushpanjali Institute of IVF and
Infertility!
This booklet explains the treatments we provide and, hopefully will answer many of
your questions. However, in case of any doubt or concern, please contact the staff. We
understand the anxieties surrounding infertility and its treatment and hence will
support you and keep you informed about the progress of your treatment.
Please read this booklet carefully as IVF and associated treatments are complex, and
the more you understand before treatment starts, the better.
Introduction
1
Watch your weight
The chance of becoming pregnant is
increased when women are the correct
weight for their height.
Stop smoking
Smoking can damage eggs and sperm.
Eat and drink healthy
Eat a well-balanced diet, and start taking
400μg folic acid daily.
1Help Your Treatment Succeed
2
Ovulation: With natural conception, a single egg develops in one of the
ovaries each month. It grows in a fluid-filled cyst (follicle) for about two weeks
before it is released – this process is known as ovulation.
Fertilization: After sexual intercourse, the egg enters the fallopian tube and
meets the sperm. Fertilization creates a fertilized egg or embryo. As the
embryo passes down the tube to the womb (uterus) its cells divide and grow.
Implantation: If the embryo implants in the lining of the uterus (the
endometrium), a pregnancy is established approximately one week after
ovulation.
The developing follicle produces a hormone (Estrogen). Estrogen levels can
be measured in the blood, and follicles can be seen using ultrasound scanning.
After ovulation, the follicle is transformed into a structure known as a corpus
luteum, which produces the hormone progesterone as well as Estrogen. These
hormones help support the lining of the womb and any developing pregnancy.
2Basics of Human Fertility - Ovulation,
Fertilization and Implantation
3
Induction of ovulation
In this treatment, gonadotropins stimulate the ovaries to produce between one
and three eggs. This treatment is used for women who fail to produce eggs but
have normal tubes and whose partner's semen is normal.
The injections usually continue for two weeks. The ovarian response is
monitored by ultrasound scans and blood tests. Once the scan and blood tests
suggest a mature follicle(s), you will be advised to have intercourse/IUI. If
too many follicles grow, treatment is stopped and it is essential that you use
condoms during sexual intercourse.
Intrauterine insemination (IUI) using donor or partner's semen
With IUI, specially prepared samples of semen are inseminated into the womb
using a fine tube passed through the cervix. This is not painful and is carried
out by our doctors.
We carry out ovarian stimulation in addition to IUI for many couples with
unexplained infertility. We offer IUI alone for couples with coital or
ejaculatory disorders. We also use IUI for couples requiring donor sperm
insemination.
3Intrauterine Insemination (IUI)
4
Laparoscopy
Laparoscopy is a surgical procedure that
involves making very small cuts in the
abdomen, through which the doctor inserts a
laparoscope and specialized surgical
instruments.
You may be advised laparoscopic surgery to help in diagnosing a cause for
infertility.
Some causes of infertility, like endometriosis, can only be diagnosed through
laparoscopy. Laparoscopy allows your doctor to not only see what's inside your
abdomen, but also biopsy suspicious growths or cysts.
Also, laparoscopic surgery can treat some causes of infertility, allowing you a
better chance at getting pregnant either naturally or with fertility treatments.
Hysteroscopy
Hysteroscopy is designed to allow the doctor to view scar tissue, polyps,
fibroids, and other defects located inside the uterus. Common Conditions
Treatable with Hysteroscopy
• Endometrial (Uterine) Polyps
• Fibroids in the Uterine Cavity
• Scar Tissue
• Uterine Septum
4Fertility Enhancing Endoscopic Surgery
5
Indications for IVF /ICSI
•
• Unexplained infertility
• Male factor infertility
- Total motile sperm count< 1 million
- <4% normal morphology and TMC< 5 million
- No or poor fertilization in the first IVF cycle when T MC <10 million
- No or poor fertilization in two IVF cycles when TMC > 10 million
- Epididymal or testicular spermatozoa
• Endometriosis
• Cervical / Immunological factor
• Hormonal disturbance
In-vitro fertilization (IVF) breakthrough in the late 1970s was the most
important advancement made in treating infertility. IVF or the “test tube baby”
technique – literally means that fertilization is made to take place in a glass
(vitro) dish or crucible. However, since the recent past, plastic crucibles are
used rather than glass ones, and in vitro now refers to any procedure taking
place outside the body.
In IVF treatment, eggs are removed from the ovary just before ovulation. The
eggs and sperm are put together in a dish. If fertilization occurs, the embryo is
Tubal factor infertility
5In-vitro fertilization (IVF) /
Intracytoplasmic sperm injection (ICSI)
6
cultured in an incubator and placed in the womb two or five days later. If a
pregnancy is achieved, the pregnancy continues naturally. IVF and its
developments are widely used to treat male and female disorders.
IVF is divided into four main stages:
Egg production
Egg recovery
Insemination and fertilization
Embryo transfer
Egg production
The chance of pregnancy is increased if more than one egg is recovered.
Initially the function of the ovary is suppressed using a drug called GnRH
agonist. The ovary is then stimulated with another drug called
gonadotrophins. The drugs are injected just under the skin, which rarely cause
soreness. Most women administer the injections themselves after training
from our nurses.
GnRH agonist injections begin approximately one to two weeks before the
start of a period. Gonadotrophin injections are administered when that period
starts. The GnRH agonist and gonadotrophin injections together continue for
another 10-12 days until you are ready for egg collection.
We routinely use this long treatment protocol. We may increase or decrease the
dose of drugs as you undergo treatment, depending on the results of your
blood tests and scans.
Blood tests during the period of stimulation are carried out to measure the
level of estrogen in the blood, to ascertain ovary response and to check for
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excessive response. Ultrasound scans using a vaginal ultrasound probe are
carried out to measure the size of the developing follicles. Vaginal scans do not
hurt and does not require a full bladder.
Egg recovery
Egg recovery is carried out under anesthesia and most women do not recollect
the egg recovery operation because of the drugs used.
Eggs are recovered by needle aspiration under vaginal ultrasound guidance.
Laparoscopic egg recoveries are only necessary in exceptional circumstances
when it not possible to use the vaginal route.
You will be admitted to the hospital ward for half a day. Do not eat anything
after midnight.
A single human egg surrounded by cumulus cells
Insemination and fertilization
The male partner provides a sperm sample on the day of egg recovery (unless
you are using frozen sperm). After egg recovery, the most active and normal
sperm are added to the eggs. The eggs and sperm are incubated overnight and
checked the next morning for signs of fertilization.
After the fertilization check, the embryos are left in the incubator to develop
Two or three days after egg recovery, the best one or two embryos are placed in
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the womb. These embryos are called early cleavage (EC) embryos. Any
remaining EC embryos of good quality may also be frozen.
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Day 2 – Two 4 cell embryos
Day 3 – 8 cell embryo
Embryo transfer
The number of embryos to be placed is made individually on the day of
transfer. Usually one to three good quality embryos is placed in any one cycle.
The remaining good quality embryos can be frozen for use in the future.
After embryo replacement you will be given another injection or hormone
pessaries to support the lining of the womb. Before you go home, you will
receive a date for a blood test to confirm pregnancy.
During this time, you should not do any strenuous activity or have unprotected
intercourse until the outcome of treatment is known.
Frozen embryo placement cycles
One or three frozen/thawed embryos are may be placed in each cycle, the
details of which will be discussed with you. Embryos are thawed before
placement and the best one or three embryos are selected for placement.
Frozen/thawed embryos are placed in a cycle controlled by drugs. This
involves GnRH agonist injections, followed by oestrogen tablets and
progesterone vaginal pessaries.
ICSI
Intracytoplasmic sperm injection (ICSI) is a refinement of the IVF technique
and offers hope to men with sperm problems and couples with suspected
fertilization defects.
If the sperm fails to fertilize the egg naturally or during IVF, this is usually
because the sperm fails to penetrate the egg's outer and inner membrane.
With ICSI, eggs are collected from the woman and sperm from the man in
exactly the same way as in IVF. After egg recovery,
a single sperm is injected with a tiny needle directly
into the egg. Approximately one in five eggs is not
mature and cannot be injected. Approximately
one in ten eggs which are injected will not survive.
If fertilization occurs, the embryos are replaced as
in standard IVF.
In current day scenario, most of the ART consultants prefer to do ICSI for all
patients in order of overcome fertilization defects and have better results.
A mature egg being injected with a single sperm
Intracytoplasmic sperm injection (ICSI)
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Conventional IVF
Egg SpermEgg
Sperm
Micro-injection
IVF and associated treatments have a limited success rate.
Approximately a fifth of IVF pregnancies may result in miscarriage after a
positive pregnancy test, a similar proportion as following natural conception.
Over one million babies have been born from IVF worldwide with no
indication of major health problems. There is no evidence that babies born
after frozen embryo replacement have an increased rate of abnormality.
6Outcome of IVF Treatment
11
PESA and TESE techniques are used when sperm is produced in the testes but
the sperm cells cannot enter the seminal fluid.
With TESE, the sperm is extracted directly from the testis and with PESA it is
aspirated from a tube lying next to the testis. The decision to use TESE or
PESA will depend on the diagnosis. The sperm is then injected into the egg
using ICSI.
7Percutaneous Epididymal Sperm Aspiration (PESA)
and Testicular Sperm Extraction (TESE)
12
Screening
All couples accepted for treatment are tested for syphilis, hepatitis B and C and
HIV. To minimize the risk of embryos contaminating other embryos in the
containers, treatment is only offered when both partners are negative to viral
screening. If you are found to carry one of these viruses, possibility of
treatment at another unit will be discussed.
Treatment cycle
The treatment cycle starts when you begin injections of gonadotrophins, and
is only considered to be complete after all embryos created during an egg
recovery cycle have been replaced. One cycle may therefore involve several
embryo replacements.
Labeling eggs, sperm and embryos in the laboratory
All samples are labeled with your name and hospital number. These details are
always checked against your hospital notes. In the laboratory, all containers
have your name and details written indelibly or etched on them. All procedures
eg, preparation of sperm is carried out for only one couple at a time and are
witnessed by two embryologists. All frozen embryos are stored individually
and labeled permanently with your full details.
Possible complications
IVF and its associated treatment can involve certain complications. There are
8Some Common Issues of Concern
13
two main risks - multiple pregnancy and ovarian hyperstimulation syndrome
(OHSS).
Multiple pregnancy
Generally, only two to three embryos are transferred. Twins are more common
– approximately 20% of all pregnancies. Multiple pregnancies have many
more complications than a singleton pregnancy. Premature birth is the most
significant, since babies born too soon may not survive or have serious life-
long disabilities. A multiple pregnancy also carries greater risk for the mother.
Ovarian hyper stimulation syndrome (OHSS)
In about 7% of cases, ovarian hyper stimulation can occur after the ovaries
have been stimulated for IVF. The severe form may have life threatening
implications. The ovaries swell and become painful and the high estrogen
levels cause nausea and vomiting. Fluid accumulates in the abdomen and
sometimes around the lungs. A small number of women – less than 1% - will
have severe symptoms and require hospital admission.
We monitor for OHSS throughout treatment and if your ovaries show
excessive response, the cycle may be cancelled. Sometimes, it is possible to
recover and inseminate your eggs and freeze the resulting embryos. The
embryos can be replaced two to three months later when symptoms have
settled.
Ovarian cancer
There have been reports that repeated ovarian stimulation increases the risk of
ovarian cancer, although no link has been proven. Women who have never
conceived have a higher risk of ovarian cancer. Women who conceive after
ovarian stimulation appear to carry the same risk of ovarian cancer as those
who conceive naturally.
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Egg, Sperm and Embryo donation
Some couples may need to consider the use of donated eggs, sperm or
embryos. Deciding to undergo treatment using donated eggs, sperm or
embryos will raise personal issues and requires careful consideration.
Sperm donation
Sperm donation may be offered to couples with a sperm disorder or those with
a high risk of passing on a serious genetic disorder.
Our sperm donors are carefully chosen, healthy men aged from 18 to 40, all of
whom are screened for Hepatitis B and C, HIV. We try to match the donor with
the male partner as closely as possible, with similar skin complexion, race,
height, hair and eye color. Donor insemination can either be used alone or in
conjunction with other procedures like IVF.
Egg donation
Egg donation is an option if the woman is a known carrier of a serious genetic
disorder or when her ovaries are absent, have ceased to function or are unlikely
to respond to induced ovulation.
9Other Treatments
15
Couples referred for egg donation will have a consultation and assessment
before treatment. The donor and her partner are also counseled. The donor
undergoes a cycle of ovarian stimulation as described above.
Embryo donation
Donated embryos can be offered to couples who have neither eggs nor sperm.
Surrogacy
Surrogacy is an arrangement in which a woman carries and delivers a child for
another couple or person. The intended parent or parents, sometimes called
the social parents, may arrange a
surrogate pregnancy because of
homosexuality, female infertility, or
other medical issues which make
pregnancy or delivery impossible,
risky or otherwise undesirable. The
sperm or eggs may be provided by
the 'commissioning' parents, but
donor sperm, eggs and embryos
may also be used.A gestational
surrogacy requires the implantation of a previously created embryo, and for
this reason the process always takes place through In Vitro Fetilization (IVF).
If the surrogate receives compensation beyond the reimbursement of medical
and other reasonable expenses, the arrangement is called commercial
surrogacy, otherwise it is often referred to as altruistic surrogacy. The legality
and costs of surrogacy vary widely between jurisdictions and is controlled in
India according to ICMR guidelines.
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