In-vitro Fertilization (IVF)

IVF is usually recommended if you have been trying to conceive naturally for over a year, with no success. But if you are over the age of 35 years, you should approach the doctor if you haven’t been able to conceive, even after trying for six months.

However, IVF is not considered as a first line treatment for everyone and depending upon the cause of infertility, you may be offered other treatments that are less invasive and usually less expensive.

To determine whether or not you need IVF, the doctor will run a few tests—it is usually a semen analysis for the man and a list of fertility tests for the women, to check her ovulation status, ovarian reserve, uterine lining, etc.

To get an honest evaluation of your infertility situation and seek the best possible treatment options, get in touch and consult with one of our top doctors.

IVF can help you if you have:

• Age-related infertility
• Anovulation
• Polycystic ovarian syndrome (PCOS)
• Endometriosis or pelvic adhesions
• Blocked fallopian tubes
• Poor egg quality
• Low AMH or poor ovarian reserve
• Low sperm count
• Poor sperm mobility
• Unexplained infertility

Also, to be a suitable candidate for IVF, you should be in good health so you are able to carry a pregnancy, once it is established.

The age of a patient can influence how successful IVF treatment may be. A fertility study published by Fertility and Sterility in 2003, concluded that age is a more important factor for IVF success as compared to FSH levels and that increasing maternal age correlates with a reduced implantation and pregnancy success rate.

IVF over the age of 40 has lower chances of success as both egg quantity and egg quality have usually declined by then. For this reason, many fertility clinics have an age limit for performing IVF. This age limit varies depending on the clinic but it is usually around 50 years.

If you are in your 40s and have been found to have a low ovarian reserve, you may be offered IVF with donor eggs.

If you are referred for IVF treatment, you will be prescribed either an Agonist treatment cycle or an Antagonist treatment cycle, which takes lesser time. An agonist cycle slowly down-regulates your hormones prior to starting the treatment. Whereas, with an antagonist cycle you will be injected with drugs starting on day 2 of your period, to stop the release of certain hormones.

Both treatment options have similar success rates. The Antagonist treatment cycle is usually offered in most cases.

A cycle of IVF is performed in distinct, key steps, as described below:

1. At the start of your period

   You will need to make an appointment to see your fertility doctor on day one or two of your period. Your doctor will be able to prescribe medications to stimulate a period if you do not have any or if they are irregular.

2. Suppression of your hormones

   Agonist cycle: At around day 21 of your cycle, your doctor will take a sample of blood from you and start you on a course of drugs to suppress your hormones.

   These drugs will be GnRH analogues, which suppress FSH (follicle stimulating hormone) and LH (luteinizing hormone) production and prevent premature ovulation. They will be prescribed to you for 12-28 days in the form of either an injection, pills, or a nasal spray. You will probably be able to administer your own injections at home.

   This treatment will temporarily make your ovaries dormant, so that they do not release eggs. This is necessary to prepare your body for the stimulation of ovulation.

   Be aware: The timings of these treatments may be changed by your doctor, in order to optimize your treatment based on how your body responds.

   Side Effects of GnRH analogues:

   Some women report that they experience headaches, hot flushes, night sweats and mood swings when taking these drugs.

   For the antagonist cycle, you will start from the next stage of treatment.

3. Ovarian stimulation

   A course of FSH injections will be prescribed to you over 5-12 days to stimulate the ovaries to make multiple follicles and eggs. You will also continue with the GnRH analogue during this time, unless otherwise advised.

   Antagonist cycle: If the GnRH analogue drugs are not needed, you may be prescribed an LH antagonist, after stimulation has started, to prevent ovulation.

   The doctor will perform an ultrasound after 5 days of stimulation, to check for follicular number and growth and the lining of your uterus.

   Follicle size: A mature follicle, in which an egg will grow, measures 18-30mm. It is normal to see 10-12 follicles, although this can vary. At least 3-4 mature follicles are needed for egg collection.

   Uterus lining: The uterus lining needs to be at least 7mm for a healthy transfer.

   The doctor may also take a blood sample to carry out some checks on your hormone levels, including progesterone and estrogen levels.

   Side effects of FSH drugs:

   Some women report bloating and discomfort as the eggs mature.

4. Trigger injection

   Once the follicles have reached the appropriate size, the doctor will prescribe you a HCG (human chorionic gonadotrophin) injection. This causes the eggs to mature and loosen their attachment to the follicle, to enable collection.

   All other drugs are stopped at this point.

   You will normally then wait 34-38 hours before egg retrieval.

5. Egg retrieval

   You will be sedated for egg retrieval, also known as ovum pick-up (OPU). A small, hollow needle will be passed through the vagina and into the ovaries where the eggs will be collected, using an ultrasound to locate them.

   As many eggs as possible will be collected and stored in an incubator until fertilization. This procedure normally takes around 30 minutes.

   Side effects:

   Following this procedure, you may experience some mild period-like pains and a small amount of bleeding from the vagina.

   Following this you will be given some medication to help optimize the lining of your womb, ready for transfer of the embryo.

   Also, at this point, the sperm will be collected and prepared.

6. Fertilization

   The eggs and sperm will be combined in a dish and left for 16-20 hours under controlled conditions to enable fertilization. The eggs will be checked the following day to determine if fertilization has occurred.

   The ICSI protocol may be used here in cases of poor sperm quantity or quality to optimize results.

7. Embryo culture

   Successfully fertilized eggs are assessed 2-3 days later for growth and quality. Doctors can transfer the zygotes at this stage or wait until day 5, when they reach blastocyst stage. Transferring blastocyst is associated with higher chances of success.

   At this stage the embryos may be frozen (if they are good quality) and genetic testing can be carried out if required, and if you have signed up for PGD and PGS testing.

8. Embryo transfer

   The best quality embryos will be picked by the doctor for transfer to the uterus.

   This procedure does not require sedation. It is similar to a smear test and may cause slight discomfort during the procedure.

   After this, the embryos are left to implant into the uterus wall, which can take anywhere between 1-10 days.

   You may be advised to follow some simple guidelines to improve the chance of successful implantation, for example:

   • Avoid long baths
   • No sex for 2 weeks
   • Limit activity for the day of transfer and take it easy for a few days afterwards
   • Take recommended pregnancy vitamin supplements and eat a balanced diet

Read the step-by-step details of IVF procedure, so you know what to expect before starting going to the doctor’s office.

Whilst transferring more than one embryo can increase the pregnancy rate with IVF, it can also increase the chances of a multiple pregnancy. Multiple pregnancies carry additional risks.

The main goal of IVF treatment is to provide you with a single, healthy baby.

However, each case is different and your doctors will look at your age and health to weigh up the risks and benefits for multiple embryo transfer.

Research has shown that older women may benefit from transferring two embryos instead of one, as the benefits outweigh the risks. Discuss in detail with your doctor to decide how many embryos to transfer in your IVF cycle, given your unique situation.

Transferring three or more embryos is usually not recommended as it could cause complications.

There are a number of options available to couples, including:

1. Storing for future use

   If you believe that you will want to expand your family in the future and infertility may still be an issue, you may opt to store your frozen embryos for use in the future.

2. Embryo donation

   You may wish to donate your embryos to other couple who are struggling with infertility. This is a very personal choice and it is important to think this through fully first.

3. Donate embryos to medical research

   Embryos can be used not only to better understand and to improve fertility treatments, but also to understand genetic conditions. This could make a vital contribution to medical understanding and treatment.

4. Dispose embryos

   Again, this is a decision that should be well thought through, but should you wish to, your fertility clinic can organize for the appropriate disposal of the leftover embryos.

Most patients as themselves “what if my IVF fails?”. This is a possibility that needs to be considered, as pregnancy in IVF is not guaranteed and infact, success rates in IVF are rather low. There are several options that may be considered if this happens:

1. Try further cycles of IVF

   There could be several reasons for failure of IVF, and if your doctor is able to figure out a certain cause in your case, it may be addressed in subsequent cycles. Preimplantation genetic testing may also be a viable option in future cycles, as it has been proven that PGS improves IVF success.

2. Surrogacy

   Some couples feel that they are unable to go through the process of IVF again as it poses risk to the health of the mother. Also, if your IVF failure was due to implantation failure, you may need to hire a surrogate.

3. Consider donor eggs

   Poor egg quality is the main reason for IVF failure in majority of the cases; healthier eggs from a donor may be recommended (especially if you are over 35 years of age)

4. Adoption

   This is a very personal decision but worth considering if your doctor tells you that your chances of conceiving are very low. You may also consider this if several cycles have failed, as the emotional and financial burden can be overwhelming.

IVF failure is something that needs to be discussed carefully and patiently, both with your partner and with your medical team.