Fertility treatment: in vitro fertilisation (IVF)

IVF is the process by which eggs are removed from your ovaries and mixed with sperm in a laboratory culture dish. Fertilisation takes place in this dish, 'in vitro', which means 'in glass'.

Thousands of IVF babies have been born since the first in 1978. In 2012, about 3.5 per cent of all children born in Australia were conceived as a result of IVF treatment.

How might we benefit from IVF?

IVF is likely to be recommended for the following fertility problems:

• If you have blocked or damaged fallopian tubes or any other problem where IVF has been identified as the only treatment likely to help you get pregnant.
• If your partner has a minor problem with his sperm. Major problems are better treated using ICSI.
• If you have tried fertility drugs, such as clomiphene, or another fertility treatment such as IUI, without success.
• If you have been trying to conceive for six months to one year depending on your age and a cause hasn't been found to explain why you have not become pregnant.

How is IVF done?

IVF follows a series of steps, starting with fertility drugs, to help you produce more than one egg, the usual aim being eight to 12 eggs, but this will vary depending on your personal circumstances.

Making IVF work for you

There are a number of different medicines on the Australian market, and your doctor will consider different combinations of the above drugs and different strategies for conducting an IVF cycle depending on your individual situation.

The three most commonly used cycles in Australia are:

• Antagonist protocol
• Long down regulation protocol
• Flare protocol

There are multiple other protocols that can be used and your specialist will be able to recommend one best suited to your individual needs.

Fertility drugs

You'll probably need to take fertility drugs to stimulate your ovaries to develop mature eggs ready for fertilisation.

During your normal ovulation cycle you release one egg per month. Your odds of getting pregnant are better with more eggs and using fertility drugs increases the number of mature eggs that are released.

It's recommended that IVF be offered with fertility drugs to stimulate your ovaries as you have a better chance of pregnancy as a result.

In Australia, the process will generally start with one set of drugs to stop your pituitary gland from releasing hormones that stimulate the ovaries to produce and release eggs (GnRH agonist or antagonist drugs).

Another set of drugs will follow to produce multiple egg follicles (FSH containing drugs) and once those follicles are mature, a third drug is used to achieve final egg maturation (this is called a 'trigger injection' of hCG drugs).

Hormone injections

You'll also have daily hormone injections for 10 to 14 days. These stimulate your ovaries to release a greater number of mature eggs than usual (ovulation induction). The hormones used are gonadotrophin, follicle-stimulating hormone (FSH) and, in some infrequent cases, luteinising hormone (LH) is added.

Women respond to these fertility drugs in different ways, and they may have strong side-effects. Your doctor will closely monitor you to make sure that you are cared for if this happens.

Ultrasound scans and possibly blood hormone tests will be offered to monitor how many and how well your ovaries are responding. This is for your safety and to check when your eggs are mature.

Egg retrieval and sperm collection

An ultrasound is used to detect when your eggs are ready to be retrieved. This is based on the size of the follicles that contain eggs in your ovaries.

Your doctor will then remove the eggs from your ovaries, using a fine, hollow needle attached to an ultrasound scan probe. The probe helps to locate the follicles that contain the eggs.

In most cases, egg collection is done under sedation in an operating theatre, but it's possible to do it with local pain relief. If so, you may feel mild discomfort during the procedure, but if you feel pain later on your specialist will prescribe painkillers.

While your eggs are being collected, your partner will need to provide a fresh sample of semen. If donated sperm or frozen sperm is being used, the sample is taken from the freezer. The sperm is washed and the best-quality sperm extracted ready to fertilise the eggs. The sperm is then combined with the eggs in a dish and left to culture in an incubator.

Fertilisation and embryo transfer

Within one day of combining the eggs and sperm, the dish is checked to see if any eggs have been fertilised and embryos created. If they have, they'll be kept in an incubator for between two and five days before being transferred back into your uterus.

Any fertilised eggs will each have become a ball of cells called an embryo. They may also be referred to by your specialist as blastocysts, if the embryos are being transferred at the later blastocyst stage, at about day five. The healthiest embryos are chosen to be inserted into your uterus.

Some clinics offer a pre-implantation test called Preimplantation Genetic Diagnosis (PGD). This screens embryos before they are transferred at the blastocyst stage. Only the embryos that are predicted to have a normal set of chromosomes are selected for transfer.

PGD may boost your chances of getting pregnant and may also reduce your risk of miscarriage when a single embryo is transferred. This is especially the case if you're an older mum-to-be, using your own eggs. Unfortunately, PGD involves significant additional costs.

By now you'll have been helping your uterus (womb) to prepare for the embryo by taking progesterone, which helps thicken its lining. You receive this by injection, pessary or gel. If your uterus lining (endometrium) is too thin, the embryos are less likely to implant.

Usually, one or two embryos are transferred with a thin catheter (tube) through your cervix into your uterus. Your fertility specialist may use an ultrasound to guide him.

To avoid the risk of a high order multiple pregnancy, no more than two embryos can be transferred at the same time.

The number of embryos that are transferred will depend on your age and your chances of success. This in turn depends on your particular fertility problem.

In Australia, single embryo transfer is usually recommended unless you're more than 40 years old, if the embryos available are of suboptimal quality or if you had a number of cycles in the past without falling pregnant. If you have one or more top-quality embryos, single embryo transfer can increase your chance of having a healthy single baby at term, and improve your and your baby's health.

If the eggs are donated, again only one or two can be transferred depending on the age of the donor and the quality of the embryos.

Repeated cycles

If there are any extra embryos, these may be frozen for future use. This is in case the first cycle doesn't succeed, or you want another baby after your successful treatment.

IVF normally involves transferring embryos two to five days after fertilisation. If transfer takes place five days after fertilisation, the ball of cells has developed into a blastocyst. Only the healthiest embryos will reach the blastocyst stage in vitro.

You may have a better chance of having a healthy pregnancy after blastocyst transfer. The risk, of course, is that none of the embryos make it to this stage. But current research indicates that embryos that don't progress to blastocyst would have a minimal chance of resulting in pregnancy.

Most clinics offer blastocyst transfer to all patients depending on quality and number of embryos available. But some clinics offer blastocyst transfer only if:

• you've had previous normal IVF with healthy embryos but they haven't implanted
• you're under 40
• you've opted for a single embryo tranfser or the number of normally fertilised embryos is higher than a predetermined number, for example, four

You can be up and about quite soon after embryo transfer, as resting for more than 20 minutes immediately afterwards makes no difference to the outcome. In a successful cycle, one or more embryos will implant in your uterine wall and will continue to grow. You can take a pregnancy test in about two weeks.

Once your pregnancy has been confirmed following IVF, you should have an early ultrasound scan at about six weeks. This is to check that the embryo has implanted in your uterus.

How long will IVF treatment last?

One cycle of IVF takes between four and six weeks to complete. You and your partner can expect to spend about half a day at your clinic for the egg retrieval and fertilisation procedures. You'll go back between two and five days later for the embryos to be transferred to your uterus.

What's the success rate of IVF?

The success rates depends on your particular fertility problem and your age. The younger you are, and the healthier your eggs are, the higher your chances of success.

Based on figures from 2010, the percentage of cycles for women using their own fresh eggs which result in a live birth are:

• 32 per cent if you're under 35
• 28 per cent if you're between 35 and 37
• 21 per cent if you're between 38 and 39
• 14 per cent if you're between 40 and 42
• five per cent if you're between 43 and 44
• two per cent if you're 45 or over

If you've been pregnant or have had a baby before, you have an increased chance of success.

You can improve your chances of success by:

• Reaching a healthy weight for your height before you have treatment. IVF is more likely to be successful if your body mass index (BMI) is between 19 and 25.
• Keeping your alcohol consumption to no more than one standard drink a day, as drinking more than this reduces the effectiveness of IVF.
• Quitting smoking (this includes your partner!). Smoking reduces success rates.
• Keeping your caffeine consumption very low. Even low rates of consumption of 2 to 50mg have been linked to lower success rates.
• Ensuring your folate and vitamin D intake is adequate. Most pre-pregnancy vitamins should suffice.

Your chance of success falls as the number of unsuccessful IVF cycles increases. So, if you haven't become pregnant after a number of attempts at IVF, you may need to accept that it isn't going to work for you.

You would be advised to have a frank and open discussion with your fertility specialist and may need to adjust your expectations depending on the results of completed IVF cycles.

This may be hard to come to terms with, but there are organisations that can support you through it. Ask your GP or fertility clinic for details.

What are the treatments GIFT and ZIFT?

Gamete Intrafallopian Transfer (GIFT) is similar to IVF. The woman's ovaries are stimulated to produce more eggs than usual, the eggs are collected, and the man needs to produce sperm (although donor sperm can be used). When egg collection has taken place, two eggs are mixed together with the sperm in a dish.

The main difference from IVF is that with GIFT the gametes (eggs and sperm) are immediately transferred to the woman's fallopian tubes, so fertilisation occurs inside, not outside, the woman's body. The embryo can begin its earliest development in natural surroundings rather than in an artificial environment.

Zygote Intrafallopian Transfer (ZIFT) is a similar procedure to GIFT, except that it is the newly fertilised egg (zygote) which is returned to the woman's fallopian tubes rather than the mixture of eggs and sperm.

This procedure shares the advantage of GIFT in that any resulting embryo will immediately be able to develop in the natural surroundings of your body. But it's a much more invasive process than GIFT, involving two procedures instead of one: egg retrieval and then a separate laparoscopy to insert the embryo.

Fertility experts prefer to use IVF or ICSI rather than GIFT or ZIFT because it's less invasive and there's more control over the quality of the resulting embryos. In recent years, there have been only a handful of these procedures attempted in Australia compared to 10,000 IVF procedures.

Experts prefer to consider GIFT and ZIFT procdures as options only for those few patients who would have strong religious objections to IVF or for those with anatomical abnormalities that prevent an embryo from being inserted via the vagina and cervix.

What are the advantages of IVF?

For most children conceived by IVF there are no long-term problems. In fact, the latest data published by Australian researchers indicates that IVF-conceived children are no more likely to develop health problems compared to their naturally conceived counterparts.

IVF can offer you a chance of having a baby if you're unable to conceive naturally, for example if you have blocked, damaged or missing fallopian tubes.

What are the disadvantages of IVF?

IVF increases your risk of certain complications, such as:

• A multiple birth, when more than one embryo is transferred to your uterus. Many couples consider twins to be a blessing. But a multiple pregnancy increases your risk of having a premature baby or a baby with a low birth weight, as well as increasing your risk of other pregnancy-related complications such as pre-eclampsia and gestational diabetes.
• Side-effects from fertility drugs are usually mild, and include hot flushes, headaches and nausea. But you'll need to be closely monitored for signs of ovarian hyperstimulation syndrome (OHSS), particularly if you have polycystic ovary syndrome (PCOS). Having OHSS may mean an interruption or cancellation of the treatment cycle and a stay in hospital while your over-stimulated ovaries settle down.
• An increased risk of ectopic pregnancy, where an embryo implants in a fallopian tube or in your abdominal cavity. This is more likely if you have previously had problems affecting your fallopian tubes.
• You may be at a slightly higher risk of your baby being born with a birth defect if you conceive with IVF. These conditions aren't common, though, and the absolute risk of your baby having a birth defect as a result of ICSI or IVF is low. More research is needed to be sure if there's a direct link between fertility treatments and birth defects.

Despite these risks, many parents still go on to give birth to much-wanted, much-loved babies through IVF. If you're considering fertility treatment, the Fertility Society of Australia offers advice and contact details for clinics. Or simply searching online for "IVF" and the name of your town or state will provide you with a list of local fertility clinics and specialists.

Source Link: https://www.babycenter.com.au/a4094/fertility-treatment-in-vitro-fertilisation-ivf