In Vitro Fertilisation refers to the Fertilization that occurs outside the human body.this method was invented initially for providing fertility solutions in females who suffer from blocked or dysfunctional fallopian tubes. currently, IVF is prescribed to patients who are unable to conceive due to other reasons as well.
IVF (In vitro fertilization)
We give you the best fertility services:
- The initial consultation: It is an initial visit where you open up with your doctor and get to know your doctor and makes him aware of your situation. A detailed history is taken of both the partners.
- Planning management and the pretreatment preparation: This includes taking a detailed blood test that also includes the hormonal assays, a uterine assessment, semen analysis or any other tests if needed. We review the patient history and all the tests and then only a comprehensive management is designed for you.
- Starting the oral contraceptive pills: You will be asked to start taking the oral contraceptive pills for a short span of about two to four weeks to make your cycle matches with that of the surrogate or an egg donor. These have the additional benefit that makes the ovaries cyst free and helps in the planning of your cycle.
- Ovarian induction : The IVF cycle starts with the stimulation of ovaries with injectable hormones every day for a short span and continuous ultrasound monitoring. A baseline ultrasound is executed before beginning the stimulation to evaluate egg production. The hormone levels are also monitored. Once the follicles become of the optimal size, you are made ready for the retrieval of the egg. .
- Visits : before the egg is retrieved three to five visits are mandatory in that IVF cycle.
- Egg Maturation : An injection is usually given 34-36 hrs before the egg retrieval.
- Egg retrieval : It is a procedure in the IVF process that is done transvaginally under ultrasound guidance using short general anaesthesia. A six hrs. fasting prior to the procedure is important. A long thin needle is inserted through the vaginal canal into the ovary and the follicular fluid is collected.The follicular fluid obtained is then collected in test tubes in a controlled temperature and handed over to the embryologist immediately in the embryology lab. The embryologist then examines the eggs. The eggs are then rinsed, counted and placed in an incubator. After few hours of incubating them, they are fertilized with the sperm by using either IVF or through ICSI. An anesthesiologist helps you in giving pain relief during the entire procedure. Chances of injury during egg retrieval is very rare. Minimum bleeding from ovaries can occur during the process but the risk of transmission is quite rare. Infection during this procedure is also extremely rare and you will be sent back four hrs. After completion of this procedure.
- Embryo Assessment : During the process of IVF, embryos are evaluated for 2-5 days in a controlled environment at a set temperature in an incubator. The day of transfer is determined after assessing the embryos between day 2-day 5. We update you about the embryos once they are ready to be transferred.
- Embryo Transfer : Embryo is transferred into the uterine cavity somewhere between day 2-5 when it becomes a blastocyst. This process does not need anaesthesia and the woman can be happy seeing the embryos being implanted into the uterine cavity. We discuss the probability and thus decides the number of embryos be transferred for the highest probability of success, at the same time also keeping in mind the risk of multiple births related to it. For the embryo transfer procedure, you need to come with a full bladder and the procedure is carried out with the help of an embryo catheter that is transferred vaginally under ultrasound supervision.
- Pregnancy test :a pregnancy test is then scheduled after10-15 days of the transfer. If the first test comes out to be positive we repeat beta HCG repetitively at an interval of every 48-72 hrs. After this period an obstetrical ultrasound is planned after two weeks of the pregnancy test when the number of embryos are determined along with the fetal cardiac activity.
ICSI (Intracytoplasmic Sperm Injection)
If you are diagnosed with male fertility issues, such as a low sperm count, previous history of vasectomy in the male partner, continuous IVF failure then standard IVF is not likely to result in fertilization. It is also done when semen has low sperm count and they need to be taken surgically from testicles. In this condition, Intracytoplasmic Sperm Injection (ICSI treatment) is suggested. It is similar to the process of IVF, the only difference being the technique that is used to accomplish fertilization. .
How is ICSI done ?
In the process of ICSI, a single sperm is injected into each ovum or egg with the help of fine micro-manipulation equipment. the human egg is one-tenth of a millimetre in diameter and the sperm is approximately 100 times smaller than the egg, this is a very sensitive method that is performed by highly skilled embryologist using a micro-manipulator.
Is ICSI successful?
Along with IVF, ICSI is one of the most common techniques that is used extensively in Assisted reproductive technology. Since its advent, this technique has led to the birth of thousands of children worldwide.
Surgical Sperm Retrieval (TESA/PESA/MESA)
The main techniques used for the retrieval of sperm surgically are
- PESA: pit is the percutaneous epididymal sperm aspiration.
- MESA: it refers to microsurgical epididymal sperm aspiration.
- TESA: TESA refers to testicular sperm aspiration. This process includes testicular fine needle aspiration (TFNA).
- TESE:This method is also known as testicular sperm extraction. Microdissection TESE
- Microdissection TESE.
- Perc biopsy: this process refers to the percutaneous biopsy of the testis. Which method will be used depends upon what the underlying problem is in the male partner, that needs complete and careful evaluation first.
Which method is used depends on the nature of the problem in the male partner, which needs to be explored carefully first.
Tests required before surgical sperm retrieval
A man who has no sperm in his semen is said to have azoospermia. This occurs due to the blockage in any of the tubes carrying sperm from the testes where they are produced, towards the penis during ejaculation. Obstructive azoospermia could be a result of testicular cancer, as the tumour presses against the vas deferens. This cancer commonly occurs in young men and can be treated successfully. Unfortunately, it can lead to male infertility, thus surgical sperm retrieval is necessary to store some sperm before starting the treatment.
Other reasons that can cause non-obstructive azoospermia, includes an abnormal cystic fibrosis gene. Men suffering from this condition fail to exhibit all the symptoms, but they often suffer a lack of vas deferens. Surgical sperm retrieval is possible but there is an equal chance that the embryos produced further by the process of ICSI and IVF will carry the similar genetic abnormality. The options that are then left are using a sperm donor and the use of intrauterine insemination (IUI) or even IVF. Pre-implantation genetic diagnosis (PGD) can also be carried out on the embryos for selecting the one that carries the normal gene.
Surgical sperm retrieval techniques used when obstruction is the problem
When the release of sperm is prevented by a blockage in the vas deferens, or by a vasectomy, several techniques can be used to retrieve the large numbers of sperm that remain inside the testes. The first three involve aspirating sperm using needles or tubes placed through the skin of the testis and are carried out under local anaesthetic. The fourth requires open surgical sperm retrieval and is usually carried out under general anaesthetic.
- TESA: TESA refers to testicular sperm aspiration, which involves keeping a needle attached to a syringe through scrotum skin and drawing out the fluid from the testicle.
- PESA: This refers to the percutaneous epididymal sperm aspiration. This also makes use of the same needle and syringe technique but in this case needle is put directly into the epididymis. .
- Perc biopsy: Perc biopsy is the short form for percutaneous biopsy of the testis. This is quite close to TESA, but it makes use of larger needle, which is a 14 gauge needle used for biopsy of the testicular tissue and it usually extracts a large number of sperm.
- MESA: MESA is the microsurgicalis epididymal sperm aspiration that is the technique of open surgical sperm retrieval using an operating microscopy for locating the tubules of the epididymis precisely, for the extraction of large numbers of sperms.
Certain studies have been conducted for comparing the success rates after doing the different types of sperm retrieval through surgery. MESA is thus known to give the highest number of sperm, recovered when compared with procedures like TESA and perc biopsy.
MESA produced sperms, which were better swimmers and thus more effective for infertility treatments, including IVF and ICSI..
Surgical sperm retrieval techniques when there is no obstruction
Men who lack any sperm in their semen, even after having clear tubes in their testicles, have an underlying problem with the process of sperm production. It is very less likely that sperm are present in large numbers, so the sperm retrieval through surgical techniques required are more invasive.
- TESE: it refers to testicular sperm extraction that involves opening up the scrotum through surgical incision and then taking a chunk of testicular tissue, derived from several regions of the testicle. Sperm are then extracted using a microscope for taking out the individual sperm.
- Microdissection TESE. It is a similar technique using a micro dissecting microscope that is used to remove the tissue through pinpoint. This procedure is helpful as it causes less damage to the structure inside the testicle,and thus have very less side effects like problems with blood supply by cutting with tiny blood. It can also enhance the number of sperm that are to be retrieved.
Success rates after surgical sperm retrieval
As these infertility treatments methods are still quite new therefore much evidences are still to be collected. However, one of the most accomplished combinations are MESA followed by ICSI, that has given great results with fertilisation and pregnancy rates between 45 % and 52 %
During the process of IVF, the embryos are cultured for around six days and during that period they receive quality grades everyday.
Egg Retrieval and Insemination Day 0
Maturity of the egg is important as a mature egg has the best chance of getting fertilized. The three different stages of egg maturation are:
- Germinal vesicle (GV): It is the stage where the egg has not begun meiosis till now and is thus considered immature.
- Metaphase I (MI): This is the first phase of the egg that is meiosis; but is not completely mature yet as it has not entered the second phase of meiosis. This type of immature egg matures after being in temperature-controlled incubation for a couple of hours.
- Metaphase II (MII): This is the second phase of meiosis of the egg, which is mature by now. Eggs at this stage are ready for fertilization and have following characteristics.
- Good and
- Clear cytoplasm/normal shape
- Single differentiated polar body
- Thin/clear zona pellucida
- Fragmented/abnormal polar body
- Slightly pigmented/amorphous zona
- Fragmented/abnormal polar body
- Slightly pigmented/amorphous zona
- Cytoplasmic bodies
- PV debris
- Dark/grainy cytoplasm/misshapen
- >1 polar body structure
- Pigmented/thickened zona
- PV debris
Fertilization Check Day One
Fertilization can be seen clearly after 16 to 22 hours after the process of insemination. Normal fertilization can be seen by exactly two pronuclei in the center of a one celled zygote. Fertilization is not abnormal when there is a single pronucleus and when there are more than two pronuclei present.
Multicell Grading Day Two/Three
On day two the single cell zygote should divide into an embryo (approx. two to four cells). On day three the embryo should continue to divide (four to eight cells).
- Good: have a clear cytoplasm with symmetrical cells
- Fair: these cells are slightly asymmetrical having slight cytoplasmic irregularities
- Poor: these cells are quite asymmetrical and might have grainy and dark cytoplasm
- A = No fragmentation
- B = <10% fragmentation
- C = 10-35% fragmentation
- D = >35% fragmentation
On the 4th day, the transition of embryos begin from a multi cell embryo to a highly advanced developmental stage. Embryos then start compacting and forming morulae. Cells of a morula-stage embryo are not quite distinct like the previous days; and hence these embryos fail to receive quality grades.
Day Five/Six Blastocyst Stage
A blastocyst is developed embryo that comprises of two different cell types: one group of cells is referred as the inner cell mass, that forms the fetal tissue and another group of cells, known as the trophectoderm, helps in the formation of placenta. Blastocysts are graded on the basis of their expansion (early, expanding, expanded, and hatching) as well as on the basis of the quality of these two different cell types (graded on a good-fair-poor scale). Blastocysts that are are good or even fair in quality can be freezed.
How we decide on which day to transfer your embryos
Embryo transfer is the last stage of the IVF treatment and is often referred to climax of the IVF treatment cycle. How is it decided on which day to transfer your embryos ? Day 1 ? Day 2 or 3 ? or even 5 ? What is better ? and why ?
Unfortunately, human reproduction is not a very efficient process as most of the embryos fail to become babies. This is due to the genetic error that many embryos contains ( which is often random) and will not lead to implantation, as nature prevents them from doing so. This is the reason, the implantation rate even for high quality embryos is only around 40%.
We are quite flexible on the day embryo is to be transferred for increasing the chances of success.
Uterine Embryo Transfer
- This is the standard process, where the Embryos are transferred directly into the uterine cavity. This procedure does not usually need Anaesthesia.
- Number of embryos to be transferred is decided after considering the day on which the transfer is to be performed.
On which day post icsi/ivf, is embryo transfer performed ?
Usually embryos are transferred on Day 2, Day 3 and Day 5 after ICSI / IVF. it must be noted that day of egg collection is considered Day 0.
How is it decided on which day the embryos are transferred back to the uterus?
There are various factors which we consider while deciding when the transfer of your embryos is placed back to your uterus.
- Number of Follicles developed during superovulation:
- Number of eggs retrieved after Vaginal Egg Collection
- The number of Mature Eggs (MII) injected
- Number of Eggs fertilized (i.e. Eggs having 2 pronuclei in them)
- Day 2 transfer is considered for all patients.
- Need to have a minimum of 6 embryos on Day 1 for considering transfer of embryos on Day 3
- transferring the best embryos into your uterus after which the High number of Supernumerary Embryos that can be frozen.
- Only 40% Embryos can make it to Day 5, which means patients having fewer eggs and those having a low fertilization rate cannot be considered for embryo transfer on Day 5. Embryo Transfer.
- Freezing rate that is lower for supernumerary embryos as all Embryos don’t turn out to be of high quality on Day 5.