In vitro fertilisation (IVF) is a procedure involving collection of reproductive cells from both partners, their fusion in laboratory conditions, culture of resulting embryos for a couple of days and transfer of one or two embryos back directly to the woman’s womb.

Indications

  • Tubal factor
  • Lack of safe ovulation possibility
  • Endometriosis
  • Male factor (including ICSI with sperm retrieved from a testicle or epididymis in the case of obstructive azoospermia)
  • Carrier HIV or HCV status of one of the partners
  • Patients’ age
  • Diminished/diminishing ovarian reserve
  • Treatment failure using other methods

Proceedings

Hormonal stimulation

In vitro fertilisation (IVF/ICSI) is preceded by a few days of hormonal stimulation. An adequate stimulation protocol is individually selected for each patient. It depends on hormone testing results, age as well as a gynaecological and obstetric history. During the stimulation, medications for pituitary suppression (i.e. the patient’s own hormone function) are administered for a certain time and followed by stimulation medications. The procedure is controlled by ultrasound scans because while taking medications, the patients must be monitored for the progress of follicles every couple of days. Hormone levels (oestradiol, progesterone) are also checked in blood tests. When the ovarian follicles are mature enough, the patient is given an ovulation-triggering medication and, 36 to 37 hours later, the eggs are collected. Mostly, a few up to between ten and twenty eggs are retrieved.

Collection of eggs and sperm

Collection of eggs involves ultrasound-guided puncture of ovaries via the vaginal top, under analgosedation (short-lasting anaesthesia). The procedure lasts approximately 10 to 20 minutes. Immediately afterwards, the fluid containing eggs is delivered to the IVF laboratory; the patient is wakened and stays in the recovery room for about an hour.

On the puncture day, the patient should come to the clinic in the fasted state. The psychomotor skills are fully restored within about 30 to 60 minutes after the procedure.

The partner provides a semen sample (via masturbation) on the procedure day, following 3 to 7 days of sexual abstinence. Previously frozen or donor sperm can also be used for fertilisation.

Fertilisation and embryo culture

The fertilisation procedure can be carried out in two ways depending on the indications:

  • In vitro fertilisation (IVF): About 2 to 4 hours after collection of the eggs, they are mixed with adequately prepared sperm. The eggs are then placed in the incubator with special culture medium, at 37 degrees, with increased carbon dioxide and reduced oxygen levels.
  • Micromanipulation (ICSI): About 2 hours after the egg collection, follicular cells surrounding the eggs are removed. Using a fine pipette, single sperm cells are introduced into each egg. The cells are then placed in the incubator with special culture medium, at 37 degrees, with increased carbon dioxide and reduced oxygen levels.
    On the next day, i.e. 18 hours after the procedure, the fertilisation process is assessed. Successful fertilisation is manifested by the presence of two (female and male) pronuclei and two polar bodies to confirm the oocyte has completed its meiotic division. The ICSI results in 70 to 80% of properly fertilised cells. Following further hours of the culture, the fertilised eggs (zygotes) start to divide as part of the so-called cleavage stage. Two days after the puncture, properly developing embryos reach the stage of 2 to 4 cells, and following three days – 6 to 8 cells. For each embryo, the cell count and morphology are assessed.
    More about embryo assessment here (reference: The embryonic report without secrets)

Embryo transfer

Between the culture Day 2 and Day 5, the embryos are transferred into the womb using a special catheter. The embryo transfer is a painless, anaesthesia-free, ultrasound-monitored procedure; the patient must have a full bladder. Following the transfer, the patient stays in a gynaecological chair for about 20 minutes. With a greater number of the embryos, the transfer is usually suggested on the fifth day of the culture when the embryos have already developed to their blastocyst stage.

Embryo freezing

All embryos that were not transferred and reached the advanced so-called blastocyst stage of development on Day five or Day six of the culture are frozen. You should remember that not each fertilised cell yields a blastocyst; some embryos do not develop properly, stops during next divisions and then degenerate.

Normal embryos are frozen for future use by means of the currently most effective technology of vitrification and stored in liquid nitrogen.

The freezing process is safe enough to ensure the same percentage of post-transfer pregnancies as for the ‘fresh’ embryo transfers.

After the procedure

The patient receives progesterone therapy for 10 consecutive days. This is so-called luteal supplementation that aims to facilitate embryo implantation and to support early pregnancy. Then, an HCG blood test and a consultation with the patient’s doctor are indicated to discuss further management.

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