IVF Procedure – How is IVF done?
IVF, or in vitro fertilisation, is perhaps the most well-known treatment for infertility, allowing couples who want to conceive but are infertile the opportunity to have their own child.
What are the requirements for IVF?
IVF can be costly, particularly if repeat runs are needed, as they often are, before a successful pregnancy. You need to be financially and mentally prepared for the process which, while effective when successful and a great relief for many couples, can be quite taxing. Typically IVF is only recommended or advised when other options have been unsuccessful or are not viable.
IVF requires healthy male and female sex cells, sperm and eggs respectively, and a healthy womb in which the pregnancy can be carried to full term (until childbirth). Donor sex cells can be used in some instances, like for same sex couples and for single parents looking to have children.
IVF is a lengthily process and if only used when less expensive alternatives have already been tried, the treatments will take place in stages. Through the procedure there are sometime choices about alternative methods that can be used. Your doctor should talk to you about which technique is being used and why it is best for you. The stages are as follows:
Egg production is stimulated using fertility medication to increase the chances of impregnation. The fertility medication that you are prescribed will stop the menstrual cycle to make you more receptive to stimulating drugs before you are given drugs to stimulate the follicles. However, you may wish to opt for natural cycle IVF, where you are not given any fertility treatment and remain on your natural menstrual cycle. This option may be taken if you are ovulating normally and cannot use fertility drugs. This may be due to risks pointed out by your doctor e.g. high risk of ovarian hyper-stimulation, or due to personal/religious beliefs.
Alternatively, your doctor may suggest mild stimulation, where less fertility drugs are used over a shorter period of time. Mild stimulation will reduce risks associated with fertility drugs, fewer eggs will be matured, fewer will be extracted, and so success rates of non-conventional IVF fertility treatment are lower.
Extracting the eggs
The eggs are prepared for extraction by giving a hormone injection of human chronic gonadotropin (HCG) that loosens the now developed eggs from their follicles to make them more accessible and ensure that the eggs are matured. The HCG injection will be given 36 hours before the eggs are retrieved. Now that the eggs are prepared for extraction you will undergo a transvaginal procedure, this involves the eggs being physically extracted using a fine needle guided by ultrasound (you will be under aesthetic whilst this procedure takes place to prevent pain, but you will be awake).
The long sharp needle will puncture each follicle, going through the vaginal wall and into the ovary. A mild suction will suck fluid up through the hollow needle where it will be examined to find eggs, if an egg cannot be found at first the follicles with be flushed in order to rinse the egg out. Once the eggs have been retrieved they will be incubated.
In some cases, your doctor may decide to use IVM (in vitro maturation). This is where eggs are taken before they are matured so you will not need to use as many fertility drugs. Again, this will be used if your health is at a high risk by taking fertility drugs and can be used proved it is only the male who is infertile. IVM follows the same procedure as conventional IVF except the eggs are taken at an earlier stage and are maturing in an incubator for 1 to 2 days before they are fertilised, however with this method there is the added risk that the eggs will not mature properly.
If either you or your partner have a genetic problem that could be passed on to the child, at this point a pre-implantation genetic diagnosis (PGD) may be performed. The genes of the embryos (between the ages of 2 to 5 days) will be checked for disease such as haemophilia and cystic fibrosis or any disease which may put the baby at risk. Your doctor will do this if you have another child with a genetic disorder or have a history of it in your family. If you are over the age of 45 or have a history of recurrent miscarriages then a pre-implantation genetic screening may be required to check for any reasons or abnormalities.
The eggs can now be fertilised with sperm extracted from a donor or partner in a petri dish. The sperm for the procedure will be produced on the same day that the eggs have been collected. Many men may find that they are unable to ejaculate, either as a result of a pre-existing condition or due to anxiety. If this is the case and the problem persists, then the doctor may offer a surgical procedure to extract the sperm. Once the sperm is collected, it is washed and spun at a high speed so that the highest quality sperm can be selected. Frozen donor sperm with be defrosted and treated in the same way.
The egg and sperm are mixed together in the tube or Petri dish and are left to incubate and hopefully fertilise. They will be incubated for 18 hours in a growth medium, a liquid which aids the development of cells. If the egg is successfully fertilised then two pro-nuclei will be visible, these are the nuclei of the egg and the sperm.
If a male has a low sperm count, then ICSI (Intra-cytoplasmic sperm injection) will be used. This is where a sperm is injected directly into the egg. The process of injecting the sperm into the egg is an intricate procedure, specialists will examine the egg over a high intensity microscope. The small amount of washed sperm is put into a dish with polyvinylpyrrolidone (PVP), this slows the sperm down in order for it to be analysed to assess which sperm are of the best quality. The tails of the sperm are squished with a fine, hollow needle and are then sucked up the needle.
The egg is held in place and prepared using an enzyme called hyaluronidase to get rid of its surrounding cumulus cells. The cumulus cells are present so that in natural fertilisation, once a sperm has entered the egg, the shell of the egg can harden to prevent other sperms from entering. A single sperm is injected directly into the eggs cytoplasm. Using the fine hollow needle the membrane of the egg is pierced and the sperm is then passes through the needle, this process has essentially eliminated male infertility.
For the fertilised egg to become an embryo they are left in a specially conditioned incubation before they are inserted into the uterus or frozen for later. It normally takes about 5 days for the embryos to be ready for insertion.
Typically a number of eggs are prepared per round of IVF to give you the best possible chance for a successful fertilisation and pregnancy. Different clinics have different success rates, but these are constantly improving so you can be confident in that the procedure is constantly evolving.
Implanting the embryo
To increase the changes of impregnation, 2 to 3 embryos will be implanted. This also means that IVF treatment has a higher rate of twins or triplets in successful pregnancies, as there is always a chance that both or one of these embryos will carry on through to a successful pregnancy. To mimic natural pregnancy you will be given hormones to help your body prepare. The technique used to insert the embryos into the uterus will differ depending on the clinic, however two typical techniques are used: embryos transfer and blastocyst transfer.
Embryos transfer involves taking the best quality embryos 2 to 3 days after fertilisation. In the similar way to the cervical smear test, a speculum is used to keep the vaginal walls apart during the procedure, a catheter (fine tube) is inserted up through the cervix, guided by an ultrasound (similar to how the eggs are extracted). The embryos are passed through the tube and into the uterus. During this procedure you will not be sedated as it is generally pain free, despite minor discomfort as it is required that you have a full bladder to use ultrasound.
Blastocyst transfer is similar to uterus transfer but instead of implanting the embryos 2 to 3 days after fertilisation, they are incubated for 5 to 6 days in order to develop. This increases the chances of pregnancy, however not all embryos will develop past 4 days in the laboratory so your doctor will discuss with you what is the safest option for you.
If the transfer is successful then the embryo will attach itself to the wall of the womb. After this procedure there will be a 2 to 3 week wait before tests are carried out to see if it was successful. You will be given blood tests and ultra sound tests to check for early signs of pregnancy. If after a further 2 weeks your menstrual cycle has not begun then urine samples will be taken for a pregnancy test to be carried out, followed by further blood tests.
A pregnancy will be determined unsuccessful if the urine tests come back negative or if you have a period during the two weeks after the procedure. In this case, IVF clinics will provide counselling services to help you overcome any emotional trauma that this causes, there is also the option to try the procedure again, especially as extra embryos will have been frozen.
If you are using IVF treatment on the NHS you will be entitled to 3 cycles of IVF, however if you are paying for private you will have to pay again for repeat cycles. Your clinic charge less for repeat cycles however, as fewer tests will be needed and extra embryos will already have been collected and stored.
If you find that you are pregnant you will be required to return to the clinic throughout the duration of your pregnancy to check that the baby is developing normally. If everything goes smoothly then nine months later the true aim of IVF becomes more than effort, and congratulations! You’re a parent.
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