In vitro fertilisation or IVF involves fertilisation of the egg by sperm outside of the body in a laboratory. It was originally described by Steptoe and Edwards, and Louise Brown was the first successful birth achieved by IVF in July 1978. They originally envisaged that it would be a treatment of tubal factor infertility as it effectively bypasses the Fallopian tubes. However, over the years, as success has improved, IVF has been applied as an effective treatment for many conditions causing infertility and is also used in treatment to avoid genetic conditions in children born to couples carrying hereditary conditions that could cause profound handicap in their children.,
Overview
IVF involves stimulating the woman using hormones that are administered by daily subcutaneous injection into the skin of the abdomen that cause the ovaries to produce more than the usual one egg that is released each month. These eggs develop in follicles on the surface of the ovaries. Response to stimulation is monitored by ultrasound scans to measure the size of the follicles and blood tests to check on the oestradiol level in the blood. When the follicles are mature (around 18-20mm in diameter) a trigger injection is given and the egg collection is performed 36 hours later.
The egg collection is performed under a light anaesthetic using a fine gauge needle mounted on the transvaginal ultrasound probe. This is no more traumatic than having a blood sample taken, but it is important that you lie still so that the ovaries and surrounding structures are not damaged. For this reason the procedure is usually done under sedation or a light general anaesthetic.
The man will usually produce a sample of sperm by masturbation whilst the woman is having the egg collection. Some men will need a surgical procedure to recover the sperm in cases where the ejaculation ducts are blocked. Donor sperm can also be used for single women or those in a same sex relationship. Donor sperm can also be used in couples where the cause of male infertility is untreatable or to avoid severe genetic issues.
Who may benefit from IVF?
IVF may be suitable for blocked or damaged Fallopian tubes, unexplained infertility, mild male factor infertility, endometriosis, older women, ovulatory disorders where ovarian stimulation has not been successful, egg donatation and surrogacy.
Ovarian stimulation protocols
There are a number of different stimulation protocols and Mr Lower will explain what is right for you. Basically they all consist of injections to stimulate the follicles to grow and another to prevent ovulation or release of the eggs before we are ready to do the egg collection. A final trigger injection causes maturation of the eggs and ovulation will usualy occur about 38-40 hours later. We plan to perform the egg collection 36 hours after this final injection.
Mr Lower prefers a protocol known as the antagonist protocol as this usually only requires monitoring for less than 2 weeks and eliminates the risk of OHSS (ovarian hyperstimulation syndrome) which is the only real risk involved in IVF treatment.
Laboratory
The eggs and sperm are incubated together overnight and a fertilisation check is made on Day 5 to see how many eggs have fertilised normally. The embryos will usually be cultured for a further 5 days to see how many develop into competent blastocysts.
Not all the embryos will survive to Day 5, but those that do have a much better chance of implantation than embryos at an earlier stage of development.
Blastocysts can be used in a fresh treatment cycle or frozen for future use. We will recommend embryo freezing where the risk of OHSS (ovarian hyperstimulation syndrome) is high. We will often recommend an embryo biopsy prior to freezing, where a few cells are removed from the embryo and sent for chromosomal analysis. This is called PGT-A (pre-implantation testing for aneuploidy or abnormal numbers of chromosomes) and although the HFEA does not recommend PGT-A for all couples undergoing IVF, it is especially useful for many of our patients where a history of Asherman’s syndrome may have been caused by multiple miscarrages. PGT-A substantially reduces the risk of a miscarriage caused by aneuploidy. In Asherman’s syndrome a further miscarriage can result of damage to the fragile endometrium after reparative surgery and we take care to reduce the risk as much as possible.
Follow this link for an explanation of the evidence behind PGT-A and the HFEA recommendation regarding its use.