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Understanding IVF

Understanding IVF

Since Louise Brown, the world’s first IVF baby, was born in England in 1978 it is estimated that over a million babies have been born worldwide using some form of assisted reproductive technology. In Australia and New Zealand 6816 babies were born in 2002 as a result of assisted reproductive technology (around 2% of all births). IVF is the most common of these technologies.

Finding a cause for infertility

By the time couples embark on IVF some will have discovered the cause of their infertility while for others no cause will have been found. Approximately one third of the cases of infertility are due to male factors, one third is due to female factors and one third is due to a combination of male and female factors.    IVF may be recommended in many of these cases.              

Getting started

In order to commence IVF you will firstly need a referral for both you and your partner from your general practitioner. You will then have a consultation with an IVF specialist. In larger services such as Sydney IVF and IVF Australia you would also meet with nurses who organise much of your care.

You will be asked to make sure you have had a recent Pap smear and breast examination. You should begin taking folic acid 500mcg to reduce the risk of spina bifida (a birth defect). In many clinics now couples are tested for hepatitis (C&B), HIV, rubella, and the blood group is confirmed.  It is important to note that every IVF provider will have a slightly different approach.

The first thing done in IVF is what is called a ‘trial wash’ on the partner’s sperm. This involves the partner ejaculating into a small container. This is then checked to see if there is enough healthy sperm for the procedure. When all this is completed and you have been advised of the cost you will start your treatment as soon as you are ready and/or the clinic you are attending can start your IVF cycle.

Stimulating the ovaries

The first stage of an IVF cycle involves the woman having a course of hormone injections to encourage the ovaries to produce more eggs than they usually would. Every month a number of follicles in women’s ovaries begin to mature. This can be anywhere from one to thirty depending on the age of the woman. In a natural cycle the first follicle that matures is ovulated while all the other developing follicles shrink away and are lost forever. The hormones given in an IVF cycle control your natural cycle and stimulate all potential follicles to grow. This enables more eggs to be accessed than would normally be the case.

Most women now give these injections to themselves through a very fine needle just under the skin (usually stomach). If you are very squeamish about needles then your partner can be trained to give the injections or you can go to the clinic. You will be giving these injections to yourself daily and in the last couple of weeks there are two injections a day.

A ‘trigger’ injection is then given about 36 hours before the egg collection occurs. This injection contains hormones that loosen the eggs in the follicle and make them ready for collection.

Common side effects from the hormone injections are moodiness, headaches, flushing, tiredness, bloating and breast tenderness.

Blood tests and ultrasounds

During the IVF cycle you will need to have several blood tests done, especially during the week leading up to egg collection. Taking regular samples of your blood whilst you are having the hormone injections enables the doctors and nurses caring for you to monitor the levels of estrogen and progesterone. Too little of these hormones can mean the stimulation isn’t working properly whilst too much can warn of the potential for ‘hyperstimulation’ (painful enlargement of the ovaries, collection of fluid in the abdomen etc). These blood tests are used to make decisions about how to manage your IVF cycle. In the larger IVF clinics you can have these blood tests done at collection centers near where you live and work to make it easier for you.

Vaginal ultrasounds are also done regularly through the IVF cycle. These ultrasounds give vital information as to the development of your follicles and thickness of the lining of your uterus. The ultrasonographer will count how many follicles are growing and measure each one. You will be able to see how they are growing and the doctor managing your treatment will use the information to decide when is the best time to collect the eggs. The ultrasounds take about 15 minutes and can get quite uncomfortable towards the end of the stimulation cycle when your ovaries are full of large follicles. Women who are really uncomfortable with vaginal ultrasounds can request to have this done abdominally but you need a very full bladder for this and the picture is not so good. Discuss this with your doctor.

Egg collection

The eggs are then collected through a procedure that is performed in a Day Only Unit. Firstly you will be given a mild sedative and then a local anaesthetic will be injected into the upper wall of the vagina. This helps make the procedure more comfortable. Under ultrasound the ovaries are scanned through the vagina and a needle is passed through the upper wall of the vagina into the ovary. The follicles in the ovary are then each pierced by the needle and the fluid and egg is removed. There is some discomfort felt mainly from the pressure on the enlarged ovaries during the procedure. There is a small amount of bleeding from the needle going through the wall of the vagina. Alternatively the eggs can be collected through laproscopy  (small incision in the navel) but this requires a general anaesthetic.

A scientist is usually present during the egg collection and they look through the fluid extracted from each follicle and find the eggs and then rate them for their maturity or quality. The scientist is working in a special chamber to ensure the eggs are kept in the best possible condition. The number of eggs retrieved varies enormously and it is strongly age dependant. For example, you may have been told at your last ultrasound that you had ten follicles but when the retrieval procedure is completed the scientist may only have six eggs of which only three fertilise and one or two are appropriate for transfer as embryos. This is why the more follicles that grow, the better the chances of ending up with an embryo that can be transferred back.

Sperm collection and fertilisation

The male will have been asked to ejaculate not more than four days before the day of egg collection to ensure that the sperm on the day is as fresh as possible. Once the eggs have been collected the partner is asked to ejaculate and the sperm provided is prepared for the IVF procedure. There are provisions made if men find this difficult, such as collecting sperm ahead of time in a special non-toxic condom.  You will be recovering from your light sedation and egg collection while he goes and does this. When this is done and the sperm are examined to make sure they are okay you will be able to go home. You will need someone to drive you home because of the sedation you receive. You might feel a little tender over the next couple of days. The relief you felt at having the large follicles drained of all their fluid will be short lived because these follicles fill up again and can take a couple of days to subside once more.

In a special laboratory scientists will put the sperm and eggs in a dish that is filled with a special nutritive mixture. The eggs and sperm are then left together in an incubator overnight and checked the next day for signs of fertilization. In some cases of extreme male infertility a procedure called intra-cytoplasmic sperm injection (ICSI) will be used, where a sperm is injected directly into the center of the egg. ICSI has a similar success rate to straightforward IVF.

Fertilisation may not occur in all the eggs. Some eggs may fertilise and then disintegrate or not grow normally. The scientists keep an eye on the development of the embryos and select the best one for transfer. You will probably be asked to ring the next day to find out how many of the eggs fertilized. Many couples find the few days that follow egg collection and fertilization very hard. You can ask to be told each day of the progress of your embryos. Don’t expect all the eggs collected will fertilise or progress to healthy embryos. An embryo that can look good on the first day may not look the same on the third day.

When the embryo is transferred back to the woman depends on the center where you have the IVF procedure. Some centers will transfer the embryo back around the second to third days, others around the fourth day and increasingly the embryo is being transferred back around the fifth day after fertilization.  The reason why some centers now transfer the embryo back five days after fertilization is because the scientists will have a better idea which embryos are most likely to be healthy and continue to develop. This is also the time when the embryo would normally implant in the lining of the uterus if the conception had occurred naturally.

Spare embryos can be frozen and kept for future attempts. If you have special moral beliefs surrounding this please discuss them with your health professional before embarking on IVF. Some IVF clinics encourage you to talk to their counselor before commencing treatment because this can be a very stressful time for you both.

Embryo transfer

The embryo transfer itself is an easy procedure and usually only takes a few minutes. You do not require anaesthesia or sedation. The embryos are picked up in a very thin plastic tube and this is guided through the cervix until it reaches the middle of the uterus where the embryo is deposited. Because the back and front of the uterus are touching each other the embryo will not drop out when you walk around. You can get up straight away after the procedure.

To make sure the lining of your uterus is ready to receive the embryo you will have a couple of injections of another hormone called hCG. A pregnancy test is usually preformed around 16 days after the egg pick up. This can fee like the longest most excruciating wait in your life.

Sample Plan For IVF Cycle


Days

Injections, ultrasounds, blood tests

First day of period

Inform the clinic so they can give you your instructions

Day 19-25

Progesterone tablets may be commenced

Day 22

Blood test may be done to monitor hormone levels

Day 23

Commence on daily injection to control natural cycle

Day 30 (approximately)

Blood test and let the clinic know when your period starts

1st day of period

Commence on follicle stimulating hormone injection (now on two injections daily)

Day 3 onwards

Abstain from intercourse, blood tests and ultrasounds every couple of days, continue with two injections daily

Day 12 (approximately)

Trigger injection given to prepare follicles for egg collection, male to ejaculate and then abstain until egg pick up

Day 14 (approximately)

Egg pick up

Day 16 to 19 embryo transferred

Further injections of hormones to prepare the uterus to receive the embryo

Day 26-29

Pregnancy test (blood test)

How many embryos should you put back.

Once it was common practice to put back two or even three embryos but now days it is far more common to put one back. The reason for this is the pregnancy success rates are just as good but the outcomes for single babies are much better than for twins or triplets. Your chances of taking home a live healthy baby is higher when one embryo is put back compared to two or more. The death rate for twins is over four times higher than for single babies and for triplets it is nearly seven and a half times greater. The severe disabilities such as cerebral palsy are also much greater for babies born of multiple pregnancies.

Preimplantation Genetic Diagnosis (PGD)

PGD is a series of techniques that are used before the embryo is transferred back to the woman to diagnose and exclude genetic abnormalities. PGD is done by making a small cut in the shell of the embryo and removing cells which are then analysed for specific genetic problems. This technique is used mainly in couples with a family history of a genetic disorder such as cystic fibrosis or muscular dystrophy. Every cell holds the complete genetic information for the future human and each cell has the ability to grow and establish a pregnancy so removing a couple of these cells will provide information and yet not result in a damaged embryo. PGD is costly and not all IVF centers are equipped to do these specialised tests. Sydney IVF is well known for being a pioneer in this field.

What are the chances of success?

The chances of IVF treatment working depend on the age of the woman, the number of eggs retrieved and the reason for the infertility. The pregnancy rates achieved by the different IVF clinics varied enormously.  The average age of women undergoing fertility treatment is now over 35 years of age, five years older than the average age of all mothers in Australia (29.2 years). This is also a time when natural fertility has already declined significantly. In 2002 in Australia and New Zealand, for women aged 25-29 years of age, around 25.9% of IVF cycles resulted in a live baby being born. For women aged between 40-44 years this rate dropped to only 6.1%. The Australian Institute of Health and Welfare puts out a yearly report on success rates from artificial reproductive technologies which can be downloaded from their website.

Is there a risk of cancer?

The long-term risk of cancer after IVF treatment is still unknown, but it is not thought to be high. There are concerns that hormone sensitive tissues in your body such as breasts, ovaries, uterus and cervix could be affect in years to come. Because the hormonal treatment could accelerate a pre-existing cancer Pap smears and breast checks are encouraged before commencing IVF.

Cost of IVF

The costs of IVF vary between clinics. Out of pocket expenses begin at $2270 for IVF Australia and $2650 at Sydney IVF. If, however you need to have other procedures as part of the IVF such as ICSI or PGD the cost will rise dramatically. There are additional costs for freezing remaining embryos. Most of the clinics will give you a quote for the procedure before you start so you know what you are up for. The recent introduction of Medicare Plus, which rebates medical expenses over a certain threshold, will reduce the cost further. Medicare used to only pay for six procedures per person but in 2000 this restriction was lifted.  

Psychological considerations

Couples undergoing IVF experience significant stress. Supporting each other and remembering it is your relationship that is most important is essential. Never hesitate to seek counselling and professional support if the process is becoming destructive to your relationship or to you as a person.

Further Reading

Websites

Books

  • ‘Getting Pregnant’ by Robert Jansen
Dr Hannah Dahlen is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also an executive member of the Australian College of Midwives, NSW Branch. She has researched women's birth experiences at home and in hospital and published extensively in this area. Hannah's website is www.hannahdahlen.com.au

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