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IN VITRO FERTILIZATION (IVF)
In
vitro fertilization (IVF) is the most sophisticated form of infertility
treatment.
It has been used for over 25 years and in this period of time it has evolved to
a relatively simple and very successful treatment option. IVF treatment is
offered to patients with damaged fallopian tubes, unexplained infertility where
other forms of treatment have failed, and in combination with ICSI (intracytoplasmic
sperm insertion) for patients with male factor infertility. It may also be
offered to women with diminished ovarian reserve or poor egg quality.
Prior to deciding on IVF treatment you will meet your physician and nurse who will explain in detail the steps involved in your treatment. You will be given ample time to reflect and thereafter, at a separate meeting, you will be given an opportunity to sign consent forms for your treatment. You will then meet with a nurse who will teach you how to self-administer injections. She will also give you a detailed plan of your treatment.
If at any time during your treatment you have any questions, please do not hesitate to contact us immediately. Our role is to make your treatment non-stressful and successful.
IVF treatment consists of hormonal suppression, ovulation induction, egg collection, embryo transfer and hormonal support following embryo transfer.
Hormonal suppression
During the IVF process it is essential for a patient not to
ovulate
prior to egg collection. To prevent this from happening we either suppress your
natural cycle with a GnRH agonist before beginning ovarian stimulation ("long
protocol"), or alternatively we use a GnRH antagonist after we have begun
ovarian stimulation ("short protocol"). In general, we prefer to use the long
protocol with a GnRH agonist in women who are young and are expected to have a
large number of eggs. In contrast, we prefer to use the short protocol with a
GnRH antagonist in women who may not have such a robust response to ovarian
stimulation.
If you are on a long IVF protocol, i.e. a GnRH agonist, you will begin daily
buserelin injections starting 7 days prior to your expected menstruation. In
general you will continue with these injections alone for about 2-3 weeks prior
to your baseline down-regulation ultrasound scan. These injections are generally
well tolerated. On occasion, patients may have side effects such as headaches,
hot flashes, bloating, vaginal dryness or mood swings.
The purpose of your baseline down-regulation scan after 2-3 weeks of the
Buserelin is to exclude the presence of ovarian cysts and to verify that your
uterine lining is thin. If you have ovarian cysts or your lining is thick your
treatment with Buserelin may be continued for another week. If, however, your
baseline scan is normal then the dose of Buserelin will be decreased and you
will start the ovulation induction phase of the treatment.
Ovarian stimulation
In
IVF treatment ovarian stimulation is achieved with injections of
gonadotropins,
e.g. follicle stimulating hormone (FSH). Gonadotropins stimulate and support
follicle development within the ovary. The dose of gonadotropins we will use
depends on your age, hormonal profile and ovarian reserve. Typically, you will
be on FSH injections for about 10 days before you are ready for your egg
retrieval. The first several days of gonadotropin administration are usually
free of symptoms. However, after about 7 days some patients experience low
abdominal tenderness and bloating.
During the time your ovaries are being stimulated you will be closely monitored with ultrasound scans. At each ultrasound scan we will count the number of follicles you have and measure their size. We may also make adjustments to your dose of gonadotropins to avoid over or under stimulation of the ovaries.
Once you have a sufficient number of follicles above 17-18mm in diameter we will schedule your egg retrieval. In the evening you will be given an injection of hCG to promote the final maturation of your eggs, and your egg retrieval will be scheduled exactly 36 hours after that hCG injection.
Egg Retrieval
This is a very interesting procedure that rarely causes more than mild discomfort. The night before the procedure you will be prescribed an anti-anxiety medication called Ativan. This pill will help you to have a good night sleep and feel relaxed during the procedure. You will be instructed not to eat or drink anything from midnight, and to arrive at the Montreal Fertility Centre one hour prior to the egg retrieval. On your arrival you will be shown to your pre-operative room, and a nurse will take your vital signs and start an intravenous. You will then be escorted to the procedure room where a local anesthetic (freezing) is injected into the skin of your vagina. Additionally, short-acting intravenous medications will be given for sedation and pain relief.
Your partner is encouraged to be with you during the egg retrieval. You can bring your favorite CD or tape with you. The egg retrieval is performed by a physician with an ultrasound guided needle puncture through the vaginal wall. As each follicle is punctured, the fluid is drained and examined under a microscope. You will be able to see on one monitor how the physician is emptying your follicles, and on another monitor connected to embryologist s microscope, you will be able to see the eggs. Not every follicle contains an egg. At the Montreal Fertility Centre, eggs are collected from approximately 90% of aspirated follicles. You will know the total number of eggs retrieved prior to leaving. You will also receive your first dose of supplemental progesterone before leaving.
Following the egg collection you will be monitored for 1-2 hours before returning home. Do not plan any other activities for the day of your egg retrieval. When you arrive home relax and have an early night. It is not uncommon for women to feel abdominal discomfort and have vaginal soreness and bleeding the evening of the procedure.
Fertilization and Embryo Transfer
Sperm is prepared and mixed with eggs several hours after
your
egg retrieval. Thereafter the sperm and eggs are left in an incubator overnight
to allow fertilization to occur. We will call you the day following egg
retrieval to inform you as to how many eggs have fertilized. We will then call
you each subsequent day until your embryos are ready for transfer to the uterus.
You will be ready for your embryo transfer either 3 or 5 days after your egg
retrieval. The decision is based on both the number and the quality of embryos
obtained. Basically, if you have many high quality embryos to choose from we may
elect to grow the embryos for 5 days and perform a blastocyst transfer. On the
other hand, if the number of high quality embryo is limited we may transfer them
3 days after you egg retrieval.
Embryos are transferred to the uterus using a fine plastic tube (transfer catheter) and ultrasound guidance. This procedure takes only a few minutes and is usually not uncomfortable.
Luteal Phase and Pregnancy
You will be encouraged to limit your activity for 24-48 hours
after
the embryo transfer. Your activity can then be gradually increased over the next
few days. Many women return to work after a few days if their jobs are not
stressful, whereas others prefer to take this time off to rest.
Two weeks after your egg retrieval we will ask you to return to the Montreal
Fertility Centre for a pregnancy blood test. If your pregnancy test is positive
you will be encouraged to continue progesterone supplementation for another 6-7
weeks. An ultrasound scan is done approximately four weeks after your egg
retrieval and may be repeated two to three times throughout the first trimester,
after which you will be returned to your referring physician for the remainder
of your obstetric care.
Intracytoplasmic Sperm Injection (ICSI)
This technique is reserved for patients with male
factor
nfertility,
those who have already had multiple unsuccessful attempts with intrauterine
insemination, or had poor fertilization in previous attempts with IVF. In this
technique an embryologist, using specialized glass needle, injects eggs obtained
by the IVF process with spermatozoa. This process allows for successful
fertilization even in patients who have very few spermatozoa in the ejaculate.
The likelihood of achieving a pregnancy following an ICSI procedure is similar
to that achieved in an IVF procedure. There is no evidence that ICSI increases
the chances of malformations or birth defects. However, in a small percentage of
cases, men with severe sperm problems may pass along the same problem to their
sons.
Patients who develop multiple good quality embryos
may be
advised
to have their embryos cultured until day five. By day five only the strongest
embryos will develop to a blastocyst stage. A blastocyst is an embryo that looks
like a transparent hollow ball and contains over 100 cells. Patients who have a
transfer of one or more blastocysts have a very high chance of achieving a
pregnancy.
zona
pellucida, is weakened by a laser beam. This allows the embryo to exit its
shell more easily and enhances implantation. Assisted hatching does not
damage embryos, and some studies have suggested that assisted hatching
increases pregnancy rate in patients who are 38 years or older, patients
whose embryos have a particularly thick zona pelucida and patients who are
transferring frozen-thawed embryos. Assisted hatching is carried out
immediately before embryo transfer. 
insufficient
number of eggs available in the ovaries. This poor ovarian reserve could be
the result of previous radiation or chemotherapy, pelvic surgery,
endometriosis or genetic disorders. It could also simply be the result of
ageing. Egg donation is generally the treatment of choice for older women or
those who have poor egg quality.