1. Before starting
Screening tests will be checked and sometimes repeated. These are:
Wife
- Complete Hemogram, Blood Sugar, Urea, SGPT
- Hepatitis B [ HBsAg ]
- HIV
Husband
- Sperm test within 6 months
- Hepatitis B
- HIV
A semen sample is generally collected and stored [ cryopreserved ]. This can be used at the time of the procedure if the sample on that day is not good or if the husband is not present or is unable to give a fresh sample.
The wife is generally put on a low dose oral contraceptive pill from the 3rd / 4th / 5th day of the period. This helps in programming the treatment cycle and avoids unnecessary delays. The wife is also given iron and vitamin tablets and the husband is given a course of antibiotics.
2. Counseling
Counseling Couples with infertility problems have faced many frustrations and disappointments so they are under stress. IVF itself can be physically and emotionally taxing and the uncertainty while waiting for result can be very stressful. Consent forms must be signed before starting treatment.
3. Ovarian Stimulation :
Drugs are used to stimulate the ovaries to produce several eggs instead of the usual one to increase the chances of pregnancy. Many variations are used and yours may be different from others.The doctor will advise regarding the required drugs and its dosage.
In general there are 3 types of protocols [ Long, short and antagonist ] and 2 types of drugs [ recombinant and urinary ]. The cost of the treatment and to some extent the success rate depends on the drugs used. The doctor will discuss this before selecting and prescribing the stimulation protocol.
a. LONG PROTOCOL :
Women receiving the Long Protocol start injections on the 21st day of the previous cycle [ i.e. when about 4 – 5 oral pills are left ]. She is asked to come to MIVFG on the 2nd or 3rd day of her next period for starting the actual overiation stimulation. Sonography and sometimes a blood test is done and then the actual stimulation is started.
b. SHORT / ANTAGONIST PROTOCOL :
For women on the Short or antagonist protocol, all the injections are started on the second day of period.
Drug Treatment :
Drugs This start from the 2nd day of the cycle and lasts for about 9-12 days daily till the eggs become mature as determined by ultrasound examination and if necessary, a blood test. To minimize disruption, many women prefer their husbands / another relative / family doctor to give their injections at home or even do it themselves. It is common to have some discomfort and mild side effect while taking the drugs. The main serious side effect is over response, which is severe in about 1 in 100 stimulated cycles.
4. Ultrasound Examination
Ultrasound Examination A vaginal ultrasound examination is done after 4 days of drugs to measure the response of the ovaries. This shows the number and size of the follicles growing in the ovaries, which is a guide to how many eggs to expect and when they will be mature. This is used to decide whether the drug dosage needs any alteration and to plan the day of egg collection.
Generally about 3 scans will be carried out during the stimulation protocol. The husband is not needed during these monitoring visits.
Sometimes if the response is very poor and only one or two eggs seem likely, the chances of pregnancy may be low and doctor may suggest canceling the cycle.
5. hCG Injection
hCG injection is given to trigger the final maturing of the eggs ready for collection. Eggs collection is planned, 34-36 hours after hCG injection. The day of egg collection will usually be decided when patient has the scan and will depend on the size and number of follicles. On the day hCG is planned, the time for injection that night together with details for hospital admission for the egg collection will be informed to by the doctor. The embryologist will inform about the time for sperm collection by the husband.
6. Egg Collection
Egg identification Patient will be asked to get admitted early in the morning on the day of egg collection.
She should have nothing to eat or drink from midnight the night before the procedure.
The eggs are collected through the vagina under ultrasound control, using a fine needle, which is passed through the vagina into the ovary. Fluid from the follicles is sucked through the needle into a test tube and is passed immediately to the laboratory next door where the scientists check for eggs under the microscope. The eggs are then placed in culture fluid in special dishes in the incubator at body temperature. The procedure is performed under general anesthesia, but can be carried out under sedation if patient prefers. The procedure takes about 15-30 minutes. Patient will be able to go home about 2 - 3 hours after the procedure and arrangements will be made for her ET time two or three days later. It is common to have some vaginal bleeding after egg collection from where the needle passes through the vaginal wall. This usually settles in one to two days and does not affect your chances of pregnancy. Some discomfort from the swelling of the ovaries is common and any painkiller can be safely used. Although this is a very minor surgery, it is not without risk.
7. Sperm Collection
A fresh sperm sample is collected on the day of egg collection. This can be done just before or just after egg collection. In case, the husband requires the presence of his wife for semen collection, he should inform this to the embryologist, so that arrangements can be made likewise. The sperm sample is best produced by masturbation and there is a room for this purpose. Lubricants should NOT be used as they can effect fertilization. It is difficult for some men to produce a sperm sample on request. If he is worried about this aspect he should discuss it with the doctor before starting treatment, so that arrangements can be made to freeze some semen, which can be used if necessary. If he lives close to the hospital, it may be possible for him to produce the sperm sample at home. Sexual activity may continue during the treatment cycle. Unless advised otherwise, it is better not to ejaculate for 2 days before the egg collection. However, more than 4 or 5 days without ejaculation may reduce sperm quality.
8.
After Egg Collection
Sperm immobilisation
Sperm catching
Egg penetration
Sperm injection
Following egg collection, the eggs will be fertilized either by standardIVF or by ICSI .
Fertilisationcheck
In about 15% of cycle no eggs fertilize. If this happens, you will be advised on the day after egg collection.
9.Embryo Transfer(ET)
Embryos ET is done two or three days after egg collection. It is simple procedures needing no medication. The women's legs are rested in stirrups and the embryo passed through the cervix into the uterus through a very fine soft plastic tube. It takes only a few minutes and is usually only as uncomfortable as having a pap smear. There is no need to rest afterwards; you may go straight home or back to work and all normal activity including sexual intercourse is permitted.
Embryo GradingO.K.
However, heavy work like lifting weights, climbing staircase etc. should be avoided. Our counselor will help you in making the period after ET as stress free as possible. If there are more than three good quality embryos, it may be possible to freeze them for later transfer. This will be discussed with you before ET. Separate consent form must be signed for embryo freezing. The wife will be asked to take some injections and / or tablets after embryo transfer to support the luteal phase.
10. Pregnancy Test
You will be given a date for a pregnancy test about 14 or 15 days after embryo transfer. It is important that you get the test done even if you have a period, as there is a small chance of pregnancy even then. If it is positive we will arrange an ultrasound examination 7 – 10 days later. If the test is negative, further treatment will depend on whether you have frozen embryos stored or not.
INTRACYTOPLASMIC SPERM INJECTION (ICSI)
Micro manipulator ICSI is a process in which the embryologist collects a single sperm using a highly specialized microscope and specially developed fine glass needles and injects it directly into the center of an egg. This process is repeated for each of the mature eggs that have been collected.
ICSI is mainly used for couples with extremely poor sperm count OR where there has been poor fertilization in previous IVF cycle OR where there is reason to believe that ICSI will be the only way to achieve fertilization. It is also used in patients with Azoospermia, where sperm are obtained by testicular biopsy or epididymal aspiration.
II. FROZEN EMBRYO TRANSFER CYCLE
Embryo freezingTreatment protocol for transfer of frozen embryos is very simple. The wife is put on tablets [ estradiol valerate ] from the 2 nd day of her periods for proper development of the lining of the uterus. She will have to come for sonography once or twice to monitor the response. When the lining has developed properly, progesterone tablets are added and embryo transfer is carries out 2 or 3 days later. Husband is not required during the entire treatment cycle
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