IVF  means in vitro fertilization. In vitro means in the laboratory ( outside the body) and fertilization refers to conception (joining of a woman’s egg and a man’s sperm in a laboratory dish) . This technology enhances the likelihood of conception for couples facing infertility issues. IVF may be considered when other treatment methods have been unsuccessful, and in certain cases, such as bilateral fallopian tubal disease, it may be the most viable option for achieving success. Beginning the IVF process can be an exciting venture for couples.

When is IVF treatment recommended?
Here are some reasons why IVF treatment may be recommended:

• Male factor infertility, such as low sperm count, poor sperm motility, or abnormal sperm morphology
• Anovulation or Polycystic Ovarian Syndrome (PCOS)
• Endometriosis
• Bilateral Tubal Disease
• Diminished / POOR Ovarian Reserve
• Unexplained infertility, where no clear cause for the inability to conceive is identified after multiple attempts
• Pre-implantation Genetic Diagnosis (PGD), which helps avoid passing on inherited genetic disorders to offspring
• Fertility Preservation, involving the freezing of eggs or sperm for various reasons, such as cancer treatment that may impact fertility. Later, these cryopreserved materials can be used in IVF once cancer treatment is completed.

   

  What screening procedures are conducted prior to initiating the IVF treatment?

•   Ovarian reserve testing
•   Semen analysis
•   Infectious disease screening
• Ultrasound scan of Pelvis

Ovarian Stimulation:
Normally, your ovaries produce one egg per month during a regular cycle. An IVF cycle uses medicine to stimulate follicle growth, which is the process by which the eggs grow, in an effort to produce more eggs. Injections are typically used to administer this medicine. You will need to come to the clinic for ultrasound scans in order to track the development of follicles during ovarian stimulation. Stimulation is finished when your doctor certifies that the follicles have grown to their ideal size.

Follicular Puncture (Oocyte Pickup): To encourage egg maturation, a trigger shot is given once the follicles have grown to their ideal size. Human chorionic gonadotrophin (hCG) injections are typically used as the trigger shot. The goal is to retrieve the eggs 34–36 hours after the trigger shot. The trigger shot must be administered at the precise time allotted because it will determine the date and time of the oocyte (egg) retrieval. This method is for day cases. Using state-of-the-art ultrasound technology, the doctor will do a transvaginal oocyte (egg) collection under local anesthesia, or in certain situations, general anesthesia.

Oocyte Fertilization and Embryo Culture: The semen sample is taken and ready for use on the day of the oocyte retrieval process. In a procedure known as insemination, our embryologists will combine the eggs and sperm in culture media dishes so that natural fertilization can occur.

Approximately 17 hours after the insemination (IVF), the oocytes are placed in our specialist incubators to be evaluated for fertilization. The “RI-Witness” method is employed at our Clinic to ensure accurate sperm and egg identification. The “Xiltrix system” keeps an eye on every incubator in the lab to make sure the embryos are kept in a secure environment.

Embryo Transfer: Every day, the embryos’ progress is assessed. When to transfer the embryo(s) to get the best possibility of a successful pregnancy is a decision made by the doctor and the embryologist. The ideal day for embryo transfer is determined by taking into account the following factors:

• The embryos’ growth (cell count and quality)
• Whether any genetic testing will be performed on the embryo
• Past treatment history

With the use of a soft, flexible catheter, the embryo(s) is/are transplanted into the uterus under ultrasound guidance. It is a straightforward, painless operation that doesn’t require any anesthetic or medication. It isn’t suggested to lie in bed after the embryo transfer. After the embryo transfer process, you can contact our team of professionals if you have any questions or concerns.

Controlled Ovarian Hyperstimulation (COH) involves inducing the development of more ovarian follicles than usual in a woman’s menstrual cycle, achieved with fertility medications. As multiple follicles develop, the number of viable eggs also increases, thereby enhancing the likelihood of conception.

• COH is necessary in three primary scenarios

1. When a patient is preparing for an IUI or IVF cycle.
2. To induce a regular menstrual cycle in women experiencing ovulatory issues.
3. If a woman intends to preserve her retrieved eggs for future use.

What is the process of COH?
The main goal of COH is to optimize and improve ovarian function. Prescribed fertility medications regulate endocrine functions, allowing doctors to anticipate hormonal fluctuations accurately, which would be difficult otherwise. This oversight aids in assessing egg quality, enabling doctors to recommend the most appropriate artificial insemination technique, such as IUI or IVF, to the patient.

Does COH improve the likelihood of conception?
COH is seen as an additional support for individuals undergoing IUI, IVF, and similar methods to conceive. Research indicates that when COH precedes an IUI procedure, there is an enhanced chance of conception.
Despite the decreased chances of pregnancy as women age, COH combined with IUI or IVF has resulted in successful pregnancies for women of advanced maternal age.

When is ICSI suggested?
ICSI is advised under the following circumstances:

• Men experiencing low sperm count, poor sperm motility, or abnormal sperm morphology.
• History of failed fertilization.
• Men who have undergone vasectomy.
• Sperm obtained through testicular biopsy.
• Cryopreserved semen samples.

   

What is the procedure for performing ICSI?
The process of ICSI follows similar steps to IVF:

1. Ovarian Stimulation: Medication is administered to stimulate follicle growth, aiming to obtain multiple eggs. Ultrasound scans monitor follicular development until optimal size is reached.
2. Follicular Puncture (Oocyte Pickup): Following follicle maturation, a trigger shot induces egg maturation. Eggs are retrieved transvaginally under ultrasound guidance, typically under local anesthesia.
3. Oocyte Fertilization and Embryo Culture: On retrieval day, semen is collected and prepared. Each egg is injected with a single sperm using ICSI. The method is determined by the doctor and embryologist to optimize fertilization.
4. After ICSI, eggs are incubated for fertilization assessment approximately 17 hours later. Advanced systems ensure accurate identification and a safe environment for embryos.
5. Embryo Transfer: Embryo progress is monitored, and transfer timing is determined by the physician and embryologist. Under ultrasound guidance, embryos are transferred into the uterus via a soft catheter in a simple and painless procedure. Bed rest is not recommended post-transfer.

What is the success rate of an ICSI procedure?
ICSI is utilized to address severe male infertility by facilitating the fertilization of the sperm and egg. It enhances the likelihood of achieving a successful pregnancy for couples affected by male factor infertility or previous IVF fertilization failures. ICSI represents a significant advancement in assisted reproductive technology, providing men with severe male factor infertility the chance to conceive biological children.

After fertilization, the embryo which develops from the fertilized egg goes through various stages of development. A normal pattern of embryo development is outlined below:

• On day 2: 2-4-cell stage
• On day 3: 6-8-cell stage
• On day 4: morula
• On day 5/ 6 : blastocyst ( trophectoderm / inner cell mass)

Blastocyst quality is determined by evaluating the external appearance of the blastocyst. As previously described the blastocyst has 2 distinct cell layers. The outer rim of cells referred to as the trophectoderm which develops into the placenta and the inner cell mass which is made up of stem cells which ultimately develop into the baby. Grading of the blastocyst is an imperfect science. Blastocysts that have been assigned a high grade/ top quality do not necessarily result in pregnancy. However, the best embryos will survive to the blastocyst stage and by virtue of the fact that they survived to day 5, day 6 indicate that they have the best implantation potential.

Blastocyst Transfer
The last step involves transferring the blastocyst to the uterus using a soft, flexible catheter guided by ultrasound. After insertion, the catheter is carefully removed, and the embryologist confirms that the blastocyst has been successfully transferred. Resting in bed after the procedure is not recommended.

Intrauterine Insemination (IUI) is a form of artificial insemination used to address infertility concerns.

How is IUI done?
During Intrauterine Insemination (IUI), processed sperm is injected into the woman’s uterus via the cervix during her menstrual cycle. This procedure can occur naturally or be controlled, with ovulation stimulated to produce a few eggs rather than the usual one or two. The process is typically painless.

The timing of IUI is carefully managed, with follicle growth monitored using ultrasound to minimize the risk of multiple pregnancies and determine the optimal time for the procedure. Once follicles reach the appropriate size, human chorionic gonadotropin (hCG) is administered to trigger ovulation. This allows the eggs to mature within the follicles, ready for release approximately 36 hours later. The IUI is scheduled accordingly, typically within 24 to 36 hours after the trigger shot.

When is IUI suggested?
IUI is typically recommended in the following scenarios:

• When the male’s semen sample falls slightly below the normal range
• For couples who are unable to conceive even after receiving psycho-sexual counseling
• In cases of unexplained infertility
• When women experience ovulation issues or mild endometriosis
• For abnormalities in the cervix
• When there are problems with sperm delivery in males due to various factors

Further IUI treatments are usually not recommended if there is no pregnancy after three insemination attempts.

An alternate technique for choosing embryos for IVF transfer is preimplantation genetic testing for aneuploidies (PGT-A), formerly known as preimplantation genetic screening (PGS). With IVF, this test finds the preimplantation embryos that have a normal chromosomal complement, or euploidy. PGT-A filters out embryos with an aberrant chromosomal copy number, increasing the success rate of conception.

What are the reasons to do PGT-A?
A healthy infant can be born into an embryo that implants and matures to full term if its chromosomal copy number is normal. Under a microscope, it is typically challenging to visually recognize the normal embryo. An embryo’s normal appearance does not guarantee that it is devoid of genetic abnormalities. Therefore, PGT-A aids in the selection of embryos with a normal number of chromosomes. 

Who should consider PGT-A?

• experienced repeated miscarriages in the past.
• had repeated implantation failures
• had a chromosomal issue during a previous pregnancy
• Are in their mid-thirties or older

When and how is PGT-A conducted? 
In this process, IVF-produced embryos are tested, and the ones with the appropriate amount of chromosomal material are chosen and transferred.

• After the embryo is grown in culture for around five days and reaches the blastocyst growth stage, which is composed of hundreds of cells, a sample is collected.
• The biopsy involves the removal of 5 to 7 cells of the external layer of the embryo, called trophectoderm, without touching the inner cell mass that gives rise to the fetus.
• The genetic material of the embryo is examined.
• After biopsy, embryos are cryopreserved. In a later round, the embryos that are suitable are frozen and implanted to the patient’s uterus depending on the PGT-M results.

   

To what extent is PGT-A safe?
This process is safe. Even after the embryo biopsy, the process should be managed carefully by a skilled embryologist so that the embryo develops normally.

Does PGT-A evaluate all genetic diseases?
Only numerical chromosomal number variations and other genetic material imbalances, such as deletions (where a chromosome is missing) and duplications (where a chromosome is duplicated), can be evaluated by PGT-A testing.