In-vitro Fertilisation (IVF)

Introduction

In-vitro fertilisation (IVF) is the union of a sperm and an egg (fertilization) outside the body within a culture dish in a laboratory incubator. This treatment method first came to public notice in 1978 with the birth of the first test-tube baby, Louise Brown. All IVF treatment clinics in the UK are monitored and licensed by the Human Fertilisation and Embryology Authority (HFEA), which is a public body set up by an Act of Parliament.
IVF involves stimulation of ovaries with injections, collection of the eggs, mixing the eggs with sperm in a laboratory dish. Hopefully the spermatozoa will fertilize the eggs and embryos result. Up to three embryos (depending on the woman's age and clinical history) are transferred into the womb and it is hoped that the embryos will implant and lead to a pregnancy.

Indications for IVF

IVF was originally established as treatment for infertility due to blocked fallopian tubes, but it is now used for infertility due to other causes including poor sperm quality, endometriosis, unexplained infertility, ovulatory disorders etc.

Preliminary assessment

You will be sent an appointment to come and see the consultant who will discuss IVF and other treatment options with you after taking a full history from you and your partner. We will ensure that all necessary tests have been done including semen analysis and routine screening to check for HIV and Hepatitis B & C on both partners. Be reassured that everything you tell us will be treated with utmost confidentiality. You also have the right to keep the record of your treatment confidential from your own GP if you wish. However, we strongly advise you to keep your GP informed as they are usually very helpful and will also be equally committed to confidentiality.

Welfare of the child

The Human Fertilisation & Embryology Act (1990) says that: “Before fertility treatment can be offered to a patient, clinics have a duty to consider the welfare of any child who may be born as a result of treatment, and the welfare of other children who will be affected by this birth. This is known as the “welfare of the child” assessment.

Counselling

There are many things to consider before starting your treatment. We encourage you to see our trained and experienced counsellor before starting treatment. This provides you with an opportunity to talk with an impartial person about the implications of the proposed treatment, for you, your family and any child born as a result of treatment. We can arrange an appointment for you to see the counsellor if you wish.

Drugs used in IVF treatment

• A nasal spray or injection (e.g. Nafarelin or Buserelin): suppresses your reproductive hormones in order to achieve better control of the treatment cycle and prevent release of the eggs before egg collection is done. This treatment starts on day 21 of your cycle, i.e. 21 days from the start of your period.

• Follicular Stimulating Hormone (FSH) Injection: Menopur or Gonal-F are examples of this hormone injection. These injections are administered daily and it stimulates the development of multiple ovarian follicles. There is a wide variation amongst women in the number of eggs developed in response to the same dose of the hormone. This response is also dependent on the cause of your subfertility and your age. The growth of the ovarian follicles and the development of the endometrium are monitored by serial ultrasound scanning.

• Human Chorionic Gonadotrophin (HCG; e.g. Pregnyl or Ovitrelle): When the follicles reach the required size and the endometrium is appropriately developed you will be told when to have the HCG injection, to cause further maturation of the eggs. It is essential that this injection is given at precisely the prescribed time. This is usually given late in the night between 9.00pm and 12.00 midnight. The egg recovery will be planned about 34-38 hours after the HCG injection. HCG injections are sometimes given following embryo replacement as luteal phase support to encourage implantation.

• Progesterone pessaries (Cyclogest): are used to support the endometrium and encourage implantation.

Possible side effects of the drugs

The nasal spray (Nafarelin or Buserelin) may cause symptoms such as hot flushes, feeling of depression and irritability, headaches and restlessness at night. These are often mild and short-lived and are no cause for concern. You may get bruising on the skin following the injections but this usually mild and soon settles.

Ovarian Hyperstimulation Syndrome (OHSS)

This complication arises if your ovaries respond excessively to stimulation. Young women with polycystic ovary syndrome are particularly at risk of OHSS. It is much less common in women aged over 35 years. Clinically the condition is characterised by grossly enlarged ovaries, varying degree of fluid collection in the abdomen, abdominal swelling and pain. If there is significant risk of OHSS the treatment cycle may be stopped. If there have been any embryos created from the cycle they may be frozen and used for treatment in a future cycle.
In mild cases, the woman has a feeling of abdominal heaviness, swelling and pain. There is very little or no fluid collection in the abdomen. In general this does not require hospital admission and will settle with rest and simple pain killers at home. In ­ moderate cases, abdominal discomfort is pronounced and nausea, vomiting and occasional diarrhoea occurs. Hospital admission for observation is often necessary. In severe cases, fluid may collect in the abdominal and chest cavities and there may be difficulty in breathing. There may also be problems with blood clotting and the kidneys failing to produce urine. Hospital admission is essential. Fortunately, however, such cases are rare.
Mild and moderate hyperstimulation do not require any active therapy other than observation and symptomatic treatment (re: painkillers, increase oral fluid intake). Severe hyperstimulation can occur in up to 2% of cases and needs hospitalisation and prompt treatment.

Egg Collection

About 36-38 hours after your HCG injection the egg recovery will be performed. This procedure is carried out under intravenous sedation. Using an ultrasound vaginal probe a needle is used to aspirate follicles through the vagina and the eggs are kept in culture medium. The whole procedure takes about 30-40 minutes and you should be fit enough to go home 2 to 3 hours later.
We will tell you how many eggs have been collected. The risk of complications from the egg collection procedure is minimal, there is less than a 1% risk of pelvic infection and heavy bleeding is uncommon. About 4-5 hours after egg collection the eggs will be mixed with your partner/husband’s sperm.
The following morning the eggs are examined for signs of fertilisation. We will telephone you at an agreed time to tell you if fertilisation has occurred and if so, how many eggs have fertilised. Usually the fertilised eggs will then undergo the process of cell division to become embryos - which will be put back into your womb on the second day after egg recovery.

Embryo Transfer

This is normally carried out 2-3 days after the egg collection and only if embryos are formed. You are able to see the embryos prior to transfer on a TV monitor in the embryo transfer room. You can also take a photo of the embryos using your mobile phone camera (or any camera). Embryo transfer is carried out using a fine catheter passed through the cervix and injecting the embryos into the uterus in a very small volume of culture medium. This technique does not normally require sedation. You will need to rest in the hospital for some time following embryo replacement. Many women prefer to go home and rest after this procedure. You should take things easy for the rest of the day and can resume your normal activities the following day. You will be given a list of do’s and don’ts following the procedure.

How Many Embryos are Transferred?

The recommendation by the HFEA and the Royal College of Gynaecologists is that a maximum of 2 embryos should be replaced in women under 40 years of age. This is to reduce the chance of multiple pregnancies. Multiple pregnancies carry a high risk of miscarriage, premature birth and other obstetric complications and are associated with a higher than normal risk of long term neurological problems in the baby.
In women who are 40 years or more, replacement of three embryos may be considered.

What happens to surplus embryos?

If you have surplus embryos and provided they of suitable quality for freezing, they can be frozen and kept in storage for you if you so wish. If the embryos are not of suitable quality for freezing or if you do not wish to store them, they will be allowed to perish.

What is involved when you have your embryos frozen?

When you have embryos frozen you undertake an agreement with the hospital to store the embryos for up to 10years. The cost of embryo freezing is £440 (includes storage for 12 months). You must inform the hospital if there is a change in your circumstances e.g. change of partner, name or address.

Pregnancy Test

You will be asked to come to the hospital for a pregnancy test fourteen days after the embryo replacement. If the test is positive we will ask you to return two weeks later for an ultrasound scan.
If you are not pregnant, you will be given an appointment to attend for review consultation to discuss any issues you wish to raise and / or to plan for future treatment.

Chances of success

This depends on your individual circumstances, e.g. your age, the cause of your subfertility and the sperm quality will influence the likelihood of success.

Risk of miscarriage or ectopic pregnancy

A positive pregnancy test is good news, but it does not guarantee that the pregnancy will result in a live baby. Once the pregnancy sac and foetal heart beat have been seen on ultrasound scan the risk of miscarriage is substantially reduced - around 5%. The risk of ectopic pregnancy after embryo transfer is about 5%, therefore, an early scan is recommended after a positive pregnancy test.
The risk of abnormality in babies born after IVF is no higher than that in spontaneous conceptions.