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In vitro Fertilization
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In vitro fertilization (IVF), commonly known as ‘test-tube baby method’ is a method of assisted reproductive technology (ART). In IVF, a woman’s eggs are fertilized with a man’s sperm in a laboratory dish and the embryos formed are transferred into the uterus for implantation (embryo attaching to the uterus lining) and normal development, to ensure pregnancy. |
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Who needs IVF? |
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IVF is an advanced treatment modality for infertility. It is opted for in women with blocked tubes/tubal damage, endometriosis, anovulation (those who do not conceive even after multiple cycles of ovulation induction), unexplained infertility (those who do not respond to preliminary treatment).
For male factor infertility, the best option is ICSI (Intracytoplasmic Sperm Injection), another method of ART. It is a micromanipulation technique in which the sperm is directly injected into the woman’s egg to enhance the fertilization chances. In presence of sperm abnormalities, ICSI gives better results compared to IVF. |
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IVF Procedure |
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A typical IVF procedure consists of the following steps:
1. Preliminary investigations
2. Downregulation
3. Ovarian stimulation
4. Oocyte retrieval
5. Fertilization of eggs
6. Embryo transfer
7. Pregnancy test and pregnancy confirmation scan |
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Preliminary Investigations |
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After the initial examination and evaluation of the couple, preliminary investigations are carried out. An ultrasound examination is performed on the woman to check her ovaries and uterus. |
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Downregulation |
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Downregulation is planned, wherein the reproductive hormones produced in the brain are suppressed to low levels, thus allowing for the cycle to be controlled from the outside. The woman is given Decapeptyl/Lupride/Buserelin GnRH injection, which acts on the pituitary to reduce production of gonadotropins (FSH and LH hormones). Downregulation can also be planned with a single dose injection of long acting Decapeptyl/Lupride depot, which is given in the luteal phase (between day 18-24) of the cycle preceding the IVF stimulation cycle. Daily injections of short acting GnRH Lupride/Buserelin can also bring about downregulation. |
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Ovarian Stimulation |
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Ovarian Stimulation is the next step in IVF procedure, wherein Superovulation/Controlled Ovarian Hyperstimulation (COH) is planned. During the stimulation cycle, daily hormonal injections are given for a span of 8-12 days to stimulate ovaries to produce an increased number of eggs. Regular follicular monitoring is done by transvaginal ultrasound to assess the ovarian response. When the ovarian follicles reach their maximum size, ovulation is triggered with the injection of hCG (human chorionic gonadotropin). During the cycle, estrogen and LH hormonal levels may be estimated as per individual requirements to assess the quality of eggs developing. |
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Oocyte Retrieval |
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Oocyte Retrieval is a procedure in which eggs are retrieved from the ovaries, using transvaginal ultrasound as guidance. Eggs retrieval is planned 35-36 hours after the hCG injection is administered. This procedure is performed under short general anesthesia. The patient is discharged after 3-4 hours of observation. The patient needs to contact her doctor immediately if she has the following complaints:
 Unusual discomfort in the pelvic area
Fever higher than 100°F
Nausea/vomiting
Any sharp/shooting pain
Abdominal distension
Difficulty in urination or bowel activity
Vaginal bleeding |
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Fertilization of Eggs |
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Fertilization of eggs is done on the same day of egg retrieval in the embryology laboratory. Sperms are obtained from the semen sample collected from the husband (usually by masturbation) on the day of egg retrieval. The sperms are separated from the seminal plasma, washed, and an optimum number of spermatozoa are placed with each egg in a separate dish containing IVF media. The sperms and eggs are placed in the CO2 incubator at 37 degrees C. Once fertilization takes place, the embryo shows two cells. Further division occurs and the embryo usually attains an 8-celled stage at the end of 48 hours of incubation, and is ready to be transferred into the uterus. |
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Embryo Transfer |
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Embryo Transfer is a simple procedure that takes only a few minutes and does not require anesthesia. During this procedure, the embryos are placed in the uterus via a catheter, which is gently passed into the uterine cavity through the cervical canal. The embryologist then examines the catheter under a microscope to make sure that all the embryos are transferred. Following the embryo transfer, the patient is discharged after 2 hours of observation. After the procedure, the patient is advised rest, though absolute bed rest is not required. Abstinence is advised following the procedure, but no diet restriction is needed. Prescribed medication needs to be taken till the day of the pregnancy test. |
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Pregnancy Test and Pregnancy Confirmation Scan |
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A pregnancy test is recommended 14 days after the embryo transfer. It is a blood test to estimate serum hCG levels. If the test is positive, a pregnancy confirmation scan is performed two weeks later. |
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Risks involved with the IVF procedure |
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Some women may complain of abdominal distension, discomfort in the lower abdomen, or a bloating sensation following the procedure. This is due to superovulation/COH, which results in the enlargement of ovaries. This is known as Ovarian Hyperstimulation Syndrome (OHSS). This can be controlled to a certain extent by careful adjustment of the hormonal injection dosage during stimulation.
There are higher chances of multiple pregnancies with IVF compared to other treatment modalities. This is because, in this procedure, about 3-5 embryos are transferred into uterus. Obstetric complications like miscarriage, preterm delivery are attributed to multiple pregnancies, but not due to the IVF procedure per se.
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Limitations of the IVF procedure |
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Women with uterine factors (for example, Endometrial pathology) have poor chances of implantation.
Women with lower ovarian reserves require higher dosage of medication for longer duration with low prognosis and high chances of cycle cancellation.
There are chances of fertilization failure
Men with low counts, low motility, or abnormal sperm morphology need ICSI and not IVF
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How many times can a woman undergo the IVF procedure? |
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Scientifically, the IVF procedure can be done any number of times. Many factors like female age, individual ovarian response for the medication given, the number and quality of eggs obtained, percentage of fertilization, quality of embryos obtained should be given importance before planning for further cycles. Financial constraints also need to be considered.
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Success Rate of IVF |
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The success of any ART procedure depends on the female age, female body mass index, cause of infertility, number and quality of oocytes retrieved, and quality of embryos obtained. Woman aged lesser than 35 years, with adequate ovarian reserve, have 30-35% success rate, which decreases gradually as the age advances. The success rate is higher when ART is done for a female factor rather than a male factor abnormality. There is no 100% success guaranteed for any ART procedure. |
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In vitro Fertilization |
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