An Infertility Clinic (often referred to as a Test Tube Baby Clinic in Kolkata) always follows a set treatment protocol while performing In vitro fertilization.
- Selection of Patients
- Pre-cycle Evaluation
- Ovulation Induction and Monitoring
- Egg Retrieval
- Sperm Processing
- In-Vitro Fertilization
- Embryo Transfer
- Post Transfer Management
- Cryo Preservation
1. Patients Selection
A complete evaluation of fertility factors (egg, sperm and uterine cavity) is important prior to considering IVF-E.T technique.
Tubal Disease Patients with tubal blockage or severe pelvic adhesions, or those who have not conceived after tubal surgery are likely to respond to IVF-E.T technique.
Patients with infertility due to Moderate to Severe Male Factor- The inadequate sperm count or motility issues can be handled effectively in the laboratory by various techniques, enabling the concentration of a large number of motile sperm around eggs through the IVF-E.T technique. This is for couples whose infertility is due to poor semen quality.
Patients with Endometriosis- This condition often results in pelvic anatomy distortion and adhesion. IVF-E.T technique procedure allows the egg and sperm to meet and fertilize in an environment free of endometriomas and be transferred directly into the uterus.
Patients with Immunologic infertility – IVF-E.T technique allows fertilization outside the body, away from the destructive actions of anti-sperm antibodies (this happens when the immune system mistakenly identifies the sperm as enemies and tries to destroy it.
Patients with unexplained infertility who have not responded to other types of therapy. IVF-E.T is an effective therapy as it catalyzes the ability of the sperm to fertilize eggs. In rare instances unexplained infertility may be due to defects in gamete function.
2. Pre-cycle Evaluation
The success of the IVF-ET depends mainly on the ability of eggs, sperm and uterine cavity to respond to the treatment.
Various factors play a role in the pre-cycle evaluation.
- The woman’s ability to respond to fertility drugs has to be evaluated. Measurements of FSH (Follicle stimulating hormone that regulates the development, growth, pubertal maturation and reproductive processes of the body) and estradiol (female hormone) on third day of the menstrual cycle help us estimate a women’s ability to produce extra eggs in response to fertility drugs. In general women with high FSH levels and/or early high estradiol are more resistant to ovarian stimulation.
- The next step is the evaluation of the uterine environment. It is recommended that the woman undergo an office hysteroscopy – a minimally invasive procedure that allows the visualization of the uterine cavity without the need for general anaesthesia, it is a highly accurate way of diagnosing any uterine abnormality like polyps, scars or fibroids that may interfere with implantation. If, however, the lady has recently undergone hysterosalpingogram (HSG) – a procedure that uses an x-ray to look at the fallopian tubes and uterus – and the uterine cavity appears normal, further hysteroscopy is not required. Measuring the length of the uterus is also recommended as it helps the Doctor to understand the challenges of embryo transfer if any.
- Cervical cultures are a must before commencing treatment. Organisms such as urea plasma have been associated with poor reproductive outcome and poor embryonic growth in the laboratory.
- The uterine lining is evaluated prior to ovulation using a sonogram. Certain patterns of uterine lining development, especially when the lining is thin, are associated with poor pregnancy rates. These sub-optimal patterns can sometimes be improved with estradiol supplementation.
- Analysing the male factor. This requires a semen analysis, and sperm antibodies are measured in both partners. High levels of sperm antibodies can interfere with fertilization in the laboratory, and special techniques are employed to correct this problem.
- Couples undergoing IVF-E.T are screened for syphilis, hepatitis and HIV.
- Patients who are suffering from or have undergone any major medical, surgical or psychological problems need to consult their treating Doctor before starting the programme.
Couples contemplating IVF-E.T are advised to meet the counsellor who is familiar with emotional impact of infertility and treatment for the same. He/she can help them deal with the emotional turmoil.
3. Ovulation Induction and Monitoring
IVF-E.T success rates depend upon the numbers of eggs, fertilized eggs and good quality embryos available for transfer. Additionally, the egg retrieval must be carefully timed so as to retrieve mature eggs. To accomplish these goals, ovulation induction medications and careful monitoring are required. In most cases, the long protocol (ovarian stimulation regimen) is followed and the patient (lady) is intramuscularly injected with decapeptyl depot 3.75mg (triptorelin 3.75mg) in their luteal phase (second half of the cycle – post ovulation period). The injection is usually given a week before (21st day of menses) of the upcoming treatment cycle – the day may vary to suit the cycle length of the patient. Sometimes progesterone may be prescribed to prevent premature ovulation.
After menses occurs, prior to starting the ovarian stimulation, we select a day for Down Check ( a final check-up to ensure everything is in order as per requirement). A sonogram is done to make sure there are no ovarian cysts, blood estradiol and progesterone levels are measured. On a specified day the lady begins injections of Gonadotropins (Gonal-F from SERENO-Switzerland, or Recagon from ORGANON-Ireland), according to a schedule that is provided by the clinic. When triptorelin is used, the ovaries remain quiescent until stimulation drugs are started. We arbitrarily call the first day of Gonadotropin administration cycle-Day1. IN order to monitor a patient’s response to these drugs. Sonograms and serum estradiol level checks are performed on Day6, Day8 and Day10. These help us to determine when the eggs are ready for collection.
Once the follicles (containing the eggs) are ready, the patient stops taking triptorelin and Gonadotropins. About 36 hours prior to the anticipated egg retrieval, the patients takes an injection of Human Chronic Gonadotropin (Hcg). This hormone replaces the women’s normal LH surge, and is necessary for a final maturation of the eggs so that they can be fertilized.
4. Egg Retrieval
In almost all cases, egg retrieval is accomplished non-surgically using a vaginal ultrasound probe to guide a needle into the ovaries. The procedure does not require general anaesthesia and is performed with just simple intravenous sedation. An anaesthesiologist administers the sedation to maximise your comfort and safety. As a result, the experience is not painful and recovery is rapid.
5. Sperm Processing
Freshly ejaculated sperm must undergo biochemical and structural change called capacitation before they can fertilize an egg. In IVF-E.T sperm are capacitated in the laboratory and the motile and healthy sperms are isolated prior to inseminating the eggs
6. In-Vitro Fertilization(IVF)
In-Vitro Fertilization literally means “fertilization of glass”. Follicular fluid removed from the ovaries is examined in our lab for presence of eggs. These are isolated and placed in cultures media where they are allowed to further mature. A few hours later, portions of the processed sperms are placed around each egg. In a laboratory only about 50 to 100 thousand sperms are needed for each egg. This is why men with low sperm counts can often fertilize eggs in the lab.
The eggs and sperms are left to incubate together in a carefully controlled environment. Approximately 18 to 24 hours following insemination, the eggs are inspected under the microscope to determine how many have been successfully fertilized. These embryos will be kept in the laboratory as they continue to grow and develop until the moment of transfer.
7. Embryo Transfer
The embryos are transferred via thin plastic tube through the cervix into the uterine cavity. They are then deposited in the upper part of the uterus and the catheter is withdrawn. This is generally a painless procedure and the patient remains immobile for 2 hours, after that she can go home. As the implementation will occur in the following few days, the patients are instructed to rest at home during this time after the transfer. Light activities that do not cause stress are allowed and a good sleep at night is a must.
We usually transfer the embryos into the women’s uterus two days after the egg retrieval. At this stage, the embryos have cleaved and contain 4 cells each. We usually transfer 3 to 5 embryos depending on the quality (grading) of the embryos.
8. Post Transfer Management
During the follow-up phase, the women receives daily vaginal suppository of progesterone with the goal of enhancing implantation. 14 days after the embryo transfer, blood and urine pregnancy tests are performed. Rising blood levels of pregnancy, HCG, indicate that implantation has occurred. Confirmation of a clinical pregnancy is made by ultrasound about 2 weeks later.
9. Cryo Preservation
Freezing extra embryos gives couples an additional opportunity to conceive without going through stimulation cycle and egg retrieval. The success rate with frozen/thawed embryo is improved when the lady uses hormone replacement instead of her natural cycle. Prior to thawing the embryos, an ultrasound assessment of the uterine lining is performed to make sure an adequate uterine environment is present. About half or two third of the frozen embryos survive the defrosting process.
