In vitro fertilization (IVF)
In vitro fertilization (IVF) – treatment of infertility, in which some or all stages of conception and early embryo development are carried out outside the woman’s body.
The principal indications for assisted reproductive technologies cycle are the following:
- tubal peritoneal infertility;
- polycystic ovary syndrome and other hormonal forms of infertility, where you cannot achieve ovulation (release of the egg) with the help of medication;
- immunological infertility;
- male infertility – decreasing of quality of one or more sperm indicators: the concentration of spermatozoa in 1 ml of semen, reduction in the frequency of motile sperm, increasing number of abnormal sperm forms;
- unexplained infertility.
Consultation, preparation for the cycle
The first step of personal contact with a patient is the first appointment. During the meeting, you discuss the future plan of treatment with the doctor.
It is not necessary that the doctor recommend you the IVF procedure. However, generally more simple treatments for the majority of patients have already been tried.
The decision of reasonability of IVF cycle is discussed in cooperation with the doctor and the couple on the basis of a combination of different factors:
- the age of the partners;
- diagnosis of wife and husband;
- duration of infertility;
- results of previous treatment.
After first consultation, the doctor can prescribe additional examinations (hormonal examination, immunogram, karyotype,etc.) or manipulative procedures (hysteroscopy, study of uterine tube patency,etc.).
After a detailed examination and consultation in the case of mutual decision, a patient starts a cycle of treatment.
IVF cycle consists of the following steps:
- Controlled ovarian hyperstimulation or endometrial preparation for transferring previously frozen/thawed embryos (“cryocycle”);
- Follicle injection to obtain eggs;
- Eggs fertilization;
- Embryo culture;
- Embryo transfer;
- Luteal phase support;
- Diagnosis of pregnancy.
2.1. Controlled ovarian hyperstimulation
This step is carried out according to several common protocols.
With all the standardization process protocols of treatment are calculated individually and depend on many factors (age of the patient, the results of hormonal studies, data from previous cycles of treatment, etc.). The main protocols used are as follows:
2.1.1. “Long protocol”
The main protocol under which about 85% of IVF cycles are undergone.
2.1.2. “Short protocol”
At the present moment, the appointment of the “short” protocol using antagonist is considered as critical, the prescription of antagonist for more than 3 days is limited. After reaching the diameter of 16-18 mm by a “leading” follicle, a patient takes medications that promote oocyte maturation
These medications should be injected for 32-36 hours before the expected puncturing of follicles.
2.1.3. Antagonist protocol
Practically it is a variant of short or ultrashort protocol without using antagonists.
2.1.4. “Natural cycle”
It is usually used for patients with bad evocation of an ovary on controlled hyperstimulation of ovaries, but with preserved natural folliculogenesis, it means patients who can produce 1-2 eggs whether using medications or without it. We do ultrasound and hormone monitoring from 7-8 day of the cycle.
Medications which promote egg maturing should be injected for 28-32 hours before the expected injecting.
In the case of the presence of cryopreserved embryos obtained in previous cycles, it is advisable to carry out their transfer. Transfer of frozen embryos avoids additional controlled ovarian hyperstimulation and follicular injection. Standard protocol for endometria preparation for the transfer of frozen embryos is similar to a “long” protocol and starts with an injection of an agonist for 19-24 days of the cycle.
2.2. Fertilization of eggs is produced within 3-8 hours after egg collection.
It is used two types of artificial insemination.
2.2.1. Routine (normal) fertilization
To perform it, you must have at least 10 million active motile sperm in the total ejaculate sperm after special treatment. In the culture plate, the minimum amount of processed sperm is added.
2.2.2. ICSI (Intracytoplasmic sperm introduction)
It is used even with minimal changes in the sperm. Carrying out this manipulation and one selected spermatozoid is injected using a special device (micromanipulator) and micropipette into an egg.
There are additional indications for this manipulation – obtaining small amounts of eggs (5 or less), the failure of the previous cycle, etc. In any case, sometimes doctors are reinsured to achieve the maximum amount of egg fertilization. Naturally, the question of the need for ICSI is desirable to decide at the start of IVF cycles, but sometimes there is a need for the appointment of this procedure, the actual day of the injection. The doctor informs you about this after the husband’s sperm preparation for fertilization.
2.3. Embryos cultivation
In 16-18 hours after artificial insemination, it is possible to estimate the possibility of fertilization. Embryos are transferred to a fresh environment for further cultivation.
Embryo transfer is carried out from the 2nd to 5th day. Preferred day of transfer depends on many factors. However, conclusive evidence about the benefits of a development day embryos for transfer to the uterus is not revealed. On the transfer of the 5th day an embryologist has more criteria for the selection of embryos, but only 40% of the embryos survive to the 5th day. Not transferred embryos of good quality shall be cryopreserved for possible use in subsequent cycles of treatment.