IVF (In Vitro Fertilization) –
Q. What is involved with in vitro fertilization?

There are five basic steps in the in-vitro-fertilization (IVF) and embryo transfer process:

  • Monitor and stimulate the development of healthy egg(s) in the ovaries.
  • Collect the eggs.
  • Secure the sperm.
  • Combine the eggs and sperm together in the laboratory and provide the appropriate environment for fertilization and early embryo growth.
  • Transfer embryos into the uterus.

Step 1: Fertility medications are prescribed to stimulate egg production. Multiple eggs are desired because some eggs will not develop or fertilize after retrieval. Transvaginal ultrasound is used to examine the ovaries, and blood test samples are taken to check hormone levels.

Step 2: Eggs are retrieved through a minor surgical procedure that uses ultrasound imaging to guide a hollow needle through the pelvic cavity to remove the eggs. Medication is provided to reduce and remove potential discomfort.

Step 3: The male is asked to produce a sample of sperm, which is prepared for combining with the eggs.

Step 4: In a process called insemination, the sperm and eggs are mixed together and stored in a laboratory to encourage fertilization. In some cases where there is a lower probability of fertilization, intracytoplasmic sperm injection (ICSI) may be used. Through this procedure, a single sperm is injected directly into the egg in an attempt to achieve fertilization. The eggs are monitored to confirm that fertilization and cell division are taking place. Once this occurs, the fertilized eggs are considered embryos.

Step 5: The embryos are usually transferred into the woman’s uterus three to five days following egg retrieval and fertilization. A catheter or small tube is inserted into the uterus to transfer the embryos. This procedure is painless for most women, although some may experience mild cramping. If the procedure is successful, implantation typically occurs around six to ten days following egg retrieval.

Side effects of in-vitro fertilization

Although you may need to take it easy after the procedure, most women can resume normal activities the following day.
Some side effects after IVF may include:

  • Passing a small amount of fluid (may be clear or blood-tinged) after the procedure.
  • Mild cramping
  • Mild bloating
  • Constipation
  • Breast tenderness

If you experience any of the following symptoms, call your doctor immediately:

  • Heavy vaginal bleeding
  • Pelvic pain
  • Blood in the urine
  • A fever over 100.5 °F (38 °C)
Q. What are the risks associated with in vitro fertilization?

As with most medical procedures, there are potential risks with in vitro fertilization . Fertility medications can have various side effects including headaches, mood swings, abdominal pain, hot flashes, and bloating, amongst other side effects. Although it is rare, fertility medications may cause ovarian hyper-stimulation syndrome (OHSS). Symptoms of OHSS may include abdominal pain or a feeling of being bloated. More severe symptoms include the following:

  • Nausea or vomiting
  • Decreased urinary frequency
  • Shortness of breath
  • Faintness
  • Severe stomach pains and heaviness.

If you experience any of these symptoms above, contact your doctor right away.

Additional risks of IVF include the following:

  • Egg retrieval carries risks of bleeding, infection.
  • The chance of a multiples pregnancy is increased with the use of fertility treatment. There are additional risks and concerns related to multiples during pregnancy including the increased risk of premature delivery and low birth weight.
  • Assisted reproductive technology (ART) involves a significant physical, financial, and emotional commitment on the pART of a couple. Psychological stress and emotional problems are common, especially if in vitro fertilization (IVF) is unsuccessful.
  • IVF is expensive, and many insurance plans do not provide coverage for fertility treatment. The cost for a single IVF cycle can range from at least Rs. 1 lakh 70 thousand to 1 lakh 80 thousand.
Q. How successful is in vitro fertilization?

The success rate of IVF depends on a number of factors including reproductive history, maternal age, cause of infertility, and lifestyle factors. It is also important to understand that pregnancy rates are not the same as live birth rates. Success rate is 40-50 %.

Q. Are there any restrictions on physical or personal activities during an IVF cycle?
  • Smoking
  • Drinking
  • Medications: If you are taking any medication, please inform your physician. Some medications may interfere with the fertility medications. A prenatal or multivitamin will be prescribed; if you are not taking a vitamin with folic acid. DO NOT USE HERBAL SUPPLEMENTS DURING YOUR IVF CYCLE.
  • An IVF cycle can be an emotional and stressful time for you and your patner. It may be helpful to have supportive personnel to speak.
Assisted Reproductive Technology (ART) Procedure –
Q. How does the ART laboratory operate and what safety measures are taken? What will happen to the eggs and sperm after retrieval?

The Procedure of Assisted Reproductive Technology (ART) is –

On the day before the oocyte (egg) retrieval, oocyte culture dishes are labeled with the patient’s name and ART identification number.

The dishes are then placed in the embryology incubator for warming to body temperature. The incubator also adjusts the pH of the culture media to the human body. A large amount of rinsing media is equilibrated in the incubator.

Upon arrival in the operating room the patient’s identity is verified by the embryologist, physician, and safety nurse.

After all of the eggs have been aspirated, insemination with sperm, and culture is done.

The maturity and health of oocytes are assessed after an incubation period. Oocytes are graded as mature, intermediate, immature, or degenerate. Approximately 30 minutes after collection, when the semen liquefies, a semen analysis is performed. The sperm is prepared for insemination.

The physician aspirates the fluid from the ovarian follicles into a test tube. A nurse passes the test tube, to the embryologist. The embryologist then dispenses the fluid into a large dish and rapidly scans it under the microscope.

Twenty to twenty-four hours after retrieval, the oocytes are transferred to fresh dishes that were equilibrated on the day of retrieval. Fertilized oocytes are returned to the main embryology incubator for 24 hours. At that time the embryos are transferred to fresh dishes where the cell stage and overall health of the embryos are microscopically evaluated. The embryos are either transferred on day 3 or placed into new dishes with a specialized culture media to allow for progression to the blastocyst stage.

Q. Am I depleting my store of eggs by undergoing an ART cycle?

A woman is born with a full complement of eggs. There are far more eggs than will ever be used during a normal lifetime and ART procedures have no measurable “lowering” effects.

Q. Is there a higher miscarriage rate for ART patients?

The miscarriage rate is about the same for  Assisted Reproductive Technology (ART) as the general population. Many times older females undergo ART and their miscarriage rates are naturally higher. Since pregnancy testing is done two weeks after embryo transfer, we often know about spontaneous miscarriages in the very early stages of pregnancy. These miscarriages would probably go unnoticed in the general population.

Pregnancy via ART Procedure –
Q. If I am not pregnant, when can we try again?

Usually we ask that patients wait one or two complete menstrual cycles before beginning another  Assisted Reproductive Technology (ART) cycle. Sometimes tests are required that may delay subsequent cycles.

Q. What happens if I become pregnant?

If pregnant, you will be asked to return to us for an ultrasound to ensure an ongoing successful pregnancy.

Q. When is the pregnancy test performed?

The blood pregnancy test is performed 14 days after the egg retrieval.

Q. Will I need a high risk pregnancy because I conceived with an ART procedure?

A high risk pregnancy only exists when there are complications that put the mother or baby at increased risk, or in the case of multiple births. Other than a higher incidence of multiple births, Assisted Reproductive Technology (ART) does not increase the risk to the fetus.

Embryo Transfer –
Q. How many embryos should be created or transferred?

The number of embryos transferred typically depends on the number of eggs collected and maternal age. As the rate of implantation decreases as women age, more eggs may be implanted depending on age to increase the likelihood of implantation. We go for two embryos transfer at a time.

Q. How do we decide how many embryos to transfer?

Your consultant will discuss with you according to embryo quality, status of the endometrium, age and many other factors. These numbers may vary depending on individual diagnosis and clinical circumstance.

Q. What if I don’t produce healthy eggs or my husband semen is low?

You may choose to use donor eggs, sperm, or embryos. However, the clinician will tell you about what procedure to go for. You will also be informed about various legal issues.

Q. What can be done to improve sperm quality?
  • During any fever or illness sperm count may be affected.
  • Discontinue alcohol and smoking.
  • If any medication has been taken during the last 3 months, notify it.
  • Do not begin any new form of endurance exercise during or 3 months prior to the ART cycle. Physical activity at a moderate level is acceptable and encouraged.
  • Abstinence not more than 2 days.
Fetal Medicine –
Q. What is Fetal Medicine?
  • Fetal medicine is the branch of medicine which deals with high risk pregnancies and health concerns of mother and baby before, during and after delivery.
  • A maternal fetal medicine specialist is a doctor who has received advanced training in diagnosis of unexpected maternal, fetal and genetic problems and is equipped to perform counselling, prenatal invasive testing and management of the same.
Q. When to consult a Maternal Fetal Medicine Specialist?

Although all pregnant women benefit from consulting a maternal fetal medicine specialist, some special situations require the expertise more than others. These include –

  • When Dual/ Quadruple test is abnormal
  • When ultrasound shows a problem in the baby
  • When there is a history of genetic disease in the family (eg. Thalassemia, Hemophilia, Muscle dystrophy, Deafness etc.
  • When there is intellectual disability/ developmental delay in previous child or any other family member
  • When there is a history of multiple abortions
  • When there is an unexplained death of a previous baby
  • When there is twin/ triplet pregnancy
  • When there is growth restriction in the fetus
Q. What Tests Should A Woman Undergo During Pregnancy?
  • Routine blood and urine tests like Hemogram, Urine routine examination, HIV, HBsAg, VDRL, TSH, GTT
  • Screening for Thalassemia Carrier status by HPLC (Blood test).
  • NT, NB Scan – Ultrasound between 11 and 14 weeks of pregnancy
  • Dual screen which is a blood test done between 11 and 14 weeks of pregnancy.
  •  Level II ultrasound between 16 – 19 weeks of pregnancy
  • Quadruple test – if a dual test is not done due to any reason, a quadruple test is advised between 15 – 20 weeks of pregnancy.
Q. Why Are These Tests Recommended?
  • Thalassemia is a blood disorder in which body makes abnormal and less amount of hemoglobin. Children with Thalassemia major require regular and multiple blood transfusions throughout life. There is higher prevalence of Beta thalassemia in Punjabis and Sindhis from Northern and Western India because of their genetic makeup.
  • If both parents are Beta Thalassemia carriers there is a 25% chance of having a baby with Thalassemia major. A fetal medicine specialist can diagnose before birth itself if the baby will be affected by Thalassemia major if both the parents have been identified as carriers.
  • NT, NB Scan is done to look for growth of baby, Nuchal translucency (which is the collection of fluid under the skin at the back of the baby’s neck) and visualize the nasal bone of the baby. An abnormality in this ultrasound requires further testing and close follow up.
  • Dual screen gives a risk of the baby having Down syndrome and some other genetic conditions. Down syndrome is a genetic condition associated with mild to moderate intellectual disability. Abnormality in Dual test requires further testing and close follow up.
  • LEVEL II Ultrasound is done to look for any abnormality in the baby.
  • Quadruple test – It gives a risk of having a baby with Down syndrome and some other less common genetic conditions.
Q. What Are The Additional Tests Which A Fetal Medicine Specialist May Advice?

In certain special conditions a fetal medicine specialist may advice –

AMNIOCENTESIS

  • During pregnancy, the baby is surrounded by amniotic fluid which contains cells and chemicals produced by the baby.
  • These cells contain information which can be used to diagnose genetic conditions in the unborn child.
  • During amniocentesis, an ultrasound is used to show baby’s position in the uterus.
  • A thin needle is then introduced through mother’s abdominal wall and uterus into the amniotic fluid present around the baby and a small amount of this fluid is removed for testing.
  • The procedure lasts for a few minutes and does not require any anesthesia.
  • It is generally performed between 16 to 20 weeks of pregnancy.

CVS (CHORIONIC VILLUS SAMPLING)

  • During pregnancy, the placenta provides blood and nutrition from the mother to the growing fetus.
  • During CVS, an ultrasound is used to show the position of the baby and placenta in the uterus.
  • A thin needle is introduced through the mother’s abdomen and uterus into the placenta and a small sample of cells is taken from the placenta where it attaches to the wall of uterus.
  • These cells contain information which can be used to diagnose genetic conditions in the unborn child.
  • The procedure lasts for few minutes and is done under local anesthesia.
    It is generally performed between 11 to 14 weeks of pregnancy.

BEFORE THE PROCEDURE (Amniocentesis or CVS)-

  • The doctor will explain the procedure to you including its risks and benefits and ask you to sign a consent form which gives your permission for performing the procedure.
  • Read the form carefully and you can ask questions regarding the procedure or if something is not clear in the consent form.
  • Your doctor will require some routine blood and urine tests before the procedure. These include Blood group, Hemogram, HIV, HBsAg, HCV status and HPLC and Urine routine examination report. An ultrasound to rule out any gross abnormality in the baby is also done before the procedure.
  • Generally, there is no special dietary restriction before the procedure.
  • Inform your doctor about all the medicines you are taking (including Ayurvedic and Homeopathic medicines). You may be required to stop some medications prior to the procedure such as blood thinning medications (Heparin, Aspirin etc.)
  • Inform your doctor if you are allergic to any medicine, iodine, latex and anesthetic agents (local and general).
  • Inform your doctor if you have a history of medical disorder especially history of bleeding disorder.
  • You may be asked to have a full bladder right before the procedure as depending on the position of the uterus and placenta, a full or empty bladder may help move the uterus into a better position for the procedure.

AFTER THE PROCEDURE

  • Both the mother and the baby are monitored for a time after the procedure.
  • The Amniotic fluid or CVS tissue will be sent to a specialty genetics lab for analysis. The credentials of the genetic lab are available with the hospital. Counseling will be done after the test results.
  • There may be some slight cramping and light spotting for a few hours after Amniocentesis or CVS.
  • You should rest at home and avoid strenuous activities for at least 48 hours. You should not douche or have sexual intercourse for two weeks, or until directed by your doctor.
  • Notify your doctor to report any of the following:

1.   Any bleeding or leaking of amniotic fluid from the vagina
2.  Fever and/or chills
3.  Severe abdominal pain and/or cramping

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