What is In vitro fertilization-Embryo Transfer (IVF-E.T)?
In Vitro Fertilization (IVF) is a type of Assisted Reproductive Technology (ART), where fertilization of female and male gamete is brought outside the human body i.e “In Vitro” literally “In Glass”. The fertilized eggs (embryos) are then placed in the women’s uterus.
What is intra cytoplasmic sperm injection (ICSI)?
Intracytoplasmic sperm injection (ICSI) is a laboratory procedure developed to help infertile couples undergoing in vitro fertilization (IVF) due to male factor infertility. ICSI, a form of micromanipulation, involves the injection of a single sperm directly into the cytoplasm of a mature egg (oocyte) using a glass needle (pipette).
Program summary for the patients undergoing IVF, ICSI and embryo Transfer
The following is an outline of the basic flow of steps for most patients.
IVF-E.T, ICSI-E.T and related procedures require the following steps:
1. Patients selection
2. Pre-cycle evaluation
3. Ovulation induction & monitoring
4. Egg retrieval
5. Sperm processing
6. In-vitro fertilization
7. Embryo transfer
8. Post transfer management
9. Cryo preservation
10. Other related procedures
11. Couple participation
1. Patient Selection
A complete evaluation of fertility factors (these are egg, sperm and uterine cavity) is important prior to considering IVF-E.T technique. The following conditions can be successfully treated with IVF-E.T technique.
Tubal Disease Patients with tubal blockage or severe pelvic adhesions, or who have not conceived after tubal surgery are good candidates for IVF-E.T technique.
Moderate to Severe Male Factor The ability to treat sperm in the laboratory by various techniques, along with the ability to concentrate large numbers of motile sperm around eggs makes IVF-E.T a potential treatment for couples whose infertility is due to poor semen quality.
Endometriosis As endometriosis often results in pelvic anatomy distortion and adhesion, the 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.
Immunologic infertility IVF-E.T technique allows fertilization outside the body, away from the destructive actions of anti-sperm antibodies.
Unexplained infertility that has not responded to other types of therapy. IVF-E.T has successfully treated such couples. IVF-E.T can demonstrate the ability of the sperm to fertilize eggs become to growing embryos. Rarely, unexplained infertility maybe due to defects in gamete function.
1.Pre-Cycle Evaluation
To achieve good success rate, it need to meticulous evaluation of three factors (egg, sperm and uterine cavity) that contribute to a favorable outcome with IVF-E.T.
A. The first of these is the women’s ability to respond to fertility drugs. While age affects thisparameter, measurements of FSH and Estradiol on the 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.
B. The second factor to evaluate is the uterine environment. It is recommended that the women undergoes a one-time office hysteroscopy prior to beginning a IVF-E.T procedure. The hysteroscope allow us to look inside the uterine cavity and make sure there are no fibroids, polyps or scar tissue that could interfere with implantation. If the women has had a recent hysterosalpingogram (HSG), and the uterine cavity appears normal, the hysteroscopy can be waived. Also, women undergoing IVF-E.T should have the length of their uterus carefully measured, in order to accomplish an atraumatic embryo transfer later on.
Cervical cultures are taken before commencing treatment. Organisms such as ureaplasma have been associated with poor reproductive outcome and poor embryonic growth in the laboratory.
Finally, 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.
C. The third factor is the male factor. This requires a semen analysis. In addition, 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 have major medical, surgical, or psychological problems are required to be treated before starting cycle.
In addition to the above medical evaluation, couples contemplating IVF-E.T are informed of the availability of a counselor. The counselor are familiar with emotional impact of infertility and infertility treatments, and can help the couple deal with this important aspect of their care.
Ovulation Induction and Monitoring
IVF-E.T success rates depend upon the numbers of eggs, fertilized eggs, good quality embryos available for transfer. Additionally, the egg retrieval must be carefully timed so as to retrieve mature eggs. To accomplish these two goals, ovulation induction medications and careful monitoring are employed. In most cases, the long protocol (one of ovarian stimulation regimens) is selected and the women begins with intramuscular injection decapeptyl depot 3.75mg (triptorelin 3.75mg) in their leutal phase, in other words after ovulation has occurred. Starting injection triptorelin does not have to be on an exact day. We usually give the injection a week before (usually 21st day of menses) of the upcoming treatment cycle. If patient have very short or very long menstrual cycles, we may adjust the day for the injection. Sometimes, we actually need to give some outside progesterone in order to allow us to start decapeptly. This hormone prevents premature ovulation.
After menses occurs, prior to starting the ovarian stimulation, we select a day for Down Check, a Sonogram is done to make sure there are no ovarian cysts, and a blood estradiol level and a progesterone level is measured to make sure that everything is in control. On a specified day the women 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 patients response to these drugs, Sonograms and serum estradiol levels are performed on day 6, day8 and day 10. 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 & Gonadotropins. About 36 hours prior to the anticipated egg retrieval, the patients takes an injection of human chorionic 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.
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 anesthesia and is performed with just simple intravenous sedation. An anesthesiologist administers the sedation to maximize your comfort and safety. As a result, the experience is not painful and recovery is rapid.
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 sperm are isolated prior to inseminating the eggs.
In Vitro Fertilization
In Vitro Fertilization literally means “fertilization in glass “. Follicular fluid removed from the ovaries is examined in our lab for the 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. Only 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 sperm 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. 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 which she can go home. We have provided a facility for an overnight stay in our center as preferred by the patients. As the implantation will occur in the following few days, the patients are instructed to rest at home during this time after the transfer. Light activities allowed without stress and most sleep well at night.
We usually transfer the embryos into the woman’s uterus two days after 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.
Post-Transfer management
During the follow-up phase, the woman 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 hormone, hCG, indicate that implantation has occurred. Confirmation of a clinical pregnancy is made by ultrasound about 2 weeks later.
Cryoprservation
Freezing extra embryos gives couples an additional opportunity to conceive without going through another stimulation cycle and egg retrieval. The success rate with frozen/thawed embryos are improved when women 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.
Other related procedures
Testicular Sperm Aspiration (TESA)
TESA is a simple and minimally invasive procedure where a small amount of testicular tissue is removed via needle aspiration. It is performed under local anesthesia and mild sedation or IVA. A sperm is then inserted into each egg using the ICSI procedure. TESA allows for the retrieval of sperm from men who are unable to produce sperm in their ejaculate because of an obstruction and absence of the vas deference.
Sperm Banking (Semen Freezing/Semen donation)
Sperm Banking is the preservation of sperms by freezing so that they may be used subsequently for Intra Uterine Insemination (IUI), In Vitro Fertilization (IVF), Intra Cytoplasmic Sperm Injection (ICSI).
Sperm Freezing is advised when partner could not be available on the day of Insemination, prior to Chemotherapy, Radiation, Vasectomy or if partner have semen collection problem when needed.
Donor Sperm is advised when the partner is Azoospermia, Oligozoospermia, Teratozoospermia, Asthenozoospermia or if the partner carries a genetic defect.
Ovum Donation
Donor Oocyte is advised when the patient could not produce their egg in case of premature ovarian failure, removal of both ovaries,
Embryo Donation
Donor embryo is advised when the patient could not produce their egg and the husband has abnormal sperm parameters (e.g. very low count, poor motility, high percentage of abnormal forms, Azoospermia (complete absence of sperm) or if the partner carries a genetic defect.
OUTCOME OF OM IVF CENTER
Since the introduction of this technology in OM HOSPITAL, to date (July 10th 2007), we have had 17 batches of IVF (each batch consists of 17-31 patients) in Om IVF Center, serving a total of 368 infertile couples. The average pregnancy rate is 37%, whereas average clinical pregnancy rate is 30%, and overall live birth rate is 33%. Till date, up to 14 batches have already delivered 102 babies. There are still 13 pregnant mothers who are carrying 19 babies
APPOINTMENTS
We do IVF in batches i.e every
month with average 20 patients in each batch. Those who are willing to do IVF in
our centre, if possible send the previous treatment history, recent Hysterescopy or Hysterosalpingogram (HSG), Transvaginal Ultrasound (TVS) reports, their last menstruation date & Menstrual cycle length by Fax/mail addressing Dr Sabina Shrestha.
If everything is normal then their treatment will start by giving the injection Decapeptyl Depot 3.75 mg a week before (usually 21st day of menses) of the upcoming treatment cycle. If patient have very short or very long menstrual cycles, we may adjust the day for the injection. After 21 days of first Injection the patient need to be present in Kathmandu for daily injection till the procedure finishes. Pregnancy can be confirmed using blood tests and urine tests about 14 days after embryo transfer and 28days after embryo transfer by ultrasound.
Message from Chairman
Om
Hospital & Research Centre (P.) Ltd. has been playing
an important role for a long time in the treatment of childless
couples in Nepal's history. Being Childless is not only
a subject of rejection in the society but it also gives
the feeling of a torturous death. Today we are at the point
of achieving our goal after the long period of struggle
and effort. The whole credit of this success goes to you
all. We are only the doer, flowing along with the wave of
emotions, when the sorrow becomes
unbearable. We apply our all effort to minimize your pain.
We have invested not only money but also our effort, goodwill
and wishes motivated by that ultimate smile on your face.
We understand the pain and further you have undergone and
will do our best to lessen it. I have full faith that I
will fulfill the dream of many wishes & blessings.
CONTACT INFORMATION'S
For any questions and detail information please contact:
1. Dr Sabina Shrestha (Consultant, IVF Department)
Phone: 00977-1- 4476224, 4476225 Ext. No. 339, Fax:00977-1- 4466128
Mobile: 9851060680
2. Mrs Yamuna Pokharel ( IVF Counsellor)
Phone: 00977-1- 4476224, 4476225 Ext. No. 601, Fax:00977-1- 4466128
Mobile: 9803150308
