IN VITRO FERTILISATION (IVF)/INTRACYTOPLASMIC SPERM INJECTION (ICSI)

IVF is where fertilisation of the egg and sperm occur in a dish in a laboratory, not in the fallopian tube of the woman’s body. The term ‘test tube baby’ was used in the 1980s. However, now you are more likely to hear the term ART (Assisted Reproductive Technology) or IVF. In 2012–2013, over 10,000 women used ART in Victoria.

The first live birth from IVF was Louise Brown in England in July 1978. In fact, Louise Brown has now gone on to have two children herself, both conceived naturally.

There are many reasons why IVF may be recommended for you. Some of these include:

• Blocked fallopian tubes
• Severe endometriosis
• Low ovarian reserve
• Women over 36 years old
• Unexplained infertility
• When other treatments have been unsuccessful
• Abnormal semen analysis
• Donor eggs, donor sperm, donor embryos
• Preimplantation Genetic Diagnosis (PGD)

How do I get started?

In Victoria, there are several steps that must be completed prior to actually commencing IVF treatment. These steps are legislative requirements regulated by the Assisted Reproductive Treatment Act 2008 (Vic), and include:

• Appropriate medical investigations
• IVF counselling

The average length of time to complete these requirements is 4–6 weeks.

TREATMENT

When your legislative requirements are complete, and you have been prescribed your personalised treatment plan, you will be given contact details to meet with your fertility nurse.

You will spend about an hour with the nurse, who will provide you with the medications and instructions about how and when these should be administered.

Many IVF medications are injections. The needle used for fertility injections is much smaller than a needle used for a blood test. Often the injections are available in pen-like devices, which are easy to administer, even if you have no medical experience.

The stages of the IVF process are:

1. Ovarian stimulation and monitoring
2. Egg (oocyte) collection
3. Fertilisation
4. Embryo development
5. Embryo transfer
6. Luteal phase support
7. Pregnancy test.

Stage 1: Ovarian stimulation and monitoring

• Fertility injections commence to stimulate the development of multiple follicles on each of the ovaries. A follicle is a fluid-filled sac that contains an egg.
• Your response is monitored with regular blood tests and ultrasounds based on your individualised protocol.
• Ultrasounds will obtain images of the ovaries and the follicles. As a follicle gets bigger, the egg within it will start to mature. The ultrasounds and blood tests will determine the best timing for the procedure to collect the eggs.
• A final ‘trigger’ medication will be self-administered to stimulate ovulation and maturation of the egg.

Stage 2: Egg (oocyte) collection

• Egg collection, also known as ‘egg pick-up’, is arranged at a specific time, usually 34–38 hours after the final trigger injection.
• Egg collection is usually performed under a general anaesthetic by a specialist.
• The follicles are identified using a vaginal ultrasound, and a fine needle is passed through the vaginal wall and directly into each follicle to collect the eggs.
• The procedure takes about 15 minutes.

Stage 3: Fertilisation

• Prior to the egg collection, a semen sample is collected and prepared to obtain optimal concentration and motility.
• If the semen results have been normal, STANDARD IVF may be recommended. This is when the eggs and sperm are placed together in a petri dish and placed in an environmentally-controlled chamber. The next day the eggs are examined under the microscope to determine whether fertilisation has occurred.
• If the semen results are NOT entirely normal, you may be recommended ICSI (Intra Cytoplasmic Sperm Injection). This is when a single sperm is directly injected into each mature eggs to assist fertilisation.

Stage 4: Embryo development

• Once the fertilised egg divides, it is called an embryo.
• The development of the embryo is assessed daily.
• Usually, embryos are ‘transferred’ back into women either 3 or 5 days after the egg collection.
• At Day 3, an embryo typically had 6–8 cells. By Day 5, an embryo may have over 100 cells, and should be at the blastocyst stage.
• There is a higher chance of pregnancy with a blastocyst embryo. However, only one in four embryos will continue to divide and develop to this stage.

Stage 5: Embryo transfer

• The embryo transfer is not a complicated procedure and is similar to a Pap Smear test. It is generally performed whilst awake, although you can choose to have an anaesthetic if you prefer.
• It is usually recommended to transfer just one embryo at a time, and any extra suitable embryos can be frozen for use in the future.

Stage 6: Luteal phase support

• The IVF medications may result in your period coming much earlier than expected. To prevent this, you will be prescribed vaginal progesterone to take after the egg collection and until the pregnancy test.

Stage 7: Pregnancy test

• A blood test to confirm pregnancy will be scheduled around 16 days after your egg collection.
• It is possible to have a positive pregnancy test, even if you have had some bleeding.
• The nurse will schedule your blood test. You will be notified on the same day on your preferred phone number.

Frozen Embryo Transfer

• If you have a frozen embryo, it can be thawed and transferred without having to have another egg collection procedure.
• For women who have a regular menstrual cycle (i.e. 25 to 35 days), the embryos can be transferred in the woman’s natural cycle (ie. no fertility drugs required). There are regular blood tests to confirm when the woman is ovulating, and the embryo is then transferred at the appropriate time after ovulation.
• Women with irregular/no periods will need to take hormone medications to prepare the uterus for implantation. This medication may include estrogen tablets, vaginal progesterone, or injections.

Coping With IVF

Starting IVF can be a very exciting time, as it is another step closer to becoming parents. Naturally, you will feel hopeful about a successful outcome. However, you also need to prepare yourself for a series of medications, numerous procedures and testing. Often you will experience a range of intense emotions, swinging from hope to despair to elation to disappointment. The experience and how you cope will depend on individual factors including your own personality, support networks, life experiences, your relationship with your partner, possible side effects from fertility medications, and the length and number of IVF treatments.

Initially, women may fear the actual process. However, often the most difficult part of the treatment is waiting for results of the pregnancy blood test. In addition to dealing with feelings of hope, anxiety and uncertainty, your body is recovering from hormonal changes from the medications. It is important at this point, if you are struggling emotionally, to utilise your support network.

OVARIAN HYPERSTIMULATION SYNDROME (OHSS)

Ovarian Hyperstimulation Syndrome (OHSS) is a medical condition that can occur as a result of taking fertility injections (FSH) to stimulate the ovaries to produce multiple eggs. All women undergoing ovarian stimulation during IVF treatment will experience enlargement of the ovaries (hyperstimulation). This can result in some abdominal bloating and discomfort that usually resolves after a few days.

OHSS is diagnosed when there is more significant abdominal bloating and discomfort, and is often associated with nausea and vomiting. Women may also suffer from dehydration, breathing and problems with urinating.

Less than 1% of women require hospital admission to manage the effects of the OHSS. Treatment may include intravenous fluids, analgesia (pain relief), anti-emetics (anti-nausea medication), blood thinners, or drainage of fluid from the abdomen (ascitic tap).

Risk factors for OHSS include:

• Younger age
• Slim/lower BMI
• Many follicles on the ovaries (e.g. PCOS)
• Previous OHSS

There are different strategies to minimise the risk of OHSS, including the use of lower doses of fertility injections (FSH), using a nasal spray trigger or freezing all embryos (and delaying embryo transfer until the following month).

Monitoring with blood tests and ultrasounds may help identify those women at risk of OHSS. However, there will always be a very small percentage of women who develop OHSS with no obvious risk factors.