IVF 

Introduction. In Vitro Fertilisation (IVF) is a type of Assisted Reproductive Technology that includes the retrieval of oocytes from the ovaries (pick-up) and their fertilisation with sperm from the partner or a donor. The embryo thus obtained can then be frozen (vitrification) or transferred into the uterus (embryotransfer).

 

Indications. These are as follows:

 

• reduced fertility in women >40 years old

• blockage or damage of the fallopian tubes

• reduced function (ovarian reserve)

• endometriosis

• uterine fibroids

• male infertility, oligospermia (low sperm count), asthenospermia (low sperm motility) or teratospermia (low percentage of sperm with normal morphology)

• unexplained infertility

• genetic disorder of one of the parents that may be inherited by the foetus (need to combine IVF with PGT-A, or pre-implantation diagnosis)

Assessment of ovarian reserve is the first step before embarking on IVF treatment. The anti-Mullerian hormone (AMH) assay is the test that is currently requested of patients, while the assessment of FSH levels has become an obsolete practice. In addition to hormonal tests, ovarian reserve can be investigated by means of antral follicle counting, which is carried out by means of a transvaginal pelvic ultrasound that allows, among other things, investigation of uterine and adnexal morphology. The partner must perform a seminal fluid analysis to assess the number of spermatozoa, their motility and morphology.

​

​

There are five stages in an IVF:

 

1. Ovarian stimulation

2. Oocyte recovery

3. Ovum insemination

4. Embryo culture

5. Embryo transfer

​

1. Ovarian stimulation. A woman produces a single oocyte each menstrual cycle. However, IVF requires more oocytes to be available. Having more oocytes available improves the chances of developing at least one viable embryo. In order to obtain more oocytes, the patient is given drugs called gonadotropins. During ovarian stimulation treatment, the doctor may request hormone tests and pelvic ultrasound scans to monitor the production of follicles, the structures that contain the eggs, and to know when to take the eggs from the ovary.

 

Egg retrieval. Egg retrieval is performed by aspiration of the follicular contents, a surgical procedure performed under sedation and vaginally under ultrasound control. A needle is guided through the vagina into the ovary and into a follicle where only one oocyte is usually present.

​

Insemination. At this point the partner must collect a sample of semen.which will be treated appropriately (capacitation) before being mixed with the oocytes in a Petri dish.

​

Embryo culture. The fertilised oocytes are checked daily to ensure that they are dividing and developing. Nowadays, embryo development is monitored using a technology called embryoscope, which allows embryos to be checked remotely without taking them out of the incubator to look at them under a microscope. When the embryos reach the fifth day of their development and are then called blastocysts, they can eventually be subjected to genetic testing (PGT-A) to rule out the presence of genetic aberrations.

 

Transfer. When the embryo has reached the desired stage of development, it can be transferred into the uterus (third to fifth day of post-fertilisation development). Embryo transfer, erroneously called implantation, requires the insertion of a thin catheter into the uterus. The procedure is performed under ultrasound control vaginally. The catheter passes through the vagina, the cervix and roughly reaches the uterine fundus where the embryo is released. A pregnancy test is carried out approximately 10 days after the embryo transfer (urine test or Beta HCG blood test).

 

As with any medical procedure, there are risks associated with IVF. Complications include:

 

• multiple pregnancies (risk of low-weight foetuses and premature births)

• abortion

• ectopic pregnancy, also called extrauterine pregnancy

• ovarian hyperstimulation, a rare condition that can lead to excess fluid in the abdomen and chest

• infection, damage to the intestines or bladder (rarely)

Conclusions. The success rate of IVF is variable. In accordance with the most recent data in the scientific literature, the pregnancy rate per embryotransfer is around 60% under 35 years of a woman's life, while this rate after the age of 35 and particularly after the age of 40 is around 20%. The rate of live births, according to the American Pregnancy Association, is 41-43% under the age of 35. This rate drops to 13-18% for women over 40.

 

Choosing to undertake an IVF is a very personal decision. There are some factors to consider:

 

• What will you do with the unused embryos?

• How many embryos do you wish to transfer into the uterus? The more embryos you transfer, the higher the risk of multiple pregnancies. The most popular strategy in the world is to transfer only one embryo into the uterus, at most two.

• How do you feel about the thought of having a set of twins, triplets or more?

• What do you think about the legal and emotional aspects associated with the use of donated oocytes, sperm from the sperm bank, etc.?

• What are the financial, physical and emotional stresses associated with IVF?