Introduction

 

In vitro fertilisation (IVF) is an assisted reproduction technique which involves bringing one or more eggs from a woman into contact with sperm from her partner, this being done in the laboratory. The aim is to increase the likelihood of fertilisation in those cases where there is a problem making natural conception difficult. Once the eggs have been fertilised the resulting embryo or embryos are transferred into the womb, a procedure which leads to pregnancy in 45% of cases. The particular characteristics of the couple, the reason for infertility, and age can all affect the probability of pregnancy. 

 

In vitro fertilisation differs from in vivo fertilisation in that the union of sperm and egg takes place in the laboratory, outside the woman’s body.


 

 

 

 

 

 

 

 

 

 

When to use it ? 
The technique is recommended to couples with various types of infertility, whether they be of male or of female origin. It was originally used in  women whose fallopian tubes were blocked (tubal factor), but is now applied in all those cases in which infertility is related to problems of fertilisation or to the first stages of reproduction (male factor, endometriosis, cervical factor, immunological factor), as well as with unexplained infertility.        

Scheduling treatment 
Before undergoing an IVF cycle in our centre you will need to be seen by a gynaecologist, who will make a diagnosis and decide on an appropriate course of treatment. When a couple has previously attended another centre it is of great help if they bring along a copy of the report describing which tests and treatment were already carried out. 
  
Once a diagnosis of infertility requiring IVF treatment has been made the couple will be included in the IVF programme; the process will then be explained to them and they will be given a request form for general tests. These tests must be done prior to starting the IVF cycle and you should make an appointment to see your doctor 1-2 months before you hope to begin treatment. You must not take any medication until told to do so and you should ensure that everything is ready for when treatment is due to begin. The medication given may vary from one patient to another, but we always ensure you receive the most appropriate for your case. 
  
The start of treatment can vary according to your individual circumstances. In some patients it begins after the first day of your period in the agreed month, this being the day on which you should telephone the Institute ( +49 201 294290). In others the start of treatment will be established on the basis of your period in the month prior to that in which the IVF cycle is scheduled; in this case, you will have to let us know when your period started.

 

 

Stimulating and monitoring ovulation

 

How does it get ovulation stimulation?    
 

The medication you will be given in this process is to stimulate your ovaries and thus obtain the large number of eggs (8-15 if possible). Research has shown that the pregnancy rate in IVF cycles is higher if more than one egg is obtained per cycle and more than one embryo is transferred to the womb.          
  
Which tests are been done to evaluate ovulation stimulation?       
The eggs develop inside follicles, which are small, liquid-filled sacs or cysts that form in the ovaries. During treatment, both the number and size of these follicles is measured by means of a transvaginal ultrasound scan. The ultrasound scans do not allow us to see the eggs, as these are of microscopic dimensions.

 

The follicles produce a hormone called oestradiol, the level of which increases as the follicles grow. Oestradiol production is assessed by means of a blood test. We must have the results the same day to assess the response to stimulation. The treatment dose will be decided on the basis of the ultrasound scans and the hormone tests and may vary from one day to the next depending on the results. It is important that the level of oestradiol increase every day until the eggs are retrieved. There is no standard level of oestradiol; in fact it varies considerably between patients. 
  
The test results as a whole tell us if the response to treatment is correct. In general, there is a direct relationship between the number of developed follicles and the level of oestradiol; the greater the number of follicles the higher the level of oestradiol detected in blood. 
  
In certain cases, and if the treatment (for example, spontaneous cycles or stimulated cycles without the use GnRH analogues) requires it, a urine test is also carried out. Samples are collected in sterile flasks and clearly identified with your full name and the date and time of urination. Only a small amount of urine is required in each flask, the rest can be disposed of. These samples enable us to determine the level of the hormone LH, which is responsible for ovulation. If an increase in LH level is detected, which would indicate the start of spontaneous ovulation, a decision will be made as to whether the cycle should be cancelled or the treatment plan modified. 
  
Cancelling an IVF cycle          
10% of IVF cycles are cancelled for various reasons to do with a poor response to stimulation treatment. Among the most common are: 
  
A lack of follicles 
Low or irregular hormone levels, suggesting that any eggs obtained will be of poor quality. 
Premature ovulation, which prevents the right moment for egg retrieval from being accurately determined. 
  
In most cases, administration of a new treatment, or changes to the existing one, enable a new cycle to be started a few months later more succesfull. 
  
Health Psychology Programme          
Couples whose social, emotional and family situation is more stable have been found to have a greater probability of conception; they are also more likely to be satisfied with treatment. Therefore, as part of our Reproductive Medicine Service we provide a programme of Health Psychology, aimed at helping couples to deal with the problem of infertility and its treatment.            
  
When is the egg retrieval scheduled?      
Thanks to the ultrasound and hormonal monitoring we are able to assess the development of follicles and thus determine the right moment to retrieve the eggs which have been produced.

Follicular puncture

 

Follicular puncture must be done just before ovulation begins. In order to plan this, ovulation is induced artificially (provided that there has been no spontaneous increase in the hormone LH) by means of a subcutaneous injection of the hormone HCG, around 36 hours before the puncture is scheduled. The doctor will tell you the exact time when the HCG injection has to be given and when the puncture will be performed.      
  
What does follicular puncture involve?         
Eggs are usually retrieved by means of a transvaginal, ultrasound-guided puncture. 
  

1. As in the previous monitoring sessions, the ultrasound scan shows us where the follicles are and on this occasion they will be punctured by passing a needle through the wall at the back of the vagina. 

2. An aspiration (suction) system is used to draw the follicular fluid containing the eggs. 

3. And these are immediately taken to the IVF laboratory for identification and assessment. 

  
The follicular puncture is performed by one of the doctors with special training in the use of ultrasound. As it is done in the operating theatre you will first need to be assessed by one of the anaesthetists so that a decision can be made about the most suitable form of analgesia for you (usually sedation). 
  
How many eggs can be collected?    
The number of eggs obtained in each cycle varies considerably from one woman to the next. On average, 6-8 mature eggs are obtained per cycle. It is important to remember that the number of eggs obtained may not be the same as the number of follicles observed during the daily ultrasound monitoring. 
  
It is rare that we are unable to obtain any eggs, although sometimes the follicles are not accessible or ovulation occurs unexpectedly, without the usual hormone changes being detected. In such cases we would study the woman’s individual circumstances and make plans so that such a situation would not arise in the future. Before starting a new stimulation cycle it is advisable to let a few cycles occur naturally without any treatment being given.

 

 

Semen samples

 

Andrology laboratory 
 

The semen sample to be used in egg insemination has to be collected on the same day as the follicular puncture is performed. Before collecting the semen sample it is important that the man urinate and wash his hands and genitals. The sample is obtained by means of masturbation and is deposited into a properly labelled, sterile receptacle. It is very important to collect all the ejaculation and to not lose any part of the sample. The male should also abstain from sexual activity for 3-5 days before delivering any semen sample.

Under special circumstances the man will be asked to provide more than one sample on the day of follicular puncture in order to make a better selection of the sperm. 
  
Freezing of semen         
Some patients may find it difficult to obtain a semen sample as described above. If you have any such concerns you should not hesitate to tell us so that we can consider the possibility of freezing a semen sample produced prior to the day of puncture. You should be aware, however, that the freezing and thawing process may affect the viability of some of the sperm cells; therefore, it is not advisable to freeze semen samples which show a very low number of mobile sperm (oligoasthenozoospermia). Freezing should be done at least 3-5 days prior to egg retrieval.     
  
Sperm bank    
The NOVUM Sperm Bank CRYOSTORE* was set up in 1981. Donors are selected according to rigorous medical guidelines and the identity of both the donor and the recipient is kept strictly confidential. 
When, for medical reasons, it is necessary to use the Semen Bank the couple’s doctor will inform them of this prior to beginning any treatment. Couples wishing to use the Semen Bank are interviewed by a member of staff from the Bank in order to identify the most suitable sample in each individual case. 
  
Sperm microaspiration/Testicular biopsy       
When there is some kind of obstruction preventing sperm from being ejaculated, even though their production in the testicles (spermatogenesis) is normal, it is possible to retrieve semen by means of a simple surgical procedure. 
Sperm is usually retrieved from the testicles by biopsy. These procedure is done in an external operating theatre, some days before stimulation treatment. The man will only need to remain in the clinic for a few hours. It is not possible to predict the quality of a sample obtained by means of sperm microaspiration or testicular biopsy, and in some cases the fluid obtained may not contain any sperm cells suitable for fertilisation.

 

 

 

 

 

 

 

 

 

 

Dipl.-Biol. Franz B. Kolodziej - Laborleiter

Oocyte insemination

 

What does oocyte insemination involve?

 

Eggs are usually inseminated 4-6 hours after being retrieved. During this time they are kept in a culture medium in an incubator at a constant temperature of 37ºC and under gasification and humidity conditions that enable them to mature. If any of the eggs obtained is not mature enough to be fertilised the culture time is extended and the insemination performed the following day.

 

 

 

The semen sample is prepared in such a way that after processing a suspension rich in mobile sperm is obtained; immobile sperm, or those with a low fertilisation capacity, are discarded. 
  
Insemination is performed with around 100,000 mobile sperm per egg. Once complete the eggs and sperm are kept together in an incubator for 24 hours; not until the following day will we know whether fertilisation has taken place. 
  
Microinsemination techniques: intracytoplasmic sperm injection (ICSI)       
Microinsemination techniques aim to make fertilisation easier by reducing or removing any obstacles in the way of sperm which are attempting to reach an egg and fertilise it. The decision about whether to use such techniques will be made by the gynaecologist or andrologist, depending on the characteristics of the semen. These procedures are only used in those cases where we can predict in advance that fertilisation will not take place; their use does not in itself guarantee the successful fertilisation of all the eggs which are microinseminated. 
  
The microinjection of a sperm cell directly inside the egg, known as ICSI, has helped to overcome many male infertility problems that could not be solved with conventional in vitro fertilisation. 
  
Testing for fertilisation            
The first test of fertilisation is done the day after insemination. The presence of two pronuclei inside the egg is the definitive sign that fertilisation has taken place; one corresponds to the male pronucleus and the other to the female pronucleus. 
  
Stored inside each pronucleus is the genetic material characteristic of the person it comes from, either the male or the female partner, and the combination of the two will determine the genetic make-up of the new embryo. 
  
When do embryos have to be transferred?    
Fertilised eggs are kept in a culture medium for one or two days more before being transferred. During this time, the development of the embryos will be monitored and any which do not divide properly will be discarded. 
  
If, on the basis of past experience, a more detailed assessment is deemed appropriate, the in vitro culture time will be extended up to 5 days. With a longer culture time the embryos can develop up to the blastocyst stage, the point at which they should be transferred to the womb for implantation. 
  
Failed fertilisation       
Incorrect fertilisation of inseminated eggs, by two or more sperm cells (polyspermia), rarely occurs; the sign of this is when several pronuclei can be observed the day after insemination. Embryos produced by polyspermic fertilisation are not viable and therefore rejected. This fertilisation failure also exists in nature and leads in case of an occuring pregnancy to abortion.      
  
The rate of fertilisation           
The rate of fertilisation in eggs inseminated by conventional in vitro fertilisation is around 70%. Lack of fertilisation may sometimes be due to a previously undiagnosed male factor, to an egg factor, or be unexplained. When none of the inseminated eggs have been successfully fertilised the case will be studied in more detail in order to decide how best to proceed. In cases of diagnosed male infertility the insemination technique used will be sperm microinjection. In those cases which, with conventional in vitro fertilisation, there would be almost no likelihood of an egg being fertilised, the microinjection technique produces a fertilisation rate of 70%.

  

 

 

 

 

 

 

 

 

 

Embryo transfer

 

The day before transfer the couple are told how, where and when the embryo transfer will take place. In most cases the procedure is straightforward, being done through the vagina with the aid of an ultrasound scan and without the need for anaesthesia. In special cases, the embryo(s) will be transferred through the muscular layer of the wall of the uterus (the myometrium) also with the aid of an ultrasound scan. 
  
At the moment of transfer the biologist loads the embryos, together with a small amount of culture medium, into the transfer catheter. The patient lies as she would for a gynaecological examination and the gynaecologist gently passes the catheter through the cervix, depositing the embryos into the womb. Although this process only takes a few minutes the patient must remain resting for 10-20 minutes afterwards. 
  
How many embryos are been transferred per cycle?            
The number of embryos transferred will vary per individual case, between 1 and 3 embryos. The gynaecologist will advise on the most suitable option per case. 
  
Under no circumstances will more than three embryos be transferred per cycle. In the event that more than three fertilized eggs (pronuclear stages; PN-Stages) are available those which are not intended for transfer will, subject to the couple’s consent, be frozen. 
  
The consent form regarding the freezing of PN-Stages will be given to the couple at the start of the cycle and should be returned, signed, as soon as possible. In the event that a couple do not wish to give their consent to the freezing of PN-Stages they should make their decision known promptly, at the day of follicular punction. 
  
  
Freezing of embryos   
Techniques for freezing PN-Stages enable those embryos which are not transferred in an IVF cycle to be used in subsequent cycles. This can be of benefit both to couples who do not achieve a pregnancy in the first cycle as well as to those who do and then wish to try for another child. 
  
In order to freeze PN-Stages they are first subjected to certain osmotic changes, enabling the water inside the cells to be substituted by a protective agent, or cryoprotector. They are then frozen and kept in liquid nitrogen at a temperature of –196ºC until the moment of thawing. 
  
  
Going home and lifestyle after transfer          
After leaving the clinic on the day of transfer it is advisable to rest as much as possible for at least the next four hours. 
  
You will have to continue with hormone treatment, as indicated by your gynaecologist, in order to ensure that the endometrium (the membrane lining the womb) is well prepared for embryo implantation. 
  
After transfer your lifestyle needs to be as gentle as possible; you should avoid any strenuous effort, sport, swimming, and refrain from sexual intercourse until after you have done the first pregnancy test. 
  
  
Pregnancy testing       
The first pregnancy test should be done sixteen days after embryotransfer was performed. If you have not had a period by then, a sample from your first urination on this day will be analysed to see if you are pregnant or by determining the level of the hormone b-HCG in your blood. In the event that your period begins prior to day 14 you should telephone to let us know. 
  
Regardless of whether you become pregnant or not please remember to keep in permanent contact with the centre so that we can make plans for the future. You will have to wait 2-3 months before repeating an IVF cycle, during which time it is helpful to make a note of the dates of your periods.

 

Pregnancy

 

Which tests are carried out to confirm pregnancy after IVF?            

The result of “day 14” tells us whether or not any of the transferred embryos have implanted, but as this is merely one of the very first stages of pregnancy it is too soon to know whether the pregnancy will develop beyond this stage.

 

 

During the first two weeks you will be monitored through a series of blood tests for the hormone b-HCG. If the results of these are favourable you will have an ultrasound scan to confirm the pregnancy; this will also tell us whether it is a single or multiple pregnancy. 
  
As the foetal heart beat cannot always be observed in the first ultrasound scan it is often necessary to repeat it a few days later. 
  
The pregnancy rate after in vitro fertilisation is about 40%, ranging from between 10-50% depending on the individual characteristics of the couple (the cause of infertility, age, previous pregnancies or miscarriages/abortions, etc.). 
  
Multiple pregnancies  
Multiple pregnancies are more common following IVF (15 - 20%) than with natural conceptions (1%). This is because embryo transfers are generally done with more than one embryo in order to increase the chances of success. The likelihood of triplets is in fact very low, although twins are common. The first ultrasound scan sometimes indicates the presence of more than one gestational sac, but not all of these will necessarily develop. Their viability is assessed through a series of ultrasound scans and the doctor will tell you when these need to be done.        
  
Monitoring pregnancy 
Pregnancies achieved by means of IVF do not require any special treatment once the pregnancy is underway and you only need to follow the advice of your gynaecologist as you would with a natural conception.            
  
Problems with pregnancy       
Unfortunately, there is a possibility with IVF, just as there is with a natural conception, of miscarriage or ectopic pregnancies and these should be diagnosed and treated as soon as possible. 
  

1. Miscarriage: The rate of miscarriage following IVF is around 18%, it being more common at the early, rather than the advanced, stages of pregnancy.

2. Ectopic pregnancy: The risk of ectopic pregnancy (where the embryo develops outside the womb) following IVF is 2%. An ultrasound scan is the only way of confirming an ectopic pregnancy; in the event that it occurs you should see your gynaecologist immediately

3. Malformations: The possibility of malformations in IVF pregnancies is the same as for natural conceptions. Embryos which carry a chromosome abnormality usually stop developing at the early stages, even prior to implantation; some may manage to implant but then fail to develop beyond the third month, while less than 7% of such embryos will go to term and produce a child with some form of abnormality, just as happens with spontaneous reproduction. 

  
Prenatal diagnosis      
After ICSI-treatment or because of your (femal) age or family history we recommend a prenatal diagnosis (chorionic biopsy, amniocentesis) in a specialized prenatal center. These tests are done between the 9th and 16th week of pregnancy.         
  
Birth    
In order to calculate the date on which your baby is due we assume that a normal pregnancy lasts for 40 weeks, counting from your last period. In those patients who have had treatment with GnRH analogues in order to suppress their hormonal response prior to ovarian stimulation, the date of their last period is taken to be fourteen days before follicular puncture. 
The type of birth (vaginal or caesarean) will be decided by the doctor, taking into account your individual circumstances.