IVF & ICSI Treatment

What is Assisted Reproduction and In-Vitro Fertilisation (IVF)?

Assisted Reproductive Treatment (ART) is all procedures that involve handling ova and sperm 'for the purposes of women becoming pregnant'. This encompasses a range of interventions including In Vitro Fertilisation (IVF) and Intra Cytoplasmic Sperm Injection (ICSI).

FRM has been at the forefront of assisted conception techniques since the late 1970s, providing couples with the hope of achieving a successful pregnancy and of giving birth to a healthy baby. Fertility clinics such as FRM add to reproductive choices and potential self-determination, and can be said to offer, at the very least, the prospect of hope where before there may have been none.

IVF is the process of fertilisation by manually combining an egg and sperm in a laboratory dish. When the IVF procedure is successful, the process is combined with a procedure known as embryo transfer, which is used to physically place the embryo in the uterus. The steps in an IVF and embryo transfer cycle are:

• Stimulate the development of follicles in the ovaries
• Cycle Monitoring
• Trigger
• Collect the eggs (follicular aspiration) and collect the sperm
• Combine the eggs and sperm together in the laboratory and provide the appropriate environment for fertilisation and early embryo growth (insemination)
• Transfer embryo/s into the uterus
• Cycle Support
• Test for pregnancy

IVF Treatment Cycle

Ovarian Stimulation Regimes

The growth of ovarian follicles is controlled by hormones from the pituitary gland at the base of the brain. Normally only enough hormone is produced to allow one follicle to fully mature. With IVF, Follicle Stimulating Hormone (FSH) is used to promote the growth of several follicles.

The medication used to stimulate the ovaries is Puregon or Gonal-F and is given as a daily injection to promote the growth of follicles within the ovary. At your pre-treatment appointment the clinic staff will explain which stimulation regime you will be using.

Antagonist Cycle

With this stimulation regime, FSH commences on day 2 or 3 following the onset of your period. An antagonist drug (Orgalutran) is commenced on the 5th or 6th day of FSH injections. This medication prevents ovulation, but allows the eggs to grow.

Down Regulation with Synarel (Gonadotrophinn Releasing Hormone GnRHa)

Synarel is used in the month prior to egg collection, to switch off the pituitary gland's control of ovulation. This enables the developing follicles to be synchronised under the influence of FSH.

The month prior to your egg retrieval (when you get your period) you will need to contact the nurses to book on for your IVF Cycle. Synarel is a nasal spray which is used morning and night, and is continued until the time of your egg retrieval.

Down Regulation using The Oral Contraceptive Pill and Synarel

The Oral Contraceptive Pill and Synarel are used in the pre-treatment cycle to switch off the pituitary gland's control of ovulation. This enables the developing follicles to be synchronised under the influence of FSH injections. The month prior to your egg retrieval (when you get your period) you will need to contact the nurses to book on for your IVF.

Synarel is a nasal spray and is used morning and night. It is continued until the time of your egg retrieval.

Nursing staff will outline your plan with anticipated dates, and you will be taught how to administer the injections. Please refer to page 22 for details regarding the potential risk of Ovarian Hyper Stimulation Syndrome (OHSS).

Cycle Monitoring

As the follicles grow they produce the hormone oestrogen which can be measured by a blood test.

The number of follicles and their size will also be measured by ultrasound, performed using a probe inserted into the vagina. This procedure requires an empty bladder. You may have more than one scan in a treatment cycle and partners are welcome to be present. The scanning procedure usually takes approximately 15 minutes.

The first blood test and ultrasound scan usually occurs approximately 8 days after starting the FSH injections and the combined results are used to decide the ideal time for egg retrieval.

There are no restrictions to having sexual intercourse during the stimulation phase of the treatment cycle. Sexual intercourse or ejaculation is recommended the evening prior to the first ultrasound.

You will be kept informed of your progress throughout your treatment cycle. Please feel free to ask the nursing staff and your clinic doctor any questions about your treatment.

Triggering

When the day and time for egg retrieval is decided, you will have a trigger injection of hCG (Human Chorionic Gonadotrophin) as instructed. hCG acts to complete the maturation (ripening) of the eggs within the follicles and to initiate changes in the follicle which lead to ovulation. This injection is timed so that the egg retrieval occurs approximately 34-36 hours later. The nurses will instruct you how to give this injection.

Please note that eggs cannot be collected if the injection is missed.

Egg Collection (Oocyte Retrieval)

Ultrasound-guided vaginal oocyte retrieval is the usual method of egg collection and is performed in the procedure room within the Reproductive Medicine Unit. A light anaesthetic will be administered by the anaesthetist. The probe of the ultrasound machine is placed in the vagina to visualise the ovaries. Under ultrasound guidance a needle is passed through the vaginal wall and into the ovarian follicles. The fluid contained in the follicles is drained. The follicular fluid is collected into a test tube and then transferred into a dish. The contents are examined under a microscope to determine whether an egg has been recovered. An egg is not always obtained from each follicle. This procedure takes about 20-30 minutes, depending on the number of follicles to be drained.

Sperm Collection

On the day of the egg retrieval, the male partner is required to produce a semen specimen by masturbation. It is desirable to produce this at the hospital. The nursing staff will inform you of the time your partner is required. He should wait with you until the nurse directs him to the room provided for this purpose. A short delay for the semen collection is of no concern, as we have allowed enough time if there is a problem collecting the specimen. A minimum of 2 days and not more than 7 days abstinence from sexual intercourse and ejaculation is recommended prior to egg retrieval. Occasionally a semen sample may contain insufficient motile sperm to fertilise an egg. If this happens, your partner may be requested to produce a second specimen later the same day.

If you feel that there may be a problem producing a sample on request under these conditions, this should be discussed with the clinic staff prior to commencing treatment.

Fertilisation

Eggs are taken back to the laboratory where they are checked and carefully washed before being placed in a small amount of culture medium in a test tube. The tubes containing the eggs are kept at 37°C in an incubator. Culture medium is layered on top of a sperm sample taken from the ejaculate.

Sperm that swim up into the culture medium are collected and used to inseminate the eggs. Approximately 100-200,000 sperm are added per egg. On the morning following the retrieval an embryologist examines each egg for the presence of 2 pronuclei, which indicates if normal fertilisation has occurred. On average, 70% of eggs will fertilise.

The culture medium is a fluid that contains all the nutrients and essential components to support the egg during fertilisation, and sustain the development of the embryo during its culture period, prior to transfer back to the uterus.

In order to meet the changing nutritional requirement of the developing embryo, in our laboratory we use sequential culture media that combines the most beneficial components to mimic the dynamic conditions that exist during the development of the embryo inside the body (from the fallopian tube to the uterus).

ICSI (Intra-Cytoplasmic Sperm Injection)

ICSI is a technique utilised to inject a single sperm into the egg with a very fine glass needle by means of a micro-manipulator in order to achieve fertilisation, unlike conventional IVF. A single motile, mature, normal looking sperm is selected for injection under a high magnification microscope.

Since the egg to sperm ratio is 1:1 for ICSI, it is the method of choice when the number or quality of sperm available is low. Men with no sperm in the ejaculate can also benefit by surgical retrieval of sperm. See page 13 for more details.

Embryo Transfer

Embryos may be transferred into the uterus at different stages of development. In most cases they are transferred on day 2 or 3 following egg retrieval, and in some cases on day 5 following egg retrieval, at the Blastocyst Stage. The embryo transfer is done as an outpatient procedure, taking approximately 15 minutes, and does not require an anaesthetic. Your partner is welcome to be present during this procedure.

You will be required to lie on the bed and a speculum is gently inserted into your vagina (similar to when you have a pap smear). The equipment used for the transfer is simple, consisting of a fine plastic tube or catheter attached to a small syringe. The embryos are drawn into the tip of the catheter which is then passed through the cervix and into the uterine cavity where the embryos are expelled. You will have an opportunity to view your embryo/s on a TV monitor prior to their transfer.

After the procedure, we advise that you resume your normal lifestyle, but we suggest you avoid becoming overheated; e.g. saunas, and spas. If you have any doubts, don't hesitate to check with the clinic staff. You may resume sexual intercourse at any time following embryo transfer.

Blastocyst Culture

Blastocysts are embryos that develop on Day 5 after fertilisation. They have two distinct groups of cells, an outer layer which is destined to be the placenta, and an inner cell mass that develops into the foetus.

With the increasing knowledge of the nutritional requirements and culture conditions necessary for the development of embryos, it is now possible to culture embryo/s beyond the traditional day 2-3 post fertilisation.

Approximately 6 to 7 days after fertilisation, the embryo enters the uterine environment, shortly before hatching and implanting.

Extended culture to the Blastocyst stage (day 5) is a process that allows for the selection of embryos that have a higher developmental potential than Day 2-3 embryos, which means increased implantation and pregnancy rates. The limitations associated with extended culture to produce blastocyst is that the embryo may fail to develop and differentiate further, so there is no transfer. To minimise this risk, the embryo quality and development is closely monitored, so that an early transfer (day 3) may be offered. Furthermore, fewer embryos are available on day 5 for freezing, so the transfer of one blastocyst in a treatment cycle is highly recommended.

So as to minimise the risk of a multiple pregnancy, a single blastocyst transfer is advised as monozygotic twining can occur with the transfer of even a single blastocyst.

Assisted Hatching

The Hatching of the embryo from its shell (zona pellucida) is crucial for a successful implantation. Assisted hatching procedure (AH) which is performed on Day 3 Embryo(s) may facilitate the hatching process once the embryo reaches the blastocyst stage.

Assisted hatching of embryos is a method of creating an opening in the outer covering of the embryo, and is performed under a high magnification microscope. A holding micropipette is used to secure the embryo and a small incision is made in the shell with a very fine cutting micropipette.

As the embryo develops and divides, it also increases in size in conjunction with the thinning of the outer shell. The small incision created will help the embryo to hatch out of the shell easily and thus improve the chance of implantation. This procedure can be performed on fresh as well as frozen embryos after thawing.

Luteal Support Phase

Following the egg collection, you will be advised when your Luteal Support will commence. This will increase the levels of the hormone progesterone, which maintains the inner lining of the uterus, the endometrium. Progesterone pessaries or Crinone Progesterone vaginal gel is used, and in some cases an injection of hCG.

Pregnancy Test

A pregnancy test will be performed approximately 18 days after your egg collection if you have not had a period. If your period commences it is important to contact the nursing staff in the clinic. If the test is positive, an ultrasound scan is performed at 7 to 8 weeks, and we look for a Fetus with a fetal heartbeat. Following your scan, you will be referred to the doctor of your choice for care in pregnancy, and you may attend a meeting with the counsellor.

Embryo Storage

Patients undergoing Assisted Reproductive Treatment can store excess good quality embryos after transfer. These embryos are in excess to the number used for transfer. Embryos are frozen and stored in liquid nitrogen at -196°C. Embryos are frozen on day 2 or 3 after egg collection.

Only embryos that have undergone cell division normally with few fragmentations and have normal morphology are selected for freezing, since experience has shown that embryos of poor quality are unsuitable for transfer after they have been thawed. Blastocysts are embryos that have progressed up to day 5 and excess blastocysts remaining after transfer can be frozen and stored.

If pregnancy does not occur in a stimulated cycle the frozen embryos may be thawed and transferred in a later cycle.

Legislation in South Australia regulating IVF units, permits the storage of embryos for a maximum of ten years. Storage of frozen embryos will cease in the following circumstances:

• Upon their use in future treatment cycles
• Upon written directive from the patient/s
• If both members of a couple or a single woman for whom the embryo is stored die, any reasonable prior directives from them/her will be followed. If no directives exist the embryo will be disposed of
• If a dispute arises between the members of a couple for whom the embryo is stored, and either person requests continued storage, the embryo will be kept in storage until the dispute is resolved or until the maximum storage period has lapsed
• Donation of the embryos to another infertile couple, except where embryo is created from donated genetic material i.e. sperm or egg donor. (This can be discussed with FRM clinic staff in order to explore options and potential recipients)

If you store embryos, under FRM policy you have the right to review consent for continuing storage at intervals of 12 months. The clinic will give written notice of that right of review at least 90 days before each anniversary date on which you gave the consent for storage.

Please keep the clinic informed of any changes of address or telephone numbers.

Frozen Embryo Cycle

In the cycle during which you are having your frozen embryos thawed and transferred, we will monitor your cycle with blood tests and, in some cases, a vaginal ultrasound scan. When ovulation is confirmed, your embryos are thawed and transferred. Between 60% and 70% of frozen embryos will thaw successfully, and can be transferred.