IVF : Indications and Complications

In vitro fertilisation (IVF) is a form of assisted reproductive technology which helps a couple conceive a baby. In vitro means outside the body, IVF is the process of fertilising a woman’s egg with a sperm from a man outside the human body, in a lab. Approximately 1.7% of infants are born with the help of assisted reproductive technology every year in USA. In 2016 263,577 ART cycles were performed in USA resulting in 65,996 live births and 76,930 infants.

Procedure of IVF

There are five basic steps to one cycle. They are

Induction of ovulation

• During a normal cycle one egg is produced by the ovary. In preparation for IVF you will be given multiple medications to increase the number of eggs produced by the ovary in once cycle. The medications are:
• Hormones like follicle stimulation hormone (FSH) or/and Luetenising hormone (LH) to increase the number of maturing eggs
• Medication to help the egg mature, like human chorionic gonadotropin (hCG)
• Medication to prepare the lining of your uterus for the implantation of the embryo.
• To monitor these changes in the ovaries, as the eggs grow, you will be requested to undergo regular trans vaginal ultrasound and blood tests.

Retrieval of egg

This is a procedure for removal of mature eggs from the body. It is performed on an outpatient basis. For this procedure you will be given pain medications and sedation.  Your doctor will insert an ultrasound probe into the vagina. Under ultrasound guidance a needle will be inserted into the ovary via the vagina. The needle is attached to a suction device which helps in collecting the eggs in a nutrition media for transport to the lab. In rare cases a laparoscopic procedure is required for egg retrieval.

Insemination and fertilisation

The sperm and egg are placed together in a controlled environment for the fusion of sperm and egg to occur, leading to the formation of a zygote. When the sperm cannot enter the egg, it can be injected into the egg artificially by a process called intra cytoplasmic sperm injection (ICSI).

Embryo culture

The fertilised egg divided to form an embryo. Within five days, a normal embryo has several, actively dividing cells. For couples with risk of transferring genetic disorders, a pre- implantation genetic diagnosis (PGD) is offered. With the help of PGD it is possible to identify the embryos with minimal chances of being born with a genetic disorder.

Embryo transfer

The embryo is placed into the womb 3-5 days after fertilisation. This procedure is done on an out patient basis. You will be awake during the procedure. Your doctor will introduce a thing tube called a catheter into your uterus via your cervix and vagina. The embryo is placed onto the uterine lining. More than one embryo is transferred at a time, hence it may lead to a multiple pregnancy.

Indications for IVF

IVF is indicated for couples with infertility or genetic problems. Infertility is defined as inability to conceive after one year of unprotected intercourse. IVF may be an option if you or your partner has:

• Impaired sperm production or function
• Damage or block in the fallopian tube: the mature egg passes through the fallopian tube to encounter sperm for fertilisation and eventual implantation of the embryo. Many infections can cause damage to  the fallopian tubes. If you have had previous tubal ligation and wish to conceive you can do so with the help of IVF
• Endometriosis: presence of uterine tissue outside the uterus, this may influence the normal functioning of the ovary and fallopian tube
• Uterine fibroids: benign growths present in the wall of the uterus which interfere with implantation
• Premature ovarian failure
• Advanced maternal age
• Unexplained infertility
• Preservation of fertility: women undergoing cancer treatment like chemotherapy and radiation can choose to have their eggs preserved for later use.

Preparation for IVF

To prepare for IVF your doctor will first like to record a history of the present and past medical conditions of you and your partner. Both of you will be requested to undergo various screening tests before an IVF cycle:

• Semen analysis: the semen will be analysed for the number, viability and motility of the sperm
• Infection disease testing: you and your partner will be screened for infectious diseases like HIV
• Ovarian reserve testing: a blood test is done to determine and quantity and quality of the reserve of eggs in the ovary. Along with an ultrasound, this helps in predicting how your ovaries will respond to various fertility medication
• Uterine cavity examination: your doctor will examine your uterus will the help of hysteroscopy or sonohysteroscopy:
• Hysteroscopy: a thin tube containing a light source and camera is inserted into the uterus to examine the uterine cavity
• Sonohysteroscopy: fluid is injected into the uterus via the cervix and then the uterus is examined with the help of an ultrasound probe.

Before the procedure your doctor will also discuss about what to do with the multiple fertilised eggs. You may choose to preserve them for later use. Your doctor will also help you decide the number of embryos that can be safely implanted in one cycle.

Complications of IVF

IVF is a long procedure which requires large amount of time, physical and emotional energy. All steps in IVF come with their own set of complications.

• Fertility medications for induction of ovulation may cause bloating, abdominal pain and mood swings. Many fertility medications are given by injection; repeated injections may lead to bruising. Rarely the medications may lead to ovarian hyperstimulation syndrome, which leads to rapid weight gain, fluid retention in abdomen and chest, reduced urine output despite adequate fluid intake, nausea and vomiting and shortness of breath. Severe cases may require hospitalisation
• Damage to ovary and structure surrounding it like the bowel and bladder during egg retrieval
• Multiple births: pregnancy with multiple foetuses has greater risk of low birth weight and premature labour
• About 2-5% of women conceiving with IVF have an ectopic pregnancy

After the procedure

You will have an appointment with your doctor 12 days or 2 weeks after embryo transfer to confirm the pregnancy. If you are pregnant you will be referred to an obstetrician who will guide you through your pregnancy. Women undergoing IVF are prescribed progesterone pill or shots for 8-10 weeks after embryo transfer. Progesterone is a hormone responsible for maintaining the inner lining of the uterus, too little progesterone may lead to a miscarriage.

Resources

• https://medlineplus.gov/ency/article/007279.htm
• In vitro fertilization (IVF): a review of 3 decades of clinical innovation and technological advancement, Jeff Wang and Mark V Sauer