- Is there an age limit for treatment?
- What is the difference between "in vitro fertilization" and "intracytoplasmic sperm injection"?
- When would we require ICSI instead of IVF?
- What is an ultrasound scan?
- Are there any risks associated with IVF?
- What are the steps involved in the IVF procedure?
- What are my chances of success?
- What is unexplained infertility?
- When does one consider Donor Eggs as a treatment option?
- What is CAT (Cumulus-aided Embryo Transfer)
- What are cumulus cells and what is their function?
- What is the difference between "culture" and "Co-Culture"?
- What are the different cells that can be used for co-culture?
- Why is cumulus co-culture better than the other techniques of co-culture?
1. Is there an age limit for treatment?
A woman's age is a significant factor that determines the success of an ART procedure. One must also consider that there is an increased risk for birth defects with advanced maternal age. We will need to discuss your case and can help you to evaluate and make decisions about these risks. At our center, improved culture techniques, the procedure of laser-assisted embryo hatching and Preimplantation Genetic Diagnostic procedures (PGD) have enabled many women in the age group of 35-40 to have healthy babies. For women above the age of 40 we would recommend considering donor oocytes as a therapeutic option.
2. What is the difference between "in vitro fertilization" and "intracytoplasmic "sperm injection"?
In the IVF technique, the oocyte and a calculated number of sperm are placed together in a petri dish in a nutritive medium for the fertilization process to take place. However, in cases where the sperm count, motility and morphology are poor, the chances of fertilization using IVF decrease.
ICSI is the procedure of injecting a single sperm directly into the cytoplasm of a oocyte. The success rate of ICSI is not dependent on sperm motility or morphology.
3. When would we require ICSI instead of IVF?
ICSI is the treatment of choice in conditions
When the male partner has a major sperm deficiency e.g. a sperm count of
lower than 5 million per ml.
When there is an absence of sperm in the ejaculate, ICSI can be performed
using sperm retrieved from the testes (TESA) or the epididymis (PESA).
When there is previous failed fertilization with IVF.
4. What is an ultrasound scan?
An ultrasound scan is a painless procedure using high frequency sound waves to produce an image of the body's internal organs or the fetus on a television screen. Ultrasound scans are an essential part of all forms of assisted reproduction and may be required at various stages of treatment. Scans are used in the preparation of the ovaries and uterus for Assisted Reproduction. For example, the doctor may want to know how the eggs are maturing inside the ovary by measuring the growth of the follicles and will judge the readiness for embryo implantation by measuring the thickness of the uterine lining. One of the reasons for the improvement in the IVF/ICSI procedure is the simplicity of oocyte retrieval by transvaginal ultrasound. In difficult situations, embryo transfer can be promoted under ultrasound guidance.
5. Are there any risks associated with IVF?
As with any medical procedure, the techniques of Assisted Reproduction can be associated with certain risks and complications. These which are rarely of a serious nature and can be attended to and treated effectively. The most common are:
Ovarian Hyperstimulation (OHSS):
OHSS occurs when too many ovarian follicles have developed as a result of the ovarian stimulation and is associated with ovarian enlargement and accumulation of fluid in the pelvic cavity. This complication occurs in various degrees of severity in approximately 5% of women undergoing IVF treatment and our team of doctors is highly experienced to treat such a condition, should it arise.
Multiple pregnancies:
We attempt to decrease the risk of multiple pregnancies by transferring 3 embryos or limiting to 2 embryos at the blastocyst stage embryo transfers. This limits the number of embryos that are transferred without lowering the chances of achieving pregnancy.
6. What are the steps involved in the IVF procedure?
The basic steps in an IVF treatment cycle are evaluation and pre-treatment of the couple, ovulation induction, egg retrieval, insemination, fertilization, embryo culture, and embryo transfer.
(1) Evaluation and Pre-Treatment
- Pre-conception counseling
- Anatomic assessment
A HSG may be recommended if it has not been already done.
Operative techniques such as laparoscopy and hysteroscopy are some times suggested if the HSG is abnormal
- Hormonal tests
- Semen analysis and sperm storage
This will determine whether IVF or ICSI will be used for in vitro fertilization.
A urology consultation for the male partner is sometimes suggested, for example if surgery is needed to obtain sperm.
- Testing both partners for infectious diseases
Screening both partners for infectious diseases like HIV and hepatitis that can be transmitted from one partner to another or from mother to fetus before birth.
(2) Ovulation Induction
A woman undergoing IVF is given fertility drugs to enhance the growth of the ovarian follicles, so she can develop more mature eggs
(3) Hormonal Tests & Ultrasound scan
The developing follicles are monitored for their maturity by measuring the follicle size through an ultrasound and correlating the finding with the blood concentration of the patient's estradiol value drawn the same day.
(4) Ultrasound guided Egg Retrieval
After ovulation induction is achieved, the next step in the IVF process involves an ultrasound guided egg retrieval, which is carried out under light anaesthesia. The egg retrieval procedure takes about 30-45 minutes.
(5) Insemination of oocytes: IVF/ICSI
IVF ICSI
A semen sample from the male partner is obtained after the egg retrieval procedure. The man's semen is then washed and prepared to obtain actively motile sperm. The prepared sperm is then used to inseminate the eggs by IVF /ICSI in the culture media.
(6) A normally fertilized oocyte
The day after egg retrieval and insemination/injection the embryologist will examine the eggs and check for fertilization. A fertilized egg will have 2 nuclei in the center, one from the egg and one from the sperm.
(7) Embryo Culture
The fertilized eggs (embryos) will spend from 3-5 days in the laboratory to allow them to develop into the eight-cell or blastocyst stage, at which time they are ready to be transferred into the woman's uterus.
(8) Assisted Embryo Hatching
Prior to implantation, the embryo has to escape from its protective shell known as the zona pellucida by a process known as hatching. If this process is not completed properly, implantation will fail and a pregnancy cannot occur. We offer the Laser technology for Assisted Hatching (LAH), where a laser beam is focused over the Zona pelucida making a small opening of about 20 microns to facilitate embryo hatching.
This technique is particularly useful in cases where women show embryos with a thick zona and also in cases with previous failed cycles.
(9) Embryo Transfer
The resulting embryos are placed back in the woman's uterus using a fine catheter through a simple procedure called embryo transfer.
(10) Cryopreservation/Embryo Freezing
Most women who undergo hormonal stimulation for an IVF or related procedure of Assisted Reproduction produce more eggs than necessary for transfer during that cycle. The extra-fertilized eggs may be frozen or "cryopreserved" and stored for future transfer if she does not achieve pregnancy initially. Even if pregnancy is achieved during the initial stimulated cycle, the couple can choose to transfer the extra frozen embryos several years later in order to become pregnant again.
(11) After Embryo Transfer
We recommend that you take rest on the day of the embryo transfer and for 2 days following the transfer. Strenuous exercises such as jogging & swimming should be avoided until the pregnancy is confirmed. Otherwise, the patient is free to return to her regular activities. The patient can take a regular home-made diet. We recommend avoiding eating papaya and pineapple.
(12) A Pregnancy test is done about 14 days after embryo transfer.
7. What are my chances of success?
Success rates for ART procedures are significantly influenced by:
· The age of the woman
· No. of eggs produced following drug induction
· Quality of the semen
· No. of embryos formed
· No. of embryos transferred
If 3 good quality embryos are produced following ICSI and the age of the woman is < 37 years, pregnancy rates are 45% in our laboratory.
8. What is unexplained infertility?
Approximately 10% of infertile couples suffer from unexplained infertility. This simply means that the evaluation of the couple has led to no defined reason for infertility. However, a more thorough search for a cause should be made, since many subtle abnormalities may be discovered to explain the infertility. Usually such problems are due to:
1. Difficulty in picking up the egg by the fallopian tube
2. Failure of the sperm to fertilize the egg even when in contact
3. Failure of implantation of the embryo into the uterus
9. When does one consider Donor Eggs as a treatment option?
The option is particularly important for older women since it has been shown that an important factor determining IVF success is the age of the egg (maternal age). Hence women over 40 years have a better success rate with the use of donor eggs and are suggested this course of treatment. Also women who prematurely reach menopause are candidates for egg donation. Women with decreased ovarian reserve due to previous ovarian surgery, severe endometriosis also qualify. Women with genetic diseases can also avail of donor eggs.
10. What is CAT (Cumulus-aided Embryo Transfer)
When a few of the feeder cells on which the embryo is being cultured are transferred along with the embryo into the uterus, the technique is referred to as cumulus-aided embryo transfer. At Jaslok Hospital, we use the patient's own cumulus cells as the feeder layer over which her embryos are cultured. These cumulus cells are rich in growth factors such as Insulin-like Growth Factor and Vascular Endothelial Growth Factor. These ensure the proper growth of the developing embryos. In order to improve the technique we go a step further. At the time of embryo transfer we add 30 microlitres of the cumulus cells to the embryos so that the nutrients secreted by the cumulus cells continue to be provided in vivo thereby enhancing pregnancy rates.
11. What are cumulus cells and what is their function?
Cumulus cells surround the oocyte (egg) during maturation of the egg in the women’s ovary. They continue to surround the egg at the time of ovulation. They are embedded in a matrix, which contains hyaluronic acid. Cumulus cells nurture the egg prior to and after ovulation.
12. What is the difference between "culture" and "Co-Culture"?
In IVF, the term "culture" means to grow or incubate embryos in a defined nutrient medium. In the technique of "Co-Culture", embryos are grown in a culture medium on top of a proliferating monolayer of cells called "Feeder" or "Helper" cells. The feeder cells assist in the growth and development of the embryo.
13. What are the different cells that can be used for co-culture?
In IVF, various cell types have been used for co-culture of human embryos in an attempt to improve embryo quality, implantation and pregnancy rates.
Fallopian tube cells from human or animal origin.
Endometrial cells from the lining of the uterus.
Vero cells which are derived from the African Monkey
Human cumulus cells
14. Why is cumulus co-culture better than the other techniques of co-culture?
We have developed a co-culture system which uses the patient's own cumulus cells. These would otherwise have been discarded. We remove them from the oocyte and make them into a layer of feeder cells for the embryos to develop on. When non-human cells are used for co-culture, there is a possibility of disease transmission to the embryo and the mother from contaminants such as bacteria and viruses contained within the feeder cells. Since the use of patient's own cumulus cells overcomes this problem and are more easily available unlike other cells like tubal or uterine cells they are ideal for use as feeder cells in a co-culture system.
OUR RESULTS WITH CAT (Study group)
| Parameters | Study GroupA | Control GroupB | PValue |
| Pregnancy Rate | 46 % | 34% | P < 0.01 |
| Implantation Rate | 27 % | 15% | P < 0.001 |
