In a woman, when the tubes from the ovary to the uterus (fallopian tubes) are blocked for whatever reason, the egg cannot meet the sperm from the man so that fertilization will not occur. Normally, the egg is fertilized by the sperm in the fallopian tube. The egg is released from the ovary into the fallopian tube. After intercourse the sperm enters the uterus and then moves up the fallopian tube. When the egg and sperm meet in the fallopian tube, fertilization may occur. This is called, in vivo fertilization. That is, fertilization occurring in the living body. If the tube is blocked, then clearly there is no way for fertilization to occur naturally and the couple will fail to conceive. If the woman’s eggs are removed surgically from the ovary and then placed into a test tube or plastic dish along with the sperm from the man, fertilization may occur under these circumstances. This process is called in vitro fertilization where fertilization occurred in a test tube or outside of the living body.
IVF was originally developed to treat those women with blocked fallopian tubes so that they may become pregnant. However, pregnancy requires a male contribution as well as the female’s egg. One of the underlying problems causing infertility is abnormalities in the man’s sperm. This abnormality may be a low count, low motility or a low number of normal sperm cells, all of which will be associated with a very low rate of fertilization. We know that there must be a critical number of live, normal sperm to survive the journey into the fallopian tubes. We also know that if there are too few of these normal sperm cells, placed into the dish with the eggs, they may not find the egg to fertilize. To work around the problem of too few sperm cells, a technique was developed whereby a single sperm cell is directly injected into the egg. This technique is performed under a microscope. It is called “intra-cytoplasmic sperm injection” or “ICSI”. It is a tool that may be used as part of an IVF cycle.
Prior to entering into an IVF treatment cycle, a number of investigations will be undertaken on the woman and man. Before we begin, we need to know the status of both participants. Lab tests including a hormone profile will be performed on both partners. The woman will have anatomical studies performed either by ultrasound or x-ray to determine if the uterus is normal and if the tubes are opened or blocked. The man will have sperm analysis performed. Based upon the results of the sperm analysis your doctor will be able to tell you whether ICSI is necessary or not. Once these investigations are completed, both partners will meet with their doctor and a plan for the IVF cycle will be determined. The plan will be signed by you and then you will be given a copy of it so everyone knows the specifics of the treatment. At some time before you start the treatment cycle, you will have to attend an IVF orientation. This is an educational seminar that will help you understand the intricacies of the cycle from start to finish. At LifeQuest, we believe that educating our patients is essential to maintain a positive attitude in everyone and keep anxiety and stress levels at a minimum. It is for these reasons that the IVF orientation is mandatory for everyone going through an IVF cycle here at LifeQuest.
There are a few underlying principles to an IVF treatment cycle. We need to harvest or retrieve a number of eggs but prevent the woman from releasing the eggs or ovulating on her own. Normally, a woman will mature one egg in a cycle. To increase the probability of fertilization and the development of a normal embryo, we push the woman’s ovaries to mature several eggs in the cycle. To do so, the woman is given a daily injection of a fertility drug.
The drug used is “follicle stimulating hormone” or FSH. The drug is continued for approximately 10 days. To prevent ovulation, the woman will be taking a second injection of a medication to block ovulation. Depending upon the treatment programme or protocol, this medication may have been started before or after the fertility drug is started. The cycle is monitored by determining the hormone blood levels and growth of the follicles in the ovary by ultrasound. (Follicles are like the egg shell with the eggs inside). Once the follicles appear to be mature, a single injection of the hormone hCG is given 36 hours before the eggs are retrieved. This will release the eggs from the wall of the follicle allowing the doctor to easily remove the egg from the fluid within the follicle on the day of retrieval. The timing of the hCG injection is critical. If missed or given too late, no eggs will be retrieved. If however, it is given too early, the woman will ovulate and the eggs will be released from the follicle unable to be recovered.
During the egg recovery or retrieval, a needle is placed into the follicles within each ovary. The fluid is removed which usually contains the egg. Since not every follicle will contain an egg, we expect that the number of eggs recovered will be less than the number of follicles seen on the ultrasound. The eggs are placed into test tubes and then passed to the embryologist in the lab. The embryologist will examine the eggs and prepare them for fertilization either by straight IVF or by ICSI. In addition, the sperm will be examined and prepared for fertilization. Whether the fertilization step is to be by straight IVF (placing the egg and sperm into a dish and allowing the sperm to fertilize the egg) or by ICSI (injecting the sperm into the egg), one embryologist will be completing the procedure from start to finish with a second embryologist checking each step. At LifeQuest, all embryologists are senior, with years of experience. They are all qualified to perform the required procedures in the embryology lab.
The embryos are evaluated on a daily basis. The IVF nurse will report to you the status of your embryos every day. This communication link is an important one and at LifeQuest we strive to keep you informed at all times regarding your progress. We are aware how stressful this entire process can be and work diligently to address your concerns. In most cases, the embryos will be incubated for 5 days to achieve the more mature blastocyst stage of development. Implantation rates are higher when blastocysts are transferred. This makes sense since if you were to conceive naturally, by the time the fertilized egg or embryo arrives in the uterus for implantation, it will be a blastocyst. Therefore, blastocyst transfer is a more physiologic process. Since the implantation rate is higher with blastocysts, it is recommended that no more than two blastocysts be transferred. Under unusual circumstances, your doctor may recommend more than two blastocysts be transferred.
LifeQuest was one of the first IVF units in Canada to undertake day 5 culture to blastocyst and has continued to improve the culture technique over the years. It is this dedication to never being content with the status quo that keeps LifeQuest on the forefront of reproductive medicine and clinical embryology.
Occasionally, embryos are transferred on day 3 of culture. Although not done frequently at LifeQuest, that recommendation will be made to you if there is concern that the embryos would survive better in a more natural environment, the uterus, than in a plastic dish. You must view a day 3 transfer as a safety net and certainly not a failure.
A few days prior to the embryo transfer, the woman will start progesterone either as vaginal suppositories or injection. The progesterone prepares the uterus for implantation of the transferred embryos. Once the embryos are transferred, the progesterone is continued until a pregnancy test is performed two weeks later. You will be informed of the result of the pregnancy test by the IVF nurse or your doctor’s office. If you are pregnant, the progesterone will continue for most of the first trimester (10-12 weeks of pregnancy is the usual). Your doctor will give you instructions regarding the progesterone.
If you are not pregnant, the progesterone is discontinued. Even if you are not pregnant, the progesterone could interfere with the onset of a period which is why it must be stopped. An IVF cycle that did not result in a pregnancy is reviewed by your physician and the embryologist prior to the cycle review with you. We all realize how upsetting it is for the cycle not to result in a pregnancy, which is why a careful review is undertaken. Often there is no good reason for a cycle not succeeding. However, we may now have some answers as to why you have not been able to conceive. Not only does an IVF cycle provide a treatment method, but it also has a diagnostic component. If you are going to repeat the IVF cycle, then all of the information from the preceding cycle is used to modify the subsequent cycle. Cycle reviews are undertaken even if you were successful in a previous cycle so that your physician and the embryologist can recommend the best course of action to follow and maximize the probability of a successful treatment programme.
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