Test
Tube Babies - IVF & GIFT
from
the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha
Malpani, MD and Dr. Anjali Malpani, MD.
table
of contents·
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Embryo
Transfer
Embryo
transfer is most often done on an outpatient basis. No anesthesia
is used, although some women may wish to have a mild sedative. The
patient lies on a table or bed, usually with her feet in stirrups..
Using a vaginal speculum, the doctor exposes the cervix. One or more
embryos suspended in a drop of culture medium are drawn into a transfer
catheter, a long, thin sterile tube with a syringe on one end. Gently,
the doctor guides the tip of the loaded catheter through the cervix
and deposits the fluid containing the embryos into the uterine cavity.
The procedure should be done with great care and usually takes between
10 and 20 minutes. Some doctors perform the transfer under ultrasound
guidance, to ensure proper placement of the embryos in the uterine
cavity. Most doctors advise a few hours of bed rest after the transfer.
Fig
5. Schematic of the embryo transfer procedure
Most
clinics today transfer 2-3 good quality embryos on Day 2 or Day 3.
Embryos are graded according to their appearance and rate of cell-division
and good quality embryos are those which have 4-8 cells, of equal
size, with clear cytoplasm, and with few fragments. You should ask
the doctor to show you your embryos under the microscope. Some times,
only embryos of poor quality are available for transfer. While the
chance of getting pregnant when only poor quality embryos are transferred,
you can be reassured that if a pregnancy results, the children will
be normal !
How many
embryos to transfer is one of the most difficult decisions facing
an IVF patient today. The more the embryos transferred, the greater
the chances of getting pregnant. Since the purpose of an IVF cycle
is to achieve a pregnancy, then why not transfer as many as possible
? However, the price you pay for transferring more embryos is that
the risk of a multiple pregnancy increases as well. In some countries,
such as the UK, doctors are allowed to replace a maximum of only 3
embryos, to reduce the risk of high-order multiple births. Some clinics
in Scandinavia have now started transferring only one embryo in young
women, in order to reduce the risk of a multiple pregnancy. In USA
and India, there are no laws, and some clinics will transfer 4 embryos
for young patients, and upto 6 for older women – and this number is
quite arbitrary. Doctors have tried to develop an embryo score ( based
on the number of embryos and embryo quality ) in order to predict
the chances of a pregnancy after embryo transfer, but this is still
not precise. Since there is no easy answer as to how many embryos
to transfer, many clinics will allow patients to decide for themselves.
This is always a difficult decision, and you need to carefully weigh
the pros and cons before making up your mind. There is no right or
wrong number – and you need to take the path of least regret. Transferring
more embryos increases the chances of getting pregnant, and also increases
the risk of a multiple pregnancy. However, a high-order pregnancy
is a complication for which the doctor can perform a selective fetal
reduction , in order to reduce this to twins. Not getting pregnant
may be a worse outcome for some patients ! If embryo freezing facilities
are available, then supernumerary embryos can be stored, and this
needs to be factored in as well.
The embryo
transfer completes the medical treatment in the IVF cycle and most
clinics provide "luteal phase support" after the transfer , usually
with estrogen tablets and progesterone suppositories, to increase
the chances of implantation. However, this period is often the hardest
part of an IVF cycle for the patient, because of the agony and suspense
of waiting to find out if a pregnancy has occurred. This can be determined
by a blood test , which measures the level of the hormone, HCG ( human
chorionic gonadotropin) only 10 to 14 days after the transfer. For
many patients, these 14 days are often the longest days of their life
!
It is
normal to blame yourself for something you may or may not have done
during this time if you do not conceive. Therefore, try not to do
anything for which you will blame yourself if you do not get pregnant.
In general the following guidelines are offered:
- No
tub baths or swimming for 48 hours after replacement
- No
douching or tampons
- No
intercourse or orgasms until the fetal heartbeat is seen on ultrasound,
or the pregnancy test is negative
- Do
not undertake excessive physical activity such as jogging, aerobics,
or tennis
- Do
not taken any non-prescription medications or other prescribed medications
without the approval of the IVF team
- No
heavy lifting
- You
may return to "work" after 24 hours of bed rest (getting up for
bathroom and meals only) and one to two days of light activity.
You may
have some vaginal spotting or bleeding prior to your blood test. However,
you must have the blood test done, even if you think your period has
started. There are no symptoms or signs which will be able to tell
you whether or not you are pregnant.
Many
doctors used to advise "strict bed rest" after an embryo transfer.
However, remember that your physical activity does not affect your
chances of getting pregnant. Resting when you are well can be very
emotionally taxing, and we encourage patients to lead as normal a
life as possible. Many patients are worried that if they cough or
sneeze , the embryo will "fall out". However, remember that this is
physically impossible, and that if the embryo is going to implant,
it will, no matter how much you exert.
Thus,
there are numerous stages to every IVF treatment cycle, each of which
must be reached and completed before moving on to the next stage:
- more
than one should egg develop
- eggs
should mature
- ovulation
should not occur before the eggs can be collected
- eggs
must be retrieved during the "pick-up"
- sperm
must fertilize at least one egg
- fertilized
eggs must divide and grow healthily,... and all this so that...
- the
embryos might get implanted in the uterus
Think
of it as a series of hurdles, all of which have to be cleared , in
order to win the race !
The enigma
of embryo implantation – why doesn’t every embryo become a baby?
While
modern technology is very good at making embryos in the laboratory,
we still cannot control the implantation process. We do not know which
embryo will become a baby – and this can be very frustrating, for
both patients and doctors ! Many patients who do not get pregnant
after an embryo transfer start believing that their bodies are defective,
and that they have "rejected" the embryo. They feel that if they failed
to become pregnant even after the doctor transferred 3-4 good quality
embryos, that they are flawed. However, you need to remember that
embryo implantation is a very complex process, which consists of a
series of phases in which the embryo has to appose and attach itself
to the maternal endometrium and invade into it.
First,
the embryo has to undergo further development, till it reaches the
blastocyst stage, when it hatches from its shell, known as the zona.
The hatched blastocyst then needs to implant in the endometrium, and
the three phases of implantation are known as apposition, adhesion
and invasion, and occur during the period of time known as the implantation
window. Apposition, or orientation of the embryo (which is at the
blastocyst stage at this time ) within the cavity of the uterus, starts
when the cavity has become minimal due to the suction of endometrial
fluid by pynopods (small protrusions found on the surface membrane
of the cells lining the uterus). Adhesion of the blastocyst is a progressive
phenomenon that ties the embryo to the endometrium and is the primary
event initiating invasion. Many molecules, such as cytokines, growth
factors and cell adhesion proteins called integrins play an important
role in this complex process during which the blastocyst and maternal
endometrium must undergo an exquisite dialogue. Invasion is a self-controlled
proteolytic process that allows the embryonic trophoblast to penetrate
deep into the maternal decidua and to invade the endometrial spiral
arteries by producing chemicals called proteinases. How implantation
is regulated and brought about remains an enigma, but we need to remember
that the implantation process is surprisingly inefficient in humans
– Nature is not always very competent! After IVF, it’s only about
10%, which means that only 10% of embryos implant successfully to
become a baby.
The responsibility
for this low efficiency has to be shared between the embryo as well
as a defective embryo-endometrium dialogue. We still cannot successfully
predict which patient will get pregnant after embryo transfer . We
now know that one of the major reasons for failure of the embryo to
implant is a genetically abnormal embryo. Basic research on implantation
is of great interest today, because embryonic implantation is the
major factor limiting in allowing pregnancy after ART, but we still
need to learn a lot about this "black hole" in our knowledge, before
we can learn to control it !
Many
patients blame themselves when they don’t get pregnant after an embryo
transfer. They feel that the fact that the embryo did not implant
means either that their body is defective; or that it "rejected" the
embryo; or that they did not rest enough. However, please do remember
that embryo implantation is a complex process, which you cannot influence
by your diet or physical activity – so there is no need for you to
blame yourself if the embryos do not implant.
Maximizing
Chances For Success
Women:
- Avoid
all medications other than Tylenol. If you are taking other prescription
medications check with us prior to beginning your treatment cycle.
- No
smoking or alcohol use. Studies show both can result in lower pregnancy
rates and a greater risk of miscarriage. Why put yourself through
this if you are not doing everything YOU can to insure your success.
- No
more than two caffeinated beverages per day.
- Avoid
change in diet or weight loss or fad diets during IVF cycle. A healthy
well balanced diet works best.
- Refrain
from intercourse three to four days prior to egg retrieval and following
embryo replacement until pregnancy determination is made.
- Normal
exercise may continue unless enlargement of your ovaries produces
discomfort.
- Avoid
hot tubs or saunas.
Men:
- Fever
greater than 100.4o one to two months prior to IVF treatment
may adversely effect sperm quality. Be sure to let us know. If you
are sick, please take your temperature and report any febrile illnesses.
- Sitting
in hot tubs and saunas is not recommended. Even a single episode
in the hot tub can adversely effect sperm function. Please refrain
from this for at least three months prior to treatment.
- Drugs,
alcohol, and cigarette smoking should be avoided for three months
prior to treatment and at all times during the ongoing IVF treatment
cycle to get the best results.
- Abstain
from intercourse for at least three days, but not more than seven
days prior to collection of semen for egg collection and during
treatment.
The
Cost of IVF
The cost
of a single IVF treatment cycle varies widely from approximately Rs
30,000 to more than Rs 75,000 depending on the program and the items
included in the fee. It is important to get an itemized listing from
the selected program of what costs are included in the treatment cycle.
Try to find your "total" medical cost - how much you will have to
spend out of your own pocket for the entire treatment. Many clinics
do not include the cost of certain procedures ( such as ultrasound
scans) and these can then add up to quite a bit ! Other expenses to
be aware of include time missed from work and travel and lodging expenses.
The number of treatment cycles needed to achieve pregnancy will, of
course, determine the final cost.
A reduction
in cost may be obtained by using "Natural Cycle IVF." This procedure
does not employ ovulation enhancement; therefore the additional expense
on the injections used for superovulation is eliminated. However,
only one mature egg is usually obtained, and the pregnancy rate per
cycle is therefore less for this method. A newer technique called
"in vitro maturation" allows doctors to collect many immature eggs,
and them mature them in the laboratory.
Embryo
Freezing
[continued
on next page]
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