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The IVF Treatment Cycle

The treatment cycle used for the different A.R.T procedures basically involves 5 steps and these will be discussed in detail.
1. Stimulation and Growth of Ovarian Follicles that contain the eggs or oocytes
2. Egg Retrieval or Egg Pick-Up
3. Preparation of Semen Sample, Insemination and Fertilisation of Eggs and Embryo Culture
4. Egg and Sperm Transfer or Embryo Transfer
5. Luteal Phase Support

STEP ONE: Stimulation and Growth of Ovarian Follicles

During a normal cycle, only one follicle is produced by your ovaries. The follicle is like a small bubble on the ovary which grows to 20mm in diameter and contains one oocyte (egg) which is about 0.1mm in diameter. When ovulation occurs, the follicle bursts and the oocyte is released into the end of the fallopian tube. In a treatment cycle, the ovaries are stimulated by certain drugs to produce several follicles.

No medication other than that prescribed by your consultant should be taken whilst having treatment.
Ovulation stimulation or induction is achieved routinely with 3 drugs. These are CLOMID (Clomiphene Citrate), PUREGON / GONAL F (Follicle Stimulating Hormone) and LUCRIN or SYNAREL (nasal spray preparation of Lucrin). See pamphlett.

Normally in a fully Stimulated Treatment, injections of FSH (Follicle Stimulating Hormone) are given from Day 4 of your menstrual cycle. There are two basic regimes for ovarian stimulation for IVF treatment – “Flare” and “Down Regulation”.

In the FLARE regime, Lucrin or Synarel is commenced on Day 2 of the cycle and FSH on Day 4 to initiate egg growth. In the DOWN REGULATION regime, Lucrin or Synarel is commenced at least 10 days before the FSH.

Basically the Flare regime is a simpler and cheaper procedure for patients and it is very useful for women whose ovaries are slower in responding to FSH. The Down Regulation cycle takes longer and is slightly more expensive because of the extra days of Lucrin/Synarel use, but there can sometimes be smoother stimulation of the oocytes (eggs) with more oocytes maturing at the same rate and time. As there does not appear to be any difference in pregnancy rates at The Wesley IVF Service between either regime, the unit is currently offering women the “flare” regime in most cases. (Synarel is also cheaper than Lucrin). The dosage of FSH will be determined by your consultant and can vary between individuals and between cycles.
A Transvaginal Ultrasound Scan is normally performed on Day 4 and then these scans are done regularly to assess follicular development. When the probe is placed in the vagina, an image of the ovaries can be seen on the scanning screen and fluid filled follicles that contain the eggs can be observed. The size of the follicle indicates the degree of egg maturity. When the egg is immature, the follicle is only a few millimetres in size, but when it is fully mature it grows to about 2cms in size. When follicles are large in size, you may experience some discomfort in the region of the ovaries. Usually 5-15 follicles will develop, but this varies considerably.

When your consultant determines that a number of the follicles are mature, usually on Day 12 or 13 (although this may vary with Down Regulation), you will be given another injection of Profasi/Pregnyl which triggers ovulation about 36 hours later. This is why the timing of the egg retrieval is very exact.
During a Minimal Stimulated Cycle, only Clomid is taken orally from Day 2 to Day 6, vaginal ultrasound scans are performed about Day 11, and Pregnyl/Profasi is also given to trigger ovulation. Usually only 2-3 follicles develop.

STEP TWO : Egg Retrieval or Egg Pick-Up

Egg (oocyte) Retrieval involves aspiration of the ovarian follicles under general anaesthesia in the operating theatre next to to the IVF laboratory at The Wesley Hospital. This is done either by using a laparoscope or by the transvaginal ultrasound method. The fluid filled follicles are aspirated under slight suction. The scientist locates the eggs, places them into culture media and then into the incubator.

Normally the eggs are collected by the transvaginal ultrasound technique. The anaesthetic for the ultrasound procedure is very light. For this procedure a probe is inserted into the vagina and this projects a picture onto a monitor which enables the doctor to direct a needle into each follicle to retrieve the eggs.

The G.I.F.T. cycle involves aspirating the eggs via a laparoscope and then placing sperm and eggs back into the fallopian tubes where fertilization may occur. This procedure therefore involves a laparoscopy also under a general anaesthetic. This is usually only performed in patients who have a religious/cultural objection to in vitro fertilization.

STEP THREE: Collection & Preparation of Semen Sample, Insemination, Fertilisation
Semen Sample – patients will be advised when the husband needs to produce a semen sample at the laboratory. Samples are first checked before processing with the count, motility, quality of motility and proportion of normal shaped sperm being recorded. The sample is then processed by spinning the specimen in a test tube through a sterile salt interface (Puresperm) which acts as sieve to catch dead and abnormal sperm. Forward swimming sperm are able to pass through the interface and are collected from the bottom of the tube. These sperm are washed and used for IVF, and related procedures.
Insemination – patients having GIFT will have processed sperm returned to their fallopian tubes together with oocytes. Oocytes are inseminated about 4 hours after egg pick-up using the microdrop technique. This involves suspending 100,000 sperm and one egg each in a tiny drop of culture media under sterile paraffin oil. This procedure confines the egg and sperm to a small volume, allowing more egg-sperm interaction. Increased numbers of sperm are added to each microdrop when a patient is anti-sperm antibody positive, where high numbers of abnormal sperm are detected in the final sample, or when the couple has a previous history of poor fertilisation.
Fertilisation – the eggs are checked for fertilisation 20 hours after insemination has been performed. Those eggs which either have not fertilised or which are abnormally fertilised (polyspermy) are discarded. Normally fertilised eggs (called pronuclear stage embryos) are either returned to the fallopian tubes for patients undergoing a PROST cycle, or cultured for a further 24 hours for subsequent TEST or IVF transfer. Embryos are assessed by looking at the stage of development and the amount of fragmentation within the embryo. Excess embryos can be frozen.

STEP FOUR: Embryo Transfer

With Standard IVF, the woman’s legs are placed in stirrups, a speculum is inserted in the vagina and the embryos are transferred into the uterine cavity by a very fine catheter which is passed through the cervical canal. Usually no anaesthetic is required. This is usually done about 2 days after egg pick-up and the procedure takes 5-10 minutes.
With GIFT, the eggs and prepared semen are placed into the fallopian tube at the time of the laparoscopic egg pick-up and it is hoped that fertilisation will occur in the tube and the resultant embryo implant in the uterus.

STEP FIVE: Luteal Phase Support

Following Egg Pick-up, most patients will require hormone support which is designed to maintain the lining of the uterus for embryo implantation.

This may be in the form of four Profasi/Pregnyl injections several days apart; or progesterone vaginal cream (Crinone) or pessaries inserted daily or twice daily.

You should have 48 hours rest at home after the embryo transfer and then you may return to your everyday activities. However, it is suggested that any strenuous exercise be avoided, and that sexual intercourse not be resumed until 1 week after embryo transfer. For those wishing to return to work, you may do so 2 days after the embryo transfer.
Pregnancy Test and Scan is performed 20 days after embryo transfer and a pregnancy scan will be arranged in 3 weeks with your consultant. If not pregnant, a consultation is arranged to review the treatment cycle and discuss the scientific report and future options.

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