In-Vitro Fertilisation- Embryo Transfer (IVF-ET)

Ovarian stimulation

The couple has to sign a consent form for IVF-ET and their marriage certificate has to be checked.

Baseline ultrasound performed on day 2-3 to exclude existence of ovarian cysts.

Blood taking for estradiol on day 2-3 to ensure cycle is at baseline level and couples’ blood taken to exclude infectious diseases

Daily gonadotrophin injection for around 10 days, recently a long acting gonadotrophin injection has been introduced with action lasting for 7 days which reduces the number of injections needed.

Monitoring with ultrasound and blood tests as necessary for follicular growth

When 3 follicles are large enough, approximately 17-18mm as seen in an ultrasound scan, an ovulating dose of hCG for final follicle maturation will be given.

IVF stimulation protocols generally involves 3 types of drugs:

Medicine to suppress LH surge and ovulation until the developing eggs are ready.
There are 2 different classes of medicine:

• GnRH (Gonadotrophin Releasing Hormone) agonist (usually start on luteal phase of previous cycle)

• GnRH antagonist (Usually start on day 6 of stimulation)

FSH (Follicle Stimulating Hormone)/HMG (Human Menopausal Gonadotrophin) to stimulate development of the eggs.

HCG (Human Chorionic Gonadotrophins) to cause final maturation

For ovarian stimulation during IVF procedure, the optimum is to retrieve 6-15 quality eggs.

When there are many follicles seen on the scan, in order to prevent ovarian hyperstimulation syndrome (OHSS), we can use antagonist cycle, do agonist trigger and counsel the patient on retrieving the eggs, fertilising them and freezing all of them for embryo transfer at a later cycle.

Q&A

Q: How do I know whether I ovulate?

If your menstrual cycle is between 28-35days, most often ovulation do occur.
You can have ovulation assessed in 3 ways

Blood LH surge tests at around ovulation time
Follicle tracking by ultrasound at around ovulation time
Blood progesterone test 7 days after ovulation

Q: If I have regular menstrual cycles, will oral ovulation induction medicine improve
my pregnancy rate?

Probably not. Regular monthly cycles indicate that you most probably ovulate regularly. Oral ovulation induction medicine like clomid may decrease the thickness of the inside lining of the uterus, making implantation of the embryo difficult.

Q: Is there medicine that can improve semen parameters?

Poor semen parameters is usually genetic in origin. Taking medicine like clomid, testosterone or steroid will not improve semen parameters. Male infertility usually necessitates in vitro fertilization treatment, with or without intracytoplasmic sperm injection (ICSI).

Q: If a couple has been diagnosed as being suffered from infertility, is the chance of
getting pregnant very slim?

No, on the contrary, if you get appropriate management of your infertility problem early, the chance of pregnancy is still pretty high. Although simple advice and measures can help for the initial stage, aggressive treatment may have to be employed at a later stage. According to Nice guideline (Feb2013), in vitro fertilization (IVF) will be offered to women with unexplained infertility, mild endometriosis and mild male infertility who have not conceived after 2 years.

Q: Will I have premature menopause after a few cycles of IVF, since many eggs have been
used up during each treatment cycle?

No. Each woman have 400,000 eggs at puberty and one egg will reach maturity to ovulate every menstrual cycle. There is a total of 400-500 menstrual cycles for the whole reproductive life span. The rest of the eggs will become atretic. Infertility treatment recruits some of the eggs that will regress anyway. Menopause is a stage when all the eggs have naturally regressed and therefore you do not have to worry about premature menopause.

Q: I have tried intrauterine insemination (IUI) for 3 times, why am I still not pregnant?

Usually, IUI is considered a milder form of treatment for infertility if the fallopian tubes are normal. The success rate is around 10 percent per cycle even if gonadotropins injection is employed. You do not have to be discouraged even if you have failed to get pregnant after 3 cycles of IUI. We can employ in vitro fertilization for treatment as the success rate is 3-4times higher than IUI. Some cases do require IVF for success.

Q: Will ovarian stimulation medicine cause ovarian cancer?

Up to date, literature has shown that ovarian stimulation will not increase the chance of ovarian cancer.

Q: What is considered completion of one cycle of in vitro fertilization?

One cycle of ovarian stimulation for in vitro fertilization may result in producing many embryos. For every subsequent cycle, we put back 1-2 embryos into the uterus, if pregnancy has not been achieved. It is not until we have put back all the frozen embryos that it is considered we have completed one full cycle of IVF.

Q: Is the pregnancy rate employing frozen thaw embryos less than fresh embryos?

No. Nowadays, we employ ultra rapid method (vitrification) for freezing embryos, which will not lead to crystal formation that is damaging to the embryos. Moreover, we usually employ natural non stimulated cycle which involves a lower estradiol levels, when we put back frozen thaw embryos and this result in a better pregnancy rate.

Q: Usually how many IVF cycles should I undergo?IVF

Usually we will advise at least 3 cycles of IVF before giving up as the cumulative pregnancy rate increases. Of course, it depends on assessment after each cycle.