IVF/ET is the most widely used method for bio-medically assisted reproduction.
Reasons to have an IVF/ET procedure:
- Blocked fallopian tubes
- Pathological findings in semen analysis,
- long marital infertility
- infertility caused by an unknown factor
Medical technology comprises the following:
Drugs are used to stimulate ovaries to release as many egg cells as possible. For the IVF procedure it is better to obtain as many egg cells as possible, since some of them will not be fertilized and developed properly. Stimulation drugs are principally non-gonadotropic, gonadotropic, agonist and antagonist GnRH (gonadotropin-releasing hormone). Several protocols are applied in ovulation stimulation. Their selection depends on the age of the patient, her body weight, previous experience with stimulation, IVF laboratory opinion, financial abilities, etc.
Ovulation induction is performed in the Institute (for patients from Sarajevo), but can also be performed in health institutions in other cities, if patients do not live in Sarajevo. It is essential that the therapy is received in a prescribed manner, in the provided dose, always at the approximately same time. Ultrasound exams are performed when scheduled, follicle growth is controlled, and therapy or dose is corrected if required. When follicle size, i.e. its mature age is achieved (ultrasound or hormonal test), a patient is administered a HCG injection. Its purpose is to increase development of the egg cell.
Aspiration of mature egg cells
In the period before and around 36 hours from administered HCG injection, puncture of mature follicles is performed. In order to ease the possible pain, we can administer certain analgesics and short anesthesia, if so required by the patient. The procedure takes several minute, and it is done transvaginally under the control of ultrasonic probe. Certain risk exists, but with a thorough examination, knowledge and experience, this is reduced to minimum.
Following the aspiration, the follicle fluid is handed over to an embryologist, who extracts egg cells from it and determines their number, quality and how mature they are. Quality and maturity of egg cells are crucial for further success of the procedure. Once they are isolated and stored in a special medium, they are kept under highly controlled conditions in an incubator.
Semen preparation is done prior to medically assisted reproduction procedure as to create the best possible conditions for fertilization. During the preparation healthy and vital spermatozoa are isolated from the rest of the semen fluid, detritus, leukocyte and other forms of poor quality, which increases their chances of fertilization. The semen preparation procedure is the same in all medically assisted reproduction methods.
Semen sample needs to be provided simultaneously with the follicle puncture. The sperm is usually collected by masturbation after previous abstinence of 2 to 7 days. Condoms or lubricants should not be used, because they might have negative effects on the sperm quality. The sample can be given in the Institute, or brought from home within one hour from ejaculation, which needs to be carried close to your body so as to preserve the temperature. The bottle must be sterile and labeled with full name, date and time of ejaculation. The Institute pays particular attention to labeling the specimen, so as to avoid possible switch.
Following the analysis, embryologist can determine which method for semen preparation and fertilization would be the most appropriate.
Fertilization and embryo development
Several hours upon extraction of egg cells and spermatozoa, their merging is performed, i.e. fertilization. The process is carried out in a sterile dish and special medium in an incubator, under strictly controlled conditions for natural fertilization. After about 20 hours, the cells are controlled and fertilization and division is detected. Embryos are then observed for 2 to 5 days, before they are inserted into patient’s uterus. The conditions in the incubator are under constant lab control as to ensure the optimum development of embryos. Morphologically adequate embryos are selected for the embryotransfer.
Embryo transfer is the last stage in the procedure, which is done 2 to 5 days upon the follicular aspiration. The number of embryos which are transferred into the uterus depends on the number of egg cells, patient’s age, embryo quality, but also on the patient’s wish. In cases when more than one embryo is inserted, there might be a risk of multiple pregnancies, which we try to reduce to minimum.
The very procedure is painless. The cervix is made visible by using the speculum. Then, a soft catheter is inserted into the uterine cavity, and the previously selected embryos are expelled. The embryos which are being transferred into the uterus are first shown to the patients on the microscope screen, so that they know what is actually being transferred and to have a less abstract feeling about the whole procedure.
The gynecologist opens the cervix and gently inserts the catheter into the uterine cavity. Then, the embryologist inserts another, smaller catheter through the previously inserted one which is somewhat wider, and gently expels the referenced contents into the uterine cavity. Then, both catheters are withdrawn and inspected under a microscope for retained embryos. If an embryo got stuck in the catheter, we must repeat the whole procedure. Within the next 2 or 3 days the transferred embryos will look for the nidation place, that is, a place to nest in the uterine mucosa. The aforementioned period is a period which cannot be actively influenced by any medical methods.
Incubator fertilization rate is very high, more than 90%, whereas the embryo transfer acceptance rate is around 30%.
Monitoring of the corpus luteum function
A patient, who has undergone an embryo transfer procedure, should first lie down for about one hour in the Institute, and after that go home and rest. The patient will get instructions about this in writing or verbal instructions from the Institute’s staff.
After approximately 12 to 18 days after the embryo transfer, a patient should have a pregnancy test measuring the βHCG level (available in the Institute as well), or a urine pregnancy test. Then, ultrasound verification of pregnancy is performed, after which regular gynecological exams follow throughout the pregnancy.
Once the embryo transfer procedure has been performed, female patient is provided with a progesterone preparation (pregnancy hormone) in forms of vaginal tablets, pills or injections, in the manner, dosage and time periods prescribed by the gynecologist. Besides the aforementioned, other preparations are also used which might help in better nidation and embryo implantation.