In vitro Fertilization (IVF) - Importance, Procedure and Cost

IVF is the fertilization of egg and sperm in a specialized lab and is carried outside your body. “In vitro” means “outside the living body”. There are two types of IVF, namely: Stimulated IVF and Natural IVF.

Let us know what these types actually mean.

1. Standard or Stimulated IVF: This is a traditional or regular type of IVF in which your ovaries are made to produce more number of mature eggs. More clearly, in this type,, you will be given fertility drugs that can stimulate your ovaries to produce multiple mature eggs.

There are some pros and cons for this stimulated type IVF, like:

Pros: With stimulated IVF you can have

• Higher rate of success
• As more eggs are produced, they can be stored for future use
• Screening of embryos for any genetic diseases is possible

Cons: They can be as follows

• You may have to face the problem of Ovarian Hyperstimulation Syndrome or OHSS.
• You should prepare financially as it is very expensive
• You may also have an increased risk of getting multiple pregnancies.

2. Natural IVF: It differs from stimulated IVF in that there is no usage of fertility drugs to stimulate your ovaries. When your body naturally produces a mature egg during regular menstruation, it is collected and is combined with the sperm in a lab.

If you wish to save money and want the treatment to have very low risks and if you are against the idea of selection and cryopreservation of embryos, then Natural IVF is best suited for you [2].

There are a few pros and cons to this type.

Pros: When opting for Natural IVF

• You don’t have the risk of getting your ovaries hyper-stimulated.
• As only one egg is collected, there is no chance of storing or disposing of extra eggs.
• You can have less chance of getting multiple pregnancies, as only one single egg is collected for fertilization with sperm.

Cons: They can be like

• You have a very minimum success rate
• If once failed to collect eggs in the first attempt, then again the egg collection process should be repeated, as there is no availability of frozen eggs for future use.
• According to a study, in women of advanced age and having repeated stimulated IVF failure, when mature egg retrieval is done through the natural IVF cycle it has been proved to be beneficial [3].

Infertility is defined as the inability to conceive even after trying for more than a year and by having unprotected sexual intercourse. If you cannot conceive for more than a couple of years then it is good to consider IVF. It is suggested for you to go for IVF, if you have been suffering for a prolonged period of time with various kinds of gynecological issues like ovulatory problems, poor egg quality, blockages in your fallopian tubes, endometriosis, fibroids of the uterus and unexplained infertility.

If you are above 40 years of age and have fertility issues, then IVF is considered as a primary fertility treatment for you. IVF is also the best option to be considered if your partner has low sperm count or if you wish to get pregnant by using donor eggs.

In older women aged above > or = 40, the need of pre stimulation testing along with screening and counselling should be considered for achieving a live birth.

A study says that the role of pre-stimulation testing in older women is considered together with the importance of screening and counselling these patients about the likelihood of achieving a live birth [4].

This is a highly advanced technology that can help in your conception by treating your fertility or genetic issues. Before taking up IVF procedure, you can also attempt less invasive treatments like taking medicines to increase your egg production and intrauterine insemination IUI, a process where healthy and selected sperm is directly injected into your uterus during your ovulation time.

If you cannot get a successful pregnancy while trying with other fertility treatments and if you finally wish to undergo IVF treatment, then you should have a basic idea of the procedures that you will have to follow. It should be clear to you that in IVF, you can use your own eggs and sperms from your husband. Due to certain conditions, IVF also involves using eggs, sperms, or embryos from an unknown donor. In rare cases, a gestational carrier, a woman who agrees to carry the baby for you in her womb, may also be involved.

As IVF is a complex procedure and to avoid issues, your doctor will perform some screening tests for you and for your partner before starting the process.

Screening Tests

The following are a few of the screening tests that are suggested before commencing IVF.

• Estimation of ovarian reserve: Measuring of certain hormones in your blood can help to know the quality and quantity of your eggs. Usually, hormones like a follicle-stimulating hormone, estrogen, and anti-mullerian are tested during the first few days i.e. from day 1 to day 5 of your menstrual cycle. Ultrasound scan of ovaries is also done along with the above hormonal tests to know the reaction of your ovaries to fertility medicines.
• Semen analysis: Your husband is asked to take up semen analyzing tests prior to IVF treatment. This test gives parameters of semen and also helps to determine how healthy his sperms are. Semen characteristics like viability, shape and motility, morphology, pH, viscosity, volume, count, and density of sperms can be analyzed with semen testing.
• Tests for infectious diseases: You and your partner may also need to take screening tests for infectious diseases like HIV, STDs.
• Examination of your uterine cavity: Your doctor may perform an examination test of your uterine cavity to determine its space and to know if there are any issues within. For a successful conception and pregnancy, all you need is a healthy uterine cavity.

Once the doctor does all the needed tests, like the above ones, he/she can schedule the IVF procedure. There are several steps involved in your IVF procedure and we will discuss them in detail now.

IVF Procedure Step by Step

The normal process of giving birth to a baby happens in your womb when your egg gets fertilized with the sperm of your husband. When this fertilized egg, called embryo starts to grow into a baby by attaching itself to the lining of the uterus, after a period of 9 months, you will give birth to your baby. As this happens naturally it is called Natural or unassisted conception.

The process of getting pregnant by using a special kind of medical technique is called IVF. It is a form of assisted reproductive technology ART and is usually preferred when other less expensive fertility treatments do not work for you in getting conceived.

You will go through various stages of getting pregnant through IVF. To make you better understand the complex process of IVF, we have simplified it as the following steps.

Let’s take a look at them:

1. Ovulation induction

Your IVF treatment starts with inducing (means to cause or to produce) ovulation. Your ovaries will release one egg every month from your puberty until you reach menopause. For IVF, either your own eggs or donor eggs can be used. If the process involves making use of your own eggs, then your ovaries are made to manufacture more eggs. Your doctor will treat your ovaries with synthetic hormones to produce multiple eggs instead of a single egg that they normally release each month. The reason for inducing ovaries to release more eggs is because some of the eggs may not undergo fertilization or may not develop properly after fertilization.

Your doctor will suggest you take medicines at various stages of treatment like:

• Stimulating ovaries: You are suggested to take either follicle-stimulating hormone injection, a luteinizing hormone injection, or an injection having a combination of both of these hormones. These injections can help your ovaries to release more eggs.
• Egg maturation: Once your ovaries produce eggs and when the follicles get prepared for egg retrieval, which is said to occur at 8 to 14 days, your doctor will give you medicines that can mature your eggs.
• To avoid premature ovulation: Your body may release the eggs as soon as they develop. To prevent this from happening, your doctor will give you medicines.
• Uterine lining: You need to take another type of medicine at your egg retrieval day or at your embryo transferring time. Progesterone is the hormone that makes the lining of your uterus thickened and ready for egg implantation. So your doctor will give you progesterone supplements to help you in preparing your uterus.

Your ovaries may take their time of 1 to 2 weeks to get stimulated and to produce eggs before the doctor retrieves them. While you are taking the course of fertility medicines, the growth of ovaries should be tracked every 2 to 3 days and for this, you need to go through some blood tests to assess hormone levels and get an ultrasound scan. All these can help your doctor to know about the growth of follicles (they are fluid-filled sacs containing mature eggs) and he can plan to collect eggs once they are ready to be retrieved.

Sometimes, your IVF cycle may be cancelled at this stage due to some reasons like premature ovulation, less than the required number of follicles developing in ovaries, or the development of numerous follicles leading to ovarian hyperstimulation syndrome. If you encounter any of the above issues and if your IVF cycle gets cancelled, then your doctor will plan to switch you to other medicines or take chances in doses of medicines to yield a fruitful response in your future IVF cycles.

2. Preparation of eggs for collection

If your follicles are ready when monitored by a doctor using ultrasound, then you will be given a hormonal injection or a trigger shot. This shot helps your eggs to mature completely and also makes them ready for getting fertilized. After a period of 36 hours of giving trigger hormonal injection, your eggs are ready to be collected.

3. Egg extraction using ultrasound

Your egg retrieval is usually done by using a Transvaginal ultrasound. For this, the doctor will sedate you giving medication and then the probe of the ultrasound device is made to pass through your vagina. With the help of this probe, the follicles are identified and a thin needle is passed through ultrasound guidance through your vagina to reach the follicles and then eggs are collected.

On collecting the mature eggs, they are immediately placed in a healthy environment of nutritive fluid and allowed to incubate. Only those eggs that look healthy and mature are allowed to be mixed with sperm to develop into embryos.

4. Sperm retrieval

Here comes the role of your male partner in providing his semen sample. He should provide the semen sample on the same day when egg retrieval is scheduled. In a special lab, sperms are separated from this semen sample and are kept already to mix up with already extracted eggs.

In very special cases only, a surgical procedure like testicular aspiration is done to your partner to extract sperms directly from his testes.

5. Fertilization

This is the most crucial phase where the egg is made to get fertilized with sperm. After the embryologist examines your eggs and your partners’ sperms, they are mixed together and allowed to be cultured in a lab for about 16 to 20 hours. After this time period, the doctor will see whether eggs are fertilized or not. When fertilization has occurred, embryos will form and they will be placed in an incubator for about 6 days. Your doctor will closely observe and monitor the growth of embryos. After examining the embryos, the healthiest and normal ones are selected to be transferred.

Upon your wish, other healthy embryos can be stored and preserved by freezing them and can be used in the future for another IVF cycle.

6. Embryo transfer

This is the final and most important step in your IVF treatment cycle. It usually takes place 3 to 5 days after the retrieval of eggs. Your success in getting pregnant depends on this step.

Taking into account your age and the severity of your fertility issues, your doctor will take the decision to place 1 to 5 embryos in your uterus. A special medical tool named speculum is inserted into the vagina by the fertility expert, and then a thin tube named catheter is followed through the cervix. It is through this tube the embryos are transferred into the uterus. .

To reduce the risk of having multiple pregnancies, the doctor may suggest single embryo transfer SET if he feels it may benefit you. In this way, the number of embryos to be transferred to the uterus can be restricted. For this SET process, you need no sedation as it is a pain-free one.

A retrospective study was done in 1313 embryo transfer cycles to investigate the factors affecting clinical pregnancy rates like age of women and the duration of embryo transfer. When embryo transfer was done in less than 44 seconds, the pregnancy rate was 31.6%, at 45-59 seconds the rate was 25.9%, and at > or = 60 seconds, the pregnancy rate was 23.6%. So it was concluded that in order to achieve a successful pregnancy in women aged 35 years and above, embryo transferring time should be maintained and kept below 60 seconds [5].

7. Implantation of embryo to uterine lining

If the embryo transfer step is done successfully, then the transferred embryo will implant itself to the uterus lining. You are advised to go for pregnancy tests after 2 weeks of embryo transfer.

According to a study, it is shown that problems to get pregnant can arise if there is the failure of any of the essential steps of IVF like ovulation induction, oocyte maturation and embryo formation get disturbed [6].

It is very important to know the causes of fertility problems in both the partners before the IVF treatment starts. Sometimes, the causes of infertility may remain unknown. Common causes of infertility in men and women should be found and treated for the successful IVF procedure.

Indications for IVF in Men

When your semen parameters do not match with the normal reference ranges given by WHO, then you may be having male factor infertility. This infertility may be due to your sperm motility being low, less than normal sperm concentration or abnormalities detected in your sperm shape and size.

For your male factor infertility, careful evaluation before starting assisted reproduction tretmane is considered. Latest techniques of ICSI in the case of severe male factor infertility increased pregnancy rates up to 52% [7].

There is no specific sign or symptom when you have male factor infertility. Very rarely, you may now and then experience symptoms related to hormonal imbalances like decreased sexual function or reduced hair growth. You should visit your fertility specialist if you notice symptoms like:

• Less than normal semen parameters in your semen analysis report like a low sperm count
• If there is a previous medical history related to prostate, testes or any other sexual issues
• If you have had treatment for any kind of cancer
• If your testes are abnormally smaller in size.

Indications for IVF in Women

In women, IVF may be an option if one or more than one of the following issues are present.

• Blockages in fallopian tubes: When there is any block in your fallopian tubes, you do not always show any specific symptoms, but may face issues in getting conceived. Your doctor will suggest removing blocks through tubal surgery.
• When your fallopian tubes are surgically removed due to certain medical issues or due to risk of ectopic pregnancy, then IVF is a good option for you.
• Endometriosis: This can lead to defective functioning of your ovaries, uterus and fallopian tubes leading to the common cause of female infertility. In endometriosis, your uterine tissue known as endometrium starts to grow on the outer surface of the uterus and other organs causing blocks and adhesions.
• In severe endometriosis natural conceiving is not possible and there is an opportunity to get pregnant through IVF treatment. In a meta-analysis study done to investigate the outcome of IVF in women with endometriosis-related infertility showed that these women responded significantly less when compared to women of other indications for IVF. This poor outcome of IVF in endometriosis women is due to the effect shown on the development of oocyte and embryo [8].
• Fibroids in uterus: Sometimes, there can be problems with implantation of fertilized egg due to the growth of benign tumours in the walls of your uterus. Surgical removal of these fibroids can help in successful IVF rate.
• Ovulation problems: If you have been already diagnosed with PCOS and suffering from irregular ovulation, then your doctor will treat you with medicines to treat PCOS or give medicines to stimulate ovaries to release eggs.

Indications for IVF in both Men and Women

There are few conditions that can make a couple choose IVF for starting a family. They are:

• Genetic disorders: With the help of recent advanced IVF medical tests like Preimplantation Genetic Diagnosis PGD, you can identify your genetic disorders that can be passed to your child [9]. In such conditions, you can opt for IVF treatment which provides you a disease-free conceiving. Your doctor will select only those embryos for implanting into the uterus and will pick up only those embryos having only the required number of chromosomes.
• Unexplained infertility: If the cause of your infertility is unknown then your doctor treats you with drugs like Clomiphene and hormonal injections. If this also does not work for you then the only option would be IVF.

When you decide to undergo IVF treatment for having a baby then it is common to have doubts about the success of the procedures and the result it gives you. Success rates of IVF treatment depend on various factors.

The factors that determine the success of IVF treatment are [10]:

• Increasing age and infertility: Your age is the most influencing factor of IVF treatment. If you are younger, then your IVF success rate is higher. It was found in a study that there were about 30 to 40% live birth rates in younger women aged 34 and less when their own eggs are used. There was a drastic decrease in success rate once you cross 35 years of age because at this age you have the poor ovarian reserve and quality of eggs will be reduced.
• Use young donor eggs: If you are using donor eggs, make sure to always use eggs from a young donor which gives a good success rate of your IVF pregnancy.
• Take into account male factor infertility: Male factor infertility also may reduce the success rate of IVF. Before you decide to start with IVF treatment, you should know of any fertility issues that are associated with your male partner.
• Other contributing factors: Other factors like status of the embryo during transfer, your past and present reproductive medical history, you and your partners’ lifestyle patterns like alcohol consumption, smoking, and excess body weight also largely impact the success rate of IVF treatment.
• Type of IVF clinic chosen: Last but not the least, the success of IVF treatment depends on the fertility clinic and the fertility specialist that you choose for your treatment.

As we discussed that the age of females plays a crucial role in achieving a successful pregnancy through IVF, below we discuss the good effects and side effects related to IVF treatment.

When you first undergo any kind of medical procedure, it is natural to feel anxious. Undergoing complex procedures like IVF even raises more concerns. It is most important for you to understand the pros and cons of IVF treatment.

some of the pros and cons of IVF treatment are:

Pros

• IVF is proven to be a popular and commonly used method in assisted reproductive technology.
• If your fallopian tubes have been surgically removed for reasons like severe pelvic infections as in appendicitis or chlamydia infections, then IVF is the best option. IVF bypasses the job of fallopian tubes, as your doctor will directly take eggs from ovaries and fertilizes it with sperm in the lab.
• It includes improved techniques like genetic screening methods called Preimplantation genetic screening that can help you to a baby free of any genetic diseases.
• As IVF procedure is controlled and supervised by your fertility specialist, you have a great chance to select comfortable time based on your personal and professional needs for getting conceived.
• There is no proven link between fertility drugs used in IVF treatment to the risk of increased ovarian cancer.

Cons

• Sometimes, IVF cycles may fail and its success is not guaranteed. In such a case, you should go through repeated IVF cycles.
• It is an expensive medical procedure. So before you think to go for it, you should enquire thoroughly about the direct and indirect expenses related to IVF.
• You may face stress and emotional anxiety as you go through testing and treatment steps of IVF.

By this time, you might have known that IVF is an extensive and complex procedure. Because of its complexity, there do exist a few risks with IVF.

Following are a few risks of having IVF treatment.

• Multiple pregnancies: There is a chance of having more than one pregnancy in IVF. When more than one embryo is placed in your uterus, it increases the risk of having twin babies or sometimes even triplets. Some women like to have twin babies while some do not. If there are multiple fetuses in your womb you may have an increased risk of miscarriage and even preterm labour.
• Ectopic pregnancy: Risk of having an ectopic pregnancy is higher in IVF. It is the implantation of an embryo on other sites other than inside of your uterus. Ectopic pregnancy in damaged fallopian tubes is common, as the tubes are not able to keep the embryo in place and the embryo cannot grow fully.
• Risk of Ovarian Hyperstimulation Syndrome OHSS: With fertility drugs, your ovaries may sometimes respond severely producing too many eggs. This may lead to a swollen and painful ovarian condition known as OHSS. It is a medical emergency situation and you need to be monitored regularly.

There are even a few side effects with IVF treatment that should be known by you like:

• Due to high levels of estrogen, you may feel tenderness in your breasts and can even experience bloating, cramping and constipation.
• When there is OHSS, you may experience mild pain in the belly, nausea and vomiting, and diarrhoea.
• Slight bleeding is the common following embryo transfer and this can be for 8 to 10 after embryo transfer.

You can expect the cost of IVF treatment in India anywhere between Rs. 60,000 to 1, 00,000. This amount can increase depending on the clinic you choose, the qualification, experience and success rate of the IVF doctor that is treating you, the medicines and injections used for you and the location of the clinic. As achieving success with the first attempt of IVF treatment depends largely on your age, the IVF cost may vary based on the treatment program that suits you.

Summary

IVF technique helped many childless couples to have a baby of their own and bought them ever ending joy. There are successful stories of couples available online. If your first IVF attempt is not fruitful, don’t lose hope and try again for a baby.