In Vitro Fertilisation (IVF)

Stimulation phase of the cycle with gonadotropin injections

• You will need to have daily injections of gonadatropin.  The drug dose is decided based on the results of Anti-mullerian Hormone (AMH – A hormone test that ascertains the ovarian reserve of eggs) blood test and ultrasound scan alongside other factors.  The dose of the drug might change during treatment depending on the response.
• Injections are subcutaneous (beneath the skin) – given through the abdomen or thigh.
• The site of the injection should be altered daily – usually from side to side (left/right).
• Women are usually advised to do the injections in the morning.
• You may experience a feeling of heaviness or pressure inside the abdomen as the ovaries get bigger – this is normal.
• It is important to follow all instructions on drug dosage and timing.  You should inform us immediately if there are any problems with this.
• The injections are normally given over 10-12 days, although this may be extended if your response is suboptimal.

Trigger injection

• A hCG or Buserelin (or both) injection is the last and final one before egg collection is done.
• Timing of this injection is CRUCIAL.
• The injection must be taken at the time advised by the Unit (this is 36 hours before egg collection and will therefore be based on the expected time of your egg retrieval procedure).
• This is a late night injection (timing starts from 10.00 pm in 30 minute intervals).
• If you miss your allocated time slot, please still take your injection as soon as you remember, as long as this is within the next couple of hours from the original time slot you were given. Please make a note of the time you actually took the injection (if taken late) and ring the Unit first thing the next morning and update the nursing staff.
• Still attend as instructed for the egg collection, but inform the nursing staff on your arrival to the ward of the delay, as it may lead to a change in the theatre list.
• A significant delay in taking the injection may compromise your treatment. Occasionally this could lead to cancellation of the cycle.

You will be required to attend for scans and blood tests to monitor how the follicles are developing.

Monitoring starts on Day 10 of the injections, but may be advised sooner in some cases.

All scans during the treatment cycle are done vaginally and in the morning along with blood tests – between 8.00 am and 10.00 am.

• Egg collection is a vaginal procedure performed under ultrasound guidance.  The procedure lasts 20-30 minutes.
• You will need to starve from midnight before egg collection (this means no food, drinks, water, sweets or chewing gum).
• The procedure can be performed under IV sedation, although on occasions general anaesthetic (GA) can be used.
• Please be aware that not all follicles seen on the scan yield eggs.
• You may experience some pain and bleeding after the procedure.

• On the day of egg collection, the male partner is asked to provide a fresh sample of semen, produced on site in the Andrology Department.
• If you have difficulty producing, it is important that you inform staff prior to the start of the treatment cycle.
• Some couples may have sperm frozen previously or may be using donor sperm.
• If sperm parameters on the day appear suboptimal, we might consider ICSI rather than IVF treatment (this will be discussed and agreed with you).  For more information about ICSI, please click here.

If the sperm parameters are normal then the egg will be inseminated using IVF, whereby the embryologist will prepare the eggs and sperm and mix them together in a container (Petridish) and allow them to fertilise naturally.

If there are any concerns about the sperm, the ICSI method will be used.  This involves taking up a single sperm in a fine glass needle and then injecting it directly into an egg.

During IVF, the embryos are cultured for up to six days and they are graded when necessary.

Grading is necessary in order to evaluate your embryos to decide which ones(s) should be selected and replaced into your uterus and which ones, if any, to store.

There are a number of ways in which embryos can be graded.  At Saint Mary’s we assess embryos by carefully evaluating and scoring some aspects based on their morphological appearance. For example, you can have 2 to 4 cells after 48 hours and 7-10 cells after 72 hours. The cells in an embryo are referred to as the ‘blastomeres’. It is generally considered best if all these blastomeres are even and similar in size or close to.

When portions of the embryo’s cell are broken and are separate from the nucleated cells, these portions are referred to as fragmentation.  Ideally, there should be very little or no fragmentation present.  However, the occurrence of fragmentation is quite common and several beautiful babies have resulted from fragmented embryos.

The blastocysts are graded based on the expansion state (early, expanding, expanded, and hatching) as well as the quality of the other cell type in the blastocyst. The blastocyst consists of the inner cell mass – which eventually forms the fetal tissues and the trophectoderm – which forms the placenta.

The pictures below show the development of a hatching blastocyst from an egg to two cells, four cells, eight cells, blastocyst and a hatching blastocyst.

We carefully assess the morphology of all the embryos and select the best embryo(s) to replace for our patients considering every individual patient’s case.

 

The table below shows an example of the outcome from an IVF cycle.  These may vary significantly, and there are not always embryos available to freeze.

Embryoscope

This is a technique involving time lapse imaging technology.  At Saint Mary’s, we use this equipment to record images of your embryos every 15 minutes.  Embryonic cells are normally programmed to divide at set time intervals and the timing of these divisions is known to be of a high clinical value to optimise IVF outcomes. Time lapse videos of your embryos enable our embryologists to enhance embryo selection for transfer by studying these timelines of cell division. This novel and unique application has shown to have a vast improvement in pregnancy rates, as patterns of embryo development can be monitored to select the most viable embryo(s) from a cohort.  Recent reports emerging about the use of this technology are promising and can also be used to reduce the number of embryos to transfer in order to minimise the risks of multiple pregnancy.

• Embryos are normally transferred back into the uterus either 2, 3 or 5 days after egg collection.
• The procedure involves introducing a speculum into the vagina, as in a smear test.
• A fine tube is passed into the womb under ultrasound guidance and the embryo(s) is replaced into the cavity of the womb.
• The procedure does not require an anaesthetic or fasting.
• No hospital admission is required.
• We recommend that after the procedure you carry on as normal.

Day of embryo transfer: Day 2, Day 3 or Day 5?

Our aim is to select the best one or two embryos for transfer to maximise your chance of pregnancy, but minimise the risk of twin pregnancy.

• You must agree to be available for embryo transfer potentially on day 2, day 3 or day 5.
• If there are 1 or 2 embryos, transfer is usually on day 2 – this applies to around 1 in 4 patients.
• If the embryos on day 2 are of suitable number and quality, we aim to extend the culture to day 3 and, if appropriate, to day 5 (blastocyst stage), when we can select the best quality one or two embryos.

• A pregnancy test is performed 14 days after embryo transfer.
• If positive – an ultrasound scan is booked 2-3 weeks later to confirm the pregnancy.

It is imperative that you inform the unit of the outcome of the treatment cycle – as it is compulsory for the unit to notify the HFEA of all outcomes.