In vitro fertilization (IVF)

IVF Definition

In vitro fertilization (IVF) is a process by which egg cells are fertilized by sperm outside the womb, in vitro. IVF is a major treatment in infertility when other methods of assisted reproductive technology have failed. The process involves hormonally controlling the ovulatory process, removing ova (eggs) from the woman's ovaries and letting sperm fertilise them in a fluid medium. The fertilised egg (zygote) is then transferred to the patient's uterus with the intent to establish a successful pregnancy.

The first "test tube baby", Louise Brown, was born in 1978 and she herself is a mother of a healthy baby boy now.

Indications for IVF

There are a variety of indications for IVF.

Male Factor Infertility : Male factor infertility includes low count and motility, high number of abnormal forms, ejaculatory dysfunctions, Failed reversal of Vasectomy/ Tubectomy , obstructive azoospermia etc.

• Age-Related Infertility : higher the age lesser the chances of conception. The fertility index keeps on decreasing after the age of 30 - 35.
• Reduced ovarian reserve, which means lower quantity (and sometimes quantity) of eggs. A day 3 FSH and estradiol test, antral follicle counts and AMH hormone levels are often done as screening tests for egg quantity. Reduced egg quantity and quality is usually treated with either IVF, or with IVF with egg donation.
• Absent or Damaged Fallopian Tubes : Rarely the fallopian tubes are found absent since birth. Many causes lead to blockage and damage of tube like severe adhesions, surgical procedures, infections etc.
• Endometriosis: The presence of tissue that normally grows inside the uterus (womb) in an abnormal anatomical location. Endometriosis is very common and may not produce symptoms, or it may lead to painful menstruation. It has also been associated with infertility.
• Endometriosis occurs most commonly within the Fallopian tubes and on the outside of the tubes and ovaries, the outer surface of the uterus and intestines, and anywhere on the surface of the pelvic cavity. It can also be found, less often, on the surface of the liver, in old surgery scars or, very rarely, in the lung or brain.
• Unexplained Infertility: Sometimes inspite of being absolutely normal male and female with normal hormonal assays, regular sexual intercourse and with all normal reports the couple is unable to conceive, this condition can be termed as unexplained infertility.
• Recurrent Intrauterine Insemination Failure : repeated failure of IUI trials is also an indication for IVF. Inspite of good IUI trials with gonadotrophins and good post wash, if conception does not take place IVF is a better option.
• Tubal and Pelvic Adhesions : pelvic adhesions and tubal adhesion may make tube incapable of nurturing the eggs and conception fails. Blockage of tubes arises due to pelvic adhesions
• Preimplantation Genetic Diagnosis (PGD) - In cases of repeated abortions and neo natal death PGD becomes necessary. PGD can be done only after IVF. [ PGD also helps in diagnosing several genetic diseases.
• Premature Menopause: Also termed as premature ovarion failure, where the function of ovaries stops before the age of 30, Egg donation proves a better option which is possible only with IVF.

Menopause : Menopause is stage of life when a woman can no longer bear a child. With IVF, this is now a false saying.

How does IVF improve fertility?

In vitro fertilization increases the efficiency of human reproduction, which is often not very efficient naturally. Essentially, we are involved in a numbers game that worsens as the female partner ages. IVF takes multiple eggs and after careful culture for 3-5 days of those eggs that fertilize, we transfer one or more of the good [Grade - I] embryos back to the uterus. Any remaining (if there are any) can be frozen for future use by the couple.

In a sense, we are compressing many months of "natural" attempts into one menstrual cycle. By transferring the fertilized embryo(s) directly to the uterine cavity, fertility is improved for many couples that have sperm issues (fertilization defects), or issues on the female side related to egg pickup from the ovary or tubal transport of the embryo to the uterus. Therefore, with IVF:

• We force the body to produce multiple follicles and eggs (only one follicle with one egg inside develops in a natural menstrual cycle)
• We take the eggs out of the ovaries when they're ready (release and tubal pickup of the egg can be inefficient naturally)
• We coerce fertilization in the lab (sperm or egg issues can cause fertilization problems in a natural situation)
• We culture the embryos for several days and then pick the best one (or more) for transfer to the female (selection of the best one(s) increases the chance of success)
• We transfer the embryo(s) to the best location in the middle of the uterine cavity (tubal transport of the embryo to the uterus is bypassed)

Implantation rates are used by fertility doctors when talking with couples about their chances for IVF success rates and multiple births. Implantation rates are also used in IVF clinics as a measure of internal quality control. If there is a weakness somewhere in the system (in the lab, or elsewhere) then implantation rates fall as embryos become "weaker" - with a decreased ability to implant and continue development.

By tracking implantation rates the IVF programs can have an "early warning system" that should trigger a thorough investigation of the entire IVF system.