In vitro fertilization (IVF) at Shivdikar Human Reproduction & Fertility Centre
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In vitro fertilization (IVF) at Shivdikar Human Reproduction & Fertility Centre

When fertilization doesn’t occur inside the body doctor consult the patient for IVF or ICSI. In vitro fertilization (IVF) literally means "fertilization outside the human body" or, in broader terms, in the laboratory. This term applies to any form of assisted conception where fertilization takes place outside the body.
When patients can be advised for IVF
1) Endometriosis
2) Tubo-peritoneal disturbances
3) Pelvic adhesions
4) PCOD
5) Unexplained infertility
6) Repeated failures of IUI Treatments
7) Male infertility (Oligozoospermia, Asthenozoospermia, Teratozoospermia etc.)
 
Treatment involves medications over several days to stimulate egg production and prepare the womb to receive embryos, the eggs are collected from the female partner by doing a minor surgical procedure. Eggs are inseminated with sperm and then embryos are cultured in the laboratory, of which one or two are transferred to a woman’s womb. Any remaining embryos will be frozen for possible use in later treatment cycles.
In vitro fertilization (IVF) literally means "fertilization outside the human body" or, in broader terms, in the laboratory. This term applies to any form of assisted conception where fertilization takes place outside the body.
The initial screening would cover hormone estimations such as a serum FSH, LH, Prolactin, FT3, FT4, Insulin, Fasting blood sugar, Anti mullerian antibodies, Anti ovarian Antibody, Inhibin and TSH. Also, a Transvaginal ultrasound to diagnose any ovarian cysts, submucous fibroids, endometrial polyps, chocolate cysts and hydrosalpinges which would require a surgical correction prior to IVF. Priliminary haematological study should be done for the medical fitness of Mother and Father such as CBC, grouping and Rh typing, Fasting Sugar, HIV, Hepatitis B & C, HbSAg, VDRL, Thalassemia and detail study of semen analysis to know the morphology, count, motility which would help in selecting between IVF & ICSI.
The next basic step after recruitment would be selection of the ideal ovarian stimulation protocol.
 
Controlled ovarian stimulation
This involves a series of hormone injections to encourage the ovaries to produce more eggs than usual. You can have these injections either at our clinic if you stay in the vicinity or from your general practitioner or you could have a nurse or clinic assistant to come and inject you at home or we could teach your husband how to give the injections OR YOU COULD SELF INJECT.
The common drugs which would be prescribed to you are as follows:
GnRH-agonist (gonadotropin releasing hormone agonist) or a GnRH-antagonist (e.g. Cetrotide / Ganirelix) to prevent release of the eggs before doctor can retrieve theFSH (Follicle stimulating hormone) or hMG (Human menopausal gonadotropin) to stimulate development of multiple follicles
HCG (Human chorionic gonadotropin) to trigger the rupture of the eggs in the follicles.
Pre-mature LH Surge can be prevented by giving Agonist or Antagonist. The purpose of the GnRH-agonist (or antagonist) is to suppress release of LH (luteinizing hormone) from the woman's pituitary gland during the ovarian stimulation process. The purpose of the FSH product is to stimulate development of multiple follicles (structures that contain eggs) in the ovaries.
Every month, as you approach ovulation, a number of follicles begin to mature (exactly how many varies, and depends on your age). Usually, the follicle that is mature first is ovulated, and all the other developing follicles shrink away and are lost in a process call atresia. When you are on the hormone treatment, most or all these developing eggs are allowed to continue growing until a number of them have reached maturity. In this way, we can make use of eggs that would have otherwise been wasted, without using up your egg reserve any faster. Thus, there is no need to fear early menopause because of these treatments. Throughout the stimulation period, you will need to visit us for ultrasound monitoring and sometimes blood hormone levels like estradiol. This will help us know when there are enough follicles that are mature enough for us to go ahead with the "egg pick-up".
   
Collecting the eggs
Initially during stimulation protocol, the size of the eggs and total number is judged by TVS (Trans Vaginal Ultrasonography). The Ovum pick-up is performed under Short General Anesthesia through the trans vaginal approach. A trans vaginal probe with the needle guided with ultrasound is used to retrieve the eggs with the suction. At the same time, the quality and quantity of the eggs are scanned by the Embryologist in the adjacent embryology laboratory.
   
Collecting the sperm
Atleast 2 semen samples of husband is store at our Sperm bank prior to Ovum Pick Up so that even if husband fails to give the fresh sample on the day of pick up, we can use the frozen semen sample of your husband.
On the day of Pick up the fresh sample is preferable. Sperm collection can be done in one of our special, very private collection rooms. Or you can choose the option of getting sample from home itself provided you stay nearby and can get sample within half an hour after ejaculation.
   
Fertilization
The procedure of ICSI and IVF is done at our Embryology lab by our team of expert Embryologist with using internationally accepted imported COOK Media. The prepared sperm and eggs are combined in a glass dish filled with a nutritive medium. The eggs are then left in an incubator overnight. The next day, the eggs are checked for signs of fertilization. You can tell the difference between a fertilized egg and an unfertilized egg by two faint spheres visible in an egg after fertilization.
These two spheres (pronuclei) hold the DNA of the sperm and the egg, and will fuse to form the nucleus of the embryo (called syngamy). The fertilized eggs will be left to grow for several days in the laboratory. The embryos grow in the special mini-incubators (Mink, Cook, Australia) that hold only 4 culture dishes, so that your embryos are not disturbed every time someone else's embryos are checked on, as they would be in the traditional bigger incubators. The embryologist will record how many eggs are successfully developing, and two or three of the embryos will be chosen for the embryo transfer. Remaining good quality embryos can be 'frozen' for future use if you wish.
By the time the embryo is transferred, it consists of at least 2 to 8 cells, surrounded by a soft "shell" (the zona pellucida). After the transfer, the growing embryo will need to hatch out of the zona pellucida to implant in the lining of the uterus.
   
Embryo transfer
The embryo transfer is a very skilled procedure which may or may not require anaesthesia or sedation. The embryos are kept in the laboratory until you are ready for the procedure. The embryos are picked up with special double channel catheter. This is carefully guided through the cervix, and a thin soft tube that will not damage the lining of the uterus is advanced inside the uterine cavity under Ultrasound guide, and the embryos are deposited there
   
After the transfer
To build up endometrium for the implantation to occur we advocate progesterone in the form of deep intramuscular injection/oral progesterone formulation/ vaginal gel or suppositories.
12 days after Embryo Transfer procedure, B-hcG test is preferred for the confirmation of pregnancy.
   
Blastocyst transfer
Blastocyst transfer is transfer of an embryo on the day 5 from ovum pick up(IVF/ICSI). Blastocyst transfer is more favourable for implantation as it offers selection of best quality embryo than day3 transfer. Embryo development occurs as follow:
The first week…
After the sperm enters the ovum, the sperm head \enlarges to form the male pronucleus. Within 24 hours, two small spheres, called the pronuclei, can be seen in the cytoplasm of the egg. These contain the genetic material from the mother and the father. When the two pronuclei fuse, joining the DNA from both parents together, fertilization is complete. As the pre-embryo grows, it undergoes cleavage, where the cell divides into smaller cells call blastomeres. After 2 days, the embryo will consist of 4-8 blastomeres. After about 3 days, when the embryo consists of 12-16 blastomeres, the cells begin to compact, forming a morula. This is the stage at which the embryo would normally enter the uterus, where it floats for a day or two before attaching to the lining of the uterus.
During those two days, huge changes in the embryo's appearance can be seen, as the cells begin to differentiate into those that will become the fetus, and those forming the amniotic sac and placenta. These changes are characterized by the formation of a cavity in the morula, to create a blastocyst.
After 4 or 5 days the embryo "hatches" out of the outer shell of the egg, the zona pellucida, and the blastocyst is able to attach to the endometrium. By Day 7, the embryo has completely implanted in the lining of the uterus.
   
Why have a blastocyst transfer?
Blastocyst transfer is done when there is previous history of implantation failure with day 3 embryo. At this stage, the embryologists can have a better idea of which embryos are most likely to be healthy and continue to develop. Of course, there are still many stages of development that the embryo must pass through to create a successful pregnancy, but choosing the healthiest day5 embryos and transferring them just before they would normally implant has given us the best success rates yet. Modern trend of embryo transfer is single blastocyst transfer to achieve the high success rates.
   
Freezing blastocysts
Normally "spare" embryos are frozen at the 4-8 cell stage, and provide good results when transferred after thawing. We are now able to successfully freeze and thaw blastocysts.
   
Laser Assisted Hatching
May be required if the egg has a very thick outer coat
   
How is assisted hatching performed?
The embryo is held with a specialized holding pipette.
Multiple point can be decided and fire with the laser to create a rough area on the zona pellucida which favours the implantation in older patients/patients with repeated implantation failure.
The embryo is then washed and put back in culture incubator.
The embryo transfer procedure is done shortly after the hatching procedure. Embryo transfer places the embryos in the woman's uterus where they will hopefully implant and develop to result in a live birth.
   
What about Bed rest?
After the Embryo transfer, the two comparative studies shown that, mobilisation of patients after Embryo Transfer has got less implantation rate than couples who have had 48hrs stay in the hospital. later on we advise minimum work at home, avoid lifting of heavy weights, long drive, intercourse and strenuous exercise.
   
What should I expect from the IVF cycle?
The success rate of IVF in any of the best centers in the world is around 30-40%, cumulative pregnancy rate is around 60-70%.
   



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Dr. Ashok H. Shivdikar
Shivdikar Hospital & Fertility clinic
Shivdikar building No. 28-A, J.B. Road,
Opp. Shirodkar Market, Parel (East), Mumbai- 400 012

 
 
     
          
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