10 things you should know about IVF

1.Infertility is not uncommon

For many people, learning that they are infertile means they will not ever have the biological child they have been hoping for. It is a great loss that many people grieve for years. This is not just for female infertility but also for males who learn they are infertile. It is a common misperception that infertility is a women’s issue. In fact, men and women are diagnosed with infertility in equal numbers. An infertility diagnosis can feel like a blow to your whole life plan or what you thought your life was going to be. All of a sudden you have to re-evaluate and adjust to a new goal of medical testing and treatment with no guaranteed outcome. This can lead to feeling overwhelmed and out of control. Grief and depression are common, the diagnosis of infertility may cause a loss of interest in sexual activity and can lead to problems in your relationship. It is important to recognize the emotional impact infertility has on your life and seek medical help.

People often feel isolated and lonely when they are diagnosed with infertility. It is not uncommon for them to avoid friends and family members who are pregnant or who have children. They feel as though others can’t understand their sadness. People diagnosed with infertility have a profound need for support.

2.Conventional IVF can be very time consuming

At roughly 36 hours after the HCG is given, the eggs will have matured and will be ready to be collected. However, if the timing is not exact, the eggs may drift away from the ovary and be irretrievable. The egg retrieval is a surgical procedure performed under sedation and involves a needle being inserted through the vaginal wall to the ovaries in order to aspirate the eggs from the follicles. The average number of eggs collected in a conventional IVF cycle is roughly 10-15. The egg retrieval is usually not very painful, and women generally recover quickly from the procedure. On the day of the egg retrieval, the male partner will need to provide a semen sample. This may be done at home, and the sample is then brought to the clinic. The sample may also be produced at the clinic through masturbation. The production of a sperm sample on the day of the egg retrieval can sometimes be difficult for the male partner who may feel under pressure.

Conventional IVF requires the female partner to take a series of daily hormonal medications to cease the normal function of the ovaries and to stimulate her ovaries to produce multiple eggs. Monitoring visits, which include transvaginal ultrasounds and blood tests, are then performed to monitor the progress of the egg development and to determine the precise timing of the egg retrieval. The transvaginal ultrasound is done by using an ultrasound probe which is inserted into the vagina. This produces a much clearer picture of the ovaries as it is much closer to the pelvic organs, thus providing a more precise assessment of the ovaries and uterus. When the monitoring indicates that the eggs are mature, an HCG injection is given 36 hours prior to the egg retrieval so that the eggs will be at the right stage of development. The precise timing for the egg retrieval is very important.

3.There are different types of IVF available

IVF may be carried out in a number of ways, depending on the clinic. Different methods have different advantages and disadvantages for individuals, and you should discuss the various options with your doctor. The main types of IVF are:

• Natural cycle IVF – no fertility drugs are used; only one egg is collected;
• Mini-stim IVF – lower doses of fertility drugs are used to produce just 3-5 eggs;

Natural cycle and mini-stim IVF are predominantly offered to women with blocked or damaged fallopian tubes. Tubes which are blocked or damaged prevent natural conception by sperm and egg, and are also a risk to the health of a pregnancy. Since the number of eggs collected from these treatments is low, they are less suitable for women with other infertility diagnoses due to the lower pregnancy rates. These methods are also not suitable for women with unexplained infertility, or severe male factor infertility. For example, in one study, IVF success rates for couples with unexplained infertility were half those of the general IVF population with normal egg numbers and quality. The reason for this is thought to be because the small number of eggs retrieved from natural or mini-stim IVF in these cases does not give a high enough chance of collecting a good quality embryo.

4.The price may be more than the cycle cost

The cost of one cycle of IVF can be much higher than you might expect. Apart from the treatment itself, there may be extra charges for drugs, tests, and consultations.  You might not also consider that you will need to take a considerable amount of time off work, especially if you experience side effects such as Ovarian Hyperstimulation Syndrome. The emotional cost should also be considered; deciding to take a break from treatment or to stop altogether as a result of the stress, anxiety, or depression that infertility can bring can be very difficult. Money can sometimes be refunded for cycles of IVF that have been funded by health insurance if the treatment has not been successful.

Studies have suggested that taking a course of IVF can result in an increased chance of a multiple birth due to the implantation of more than one embryo in the hope that it will increase the chances of conception. However, this can lead to complications during pregnancy and birth, resulting in a longer stay in the hospital for both the mother and the babies and the need for further medical care. This can be an added cost to what is already an expensive treatment.

5.Age matters

Women with normal ovarian response and a good number of quality eggs but have been trying to conceive and have not been successful for 12 consecutive months are diagnosed as being infertile. This is the same diagnosis for women 35 and older who have had 6 months of trying without success. This does not mean that a woman 35 can’t conceive with her own eggs, but a diagnosis is necessary to compare the success rates for each group. Success rates compared with the ability to use a donor egg to that of the woman’s own egg is another issue which has its own factor. Whether or not to use a donor egg will depend on that particular woman, but the comparison of success rates can be measured with the woman’s age. Success rates drop after the age of 35 and are very low after age 37 with the use of that woman’s own egg. This is primarily due to the age-related increase of chromosomal abnormalities in the eggs. Higher rates of miscarriage and chromosomally abnormal conceptions often result in no pregnancy at all or the birth of a child with mental or physical disabilities. These risks, of course, would outweigh the success of IVF and are also incentives for older women to use donor eggs. High success rates and no risks of genetic complications with the child are the reasons for comparing using a donor egg to that of the woman’s own egg. Coming back to the comparison of success rates with the ability to use a donor egg, the success of a woman under 35 using a donor egg is higher than that of her own egg at any age, and the success of a woman over 35 using a donor egg is higher than that of her own egg at the same age. With each scenario, the comparison of the two success rates would be its own factor, but the general trend can be compared to the age factor.

6.Success rates can be misleading

The introduction of the age cut-off has the effect of creating two tiers of patient population, which in turn creates a selection bias on the comparison of success rates between different clinics. A lower age cut-off will raise the average age of the patient population. The clinic will naturally have a higher success rate. However, this does not mean that the infertile couple with the older female partner will have a better chance of having a baby at the clinic with the same live birth rate. As the couples’ expected success rate would be above what could be obtained at a higher success rate clinic with an older patient population.

A very important consideration with regard to realistic success rates is the age distribution of the population of patients being assessed. In an effort to improve their success rate, many clinics have introduced stringent age cut-offs beyond which patients will no longer be offered treatment. This is a safeguarding measure to protect patients from undergoing costly treatment with very little chance of success, and while it is appropriate in some situations, an arbitrary age cut-off discriminates against many older patients who would still stand to obtain good benefit from treatment.

7.You may need more than one cycle of treatment

People vary in their response to treatment. Younger women with more healthy eggs in their ovaries will respond better. Donor eggs are sometimes recommended for women who have an extremely poor chance of success with their own eggs. Your doctor will be able to advise you on the chances of success with further treatment using your own eggs.

There is considerable debate among doctors as to how many cycles of IVF a couple should try if the treatment is not successful. The cumulative chances of success appear to tail off after four or five cycles, but there is evidence to show that pregnancies do occur, even in women who have been trying treatment for many years. It is generally recommended that couples do not go on trying treatment indefinitely without success and that a decision to stop should be made after careful thought and discussion with the doctor.

A failed IVF attempt can still be a useful diagnostic tool. If the embryos appeared to be of good quality, and your uterus and fallopian tubes were shown to be normal at laparoscopy, then there may be a problem with the endometrial lining. If poor quality embryos were seen it may be a sign of oocyte (egg) or sperm problem, and the doctor may recommend more basic science investigations to try and find the cause of the problem. In some cases a specific problem is found, and with correction of the problem, successful treatment can be achieved.

8.Frozen is just as good as fresh

For the first time in the history of IVF, it has been shown that a frozen embryo, stored and then thawed for use at a later date, is just as good as a fresh embryo for establishing a pregnancy in a large randomized study of over 1500 women. This conclusion challenges practices used since the inception of IVF roughly 25 years ago. Researchers enrolled women who were about to begin IVF. After an egg was fertilized, each woman was randomly assigned to have two or three fresh embryos transferred to the uterus within a few days, or to have all the embryos frozen and transferred to the uterus later. Blood tests were done to compare pregnancy and delivery rates. The results of this trial will have huge implications for the way IVF cycles are conducted and will put to rest the long-standing practice of transferring multiple fresh embryos to avoid the low survival rates of frozen storage. Dual stimulation technique was first developed in an attempt to reduce the number of twins associated with IVF. This method allows for two cycles of egg harvest and the freed up opportunity to freeze all the embryos.

9.You are more likely to have a multiple pregnancy with IVF

Multiple pregnancies are much less common in natural conceptions because nature has a way of making sure that only one baby is conceived at a time. Around one in three IVF pregnancies is a multiple pregnancy. Twin pregnancies have a much higher risk of complications and the babies are more likely to be born early, be small or have problems at birth. Triplets and other higher multiple pregnancies are risky for the babies and often result in miscarriage. Because of the risks associated with multiple pregnancies, fertility doctors are encouraged to only replace one embryo into the womb and an increasing number of clinics in the UK now have a policy of only transferring one embryo. This is to reduce the number of multiple pregnancies and the associated health risks. This may mean that it will take longer for you to get pregnant. Although the multiple pregnancy rate is around 25% of women who have IVF treatment, the overall chance of still having a baby is higher with one embryo transfer over two.

10.There are lots of additional techniques available

Andrology – the study of male-specific health diseases and male healthcare. Often, IVF is pushed towards the female partner when difficulty in conceiving can be attributed to the male. This may be because semen analysis tests at GP level are not accurate, and it is known to be a sensitive subject for a male who may not want others to know of his problem. With new technology, it is possible for the man to take medication to produce more sperm or more viable sperm. Any new viable sperm may also be frozen for future use with ICSI. This may also increase the chances of natural conception.

Time lapse technology – Embryos will be formed over the course of 5 days. At present, they are observed on day 1, 2, or day 3 and then again if they have made it to day 5. Research has shown that embryos splitting from 1 to 2 or 2 to 4 cells should be in an incubator for 2 days and 1 day respectively, as it is the equivalent of the ball of cells in the fallopian tube and that it would have just reached the uterus. This technology takes images of the embryos every 10-15 minutes and compiles a video of the development. This information is then used to determine the best possible embryo(s) for transfer and any additional good quality embryos to be frozen. In turn, this will increase the chances of pregnancy in that cycle and also offer the opportunity for multiple pregnancies from a single transfer at a later date. This technology is known to be safer than the previous method of removing embryos from the incubator to be observed, as it demonstrates embryos do not need to leave the incubator from the time of egg collection until the time of transfer.

AHM – Anti-Mullarian Hormone is released by a small sack on the surface of the ovary. The AMH level is now known to be a good indicator of the quantity of eggs available. It is used to determine and maximize dosages of fertility drugs at a time that is suitable for eggs to be retrieved. By doing this, it is possible to decrease the risk of cycle cancellation and may also increase the chances of pregnancy in that cycle. These new techniques have been developed to try and enhance success rates, as well as decrease risks of multiple pregnancies.