Author: Shruti N Mane

Qualification – M.B.B.S, M.S (OBG), PG Diploma in ART AND Reproductive Medicine

Assisted Reproductive Technology (ART)  includes all fertility treatments incycle which either eggs or embryos are handled outside of the body.

In general,  ART procedures involve removing mature eggs from a woman’s ovaries using a needle under ultrasound guidance, combining the eggs with sperm in the laboratory, and returning the embryos to the woman’s uterus.

 The most commonly used types of ART treatmentsare – 

  • In vitro fertilization (IVF)
  • Intracytoplasmic sperm injection (ICSI)

What is IVF?

  •  Let’s start by defining IVF – in vitro means “in the lab” – you’ll also hear this process referred to as ‘lab assisted conception.’
  •  Initially IVF was only designed to treat tubal factor infertility but now it is a treatment of choice for many other causes of infertility that are refractory to more conservative treatments.
  • IVF is the most successful infertility treatment that can be offered due to its advancement in techniques in the last 20 years.
  • Women over 40 years may consider seeking more immediate evaluation and treatment.

Why do I need IVF ?

IVF is mostly indicated when infertility results from one or more causes having no more effective treatment.
  • Tubal causes:  In cases with blocked fallopian tubes, hydrosalpinx, damaged tubes. IVF is the best choice as compared to surgery.
  • Endometriosis: Ovarian endometriomas if operated will cause a decline in ovarian reserve, hence it is advised to consult a fertility doctor before any corrective surgeries.

  • PCOS,who have failed to respond to conventional ovulation induction , IVF can save the day.

  • Ovarian ageing: Increase in maternal age can lead to a diminished ovarian reserve . IVF helps to overcome the reduced ovarian function.

  • Male factor infertility :  In cases with azoospermia ( absence of sperms) ,   oligozoospermia ,severe oligoasthenoteratozoospermia.
  • When no cause of infertility is found .IVF is indicated if duration to infertility is 3 years or longer . If a woman is older than 36 years IVF may be considered early.     

What are the steps involved in an IVF Cycle:

IVF is a four step process:

  • Controlled Ovarian hyperstimulation
  • Oocyte retrieval
  • Oocyte insemination with the male gamete the sperm
  • Embryo transfer

 What do you mean by Controlled Ovarian hyperstimulation?

  •  The woman takes hormonal injections from day 2/3 of her cycle for an average period of 10-12 days to stimulate the production of additional eggs in the ovary .
  • The ovarian response to these injections is monitored through transvaginal ultrasound .
  • In a regular cycle, you tend only to release one or two eggs; for conventional IVF to work, you need plenty of eggs.
  • If you don’t want to take injectable medications, you can also consider minimal stimulation IVF (aka mini-IVF).
  • Once the majority of follicles(eggs) reach a size of 18mm a trigger agent is added.
  • The trigger agent (HCG or GnRH agonist) is decided by your clinician on the basis of your ovarian response and the ovarian stimulation protocol used .
  • The trigger agent helps in the final oocyte maturation prior to oocyte retrieval; it mimics the role of LH surge in a natural cycle .

When do you plan oocyte retrieval ?

  • The oocyte retrieval is scheduled 34-36 hrs from the time of administration of the trigger agent.
  • The doctor retrieves your eggs from your ovaries with a transvaginal ultrasound-guided needle under the effect of light anaesthesia.
  • The procedure usually takes about 15-20 mins

What are the steps of Oocyte retrieval:

  • Under the effect of anaesthesia , your vagina is cleaned thoroughly with normal saline
  • Betadine is not used as it is toxic to eggs.
  • The transvaginal probe is then placed in the vaginal cavity and the ovary and ovarian follicles are located .
  • The fluid is aspirated from the follicles with the help of a needle attached to a suction pump into a test tube.
  • The aspirated fluid is then examined by an embryologist under a microscope to identify the oocyte (eggs).
  • All follicles in both the ovaries are aspirated and examined.

What happens to the oocytes(eggs) after they are retrieved?

Once the eggs are aspirated (retrieved) they are placed in culture plates with nutrient media and then placed in the incubator. 

Are there any complications associated with oocyte retrieval?

The overall complication rate for an oocyte retrieval procedure is < 1%. Following are the possible complications with their incidence rates –

  • Vaginal bleeding – It can be seen in 1.4% cases, if the probe is rotated with the needle inside it can cause damage and tear to the vaginal and ovarian surface.
  • Intraperitoneal bleeding – It is a very rare complication seen in 0- 1% cases .
  • Infections – The risk is 0.2% -0.5 % as the vaginal flora is carried into the peritoneum with needle puncture.

What does Oocyte insemination mean?

Oocyte insemination is a process where the two gametes egg and sperm are united in the laboratory under suitable conditions for the process of fertilization.

It can be performed by two methods

  • Standard Insemination (IVF)
  • ICSI – Intracytoplasmic sperm injection.

The type of insemination method depends on the sperm concentration, motility and morphology
in the semen sample on the day of oocyte retrieval.

  • After assessing the semen sample for the sperm count, motility and morphology .
  • A total of 50,000 motile sperm are placed with the eggs in a petri-dish, which is then placed in the incubator.
  • Ideally, the sperm will fertilize at least some of the eggs and go on to become embryos.

When is ICSI used as a method of insemination?

  • If the sperm has mobility, shape, or count issues, doctors may recommend ICSI or intracytoplasmic sperm injection.
  • If the previous IVF cycle where standard insemination was used resulted in < 30% fertilization rate .

What is ICSI ?

  • Only one sperm is required to fertilize a single egg, realising this concept the method of ICSI was designed .
  • It involves injection of single sperm directly into the oocyte(egg) .
  • Fertilization rates after the use of this technique are between 60% -70%.
  • Now, ICSI has become the most widely used technique for the process of insemination in most of the fertility clinics worldwide.

What happens after insemination?

  • The morning after insemination (i.e. DAY 1) the eggs are examined under the microscope to determine whether fertilization has occurred .
  • Once the egg is fertilized it starts dividing and the stages of embryo development begin.
  • The embryos are assessed for their development, depending on their number, quality and rate of growth they may be cultured to day 3 or day 5.
  • Day 3 embryo is called a cleavage stage embryo and a Day 5 embryo is termed as blastocyst .
  • Depending on your case history, your clinician may plan a fresh or frozen embryo transfer for you.

When is embryo transfer performed?

  • Embryo transfer can be performed either on Day 3(cleavage stage embryo) or Day 5 (blastocyst stage).
  • If the transfer of embryos is performed in the subsequent cycle after oocyte retrieval it is termed as a frozen -thawed embryo transfer as the embryos are cryopreserved or frozen until the transfer occurs.

Is Day 5 embryo transfer better than Day 3? Why?

  • On Day 3, good quality embryos are between 6 and 8 cells.
  • The advantage of selecting day 5 embryos is it provides additional time for selecting better quality embryos.
  • Only 50%-60% of embryos have the capability of developing into blastocyst and therefore fewer embryos are available for freezing and transfer.
  • Evidence suggests a higher implantation potential for blastocyst embryos(day 5) than day 3 embryos.

Why should I consider Day 3 embryo transfer?

  • In cases where fewer embryos are available for transfer it is advised to undergo a Day 3 transfer.
  • In such cases culturing the embryos to Day 5 may increase the risk of cycle cancellation as you may lose all embryos in the process .
  • The blastocyst culture environment is not suitable for all embryos , such embryos may do better in the uterus when transferred at the right time(Day3/Day2) than the incubator.

How successful are IVF cycles?

  • IVF can be successful, but it’s important to remember that it is a number game.
  • Chances of success increase with every successive IVF cycle .
  • However, as you age, IVF success rates decrease.
  • 35%-40% for women under 35
  • 30% for women aged 35 to 37
  • 23% for women aged 38 to 39
  • 10% for women aged 40 to 42
  • 3% for women aged 43 to 44
  • 2% for women aged over 44

Above success rates are for self IVF cycles .

What are the costs of IVF cycles in India?

  • Considering fertility treatment it’s important to understand costs and finance options.
  • The key message is that before you move forwards and say yes to treatment with a fertility clinic, it’s important for you to do your research.
  • We want you to completely understand that IVF is an accumulative process and no-one can assure that you will be successful on your first round.
  • On average, it can take 3 rounds of IVF to achieve a live birth. So, this is something to bear in mind if you are having to fund your IVF cycles yourself.
  • Fertility clinics in India offer IVF at deeply discounted rates when compared to other markets in the U.S. and Europe.
  • The average IVF cost for one cycle of IVF in India ranges from
    INR 1,50,000 to 3,50000 (approximately $1,317 to $4,610), but this does not include oral medications, testing, or additional procedures that may be required.

 In conclusion, the cause of infertility, although difficult to determine the above mentioned key indicators, significantly help couples know their chances of conception. To know more causes, evaluation and treatment of infertility consult with IVF Specialists at Motherhood Fertility & IVF Centre by calling 08067238900 or book an appointment with us.

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