What is IVF?

In-Vitro Fertilization (IVF) is one part of specialised infertility treatment. In the last 30 years it has already helped millions of people who had problems with fertility.

 

The earliest generation of IVF was simply putting an egg and sperms together in a laboratory environment for fertilization and then transferring to the patient. However, the success rate was limited due to its poor understanding of the importance of the stimulation on egg quality, preparation of the sperm and appropriate fertilization techniques.

 

Intra-cytoplasmic Sperm Injection (ICSI) is the advanced technology which allows selection and the direct injection of a sperm into the egg and so improving the success of fertilization considerably — especially cases with sperm disorders.

 

LaVida is adopting the latest IVF technologies which include Preimplantation Genetic Testing (previously called PGD/PGS) with Next Generation Sequencing (NGS). These technologies enhance implantation rates, reduce spontaneous abortions to increase ongoing pregnancy and final birth rates, just as important, they provide best opportunity in minimizing the risk of conceiving babies with genetic disorders.

An IVF cycle begins with a comprehensive health check and an in-depth consultation to ascertain the best program for treatment. Next is a prescription to boost egg quantity. Following oocyte retrieval and sperm collection, embryos are created in the laboratory. Several days later after embryo growth and development, the cycle ends with an embryo transfer and finally a pregnancy test. The time frame will depend on medication selection and whether the specialist has determined whether a “long protocol” or “short protocol” is most appropriate for you.

 

A long protocol could take up to two months and may be indicated by special clinical conditions.

 

A short protocol is a result of technological advancement and it takes just two to three weeks. The short protocol reduces physical and mental burden to the patient, so it is widely adopted by IVF clinics across the globe.

 

Step 1: The IVF cycle before treatment

 

The menstrual cycle before your actual IVF treatment is selected and marks the beginning of the treatment; you may be put on control pills or may start taking a GnRH antagonist or a GnRH agonist. This is so the specialist can have complete control over ovulation once your IVF treatment cycle begins.

 

Step 2: Periods during IVF treatment

 

The first day of your IVF treatment cycle is the day when you get your period. You should have arrived in Bangkok by that day.

 

On the second day of your periods, you will have to visit LaVida according to your appointment time. Your Doctor will order a blood test and an ultrasound. This is referred to as your baseline blood test and your baseline ultrasound. Blood tests include hormone tests and screening for selected infectious diseases — HIV, Hepatitis A and Hepatitis B etc.

 

In your blood test, your doctor will be looking at your hormone levels, specifically your E2. This is to make sure your ovaries are “sleeping”, the intended effect of the shots or GnRH antagonist. The ultrasound is to check the size of your ovaries, and follicle size.

 

Step 3: Ovarian Stimulation and Monitoring as a part of IVF treatment

 

If your blood test and ultrasound look normal, the next step in the IVF treatment is ovarian stimulation with fertility drugs and its monitoring. Depending on your IVF treatment protocol, this may mean anywhere from one to several shots every day, for about a week to 10 days.

 

GnRH agonists are injectables which could be self-administered. Our nurses will teach you how to give yourself the injections as well as providing tips and instructions.

 

If you don’t want to inject by yourself, you can make appointment to visit LaVida, and our nurses will help in injection execution.

 

During ovarian stimulation, your doctor will monitor the growth and development of the follicles. At first, this may include blood test every few days, to monitor your hormone levels, and ultrasounds, to monitor the oocyte growth. Monitoring the IVF treatment cycle is important. These parameters provide important and valuable information for your doctor, especially on decisions related to dosage adjustment.

 

Step 4: Final Oocyte Maturation in IVF treatment

 

The next step in your IVF treatment is triggering the oocyte to go through the last stage of maturation, before they can be picked up. This last growth is triggered with a special injection (Trigger shot). Timing this shot is vital. If it is given too early, the eggs will not have matured enough. If given too late, the eggs may be “too old” and would not fertilize properly. The daily ultrasounds at the end of the last ovarian stimulation step are meant to time this trigger shot just right. Usually, the injection is given when two or more follicles have grown to be 18 to 20mm in size and your hormone levels are greater than 2,000pg/ML. This shot is typically a one-time injection. The timing of the shot will be based both on your ultrasounds and blood test and enables us to schedule your retrieval.

 

Follicle growth and IVF treatment

 

If not enough follicles grow or if you are at risk for severe ovarian hyperstimulation syndrome (OHSS), your IVF treatment cycle may be cancelled. If the IVF treatment is cancelled because your ovaries did not respond well to the medications, your doctor may recommend different medications to be tried on the next treatment cycle. While not common, an IVF treatment cycle can also be cancelled if ovulation occurs before retrieval can take place. Once the eggs ovulate on their own, they cannot be retrieved. IVF treatment cancellation happens in 10 to 20% of cycles. The chance of cancellation rises with age, with those above age 35 more likely to experience IVF treatment cancellation.

 

Step 5: Egg retrieval or Ovum pick up

 

About 34 to 36 hours after you receive the trigger shot, the egg retrieval or ovum pick up will take place. This is yet another important step in IVF treatment. It is normal to be nervous about the procedure, but most women go through it without much trouble or pain.

 

Before egg retrieval

 

Before the egg retrieval, an anaesthesiologist will give you some medication intravenously to help you feel relaxed and pain free. Short general anaesthesia, is generally used at LaVida for egg retrieval. Side effects and complications are less common.

 

Once the medications take their effect, your doctor will use a trans-vaginal ultrasound to guide a needle through the back wall of your vagina, up to your ovaries. The doctor will then use the needle to aspirate the follicle(s), by gently sucking the fluid and oocyte from the follicle into the needle. There is one oocyte per follicle. These oocytes will be transferred to our laboratory for examination and fertilization.

 

The number of oocytes retrieved varies but can usually be estimated, via ultrasound, before egg retrieval.

 

After oocyte pick up

 

After the retrieval procedure, you will be resting in the recovery area for a few hours to make sure all is well. Light spotting after the procedure is common, as well as some lower abdominal cramping, but most feel better in a day or so after the egg retrieval procedure and so this is nothing to be overly concerned with. You will also be told to watch for any signs of ovarian hyper stimulation syndrome (OHSS), a side effect from fertility drug use during IVF treatment — modern treatments have reduced the incidence of this condition and it now occurs in less than 10% of patients.

 

Step 6: Egg Fertilization – IVF treatment step

 

While you are at home recovering from the egg retrieval, the follicles that were aspirated will be searched for oocytes, (eggs) for fertilization. Not every follicle will contain an oocyte. Once the oocytes are found, they will be evaluated by the embryologist. If the eggs are overly mature, egg fertilization may not be successful. If they are not mature enough, the embryologists may be able to stimulate them to maturity in the laboratory. The egg fertilization in the IVF treatment procedure has some advanced techniques, which will ensure high egg fertilization chances.

 

Semen collection by your partner

 

Fertilization of the oocytes must happen within a few hours of pickup- typically within 4-6 hours but success has also been seen if fertilization is within 12 to 24 hours. Your partner will likely provide a semen sample the same morning you have the retrieval. The stress of the day can make it difficult for some, and so just in case, your partner may come to LaVida to collect semen and freeze the sperms for backup earlier in the IVF treatment cycle. This sample could be thawed on day of the retrieval in case a fresh semen sample could not be collected.

 

When the semen sample is ready, it will be put through a special washing process, which separates the sperm from the other stuff that is found in semen. ICSI will then be performed. The embryologist will choose a healthy-looking sperm and inseminate the oocyte with the sperm using a special thin needle.

 

The culture dishes are kept in a special incubator, and after 17-21 hours, they are inspected for signs of egg fertilization.

 

Step 7: Embryo Transfer and IVF treatment

 

Several days after the retrieval, the fertilized eggs will develop into embryos. These embryos could be transferred fresh on Day 3 or Day 5. If Pre-Implantation Genetic Testing (PGT) is required, biopsy will be performed and related embryos would have to be frozen to wait for the test results. Your Doctor will then choose only healthy embryos for transfer when the endometrium is ready for transfer – usually in the next menstrual cycle, typically 28 days later.

 

Embryo transfer is straightforward and generally anesthesia is not needed. Ultrasound guidance is essential in order to locate the best spot for the embryo to be positioned.

 

For the embryo transfer, a thin tube, or catheter, will be passed through your cervix. You may experience very light cramping but nothing more than that. Through the catheter, they will transfer the embryos, along with a small amount of growth fluid.

 

The number of embryos transferred will depend on the quality of the embryos, previous discussion with your doctor and result from PGT.

 

After the transfer, you will stay lying down for a short time and then you can head back home.

 

If there are high quality embryos left over, you may be able to freeze them. This is called “embryo cryopreservation.” They can be used later if the current IVF treatment cycle is not successful or another pregnancy attempt is wanted.

 

You are advised to avoid excessively strenuous exercises after embryo transfer. Reducing unnecessary daily activities may be recommended in some instances in order to improve the likelihood of successful implantation.

 

Step 8: Luteal Support

 

On or after the day of your egg retrieval, and before the embryo transfer, you will start giving yourself medicine supplements that will maintain the receptivity of the endometrium. Usually, the supplements are given as as oral medications, vaginal gel or a vaginal suppository.

 

Besides the supplement and transfer, there really isn’t much going on for the 10 days following pickup. In some ways, the next 10 days after the embryo transfer may be more difficult emotionally than the two weeks of actual IVF treatment.

 

During the previous IVF treatment steps, you were required to visit your doctor perhaps every other day. Now, after embryo transfer, there will be a sudden lull in activity.

 

You don’t have to stay in Bangkok for the 10 days following embryo transfer. You may choose to fly back to your home country after embryo transfer — whenever you feel secure of your own condition.

 

Step 9: Pregnancy test and follow up after IVF treatment

 

10 days after the embryo transfer, a pregnancy test and follow up is ordered as the next step of the IVF treatment. This is usually a serum pregnancy test. The test may need to be repeated according to doctor’s advice.

 

If the pregnancy test is positive, you may need to keep taking the supplementation for another several weeks. Follow up comprises occasional blood tests and finally ultrasounds to monitor the pregnancy and watch for any unusual events.

 

On demand, LaVida offers you additional consultation and support.

 

After birth LaVida will be glad to have a meeting with you and your baby and a review of your experiences during the IVF treatment.

What is Pre-Implantation Genetic Diagnosis (PGD) or Pre-Implantation Genetic Screening (PGS)

 

Preimplantation genetic screening / preimplantation genetic diagnosis (PGS / PGD) is a technique that allows you to increase the effectiveness of ART programs (IVF) through the selection of embryos free of genetic disease.

 

Both PGD and PGS utilize Next Generation Sequencing (NGS) technology to evaluate the copy of the number of the 23 pairs of chromosomes, micro-deletions as well as genetic disorders The advantage of PGD/PGS is to avoid selective termination of pregnancy as it makes transfer an embryo free of the genetic disease possible.

 

Pre-Implantation Genetic Diagnosis (PGD) identifies the embryo which does not carry the targeted genetic mutation for intrauterine transfer

  • Avoid selective early pregnancy termination due to the inheritance of the patient’s disease gene
  • Lower the chance of passing inheritable diseases to the next generation, for example, Thalassemia, Sickle Cell Anemia, Cystic Fibrosis, Hemophilia etc.  

 

Pre-Implantation Genetic Screening (PGS) identifies chromosomally normal embryos for intrauterine transfer.  When an embryo carries an incorrect number of chromosomes, it will often fail to implant or will result in an early miscarriage.

 

However, some pregnancy with chromosomal abnormality can survive to term, for example, trisomy 21 (Down syndrome), which is a result of gaining an extra chromosome 21; and Turner’s syndrome, which is a result of one normal X chromosome existing in a female’s cells and the other sex chromosome missing.

 

  • Improved implantation rate in those with repeated implantation failure  
  • Reduced risk of miscarriage in those with recurrent miscarriage  
  • Reduced risk of birth defects
  • Single embryos transfer, which reduces the risk of multiple pregnancies
  • Increased chance of delivering a healthy baby

 

Knowing this, the patient has additional information for decision.

 

How PGD/PGS is carried out?

 

On Day 3 of development, one cell is taken out of every embryo; or alternatively, on Day 5 of development, a few cells are taken out of every embryo for testing.

 

The biopsied cell will be analysed while the embryo continues to grow.  Results will usually be available within a few days.  Express service is available on request with results coming out in 24 to 48 hours.   Normal embryos can be transferred or cryopreserved.

Who may benefit from PGD/PGS?

 

PGD by molecular technique may be beneficial to patients who know  (or do not know) to be carriers of defects like a monogenic disease or a balanced chromosomal translocation and who want to be sure their baby will be healthy.

 

PGS is the most advanced testing procedure.  

Based on published data, patients with the following may benefit:

  • Advanced maternal age (age 38 or above)
  • Recurrent miscarriages
  • Repeated implantation failure
  • Severe male factor infertility  

 

For further information about PGD, please click HERE

For further information about PGS, please click HERE

For further information about NGS, please click HERE

Next Generation Sequencing (NGS) is used as a part of in vitro fertilization and provides comprehensive information concerning embryo’s DNA for diseases or genetic mutations. It provides physicians with a unique opportunity to help couples who are exposed to an increased risk of genetic abnormalities in the foetus. This is the first solution of this kind in the world.

Innovative possibilities of the NGS method in preimplantation genetic diagnosis

 

  • High accuracy in research
    • Accuracy of research: analysis of all 24 chromosomes at the same time shows an accuracy of more than 99.9% (higher accuracy if compared to the aCGH method).
    • Sensitivity research: direct reading (decoding) of the genetic information encoded in the DNA of the embryo.
  • Greater possibilities for the analysis of the embryo’s genome – the possibility of combining the research of chromosomal and monogenic diseases in a single analysis.
  • Safety of the embryo – only one embryo biopsy for the diagnosis of chromosomal and monogenic diseases.
  • Greater automation of the process – avoiding any mistakes from the moment of receiving material from the embryo.

 

Benefits of the NGS method in preimplantation genetic diagnosis

 

  • Analysis of all 24 chromosomes simultaneously with the highest accuracy compared to other methods.
  • Increasing of accuracy for the diagnosis of mosaic aneuploidies.
  • Possibility to distinguish a balanced set of chromosomes from a normal one.
  • Possibility to detect uniparental disomy (by analysis of samples of the parents).
  • Identification of haploid and triploid.
  • Possibility to identify the micro and macro rearrangements (5 bp).
  • Simultaneous diagnosis of chromosomal and monogenic diseases as well as other mutations.
  • Prospect of excluding a variety of pathogenic mutations in the future of the children, including screening couples with infertility, sperm and oocyte donors, and possibly even all people (for example cystic fibrosis, autism, intellectual disabilities, spinal-muscular atrophy, etc. to infinity).
  • The tendency in the long term to reduce the cost, repeating in the approximation the law of Murr for semiconductors.

Vitrification

In the fertility world, vitrification is used for cryopreservation of eggs, embryos, and sperm. Generally speaking, vitrification is a method of transforming something into a glass-like substance.

The word “vitrification” comes from the Latin term for glass, vitrum. Vitrification is the process of freezing so rapidly that that the water molecules don’t have time to form ice crystals, and instead instantaneously solidify into a glass-like structure. It’s a much more complicated practice than previous “slow freezing” methods, and it has yielded good results. Currently, pregnancy success rates from vitrification are comparable to fresh IVF cycles.  

Vitrification uses an extremely quick freezing rate (approximately 15,000°C/min) for near-instantaneous freezing. Furthermore, vitrification suspends cryopreserved samples in a crystalline lattice structure that does not have ice crystal formation as a side effect. Many studies have shown very minimal damage that is caused as a result of any vitrification process. Additionally, vitrification technology allows specimens to be stored indefinitely, with little or no negative impact on the length of time the sample is stored. Vitrification has shown extremely encouraging results.

 

For further information about Vitrification, please click HERE

 

Oocyte cryopreservation (Egg Freezing)

Human oocyte cryopreservation (Egg Freezing) is a procedure to preserve a woman’s eggs (oocytes). This technique was mainly developed to enable women who, due to studies or any other complication can´t deal with pregnancy during their most fertile years, to postpone their maternity until their personal situation is the right to form a family. Several studies have proven that most infertility problems are due to germ cell deterioration related to aging. Surprisingly, the uterus remains completely functional in most elderly women. This implies that the factor which needs to be preserved are the woman’s eggs. The eggs are extracted, frozen and stored. The intention of the procedure is that, in the future, the woman may choose to have the eggs thawed, fertilized, and transferred to the uterus as embryos to facilitate a pregnancy. The procedure’s success rate (being the chances of a live birth using frozen eggs) varies depending on the age of the woman, and range from 14.8 percent (if the eggs were extracted when the woman was 40) to 31.5 percent (if the eggs were extracted when the woman was 25).

 

For further information about Oocyte cryopreservation (Egg Freezing), please click HERE

 

Semen cryopreservation (Sperm Freezing)

Semen cryopreservation (Sperm Freezing) is a procedure to preserve sperm cells. Semen can be used successfully indefinitely after cryopreservation. For human sperm, the longest reported successful storage is 24 years.

 

It could be used for preserving patient’s fertility undergoing vasectomy or treatments that may compromise their fertility, such as chemotherapy, radiation therapy or surgery.

 

For further information about Semen cryopreservation (Sperm Freezing),

please click HERE

Embryo cryopreservation (Embryo Freezing)

Embryo cryopreservation is useful for leftover embryos after a cycle of in vitro fertilisation, as patients who fail to conceive may become pregnant using such embryos without having to go through a full IVF cycle. Or, if pregnancy occurred, they could return later for another pregnancy.

 

The main techniques used for embryo cryopreservation are vitrification versus slow programmable freezing (SPF). Studies indicate that vitrification is superior or equal to SPF in terms of survival and implantation rates. Vitrification appears to result in decreased risk of DNA damage than slow freezing.

For further information about Embryo cryopreservation (Embryo Freezing), please click HERE