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In-vitro Fertilization (IVF)

Basically, In-vitro Fertilization consists of putting the eggs and the sperm in contact in the lab. It is precisely called in vitro because it is a process that takes place in the lab, outside the female body. The fertilized eggs produce embryos that are transferred into the uterus where they are to continue their development and implant.

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Ovarian stimulation

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One reason why pregnancy chances increase in In Vitro fertilization is the availability of several eggs in the same cycle. This optimizes the process and boosts the possibilities of generating embryos. A higher number of embryos will, in turn, allow for the selection of those with best quality thus increasing the implantation rates.

To obtain more than one egg, which is otehrwise normal in a natural menstrual cycle, hormones are used to stimulate the ovary. The doses are individualized according to certain parametres, like body mass index (BMI), female age, hormonal results in the early follicular phase, ovarian morphology (preantral follicle count), previous response to stimulation -if any- and the expertise of our professionals.

The exhaustive control of the ovarian stimulation requires several ultrasound controls (3 or 4) to monitorize the response obtained in each case. The stimulation process normally lasts between 8 and 12 days. When the hormonal levels and the count and size of the eggs is optimal, a last medication, a hormone called human chorionic hormone (HCG) is administered to trigger egg maturation.

Egg retrieval (follicular puncture)

Egg retrieval or follicular puncture is performed in the operating room for outpatient surgery in the clinic under sedation, via intravaginal ultrasound monitoring, around 36 hours post HCG administration. The eggs are retrieved by puncturing the mature follicles and aspirating the follicular liquid where the egg is supposed to be.

The mean duration of this intervention is 15-20 minutes and is performed under anesthesia (deep sedation) to prevent patient discomfort.

The patient recovers very quickly and she is discharged home 1 or 2 hours later. The risk of complications during egg retrieval is 1 in 2.500 cases, so it is considered an insubstantial risk.

Invitro Fertilization Lab

Egg identification

The follicular fluids obtained during puncture are taken to the In Vitro Fertilization Lab where all the eggs are spotted and retrieved. They are placed in dishes with adequate culture medium duely identified and numbered into the incubator. The incubators keep them in an adequate atmosphere as regards temperature, humidity, proportion and purity of gases.

Semen preparation

The Andrology Lab processes the sample with the Sperm Capacitation Technique that best suits the quality of the sperm. This technique helps to select and aisolate the spermatozoa with the best motility, morphology and/or minor degree of DNA fragmentation.

Fertilization technique

There are mainly two methods that enable gamet fertilization (reproductive cells):

1) Conventional Fertilization: It entails placing the eggs inside the cumulus cells (the group of cells surrounding the egg) in the same medium with the previously treated sperm to let the gamets themselves perform the fertilization spontaneously. This technique requires a minimum concentration of sperm with good motility of 100.000 spermatozoa per milliliter and per oocyte.

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2) Intra Citoplasmatic Sperm Injection – ICSI: It consists of inserting a single sperm directly into a mature oocyte by means of micromanipulation. In this case, only one motile sperm is needed per each mature oocyte, therefore, this technique can be applied in sperm samples of very low quality. It also allows for the use of sperm coming from the epididymus or the testicle (obtained by aspiration or testicular biopsy in cases where there are no sperm in the ejaculate and these are mostly immotile – TESE/TESA). Right before performing ICSI, the cells surrounding the oocytes (cumulus cells) are removed to be able to check oocyte maturity and proceed to their correct micromanipulation.

Fertilization assessment

Fertilization assessment takes place 16 – 20 hours post ICSI or Conventional IVF. For fertilization to be optimal, the embryo should present structures that are proper to fertilization. Any variation or the lack of these structures imply the absence of correct fertilization and therefore rules these eggs out to continue the process. From that moment onwards, we speak of an “embryo”.

Embryo culture – the EMBRYOSCOPE

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In 2011 EMBRIOGYN embraced the revolution in reproductive medicine incorporating the time-lapse embryo culture system, the Embryoscope. Since then, we have used the Embryoscope for all our cultured embryos and we have improved pregnancy rates around 15 to 20% thanks to the advantages brought about by this embryo culture system.

The fertilized oocytes, now embryos, are kept in culture in the incubator between 2 to 6 days before placing them back into the uterus. The embryo culture allows the in-vitro development of embryos whilst enabling the assessment of the evolution of each individual one. For Embriogyn, the Embryoscope is the key tool to enhance the success of this embryo culture.

The Embryoscope is technically the most modern and advanced incubator in the market incorporating an image acquisition system that allows for the recording of the whole sequence of cellular division that occurs until day 5 or 6 of embryo development. This sequence of images provides unique, objective and truthful information for the selection of embryos with enhanced implantation potential to be transferred into the womb or to be frozen. A substantial increase in clinical results derives from the combination of the Embryoscope in the embryo culture system, the reduction of embryo manipulation and the amount of information obtained from each embryo thanks to this non-invasive system. This culture system enables embryologists to identify many more parameters (number of cells, cellular symetry, cellular nuclei, fragmentation, embryo kinetics, etc.) to select the embryos with the highest implantation potential.

Embriogyn was one of the first Assisted Reproduction Centers in Spain to offer such revolution to our patients and in fact, its implementation has rewritten clinical embryology at a global level.

Also, in Embriogyn we share the information gained from the Embryoscope with the patients allowing them to see their own embryos, bestowing trust and transparency to the whole process performed in the In-vitro Fertilization Lab as well as a high level of knowledge and understanding of the process by the patients.

Embryo transfer

The right time for the embryos to be placed again in the uterus is decided in every individual case. Depending on the characteristics of the embryos and the medical and reproductive antecedents of the couple, the embryologist advises on the most appropriate time for transfer (normally, on day two, three or five after egg collection).

Occasionally, due to various reasons, a fresh embryo transfer is not advised. In this cases, all the embryos obtained in the cycle are frozen to be transferred later in a cryotransfer process.

Embryo transfer is a painless procedure that normally does not require the use of anesthesia. The embryos are placed in the fundus of the uterus by means of a catheter. This process is controlled via abdominal ultrasound scan.

Currently, 1 or 2 embryos are transferred, by consent with the couple and the medical advice assessing the individual antecedents that pertain to each case with the purpose of gaining the most chances of pregnancy whilst minimizing the risk of multiple pregnancy.

Vitrification of surplus embryos

Once the selected embryos have been transferred, the surplus embryos that present good quality enabling them to preserve their potential for a later time are vitrified. It should be noted that the pregnancy rate expected from frozen embryos resulting from vitrification is very high, with results that practically equal the transfer of fresh embryos. Therefore, embryo freezing is very effective for preservation of fertility. However, the standards for freezing should be very strict and only those embryos with genuine fertilization potential should be frozen to give real chances to the parents who desire to use their frozen embryos later.

Pregnancy test and ultrasound scan

In Embriogyn we indicate that 14 days after egg retrieval, independently of the day of embryo transfer, the woman should have a pregnancy test with the first morning urine. Depending on the result obtained, the Embriogyn doctors will give the women or couples the necessary instructions to follow from that moment onwards.

When the result comes back positive, medical instructions are given and an ultrasound scan is scheduled for 3 weeks later in order to check the viability of pregnancy. This ultrasound scan is performed on week 6-7 of pregnancy where a gestational sac and the yok sac of the embryo with heart beating should be seen.

Indications

  • Moderate and severe male factor (when MSR Test allows the recovery of less than 5 million spermatozoa with good motility)
  • Tubal factor (when the fallopian tubes are partially or totally blocked)
  • Grade III and IV endometriosis.
  • Ovarian dysfuntcion.
  • Female age
  • Failure in other techniques
  • Infertility (repeated abortions)
  • Sterility of unknown origin
  • Long history of sterility
  • Advanced maternal age (>38-40 years)
  • Hereditary genetic diseases
  • Risk of transmitting infectious diseases to the offspring

Types of In-vitro Fertilization

Depending on the origin of the reproductive cells used in this procedure, there are different types of In Vitro Fertilization:

  • IVF with eggs and sperm from the couple.
  • IVF with eggs from the couple and sperm from donor.
  • IVF with eggs from donor and sperm from the couple.
  • IVF with eggs and sperm from donor.