In Vitro Fertilization IVF

Introduction

In-vitro fertilisation (IVF) is just one of several techniques available to help couples with fertility problems to have a baby.

It involves surgically removing an egg from the woman's ovaries and fertilising it with sperm in a laboratory. The fertilised egg, or embryo, is then placed back into the woman's womb to grow and develop (see How it is performed).

Who can have IVF?

Guidelines suggest that couples may be eligible for IVF treatment on the NHS if:

• the woman is between 23 and 39 years of age at the time of treatment, and
• a cause for their fertility problems has been identified, or
• they have had infertility problems for at least three years.

However, the decision on eligibility is made locally, by primary care trusts, and priority is given to couples who do not already have children.

IVF is not usually recommended for women who are over the age of 42, because the chances of a successful conception are thought too low to justify the treatment (see below).

Success rate

The success rate of IVF is determined to a large degree by the age of the woman undergoing the treatment. Younger women tend to have healthier eggs, which increase the chances of success.

In 2006, the percentage of IVF cycles started that resulted in a live birth were:

• 29% for women aged under 35,
• 26% for women aged 35-37,
• 17% for women aged 38-39,
• 11% for women aged 40-42,
• 5% for women aged 43-44, and
• less than 1% for women aged over 44.

Availability on the NHS

The National Institute for Health and Clinical Excellence (NICE) published guidelines in 2004 recommending that suitable couples receive up to three cycles of IVF treatment on the NHS.

The provision of IVF treatment varies across the country, but NHS trusts across England and Wales are working to provide the same levels of service.

The Human Fertilisation and Embryology Authority regulates and licenses fertility clinics.

Getting started

If you are having problems getting pregnant, see your GP.

Your GP will look at your medical history and give you a physical examination, and may recommend some lifestyle changes.

You may only be considered for infertility investigations and treatment after you have been trying for a baby for at least a year without becoming pregnant.

Your GP will be able to refer you (and your partner, if you have one) to an infertility specialist at an NHS hospital or fertility clinic.

Referral to an infertility specialist

The specialist will take your fertility history and may carry out a physical examination.

They may do tests to check your blood hormone levels and ovarian function, and your partner's sperm quality.

You may also have an ultrasound or X-rays of your reproductive organs, to see if there are any blockages or structural problems.

If the specialist concludes that the cause of your infertility may be treatable by IVF, or if you have been unable to conceive for at least three years, you may qualify for funding for IVF treatment.

The specialist will advise your GP as to whether IVF is the best treatment for you and, if it is, will refer you to an assisted conception unit (see below).

For more information, go to Health A-Z: diagnosing infertility.

The assisted conception unit

Once you are accepted for treatment at the assisted conception unit, you (and your partner, if you have one) will have a blood test for HIV, hepatitis B, hepatitis C and syphilis, and to check you are immune to rubella (German measles).

Your hormone profile will also be assessed. A blood sample will be taken early in your menstrual cycle to see if there is likely to be any difficulty in obtaining eggs, and to detect any hormone imbalance. A further semen sample may be analysed.

The specialist will then discuss your treatment plan with you in full.

You will need to sign consent forms giving permission for the use and/or storage of your eggs, sperm or embryos.

You may find counselling helpful while going through this process. For more information, go to HFEA: benefits of counselling and how to access it

How IVF is performed

The basic IVF technique was developed in the 1970s. It can differ from clinic to clinic, but a typical treatment is as follows.

For women

Step one: suppressing the natural monthly cycle

You are given a drug to suppress your natural cycle. This is given either as a daily injection (which is normally self-administered) or a nasal spray. You continue this for about two weeks.

Step two: boosting the egg supply

After your natural cycle is suppressed, you are given a fertility hormone called FSH (follicle stimulating hormone). This is usually taken as a daily injection for around 12 days. It will increase the number of eggs you produce, so more eggs can be fertilised. With more fertilised eggs, the clinic has a greater choice of embryos to use in your treatment.

Step three: checking on progress

The clinic will monitor your progress throughout the drug treatment. This is done by vaginal ultrasound scans and possibly blood tests. 34-38 hours before your eggs are due to be collected, you have a hormone injection to help your eggs mature.

Step four: collecting the eggs

Eggs are usually collected by ultrasound guidance under sedation. This involves a needle being inserted through the vagina and into each ovary. The eggs are then collected through the needle.

Cramping and a small amount of vaginal bleeding can occur after the procedure.

Step five: fertilising the eggs

Your eggs are mixed with your partner's or the donor's sperm and cultured in the laboratory for 16-20 hours. They are then checked to see if any have fertilised.

If the sperm are few or weak, then each cell may need to be injected individually with a single sperm. This is called intra-cytoplasmic sperm injection (see below).

The cells that have been fertilised (embryos) are grown in the laboratory incubator for one to four days before being transferred. The best one or two embryos will be chosen for transfer.

After egg collection, you are given medication to help prepare the lining of the womb for embryo transfer. This is given as a pessary (placed inside the vagina), an injection or a gel applied to the skin.

Step six: embryo transfer For women under the age of 40, one or two embryos can be transferred. If you are 40 or over, a maximum of three can be used.

The number of embryos is restricted because of the risks associated with multiple births. Remaining embryos may be frozen for future IVF attempts, if they are suitable (see HFEA: freezing and storing embryos).

Some clinics may also offer blastocyst transfer, where the fertilised eggs are left to mature for five to six days and then transferred. For more information about embryo transfer, go to the HFEA factsheets on:

• embryo transfer,
• blastocyst transfer, and
• assisted hatching (helping the embryo to break from its outer layer so it can attach to the wall of the womb).

For men

Around the time your partner's eggs are collected, you are asked to produce a fresh sample of sperm. The sperm are washed and spun at a high speed, so the healthiest and most active sperm can be selected.

If you are using donated sperm, it is removed from frozen storage, thawed and prepared in the same way.

Information on other techniques

There are many alternative methods that can help a couple to conceive. For more information, go to the HFEA factsheets on:

• Natural cycle IVF - IVF without fertility drugs and hormones to boost the supply of eggs.
• Intra-cytoplasmic sperm injection (ICSI) - injecting a single sperm directly into an egg to fertilise it.
• Intrauterine insemination (IUI) - separating fast-moving sperm from more sluggish or non-moving sperm.
• Gamete intra-fallopian transfer (GIFT) - placing the healthiest eggs and sperm together in the woman’s fallopian tubes so fertilisation takes place in the body.
• In-vitro maturation (IVM) - maturing the eggs in the laboratory before fertilising them.

Risks of IVF

The potential problems associated with IVF are outlined below.

Drug reaction

You may experience any of the following symptoms as a reaction to fertility drugs:

• hot flushes,
• feeling down or irritable,
• headaches, and
• restlessness.

See your doctor if these symptoms do not get better.

Ovarian hyper-stimulation syndrome

Ovarian hyper-stimulation syndrome (OHSS) is an uncommon but known complication of IVF. It occurs in women who are very sensitive to the fertility drugs given to stimulate egg production. Too many eggs develop in the ovaries, which become very large and painful.

It can result in pain and bloating low down in your stomach, nausea or vomiting. Severe cases can be dangerous. See your doctor if you experience any of these symptoms.

Ectopic pregnancy

An ectopic pregnancy occurs when the fertilised egg implants outside of the womb ('ectopic' means in the wrong place).

If you have IVF, you have a slightly higher risk of ectopic pregnancy, where the fertilised egg implants in the fallopian tubes rather than in the womb. This can cause vaginal bleeding or bleeding into your abdomen.

Hormone tests and scans are used to detect ectopic pregnancies, and you should tell your doctor if you experience vaginal bleeding or stomach pain after having IVF and a positive pregnancy test.

Multiple births

There is an increased chance of producing twins or triplets with IVF treatment if more than one embryo is put back into the womb.

Having more than one baby may not seem like a bad thing, but it does significantly increase the risk of developing complications for you and your babies:

• Multiple pregnancy can cause your blood pressure to rise significantly.
• You are two to three times more likely to develop diabetes during pregnancy if you are carrying more than one baby.
• Around half of all twins and 90% of triplets are born prematurely, or with a low birth weight. The risk of your baby dying in the first week of life is five times higher for twins than for a single baby. For triplets this risk increases to nine times higher.

The Human Fertilisation and Embryology Authority (HFEA) therefore recommends that a maximum of two embryos are put back into the womb during treatment in women under the age of 40.

Also, the HFEA is encouraging a single embryo transfer in women who are at most risk of having twins (for example, younger women who have produced a lot of embryos). For more information, go to the One at a time website

Support during IVF

Counselling

Undergoing IVF can be emotionally and physically draining. It is important that couples are offered counselling where appropriate, for example to understand the implications of treatment, or as a means of support at a critical time (for example, if an IVF cycle has failed).

NICE recommends that counselling should be offered before, during and after IVF treatment (regardless of the outcome of the procedures) by someone who is not directly involved in the management of the couple's fertility problems.

For more information, go to HFEA: benefits of counselling and how to access it

Adapting to parenthood

It is not uncommon for couples who have been successful in their attempts to start a family to find it difficult to adjust to their new life. It is important to seek help from health professionals (for example, your fertility consultant, GP, midwife or health visitor).

Contacting a fertility support group and talking with others who can empathise with your experiences can also be helpful (see Useful links).