In Vitro Fertilisation (IVF)
In Vitro Fertilisation (IVF) is the process by which oocytes are taken from the woman’s body, fertilised in a laboratory with the sperm and incubated, then replaced into the woman’s body a few days later for development. The basic stages involved in the IVF procedure are detailed below, but do not be surprised if the stages are slightly different to the procedure you follow. Everyone is an individual and the tests may differ or some stages may be added or not included in your treatment. This is designed to be an overview and lists the options available. You should discuss your treatment with your specialist and the Nurse Coordinator.

The IVF treatment involves six main stages:

> Growth and maturation of several oocytes;

> Exact timing of retrieval of these oocytes;

> The retrieval of the oocytes;

> Fertilisation of the oocytes that may become embryos;

> Transfer of the embryo/s back into the uterus;

> Freezing of remaining suitable embryos.

Medications used in Ovarian Stimulation
The normal cycle usually produces one oocyte but fertility drugs are used to hyperstimulate the ovaries to develop a number of oocytes in the IVF cycle. Pregnancy rates in IVF/GIFT are improved if a number of oocytes can be collected. Follicle Stimulating Hormone is the most common method of stimulating follicular development. PUREGON and GONAL-F are synthetic forms of Follicle Stimulating Hormone (FSH) and your specialist will prescribe one of these medications to stimulate the ovaries to produce multiple oocytes. Some patients may be treated with FSH only, but most patients will also use Lucrin, Synarel, Cetrotide or Orgalutran in conjunction with the FSH injections. Lucrin and Synarel are both GnRH agonists and Cetrotide and Orgalutran are GnRH antagonists. These four medications act on the pituitary gland to stop ovulation occurring before the oocyte retrieval in an IVF or GIFT cycle. Individual instructions will be given to you. Currently Medicare supplies the FSH if you are eligible for a Medicare rebate. Please discuss the cost of Lucrin/Synarel/Cetrotide/ Orgalutran before commencing.

Injections (Lucrin, Puregon and Gonal-F) can be conveniently self-administered at home by yourself or your partner. The nurse coordinator will give you and your partner instructions and a teaching session/s. You will be supervised at the clinic until you feel confident to self-administer at home. The Cetrotide or Orgalutran injection is usually administered at the clinic but may be administered at home with prior instruction. Synarel nasal spray is conveniently given at home and an instruction sheet and video are available.

Ovarian Stimulation Protocols
There are almost as many stimulation protocols in use in the world as there are IVF clinics. The most common protocol used by our clinic is the Down Regulation Protocol (Chart 1) and it is very similar to that used by most IVF units around Australia. Others used include Flare Protocol using GnRH (Synarel/Lucrin), Flare Protocol using Cetrotide, and combination protocols. Your specialist will advise you which protocol he believes will provide the optimum result.

Overview of the Down Regulation Protocol
In this protocol the GnRH analogue (Lucrin or Synarel) is started in the mid-luteal phase, 7 days after ovulation. Lucrin or Synarel is continued daily for 10 days then a blood test is performed to check that hormone levels are at a baseline. If a baseline has not been reached then Lucrin or Synarel is continued for a further three to five days. A blood test is performed again to test for baseline levels. This is performed every 3–5 days until baseline levels have been achieved then the stimulation drugs (Puregon or Gonal-F) are commenced, concurrently with the GnRH.

Monitoring oocyte Development
The oocytes (ova) develop inside the ovaries in follicles, which are like little cysts or fluid filled sacs. These follicles produce increasing amounts of oestradiol (an oestrogen hormone) as they grow. The size can be measured by ultrasound, although the oocytes themselves are much too small to see. A blood test and ultrasound scan will be done on about the seventh day after commencing FSH. Thereafter blood tests and ultrasound scans will be carried out as required. When you contact the Canberra Fertility Centre that same afternoon, you will be informed when another scan or a blood test is required.

a) Blood Tests
Blood is taken at intervals from about Day 7 of the stimulated cycle to measure oestradiol levels. This is to be done between 7.30am and 9.00am so that the results are available the same day. Blood test analysis is done at the Canberra Fertility Centre.

b) Ultrasound Examinations
Patients will have ultrasound examinations to measure the size, number and development of follicles growing. Ultrasound’s are performed trans-vaginally and an empty bladder is required. Sound waves are used to produce pictures of the growing follicles, so that they may be counted and measured. The number of oocytes collected may differ from the number of follicles seen on ultrasound. These scans are done at Canberra Fertility Centre between 7.30am and 9.00am weekdays by appointment.

Admission to CAPS Clinic
Admission will be arranged at the CAPS Clinic prior to oocyte retrieval. You are to remain in recovery for about 2–4 hours after oocyte retrieval until recovery from the anaesthetic/sedation used during surgery.

Timing of oocyte retrieval
This will be undertaken using laparoscopy or an ultrasound guided retrieval. Your specialist will advise you as to which method will be best for you. The oestradiol levels (from the blood tests) and the number and the size of the follicles (from the ultrasound) are together used to assess the maturity of the oocytes and the right time for oocyte retrieval. There is no “correct” oestradiol level to reach and there is enormous variation between patients. It is the whole pattern of blood and ultrasound results which determine whether the response to treatment is optimum. In general, however, it is important that the oestradiol level rises steadily until the oocytes are collected. It is very important to realise that a wide range of individual treatments are used in the program. Please do not be alarmed if your treatment is different from someone else’s. The aim is to design the best individual protocol for you. For patients who are not using Lucrin, Synarel, or Cetrotide, the hormone that normally triggers ovulation, LH, may be present and its levels are not under your specialist’s control. If it is detected, oocyte retrieval must be timed according to the results of the blood tests.

hCG Injections
hCG (human chorionic gonadotropin) is a hormone that performs the function of LH, triggering the final maturation of the oocytes and ovulation. In an IVF cycle a single injection of hCG medication (Pregnyl or Profasi) is given usually 37 hours before the operation is planned. Your operation time is determined by the oestradiol level and the ultrasound measurement. Most patients give this injection at home at the specified time, and you will receive instruction by one of the Canberra Fertility Centre Nurse Coordinators. After this trigger injection the other two medications (Lucrin / Synarel / Cetrotide and Puregon / Gonal-F) are normally stopped.

Oocyte retrieval
The oocyte retrieval is done under a “light” sedation. The follicles are visualised using trans-vaginal ultrasound, and the fluid inside them is sucked through a needle and tubing into a test tube. The tube is passed immediately to the embryologist who looks for the oocyte under the microscope. The oocytes are then put in the incubator. Most patients are sleepy, and some are nauseated for a few hours after the operation. You can be discharged 2–4 hours after the operation. You will be visited by the Canberra Fertility Centre nurse coordinator and given further instructions before discharge.

Fate of recovered oocytes
It is important to understand that not every follicle seen on ultrasound yields an oocyte. The following chart shows the average fate of follicles from ultrasound to embryo transfer. Only 28% (less than a third) of follicles finally yield usable material and only 71% of follicles yield oocytes.

No oocytes collected
This occassionally happens, and can occur where there is no access to the ovary (very rare) or ovulation has unexpectedly occurred prior to the oocyte retrieval procedure or there are no oocytes obtained from the follicles. The latter is called Empty Follicle Syndrome (EFS) and is a frustrating condition in which no oocytes are retrieved at IVF, even though ultrasound and estradiol measurements showed the presence of potential follicles. The mechanism responsible for EFS remains obscure. Many hypotheses have been put forward but none truly explain the syndrome. EFS are an infrequent event and have been estimated to occur in 2–7% of IVF cycles. However, the overall risk of recurrence in a later IVF cycle is 20% and the risk of recurrence is higher as the age of the patient increases.

If an EFS cycle does occur please make sure you discuss it thoroughly with your specialist and the clinic counsellor.

Sperm retrieval
We will inform you of the approximate sperm retrieval time once the oocyte retrieval time has been arranged. It is usually 1–3 hours after the operation. Two to three days abstinence from intercourse/masturbation is preferred prior to oocyte retrieval. The sperm sample is produced by masturbation at the Centre or by other means by arrangement. There is a room for this purpose. You are asked to wash your hands beforehand to minimise the chance of contamination. Lubricants are NOT to be used. It can be very difficult for some men to produce a sperm sample on request under these conditions. If you are worried about this aspect of the program, please discuss it with us at or before the start of the treatment cycle, so that arrangements can be made to freeze some semen if necessary as freezing must be done at least a week before oocyte retrieval. Sexual activity may be continued as usual until three days before the time of the woman’s oocyte retrieval. Sexual activity may resume 48hrs after the embryos are transferred if comfort levels allow.

Events in the Laboratory
The sperm sample is prepared and put with the oocytes (fertilisation), 3–6 hours after retrieval. The oocytes and sperm are kept in an incubator until next inspected 15–20 hours later. At this time they are checked under the microscope to determine whether fertilisation has occurred. You will be in contact with the Nurse Coordinator during these interim days and they will inform you of the fertilisation results and embryo progress results. At about 60–70 hours after fertilisation, the embryos will be transferred to the uterus.

No Fertilisation
This happens in about 5% of patients who have oocytes collected. Sometimes it is because of known problems such as low sperm count, sometimes because of unpredicted problems with oocytes or sperm, and sometimes there is no obvious reason. This will be discussed with you and usually an appointment will be made to further review the situation and make future plans.

Embryo Transfer
We will inform you of progress daily. Transfer usually takes place around 2-3 days after retrieval. The embryo transfer is carried out in the IVF Unit. Under normal circumstances no more than 2 embryos will be replaced because of the risk of multiple pregnancies. No anaesthetic is required and the procedure itself takes approximately 3 minutes. The Specialist will insert a speculum into the vagina, as for a Pap smear. This allows a view of the cervix. A fine tube (catheter) is passed through the cervix and up into the uterus. The embryos are then injected using a fine inner catheter high into the uterus in a minute amount of culture medium. This technique does not normally require sedation, and may be a little uncomfortable but not painful.

You are then requested to do light duties only, and if possible, avoid strenuous work or activities until the pregnancy has been diagnosed. Menstruation does not necessarily mean that a pregnancy is not developing. You must continue blood tests until a final outcome is known.

IVF vs GIFT (GAMETE INTRAFALLOPIAN TRANSFER)
GIFT is a modification of the classic IVF technique where, instead of fertilisation occurring in the laboratory, it occurs within the fallopian tube, the normal site of fertilisation. Only women who have at least one normal/patent fallopian tube can be considered for treatment by GIFT. There must also be a sufficient number of normal, healthy sperm to allow this method to be used. The aim is to place two, or in some instances three oocytes and a prepared sample of sperm into the fallopian tubes, allowing fertilisation to occur naturally. As conception occurs within the fallopian tube, there are fewer objections on religious or moral grounds when compared to the IVF program.

Admission will be arranged at the John James Memorial Hospital prior to oocyte retrieval. You are to remain in hospital for about four–six hours after the GIFT procedure. In the GIFT program it is necessary to obtain the partner’s sperm sample before the wife goes into the operating theatre. This is different to IVF where the sample is obtained several hours after the operation. Partners will usually be required about ninety minutes prior to the operation so the laboratory will have time to “wash” and separate out the best sperm for the procedure.

The GIFT operation is divided into two parts:
a) Ovum Retrieval (oocyte retrieval)
This is identical to oocyte retrieval in IVF patients and is most often done using trans-vaginal ultrasound guided technique and sometimes laparoscopically. With both retrieval techniques a general anaesthetic will be administered and both parts of the procedure are done under the same anaesthetic.

b) The GIFT
Once the oocytes are obtained the laboratory scientist will choose the best ones up to the number you have agreed to have replaced. The oocytes and a measured amount of sperm will then be loaded into a thin catheter. This will be introduced laparoscopically into the abdomen and the Fallopian tube cannulated from its outer end just near the ovary. The sperm and oocytes will then be gently flushed into the tube. A few patients will not get the preferred number of oocytes due to a poor response to stimulation. In this case whatever oocytes are obtained will be placed into the Fallopian tube.

Recovery time from GIFT is no longer than for a normal laparoscopy. Patients will usually go home four-six hours after the operation. Gentle activities may be resumed at home, sexual intercourse may be resumed 1– days after the operation.

Surplus oocytes
Some patients will have more than two or three ova retrieved. Before the cycle commences patients will be asked what they would prefer done with excess ova and will indicate this on their signed consent form. One option which is available is to attempt to fertilise the excess oocytes and freeze the resulting embryos and transfer them in a later cycle. Embryos that are no longer wanted can be donated or disposed of. They can remain in storage for a maximum of three years.

Follow-up Tests
Blood tests may be done at frequent intervals to monitor progesterone levels and determine the cycle outcome. To maintain your progesterone levels after IVF progesterone support is often prescribed and is routinely given as a Vaginal Pessary. The Nurse Coordinator will instruct you on their use. In some situations, absorption of the progesterone is poor, so injections may be given to further supplement the progesterone levels. A series of blood tests for progesterone and pregnancy hormone will be carried out (often 7, 10, and 12 days post oocyte retrieval). If the tests do not indicate that pregnancy has occurred within this time then the progesterone support will be stopped. A menstrual period can be expected within a few days of cessation of progesterone support.

Pregnancy
The blood tests taken two weeks after the oocyte retrieval will detect whether the pregnancy hormone (HCG) is present: however it is too early to know whether there is a healthy continuing pregnancy. Further blood tests and an ultrasound examination are needed. Your specialist usually orders an ultrasound at approximately 7 weeks of pregnancy, and antenatal visits with your specialist commence at 10–12 weeks of pregnancy. Please refer to your specialist and the Canberra Fertility Centre for instructions. Unfortunately IVF/GIFT, like natural conception, can lead to a biochemical pregnancy (a transient rise in pregnancy hormone followed by a late period), miscarriage (needing curettage), or an ectopic (tubal) pregnancy (requiring surgery), as well as the happier outcomes. So, unfortunately even a positive blood test is not the end of the waiting. Multiple pregnancy (twins or triplets) are more common with IVF/GIFT than with natural conception, because of the practice of transferring more than one embryo/ova. If you do not want to risk having twins or triplets please discuss with your doctor the replacement of only one embryo in an attempt to reduce this risk.

Further Steps—Unsuccessful Cycles
All patients are asked to notify us of their next period whether or not ovum retrieval and/or embryo transfer is performed. This information helps us plan future management.

Repeat In-Vitro Fertilisation/GIFT attempts
No pregnancy resulting after an embryo transfer is still the most common outcome of IVF and reflects our current state of knowledge. We are continually working to find what is different about pregnancy cycles so that the outcomes may be improved. Often, we will be unable to give a reason why the embryo transfer has failed.

If pregnancy does not occur, a cycle to transfer frozen embryos or a repeat attempt of IVF/GIFT can usually be made approximately 3 months later, depending on findings of the most recent treatment cycle. Make an appointment to see your gynaecologist after your period for review.

Cancellation of Cycles
Hormone levels (Oestradiol) from the blood tests and follicle numbers from the ultrasound scan will be used to assess the progress of the cycle. The aim is to collect between 6 and 10 oocytes. If your blood hormone levels and follicle numbers are too high, your Specialist may decide that your cycle be cancelled to avoid the risk of OHSS (Ovarian Hyperstimulation Syndrome). The Nurse Coordinator will explain this risk to you at the initial meeting. This is only a temporary set back. Similarly if the blood hormone levels and ultrasound measurements show that insufficient follicles are growing then your Specialist may also decide that the cycle be cancelled. A cycle may also be cancelled if follicles develop on an inaccessible ovary (eg. follicles developing on the wrong side when scar tissue allows only one ovary to be accessible) or if ovarian cysts impede the cycle.

Cycle cancellation occurs in about one in seven cycles. In the majority of cases, this is just a reflection of the variation in the biological system and a more satisfactory response is obtained in the next cycle attempt, possibly using a different drug dose or protocol. Rarely an industrial dispute or other circumstances beyond our control could result in a cycle being cancelled.