In Vitro Fertilization

Infertility impacts on an average 4 out of 10 couples, while the number of those facing this issue increases every year. This is defined as the inability to conceive for 12 months, in the context of regular, unprotected sexual contact, under 35 years of age, or for 6 months, when over 35.

In vitro fertilization is a medically assisted reproduction procedure that consists of fertilizing the woman’s egg with the man’s sperm outside the body, in a specialized laboratory. The purpose of this procedure is to help couples who cannot conceive naturally because of fertility issues. The assisted human reproduction procedures that patients can benefit from in our clinic are in vitro fertilization or intrauterine insemination.

Intrauterine insemination and in vitro fertilization are two medically assisted reproduction procedures aimed at helping couples who cannot conceive naturally. Both procedures involve the introduction of sperm, or of already formed embryos in the uterus, but they differ in the way and place where fertilization takes place.

Intrauterine insemination (IUI) is a simpler and less expensive procedure, which consists of injecting a sperm concentrate directly into the woman’s uterus, around the ovulatory period. Sperm must swim to the fallopian tubes, where they can meet and fertilize an egg released from the ovary. Fertilization occurs naturally at the level of the fallopian tube and subsequently the zygote thus formed migrates for implantation in the uterus.

In vitro fertilization (IVF) is a more complex procedure, which consists in harvesting mature oocytes from the woman’s ovaries and combining them with sperm in a culture medium, outside the body, in a specialized laboratory. Fertilization occurs artificially, outside the woman’s body. The fertilized eggs become embryos and are transferred to the woman’s uterus after a few days of development. In vitro fertilization is recommended in cases of severe infertility or when intrauterine insemination has not worked.

In vitro fertilization is recommended when other methods of infertility treatment have not worked or when there is a severe or irreversible cause of infertility, such as:

• Blocked or absent fallopian tubes;
• Male infertility;
• Old age of the patient;
• Infertility caused by endometriosis, ovulation disorders, uterine fibroids or other gynecological conditions;
• Inherited genetic diseases;
• Premature ovarian failure;
• Unexplained infertility.

The IVF preparation stage involves several steps. The couple shall undergo an initial consultation with the assisted reproduction specialist. A detailed anamnesis shall be performed, then the patient shall be assessed from an ultrasound point of view. Subsequently, both partners shall undergo a series of medical tests, depending on their respective medical context and medical history. The couple shall adopt a healthy lifestyle prior to IVF, which includes a balanced diet, adequate hydration, avoiding smoking, alcohol and drugs, reducing stress and practicing moderate physical activity.

Ovarian stimulation is an essential step in the IVF process, since it is aimed at obtaining as many mature and quality oocytes as possible, which can be fertilized with sperm in the laboratory. The procedure is performed by administering hormonal drugs, under the supervision of a specialist in medically assisted human reproduction. Ovarian stimulation usually begins in the first few days of a woman’s menstrual cycle and lasts about 10-14 days. Depending on the type of protocol chosen, the process may involve the following steps:

• taking medicines that block the natural secretion of pituitary hormones (FSH and LH), which control ovulation. The drugs used are exogenous gonadotrophins (FSH, LH) and GnRH antagonists (gonadotrophin-releasing hormone) and shall be given as subcutaneous or intramuscular injections.
• administration of drugs that stimulate the growth and maturation of several ovarian follicles, which contain oocytes. The drugs used for follicular stimulation are gonadotrophins (FSH and LH) and shall be given subcutaneously. The dose and duration of follicular stimulation shall be determined individually, in relation to the ovarian response of each patient.
• giving a hCG (human chorionic gonadotropin) injection which mimics the action of natural LH and triggers ovulation. The purpose of this step is to induce the final maturation of oocytes and their release from follicles. The hCG injection shall be given at a precise time, established by the doctor, usually 35 hours before oocyte retrieval.

During stimulation, periodic ultrasound checks shall be performed to monitor the evolution.

Approximately 35 hours after the administration of medication to trigger ovulation, oocytes are harvested by ovarian puncture under ultrasound guidance. The procedure shall be performed under analgosedation and is painless for the patient. Under ultrasound guidance, the specialist punctures the ovaries and aspirates the follicular fluid containing the oocytes. This is immediately stored in sterile test tubes at human body temperature and handed over to the embryologist. The male genetic material shall be harvested at the same time interval and immediately transferred to the laboratory, to launch the fertilization process.

The process of laboratory fertilization is the stage during which harvested oocytes are combined with the sperm of the partner or of a donor, under controlled conditions, to obtain embryos. The laboratory fertilization process can involve two main techniques: standard IVF or ICSI.

After retrieval, oocytes shall be examined under a microscope to verify their maturity stage and integrity. Only mature oocytes (with two pronuclei) can be fertilized. Immature oocytes (with a single pronucleus) can be cultured to see if they reach maturity or can be removed. The harvested sperm is processed by various methods, to separate viable from dead or immobile sperm and other cells or substances. Sperm are selected according to motility and morphology and shall be kept in a culture medium until fertilization. Whenever IVF is used, each mature oocyte is placed in a drop of culture medium, along with a sufficient number of sperm (approximately 50,000-100,000). The droplets are coated with mineral oil to prevent evaporation and contamination and incubated at 37°C, for 16-18 hours. In ICSI, each mature oocyte is immobilized using a special pipette and injected with a single sperm, using a thin needle. The injected oocytes are then placed in a culture medium and incubated at 37°C, for 16-18 hours.

The embryo transfer procedure is the last stage of the in vitro fertilization process, which involves transferring the embryo(s) to the uterine cavity. It is a simple and painless procedure that does not require anesthesia and is more like a regular gynecological examination. It is recommended to transfer only one embryo and, in selected cases, 2 embryos at most.

In the period prior to the procedure, the preparation of the uterus shall be carried out, through hormonal treatment that stimulates the thickening of the endometrium or the thickening of the uterus naturally, without drug treatment. The best embryos shall be chosen for transfer, based on their quality and viability. The transfer to the uterus shall be performed through a thin and flexible catheter, which shall be inserted through the cervix to the level of the uterine cavity, where the doctor releases the contents.

In vitro fertilization is a process that can be demanding, both physically and emotionally. Preparation for IVF starts the moment of the initial consultation and ends with the embryo transfer. The couple shall adopt a healthy lifestyle and go through a series of medical tests required to assess their health.

The success rate of IVF procedures depends on several factors. The most relevant are the age of the woman and the number of oocytes harvested. But other factors can also influence the likelihood of success, such as sperm quality, couple’s lifestyle, certain associated medical conditions and the circumstances in the IVF laboratory where the procedure is performed.

The IVF treatment success rate is also influenced by the number of oocytes harvested from a woman in a cycle. The likelihood of obtaining quality embryos for transfer to the uterus increases with the number of eggs retrieved.

IVF procedures have higher chances of success if there are no associated pathologies and if the woman has a good ovarian reserve, if many oocytes are harvested and if there is a good quality endometrium. Sperm quality also makes a difference.

The success rate is higher the younger the woman is, while the absence of other pathologies that could prevent or hinder the process is of the essence. The decisions of the specialist doctor regarding the stimulation protocols are very important, but so is the laboratory where the fertilization procedure takes place. Note should be taken that it often takes several cycles of treatment to succeed.

Subsequent to the IVF procedure, after the embryo transfer, patients can resume their normal activity, with certain restrictions relating to excessive effort, extreme environmental conditions and exposure to stressful situations. There are a number of typical symptoms after IVF procedure, such as bloating, cramping, constipation, breast tenderness, etc. There are also situations that may require a specialist examination to rule out a possible infection, ovarian torsion, or ovarian hyperstimulation.

The in vitro fertilization process is not devoid of risks. It is important to inform patients of all the implications of the process. These are some of the most important risks involved by the IVF process:

• ovarian hyperstimulation syndrome;
• multiple pregnancy;
• ectopic pregnancy;
• infections;

Moreover, emotional issues are a part of the process that should not be ignored.

Medicine offers solutions that we make available to patients under the guise of the latest assisted human reproduction techniques. Each case is subjected to a thorough anamnesis. We attach great importance and embrace a holistic approach to the particularities of each person. Our clinic is endowed with state-of-the-art equipment. Our embryology and andrology laboratories are in the top tier in the country.

High-performance equipment helps us quickly and correctly identify the causes of infertility, and state-of-the-art fertilization techniques significantly contribute to increasing the prospects of pregnancy.