preparation

As soon as you are put on the waiting list for IVF an extensive consultation will take place. This will include a verbal explanation of the procedure (supported by written information) where obviously you will have the opportunity to ask questions. It is critical that everything is clear to both partners before beginning treatment. You will also be told how to use the various drug therapies needed and, where appropriate, you will be taught how to administer them.

The preliminary examinations that have to take place will also be discussed with you. These might include, for example, an extra blood test (for infectious diseases or hormone assessment), or another semen analysis. Additional heredity tests (chromosomal studies) on a blood sample from the man in the case of ICSI treatment.

You will also be given further information on daily practice in your clinic; it is essential that you know whom to contact, and when, if you have questions or problems.

IVF treatment not only takes up a lot of time, but also demands considerable flexibility. The course and duration of the stimulation is not easy to predict, as a result of which follow-up checks and even the day of the puncture to collect the eggs can only be scheduled shortly in advance. It is important that you bear this in mind during the month of your treatment.

Back to top

treatment plan

There are different types and brands of the drugs that may be prescribed to you. The precise drug therapies you use will depend on your personal situation and the clinic’s general policy. Usually the women’s own hormone production must be suppressed initially. Various methods are available for this.

The woman then begins daily injections to stimulate the ovaries to produce a number of egg cells. Ideally the aim is to obtain 10 (5 – 15) egg cells. The quantity of drugs (dosage) required for this is estimated in advance. Do not expect from the start, however, to always be able to predict how the ovaries will react. If there are too many egg cells, your treatment may have to be cancelled. If the reaction is moderate, the dosage can sometimes be increased during the treatment, but a treatment may also be cancelled if there are too few egg cells. Although disappointing, you can at least take some solace from the fact that this experience can be used to improve the chance of success for a possible subsequent IVF treatment.

Back to top

checkups

The egg cells are found in fluid-filled follicles in the ovaries. The size of a follicle provides an indication of the maturity of the egg cell. During the treatment, you will have frequent checkups at the outpatients department to track the reaction of the ovaries to drug therapy using vaginal ultrasonography. The size of the follicles and the viscosity (thickness) of the cervical mucus are measured at each check-up to determine the right time for the puncture. Blood may also be taken to measure the hormone levels.

Back to top

puncture

At the point when the egg cells are almost mature, ovulation is artificially induced by means of an injection of human Chorionic Gonadotropin (hCG).

It is crucial that this injection is carried out correctly and at exactly the stated time. This injection stimulates the final maturation of the egg cells so that they are released from the follicles. The egg cells are removed from the body by needle biopsy (puncture) 35 hours after the injection.

Puncturing the follicles is called follicle puncture. The puncture is carried out via the vagina with the aid of vaginal ultrasonography. You are generally given an anaesthetic for this, although practice may vary from clinic to clinic. The vaginal ultrasonic probe is fitted with a thin needle holder. A special hollow needle is then inserted into this holder. Both the needle and the follicles are visible using ultrasonography on the monitor. The follicles are punctured with the needle one at a time and aspirated (collected). You can follow the procedure yourself on the screen.

The egg cells and surrounding fluid are drawn into a tube, which is then transferred to the embryo laboratory. The whole procedure generally takes about half an hour. The puncture itself lasts approximately five or ten minutes depending, among other things, on the number and position of the follicles. You will only find out whether egg cells have been obtained during the puncture, and if so how many there are, after the embryologist has been able to examine the fluid obtained. The number of egg cells may be lower than the number of follicles punctured, either because not all the follicles contain an egg cell or some egg cells are not fully mature.

The pain or discomfort felt during the puncture may vary from patient to patient, but is generally well-tolerated. You may also feel some discomfort after the procedure. It is therefore sensible not to make any other plans for that day. Just as with every other medical intervention, puncture carries a small risk of complications. Haemorrhages and infection are two possible complications, but are relatively rare. In general, the recovery period is short.

Back to top

fertilisation

In the laboratory, embryologists then examine the fluid removed from the ovary for egg cells. The egg cells are graded according to their maturity, to see whether they are suitable for fertilisation. If fresh sperm is used, the male partner is asked to supply sperm. A semen analysis is then carried out and the sample is washed with a special nutrient solution to isolate the more motile sperm.

Then comes fertilisation. Exactly which process is used depends on the clinic and the type of infertility involved. In standard IVF, the sperm is placed in a dish along with the egg cells.

• Within 18 hours the embryologist can tell whether fertilisation has occurred.
• Within 24 to 72 hours the embryologist can tell whether the embryos are growing.

The sperm and the egg cells are placed in growth media; special nutrient solutions to give them the maximum chance to fertilise or to be fertilised. In conventional IVF, every dish containing an egg is filled with at least 50,000 sperms. In the laboratory, the embryos are then left, for between 2 - 5 days, to grow and divide into several cells. This is called an embryo culture.

Back to top

embryo transfer

After the puncture, the woman is often prescribed drugs to prepare the uterus (womb) for embryo transfer. Embryo transfer usually occurs two to three days after fertilisation. There are special criteria against which the quality of an embryo can be assessed.

Embryos can be classified into different quality categories. A good or perfect embryo is an embryo that the embryologist believes has a good chance of implantation. If an embryo is classified as “bad”, the theoretical chances of implantation are indeed smaller, but implantation is not ruled out. If this type of embryo does implant, it can develop into a normal pregnancy and a healthy baby.

However, embryos can usually only be assessed on external features. In some cases, closer examination of the embryo’s hereditary material can be done prior to the embryo transfer.

The best embryo, or the three best embryos at most, are placed in the woman’s uterus. The embryos are transferred into the uterus by inserting a thin tube, or catheter, through the cervix. The depth of the uterus is measured in advance to determine the right place for the transfer.

Transferring several embryos increases the risk of multiple births. A strict transfer policy (see below), is therefore adopted to try and limit the number of twins and multiple births due to the increased chance of complications. The maximum safe number depends on the age of the woman, the quality of the embryos and the success rate of the programme concerned. In Singapore, a maximum of three embryos are replaced in the woman’s uterus.

The embryo is sometimes transferred after five to seven days. As a result, the embryo has had more time to develop and is referred to as a blastocyst. During this extra time, embryologists can better identify the best quality embryos for transfer. By transferring fewer but better quality embryos, the chances of success are improved and the risk of a multiple pregnancy is reduced. Not all embryos that begin the fertilisation process grow into a blastocyst. On average, 40 to 50% of the fertilised embryos develop into blastocysts so delaying transfer allows the “survival of the fittest”.

Back to top

frozen embryos (cryopreservation)

In the event that embryos remain after transfer, they may possibly be frozen in the laboratory. Freezing is only possible with good-quality embryos. The embryos have to be able to be frozen and, after thawing, replaced in a later cycle. For this reason there is strict selection procedure, which means only 10-15% of the remaining embryos are usually of sufficient quality to be frozen.

After thawing, the frozen embryos can be transferred in a normal menstrual cycle or in what is called a “cryo-cycle”, in which the woman takes hormone tablets to prepare the uterus for possible implantation. However, you must bear in mind that, once the embryos have been thawed and if the quality is insufficient, they may no longer be suitable for implantation.

The chances of success with transferring frozen embryos is lower than with replacing “fresh” embryos, but it is still an extra chance with less stress for the woman.

How you and your partner feel about the freezing and storing of embryos is a very personal matter. The ethical aspects are sometimes a source of discussion and it is important that you both reach an agreement about whether you would like to use this opportunity before you start an IVF/ICSI treatment.

Prior to commencement of the treatment, the centre will require a written instruction from you and your partner in which the conditions for storage are all set out.

Back to top

embryo transfer

After the puncture, the woman is often prescribed drugs to prepare the uterus (womb) for embryo transfer. Embryo transfer usually occurs two to three days after fertilisation. There are special criteria against which the quality of an embryo can be assessed.

Embryos can be classified into different quality categories. A good or perfect embryo is an embryo that the embryologist believes has a good chance of implantation. If an embryo is classified as “bad”, the theoretical chances of implantation are indeed smaller, but implantation is not ruled out. If this type of embryo does implant, it can develop into a normal pregnancy and a healthy baby.

However, embryos can usually only be assessed on external features. In some cases, closer examination of the embryo’s hereditary material can be done prior to the embryo transfer.

The best embryo, or the three best embryos at most, are placed in the woman’s uterus. The embryos are transferred into the uterus by inserting a thin tube, or catheter, through the cervix. The depth of the uterus is measured in advance to determine the right place for the transfer.

Transferring several embryos increases the risk of multiple births. A strict transfer policy (see below), is therefore adopted to try and limit the number of twins and multiple births due to the increased chance of complications. The maximum safe number depends on the age of the woman, the quality of the embryos and the success rate of the programme concerned.

The embryo is sometimes transferred after five to seven days. As a result, the embryo has had more time to develop and is referred to as a blastocyst. During this extra time, embryologists can better identify the best quality embryos for transfer. By transferring fewer but better quality embryos, the chances of success are improved and the risk of a multiple pregnancy is reduced. Not all embryos that begin the fertilisation process grow into a blastocyst. On average, 40 to 50% of the fertilised embryos develop into blastocysts so delaying transfer allows the “survival of the fittest”.

Back to top

frozen embryos (cryopreservation)

In the event that embryos remain after transfer, they may possibly be frozen in the laboratory. Freezing is only possible with good-quality embryos. The embryos have to be able to be frozen and, after thawing, replaced in a later cycle. For this reason there is strict selection procedure, which means only 10-15% of the remaining embryos are usually of sufficient quality to be frozen.

After thawing, the frozen embryos can be transferred in a normal menstrual cycle or in what is called a “cryo-cycle”, in which the woman takes hormone tablets to prepare the uterus for possible implantation. However, you must bear in mind that, once the embryos have been thawed and if the quality is insufficient, they may no longer be suitable for implantation.

The chances of success with transferring frozen embryos is lower than with replacing “fresh” embryos, but it is still an extra chance with less stress for the woman.

How you and your partner feel about the freezing and storing of embryos is a very personal matter. The ethical aspects are sometimes a source of discussion and it is important that you both reach an agreement about whether you would like to use this opportunity before you start an IVF/ICSI treatment.

Back to top

checkups

The egg cells are found in fluid-filled follicles in the ovaries. The size of a follicle provides an indication of the maturity of the egg cell. During the treatment, you will have frequent checkups at the outpatients department to track the reaction of the ovaries to drug therapy using vaginal ultrasonography. The size of the follicles and the viscosity (thickness) of the cervical mucus are measured at each check-up to determine the right time for the puncture. Blood may also be taken to measure the hormone levels.

Back to top

puncture

At the point when the egg cells are almost mature, ovulation is artificially induced by means of an injection of human Chorionic Gonadotropin (hCG).

It is crucial that this injection is carried out correctly and at exactly the stated time. This injection stimulates the final maturation of the egg cells so that they are released from the follicles. The egg cells are removed from the body by needle biopsy (puncture) 35 hours after the injection.

Puncturing the follicles is called follicle puncture. The puncture is carried out via the vagina with the aid of vaginal ultrasonography. You are generally given an anaesthetic for this, although practice may vary from clinic to clinic. The vaginal ultrasonic probe is fitted with a thin needle holder. A special hollow needle is then inserted into this holder. Both the needle and the follicles are visible using ultrasonography on the monitor. The follicles are punctured with the needle one at a time and aspirated (collected). You can follow the procedure yourself on the screen.

The egg cells and surrounding fluid are drawn into a tube, which is then transferred to the embryo laboratory. The whole procedure generally takes about half an hour. The puncture itself lasts approximately five or ten minutes depending, among other things, on the number and position of the follicles. You will only find out whether egg cells have been obtained during the puncture, and if so how many there are, after the embryologist has been able to examine the fluid obtained. The number of egg cells may be lower than the number of follicles punctured, either because not all the follicles contain an egg cell or some egg cells are not fully mature.

The pain or discomfort felt during the puncture may vary from patient to patient, but is generally well-tolerated. You may also feel some discomfort after the procedure. It is therefore sensible not to make any other plans for that day. Just as with every other medical intervention, puncture carries a small risk of complications. Haemorrhages and infection are two possible complications, but are relatively rare. In general, the recovery period is short.

Back to top

fertilisation

In the laboratory, embryologists then examine the fluid removed from the ovary for egg cells. The egg cells are graded according to their maturity, to see whether they are suitable for fertilisation. If fresh sperm is used, the male partner is asked to supply sperm. A semen analysis is then carried out and the sample is washed with a special nutrient solution to isolate the more motile sperm.

Then comes fertilisation. Exactly which process is used depends on the clinic and the type of infertility involved. In standard IVF, the sperm is placed in a dish along with the egg cells.

• Within 18 hours the embryologist can tell whether fertilisation has occurred.
• Within 24 to 72 hours the embryologist can tell whether the embryos are growing.

The sperm and the egg cells are placed in growth media; special nutrient solutions to give them the maximum chance to fertilise or to be fertilised. In conventional IVF, every dish containing an egg is filled with at least 50,000 sperms. In the laboratory, the embryos are then left, for between 2 - 5 days, to grow and divide into several cells. This is called an embryo culture.

Back to top

embryo transfer

After the puncture, the woman is often prescribed drugs to prepare the uterus (womb) for embryo transfer. Embryo transfer usually occurs two to three days after fertilisation. There are special criteria against which the quality of an embryo can be assessed.

Embryos can be classified into different quality categories. A good or perfect embryo is an embryo that the embryologist believes has a good chance of implantation. If an embryo is classified as “bad”, the theoretical chances of implantation are indeed smaller, but implantation is not ruled out. If this type of embryo does implant, it can develop into a normal pregnancy and a healthy baby.

However, embryos can usually only be assessed on external features. In some cases, closer examination of the embryo’s hereditary material can be done prior to the embryo transfer.

The best embryo, or the three best embryos at most, are placed in the woman’s uterus. The embryos are transferred into the uterus by inserting a thin tube, or catheter, through the cervix. The depth of the uterus is measured in advance to determine the right place for the transfer.

Transferring several embryos increases the risk of multiple births. A strict transfer policy (see below), is therefore adopted to try and limit the number of twins and multiple births due to the increased chance of complications. The maximum safe number depends on the age of the woman, the quality of the embryos and the success rate of the programme concerned. In Singapore, a maximum of three embryos are replaced in the woman’s uterus.

The embryo is sometimes transferred after five to seven days. As a result, the embryo has had more time to develop and is referred to as a blastocyst. During this extra time, embryologists can better identify the best quality embryos for transfer. By transferring fewer but better quality embryos, the chances of success are improved and the risk of a multiple pregnancy is reduced. Not all embryos that begin the fertilisation process grow into a blastocyst. On average, 40 to 50% of the fertilised embryos develop into blastocysts so delaying transfer allows the “survival of the fittest”.

Back to top

frozen embryos (cryopreservation)

In the event that embryos remain after transfer, they may possibly be frozen in the laboratory. Freezing is only possible with good-quality embryos. The embryos have to be able to be frozen and, after thawing, replaced in a later cycle. For this reason there is strict selection procedure, which means only 10-15% of the remaining embryos are usually of sufficient quality to be frozen.

After thawing, the frozen embryos can be transferred in a normal menstrual cycle or in what is called a “cryo-cycle”, in which the woman takes hormone tablets to prepare the uterus for possible implantation. However, you must bear in mind that, once the embryos have been thawed and if the quality is insufficient, they may no longer be suitable for implantation.

The chances of success with transferring frozen embryos is lower than with replacing “fresh” embryos, but it is still an extra chance with less stress for the woman.

How you and your partner feel about the freezing and storing of embryos is a very personal matter. The ethical aspects are sometimes a source of discussion and it is important that you both reach an agreement about whether you would like to use this opportunity before you start an IVF/ICSI treatment.

Prior to commencement of the treatment, the centre will require a written instruction from you and your partner in which the conditions for storage are all set out.

Back to top