In-Vitro Fertilisation (IVF) and Intra-Cytoplasmic Sperm Injection (ICSI)

Counselling and consent

There will be a session where the clinician will explain and discuss the procedure with you. Any questions that you have about the treatment can be raised at this time. This will enable you to fully understand the treatment you are about to embark on. You will also need to make some decisions regarding unfertilised eggs and abnormal/poor quality embryos.

A written consent for IVF/ICSI and cryopreservation/thawing of the embryos is also obtained.

You will also need a separate session by our IVF counsellor on the emotional and physical demands of undergoing the treatment programme and dealing with disappointments of failed attempts.

Pre-programme preparations

Blood tests have to be performed to exclude venereal diseases such as syphilis, human immunodeficiency viruses (HIV), hepatitis B and acquired immunodeficiency syndrome (AIDS). A rubella antibody test will also be carried out. You will be advised to have a rubella vaccination before the IVF procedure if you have no immunity against it. You should also start taking folate daily.

Your husband will have a pre-IVF semen analysis to determine any need for the sperms to be frozen and stored.

A typical IVF cycle

1. Controlled ovarian hyperstimulation and monitoring
   Hormone injections are administered to stimulate the production of multiple eggs in each ovary (versus the usual production of a single egg per month), which hence results in a better chance of pregnancy.
   
   This stimulation process usually requires the initial daily use of a GnRH agonist injections (e.g., Lucrin) to suppress the body’s spontaneous ovulation, and to ensure that the ovarian follicles grow in a synchronous fashion. It usually starts in the second half of your menstrual cycle and continues for about 14 to 20 days. Some patients may need to take this medication for longer periods. Blood tests and ultrasound scans will be done to ensure that the optimum response is reached. Once this is achieved, you will proceed to the gonadotrophin injections.
   
   Daily gonadotropin injections (e.g., Gonal-F or Puregon) into the muscle/subcutaneous tissue of your thigh or buttock are then added to stimulate growth of the follicles in the ovaries. After several days of gonadotrophin injections, an ultrasound scan is performed to determine the number and size of the growing follicles. You will need additional injections if the follicles have not reached the desired size.
   
   Transvaginal ultrasound scan showing follicles in the ovary after hormonal stimulation
   
   When the follicles have reached the desired size, an injection of human chorionic gonadotropin (hCG) is given, with the discontinuation of GnRH agonist and gonadotrophins. The hCG is required for the final maturation of eggs before egg collection. The egg collection is scheduled about 36 hours after the HCG injection.


2. Sperm preparation
   During the gonadotrophin injections, your husband need not abstain from sexual intercourse before the egg collection. On the day of the egg collection, your husband needs to produce a fresh masturbated semen sample.


3. Oocyte pick-up (egg retrieval)
   Oocyte pick-up is performed by placing a special needle attached to an ultrasound vaginal probe into the ovary, and removing the oocyte-cumulus complex (containing the egg). A mild sedative will be given to you, as only minimal discomfort will be experienced during the procedure.
   
   After the egg collection, you will be observed for a few hours before going home. Multiple eggs may be retrieved at a time depending on the success of the stimulation process. It is important to understand that not all follicles will necessarily contain an egg and that some of the eggs may not be ripe enough for fertilisation. An overnight fast is required before oocyte pick-up procedures.
   
   Hormonal stimulation induces superovulation; eggs aspirated from the mature follicles transvaginally with ultrasound-guided needle


4. Fertilisation
   Following egg retrieval, sperm is added to the eggs in a dish to allow fertilisation to occur by natural selection in the laboratory. A check to confirm that fertilisation has occurred is carried out the following day. Unfortunately, in about 10% of couples, there is no fertilisation at all.
   
   Intra-cytoplasmic sperm injection (ICSI) may be performed on the day of oocyte pick-up if the sperms quality is poor or if you have had difficulties with fertilisation in the past. During the procedure, a single sperm will be injected into each egg via a microneedle. On the following day, a check is made to confirm that fertilisation has occurred.


5. Embryo transfer
   Fertilised embryos are transferred into the uterus between day two and day five of fertilisation using a fine catheter. This is usually painless and takes only a few minutes. An overnight fast is recommended before the embryo transfer procedure. We encourage your husband to sit in during the embryo transfer.
   
   Usually, a maximum of two embryos are transferred at a time. A smaller number may be transferred if there are insufficient embryos or in younger patients. Up to three embryos may be transferred under exceptional circumstances (please ask your doctor for more information).
   
   You may go home shortly after the embryo transfer. You will be given hormones either orally, vaginally or even by injection to support the lining of the uterus and to enhance the chances of the embryos implanting. There is no restriction on activities including sexual intercourse.
   
   Eggs fertilised in-vitro (IVF) with sperms. Embryo transferred directly into uterus, bypassing tubal occlusion.


6. Freezing of extra embryos
   A proportion of patients may have excess good quality embryos. These may be frozen for future use. Patients do not need to undergo controlled ovarian hyperstimulation and egg collection again for these future thaw cycles. The survival rate for thawing these embryos is about 83%. There is an annual storage fee for these frozen embryos, and they can be stored up to 10 years at our facility.


7. Testing for Pregnancy
   You will need to come back between 14 to 17 days after the embryo transfer for a pregnancy test, which measures the pregnancy hormone b-hCG in the blood. If you are pregnant, subsequent ultrasound scans and blood tests will be arranged to ensure that the pregnancy is proceeding normally. If you are not pregnant, you may consider proceeding to a frozen (thaw) cycle of IVF if you have additional frozen embryos in storage.
   
   You should call your healthcare team if you are menstruating, so that further instructions can be given.