IVF & ICSI

The history of In Vitro Fertilization (IVF) dates back as early as the 1890s when Walter Heape a professor and physician at the University of Cambridge, England, who had been conducting research on reproduction in a number of animal species, reported the first known case of embryo transplantation in rabbits, long before the applications to human fertility were even suggested. However it was not until 1959, that indisputable evidence of IVF, was obtained by Chang who was the first to achieve births in a mammal (a rabbit) by IVF.  

The first IVF pregnancy in humans was reported in 1973 by the Monash research team of Professors Carl Wood and John Leeton in Melbourne, Australia. Unfortunately, this resulted in an early miscarriage. 

In July of 1978 Louise Brown was born in Oldham, England, as the first baby to ever be born through IVF. This birth attracted attention all over the world and was the result of the collaborative work between Robert Edwards and Patrick Steptoe. It had taken them over 100 IVF attempts to achieve the first pregnancy which was carried to term. Initially, however, many colleagues as well as voices in the general public were critical. In 2010 the Nobel Prize in Medicine was awarded to Robert Edwards for the development of in vitro fertilization.  

It is estimated that over 8 million babies have been born worldwide through IVF, an achievement that gives hope to many couples who suffer with infertility. 

The purpose of this introduction is to acknowledge those, who initiated the steps for the development of IVF, the most important method for treatment of infertility. 

Our individualised approach means that every couple will vary in how their treatment is planned and managed. 

The IVF process involves the following steps:  

STEP 1- OVARIAN STIMULATION

Stimulation of the ovaries with hormones known as gonadotrophins is usually required for a period between 10 to14 days. The hormones are in the form of self-administered subcutaneous injections and need to be taken daily. The aim is to stimulate the ovaries produce multiple follicles simultaneously. Your response to the hormones is monitored very closely with daily hormonal blood tests and ultrasound scans on alternate days, to pick up the slightest changes, which will impact on the choice of medications and timings of treatment. Medications may be altered and dosages may be changed if required. This level of monitoring may be inconvenient in the short term, but we believe it is vital and can make the difference in the quality of the eggs you produce. This approach in treatment is strictly individualized and it is this attention to detail and dedication that contributes to excellence in results.

When the follicles in the ovaries reach the appropriate size we plan your egg collection. A trigger injection is given approximately 36 hours before the egg collection. The exact timing of the trigger injection and the egg collection is essential for the optimal outcome with regards to the egg quality and quantity.

STEP 2- Egg collection

On the day of the egg collection you need to present at the clinic in the morning, having had nothing to eat or drink from midnight the night before your procedure. Nail polish, make-up, jewellery and contact lenses should be removed prior to coming in. Prior to moving to the operating theatre you will be reviewed by the cardiology and the anaesthetic team and you will be asked to sign the relevant consent forms.

Egg collection is a day case procedure, which usually lasts for approximately 20 minutes and is performed under light sedation. With the use of a fine needle under ultrasound guidance, the fluid in the follicles in each ovary is aspirated and the eggs are obtained.

Following the procedure you will be given antibiotics and painkillers and you will be taken to a recovery room to rest, for approximately 2-3 hours. Once you are fully awake and able to eat, drink and pass urine, you will be able to leave the clinic. You are strongly advised to arrange for someone to drive you home and avoid driving for 24 hours.

STEP 3- Fertilisation and embryo culture

Shortly after the eggs are retrieved, the male partner produces a semen sample. Frozen or donor sperm may also be used.
The eggs and the sperm are put together in a culture dish and incubated overnight to undergo fertilisation and create the embryos. As with a natural conception, once the eggs are exposed to the sperm, many sperm will attach to the egg but usually only one sperm will enter each egg. This process is known as fertilisation.
If there are concerns with regard to sperm quality, a variant of IVF known as ICSI (intracytoplasmic sperm injection) is likely to be advised to achieve fertilisation. This involves the injection of a single sperm selected by the embryologist directly into the egg.

Following fertilisation, the embryos are cultured in the laboratory under optimum conditions, resembling the natural environment and are monitored regularly by our embryologists to make sure they are developing normally.

Two to three days after the egg collection, the embryos have usually divided into four to eight cells. They subsequently continue to develop and by day 5 they reach the “blastocyst stage”. The embryos are then scored against a specific grading system, which allows us to select the best possible embryo(s) for transfer.

Whenever appropriate, we aim to culture the embryos for five or six days, to allow them reach the “blastocyst’ stage”, which is likely to improve the chances of success. However, If only a small number of embryos are available, then the embryo transfer will be scheduled on the 2nd or 3rd day following the egg collection.
Embryos that are not transferred will be assessed for suitability to be frozen for future use. In most cases, we would only advise freezing top quality blastocysts to secure a high chance of surviving the freeze/thaw process (>90%).

STEP 4- Embryo transfer

Embryos will usually be transferred on Day 3 or 5 but may, on occasion, be transferred on Day 2 or 6 after egg collection.

What will determine the number of embryos we transfer are your age, your previous reproductive history and the quality of your embryos.

We always adhere to rules laid out by the Greek National Authority of Assisted Reproduction, which dictate the number of embryos allowed to transfer.

We give you pictures of your embryos and we show you them on a screen, via a camera we have placed in the laboratory. We then transfer your embryos to your uterus using a soft catheter, which is gently passed through your cervix.

The procedure is painless (similar to a smear test) and you do not need any sedation. We always encourage your partner to attend the procedure.

STEP 5- After- care

The days following the embryo transfer are crucial for the implantation of the embryo(s). Therefore we continue the close monitoring to pick up even slight changes in your hormone levels, which could negatively affect the outcome if left undiagnosed. You will be taking progesterone supplements, which could be in the form of pessaries, vaginal gel, subcutaneous, or intramuscular injections, during that time to support the lining of the uterus. Medications are often adjusted as a result and tailored to your body’s needs to promote the embryo implantation.

The pregnancy test will be 15 days after the egg collection. In the event of a positive pregnancy test, the frequent monitoring of your pregnancy hormonal levels to ensure optimal levels and the progesterone supplementation are both continued. An ultrasound scan is usually performed 2-3 weeks later to confirm the viability of the pregnancy.

We continue communication with our pregnant patients throughout the pregnancy, often adjusting their medication and providing advice and support whenever necessary.

Should your pregnancy test, unfortunately, be negative then you will be offered a Skype or face-to-face, free of charge follow-up consultation with Dr Diamantopoulos, to discuss the details of your treatment, get answers to your questions and be advised on the best way of moving forward.

According to the rules laid out by the Greek National Authority of Assisted Reproduction the highest number of embryos that can be transferred is as follows:  

• For women below the age of 35, a maximum number of 2 embryos are allowed. 
• For women above the age of 35 and below the age of 40, a maximum number of 3 embryos are allowed only if they have a history of 2 or more previously unsuccessful embryo transfers, otherwise the maximum number of embryos allowed are 2 
• For women above the age of 40, a maximum number of 3 embryos are allowed. 
• For women above the age of 43, a maximum number of 4 embryos are allowed. 

The Greek Law permits fertility treatment (all kinds) for women up to the age of 50. 

Although significant complications are uncommon with IVF treatment, the potential risks are listed below: 

Medication related side effects

Some women do experience side effects from the fertility drugs they take during the stimulation, which are usually mild. The most common side effects include a local reaction at the injection site, dizziness, mood swings, hot flushes and feeling bloated. 

Ovarian Hyperstimulation Syndrome (OHSS) 

It is a serious complication arising in a very small proportion of women undergoing IVF. It is due to the over-response of the ovaries to the fertility drugs in certain patients, such as those with polycystic ovaries and those of younger age. Symptoms include abdominal discomfort, swelling of the abdomen due to enlarged ovaries, nausea, vomiting, weakness, shortness of breath, thirst, decreased urine output and dehydration. 

OHSS normally occurs in the week after the egg collection or just after the embryo transfer. In most cases the condition is mild or moderate with self-limiting symptoms and can be managed conservatively. It is only very rarely that women developing the condition will require hospitalisation and intensive care treatment. OHSS does not persist beyond the first three months of pregnancy. Patients who are not pregnant should recover by the time their next period is due.  

Dr Diamantopoulos has extensive experience in the prevention and management of this condition. Those at increased risk are identified and specific measures, such as intravenous fluid infusion and freezing of all embryos for transfer in a later cycle, are implemented. 

Multiple Pregnancy

The incidence of multiple pregnancies is higher among women who conceive following IVF treatment compared to women who conceive naturally.  

Multiple pregnancies, including twins and triplets in particular, are associated with risks. Miscarriage and preterm delivery with its associated higher chance of the babies suffering both short- and long- term difficulties, are both complications more frequently seen in multiple pregnancies as opposed to pregnancies with one baby. 

It is important to be aware that although the majority of IVF twins are  

non-identical, originating from different embryos, identical twins can also occur when one embryo splits into two. Multiple pregnancies with identical twins carry an even higher pregnancy complication rate. 

For these reasons multiple pregnancy is an undesirable outcome of IVF, therefore transfer of three embryos is limited to women over forty years of age or to younger women with more than previous 2 unsuccessful IVF treatments. 

Miscarriage

Approximately 20-25% of all IVF pregnancies will miscarry. This is slightly higher than for naturally conceived pregnancies, largely due to the proportion of older women attempting IVF and possibly due to the presence of contributing factors associated with some types of infertility.  

Ectopic/ Heterotopic Pregnancy

This is a pregnancy that implants outside the uterine cavity, most commonly in one of the fallopian tubes. The incidence of ectopic pregnancy with IVF treatment is approximately 2- 3%. It is a potentially serious condition, that may be indicated by fluctuating hormone levels, bleeding and abdominal pain and can be detected very early in the pregnancy by ultrasound scan. The pregnancy cannot continue and therefore must be either removed surgically or in selected cases a conservative or medical (use of drugs instead of surgery) approach could be considered. 

If two or more embryos have been transferred there is a tiny possibility of a “heterotopic pregnancy” where one implants in the correct place and one implants in the tube.  

 

“Freeze-all” 

Occasionally following the commencement of stimulation in an IVF cycle, a series of conditions could be identified, that may reduce the chances of the embryo we transfer to successfully implant in the uterus or potentially put you at risk.  

Such conditions include:  

• High progesterone levels prior to egg collection. 
• Very high oestrogen levels, which are associated with increased risk of severe ovarian hyperstimulation. 
• The presence of a fibroid or a polyp within the uterine cavity.
 
• The presence of a hydrosalpinx (dilated fluid-filled tube). 
• A thin endometrium. 
 

In these circumstances it is likely to offer you the “Freeze-All” approach.  

That means to continue with the stimulation, have your eggs collected and fertilized and electively freeze the embryos instead of proceeding with an embryo transfer. These embryos can be thawed and transferred in a future cycle. An alternative would be to have your cycle cancelled, address the problem and start a new stimulation in the future. 

 

Poor Response/ No Eggs

Although ultrasound scans and results of hormonal blood tests are useful tools to monitor the ovarian response, in some cases the ovaries fail to respond adequately to stimulation, resulting in acquiring less than expected or even no eggs at the egg collection, despite satisfactory ultrasound scans and adequate hormonal levels.  

In these cases, it is possible that the follicles are empty or the eggs inside the follicles are immature or abnormal. Another reason would be that ovulation may has occurred before the time of egg collection. 

 

Failure of Fertilisation

Sometimes the eggs may not get fertilised, or may get fertilised but the resulting embryos may stop growing. This may be due to suboptimal sperm quality, poor egg quality or a combination of both. 

Many women are concerned whether the hormones administered during the stimulation process of the ovaries can cause malignancies and, specifically, breast cancer. This is a myth, which has not been proven to be true. According to large epidemiological studies, conducted worldwide, including hundreds of thousands of women there is no difference in the incidence of breast cancer between women who took and those who didn’t receive hormones during fertility treatments. 

Nevertheless, hormones should be used cautiously and women should receive the “right” amount rather than take excessive dosages of the hormonal drugs. 

A common misconception is that an IVF treatment may reduce the number of the remaining eggs in women. That is not true. 

In a natural menstrual cycle, a number of follicles containing eggs are recruited from the stores in the ovaries, in response to the natural Follicle Stimulating Hormone (FSH) and initially all begin to grow. However only one follicle becomes the dominant follicle, continues to grow and is the one that ovulates and releases the egg within it, while the rest of the follicles regress. 

In a stimulated IVF cycle the administration of hormonal (FSH containing) injections, makes the above process more efficient by stimulating simultaneously multiple follicles to continue growing, thus allowing the collection of as many eggs as possible. Those follicles are not any more than those already recruited through the natural process. 

Therefore there is no long-term adverse implication to the fertility potential or any risk of earlier menopause. 

For you, the following tests are required:  

• Anti-Mullerian Hormone (AMH)- (within 1 year of treatment) 
• A full hormone profile done between the 2nd – 3rd day of your period (within 1 year of treatment). That would include the following hormones: FSH, LH, Oestradiol (E2) and Prolactin 
• Blood group and Rhesus status 
• Haemoglobin electrophoresis, to exclude carriers of thalasaemia or sickle cell disease 
• Rubella IgG, to check for immunity to Rubella 
• CMV (cytomegalovirus)- only if you are using a sperm donor 
• FBC (within 2 months of treatment)  
• Thyroid stimulating hormone (TSH) (within 2 months of treatment)  
• Vitamin D (within 2 months of treatment) 
• Screening for Cystic Fibrosis 
• Chlamydia test (within 2 years of treatment)  
• Cervical smear (Pap- test)- in line with national screening guidelines  
• Mammogram – if aged 40 years or above – In view of the increased prevalence of breast disease we would recommend screening prior to commencing a treatment (unless one has been performed within the last 3 years).  

Furthermore the following blood tests are mandatory for you and need to be done within 6 months of the treatment:  

• HIV  
• Hepatitis B surface antigen (HBsAg)  
• Hepatitis C (Anti-HCV) 
• Syphilis 

A baseline ultrasound scan to exclude conditions such as ovarian cysts, uterine polyps or fibroids and/ or fluid-filled fallopian tube (hydrosalpinx) which can severely reduce the chances of a pregnancy if left untreated, needs to be done before embarking into a fertility treatment. If any of the above findings are present then a surgical procedure, hysteroscopy or laparoscopy may be recommended prior to starting your treatment.

If you have a male partner/ husband using his own sperm he will need to have the following tests: 

• Blood group and Rhesus status 
• Haemoglobin electrophoresis, to exclude carriers of thalasaemia or sickle cell disease 
• Screening for Cystic Fibrosis 

• Semen Analysis & Sperm culture (within 12 months of treatment)  

Furthermore the following blood tests are mandatory for him and need to be done within 6 months of the treatment: 

• HIV  
• Hepatitis B surface antigen (HBsAg)  
• Hepatitis C (Anti-HCV) 
• Syphilis 

BE AWARE THAT FURTHER TESTING MAY BE ADVISED BASED ON YOUR HISTORY 

Whether requiring donor sperm due to significant male factor fertility problems, or as a woman with no male partner we will give you all the information you need to help you find a suitable donor and source the donor sperm. You need to take into consideration that according to Greek Law, sperm donation is strictly anonymous. 

We collaborate with the most reputable International and Greek sperm banks and we are confident that the highest standards are met regarding the safety and the selection of their donors.  

Once you have chosen a donor, the sperm will arrive to us within a week and your treatment can start. 

A counselling session for everyone using donor sperm is highly recommended. An open discussion about the implications of the treatment can give answers to your questions and help you deal with any concerns or fears you may have. You should always remember that the ultimate decision is yours.