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About 15% of married couples in Our Country suffer from infertility. And this number is growing year by year. There are many reasons for infertility. Early onset of sexual activity, sexually transmitted infections, inflammatory diseases of the reproductive organs, late pregnancy planning, and so on. IVF has become a routine procedure in many ways. What does it consist of.
Stage 1: Diagnosis of infertility
Infertility is diagnosed when there is no pregnancy within 1 year of regular intercourse without the use of contraception. If a woman is over 35 years old, this period is reduced to 6 months. Therefore, in the absence of pregnancy for 1 year in women under 35 years of age and 6 months in women over 35 years of age, it is necessary to consult a reproductive specialist.
– Many people think that a reproductologist only does what he does IVF. It is worth coming to him – and you are already on the protocol. In fact, there are strict indications for the IVF program. And without the need to do it, no doctor will not. There are controversial cases, there are situations of choice when we have time and opportunity to try other, more gentle methods. And most importantly, there is a chance that they will work, – comments obstetrician-gynecologist, reproductologist Yulia Golesheva.
The causes of infertility can be associated with health problems in both women and men. Among the possible causes of female infertility are the following.
- Lack of ovulation (eg, in polycystic ovary syndrome, premature ovarian failure).
- Obstruction of the fallopian tubes.
- Diseases of the uterus (endometriosis, uterine fibroids, malformations of the uterus).
- Diseases of the cervix (cervicitis, narrowing of the cervical canal).
- Immunological disorders (for example, the presence of antisperm antibodies).
- Infertility of unknown origin.
- Combined infertility (in the presence of both female and male factors).
The causes of male infertility include a number of factors.
- Various congenital anomalies of the testicles (hypogonadism or underdevelopment of the testicles, cryptorchidism or undescended testicles into the scrotum, congenital absence of the testicles).
- Infertility associated with exposure to harmful factors (infections, radiation, prolonged cooling).
- Injuries.
- Varicocele (dilation of the veins of the spermatic cord and testicle).
- Infertility of unknown origin.
– IVF is indispensable with the tubal factor, the absence of the uterus (IVF program with the involvement of a surrogate mother). As for men, about half of them are now diagnosed with infertility (1). This may be, for example, azoospermia, when there are no spermatozoa in the ejaculate at all, the doctor noted. – Only IVF will help here too.
Stage 2: Preparation for IVF
In vitro fertilization is a complex and multi-stage procedure that requires both physical and moral preparation. At the consultation, the doctor will definitely recommend that you first prepare the body for pregnancy. Give up all bad habits, distribute physical activity and eat well (2).
Psychological preparation is the most important. It is necessary to tune in to a multi-stage treatment and be prepared for a possible unsuccessful outcome. The most important thing during the procedure is a positive attitude and faith in success!
In order to make sure that the IVF procedure is possible, both a man and a woman must undergo a series of examinations and pass tests.
As the gynecologist Yulia Golesheva notes, IVF takes place in several stages:
- Conducting a preliminary examination of a married couple and determining a treatment regimen.
- Treatment of infections, hormonal abnormalities and disorders of spermatogenesis.
- Stimulation of superovulation (the maturation of several eggs in one woman’s menstrual cycle).
- Obtaining eggs by ovarian puncture.
- Fertilization of eggs “in vitro”.
- Growing embryos up to 2-5 day stage.
- Transfer of embryos into the uterine cavity.
- Hormonal support for early pregnancy after IVF.
- Pregnancy test to detect hCG hormone in the blood (12-14 days after embryo transfer).
- Ultrasound – diagnosis of pregnancy.
The list of necessary examinations for patients entering the IVF program is approved by the order of the Ministry of Health. Below is a complete list of them.
Tests for men
- Blood test for HIV, hepatitis B and C, pale treponema (3 months).
- PCR for Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, Neisseria gonorrhoeae (1 year).
- Spermogram (6 months).
- Andrologist consultation (6 months).
Analyzes for women
- Complete blood count (+ platelets) (1 month).
- Biochemical blood test (glucose, cholesterol, total protein, creatinine, total bilirubin, urea, AST, ALT) (1 month).
- Coagulogram (fibrinogen, APTT, RFMK) (1 month).
- Urinalysis (1 month).
- Blood type and Rh factor (once, indefinitely).
- Determination of antibodies to pale treponema in the blood (ELISA) (3 months).
- Determination of antibodies and antigen to human immunodeficiency virus (HIV) 1 and 2 (3 months).
- Determination of class M, G antibodies to hepatitis B and C viruses (3 months).
- Determination of antibodies of class M, G to the rubella virus in the blood, with a negative result for rubella, vaccination is mandatory, indicating the date of vaccination (once).
- Determination of antibodies of class M, G of cytomegalovirus and toxoplasmosis in the blood (6 months).
- Determination of antigens of herpes simplex viruses in the blood (PCR) (6 months).
- Determination of the hormonal profile on an empty stomach on the 2nd-3rd day of the cycle: FSH, AMH (6 months).
- Determination of the hormonal profile on an empty stomach on day 2-3 of the cycle: LH, prolactin, TSH, free T4, antibodies to TPO (1 year).
- Microscopic examination of smears from the cervical canal and vagina (for flora, purity, GN and Trichomonas) (1 month).
- A smear for oncocytology (1 year).
- Test for urogenital infections: PCR diagnostics for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium (3 months).
- Research on urogenital infections: PCR diagnostics for Ureaplasma spp. (parvum and urealyticum), Mycoplasma hominis, HSV DNA types I and II (qual.), CMV DNA (qual.) (1 year).
- Fluorography (1 year).
- Electrocardiogram (ECG) (1 year).
- Transvaginal ultrasound of the pelvic organs (2 weeks).
- Ultrasound of the mammary glands on the 7-11th day of the cycle, if pathology is detected, consultation of an oncologist-mammologist (1 year).
- Mammography for women over 40 years old, if pathology is detected, consultation with an oncologist-mammologist (1 year).
- Ultrasound of the thyroid gland (1 year).
- Endocrinologist consultation according to indications.
- Consultation of a geneticist in the presence of hereditary diseases.
– Depending on the indicators, the reproductologist may prescribe additional studies. In preparation for IVF, both spouses need to drink folic acid – 400 mg per day. Most importantly, remember – the examination before IVF is not carried out for show! The results of the analyzes allow us to adequately assess the possibilities and risks of the couple, choose the drugs and dosage, correct possible problems before entering the IVF protocol,” she said. obstetrician-gynecologist, reproductologist Yulia Golesheva.
Stage 3: Stimulation of superovulation
In order to get more eggs for subsequent fertilization, ovarian stimulation is performed. This process is also called “superovulation stimulation”.
To achieve the maturation of more eggs, daily injections of gonadotropins are prescribed – hormones that lead to the maturation of several eggs at once, and not one, as in a normal menstrual cycle.
The duration of this stage depends on the choice of stimulation protocol. The puncture of the follicles usually falls on the 12th-14th day, less often on the 13th-18th day of the cycle. The stimulation regimen (protocol, doses of drugs) is selected individually. The maturation of follicles is controlled by ultrasound. Stimulation of ovulation takes place under the close supervision of a doctor.
Stage 4: Puncture of follicles
When the follicles reach maturity, it is necessary to make a special injection – to introduce a trigger for the final maturation of the eggs. Follicle puncture and oocyte retrieval is carried out 35-36 hours after trigger injection, only after this time it is possible to obtain mature oocytes.
The procedure is performed under general anesthesia and is monitored by ultrasound. The doctor uses a special needle to take the follicular fluid and transfer the material to the embryologist. The embryologist selects the eggs for further fertilization. The more eggs you get, the better. Unused eggs in the protocol can be frozen for several years and used in a second IVF attempt.
Stage 5: Fertilization of the eggs
The resulting eggs and sperm are placed in a special incubator, in a nutrient solution at a temperature of 37°C and high humidity. This is where fertilization takes place.
In some cases, embryologists resort to intracytoplasmic sperm injection into the egg (ICSI). With this technique, the embryologist selects the most promising sperm and introduces it into the cytoplasm of the egg. The procedure is resorted to when the quality of the ejaculate or eggs is low, or the use of “frozen” eggs.
Step 6: Embryo culture
The day after fertilization, the embryologist determines how many eggs have been fertilized and monitors the development of the embryos over the following days. Some of them may lag behind in development or not develop at all. The most promising embryo is selected for transfer to the uterus.
Step 7: Embryo transfer
A few days after fertilization, the embryo is transferred to the uterus. Transfer is carried out using a catheter through the cervical canal. The procedure is painless and does not require anesthesia.
Stage 8: Pregnancy control and support
During a normal pregnancy, a corpus luteum is formed at the site of the ruptured follicle, releasing progesterone. This hormone is necessary for the development of pregnancy. The corpus luteum at the site of punctured follicles may not form or be defective. Therefore, after embryo transfer, patients require support with progesterone preparations, and sometimes in combination with estrogens.
– There are two types of IVF protocol – long and short, – continues the reproductologist. – The long protocol takes up to 40 days, the short one 25-30. We start a long cycle from 20-21 days of the cycle or 5-7 days before the onset of menstruation, stimulation begins on days 2-4. It lasts 10-14 days under constant ultrasound control. 36 hours before the puncture, we introduce a trigger (hCG injection). Next – puncture, fertilization, cultivation of embryos. And then according to the situation – transfer or cryopreservation. Short begins on the 2-3 day of menstruation. Everything goes the same as in the long protocol.
Which protocol to choose? Patients do not have this choice, only the doctor always decides. There is no single correct universal approach. It all depends on this particular situation. Trusting the doctor and following all the recommendations is the best thing you can do. But still, imagining how different schemes work is useful and interesting.
Popular questions and answers
Together with a reproductologist, we answer the most popular questions about IVF.
Who is IVF suitable for?
– Tubal infertility due to the absence of the fallopian tubes during their removal or obstruction.
– Infertility associated with endometriosis.
– Endocrine diseases that lead to disruption of ovulation.
– Uterine forms of infertility.
– Diseases of a hereditary nature (hemophilia, etc.). During the IVF procedure, embryos are diagnosed before transfer. Only genetically healthy embryos are transferred to the uterus.
– Male infertility. The partner’s spermatozoa are not capable of fertilization.
– Infertility of unknown origin.
– Premature ovarian failure.
IVF is contraindicated for people with severe mental and physical illnesses, abnormal development of the organs of the reproductive system, benign tumors of the uterus that require surgery, malignant tumors of any localization.
What new technologies exist in the field of in vitro fertilization?
How often are unsuccessful attempts?
As women age, a woman’s natural fertility declines. This is especially noticeable after 38 years. Likewise, the rate of successful IVF cycles will decrease with age. According to doctors, the whole point is that with increasing age, a woman matures fewer eggs and these eggs are of poorer quality, which, during fertilization, contributes to the formation of genetically unhealthy embryos.
The age of a man also affects the success of IVF, but to a much lesser extent.
Also, the outcome of the procedure is affected by the number of oocytes received, the woman’s ovarian reserve.
How much does the procedure cost and who pays?
The IVF procedure under the MHI policy may be denied for some reasons: with a low ovarian reserve, i.e. when there are few eggs in the ovaries, and donor eggs are required for pregnancy.
Under the compulsory medical insurance policy, it is only possible to conduct a basic IVF program with superovulation stimulation (with your own germ cells) free of charge. Donor programs (with the use of donor eggs, donor embryos), programs with the use of a surrogate mother are not paid from the Compulsory Medical Insurance Fund. Without stimulation, due to various reasons, the program is paid by the patients themselves.
The IVF procedure in case of refusal under compulsory health insurance or if desired, you can go through for a fee. The cost is calculated individually. On average, the price of basic IVF ranges from 110 to 150 thousand rubles. It includes all four stages of IVF with drugs for stimulation, provided that you use your own germ cells. Donor eggs and donor sperm are paid separately.
The necessary tests are also not included in the cost of basic IVF.
The cost of 1 egg is from 20 thousand rubles. The cost of donor sperm is from 12 to 35 rubles per 1 portion.
Pre-implantation genetic diagnosis of embryos, which allows to exclude genetic diseases in the embryo, is paid separately. As well as a biopsy of the trophectoderm of embryos for a biopsy of all embryos.
The transfer of previously frozen embryos can be carried out both free of charge under compulsory health insurance and on a commercial basis.
The cost of defrosting an embryo and transferring it to the uterus costs an average of 30 to 50 rubles.”
Sources:
- Yakovenko E.M., Yakovenko S.A. / In vitro fertilization (IVF) and other methods of overcoming infertility // 2016
- Kay Elder, Brian Dale / In vitro fertilization // 2008
- Kulakov V.I. / In vitro fertilization and its new directions in the treatment of female and male infertility // 2004