CRGW Ltd: 07029220
IVF & ICSI INFORMATION BOOKLET
The Unit
The Centre for Reproduction and Gynaecology Wales (CRGW) has been established to provide a full range of investigations and treatment for couples experiencing infertility. It is housed in purpose built premises. We offer preliminary investigations, ovulation induction, secondary sperm function testing, intrauterine inseminations, donor sperm treatment, in vitro fertilisation (IVF), intracytoplasmic sperm injection (ICSI), assisted hatching, oöcyte donation, and freezing of sperm and embryos. The Centre is fully licensed by the Human Fertilisation and Embryology Authority and all work is carried out in accordance with the Human Fertilisation and Embryology Act and the Authority’s Code of Practice.
The Team
The team includes senior medical, nursing, scientific and administrative staff that have many years of experience in infertility treatment. Our expertise and knowledge has been accumulated in some of the best Units in the UK.
We, as a team, believe in providing the highest quality of treatment and care while understanding the anxieties and concerns of the couple. We offer a caring sensitive approach within a dedicated and knowledgeable team who appreciate the nature and problems of infertility, both physical and emotional.
Natural Conception
Every month an egg is released from the ovary and moves slowly down the Fallopian tubes (tubes) towards the uterus (womb). If sperm have been released in the vagina during intercourse within the previous day or two these may have swum up to the tubes where they attempt to combine with the egg. If this union is successful, the fertilised egg continues along its path to the womb growing along the way. After 5 days, the embryo (as it is now called) begins to implant in the lining of the uterus. If this implantation is successful and the embryo establishes itself well, a pregnancy will result. If no sperm were present, or they did not fertilise the egg, the egg will continue towards the womb, be expelled and a period will begin (two weeks after the egg was first released).
What is IVF?
In vitro fertilisation (IVF) is a phrase, which describes the process by which the oöcyte or egg is fertilised by the sperm outside the body. Originally, this was carried out in glass dishes, which is how the term “in vitro” arose, as this literally means “in glass”. IVF involves the collection of eggs and sperm, which are then mixed in the laboratory under strictly controlled conditions.
The eggs, which fertilise normally, are left to grow for a further day or two to check that they are developing normally. In most women a maximum of two embryos are replaced in the womb (although the law allows us to replace up to three in patients over the age of 40), and if there are remaining embryos, which are of suitable quality, they may be frozen. The frozen embryos can be thawed and replaced at a future time.
What is ICSI?
ICSI stands for intracytoplasmic sperm injection and is a technique used for male factor causes of infertility such as a very low sperm count. The process is very similar to that in IVF cases, but the difference is that a sperm is injected directly inside each egg. By placing the sperm inside the egg it gives an opportunity for fertilisation to occur where it is not possible naturally due to poor sperm quality. This is still a relatively new technique that has been used routinely in the UK since the early to mid 1990’s. There are a number of specific risks associated with ICSI, they are:
· a reduced number of eggs being available for treatment (compared to IVF), due to eggs being immature or damaged by the process of ICSI
· children conceived having inherited genetic, epigenetic or chromosomal abnormalities (including cystic fibrosis gene mutations, imprinting disorders, sex chromosome defects and heritable sub-fertility). Genetic testing of the male partner is performed in cases where men’s sperm count is low.
IVF / ICSI Split
In some couples having IVF who have not had any pregnancies together, there is up to a 3% chance that the eggs and sperm will not fertilise. This risk can be reduced to 0.5% by using the ICSI process. Therefore couples undergoing their first cycle of treatment, we would advise that we fertilise half of the eggs by IVF and the other half by ICSI so that fertilisation rates and embryo quality can be compared between both methods to determine the best option for future treatments, if needed.
Who Can Benefit from IVF and ICSI?
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Couples having difficulty conceiving a child may be having a problem in any or several of the steps involved in natural conception. IVF and/or ICSI can help many couples including those in which the woman has blocked, damaged, or no fallopian tubes; the woman has the condition called endometriosis; the man has a reduced sperm count; the woman has problems ovulating or no cause of infertility has been found.
Patients We Treat
We recommend that to increase your chances of a successful treatment that you are the right weight for your height. A measurement used to help assess if you are within a healthy range is called Body Mass Index (BMI). A member of our team can work this out for you. Excess weight may not only reduce your chance of success but in extreme cases is associated with a significant health risk to both mother and baby.
When couples request treatment, we are by law required to take in to account the welfare of a future child. Our unit policy is to assess each couple individually.
The Treatment
There are four main stages, which IVF requires:
1. The use of special hormones to stimulate the ovaries to produce more than one egg.
2. Collecting the eggs from the ovaries. This is usually performed under sedation.
3. Preparation of the sperm sample for mixing with the eggs on the day of egg collection.
4. Replacement of fertilised eggs (embryos) into the womb.
During a natural cycle the ovary produces one and occasionally two eggs. For IVF the production of a greater number of eggs increases the chances of success and the ovaries can be “stimulated” to produce more eggs. The stimulation of the ovaries is achieved with hormones that are the same ones normally produced by the body. These hormones cannot be taken orally (by mouth) as they are digested and destroyed in the stomach and would not have any effect on the ovaries. These hormones are administered by injection and the clinic will instruct you on how to use and take these hormones.
Down-Regulation
The first stage of stimulating the ovary is to suppress the woman’s own hormone production in the pituitary gland (a small gland at the base of the brain which controls the ovaries). Switching off the pituitary prevents any activity within the body, which could interfere with the stimulation procedure. These drugs are called gonadotrophin releasing hormone agonist (GnRH-a) or antagonists. Treatment is usually started following a period of taking the contraceptive pill and continues right up until the day of egg collection.
The GnRH-a can be taken by nasal spray, depot injection (once a month) or daily subcutaneous injections. Exact instructions will be given by the clinic when your treatment starts. Side effects, which may be experienced with these drugs, are described below. A few days after starting GnRH-a treatment a period may occur. This signifies that the pituitary has been suppressed, called down-regulation.
Stimulation
After down-regulation has been achieved further hormones will be given in specific and timed daily doses, which will stimulate the ovaries. There are various types and brands that can be used and details will be given by the clinic when treatment begins. These hormones are given by injection under the skin. Each woman will respond slightly differently to these hormones and will be carefully monitored by the clinic. This is done by regular ultrasound scans (to look at and measure the ovaries). The ultrasound scan is performed using a small probe in the vagina from which the ovaries can be clearly seen. Ovaries contain follicles, which are small fluid filled sacs. These grow and develop in response to the stimulation hormones. As the follicles grow and develop so does the egg that is contained within the follicle (not every follicle will contain an egg).
At a suitable time when there has been enough stimulation of the ovaries a final injection is given which will cause the eggs to finish developing. This is called the human chorionic gonadotrophin (hCG). The clinic will instruct you to have this injection at a specific time, usually at night. It is very important that you have this injection at the time instructed because this is necessary to make sure that the eggs are well developed and can be collected. If you take this injection at the wrong time, we may not be able to collect any eggs or they may not be mature and the treatment will be compromised.
Egg Collection
The mature eggs are removed from the follicles so that they can be mixed with sperm in the laboratory. The egg collection is usually carried out under sedation, which is a sleepy state where you may feel some discomfort but will not be knocked out. An ultrasound machine is used to
watch the ovaries while the eggs are being removed. Your partner is welcome to be present at the time of egg collection.
As the ovaries have been stimulated they become enlarged and lie close to the top of the vagina. The egg collection is done with a fine needle, which is attached to a special guide on the ultrasound probe. The needle is passed through the wall of the vagina into the ovaries, which can be seen, on the ultrasound scan. The tip of the needle can be seen on the ultrasound and is placed in each follicle to remove the contents, which will also, hopefully, contain an egg. Every single follicle does not contain an egg and so there may be fewer eggs than the total number of follicles seen during the stimulation of the ovary.
The fluid collected from the follicles is passed to the Embryologist who will look at it under the microscope and find the eggs. The eggs are then put in a special fluid (culture medium) and placed in an incubator for a few hours prior to insemination.
Sperm Collection
On the day of egg collection a sperm sample is required, usually around the same time as the egg collection. The man should abstain from intercourse (ejaculation) for 2-5 days before the egg collection. Abstaining for shorter (less than 2 days) or longer (more than 5 days) periods can affect sperm quality and should be avoided. The sperm sample will be prepared to obtain a sample with many motile sperm, which are the sperm capable of getting to, attaching and hopefully fertilising an egg. The prepared sperm are then mixed with the eggs. The eggs will then be checked the following morning at which time the Embryologist will be able to find out how many eggs were fertilised. Occasionally, and unexpectedly, the eggs may not fertilise. The failure to fertilise may occur even if the eggs and sperm do not appear to have any problems.
Intracytoplasmic Sperm Injection
If there are sperm problems (low sperm count etc) then there may not be enough sperm to mix with eggs to achieve fertilisation. In this case the procedure of intracytoplasmic sperm injection (ICSI) is carried out. The sperm are injected into the egg and this improves the chances of fertilisation for couples with very low sperm numbers or no sperm in the ejaculate. The eggs are collected as described above and if they are sufficiently mature a single sperm will be injected into each egg. The egg is held with a fine glass pipette and a single sperm is identified and picked up with a very fine glass needle. The needle is then gently pushed into the egg and the sperm released. The injection needle is gently removed and the egg put away in the incubator.
The eggs are left overnight in the incubator and checked the following morning for fertilisation. As a needle is being placed in the egg, there is a risk of damage to the egg, which is expected to be around 10-15%, although in some cases the eggs may be more fragile and damage more easily.
Although there have been many babies born from this treatment, the first was only born in 1992 and therefore the long term safety of this technique is still not fully known.
Recent publicity regarding the risks associated with assisted conception techniques (IVF/ICSI) implied there is a slight increased risk of genetic/birth defects.
The risk of birth defects in the general population is low, 2% of children born in Europe are born with birth defects. Some research has suggested that there might be an increased risk for babies born as a result of IVF/ICSI. This risk rises to 2.6%, which is still very low.
However, the research cannot say with absolute certainty that this increase risk is due to the use of assisted conception techniques rather than other causes such as the age of the patient and the cause of infer
Training with Eggs, Sperm and Embryos
Consent will be sought from you to allow the lab to use any spare unfertilised eggs or spare embryos, or sperm samples for the training of laboratory staff in techniques such as ICSI (as above) or for the development of new techniques and services e.g. new embryo freezing techniques. Only eggs and embryos that are unsuitable for your treatment or storage will be used. No sperm will be inseminated or injected into any eggs. If you have any further questions regarding the use of your samples in training then please ask to speak to a member of the lab team.