IVF (In-vitro Fertilisation) is a fertility treatment used to help couples conceive if they can’t conceive naturally. In-vitro means ‘inside the glass’ so IVF is essentially combining eggs and sperm in a petri dish in a laboratory to achieve fertilisation.

The process of IVF initially involves obtaining a sperm sample and a number of eggs. The sperm sample is obtained from the male by ejaculation.

The eggs are harvested from the woman after a process of ovarian stimulation. This involves temporarily shutting down (called down-regulation) of the woman’s own natural menstrual cycle. The natural menstrual cycle involves 1 dominant follicle or occasionally 2 follicles to develop and mature each month. 1 (or 2) eggs ovulate each month. In preparation for IVF, this cycle is shut down and instead the ovaries are stimulated, by injecting gonadotrophin hormones, to encourage numerous follicles to develop and grow. The aim is to safely obtain as many eggs as possible without overstimulating the ovaries. The eggs are removed by extraction using a needle and ultrasound guidance (under sedation).

If there are no known problems with the quality, motility, shape or number of the sperm (i.e., no history of male factor infertility) then IVF involves combining a sperm sample and eggs (obtained by egg harvesting from the ovaries) in a petri dish under lab conditions and waiting for the sperm to penetrate the eggs and fertilise. The aim is to have at least one embryo but ideally multiple embryos. The growth of these embryos are monitored under special conditions. The divide and develop into blastocysts (day 5). The embryologist will decide when is the best day for the embryo or blastocysts to be transferred into the woman.

ICSI

ICSI (Intra-cytoplasmic injection of sperm) is a form of IVF. It is the process of injecting a single sperm into a mature egg to achieve fertilisation. This technique is used when the spontaneous fertilisation of the eggs with sperm during IVF has not been successful or when there are not enough sperm to fertilise eggs during conventional IVF with the sperm. These problems are usually related to abnormal sperm properties. The sperm may be obtained from ejaculation or if there is azoospermia (no sperm in the semen) by a surgical sperm retrieval. The healthiest sperm are selected for injection.

There is often a misconception that IVF is the first step in fertility treatment for everyone. Is this true?

IVF is not the first step in treatment for everyone. For some couple’s IVF at the first stage is the only option e.g., women with premature ovulation failure, using frozen eggs or donor eggs for medical reasons e.g., after certain cancer treatments, male factor infertility. Every individual or couple who are having difficulty conceiving will undergo investigations to try to understand if there is an underlying cause and also if that underlying cause can be treated.

IVF is used when an individual or couple are not able to conceive naturally. There are many instances where a couple may be able to conceive naturally with medical assistance so other options may be more relevant at the initial stages.

Ovulation Induction

Ovulation induction may be indicated in a woman who is not ovulating (anovulation) or ovulating infrequently. This often presents as irregular or absent menstrual periods. If a woman is ovulating infrequently or not ovulating at all, they may be suitable to take drugs that stimulate ovulation. Those who may be experiencing ovulation disorders are usually classified into three groups (by the WHO) I, II and III, and different procedures are used as a result.

Ovulation induction can include an injection of a combination of the hormones gonadotrophins (FSH and LH) but at an amount that only encourages 1 or 2 follicles to develop. Once the follicles are mature, an HCG injection is given to release the egg and the couple is advised to have sex.

Ovulation induction with clomiphene citrate (Clomid) is most commonly used for those who suffer from PCOS. Metformin is another drug that may be used or a combination of clomiphene citrate and metformin if clomiphene citrate isn’t successful. Laparoscopic ovarian drilling is another treatment that may be offered or gonadotrophins e.g. Letrozole may be used if Clomid is not successful, if there are problems using Clomid or not tolerated. The ovaries are monitored by ultrasound scan and again sexual intercourse is advised at a particular time.

Those who fall into WHO Group III ovulation disorder are females with ovarian insufficiency and lack of viable eggs, so ovulation induction is not used as a form of treatment. These women may be offered IVF if possible, using their own eggs or using donor eggs.

Intra-uterine Insemination (IUI)

Some couples may be suitable for intra-uterine insemination (IUI) rather than IVF at the first stage. This includes people in same-sex relationships or individuals using a sperm donor, people who may not be able to have sex e.g., disability or problems having sex, people that may require treatment of sperm before insemination e.g., if man is HIV positive.

Success rates vary between treatments and between individuals. The Fertility treatment 2018: trends and figures guide is certainly worth a read as it provides information on IVF success rates including the IVF success rates with donor eggs.

The information gathered by the HFEA on individual clinic success rates can also be a useful guide, but I wouldn’t advise anyone to select their clinic based on success rates alone. This is because the success rate can vary according to a number of factors including the age of the patient, the complexity of their fertility and/or medical history, the number of previous IVF cycles, whether they required any additional medical treatments or IVF add-ons etc.

Your fertility specialist should be able to provide a guide for your success rate, based on your individual.

Success rates can be underreported or may not be accurately reported because of loopholes. I was a patient at a clinic that had some of the ‘best success rates’ in the country but I ended up having my embryo transfer in one of their satellite clinics (which I did not know until just before the transfer). Therefore, my failed cycle would have been registered under a different clinic and would not have affected the success rates published for the clinic that I actually attended and paid for treatment.

Important: Please note that my answer is based on opinion rather than facts. I haven’t reviewed evidence on this particular topic of myths.

My opinion: There is a perception that IVF or adoption or surrogacy are easy and available solutions to help anyone who isn’t able to conceive. Certainly, these are always the solutions that people refer to when I share details about my infertility experiences. There is a lack of general understanding about these other options including the processes that need to be undertaken to pursue these routes. Egg donation is discussed less frequently. Egg freezing is being discussed more frequently but more with curiosity rather than certainty.

I recall there was a time where it seemed like many women were conceiving twins from IVF treatment, so it was seen as a way to have a complete family in one go. IVF was frequently talked about as an option for those who wanted to delay ttc for social reasons e.g., until they had established their career or found the right partner. Now egg freezing is slowly being considered as an alternative option to help fertility preservation. Egg freezing does require IVF to be successful.

The lay person also doesn’t understand what IVF involves and how physically and emotionally demanding the treatment is as well as the reality of the success rates and costs. Overall, the impact of infertility on social, physical and psychological wellbeing was not being emphasised.

I do believe slowly these perceptions and myths are changing particularly as more people are sharing their stories and truths about their struggles with IVF, pregnancy loss, using egg donors as well as sharing their experience of the adoption process and surrogacy as well as more people discussing childlessness. Fertility awareness is improving, and I believe the attitudes towards infertility will change as a result. So do I Belinda, so do I.