It is a technique for assisted reproduction in which the eggs obtained after ovaric stimulation are fertilized by the spermatozoids in the laboratory. The embryos obtained in this way are transfered to the patient's uterus. IVF has four phases: ovaric stimulation, ovarian puncture, fertilization of the ovule, and embryo transfer. These four phases are now described.

During the natural menstrual cycle, many follicles start to develop inside each ovary. Follicles are small cysts filled with liquid that contain the ovules. When one of these follicles - during the natural cycle - reaches a bigger size, there is an inhibition in the growth of the rest. With the treatment larger number of follicles developing (within reason), we obtain a larger number of ovules for the embryo transfer.

Before starting the ovaric stimulation, a selective inhibition of the hypophysis is carried out to avoid spontaneous ovulation. This is normally done under the so-called "long protocol". With this process inhibition starts on day 21 of the cycle, before menstruation. Inhibition is achieved with a medication applied subcutaneously (Decapeptyl® /Procrin®) or nasally (Synarel®), daily, until two days before the puncture.

The patient will contact our Medical Center as soon as she starts menstruation to schedule a visit where we will make an ultrasound scan. The same day of the visit the patient will have a blood test. The result of the test will be sent to our Medical Center in a few hours. If the ultrasound scan results and the blood test results are correct, we will start the ovaric stimulation with medication (Puregón® / Gonal F® / Menopur® / Luveris®) containing follicle-stimulating hormone (FSH) and/or luteinizing hormone (LH). These hormones are applied subcutaneously.

With the ultrasound scan, the number of follicles in each ovary and their growth can be controlled. According to the result of these controls, the dose will be adjusted in each particular case to achive optimum results. Ovaric stimulation lasts between 10 to 13 days. When in the ultrasound scan a minimum of 3 follicles over 18mm can be observed, the stimulation phase is considered to be over, and ovulation is induced with a medication called Ovitrelle 250®. Ovulation will happen 36 hours after having applied the medication. It is very important to observe the time of the application, because the ovules reach their optimal maturity not long before ovulation. Because of this, the extraction of the ovules will be done 35-37 hours after having taken Ovitrelle 250©.

In this phase the extraction of the ovules takes place with the puncture of the ovarian follicles. This extraction is done with trans-vaginal ultrasound-scan control. A needle is adapted for the trans-vaginal ultrasound-scan. The ovarian follicles are punctured trans-vaginally under ultrasound guidance. With an aspiration system connected to the needle, the follicular liquid containing the ovule is collected and stored in test tubes. These tubes are handed over to the biologists, who immediatly put them under the microscope to observe and isolate the ovules.

The ovarian puncture is not painful. The anesthetist induces a deep sedation so that the patient will be asleep and will not feel any discomfort. For this it is important to come with an empy stomach to the Clinic.

The follicle puncture is a day surgery operation that lasts approximately 30 minutes. After the operation the patient goes to the recovery area. During this recovery period the gynecologist or the biologist will inform the patient of the number and quality of the ovules that have been extracted.

Aproximately one and a half hours after the puncture the patient is discharged from the Clinic. We recommend the patient to rest during the remainder of the day.

The number of ovules that are obtained per cycle vary depending on the woman. We can generally say that the number fluctuates between 7 and 12 per puncture. The number of ovules obtained is normally different from the number of follicles observed during the ultrasound controls.

We also have to mention the possibility of not obtaining ovules during the puncture. Although this possibility is quite exceptional, it can happen that the follicles are not accessible, an unexpected ovulation has happened, or the ovules are so immature that they can not be recovered.

The same day of the puncture, in the evening, vaginal progesterone (Utrogestan 200mg) is administered. It will be applied three times a day until the day of the pregnancy test.

The sperm has to be obtained not much later than the ovarian puncture. There has to be a previous period of sexual abstinence of 3 to 5 days. Before obtaining the semen through masturbation, it is necessary to urinate and wash hands and genitals only with water. It is recommended that the sperm be produced and collected in the Clinic, although this can also be done at home.

During the 24 to 48 hours following the puncture, there can be slight feelings of discomfort in the abdominal area and slight vaginal bleeding, which is normal. For any questions contact our Medical Center.

 Ovarian puncture

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After the puncture, the ovules are classified in the laboratory according to their degree of maturity. They are incubated between one to eight hours before the insemination, in culture mediums of 37ºC and in an adequate atmosphere. If any of the ovules obtained do not present a sufficient degree of maturity in order to be inseminated, the culture time can be extended and insemination can even be done the next day.

On the day the ovules are extracted, the semen sample is prepared for fecundation. The seminal fluids which might inhibit fertilization are eliminated.

The semen sample is prepared in such a way that after being processeced, it is rich in spermatozoids with good mobility; immobile ones are eliminated because they have a smaller fertilizing capacity.

OVULE INSEMINATION METHODS

1.-In Vitro Insemination or Conventional IVF

Insemination of the ovules is done with about 100.000 mobile spermatozoids per ovule. The ovules and the spermatozoids are kept together in the incubator until the next day, when it is possible to evaluate if fertilization has taken place.

Intra Cytoplasmic Sperm Injection (ICSI)

The intra cytoplasmic sperm injection involves the introduction, with a micro needle, of a spermatozoid in the ovule's cytoplasm. After the first birth using the ICSI technique, published in 1992, this method has been applied worldwide to treat severe male factor infertility.

The fertilization rate with conventional in-vitro fertilization or ICSI is approximately 70-80% respectively. When the embryo quality - obtained with either of the two techniques - is similar, the pregnancy possibilities are the same.

The day afer the puncture (called 'day one') the gynecologist will contact the patient to let her know how many ovules have managed to be fertilized. On this 'day one' embryos are in Xpro-nucleoX phase, when the embryo is made of only one cell. From here onwards, the embryo starts to divide and goes to have from 2 to 4 cells after the puncture and 8 or more cells three days after the puncture.

The embryo transfer is done 2 or 3 days after the puncture. The day and the time are communicated by the gynecologist.

The embryo transfer is a very simple method: it is done through the vagina and it does not require anesthetic.

On the day of the transfer, the biologist selects the 2 or 3 best embryos. The remaining embryos will be frozen. The transfer is similar to an annual cytology: the first step is for the biologist to introduce the embryos in a transfer catheter. The patient lies in gynecological position, and the gynecologist gently inserts the catheter through the neck of the uterus, where the embryos are deposited. After the transfer the patient stays resting for an hour to an hour and a half resting in the recovery area of the Clinic, as a preventive measure.

After this the patient is discharged.

Once the embryo transfer is complete, there is a period of 13 days until a pregnancy test takes place (blood test). During this period it is necessary to take progesterone in the indicated doses. Physical effort, and sexual relations with penetration, should be avoided during this period.

It is frequent for the patient to become nervous when as the date of the pregnancy test approaches. The patient needs to be psychologically prepared for this. Relaxation exercises, and taking valerian can help reduce anxiety. Understanding and support from within the couple is very important at these times.

The embryo transfer is done 2-3 days after the puncture. The day and the time are communicated by the gynecologist.