The 5 W’s of IVF
The first baby born from in vitro fertilization (IVF) arrived almost four decades ago. Since then, the use of IVF has skyrocketed. Worldwide, it has been estimated that over 5 million children have been conceived with the help of IVF. In Canada alone, about 30,000 cycles of IVF are done a year.
As more and more couples build their families with IVF, society is starting to accept and embrace this technology. Most people are aware of what IVF is, as its benefits have been touted by many celebrities in the media. Many couples also have a family member, friend or acquaintance who has done IVF at some point. At present, 1 to 2% of all children in North America are conceived by IVF!
Given the rapid advancements in IVF, a steady stream of information is circulating on the Internet. Some of this information is accurate, some not so much. Here is our attempt to review the who, what, where, when and how of IVF treatment.
Who needs IVF?
IVF was originally designed to help infertile women with blocked fallopian tubes get pregnant. However, this treatment is now used to treat all types of infertility, including sperm and egg issues. IVF is also the most effective treatment for unexplained infertility, where couples aren’t conceiving naturally despite the fact that all of their testing is normal. Couples who have failed simpler fertility treatments, such as intrauterine insemination (IUI), could also consider doing IVF. Infertility aside, IVF is also used to “preserve” fertility, as women can produce and freeze eggs or embryos for future use. Same-sex couples might do IVF so that the eggs from one woman can be used to make embryos for her partner to carry. Finally, embryos grown from IVF can also be tested to avoid passing on inheritable diseases or genetic abnormalities. So, if you or someone you know is doing IVF, there could be many reasons for the treatment.
What is IVF?
In vitro fertilization literally means combining egg and sperm outside the body, “in glass.” It is a misnomer because it doesn’t really take place in glass or in a test tube, as many people think. Egg and sperm are combined in specialized dishes made of safe plastics, and the resulting embryos develop in warm incubators, before they are transferred to a woman’s uterus. The fluid that the embryos are grown in and the incubator conditions are designed to closely mimic the natural uterine environment.
Where does someone do IVF?
In Canada, there are about 35 fertility clinics that offer the full range of fertility treatment, including IVF. Some areas of the country are overly represented. For example, a third of the country’s clinics are located in the Greater Toronto Area alone. This means that couples living in Toronto have a lot of options for choosing a clinic. Some provinces and the territories don’t have a single IVF clinic, and patients have to travel to another province for treatment. Access is a huge issue in parts of our country, and we hope that our blog reaches far and wide and empowers Canadians and health policy makers to improve fertility care!
When can someone do IVF?
In most of the country, IVF is a private treatment that is not covered by provincial health plans. If you are already a patient at an IVF clinic, there is usually no wait to start a self-funded IVF cycle. However, the wait to get in to see a reproductive endocrinologist could be up to months in some under-serviced areas. In Ontario, the provincial government offers public funding for a single IVF cycle for women under the age of 43. This covers the hefty procedural costs of IVF, but not costs such as embryo storage or medications. The funding has been a great help to Ontarians, but the biggest issue is the long waiting list for publicly funded IVF cycles, which can be as long as two years in some clinics! Our recommendation is to be proactive about your fertility. If you have been trying unsuccessfully for 6 to 12 months or if you have a condition that could affect fertility, seek help early because it might be a bit of a wait before you can access IVF.
How is IVF done?
IVF can be broken up into four parts:
- Stimulation of the ovaries
Because IVF is an expensive and invasive procedure, stimulation medications are usually given to encourage multiple eggs to grow at once, so that there are more eggs to work with in the laboratory. Given that not every egg is able to fertilize normally, and not every fertilized embryo develops normally, starting out with more eggs is often advisable. Your doctor will prescribe injectable medications, called gonadotropins, as well as other associated medications. “Cycle monitoring” with frequent ultrasounds and blood tests are done during the stimulation phase to make sure the eggs are growing on track. Once the egg follicles have reached a good size, a final injection, called the “trigger shot,” is given to allow the eggs to mature.
- Egg retrieval
Eggs are usually retrieved using a fine needle that is inserted through the vagina. Ultrasound is used to identify the egg follicles, and fluid containing the egg is drained from each. Everyone who does IVF is understandably a little nervous about this step, but we try to be as gentle as possible, and patients are usually well sedated for the procedure, so that discomfort is minimized. For many patients, having their partner in the room for support makes it easier.
- Fertilization and embryo culture
This is when the lab takes over for a few days, while you recover from the egg retrieval. Sperm and egg are fertilized either by “standard IVF,” where sperm and egg are allowed to come together naturally in a dish, or by ICSI, where one sperm is injected into each mature egg. The choice of standard IVF or ICSI is one that your physician should advise you about. The day after fertilization, the clinic will call you to let you know how many eggs fertilized (i.e. how many embryos were formed). Over the next few days, the embryos are grown in incubators. Expect a drop-off in the number of growing embryos each day. It is typical that only a fraction of the embryos will survive and continue to develop. The ones that continue to develop normally are the strongest ones with the best chance of contributing to a pregnancy.
- Embryo transfer
This is an exciting day, especially after all the work you have put into the IVF cycle. An embryo transfer does not involve any needles or sedation. There is a speculum involved, because your doctor needs to find your cervix to pass a soft catheter into the uterus. It is usually done with the help of ultrasound, so that your doctor can see where they are placing the embryo. Once the catheter is in the right place, the embryo(s) that you have chosen to transfer are brought out of the warm incubator and immediately placed into the middle of your uterine lining. To this point, you and your doctor and the IVF team have done everything within human control to maximize success. This is the point when the uterus takes over, hopefully resulting in a beautiful pregnancy!