From test tube to delivery: How and why do IVF
Infertility - a difficult diagnosiswhich may have a variety of reasons. If a couple wants a child, but pregnancy does not occur, there are several options, the choice of which depends on the specific characteristics of the partner’s or partner’s body, and on financial possibilities and personal preferences: to seek adoption, use the services of a surrogate mother, try to achieve pregnancy with in vitro fertilization procedures (IVF). Everybody heard about the latter, but many are still not sure how it actually happens. We talked with Tatiana Verkhovnikova, a reproductive physician at the Mother and Child Clinic in St. Petersburg, and asked about the IVF experience of women who passed through it.
How to prepare for IVF
Preparation is first of all a survey, which is carried out according to a certain scheme (in Russia it is determined by the Order of the Ministry of Healthcare number 107n). The purpose of the survey is to understand whether IVF is indicated and whether the pregnancy will be safe for the patient. A couple donates blood, tests for infections are performed, a man is given spermogram. The woman is also being tested for hormones in order to identify diseases that may prevent the occurrence and carrying of pregnancy - for example, problems with the thyroid gland. The level of the so-called anti-Mullerian hormone is determined, which helps to understand how many eggs are left in the ovaries, and predict how many of them can be obtained.
Also, general blood and urine tests are done, ECG and fluorography are performed, therapist is advised, a woman should undergo a breast examination - stimulation with hormonal drugs can affect their condition. Sometimes you need advice from other specialists to get their permission and recommendations. If the examination revealed any violations, it may take several months to correct them. In addition, since the goal of IVF is pregnancy, the couple should follow general guidelines for a healthy lifestyle: be active, get enough sleep, do not smoke and give up alcohol, stick to a balanced diet; A woman should start receiving folic acid three months before the procedure.
How eggs are fertilized and fertilized.
IVF is a team work of the patient, fertility specialist and embryologist. From the first day of the menstrual cycle, a woman begins hormonal drugs to help mature more than usual number of eggs. These medicines are selected individually by the reproductologist; they are injected in the form of injections, subcutaneously (in the abdomen) or intramuscularly - in the latter case, the injections bring quite noticeable discomfort. Ovules develop inside the ovary in the follicles - structures like vesicles filled with fluid (under natural conditions, the follicle breaks at a certain point, releasing the egg - this is called ovulation). Stimulation with hormones lasts ten to twelve days, during which two or three times an ultrasound is done to assess the growth of follicles and to adjust the dosage of the drug. In the middle of the menstrual cycle, when the follicles grow to a certain size, the last injection is done to make the eggs mature, and the day of puncture is appointed when they are finally removed.
Taking eggs is usually done under general anesthesia (anesthesia); each follicle is punctured with a thin needle, and the collected fluid is transferred to the laboratory, where embryologists look for eggs under it under a microscope. On the same day, a man hands over semen, in which the same embryologists detect motile spermatozoa. The patient goes home, and embryologists begin to engage in fertilization of the received eggs. If there are a lot of motile spermatozoa, then conventional extracorporal fertilization is carried out: spermatozoids and eggs are left in one cup with a nutrient medium in an incubator for sixteen to eighteen hours and there fertilization takes place in the same way as in the uterus. But if there are few motile sperm cells or they are of poor quality, then the ICSI procedure (intracytoplasmic sperm injection, ICSI) is performed. At the same time, an embryologist introduces a sperm cell into each egg cell under a microscope and leaves them in an incubator; spermatozoa are selected, focusing on the absence of deviations in their structure and normal mobility.
The puncture lasts about half an hour, is done under general anesthesia, under ultrasound control. I transferred everything very easily, there were no side effects. Then, however, for several days there was discomfort in one of the ovaries - from there more eggs were taken. On the same day they took sperm from her husband and did fertilization.
How embryos are planted
On the day after fertilization and in the following days, the embryologist evaluates the fertilized egg (from the fifth day it is called a blastocyst); it examines the internal cells that turn into a fetus, the outer layer of cells that will become the placenta, and the cavity between them. There are criteria (what should be these cells and how many should they be) that help determine the "quality" of the embryo, that is, its viability and development prospects. It often happens that the processes do not go as we would like, and some embryos do not develop - that is why during stimulation it is important to get not one egg but several, so that there is a choice. The next three to five days the embryos grow in a nutrient medium, and their condition is assessed every day by a specialist.
Then one or two embryos that meet medical criteria are selected - and they are transferred into the uterine cavity. This procedure does not require pain relief; the patient sits in an ordinary gynecological chair, and embryos are transferred into the uterine cavity through the vagina with the help of a tube (catheter). Finally, two weeks after that, the patient does a pregnancy test (usually a blood test, because it is more reliable than a urine test).
According to Verkhovnikova, now that reproduction and embryology have reached a higher level, as a result of IVF, more embryos are obtained with the prospect of engraftment and growth - and the transfer of several embryos quite often leads to multiple pregnancies. In itself, pregnancy by more than one child is considered complicated: such pregnancies are more likely to be interrupted or end in premature birth, which is dangerous for both the mother and children. Since this differs from the very idea of IVF, designed to give birth to a healthy child and preserve the health of a woman, recently only one embryo is being transferred. The rest can be frozen and stored in a special biomaterial bank; storage can cost about 35 thousand rubles for ten years. In the future, the couple may return to the clinic and use one of their own embryos for a second pregnancy - or sign a consent to donation. Unfortunately, not all embryos undergo defrosting, too - about 15% lose their viability.
At first, one embryo was transferred to me, but it did not take root - it turned out that the endometrium (the inner layer of the uterus) was not ready for pregnancy. I was reassured by the thought that two more embryos are stored in the freezer, but it was necessary to prepare the endometrium. For this, for several months I took medicines and smeared the stomach with a special ointment. It lasted somewhere from April to August, and finally two embryos were successfully transferred to me. The procedure does not cause any discomfort: you lie in your chair, and embryos are injected with such a large syringe with a long tube.
A few days later one of the embryos split in two - I remember how I was covered at that moment with a hormonal wave. Of course, when the doctors saw the triplets, I was offered to make a reduction, that is, to remove one embryo - this is a standard procedure, they are told about this first thing. Multiple pregnancy is generally a risky thing, both for children and for the mother, and with identical twins the risks are even higher. But we still decided to reduce nothing, and now our triplet is already two years old.
How often are failures
The reproductologist notes that the likelihood of pregnancy after IVF depends on age. Oocytes are laid at birth, and new ones do not appear in the process of life, but are only wasted; The quality of spermatozoa also, unfortunately, decreases with age. If the probability of becoming pregnant using their own eggs in women under the age of thirty-five years is more than 30%, then after forty-five years the chances drop dramatically. It is clear that even with the maximum chances of a first attempt, pregnancy may not occur. On average, a young couple for pregnancy requires three attempts of IVF, although everything can happen and the first time.
I was given one embryo, and it did not take hold. The easiest way is when several embryos are transplanted on the third day and waiting for at least one to take root. But here there is a risk of multiple pregnancies. Therefore, we took the path of growing embryos until the fifth day and planting one of them. It was the worst stage: on the fifth day, it turned out that there were five of nine embryos left, and all of them were not very viable. The doctors decided that they still wanted to watch them, so I did not have time to transplant anything in this cycle. Two days later only two embryos were frozen with BB quality. (in the quality classification of embryos, the letters A, B and C evaluate two different parameters, and A means the most favorable option; that is, the best prospects will be for embryos rated as AA, and then AB. - Ed.). Replanting was done in the next cycle, and there was still a chance that the embryo would not survive the thaw, but everything went well. But in the end, pregnancy still did not come.
It was very hard, because it all goes under a hell of hormones, you are constantly ill. In addition, some of the drugs that I had to prick, the instructions described the terrible possible side effects - this also did not add joy. I also very badly suffered the taking of the eggs, it was two days away from anesthesia (typical side effects of anesthesia include drowsiness, confusion, memory impairment. - Approx. ed.). We decided not to try again - I’d have one and I wouldn’t want my physical or mental health to deteriorate because of the ghostly possibility of conceiving from the tenth attempt.
Why everything is so - no one knows. It is possible that our genes are simply not very useful for reproduction, and therefore even with IVF the embryos are not viable. In general, the idea of adoption is more organic for me, and if it were not as complicated as it is now, then I would not have thought about IVF. Once again, I am not ready to go through such a load - I came to my senses for about a year.
How much does it cost and who pays
The cost of IVF in Russia is from one hundred to three hundred thousand rubles, and it depends on how many hormonal drugs are needed, what procedures will be needed (ICSI, genetic screening of embryos - it is performed to eliminate dangerous genetic diseases, especially if their risk is increased, for example , they were or are from close relatives), whether donor material is used (eggs or sperm). True, not everyone knows that OMS covers IVF, that is, it gives the opportunity to do it for free. To do this, you need to undergo an examination according to the Order No. 107n and collect a package of documents; the patient can choose the clinic where she would like to have IVF.
According to Verkhovnikova, the queue in Russia for free treatment of infertility is very small - in other countries like the UK, France or Spain it can take several years, and in the United States there are no free IVF programs at all.
We used to live in Vladimir, and I was familiar with people who did IVF on OMS. They had to wait a year or more. Already in Moscow, when we decided on this, I wanted to do everything in a certain center; there was money at that time, so we decided not to wait for any quotas, but to go there. The whole protocol of IVF with drugs cost us about a hundred and twenty thousand rubles. Then, when it turned out that I have a triplet, I turned to a very good specialist for the management of the pregnancy - she is a doctor of science and specializes in multiple pregnancy. As a result, everything together, from preparation for IVF to childbirth, cost about three hundred and thirty thousand.
Why sometimes IVF "cures" infertility
There are cases when a couple tries unsuccessfully to conceive, does IVF, and after some time after the birth of a child, a spontaneous pregnancy suddenly occurs. In such cases, there are usually no problems, such as obstruction of the fallopian tubes, and the problem was hormonal, and after the birth, the hormones reached equilibrium. Theoretically, the changes may be due to psychological reasons: the couple stopped worrying and began to have sex, not for the sake of conception, but into pleasure. True, according to Tatyana Verkhovnikova, psychological infertility is extremely rare and usually there is some other reason that may not have been recognized.
In addition, long observational studies show that the likelihood of pregnancy increases with time. In practice, this means that although the couple could be diagnosed with infertility after a year of active sex life without contraception, this does not mean that there is no chance, and in the following years, pregnancy may well occur without any treatment.
I had two IVF attempts, the second was successful, and in September 2013 we had a daughter. We planned a second pregnancy, believing that we were using the remaining embryos - but the pregnancy suddenly came on its own. It was very strange, because before IVF, we didn’t work for two years, and the diagnosis sounded like "infertility of unknown origin." The second pregnancy was easy, as was the first, despite the fact that I was already forty years old. The only negative point in this whole story is the remaining "snowflakes", that is, frozen embryos. The question of what will happen to them is not solved by us and hangs with a heavy load.
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