A Treatment Cycle

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For Women

Medications

An IVF treatment cycle involves a sequence of steps that also includes the administration of medications.

We ask patients to take responsibility for the administration of any medications during their treatment cycle, including the nasal spray and injections. Some patients will be prepared to give themselves the injections while others ask their partner, another family member or a friend to do it for them.

A patient coordinator will show you how to use the intranasal spray as well as prepare and administer the injections during your pre-treatment interview. You will be informed as to when the nasal spray and injections should be given.

Videotapes that demonstrate injection techniques are available for hire from each Monash IVF clinic.

If you have your local doctor give you your injections, you will be required to pay for the consultation, as it is not covered by Medicare or your private health fund.

Sequence of Steps for an IVF Treatment Cycle

1. Suppression of own hormones using nasal spray ( & contraceptive pill)
2. Follicle growth (stimulation by injections)
3. Ovulation timing (based on blood tests and ultrasound scan)
4. Collecting the eggs from the follicles using the ultrasound scanning machine
5. Collection and preparation of sperm
6. Insemination of eggs with sperm
7. Assessment of fertilisation
8. Embryo transfer to the uterus
9. Embryo freezing
10. Pregnancy blood test
11. If pregnancy is confirmed, further blood tests and an ultrasound will be required.

Suppression of own hormones using nasal spray

Before we stimulate your ovaries it is usually necessary to suppress your own hormonal cycle. This may be achieved using the oral contraceptive pill and Synarel nasal spray. Some types of cycles do not require this suppression. Your Fertility Specialist will decide which is appropriate for your treatment.

Stimulation of Follicle Growth

To maximise the pregnancy rate using IVF, we aim to transfer one or two embryos into the uterus. To do this, it is necessary to stimulate the growth of several follicles for each treatment cycle. The follicle is the fluid-filled sac in which the egg develops. The follicle is 18-25 millimetres (one inch) in diameter at the time of ovulation. The egg or ovum itself is less than the size of a pinhead (one tenth of a millimetre). The follicle growth is controlled by a synthetic hormone FSH (Follicle Stimulating Hormone) copying what is naturally produced by the human pituitary gland. The daily FSH injections should stimulate three or more follicles to grow and mature.

Approximately ten to twelve days of FSH injections are required to stimulate follicle growth and the development of eggs within these follicles. Synarel nasal spray is used in conjunction with the FSH injections and prevents premature ovulation (release of the egg).

Monitoring of Follicle Growth

The growing follicles produce a hormone called oestrogen. For this reason, blood may be taken from your arm on approximately Day 9 of your FSH injections.

One or two ultrasound scans will be performed to find out how many follicles are developing, what size they are and in what ovary they are growing. The scan is done vaginally, where the scan probe is inserted into the vagina. For this, an empty bladder is preferred. For hygienic reasons, the ultrasound probe is cleaned after each use and covered in a clean, disposable sheath for each patient, so there is no risk of developing infections from the examination.

Ovulation Timing

Timing of the egg collection is based on the oestrogen levels in your blood and/or the scan findings. Synarel and FSH injections stop and an injection of hCG is given to trigger egg maturation. The egg collection is timed for approximately 36 hours after this.

Egg Collection

Day Procedure Centre

Day Procedure Centres do not operate like hospital wards. You are given an admission time that is one hour before the actual procedure time. On admission, patients are interviewed by a nurse and anaesthetist and remain dressed until they are ready to go to Theatre for their procedure. Once changed into a gown, a nurse will escort you to Theatre. (At some sites you may be required to shower before you go to theatre). Following the procedure you will be transferred to the Recovery Room and then to a reclining chair where you remain until you are ready to go home (approximately 4 hours).

Anaesthesia

Undergoing egg collection involves a light anaesthetic that requires that you fast for six hours prior to the procedure. The anaesthetics used allow you to recover quickly so you are awake soon after the procedure is completed.

Human Serum Albumin (HSA)

Protein in one form or another is a necessary component of all media used to culture cells, including sperm, eggs and embryos. A patient's own serum (maternal serum) or Human Serum Albumin is the usual protein source.

There are several other media such as embryo freezing medium and medium used in the sperm injection technique, which also require protein supplementation. Human Serum Albumin or HSA is a protein fraction extracted from human blood. Our HSA is obtained from a major supplier of pharmaceutical products and is repackaged for use as a culture medium supplement. It has been screened and tested to pharmacological standards for a range of infectious conditions in the same way that all blood transfusion products are screened. The use of albumin as the protein source in IVF culture media is a common practice throughout the world. The HSA complies with the pharmaceutical standards required by the Federal Drug Administration (FDA) and those within the European community.

Please discuss any concerns or questions you may have regarding HSA with your Fertility Specialist as you may opt to use your own serum if you wish.

Transvaginal Oocyte (Egg) Retrieval/Collection

Once you are asleep, a similar vaginal probe as used for ultrasound scanning is inserted into the vagina to collect the eggs. On this occasion it is equipped with a needle guide. Using the ultrasound scan, the follicles are lined up in the needle track and the needle is then pushed through the wall of the vagina, into the ovary and into the follicle to suck out its contents. Each egg collected is then washed and placed in a culture dish containing media. The number of follicles seen does not necessarily correlate with the number of eggs collected as not every follicle contains an egg.

Collection and Preparation of Sperm

At an arranged time (usually close to the time of egg collection), your partner will be asked to produce a semen specimen that is prepared and washed to select the most motile sperm. Occasionally a second sample will be requested to increase the number of sperm available. Please ensure 3-5 days of abstinence from sexual activity prior to the egg collection date. Do not abstain for longer than 5 days.

Insemination of Eggs (IVF)

The washed sperm are added to the eggs and placed in a special incubator. About 18-24 hours after adding the sperm, the eggs are re-examined to assess whether fertilisation has occurred. If it has, there will be two clear areas within the egg, which are the collection of genes from each parent before they have joined together. This stage is called "pro-nuclei development". These results will be available from your patient coordinator the day after egg collection.

Embryo Transfer (ET)

Embryos may be transferred to the uterus at different stages of development, anytime from 1 - 7 days after egg collection. A fine plastic tube containing the embryo/s and a small amount of media is passed from the vagina, through the cervix (neck of the womb) up into the cavity of the uterus (womb). Similar to a Pap smear, it is a relatively painless procedure and an anaesthetic is rarely needed.

Embryo Freezing

If requested on the Procedure Form this procedure can be performed if:

• viable embryos (ones that have reached the required cell stage) are available in excess of those used for the fresh embryo transfer
• vaginal bleeding makes transfer of the fresh embryo(s) undesirable
• a medical condition, such as ovarian hyperstimulation, contra indicates the transfer of fresh embryos

Post Transfer

Normal activities, including sexual intercourse, may be resumed after embryo transfer. Activities not recommended for pregnant women (like squash or aerobics or anything that can leave you gasping for breath) should probably be stopped, although there is no firm data about this. You should keep up the regular exercise that you are used to, providing it is not strenuous. Try to avoid excessive rises in body temperature.

You will be required to use a Progesterone supplement (either pessaries or gel as prescribed by your Fertility Specialist) until the results of your pregnancy blood test are known. Progesterone is a hormone that supports the lining of the uterus in preparation for a possible pregnancy. DO NOT stop the progesterone medication unless instructed by a patient coordinator.

Waiting Time

People report this as the most difficult time in the treatment cycle. Whilst there are few limitations on your physical activities, many people will find it difficult to keep their minds off their recent treatment cycle. Bear in mind that this period of hope has associated anxieties. If you have any difficulties coping in this time, do not hesitate to contact one of the counsellors or a patient coordinator. Our staff is available for moral support - we understand it is a difficult time for you.

Pregnancy Test Results

A pregnancy blood test is performed approximately 16 days after egg collection. These results will be available on the same day and given to you over the telephone by one of the patient coordinators - usually your own. It is important that this test is performed even if you experience bleeding suggestive of a period.

Frozen Embryo Cycle

A treatment cycle in which frozen embryos are to be thawed and transferred can be undertaken in several different ways. The most traditional methods have been to allow women to ovulate naturally or with Clomiphene Citrate followed by the transfer of embryos when the uterus is prepared to accept embryos.

Alternatively, Hormone Replacement Therapy (HRT) can be used to prepare the uterus to accept embryos. (HRT cycles need to be booked in advance.) Your Fertility Specialist needs to recommend what is appropriate for you.