In Vitro Fertilisation (IVF) - ICSI
In vitro fertilisation treatment (IVF) consists on the retrieval of oocytes (eggs) from inside the ovaries which are then fertilised with sperm in the laboratory to create embryos. Afterwards, these are transferred back into the uterus. The sperm used can come from a partner or a donor.
In Vitro Fertilisation. Steps.
- 1 - Hormone therapy
- 2 - Monitoring Cycle
- 3 - Oocyte retrieval
- 4 - Oocytes Fertilisation
- 5 - Embryo transfer
- 6 - Pregnancy test
Hormone therapy for IVF is more complex than the one used in artificial insemination procedures. From a hormonal perspective, the aim consists in stimulating the ovaries to produce as many mature eggs as posible, while preventing early ovulation to happen before egg retrieval. There are different medications and strategies that can be used to achieve both ovarian stimulation and ovulation control.
A personalized treatment is planned based on patients´ diagnosis, taking into account their past medical history and relevant tests results. Given the wide range of therapeutic plans available, the lenght of a treatment will vary depending on protocols and patient´s response.
Egg retrieval can be scheduled when at least three follicles reach maturity. Full follicular maturity is triggered by a hCG injection, applied 36 hours before the punction.
Pick-up usually takes 5 to 10 minutes to be completed, but this may vary depending on the number of follicles. This procedure is performed using an intravenous mild sedation and painkillers which are administered by an anaesthesiologist and the patient is closely monitored throughout the process. It is important that you feel comfortable during the procedure and sedation is aimed to offer a positive and relaxed experience, reducing any discomfort.
During the procedure, a thin needle is passed through a guide attached to the ultrasound probe, which is inserted into the vagina. Like this, the fluid inside each follicle is aspirated through the needle. This fluid is examined by a biologist under the microscope to determine the presence of the oocytes, and assess their maturity and suitability to be fertilised.
Recovery time after egg retrieval procedures is 1 to 2 hours. Light spotting may occur, which is perfectly normal. Pelvic discomfort may persist until the following day, but it is typically controlled with oral analgesia (Paracetamol or Panadol®). Regular daily life activities can be resumed from the they after.
In the case of a fresh transfer, the male should attend to the clinic on the same day of the puncture to provide a semen sample. This is not necessary when using frozen sperm from a partner or a donor.
Retrieved oocytes are placed in petri dishes containing a culture medium providing them with the nutrients needed to grow; then sperm is added to allow fertilisation to occur. These plates are then placed into an incubator. This is known as classic IVF. Another fertilization procedure, called ICSI, is detailed below.
Nowadays, Intracytoplasmic Sperm Injection (ICSI) is the preferred technique used for egg fertilization. To begin with, sperms are selected following morphological criteria. Once this is done, each selected sperm is microinjected into each mature egg. ICSI is usually indicated when there is a low sperm count and/or low quality of the sperm, and in case of testicular biopsy or subsequent failures of classic IVF treatments and low fertilization rates. Regardless, ICSI is now a widespread technique and is used for the majority of fertilization treatments as it has proven a high fertilization rate.
Embryo transfer takes place 5 to 6 days after egg retrieval. The date of the transfer is assessed on a case-to-case basis, as it depends on the quality and quantity of embryos.
The number of embryos transfered is also assessed this way, since it depends on the age of the woman, her reproductive history, previous treatments outcome, and quality of the embryos. Advice regarding this matter is given at the beginning of the treatment and also before the transfer, and it is aimed to minimise the risk of multiple pregnancies while maximising the chances to conceive.
At the time of the embryo transfer, the embryo(s) is loaded into a fine plastic catheter and inserted into the uterine cavity. This procedure takes around 15 minutes and it does not require anaesthesia since it does not cause any discomfort. After the transfer, the woman rests 15 minutes in her room and is able to resume her daily activities afterwards.
A pregnancy blood test is performed 12 days after an embryo transfer. An ultrasound scan is scheduled two weeks after a positive pregnancy test to confirm a pregnancy is in progress.
This technique is recommended when there are lesions in the fallopian tubes, severe male infertility, severe endometriosis, low ovarian reserve or when other treatments have failed.
- Oral Contraceptives: The oral contraceptive pill is used to prevent the formation of cysts in the ovaries before treatment (cysts are not dangerous, but interfere with the process of ovarian stimulation), and to plan and schedule the right time to start the treatment. Oral contraceptives are used for a short period of time and are not usually associated with side effects.
- Gonadotropins (FSH and LH): Prescribed gonadotropins are used to stimulate the ovaries and produce the greater number possible of follicles in preparation for egg retrieval. Gonadotropins are administered daily through subcutaneous injections over a period of 8 to12 days. Serious side effects are unlikely to happen, but some women may experience some temporary side effects such as inflammation of the injection site, mood swings, breast tenderness, bloating or abdominal discomfort and headaches that are usually easily tolerated.
- GnRH Agonist / Antagonist GnRH (Gonadotropin-releasing hormone): Agonists or GnRH antagonists are prescribed to prevent premature ovulation during treatment. Agonists and antagonists act on the brain supressing the secretion of LH that will normally trigger ovulation. Both GnRH agonists and antagonists are also administered daily with a subcutaneous injection. Side effects of GnRH agonists are rare, but some women may experience menopause-like symptoms, including; temporary hot flashes, headache and mood swings. The use of antagonists is not generally associated with side effects.
- hCG (Human chorionic gonadotropin): Human chorionic gonadotropin (hCG) induces final oocyte maturation. HCG is administered by a subcutaneous injection 36 hours prior to egg retrieval. Side effects are extremely rare, and include; inflammation on the injection site and pelvic discomfort, similar to menstrual cramps.
Additional hormone therapy is administered after egg retrieval, in order to assist embryo implantation and support pregnancy. These medications include:
- Oestrogen: Oestrogen helps develop and thicken the endometrium (lining of the uterus), before or during stimulation and/or in perparation for a frozen embryo transfer. Oestrogen is presented in tablets which are taken daily. Side effects are rare but may include breast tenderness, mood swings, fluid retention, nausea and fatigue.
- Progesterone: Progesterone plays a major role in supporting the endometrium during pregnancy. Progesterone is administered during the first trimestre of the pregnancy, typically in a vaginal capsule presentation, but it is also available as an injection (intramuscular or subcutaneaous) or oral tablets. Side effects are rare, but may include skin reactions on the injection site, nausea, insomnia, mood swings, post menstrual symptoms, and more rarely, mild allergic reactions.
- Azithromycin: Azithromycin is an antibiotic that is usually given orally the day before a folicular punction, preventing infection after the procedure. For a minority of patients, it may cause temporary gastrointestinal symptoms.
IVF treatment is considered generally safe. However, there are some risks to consider.
The biggest risk are multiple pregnancies. When 2 or more embryos are transferred in an IVF treatment, there is a risk of more than one implantation. About 25% of IVF pregnancies are twin pregnancies and 5% are triplet pregnancies. Multiple pregnancies are considered high risk since they compromise the health of both mother and child (this applies to all multiple pregnancies, either natural or assisted) Maternal risks associated with multiple pregnancies include: increased risk of gestational diabetes, hypertension, and bleeding during childbirth. Foetal complications include increased risk of preterm birth, foetal death, cerebral palsy and low birth weight. When a triplet pregnancy occurs, we strongly recommend a reduction to a single or twin pregnancy.
A rare side effect of hormone therapy (affecting approximately 1% of women) is called ovarian hyper stimulation syndrome (OHSS). OHSS is a complication that occurs in the form of an over-response to ovarian stimulation, where ovaries produce an excessive number of oocytes. OHSS is more common in young women and women with polycystic ovaries (polycystic ovarian syndrome). Symptoms range from mild to severe discomfort and can include nausea and / or vomiting, abdominal bloating, discomfort / pain, shortness of breath, edema (fluid accumulation) and blood changes. The OHSS can last from few days to weeks and usually resolves itself, but requires close monitoring and treatment of the symptoms. Rarely, women with OHSS must be admitted to hospital, where the fluid accumulated in the abdomen wiill be drained. Every effort to avoid OHSS is made during treatment, in order to react quicly to any sign of OHSS, modifying the medication if necessary to prevent the onset or serious complications of the syndrome.
Egg retrieval carries a very low risk of complications, including pelvic infection (1 in 500 cases) and significant bleeding (1 in 1,000 cases)
There is also risk of an ectopic pregnancy after an IVF cycle. An ectopic pregnancy is a pregnancy in which the embryo grows outside the uterus, often found in the fallopian tube. The incidence of ectopic pregnancy is slightly higher after IVF (5%) compared to naturally conceived pregnancies (1.6%).
To conclude, there is a slight higher risk of complications during an IVF pregnancy compared to a naturally conception, however, the cause is unclear and may be due to many factors, such as maternal age, cause of infertility and patient´s fertility.
*Add on 435€ when donor´s sperm is required.
Case-oriented cycle planning and all consultations
HERES Carrier Screening test (16,592 mutations) both partners
Ultrasound scans (unlimited)
- Fixed Price: This is a fixed priced treatment that includes the services detailed on the cost breakdown. Supplementary tests may be required according to medical criteria, however, these will be notified in advance.
- Additional stimulations (oocyte accumulation): When supplementary stimulations are needed, an additional cost of 2.485 € per cycle will apply.
- Embryo devitrification: When an embryo transfer fails, an additional cost of 1.860 € will apply to subsecuent attempts.
- Validity: The validity of this estimate is 6 months from the date of your first consultation.
- Medication: Medication costs are not included. These will be assumed by the patient.
- Cancellation by the patient: In case of cancellation of the treatment, the patient must pay the costs incurred until that point.
- Transfer cancellation: When transfer needs to be cancelled due to embryos failing to evolve as expected, 220€ will be refunded.
- After 2 years of embryo crypreservation: It will be your decision to either chose from one the authorised applications regarding embryo donation/destruction or the payment of a 435€ fee per year of conservation for future use.
- Sperm preservation: This has a cost of 250€, and 230€ per year of conservation.