A thorough medical history, a physical examination and assessment of the patient with fertility problems are essential before proper counseling regarding treatment options that can be provided.
The initial consultation aims to gather the necessary information to guide appropriate testing, but it is also an important step in establishing a relationship with the patient.This is a crucial first step because the patient will opt for a psychologically demanding and potentially time-consuming treatment. It will be brought to their attention that the result might not be the one expected and also, the costs of the procedures will be discussed.
The decision to go for in vitro fertilization (IVF) comes after a full evaluation or when a simpler and less expensive fertility treatment has failed. In both situations, the patient may not be psychologically, emotionally, or financially ready for IVF, and this dilemma underscores the importance of the stability of a positive report as a component of the pre-IVF assessment of women or infertile couples.
In vitro fertilization (IVF) is a type of assisted reproductive technology (ART). This involves retrieving eggs from a woman’s ovaries and fertilizing them with sperm. The fertilized egg is known as an embryo.
The embryo can then be frozen for storage or transferred into a woman’s uterus.
Depending on each individual situation, IVF can use:
• the patient’s eggs and the partner’s sperm;
• the patient’s eggs and the sperm from the donor;
• donor eggs and partner’s sperm;
• donor eggs and donor sperm.
As can be seen from the list above, the IVF procedure can also be done with a surrogate mother, this approach being necessary or desired in some cases.
The success rate of IVF varies. The birth rate for women under 35 undergoing IVF is 41% to 43%. This rate drops to 13-18% in women over the age of 40.
IVF helps people with infertility who want to have a child, but couples often try other fertility treatments first. These may include taking fertility drugs or intrauterine insemination. During this procedure, the doctor transfers the sperm, prepared in the laboratory with special media, directly into a woman’s uterus.
• reduced fertility in women over 40 years of age;
• blocked or absent fallopian tubes;
• reduced ovarian function;
• uterine fibroids;
• male infertility, such as low sperm count or abnormalities in sperm shape;
• unexplained infertility (25% of infertile couples).
Parents may also choose IVF if they are at risk of passing on a genetic disorder to their baby. A medical laboratory can test the embryos for genetic abnormalities, then the doctor implants only embryos without genetic defects.
The medical history is essential, the discussion with the infertile couple identifies the risk factors for infertility. After a complete evaluation, the cause of infertility for most patients will fall into one of several diagnostic categories.
Both partners will participate in the initial fertility consultation.
The doctor is in the ideal position to optimize the patient’s health before pregnancy and to provide preconception screening to detect diseases that may appear in the offspring, such as: cystic fibrosis, spinal muscular atrophy and other genetic conditions.
Although there are guidelines for minimal preconception counseling and testing, recommendations regarding management options for specific reproductive conditions, including recurrent pregnancy loss or endometriosis, are less clear. When possible, both partners of a couple should be present at the initial consultation, especially when treatment decisions might be decided.
There are five steps involved in IVF:
1. ovarian stimulation;
2. egg harvesting;
3. insemination (fertilization);
4. embryo culture;
5. transfer in utero.
A woman normally produces one egg during each menstrual cycle. However, IVF requires more eggs. Using more eggs increases the chances of developing a viable embryo. Fertility drugs are recommended to increase the number of eggs. Blood tests and ultrasounds will be performed periodically (3 times during a stimulation cycle) to monitor the development of ovarian follicles (from where the ovules are aspirated) and to guide the doctor in order to establish the perfect time when they should be collected.
Egg harvesting is known as follicular aspiration. It is a surgical procedure performed under anesthesia. The doctor will perform the aspiration under ultrasound guidance.
A sample of seminal material (sperm) will be taken from your partner. It will be processed with special media, then it will be mixed with the eggs through a standard technique, in order to inseminate.
The fertilized eggs will be monitored periodically to make sure they are dividing and developing. At this point, the embryos can undergo genetic testing.
When the embryos are sufficiently developed, they can be implanted in the uterus. This usually happens three to five days after fertilization. Implantation involves the introduction of the embryo into the uterus.
Pregnancy occurs when the embryo implants in the uterine wall. This may take a few days after the intrauterine transfer.
Obtaining a medical history directed toward the causes of infertility is imperative because it can easily identify risk factors for infertility and lead to an effective evaluation. But age is one of the major risk factors for infertility.
Ovulatory dysfunction may be suspected from a history of irregular menstrual cycles. When accompanied by symptoms of hyperandrogenism, polycystic ovary syndrome (PCOS) may be suspected.
Signs of hyperprolactinemia, such as nipple discharge, headache, and visual changes, should be considered in the review of symptoms.
Uterine, cervical or tubal risk factors can be evaluated if we consider the antecedents of pelvic infection or recurrent miscarriage, previous surgical intervention, such as curettage and cervical cryotherapy or conization, the use of an intrauterine device for contraception or ectopic pregnancy.
Exposure to cigarette smoke, excessive alcohol consumption, stress, unbalanced diet, vigorous exercise, and obesity are risk factors that should be considered during the initial consultation.
Women who have signs and symptoms consistent with endometriosis or adenomyosis (endometrial implants outside the normal physiological place where they should be) may have more difficulty getting pregnant. While the staging of endometriosis standardizes the description and severity of the case, it does not predict fertility.
IVF is considered the most effective fertility treatment for patients with endometriosis. The role of surgery in endometriosis is reserved for cases of repeated IVF failure and could improve the results of IVF.
Celiac disease is an enteropathic immune disorder of gluten intolerance.
About 1 in 133 people have this condition and cannot digest foods that contain or are covered with gluten, such as wheat, rye, barley, or medicines.
When ingested, immune destruction of the intestinal villi prevents adequate absorption of nutrients into the bloodstream, causing typical nonspecific symptoms of constipation, diarrhea, abdominal pain, vomiting, and weight loss.
As a multifactorial genetic disorder, the symptoms of this disease are highly variable. It is associated with HLA-DQ2 and HLA-DQ8 and coexisting autoimmune disease is also common.
It is often chronically present, but can be triggered by stressful events such as surgery, pregnancy or infections. Celiac disease can occur along with unexplained infertility or recurrent miscarriage. Testing of patients with these reproductive problems for anti-tissue transglutaminase (tTGA) or anti-endomysium (EMA) IgA antibodies is recommended.
Undiagnosed or insufficiently controlled diseases such as hypertension, diabetes, autoimmune diseases, abnormal uterine bleeding and neoplasia have an important role in determining the subsequent approach.
Careful review of patient regimens for other comorbidities may reveal those drugs known to induce fetal toxicity in humans or have been shown to have adverse effects in animal studies. The decision to continue any medication should consider the benefits and risks of continuing treatment, planning the conception in close collaboration with the attending specialist.
Comprehensive guidelines for preconception counseling and antepartum care for all women have been published.
We emphasize the importance of annual medical check-ups that emphasize the medical history, physical examination with monitoring of physiological parameters, blood tests, Pap smear, breast ultrasound with or without mammography (recommended for women over 40 years of age or earlier for those with a significant family history).
In determining the appropriateness of IVF, a complex assessment is made.
Women with a body mass index (BMI) of 30 kg/m2 or more are at increased risk of medical and obstetric complications, such as:
For these reasons, women with obesity, especially morbid obesity, require a thorough consultation during preconception planning and before IVF treatment. Supplementation with 1 mg of folic acid per day (routine dose is 0.4 mg per day) may be considered, although the benefit of this dose in obese non-diabetic patients is not established.
Multiple studies have shown that addressing nutritional issues and weight loss lead to better pregnancy outcomes and births in IVF.
Before starting IVF, tests will be done to estimate ovarian reserve. A blood sample will be taken to test the level of FSH (follicle-stimulating hormone). The results of this test will give your doctor information about the size and quality of your eggs.
During the clinical examination:
• The uterus will be examined;
• An endovaginal ultrasound will be performed to determine the best way to implant the embryos.
The partner will do the spermogram (examination of a sample of semen to analyze the number, size and shape of the sperm). If the sperm is weak or damaged, a procedure called intracytoplasmic sperm injection (ICSI) (injecting the sperm directly into the egg) may be needed.
Choosing IVF is a personal decision. There are a number of factors to consider:
• What will you do with the unused embryos?
• How many embryos do you want to transfer? The more embryos transferred, the greater the possibility of a multiple pregnancy. Generally, no more than two embryos are transferred.
• What do you think about the possibility of having twins, triplets or a higher order multiple pregnancy?
• What are the legal and emotional implications associated with using donated eggs, sperm and embryos or a surrogate?
• What are the financial, physical and emotional implications associated with IVF?
The following tests are considered routine prenatal tests for all women who are planning a pregnancy or are already pregnant:
• blood count with: Hb, Ht;
• blood group and Rh type;
• screening for: hepatitis B, hepatitis C, HIV, syphilis;
• urinalysis and urine culture;
• biochemistry (blood glucose, creatinine mandatory);
• TORCH profile (antibodies that detect infections with toxoplasma, cytomegalovirus, rubella virus, herpes simplex virus 1 and 2);
• cytology for chlamydia trachomatis, neisseria gonorrheae;
• Cervical cytology Pap smear;
• karyotype, genetic counselling.
Genetic counselling before testing is important in determining pregnancy risk.
Assessment of uterine cavity and tubal patency is fundamental to pre-IVF assessment. A hysterosalpingogram (HSG) is usually performed by imaging means.Occlusion of both fallopian tubes on HSG with or without distal dilatation is present in about 20% of infertile women and is a major age-independent reason for IVF treatment.
The presence of: endometrial polyps, fibroids with cavitary involvement, adhesions, Asherman’s syndrome and anatomical mulerian variants such as uterine septa, fusion abnormalities and T-shaped cavity are assessed. These abnormalities can be evaluated ultrasonographically or by MRI and, thus, the need for surgery prior to IVF is determined.
Endometrial biopsy has limited indications, e.g. dysfunctional uterine bleeding, suspected endometrial carcinoma.
When ovulatory dysfunction is suspected, further evaluation is necessary to determine the underlying etiology. For example, the infertile woman who has irregular menstrual cycles may or may not have symptoms of hyperandrogenism.
Total and free testosterone testing combined with ultrasound assessment of the ovaries is recommended.
Patients with PCOS are at risk of metabolic syndrome, with long-term repercussions, highlighting the need to optimise health status before IVF and pregnancy.
Further testing for decreased glucose tolerance, fasting lipid profile, blood pressure and occult endometrial carcinoma, etc. should be performed.
It is important that the patient be specifically evaluated for other conditions that may occur with ovulatory dysfunction, such as: thyroid disorders, Cushing’s disease, adrenal or ovarian tumours, insulin resistance or prolactinoma.
Preparing the infertile woman for IVF involves a detailed discussion and consent process that must be documented and must include:
1. Stages of an IVF cycle, including how the ovaries will be stimulated, side effects of medication, control of follicular maturation, monitoring and expected duration of gonadotropin stimulation;
2. Alternatives to IVF;
3. The oocyte retrieval process and the risks of surgery and anesthesia;
4. Risk of ovarian hyperstimulation syndrome and ovarian torsion;
5. Current data on the risk of treatment-related pathologies;
6. Risk of genetic disease and birth defects or other disorders in the child potentially related to IVF;
7. Estimated pregnancy rates and failure rates based on age-related low fertility and increased aneuploidy;
8. Pregnancy complications seen after IVF, including ectopic pregnancy, premature birth, lower birth weight and placental abnormalities;
9. Classic in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI);
10. Culture length and number of embryos for transfer;
11. When other treatment such as assisted hatching and pre-implantation screening (PGD) should be considered;
12. The risk of multiple pregnancy;
13. Success cannot be guaranteed;
14. Disposing of unused embryos, including freezing, donating, destroying or using them for research;
15. Progesterone supplementation when prescribed.
• If there are any doubts and/or questions, of any kind, you should talk to the specialist about it.
• For performing ultrasound scans, a clear protocol should be considered;
• Close contact with the attending physician must be maintained;
• Another important part of the IVF procedure is a good communication with your medical providers. It is necessay for the patients to be aware of the stages of fertilization, information about the embryos obtained, the result of the pregnancy test and the next steps.
• The support of your partner is essential and they must be correctly and fully informed about the IVF process.