Understanding ovarian stimulation for IVF
IVF treatment is the preferred choice for fertility treatment not just in India but all over the world. IVF has proved to be the most successful method for conception. Numerous couples around the globe are facing problems with getting pregnant. It could be a problem of male infertility or female infertility or both. Either way IVF treatment provides the solution.
Few decades ago infertility was a rare occurrence but today due to lifestyle choices, working patterns, stressful and pressured jobs, unhealthy diets, sedentary lifestyles and lack of physical exercise all put together has over the years culminated in a number of ailments. This has also had an adverse effect on the fertility of men and women alike.
In Vitro Fertilisation is a fertility treatment that caters to score of people who are not able to get pregnant. The problem could be with either partner and there is a wide range of issues that affects conception. The problem could be due to some minor hindrance or it could be some major obstruction or issue with the functioning of any one of the reproductive organs.
The bottom line is that as long as the uterus is healthy a female can undergo pregnancy. The IVF treatment is a technique in which the female eggs are extracted from the ovaries and the male sperm is sourced from the semen sample. In the body the female eggs are stored in the ovaries in follicles. A woman has two ovaries and each one of these ovaries has many follicles. The follicles contain immature eggs. During each ovulation cycle one egg will mature. The maturation of the egg is triggered by a hormone called FSH (follicle stimulating hormone). For the IVF treatment we need mature eggs. To source these mature eggs the ovaries are stimulated by externally administrating the required hormones.
The IVF treatment includes a number of different stages. One of the essential stages of the treatment is the stimulation of the ovaries. The ovaries are naturally stimulated for the ovulation cycle by the Follicle Stimulating Hormone. This hormone is released by the pituitary gland a little before ovulation and it encourages about 5 follicles to start maturing for ovulation. Of these 5 follicles only one dominant follicle matures completely and is ready for fertilisation. The other eggs usually do not mature fully and are lost.
For the IVF treatment we need a large number of eggs. These eggs need to be absolutely mature or they will not fertilise. To obtain a larger number of mature eggs the patient is given medication to induce the follicle maturation. This medication includes additional doses of the FSH hormone along with others fertility drugs. The hormones encourage about 10 to 13 eggs to mature.
Ovarian stimulation not only promotes the maturation of the follicles for retrieval but it also helps to prepare the uterus as is the process in a normal ovulation cycle. The inner wall of the uterus grows an endometrial lining. When the embryo enters the uterus it will implant itself into this tissue. Without the receptivity of the uterus the implantation will not take place. Implantation is imperative for a successful pregnancy. An embryo cannot grow if it does not attach itself to the endometrial lining. Hence the preparation of the uterus to receive the embryo is important for a successful IVF treatment.
Ovarian Stimulation process
The ovarian stimulation process has to be carefully timed to match the regular cycle of the patient’s body. Ovarian stimulation involves various stages and each one has to be cautiously monitored to understand how the body is reacting to the medication that is being given. It is also important to know the progress of the follicle maturation as well as what is happening so that the medication for the next stage can be given.
There are namely three stages to the ovarian stimulation which induces the maturation of the oocyte follicles in the ovaries. Oocyte is another term for the female egg. The three stages are:
1. Stimulate growth of follicles: Anti-oestrogen medication is given to encourage the ovarian follicles to grow and mature the eggs that are contained within them. The intention of this stage is to encourage as many follicles to start maturing the eggs.
2. Prevent the oocyte release: In the natural ovulation process once the follicles mature the oocyte is released into the fallopian tubes. The release of the oocyte is invoked by the Lutenisinghormone (LH) surge. During IVF ovarian stimulation special medication is given to the patient to prevent the surge of the LH which also ensures that the oocytes are prevented from being released and remain within their follicles. If the oocytes are released into the fallopian tubes they cannot be retrieved for the IVF process..
3. Final maturation: The final maturation stage is closely monitored and the eggs are retrieved as soon as they are fully matured. This final maturation processtakes about 36 hours after the HCG medication has been administered. In this stage the ovarian follicles rupture and this results in the release of the oocyte. As soon as the follicles rupture the egg retrieval process is initiated, so as to not lose any eggs.
The medication for each stage of the ovarian stimulation varies. Ovarian stimulation is an important part of the IVF treatment. The number of eggs harvested from the ovaries depends largely on how accurately each stage of the ovarian stimulation has been carried out.
Risks of ovarian stimulation
Many women who take medication for ovarian stimulation suffer from Ovarian Hyper Stimulation Syndrome (OHSS). This happens a few days after the eggs have been retrieved. OHSS is caused due to a huge quantity of hormone medication in the body. It causes the ovaries to become swollen and painful. Usually most women get a mild condition of OHSS, but there are rare cases where the medication can have a sever effect on the patient.
Symptoms of OHSS
There are some symptoms of OHSS that most women experience. OHSS symptoms do not last long and should be over is about a weekor so if you do not conceive. If the symptoms persist then you should visit the doctor. If you get pregnant you would experience pregnancy symptoms and the OHSS symptoms may not be as noticeable. Women who get pregnant can experience worse OHSS symptoms which can last for 2 or 3 weeks or more. These symptoms are similar to pregnancy symptoms hence it is difficult to tell the difference.
Some of the common symptoms of OHSS are:
- Bloated feeling in the abdomen
- Pain or cramping feeling in the lower abdominal area
Other symptoms of OHSS such as:
- Difficulty breathing
- Sudden weight gain in few days
- Reduced urination
- Severe abdominal pain
These are symptoms of a severe OHSS and you should get immediate medical help. Very few patients suffer from severe OHSS but it can even be fatal in some cases. Even if you are pregnant it is important to look out for these symptoms. Weight gain in pregnancy does not start at the onset hence an unusual weight gain should be noted as unusual and reported to the doctor.
A technique that is gaining popularity in the west is something called Mild IVF. The Mild IVF is founded on a concept of performing a milder stimulation to the ovaries for egg maturation. Mild IVF is also referred to as Mini IVF, Micro IVF or minimal stimulation IVF. The standard ovarian stimulation involves a substantial dosage of hormone medication administered to the patient over a period of 8 to 15 days. Usually this medication is given via injections. It is an aggressive ovarian stimulation method to try and mature as many eggs as possible.
The Mild IVF involves a milder medication dosage which can be taken orally or in the form of injections. This medication has a very low dosage. The stimulation to the ovaries is much milder and hence very few eggs mature. The number of eggs retrieved with a Mild IVF is usually around 2 or 3 and sometimes even fewer like 1 or 2.
Why are many eggs required for IVF?
A standard ovarian stimulation results in the retrieval of around 10 eggs or more which are mature and can be used for the IVF treatment. All the retrieved eggs are placed together with the sperms for fertilisation. Not all the eggs fertilise and become embryos. This reduces the number of embryos to work with. Most of the embryos make it to the Day 3 stage. Some of the embryo arrest by the 4th or 5th day. The fact that some embryos will arrest by the 5th day is a well-known fact in the IVF industry. Only a few embryos become into blastocysts and by the 5th or 6th day it is only the good embryos that have survived to this stage. Some embryos may have chromosomal abnormalities and these usually arrest naturally.
With the Mild IVF ovarian stimulation technique we get considerably fewer eggs. Some of these eggs may not fertilise and hence the quantity of eggs that become in embryos is even fewer. The probability of embryos making it to the blastocyst stage is greatly reduced and sometimes no embryos remain. Hence it becomes a cancelled IVF cycle due to the lack of embryos to transfer.
Comparison of success rates
When we compare the success rates of the standards ovarian stimulation to the Mild IVF it becomes very apparent that the standard ovarian stimulation has a much higher success rate as there are more embryos to work with.
The quality of the eggs also plays a vital role in determining the success of the IVF treatment as a whole. The quality of the eggs is greatly influenced by the age of the patient. The older the patient the poorer the quality of the eggs they have. Women under the age of 35 have better quality eggs. After 35 there is a steady decline in the egg quality with each passing year. This is a general assumption and there is a possibility that a healthy older woman can have good quality eggs and an unhealthy younger woman can have poor quality eggs. But the general statistics determines the quality of the female egg with the age of the woman. There is no way to test the quality of an egg or an embryo hence we usually trust the good judgement of the embryologist. We determine quality based on his observations and study of the embryos as he monitors their development.
With a standard ovarian stimulation we may end up with some extra embryos. This does happen quite often even after culturing the embryos to a blastocyst stage. The best advice a doctor can give a patient at this stage is to freeze the additional embryos. Many small clinics in India discard the additional embryos. This is quite a waste especially if the IVF cycle is not successful. In this case the female patient has to undergo ovarian stimulation process once again to extract the eggs for the next IVF cycle.
Fertility Clinics like Medicover advise patients to freeze the embryos for future use. Medicover has their own preservation facilities which can be used by the patients or they can choose where they wish to store their embryos.
Pooja a Medicover IVF patient says, “I suffered a lot of pain and discomfort during the ovarian stimulation and was not keen to undergo the process again. My body reacted differently to the ovarian stimulation medication and so I had an unusually bad time. However the egg retrieval process was successful and the doctors were able to retrieve 13 eggs, all of which fertilised. The embryos were cultured to the blastocyst stage and we had 10 blastocysts. The doctor advised us to transfer 2 blastocysts and to freeze the remaining embryos in case I did not get pregnant. Somehow I did not conceive and I feel I did not follow all the precaution and that is why. For the next IVF procedure I was very relaxed as I just had to undergo the IVF transfer. Two of our frozen embryos would be thawed for this process. I did not have to have any more ovarian stimulation injections and I was really happy about that. My 2nd IVF cycle was successful and now I am pregnant. I am also happy that I still have 6 embryos frozen so that when we plan our next child it is will be easy with just an IVF transfer procedure. This is a brilliant service by Medicover.”
Mild IVF in India
The technique of Mild IVF does not facilitate the IVF treatment in any way and hence is not a practice at reputed fertility clinics in India. While the use of lower dosage medication may lower cost momentarily, but the reduced rate of success leads to a higher cost in the long run when the IVF treatment has to be repeated several times to achieve success.
Patients who would like a Mild IVF treatment are basically looking for a way to waste their time and money. Some smaller clinics and fertility doctors do administer a milder dosage of ovarian stimulation medication but this is not as a Mild IVF treatment but to save their own cost if they have offered the patient a cheaper treatment package. These places end up with very few mature eggs and hence there is a reduced pregnancy chance. Getting IVF treatment at a reputed and specialised fertility clinic like Medicover is always advisable.
IVF success at Medicover
Reputed Fertility Clinics in India like Medicover believe in delivering results. When a patient visits Medicover to have a baby the ultimate goal of the treatment is to enable the patient to have a baby. Medicover has a very good global success rate of delivering a Medicover baby every 3 hours. Every Medicover patient is given ovarian stimulation medication according to requirement. The dosage and its effects are closely monitored and the strength of the medication altered accordingly. Great care is taken to prevent any health risk to the patient.
Aggressive ovary stimulation
A standard ovarian stimulation generally carried out for an IVF treatment is now called aggressive ovary stimulation by the western countries. The term aggressive stimulation came about as a contrast to the mild stimulation.
Benefits of aggressive ovary stimulation
While the mild ovary stimulation may be gentle on the human body it does not serve the purpose of the treatment. When the ovaries are not sufficiently stimulated it does not mature more eggs than normal and hence is a futile process.
The intention of stimulating the ovaries is to be able to harvest as many eggs as we possibly can get. A larger number of eggs improve the chances of pregnancy. Once the eggs are fertilised and form embryos they can easily be cultured to the blastocyst stage without the fear of losing some along the way.
The basic objective of ovarian stimulation is to obtain mature eggs from the ovaries and to safe guard the health of the patient throughout the IVF treatment. The standard ovarian stimulation process serves this purpose well.
Q: I had a severe case of OHSS due to which the IVF transfer was not carried out and my eggs were discarded. Now I am scared to undergo ovarian stimulation. Are there any preventive measures?
A: There are some measures you can take such as increasing your salt intake. You need additional sodium and potassium in your body. Take high protein supplements drinks. Substitute your liquid intake with electrolyte based drinks. Avoid walking or staying on your feet as this can increase ovary pain. Ask your doctor for pain killers.
Q: A high dose of the ovarian stimulation medication made me very sick due to which I did not continue the treatment. A second opinion doctor states that my ovaries are very responsive to the medication.
A: Each person’s ovaries respond differently to the medication. This is the reason the effect of the ovary stimulation medication is closely monitored. If the patient is not responding the dose is increased if the ovaries respond well the dosage is lowered.
Q: What is the probability of my suffering from OHSS during IVF treatment?
A: Most women experience the symptoms of OHSS to a certain degree. You can lower your risk of suffering from OHSS symptoms by taking preventive measures.
Q: When do OHSS symptoms occur?
A: The OHSS symptoms usually occur after the eggs have been retrieved from the ovaries.
13 November, 2018
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In vitro fertilization (IVF) is a very clinical subject and most people......Read more