Last Updated on March 19, 2024 by Partha Protim Choudhury
This is a discussion on IVF or in vitro fertilisation. IVF has become both important and famous in contemporary times due to its high success rates, versatility in addressing diverse fertility issues, and its role in helping individuals and couples overcome age related fertility challenges and achieve their dreams of parenthood.
To understand about this in detail, we have with us Dr Shital Punjabi, an IVF specialist with more than 25 years of experience in gynaecology. Currently, she’s the Founding Director of Shashwat IVF and Women Hospital and the IVF department at Motherhood Women’s Hospital. She’s also a consultant in cosmetic gynaecology and has assisted over 10,000 childless couples and conducted numerous deliveries and gynae laparoscopic surgery. For the detailed interview click on the link below.
Q. Would you explain to us what are the main steps involved in the IVF process?
Normally in every female she releases one egg from one of her ovaries and alternate ovaries they’re working. So, in a month she has one egg and one chance of pregnancy naturally. When we do IVF, we want a minimum of three top quality embryos. So, for that we need a minimum seven to eight top qualities of the eggs. And for that we are giving injections. Injection gonadotropins to the female right from the first or second day of her menstrual period, daily she is supposed to take the injection.
Now when we are giving this injection, we are aiming at producing around eight to ten eggs collectively. From both the ways there are five, six eggs from each of them. When we are giving this, there is an increase in the extrusion level, and we want to prevent that resulting in early release of the LH. LH is the hormone which is necessary in the second half of the ovulation process. So, we want to stop that premature surge of LH. For that we give either down regulation or we give antagonist protocol. This is the second injection we are adding and usually the cycle length is between 9 to 15 days for the stimulation.
So, this is known as individualised ovarian stimulation for IVF. So, after the stimulation there, the eggs, like severe sonography, are being done. Every alternate day from the 9th day of the period a blood work is being done wherein we check the serum oestrogen label in the blood of the female which gives us ideas about what to do next.
Then a day comes when the eggs are matured. Then a final maturation injection is given which is known as trigger in general language. And after 35 hours of the trigger the eggs from the ovaries are being retrieved. That is ovum pickup is being done. That is the female is admitted. Ten minutes of serration anaesthesia is given and then through ultrasonographic guidance the eggs from each ovary are taken out. That is retrieved using the pressure pump and it is being taken in the test tube.
Then they are being checked under the microscope. They are clean. And then whichever eggs are good in quality we call them ‘meiosis 2 eggs’. Those M2 eggs are being processed. In case of IVF, we are kept in the culture dish, and they are made to interact with the sperm of the patient’s husband. Then through injection the one sperm, one selected sperm is being injected inside the cytoplasm of the egg.
And then that egg is now in a way injected and then it is kept in the incubator with a proper culture condition which has been provided by the fallopian tube. Naturally the same thing is created inside the embryology lab with CO2, that is carbon dioxide and nitrous and oxygen and the pH and the temperature like class 10,000 air. Everything is being maintained. And in that embryology lab for four to five days embryos are grown.
Once the embryos are grown, we see the morphological criteria of those embryos. So those top-quality embryos are being taken in the catheter and then again, the female is admitted and under the ultrasonographic guidance, the embryos are nicely kept inside the uterus at a point where there are highest chances of those embryos to get implanted. And then they may grow and grow till nine months of the pregnancy and then they give us the full-term healthy baby.
So, this is the whole process right from the stimulation of the ovary to inducing the ovary for superovulation and then the serial sonography and then checking for the maturation and then giving the trigger and then doing oocyte retrieval. Then the embryological app processes and the embryos are created. Then the embryos are put back inside the uterus for embryo transfer. After completing the embryo transfer, the medical team administers specific tablets and injections to the female. So that embryo gets implanted and gets nutrition, and then it continues ahead as a pregnancy. So that’s how the whole process is.
Q. How long is the process, like from initial consultation to embryo transfer? What is the duration of this period?
From initial consultation to the starting of the stimulation that requires a pretreatment, usually it takes around one month, a proper evaluation, medical fitness, gynae fitness, everything is to be checked and then pretreatment is given. And when we start with the stimulation of the ovary, then usually it is 12 to 15 days for the stimulation. And then once the embryo is being transferred, then nothing is to be done. The patient doesn’t have to visit the gynaecologist or the women’s hospital or idea centre for 15 days. She’s supposed to take certain medications which help in the pregnancy maintenance.
And then at the end of the 15 days of the embryo transfer, the medical team conducts a blood beta ECG report, which gives us the idea that there is a pregnancy. So, it’s like 15 days of coming daily to the hospital, getting injections and getting treatment and getting ultrasonography and then embryo.
Q. What is the success rate of the IVF procedure, and which are the factors which are involved here?
For success, we can say that in India we are able to transfer two to three embryos in an attempt. So, in India, the success rate is higher per IVF. This is good news, right, about India. See, normally, internationally, it is legally regulated to transfer only one embryo for preventing twins and preventing the complication of the twins.
So outside India, it is only one embryo transfer which is allowed. So there the success rate varies between 38.7% to 50%. But here in India, we can transfer two top qualities of embryos. So, the success rate is between 60% to 80%, depending on different age, pathology and everything. But we have very good results in IVF in India because of that policy.
When it comes to the risk factors, it starts with the age, starts with EMI, the couple seeking fertility treatment after their marriage. So, then they have a high success rate. But if somebody has waited for ten years and then if they are going, they have ten years of infertility and they are seeking the treatment, they have a relatively less success rate and the more the quality of the egg and sperm, better the quality of the egg and sperm, more the number of the eggs, there are better chances of pregnancy, less the pathology, better the chance of pregnancy, less the manageable pathology, better the chance of pregnancy, less hormonal disturbance, better the chance of pregnancy. Non PCO, better chances. Non endometriosis, better chances. But if somebody is suffering from PCO and a lot of hormonal disturbance, less chances of pregnancy like that.
In my own centre, in my own evidence, all the databases, we get more than 80% results in the rural population. Likewise, we get around 60% to 70% results in the urban population, because there are two different sets of pathologies.
Q. How many embryos are typically transferred in every case and how is the decision made?
In India, up to three embryos can transfer, first thing. Second embryo morphology and the basic pathology, why we are doing IVF, that is taken into account how many numbers of the embryos will be transferring. So that is the most important thing. Now, if somebody has only three eggs and only one embryo is there, then obviously we’ll be able to transfer only one embryo.
But there are certain females, we have seven, eight cultures of embryos, then we select only the top quality of embryos and then we transfer that. So, it is more like, what is the quality of the embryo and how many embryos are there – that decides how many embryos will be transferred back inside the womb.
Q. Are there any lifestyle changes or preparations that are needed before starting an IVF cycle for both the man as well as the woman?
Yeah. So first let us check the female part. As a female, I would strictly educate everyone to plan their first baby before the age of 30. As I have shared, that biological clock is ticking. The fertility reduces sharply after the age of 13. The quality of the egg deteriorates sharply after the age of 30. Pregnancy complications are high after the age of 30. Getting multiple anomalies during the child is higher than the girls who have delivered before the age of 30. So, these are the things. So, age is the first factor.
Second, which is most commonly seen in the young girls in urban population is they are using IP left, right and centre as a routine contraceptive. So, second advice is that we should not be using IP as a regular contraceptive, birth control pills are far better than using IP. Like what I have learned in my IVF practice is something which I would like to tell you. So, this is the second thing.
Third, use of empty peels. Quite frequent and over the counter empty pills are available. So, the female doesn’t want to continue with the pregnancy. For that they swallow some pills and then they think that she is fine. But later on, it becomes very difficult for her to conceive. So, this is the most important thing.
Fourth, the junk food and late nights and overexposure to smoking and alcohol. In smoking it is primary, secondary. Both are having a bad effect. So those things are very important, at least for the egg to get mature in the ovary it takes around 81 to 89 days. So, I advise all my patients that for three months, take a good detox in all the ways emotional, social, like the toxic radicals and everything. And we even give a lot of Ayurvedic and naturopathy pretreatment before we start with the IVF cycle and yoga, meditation, everything.
So that holistic approach of the pretreatment increases the chance of pregnancy, decreases the chance of abortion, decreases the chance of the child with anomalies, decreases the chances of medical disorders like diabetes, hypertension during pregnancy and increases the chances of carrying a baby weight. These are all the things which are very important. So, these are about diet and lifestyle.
Avoid certain things in the diet like junk food, particularly the food with the preservative, the late-night foods. And all this stuff for male, exactly the same way, like smoking, alcohol are two important things. Third is taking care of the infections, good hygienic practices and taking antioxidants. Consumption of the antioxidants improves the sperm motility and sperm fertility index. So that is important. So good vitamin B12, good vitamin B3. And antioxidants to both the partners. And one more important thing, though science has not 100% given the evidence for that. But the use of laptops in the lab, use of mobile in the bottom pockets has some effect on the sperm function.
So those who are planning their family, they should use either the Wi-Fi and Wi-Fi protectors or they should keep those gadgets away from the private part so that there is less exposure to those things. I have seen a couple of patients who have worked with radar technology, and they ended up with absolutely zero sperms. Like with a normal sperm report to absolutely zero sperm. So that’s how the rays have the effect. So, this is what I would like to tell the male.
Q. Despite the lifestyle changes and preparations, there can be certain risks and complications with the procedure. So, could you please elaborate on that?
The risk of the procedure is always there. There usually comes in two things. One is for females when they are given these injections, and they are like injections related to complications they have. And second is procedure related. So, once they are admitted, the procedure is being done and that’s it.
So, in the injection related or when supervision is done, then it may start from basic allergy to eruptions on the face. Because of overexposure to the hormones and relatively temporary weight gain because of those topics and water retention. This may happen in a few of the females. When they have produced multiple, their ovaries have responded extraordinarily, and they produce more than 20 eggs. When their oestrogen level shoots up more than 5000, then they may have OHSS. And OHSS is a very complex radio complication. This is known as ovarian hyperstimulation syndrome. That means ovaries have produced an excess number of eggs.
Q. How typically would the procedure of IVF cost at the right place and even at the rural and urban places? And what are the components of this cost?
Usually, the treatment cost ranges between 1.75 lakh rupees to 4 lakh rupees depending on the centre, whereas in relatively small metro cities, the cost ranges from 1.5 lakh rupees to 2.5 lakh rupees. And then later on like after ten years also if they want to plan their pregnancy, they can pretty well go for that. Freezing cost over two lakh rupees for ten years. And IVF that cost ranges between 1.2 lakh rupees to two lakh rupees approximately.
The range is between 1.3 to 1.5 per attempt of the cycle. And this includes everything right from the selection of the patient to all the injections and gonad choppings and blood reports and ultrasonography and then trigger injection and anaesthesia charges, medicine charges, OT medicine charges, embryologist charges, embryology lab charges, the consumables and disposables of the embryology lab, then incubator charges and then selection of the embryos and then taking the embryos and then putting back inside the uterus of the mother and then post embryo transfer medicine to nurture the embryos. All this together and the professional fees of the doctor and the professional fees of the institute together. Usually this is in India.
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