In vitro fertilization (IVF) means fertilization outside of the body. IVF is the most effective ART. It is often used when a woman's fallopian tubes are ed or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.

Intracytoplasmic sperm injection (ICSI) is often used for couples in which there are serious problems with the sperm. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube.

Invitro Maturation (IVM) is a technique by which the eggs are taken out before they are fully mature and cultured outside in specific medium to make it mature outside and then ICSI is done. By this we are preventing the only dreaded complication in ART, ie OHSS (Ovarian Hyperstimulation Syndrome) which happens in few group of patients who are prone to making large number of Eggs.

Intracytoplasmic Morphologically selected Sperm Injection (IMSI) is a relatively new technique used to improve results in ICSI Cycles, especially in repeated ICSI failures. In IMSI sperms are selected under high magnification (7000-10000 times) and then ICSI is done. This will detect abnormalities in sperm head like vacuoles which are not seen on the conventional ICSI magnification. By adding IMSI to your ART treatment will be helping you to better our results..

ART procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperm, or previously frozen embryos. Donor eggs are sometimes used for women who can not produce eggs. Also, donor eggs or donor sperm is sometimes used when the woman or man has a genetic disease that can be passed on to the baby.

You may be wondering how everything will come together. While every clinic's protocol will be slightly different and treatments are adjusted for a couple's individual needs, here is a step-by-step breakdown of what generally takes place during an IVF treatment cycle.

Step 1 : The Cycle before treatment

The cycle before your IVF treatment is scheduled, you may be put on birth control pills or may then have you start taking a GnRH antagonist or a GnRH agonist, such as Lupride. This is so they can have complete control over ovulation once your treatment cycle begins.

Step 2 : When you get your periods

The first official day of your treatment cycle is the day you get your period. (Even though it may feel like you've already begun with the medications you've started before in step one.) On the second day of your period, your doctor will likely order blood work and an ultrasound. (Yes, an ultrasound during your period isn't exactly pleasant, but what can you do?) This is referred to as your baseline blood work and your baseline ultrasound.

In your blood work, your doctor will be looking at your estrogen levels, specifically your E2 or estradiol. This is to make sure your ovaries are “sleeping," the intended effect of the Lupride shots or GnRH antagonist.

The ultrasound is to check the size of your ovaries, and look for ovarian cysts. If there are cysts, your doctor will decide how to deal with them. Sometimes your doctor will just delay treatment for a week, as most cysts will resolve on their own with time. In other cases, your doctor may aspirate, or suck, the cyst with a needle.

Usually, these tests will be fine. If everything looks OK, treatment moves on to the next step.

Step 3 : Ovarian Stimulation & Monitoring

If your blood work and ultrasounds look normal, the next step is ovarian stimulation with fertility drugs. Depending on your treatment protocol, this may mean anywhere from one to four shots every day, for about a week to 10 days. (Ouch.)

You'll probably be a pro at self-injection by now, as Lupride and other GnRH agonists are also injectables. Your clinic should teach you how to give yourself the injections, of course, before or when your treatment begins. Some clinics offer classes with tips and instruction. Don't worry, they won't just hand you the syringe and hope for the best.

During ovarian stimulation, your doctor will monitor the growth and development of the follicles. At first, this may include blood work every few days, to monitor your estradiol levels, and ultrasounds, to monitor the oocyte growth. Monitoring the cycle is important, as it helps your doctor decide whether or not the medications need to be increased or decreased in dosage.

Once your largest follicle is 16 to 18mm in size, your clinic will probably want to see you daily.

Step 4 : Final Oocyte Maturation

Step 5 : Egg Retrieval or Ovum Pick Up

About 34 to 36 hours after you receive the hCG shot, the egg retrieval will take place. It's normal to be nervous about the procedure, but most women go through it without much trouble or pain.

Before the retrieval, an anesthesiologist will give you some medication intravenously to help you feel relaxed and pain free. Short general anesthesia, is generally used at our clinic during pick up. Side effects and complications are less common.

Once the medications take their effect, your doctor will use a transvaginal ultrasound to guide a needle through the back wall of your vagina, up to your ovaries. She will then use the needle to aspirate the follicle, or gently suck the fluid and oocyte from the follicle in to the needle. There is one oocyte per follicle. These oocytes will be transferred to the embryology lab for fertilization.

The number of oocytes retrieved varies but can usually be estimated before retrieval via ultrasound. The average number of oocytes is 8 to 15, with more than 95% of patients having at least one oocyte retrieved.

After the retrieval procedure, you'll be kept for a few hours to make sure all is well. Light spotting is common, as well as lower abdominal cramping, but most feel better in a day or so after the procedure. You'll also be told to watch for signs of ovarian hyperstimulation syndrome, a side effect from fertility drug use during IVF treatment in 10% of patients.

Step 6 : Egg Fertilization

While you're at home recovering from the retrieval, the follicles that were aspirated will be searched for oocytes, or eggs. Not every follicle will contain an oocyte.

Once the oocytes are found, they'll be evaluated by the embryologist. If the eggs are overly mature, fertilization may not be successful. If they are not mature enough, the embryology lab may be able to stimulate them to maturity in the lab.

Fertilization of the oocytes must happen with 12 to 24 hours. Your partner will likely provide a semen sample the same morning you have the retrieval. The stress of the day can make it difficult for some, and so just in case, your partner may provide a semen sample for backup earlier in the cycle, which can be frozen until the day of the retrieval.

Once the semen sample is ready, it'll be put through a special washing process, which separates the sperm from the other stuff that is found in semen. The embryologist will choose the “best looking sperm," placing about 10,000 sperm in each culture dish with an oocyte. The culture dishes are kept in a special incubator, and after 12 to 24 hours, they are inspected for signs of fertilization.

With the exception of severe male infertility, 70% of the oocytes will become fertilized. In the case of severe male infertility, ICSI (pronounced ick-see) may be used to fertilize the eggs, instead of simply placing them in a culture dish. With ICSI, the embryologist will choose a healthy-looking sperm and inseminate the oocyte with the sperm using a special thin needle.

Step 7 : Embryo Transfer

About two to three days after the retrieval, the fertilized eggs will be transferred. The procedure for embryo transfer is just like IUI treatment. You won't need anesthesia.

During the embryo transfer, a thin tube, or catheter, will be passed through your cervix. You may experience very light cramping but nothing more than that. Through the catheter, they will transfer the embryos, along with a small amount of fluid.

The number of embryos transferred will depend on the quality of the embryos and previous discussion with your doctor. Depending on your age, anywhere from two to five embryos may be transferred..

After the transfer, you'll stay lying down for a couple hours (bring a book) and then head home.

If there are "extra" high-quality embryos left over, you may be able to freeze them. This is called "embryo cryopreservation." They can be used later if this cycle isn't successful, or they can be donated.

Step 8 : Luteal Support

On or after the day of your retrieval, and before the embryo transfer, you'll start giving yourself progesterone supplements. Usually, the progesterone during IVF treatment is given as an intramuscular self-injection as progesterone in oil. (More shots!) Sometimes, though, progesterone supplementation can be taken as vaginal gel or vaginal suppository.

Besides the progesterone, there really isn't much going on for the next two weeks. In some ways, the two weeks after the transfer may be more difficult emotionally than the two weeks of treatment. During the previous steps, you will have visited your doctor perhaps every other day. Now, after transfer, there will be a sudden lull in activity.

All you can do is wait the two weeks and see if pregnancy takes place. It can help to keep busy with your life during this wait time and avoid sitting and thinking about whether or not treatment will be successful. I know, it's much easier said than done.

Step 9 : Pregnancy Test & Follow Up

About fifteen days after the embryo transfer, a pregnancy test is ordered. This is usually a serum pregnancy test (more blood work). The test may be repeated every few days.

If the test is positive (yeah!), you may need to keep taking the progesterone supplementation for another several weeks. Your doctor will also follow up with occasional blood work and ultrasounds to monitor the pregnancy and watch for miscarriages or ectopic pregnancies. During IVF treatment, miscarriage occurs up to 15% of the time in women under age 35, 25% of women age 40 and up and 35% of the time after age 42. Your doctor will also monitor whether or not the treatment led to a multiple pregnancy. If it's a high-order pregnancy (4 or more), your doctor may discuss the option of reducing the number of fetuses in a procedure called a "multifetal pregnancy reduction." This is sometimes done to increase the chances of having a healthy and successful pregnancy.

If the pregnancy test is still negative 15 to 17 days post-transfer, however, your doctor will ask you to stop taking the progesterone, and you'll wait for your period to start. The next step will be decided among you, your partner and your doctor.

Having a treatment cycle fail is never easy. It's heartbreaking. It's important, however, to keep in mind that having one cycle fail doesn't mean you won't be successful if you try again.You will have to discuss with your doctor what will be the best option

Success rates vary and depend on many factors. Some things that affect the success rate of ART include:

	Bilateral Tubal
	age of the partners
	reason for infertility
	clinic
	type of ART
	if the egg is fresh or frozen
	if the embryo is fresh or frozen
	For women younger than 35, the percentage of live births per cycle is 39.6%.
	For women ages 35 to 37, the percentage of live births per cycle is 30.5%.
	For women ages 38 to 40, the percentage of live births per cycle is 20.9%.
	For women ages 41 to 42, the percentage of live births per cycle is 11.5%.
	For women ages 43, the percentage of live births per cycle is 6.2%.
	After age 44, little more than 1% of IVF cycles with non-donor eggs lead to live birth.

As you can see, IVF success goes down significantly after age 40. For this reason, most women 40 yrs and above use donor eggs.

It's interesting to note that IVF success rates with donor eggs are even higher than a woman younger than 35 using her own eggs. Donor eggs offer the best chance for success.

The average IVF cost is 1.3 lakhs, but it can be as much as 1.75lakhs. It may be as low as 1 Lakh, but it’s rarely lower than that. These prices are for one cycle of IVF.

If a fertility clinic tells you that their IVF costs less than 1 Lakh, they are probably leaving something out from their price quote. Ask them if their price quote includes everything, including fertility drug purchases, ultrasound and monitoring costs, blood work, and any options they consider “extra”.

If you have frozen embryos from a previous cycle and want to use them, doing so is significantly cheaper than doing a complete IVF cycle with fresh embryos. The average cost for a frozen embryo transfer (FET), is about 40-50,000 Rs.

While basic IVF costs around 1- 1.5 lakhs INR, if you need additional assisted reproductive technologies like IVM,IMSI,PGD etc, the cost will be higher.

Complications are very rare in IVF treatment other than the few listed below

Multiple Pregnancy

OHSS

Some enlargement of the ovaries is normal during fertility drug treatment. With ovarian hyperstimulation syndrome, though, the ovaries become dangerously enlarged with fluid. This fluid can leak in to the belly and chest area, leading to complications. But the majority of the fluid doesn't come from the follicles themselves. Most of it comes from blood vessels that are "leaky" due to substances released from the ovary.

Ovarian hyperstimulation syndrome can only occur once ovulation takes place. If your doctor suspects that you’re at risk, he may cancel your treatment cycle. (Any fertilized embryos from an IVF treatment cycle may be frozen and saved for use during a future cycle.) Or your doctor may use medications to delay ovulation by a few days. She may prescribe a GnRH antagonist, which will prevent the body’s natural LH surge, preventing or delaying ovulation.

Another option may be that your doctor may simply delay administering the hCG trigger shot, a fertility drug that triggers ovulation. Delaying ovulation to lessen the risk of ovarian hyperstimulation syndrome is sometimes referred to as “coasting." This delay of a few days can lower the risk and severity of ovarian hyperstimulation syndrome, without seriously decreasing your chances of successful pregnancy.

Symptoms of Ovarian Hyperstimulation Syndrome

As noted above, ovarian hyperstimulation syndrome can only occur after ovulation has taken place. Symptoms may occur a few days after ovulation or IVF egg retrieval or they may not show up for a week or more after ovulation.

Mild symptoms include:

	Bloating
	Mild pain or discomfort in the abdomen
	Mild weight gain
	Mild nausea
	Diarrhea

More serious symptoms include:

	Rapid weight gain, more than 10 pounds in 3 to 5 days.
	Mild pain or discomfort in the abdomen
	Severe abdominal pain
	Severe bloating
	Severe nausea (so much that you can’t keep down any food or fluids)
	Dizziness
	Trouble with urinating
	Shortness of breath
	Rapid heartbeat

If you experience mild symptoms, you should contact your doctor as soon as possible, so he or she can monitor the situation. If you experience any of the serious symptoms, contact your doctor immediately.

Prevention and Treatment of Ovarian Hyperstimulation Syndrome

While you take fertility drugs, your doctor should monitor your body’s response to the medications with blood tests and ultrasounds. Rapidly increasing estrogen levels or ultrasounds that show a large number of medium-size follicles, are all possible indicators of ovarian hyperstimulation syndrome risk.

If you develop a mild case of ovarian hyperstimulation syndrome, you probably won’t need special treatment.

Here are some things you can do at home to feel better: 

	Don’t overexert yourself; take it easy while you recover
	While you shouldn’t overexert yourself, you should maintain some light activity. Total bed rest can increase the risk of some complications
	Put your feet up. This can help your body get rid of the extra fluid
	Sex should be avoided until you feel better. Sexual activity may increase your discomfort, and in the worst case scenarios, may cause ovarian cysts to leak or rupture.
	Do drink plenty of fluids, around 10 to 12 glasses a day.

Your doctor will give you instructions on what to watch for and when to contact him. If your symptoms get worse, you should definitely let them know. She may ask you to weigh yourself daily, to monitor weight gain. If you find yourself gaining 4 or more Kg per day, you should call your doctor.

In rare cases, you may need to be hospitalized. Hospitalization may include receiving fluids intravenously (through an IV), and they may remove some of the excess fluids in your belly via a needle. You may also be kept in the hospital for careful monitoring until your symptoms lessen.

Usually, symptoms will decrease and go away once you get your period. If you get pregnant, though, your symptoms may be prolonged, and it may take several weeks to feel completely better. Pregnancy can also make the symptoms worse, so your doctor will want to monitor your situation carefully.