BHUBANESWAR: After trying to naturally conceive for a year, 45-year-old Swagatika (name changed) and her husband sought help from a fertility clinic. As the couple had already lost a teenage son, they did not take risks. Advanced age and diminished ovarian reserve was found to be the cause of her infertility. She agreed to undergo in vitro fertilisation (IVF) with donor oocytes and conceived in the first attempt to successfully deliver a healthy baby.
IVF is a process of fertilisation where an egg is combined with sperm in vitro (outside the human body) in a laboratory. The process involves monitoring and stimulating a woman's ovulatory process, removing an ovum (egg) from her ovaries and letting sperm fertilise them in a culture medium.
Invented initially for providing fertility solutions to women who suffer from blocked or dysfunctional fallopian tubes, it is now prescribed to women who are unable to conceive due to various reasons. Infertility, which affects approximately 15% of Indian couples, is viewed as a major problem with far reaching consequences. Myriad causes include late marriages which are becoming the norm, stressful lifestyle, obesity, junk food intake, smoking, alcoholism and drug addiction.
There has been a significant rise in infertility rate in Indians in the last two decades. The top five causes of infertility in women include polycystic ovarian syndrome (PCOS), endometriosis, abnormal male factor, tubal blockages and ovulation problems.
IVF is the most effective fertility treatment and one of the widely known types of assisted reproductive technology (ART). It involves a sophisticated set of techniques that are used to aid in the conception of a child, aid fertility or prevent genetic abnormalities.
Head of the Centre for Human Reproduction (CHR), the infertility and IVF unit of Institute of Medical Sciences and SUM Hospital Dr Sujata Pradhan said IVF works by using a combination of medicines and surgical procedures to help sperm fertilise an egg and help the fertilised egg implant in the uterus.
“Mature eggs are extracted from the ovaries and fertilised with sperm in a laboratory. IVF can be done using a couple's own eggs and sperm or it may involve eggs, sperm or embryos from a known or unknown donor. In some cases, it is also done for gestational carriers (who have an embryo implanted in the uterus),” she said.
IVF has emerged as a lifeline for countless couples who have been fighting infertility.
While an estimated 2-2.5 lakh IVF treatments are reported annually, the demand for assisted reproductive services is likely to go up to 20% in the next five years.
“Distinctive trends have emerged among patients, reflecting a significant shift in societal perceptions. This transformation has given rise to notable patterns, with IT couples, professionals from diverse backgrounds and individuals in remarriages or opting for parenthood later in life increasingly turning to IVF. Delay in family planning has become a prominent factor driving advanced-age couples towards fertility treatment,” said Dr Rabeeh Valiyathodi, consultant at Fertility Clinic, KIMS Health, Thiruvananthapuram.
The procedure
Proper diagnosis and treatment are paramount to get success in IVF. Since the birth of the first IVF baby in 1978, the process has undergone many modifications. In conventional IVF, the female undergoes controlled ovarian hyperstimulation with gonadotropin hormones. The procedure involves six major steps - stimulating the ovary, egg recovery, sperm retrieval, fertilisation and insemination, embryo culture and embryo transfer.
For stimulating the ovary, the patient is given hormone-based fertility medicines to encourage her ovaries to produce more eggs than usual. During each ovulation cycle, a woman’s ovary typically produces one egg. Transvaginal ultrasound images and routine blood tests are used to continuously track the development of eggs after the medications are administered.
Once the eggs develop, the process of harvesting eggs is done under anaesthesia. The eggs and associated fluid are individually extracted from each follicle using a needle that is connected to a suction apparatus. If any woman is unable to produce eggs, donor eggs are utilised.
Prior to retrieval of eggs, semen samples need to be collected under supervision. It can be collected on the same day or ahead of time and frozen. Testicular aspiration that uses a needle to collect sperm directly from the testicle is adopted if a person cannot ejaculate. Sperm from a donor also can be used. It is separated from the semen fluid in the lab.
Two common methods are used to fertilise eggs with sperm. In conventional insemination, healthy sperm and mature eggs are mixed and kept in a controlled environment called an incubator. In intracytoplasmic sperm injection (ICSI) method, a single healthy sperm is injected right into each mature egg.
Some other procedures are also recommended before embryos are placed in the uterus in certain situations. Assisted hatching is recommended if someone is older and wants to get pregnant, or if she has had past IVF attempts that didn't work. In this process, an embryo hatches from the thin membrane that surrounds it around five to six days after fertilisation. It lets the embryo attach to the lining of the uterus.
After a division of a fertilised egg produces an embryo, it is monitored frequently to ensure its normal development and prevent division of cells. Lastly, one to two embryos are transferred in the woman’s uterus about three to five days after the eggs are removed and fertilised and once they reach a particular size. Pregnancy is confirmed through blood tests. If it is positive for pregnancy, further confirmation is done by transvaginal ultrasonography after two weeks.
Dr Akhila Ayyagari from Oasis Fertility in Banjara Hills said the first step in IVF is taking fertility medications to help the ovary produce quality eggs that are mature and ready for fertilisation. Apart from providing advanced treatments for various fertility challenges, the focus must be on improving the quality of eggs and sperm through a variety of interventions, leading to higher success rates, especially when pre-genetic testing is involved.
“After the embryo is transferred, the patient can go back to normal activities the next day. They are kept under daily shots of progesterone for the first 10 weeks. The hormone makes it easier for the embryo to survive in the uterus,” Dr Ayyagari said.
Available facilities
There has been a lot of advancement in treatment of infertility. Patients now have access to a comprehensive range of internationally available facilities, including innovative techniques like preimplantation genetic testing (PGT), time-lapse technology and top-quality ultrasound imaging. These advancements are revolutionising IVF, offering precision and effectiveness in treatment.
Standalone hospitals and clinics are now offering counselling, transvaginal scan, ovulation induction and follicular monitoring, fertility enhancing laparoscopic surgeries, semen analysis, IVF, ICSI, intrauterine insemination (IUI), surgical sperm retrieval procedures (TESA/PESA), semen and embryo freezing and donor sperm IUI and IVF.
The future of IVF is brimming with possibilities with potential trends that include uterine transplants, three-parent IVF, enhanced genetic assessments, and more effective management of conditions like non-obstructive azoospermia (NOA), thin endometrium and diminished ovarian reserve (DOR). These innovations are poised to reshape reproductive medicine and offer renewed hope to couples embarking on their path to parenthood.
Amrita IVF Centre head Dr Fessy Louis said things around IVF treatment have changed in the last decade. Almost all advanced treatment methods are now available in the country. “The common age group that approaches the hospitals for the treatment is 30 to 35 years. The number of people who seek IVF treatment has increased due to increased awareness and affordability,” he added.
IVF treatment is now regulated by national and state ART regulation authorities following all the regulations of Assisted Reproductive Technology Regulation Act and Surrogacy Regulation Act.
However, cost and availability also restrict many couples avail this facility. Use of higher doses of hormone injections may sometimes lead to ovarian hyperstimulation syndrome. “The most common complication of IVF is multiple pregnancies which may lead to various short term and long term implications. This can be avoided by adopting the policy of single embryo transfer,” said Dr Pradhan.
Use of AI and IoT
IVF has limited success rates ranging from 60-80%. Recent advancements in technology, particularly in granular biology and artificial intelligence (AI), are paving the way for greater accessibility and enhancing the accuracy and efficacy of the IVF process.
Some centres have adopted cutting-edge AI technology to analyze semen samples. This not only expedites the process but also instils confidence and transparency in the IVF procedure. Similarly, the selection of eggs has long been a challenging aspect of IVF, often relying on indirect parameters. Santaan Fertility Clinic and Research Institute has pioneered a method that utilises biomarkers directly from the oocyte to classify the most suitable eggs for IVF.
Another promising application of AI in IVF is embryo selection and drug development. Using computer vision-based morphokinetics applications, specialists can optimise the selection of embryos. By sifting through vast datasets of genetic and clinical information, AI can identify potential drug targets and design new medications while optimizing their dosages.
Santaan Fertility Centre founder and chief innovation officer Dr Satish Prasad Rath said automation of various IVF tasks, including egg retrieval, embryo transfer and lab environment control is yet another facet of technological revolution in fertility treatment. “By introducing automation at every step of the IVF process, we can make the entire fertility journey more predictable and transparent,” Dr Rath added.
(With inputs from Unnikrishnan S @T’puram, Renuka Kalpana @Hyderabad and Anna Jose @Kochi)