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Encyclopaedia


IVF

Introduction

In vitro fertilisation (IVF) is one of several techniques available to help people with fertility problems have a baby.

During IVF, an egg is removed from the woman's ovaries and fertilised with sperm in a laboratory. The fertilised egg, called an embryo, is then returned to the woman's womb to grow and develop.

It can be carried out using your eggs and your partner's sperm, or eggs and/or sperm from donors.

Who can have IVF?

The National Institute for Health and Care Excellence (NICE) has published fertility guidelines that make recommendations about who should have access to IVF treatment on the NHS in England and Wales.

These guidelines recommended that IVF should be offered to women under 43 years of age who have been trying to get pregnant through regular unprotected sex for two years, or who have had 12 cycles of artificial insemination.

However, the final decision about who can have NHS-funded IVF in England is made by local Clinical Commissioning Groups (CCGs), and their criteria may be stricter than those recommended by NICE.

If you're not eligible for NHS treatment, or you decide to pay for IVF, you can have treatment at a private clinic. Costs vary, but one cycle of treatment may cost up to £5,000 or more.

Speaking to your GP about IVF

If you're having trouble getting pregnant, you should start by speaking to your GP. They can advise on how to improve your chances of having a baby.

If these measures don't work, your GP can refer you to a fertility specialist for a treatment such as IVF.

What happens during IVF

IVF involves six main stages:

  1. Suppressing your natural cycle – the menstrual cycle is suppressed with medication
  2. Boosting your egg supply – medication is used to encourage the ovaries to produce more eggs than usual
  3. Monitoring your progress and maturing your eggs – an ultrasound scan is carried out to check the development of the eggs, and medication is used to help them mature
  4. Collecting the eggs – a needle is inserted into the ovaries, via the vagina, to remove the eggs
  5. Fertilising the eggs – the eggs are mixed with the sperm for a few days to allow them to be fertilised
  6. Transferring the embryo(s) – one or two fertilised eggs (embryos) are placed into the womb

Once the embryo(s) has been transferred into your womb, you'll need to wait two weeks before having a pregnancy test, to see if the treatment has worked.

Chances of success

The success rate of IVF depends on the age of the woman undergoing treatment, as well as the cause of the infertility (if it's known).

Younger women are more likely to have a successful pregnancy. IVF isn't usually recommended for women above the age of 42, because the chances of a successful pregnancy are thought to be too low.

In 2010, the percentage of IVF treatments that resulted in a live birth was:

  • 32.2% for women under 35
  • 27.7% for women aged 35-37
  • 20.8% for women aged 38-39 
  • 13.6% for women aged 40-42 
  • 5% for women aged 43-44
  • 1.9% for women aged over 44

Maintaining a healthy weight and avoiding alcohol, smoking and caffeine during treatment may improve your chances of having a baby with IVF.

What are the risks?

IVF doesn't always result in pregnancy, and it can be both physically and emotionally demanding. You should be offered counselling to help you through the process.

There are also a number of health risks involved, including:

  • side effects from the medications used during treatment, such as hot flushes and headaches
  • multiple births (such as twins or triplets) – this can be dangerous for both the mother and the children
  • an ectopic pregnancy – where the embryo implants in the fallopian tubes, rather than in the womb
  • ovarian hyperstimulation syndrome (OHSS) – where too many eggs develop in the ovaries
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Availability

IVF is only offered on the NHS if certain criteria are met. If you don't meet these criteria, you may need to pay for private treatment.

NICE recommendations

In 2013, the National Institute for Health and Care Excellence (NICE) published new fertility guidelines that made recommendations about who should have access to IVF treatment on the NHS in England and Wales.

However, individual Health Boards make the final decision about who can have NHS-funded IVF in their local area, and their criteria may be stricter than those recommended by NICE (see below).

Women under 40

According to NICE, women aged under 40 should be offered three cycles of IVF treatment on the NHS if:

  • they've been trying to get pregnant through regular unprotected sex for two years, or
  • they've not been able to get pregnant after 12 cycles of artificial insemination

If you turn 40 during treatment, the current cycle will be completed, but further cycles should not be offered.

If tests show that IVF is the only treatment likely to help you get pregnant, you should be referred for IVF straight away.

Women aged 40 to 42

The NICE guidelines also say that women aged 40 to 42 should be offered one cycle of IVF on the NHS if all of the following four criteria are met:

  • they've been trying to get pregnant through regular unprotected sex for two years, or haven't been able to get pregnant after 12 cycles of artificial insemination
  • they've never had IVF treatment before
  • they show no evidence of low ovarian reserve (where eggs in your ovaries are low in number or quality)
  • they have been informed of the additional implications of IVF and pregnancy at this age

Again, if tests show that IVF is the only treatment likely to help you get pregnant, you should be referred for IVF straight away.

IVF on the NHS

NHS trusts across England and Wales are working to provide the same levels of service. However, the provision of IVF treatment varies across the country and often depends on local health board policies.

Health Boards may have additional criteria you need to meet before you can have IVF on the NHS, such as:

  • not having any children already, from both your current and any previous relationships
  • being a healthy weight
  • not smoking
  • falling into a certain age range

In some cases, only one cycle of IVF may be routinely offered, instead of the three recommended by NICE.

Ask your GP or contact your local Health Board to find out what the criteria for NHS-funded IVF treatment are in your area.

Private treatment

If you're not eligible for NHS treatment or you decide to pay for IVF, you can have treatment at a private clinic. Some clinics can be contacted directly without seeing your GP first, but others may ask for a referral from your GP.

The cost of private treatment can vary, but one cycle of IVF can cost up to £5,000 or more. There may be additional costs for medicines, consultations and tests. During your discussions with the clinic, make sure you find out exactly what's included in the price.

Some people consider having IVF abroad, but there are a number of issues you need to think about, including your safety and the standard of care you'll receive. Clinics in other countries may not be as regulated as they are in the UK.

You can read about private fertility treatment and the issues and risks associated with fertility treatment abroad on the Human Fertilisation and Embryology Authority (HFEA) website.

You can also search for HFEA-regulated fertility clinics in the UK.

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Getting Ready

If you're having problems getting pregnant, see your GP. They will look at your medical history and give you a physical examination.

They may also recommend some lifestyle changes to help fertility.

Unless there are reasons that may put you at high risk of infertility, such as cancer treatment, you'll usually only be considered for infertility investigations and treatment if you've been trying for a baby for at least a year without becoming pregnant.

If appropriate, your GP can refer you to a fertility specialist at an NHS hospital or fertility clinic.

Seeing a fertility specialist

The specialist will ask about your fertility history, and may carry out a physical examination.

Women may have tests to check the levels of hormones in their blood and how well their ovaries are working. They may also have an ultrasound scan or X-ray to see if there are any blockages or structural problems.

Men may be asked for a semen sample to test sperm quality.

If the specialist thinks your infertility could be treated by IVF, or if you've been unable to conceive for at least two years, you may qualify for funding for IVF treatment.

If IVF is the best treatment for you, the specialist will refer you to an assisted conception unit (see below).

At the assisted conception unit

Once you're accepted for treatment at the assisted conception unit, you and your partner will have blood tests for HIV, hepatitis B and hepatitis C, and to check if you're immune to rubella. Your cervical screening tests should also be up to date.

The specialist will investigate the amount of eggs in your body and their quality (your ovarian reserve) to estimate how your ovaries will respond to IVF treatment.

This can be assessed by measuring a substance called anti-mullerian hormone (AMH) in your blood, or by counting the number of egg-containing follicles, known as your antral follicle count (AFC), using a vaginal ultrasound scan.

Your specialist will then discuss your treatment plan with you in detail and talk to you about any support or guidance you may find helpful.

 


 

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How is it performed?

What happens during IVF may differ slightly from clinic to clinic, but a typical treatment follows the main steps below.

For women

Step one: suppressing the natural menstrual cycle

You are given a medication that will suppress your natural menstrual cycle. This can make the medicines used in the next stage of treatment more effective.

This medication is given either as a daily injection (which you'll be taught to give yourself) or as a nasal spray. You continue this for about two weeks.

Step two: boosting the egg supply

Once your natural cycle is suppressed, you take a fertility hormone called follicle stimulating hormone (FSH). This is another daily injection you give yourself, usually for about 10-12 days.

FSH increases the number of eggs your ovaries produce. This means more eggs can be collected and fertilised. With more fertilised eggs, the clinic has a greater choice of embryos to use in your treatment.

Step three: checking progress

The clinic will keep an eye on you throughout the treatment. You will have vaginal ultrasound scans to monitor your ovaries and, in some cases, blood tests. About 34-38 hours before your eggs are due to be collected, you'll have a final hormone injection that helps your eggs to mature.

Step four: collecting the eggs

You'll be sedated and your eggs will be collected using a needle that's passed through the vagina and into each ovary under ultrasound guidance. This is a minor procedure that takes about 15 to 20 minutes.

Some women experience cramps or a small amount of vaginal bleeding after this procedure.

Step five: fertilising the eggs

The collected eggs are mixed with your partner's or the donor's sperm in a laboratory. After 16-20 hours, they're checked to see if any have been fertilised.

In some cases, each egg may need to be injected individually with a single sperm. This is called intra-cytoplasmic sperm injection or ICSI. You can read more about ICSI on the Human Fertilisation and Embryology Authority (HFEA) website.

The fertilised eggs (embryos) continue to grow in the laboratory for up to six days before being transferred into the womb. The best one or two embryos will be chosen for transfer.

After egg collection, you will be given hormone medicines to help prepare the lining of the womb to receive the embryo. This is usually given either as a pessary (which is placed inside the vagina), an injection, or a gel.

Step six: embryo transfer

A few days after the eggs are collected, the embryos are transferred into the womb.

This is done using a thin tube called a catheter that's passed into the vagina. This procedure is simpler than egg collection and similar to having a cervical screening test, so you won't normally need to be sedated.

The number of embryos that will be transferred should be discussed before treatment starts. It usually depends on your age.

  • Women under 37 in their first IVF cycle should only have a single embryo transfer. In their second IVF cycle, they should have a single embryo transfer if one or more top-quality embryos are available. Doctors should only consider using two embryos if no top-quality embryos are available. In the third IVF cycle, no more than two embryos should be transferred.
  • Women aged 37-39 years in the first and second full IVF cycles should also have single embryo transfer if there are one or more top-quality embryos, and double embryo transfer should only be considered if there are no top-quality embryos. In the third cycle, no more than two embryos should be transferred.
  • Women aged 40-42 years may have a double embryo transfer.

If any suitable embryos are left over, they may be frozen for future IVF attempts.

You can read the HFEA factsheets on embryo transfer and freezing and storing embryos for more information.

For men

Around the time your partner's eggs are collected, you'll be asked to produce a fresh sperm sample. The sperm are washed and spun at a high speed, so the healthiest and most active sperm can be selected.

If you're using donated sperm, it's thawed before being prepared in the same way.

Finding out if you're pregnant

Once the embryos have been transferred into the womb, you'll be advised to wait around two weeks before having a pregnancy test, to see if the treatment has worked.

Some clinics may suggest carrying out a normal urine pregnancy test at home and letting them know the result, while others may want you to come into the clinic for a more accurate blood test.

This "two-week wait" can be a very difficult period, because of the anxiety of not knowing whether the treatment has worked. Some people find it the hardest part of the treatment process.

During this period, you may find it useful to speak to a counsellor through the fertility clinic, or to contact other people in a similar situation to you via the HealthUnlocked IVF community.

If you do become pregnant, ultrasound scans will be carried out during the following weeks to check things are progressing as expected. You will then be offered the normal antenatal care given to all pregnant women.

Unfortunately, IVF is unsuccessful in many cases and you should try to prepare yourself for this possibility. You may be able to try again if treatment doesn't work, although you shouldn't rush straight into it. You may find counselling or fertility support groups helpful during this difficult time.

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Risks

Before starting IVF, it's important to be aware of the potential problems that could occur.

Some of the main risks are outlined below.

Medication side effects

Many women will have some reaction to the medications used during IVF. Most of the time, the side effects are mild and may include:

  • hot flushes
  • feeling down or irritable
  • headaches
  • restlessness
  • ovarian hyperstimulation syndrome (see below)

Contact the fertility clinic if you experience persistent or worrying side effects during treatment.

Multiple births

If more than one embryo is replaced in the womb as part of IVF treatment, there's an increased chance of producing twins or triplets.

Having more than one baby may not seem like a bad thing, but it significantly increases the risk of complications for you and your babies. Problems more commonly associated with multiple births include:

Your babies are also more likely to be born prematurely and/or with a low birthweight, and are at an increased risk of developing life-threatening complications such as neonatal respiratory distress syndrome (NRDS) or long-term disabilities, such as cerebral palsy.

NICE guidelines recommend that double embryo transfers should only be considered during treatment in women aged 40-42. Younger women should only be considered for a double embryo transfer if there are no top-quality embryos to choose from.

You can read more about the risks of multiple births on the One at a time website.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a rare complication of IVF. It occurs in women who are very sensitive to the fertility medication taken to increase egg production. Too many eggs develop in the ovaries, which become very large and painful.

OHSS generally develops in the week after egg collection. The symptoms can include:

  • pain and bloating low down in your tummy
  • feeling and being sick
  • shortness of breath
  • feeling faint

Severe cases can be dangerous. Contact your clinic as soon as possible if you have any of these symptoms. It may be necessary to cancel your current treatment cycle and restart with a lower dose of fertility medication.

Ectopic pregnancy

If you have IVF, you have a slightly higher risk of an ectopic pregnancy, where the embryo implants in the fallopian tubes rather than in the womb. This can cause pain in the tummy, followed by vaginal bleeding or dark vaginal discharge.

If you have a positive pregnancy test after IVF, you'll have a scan at six weeks to make sure the embryo is growing properly and that your pregnancy is normal.

Tell your doctor if you experience vaginal bleeding or stomach pain after having IVF and a positive pregnancy test.

Risks for older women

IVF treatment becomes less successful with age. In addition, the risk of miscarriage and birth defects increases with the age of the woman having IVF treatment.

Your doctor will discuss the increased risks that come with age, and can answer any questions you may have.

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Support organisations

Having IVF can be emotionally and physically draining, but help and support is available if you need it.

Your fertility clinic will offer you an opportunity to talk to a counsellor, and you may find it useful to join a fertility support group or online forum for support.

Counselling

The National Institute for Health and Care Excellence (NICE) recommends that counselling should be offered before, during and after IVF treatment (regardless of the outcome) by someone not directly involved in the management of the couple's fertility problems.

Counselling is a type of talking therapy that allows a person to talk about their problems and feelings in a confidential and dependable environment. It can help couples to understand the implications of treatment and offer support at a critical time, such as when an IVF cycle has been unsuccessful.

Read more about the benefits of counselling and how to access it on the Human Fertilisation and Embryology Authority (HFEA) website.

Unsuccessful IVF treatment

In many instances, IVF treatment is unsuccessful. Under these circumstances, it's a good idea to wait for a couple of months before thinking about trying again. This will give you a break from the stresses of treatment and allow your body time to recover.

This break can give you a chance to talk with the clinic about the reasons the IVF was unsuccessful, to talk to your partner about how you both feel, and consider your options going forward.

It can help to talk to other people who have been through IVF. A support group or online forum, such as the HealthUnlocked IVF community, may be helpful.

Read advice on what to do when fertility treatment fails on the HFEA website.

Adapting to parenthood

Some couples who have successfully started a family with IVF can find it difficult to adjust to their new life. It's important to seek help from health professionals (such as your fertility consultant, GP, midwife or health visitor) if you think you need it.

Contacting a fertility support group and talking with others who can empathise with your experiences can also be helpful. Infertility Network UK and Fertility Friends both have online forums where you can find other people who have dealt with the same issues.

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 19/08/2015 15:07:50

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