In Vitro Fertilization

In vitro fertilization (IVF; Latin “fertilization in a glass”) is a method of artificial insemination. Prerequisites for using the method: the condition of the fallopian tubes must be known (laparoscopy). IVF treatment is indicated only if damage to the tubes (fallopian tubes) cannot be repaired surgically.

Indications (areas of application)

  • Tubal sterility (transport disorder) – currently only circa 50% of cases of performed in vitro fertilization!
  • Immunologically induced sterility (spermatozoa antibodies).
  • Condition, for example, after unsuccessful inseminations.
  • Idiopathic (unexplained) infertility, ie, all diagnostic and therapeutic options (condition after unsuccessful inseminations) of infertility treatment have been exhausted, including psychological examination.
  • Male subfertility, provided that treatment attempts with intrauterine or intratubal insemination do not promise success or have been unsuccessful.

Before surgery

Before in vitro fertilization (IVF) must be preceded by an examination of the man by doctors with the additional designation andrology. This includes a self, family, and couple history including a sexual history, a physical examination an ejaculate analysis (including spermiogram/sperm cell examination). If indicated, this is supplemented by scrotal sonography (ultrasound of the testicles and epididymis) and, if necessary, hormone diagnostics and cyto- or molecular genetic diagnostics. If sexually transmitted diseases (STDs) and other urogenital infections are present that could endanger the woman or child, these must be treated [Guidelines: Diagnosis and therapy before assisted reproductive medicine treatment (ART)].Anticoagulants (anticoagulants) should not be taken for up to 7 days before surgery.

The procedure

In in vitro fertilization, after previous follicle maturation therapy (hormone therapy: ovarian hyperstimulation), which should lead to the maturation of several eggs, the woman’s eggs are retrieved from the ovaries (ovaries) under ultrasound vision – by vaginal sonography – through a puncture through the vaginal wall. The egg collection is also called follicular puncture. It takes about 5-10 minutes. The eggs are then fertilized extracorporeally, i.e. outside the body, with the previously prepared sperm – after sperm preparation – in an incubation system – also called a retort. The intensity of ovarian stimulation (ovary stimulation/ovary stimulation) does not appear to affect the rate of euploidy and live births, regardless of the woman’s age.A decrease in the rate of euploidy has been demonstrated after the age of 35; the number of embryos that can be retrieved also decreases with age.Note: Euploidy is the presence of a complete, whole-multiple set of chromosomes. Note: Women in physically demanding occupations had significantly fewer oocytes (by 1.0) and fewer mature oocytes (by 1.4) after ovarian stimulation. Pronuclear stage After approximately 18 hours, fertilization of the oocytes is controlled. A fertilized oocyte can be recognized by the two pronuclei, which correspond to the genetic material of sperm (sperm cell) and oocyte (egg cell). This stage is referred to as the “pronucleus stage”. At this stage, the oocytes are selected that will later be returned to the uterus. According to the German Embryo Protection Act, it is not allowed to further cultivate or return more than three embryos. The other eggs are therefore either discarded or frozen. Quadruplets A little more than 48 hours after egg puncture, the embryos are usually returned to the uterine cavity (transfer). At this point, they have already divided and are at the 4-8 cell stage. In the case of blastocyst transfer, the embryos are returned to the uterus at a later time – for example, on the 5th or 6th day after oocyte retrieval.Note: It is still debatable whether there is a general superiority of blastocyte transfer.

Pregnancy rates

  • The pregnancy rate in Germany per embryo transfer in 2016 was 33.8% after IVF and 31.8% after ICSI (intracytoplasmic sperm injection).
  • After age 35, there is a steady decline in pregnancy rates after IVF from 24.1% per embryo transfer at age 40 to 14.6% at age 43.
  • Age 35: one year after starting IVF treatment, 39.8% of women were pregnant; among women who had waited, the proportion was only 26.1%.
  • After IVF treatment, approximately 65% of women become mothers within 3 years.
  • After IVF/ICSI treatment, there is a risk of increased preterm birth rate; 10.1% versus 5.5% for pregnancy by natural means.
  • Prospects of success of having another child by this route after birth of a first child using assisted reproductive technology (ART; here, intracytoplasmic sperm injection (ICSI) and IVF) (note: in three-quarters of women, supernumerary frozen embryos from the first time could be used):
    • In 43.4% of cases, even the first cycle of treatment, including the transfer of frozen embryos, resulted in the birth of a child
    • After a maximum of three complete treatment cycles, the cumulative live birth rate was conservatively estimated at 60.1% and at best 81.4%.
    • Cumulative live birth rate after up to six cycles ranged from 50% to 88%.

Possible sequelae

  • Women who become pregnant with the help of in vitro fertilization (IFV) have more than double the risk of severe pregnancy complications. Possible causes are that these women are older on average and therefore more likely to have obesity more often hypertension and type 2 diabetes.
  • Women who had unsuccessfully undergone ovarian hyperstimulation to achieve pregnancy were more likely to develop heart failure (heart failure) (rate ratio 2.25; 2.06-2.4) or apoplexy (stroke) (rate ratio 1.33; 1.22-1.46) in subsequent years than women with successful fertility therapy.
  • A population-based cohort study in which more than 105,000 patients were followed up for at least 10 years showed that significantly more ovarian cancer (ovarian cancer; 405 versus 291), both invasive (264 versus 188) and borderline (141 versus 103), occurred, representing 3.4 and 1.7 additional cases per 100,000 person-years, respectively. The increased risk of ovarian cancer was limited to women with endometriosis (presence of endometrium (lining of the uterus) extrauterine (outside the uterine cavity)) or few births. Furthermore, patients in the IVF group were significantly more likely to develop in situ breast carcinoma (early breast cancer) than the general population without IVF (291 versus 253; 1.7 more cases per 100,000 person-years). The risk of in situ breast carcinoma was dependent on the number of hormone cycles administered.
  • Children conceived via IVF exhibited arterial dysfunction as adolescents in an observational study, which is considered a precursor to atherosclerotic vascular damage that could increase cardiovascular risk in the long term. It was shown that flow-mediated dilation (FMD) of the brachial artery, a test of endothelial function, was reduced by 25% compared to a control group of 57 naturally conceived children. Furthermore, the intima-media thickness of the carotid artery was increased.At the age of almost 17 years, ambulatory blood pressure monitoring (ABDM; engl. ambulatory blood pressure monitoring, ABPM) revealed slightly elevated values: 8 of the 52 IVF/ICSI children, but only 1 of the 43 children of the control group met the criteria of arterial hypertension (blood pressure above 130/80 mmHg and/or above the 95th percentile).
  • IVF treatment is associated with a 5-fold increased risk of postpartum cardiomyopathy (PPCM). The clinical symptoms are difficult to distinguish from normal pregnancy symptoms: Fatigue, dyspnea (shortness of breath), nocturia (urination at night). The authors suspect common risk factors, so that IVF-treated patients more often develop PPCM.

Please note

The physical and mental health of man and woman as well as a healthy lifestyle are important prerequisites for successful fertility treatment. Before starting therapeutic measures, you should in any case – as far as possible – reduce your individual risk factors! Therefore, before starting any reproductive medical measure (e.g. IUI, IVF, etc.), have a health check and a nutritional analysis performed to optimize your personal fertility (fertility).