15 – 16

A brief outline

What happens in an The six stages of an IVF cycle

Over the next few pages, we have outlined
What’s the difference between
IVF and ICSI?
each stage of In Vitro Fertilisation (IVF) cycles. Ovarian stimulation and egg collection in

In Vitro Fertilisation There are different protocols used during IVF

cycles depending on your age, hormone levels
Intracytoplasmic Sperm Injection (ICSI)
and IVF cycles are exactly the same. The
difference between the cycles is that in an

(IVF) cycle? and previous response to stimulation.

Stage 1 The woman’s normal hormone

IVF treatment is made up of six stages which are discussed during the
following pages in detail. These stages take you through your medication and
scan regime to the egg collection procedure towards fertilisation and
embryo development ahead of your embryo transfer.
ICSI cycle, each egg is ‘stripped free’ of its
outer coating cells to determine its maturity.
Each suitable mature egg is then injected
production is often temporarily switched off
with a single suitable sperm obtained from
(down-regulated) by using medicine
the prepared partner or donor sperm sample.
(gonadotrophin releasing hormone) GnRH
analogue (synarel, buserelin), so that control of
In an IVF cycle, eggs are placed together
egg production and release can be obtained.
with a number of sperm in a petri dish to
Stage 2 The woman’s ovaries are stimulated allow fertilisation.
with hormone injections (Gonal-F, Menopur)
to produce eggs.
Stage 3 The male produces a semen sample
or the donor sperm sample is prepared.
Stage 4 The woman’s eggs are collected
from her ovaries.
Stage 5 The eggs and sperm are placed
together in a petri dish to allow fertilisation
(or the mature eggs are stripped and injected
to promote fertilisation in the case of ICSI
treatments) and early embryo development
should occur. The female patient then
commences progesterone supplements
(for example Cyclogest pessaries or Gestone
injections).
Stage 6 The embryos are monitored daily
for the next 3–5 days. On day 3 the embryos
may contain 6–9 cells. If there are sufficient
good quality embryos on day 3 they will be
left for an additional 2–3 days for extended
blastocyst culture. Depending on the case,
the embryos are placed in the woman’s
uterus (under ultrasound guidance) between
days 1 and 6 of embryo development.

Stage 1: Down-regulation and baseline scans
In Vitro Fertilistation (IVF)
‘Vitro’ is derived from the Latin, ‘vitrum’, which means glass. ‘In-vitro fertilisation’ (IVF) literally
means ‘fertilised in glass’, which is why children resulting from this treatment are often referred We ask you to attend a scheduled
to as ‘test tube babies’. It was developed more than 30 years ago for the treatment of women appointment before the actual treatment
with damaged Fallopian tubes, and this remains an important reason for treatment today. cycle begins. We will describe to you in detail
how to use the medicines and give you a
written schedule to follow.
On the standard regime, you will start the
first medication 21 days after the first day of
Egg isolation your period, and will continue with it until
two nights before your egg collection. In this
standard form of treatment, the first
Fertilisation
medicine you will be asked to use is usually
an GnRH analogue, such as Buserelin, which
Implantation is injected under the skin in the thigh or
tummy, or Nafarelin (Synarel) nasal spray
which is taken once to twice daily – your
LWC team will advise you on the amount
suitable for you. This part of treatment:
• Makes the ovaries temporarily inactive
• Makes sure the ovaries respond better to
The egg is bathed the hormone injections
in washed sperm
• Prevents you from releasing all of your eggs
before we can collect them
IVF with ICSI Fertilistation
Intracytoplasmic sperm injection (ICSI) is a technique in which a single sperm is injected into
the centre of an egg.
With ICSI an individual
sperm is injected directly
into the egg
17 – 18
Alternative treatment cycles will require you
to take the contraceptive pill for a number of
days/weeks before or during your stimulation
stage of your treatment. Again, your LWC
team will advise you on if and when you
need to take this to help prepare your body
for stimulation.
Side effects (‘Risks of IVF’, page 29) can occur
from these preparations and down-regulation
medications because they affect the
oestrogen hormone levels in your blood.
You may not experience all or any of these
symptoms but, if you do, they will usually
improve once you start the stimulation phase
of your treatment.
On day one of the menstrual period, whilst
you’re on down-regulation/preparation
medication, you will be asked to call the clinic
to book a baseline scan. Your Nursing Team
will advise you on what to do if this is over
the weekend.
All baseline, treatment cycle and early
pregnancy scans are performed vaginally.

The baseline scan is usually performed after
two to three weeks of down regulation.
This will check that the ovaries are inactive
and contain no large follicles or cysts, and
that the lining of the uterus (endometrium)
is appropriately thin. If this is not the case,
we will ask you to continue the down-
regulation/pills for another week or two.
If there is an ovarian cyst present after
down-regulation we may advise you to have
this drained using a procedure similar to an
egg collection (most of our LWC clinics can
perform this procedure for you – please see
your LWC clinic price list for details).
You can have sexual intercourse throughout
your treatment and it is possible to get
pregnant during the down-regulation period.
If this happens it is important that you tell
your LWC nurse or doctor so that they can
give you the correct advice. It is also
especially important to use barrier
contraceptives during the stimulation stage.
Checklist
• Order your donor sperm if required
• Take medication as advised
• Call the clinic on the first day of your
period during down-regulation/
preparation to book a baseline scan
• Use barrier contraceptives during the
stimulation stage
• Tell us straight away if you think you
have become pregnant during
down-regulation
• If you wish, make a nurse consultation
to learn how to self-inject
Stage 2: Ovarian stimulation and scans
If the baseline scan confirms that the female
undergoing treatment is down-regulated or
prepared appropriately, then the stimulation
stage can be started.
Follicle Stimulating Hormone (FSH) injections
(Gonal-F, Puregon or Menopur) are given to
the woman as a daily injection, over 10 – 14
days, to stimulate egg development in the
ovaries. The injections are given just under
the skin on the thigh or tummy. We will teach
you or your partner to do this. Alternatively,
you can make arrangements with your GP or
local hospital to have the injections.
Further information about possible side
effects is also available in the manufacturer’s
leaflet that comes with the medicine (see
‘Risks of IVF’, page 29).
We will monitor your response to the FSH
injections using vaginal scans, which measure
the number and size of the follicles within
the ovaries. The first scan is usually done four
or five days after starting the injections.
Further scans are needed, usually 48 hours
later. We are aiming to get at least three
follicles, which measure about 18 – 20
millimetres in diameter, before we book
your egg collection.
19 – 20
You normally have FSH injections prescribed
for 10 – 14 days depending on your
prescribed dose and usage. If you need
further FSH injections or run out of any
other medication it is important that you
inform your LWC Nursing Team as they can
arrange for another prescription or for more
stock to be made available to you.
About 36 – 40 hours before the planned
egg collection, you will be asked to
administer Human chorionic gonadotrophin
(hCG), (for example Ovitrelle) as a ‘one off ’
injection, which is given in the same way as
the FSH injections but late at night. The
specific time that you need to take this will
be prescribed and explained to you by your
LWC Nursing Team. The timing of this
injection is important. The eggs will not be
mature and are unlikely to fertilise if they are
collected too soon after the injection. If the
collection is too long after the injection has
been given, you may have already ovulated
and released all of the eggs before we can
collect them.

Your egg collection might be cancelled if not
enough follicles have developed in the
ovaries. If your fallopian tubes are open and
one or two follicles have developed, we
might still ask you to take the hCG
(Ovitrelle) injection. We will then advise you
to have intercourse at a certain time or
arrange for intrauterine insemination (IUI),
which is when the prepared semen is placed
directly inside your uterus.
Your egg collection might also be cancelled
because you have produced too many
follicles. This means you are at risk of ovarian
hyperstimulation syndrome (OHSS) (see
‘Risks of IVF’, page 29) and this will be made
worse if you become pregnant. Using barrier
contraception is highly recommended
because if a large number of eggs are
released at once, a multiple pregnancy could
result. The more babies you are carrying, the
greater the chance of miscarriage or other
problems (also see ‘Risks of IVF’, page 29).
Checklist
• Inject FSH hormones daily for
10 – 14 days as advised
• Inject hCG hormone when advised
• Use barrier contraception
throughout this stage other than
when you are advised to have
intercourse by the clinic
• Ensure you have enough medication
to last at least the next 3 days
21 – 22
Stage 3: Semen sample
If a male partner’s fresh sperm sample is
being used in the treatment, then he needs Checklist
to attend on the day of egg collection.
Intercourse or masturbation and ejaculation • Before providing a semen sample,
should have been avoided for three days (no avoid intercourse, masturbation and
less, no more) in order for the best semen ejaculation for three days (no more,
sample to be obtained for the treatment. If no less)
the sample is not of sufficient quality or
quantity to do IVF, then the laboratory may
recommend ICSI instead. (Please see your
LWC clinic price list for details of this cost).
If a frozen semen sample (partner or donor)
is being used, then the lab will ensure all
the preparations have been made the day
before egg collection to ensure that optimal
thawing of the sample on egg collection day
can be carried out.
There are occasions even when using donor
sperm, when the thawing of frozen samples
does not generate the correct amount of
quality sperm and so ICSI may be
recommended

Stage 4: Egg collection day
The female patient who is undergoing egg
collection will have been advised by their
LWC Nursing Team to avoid having anything
to eat or drink for six hours before egg
collection. This is because she will be given a
type of sedative for the procedure. This
medicine helps relaxation and minimises any
pain that might be felt during the procedure.
It can sometimes make you feel nauseated
and if your stomach is empty, this will reduce
the chance of complications if you do vomit.
You can have a bath or shower in the
morning of your egg collection. Please do
not wear make-up, nail varnish, perfume or
contact lenses.
We encourage the partner to be present
on the day of egg collection as he/she is an
essential part of the IVF process and can
give you support.
You may be asked to take pain-relieving
medicine and antibiotics before the
procedure. This medicine is in the form of
suppositories, which are dissolvable medicines
that are inserted into your rectum (back
passage). Please speak to a nurse if you are
concerned about this.
Once you are in the egg collection room you
will be introduced to the team involved in
the procedure. This will include a doctor,
nurse, embryologist, an anaesthetist nurse or
an anaesthetist and their assistant.
As part of our strict witnessing procedure
we will ask you to tell us your name and date
of birth. We check these details against your
medical records and confirm the petri dishes
for your eggs are correctly labelled.
A small cannula (plastic tube) is put in a vein
in your arm or hand and is used to give you
medicine to keep you sedated during the
procedure. Sedation is given by an anaesthetic
nurse or anaesthetist. It keeps you relaxed
with minimal pain during the procedure. We
will give you oxygen to breathe and we will
monitor your pulse, blood pressure and
breathing throughout the egg collection.
An ultrasound probe is placed inside the
vagina and a fine needle is attached to the
side. The needle is gently passed through the
vaginal wall into the nearest follicle in the
ovary. The fluid from the follicle is drained
into a small tube. The needle is moved from
one follicle to the next until we have
emptied all the follicles in the ovary. The
needle is then removed and the procedure is
repeated in the other ovary.
The Embryologist will examine the fluid from
each follicle under the microscope and check
for any eggs. As each egg is found, it is placed
in special fluid in a petri dish before being
placed in a monitored incubator.
Not every follicle will contain an egg and on
rare occasions no eggs may be found during
egg collection. Sometimes despite draining a
good number of follicles we may get a low
number of eggs. We will tell you after the
procedure how many eggs were collected.
The egg collection procedure usually takes
about 10 – 20 minutes, depending on the
number of follicles to be drained. After the
procedure you will be asked to rest on a bed
in the recovery area for up to one or two
hours where you can take something to
drink (and eat if you wish).
A responsible adult will need to drive you
home or accompany you in a taxi. This is
also a requirement if your male partner has
had a sperm retrieval procedure (PESA or
TESA/TESE) on the same day as your
procedure as he will have also had sedation.
We do not recommend public transport
because you might need assistance after
having sedation.
Sedation can affect your reasoning, reflexes,
judgement, coordination and skill. For 24
hours after the procedure, please do not:
• Stay alone – a responsible adult must stay
with you during this time
• Drive any vehicle, including a bicycle
• Operate any machinery
• Attempt to cook, use sharp utensils or
pour hot or boiling liquids
• Drink alcohol
• Smoke
• Take sleeping tablets
• Make any important decisions or
sign any contracts
It is not unusual to feel some lower tummy
or pelvic pain after the procedure. It is
perfectly safe to take paracetamol for this,
without altering your chances of IVF working
or damaging a pregnancy.
You might have some blood stained, vaginal
discharge, which should become darker and
stop after a few days. This blood is coming
from the site where the needle has been
passed through the vaginal wall and is not the
lining of the womb breaking down.
23 – 24
You will be prescribed the hormone,
progesterone, to take for 17 days following
the egg collection to help the lining of the
uterus (endometrium) to be as receptive as
possible to the embryos. Progesterone can
be given twice daily, each morning and night
as a pessary into the rectum or as an
injection every day.
Checklist
Before egg collection:
• Bring a friend/relative/partner on the
day to take you home
• Avoid eating and drinking for six hours
• Remove all make-up, nail varnish,
perfume or contact lenses
• If required, take pain relieving medicine
and antibiotics
• Bring some sanitary pads
After egg collection:
• You can eat or drink during your
recovery at the clinic if you wish
• Organise for a responsible adult
to drive/accompany you home
• Follow the advice given for the first
24 hours following this procedure
• Take hormone treatment as
prescribed for 17 days

Stage 5: Fertilisation and embryo development
Fertilisation preparation
We have extremely rigorous checking and
witnessing protocols for all laboratory
procedures to make sure that the eggs,
sperm and embryos used in your treatment
belong to you. A number of our clinics now
include an electronic witnessing system –
IVF Witness™ or Matcher™ – which adds to
the security. All the dishes and records are
prepared and checked one last time in the
lab the day before your egg collection.
These are then compared against your
patient label and patient details when you
arrive in theatre to ensure that they all match
up to the correct person and procedure.
Your sperm, or donor sperm sample, is
prepared by separating the normal and
moving sperm from the ejaculated fluid and
placing it into a labelled petri dish which has
been assigned for your treatment. In an IVF
cycle, the prepared sperm and egg(s) are
placed together into your assigned dish(es).
In an ICSI cycle, a single sperm is injected
into each mature egg and these are then put
into your assigned dish and left in the
incubator overnight to allow fertilisation to
take place.
Day 1 in the lab:
Fertilisation
The next morning, our Embryologists
carefully examine each egg to see if
fertilisation has happened. We will be in
contact with you at a pre-arranged time to
tell you how many eggs have fertilised.
Rarely, about one in 100 times, none of the
eggs fertilise and there are no embryos to be
replaced. This is obviously very disappointing.
We will offer you the earliest available
appointment to see a doctor to discuss the
cycle and your future treatment options.
You will also be offered an appointment to
see one of our counsellors.
Day 2 – 6 in the lab:
Embryo development
Eggs that have fertilised are called embryos.
As embryos develop their cells divide.
The number of cells that we expect your
embryos to be during the different days of
development are shown below:
Day 1 one cell with two pronuclei
Day 2 two to five cells
Day 3 six to nine cells
Day 4 Morula stage 30 cells
Day 5/6 Blastocyst 100 – 150 cells
Our Embryologists will regularly monitor
the embryos each day until the best quality
embryos are ready to be transferred
and/or frozen. We transfer embryos into
the uterus between days one and six after
fertilisation, depending on the number
of eggs fertilised and the embryo’s
development. The Embryologist will select
the best embryo(s) for transfer – the IVF
Specialist and the Embryologist will discuss
this decision with you. Any embryos which
are showing signs of deterioration or demise
are carefully discarded.
By day five after egg collection the embryos
most likely to lead to a pregnancy have
undergone further development to become
fluid filled balls of cells called ‘blastocysts’.
Recent evidence suggests for some patients
waiting until day five allows us to choose the
embryos with the best potential of achieving
a pregnancy to be transferred.
As part of our strategy for Elective Single
Embryo Transfer reducing the number of
twin or triplet pregnancies, we recommend
that women under 35 years of age and those
receiving donated eggs have only a single
embryo replaced, especially if they have
additional embryos available for freezing.
This gives a high chance of pregnancy
(around 50%) and a much lower chance of
twins. Please check with your LWC clinic the
criteria for elective single embryo transfer.
Two embryos may be advised if you are over
35 years of age, or if the embryo quality is
less than good. If you are aged 40 or over
and using your own eggs, we will talk to you
about how many embryos are advisable
to transfer.
The greatest benefit of blastocyst culture is
for patients who have a good chance of
becoming pregnant, but who also have the
greatest risk of having a twin pregnancy if
two embryos are transferred. We can identify
this group of women, and if we transfer a
single embryo, we hope to reduce the
incidence of twin pregnancies, without
25 – 26
reducing the overall chance of pregnancy.
So, depending on your age and, if on day
three after egg collection there are a number
of good quality embryos available, we
may recommend that we continue to
culture your embryos until they reach the
blastocyst stage, freezing excess blastocysts
for future use, if you wish. (Please see your
LWC clinic price list for details of this cost).
Current HFEA guidelines will allow us to
transfer a maximum of two embryos. The
remainder are checked for suitability for
freezing for use in the future should you
wish.
Checklist
• Ensure you know the time when
news of fertilisation will be available
• Ensure you know the date and time
for embryo transfer
 27 – 28

Stage 6: Embryo grading and transfer

The illustration below will give you an understanding of how embryos look when they are During embryo transfer we place the best
graded. Each set of illustrations shows the embryos as four cell, six cell, seven cell, and eight cell one or two embryos into the woman’s
division stages, respectively. uterus. This is a much simpler procedure
than egg collection and there is no need
for sedation.
Grade one embryos
These embryos have cells of an even size, consistent colour and have no fragmentation. Grade one You will need to have a full bladder for this
embryos have the best implantation rates and will also be considered for cryopreservation (freezing). procedure so that we can see the uterus
clearly on the ultrasound scan. You should
drink one litre of water half an hour before
the procedure. A full bladder makes the
procedure technically easier as the bladder
lies in front of the uterus and, in four out of
Grade two embryos five women, the uterus naturally bends
forwards. Filling up the bladder will, therefore,
These embryos may have slightly uneven cells, slight fragmentation or both. Like grade one embryos,
they are good quality embryos with slightly decreased implantation rates when compared to grade one. ‘straighten out’ the uterus and make it
easier to direct the soft catheter containing
the embryos.
The catheter is then removed and checked
to make sure the embryo(s) have been
replaced. Sometimes, the embryo(s) remain
in the catheter. The procedure will then need
to be repeated until we are sure the
embryo(s) are in your uterus – this does not
affect your chances of getting pregnant.
You will be able to empty your bladder
immediately after the transfer without any
risk of losing the embryos.
If you are admitted to hospital for
assessment or treatment and the condition
was related to your treatment, please
contact your LWC clinic (see following page
for details).

A speculum, which is the instrument also Checklist

used to help view the cervix during a smear
test, is placed in the vagina. The outside of
Grade three embryos the cervix is cleaned and any mucus from
• Drink one litre of water half an hour
before embryo transfer
These embryos have even more uneven cells, more fragmentation or both. The implantation rate for
inside the cervical canal is removed. This
these embryos is probably not as good as for grade one or two embryos. These embryos have poor
implantation rates and are not usually considered for cryopreservation as their survival rate is poor
mucus might prevent the embryos getting to • Make sure you have enough
where we want them to be in the uterus. medication to last until your
following freezing/thawing.
During the procedure, we use the ultrasound pregnancy test date
probe placed on your tummy to help us view
the catheter placement.
• Make sure you know when to do the
pregnancy test and who to call with
the result
We may try with an empty catheter first to
see the best position and path. Once we are
Blastomere (cell) Perivitelline Space Zona Pellucida Fragmentation
happy that the catheter can be easily
inserted, the soft catheter, which holds the
embryos, is gently inserted through the
cervical channel and into your womb cavity
using the ultrasound probe to ensure that we
transfer the embryos into the area where
they have the highest chance of implantation.

What are the risks of IVF?
Multiple and ectopic pregnancies
The major complication of IVF is multiple
pregnancy. Multiple pregnancies have a much
higher risk of pregnancy complications
including miscarriage, high blood pressure
and premature birth. Premature babies have
a higher risk of complications, such as a
weakened immune system, physical and
mental disability as well as feeding and
breathing difficulties. The risks at all stages of
a twin pregnancy are even higher and so the
chance of having even one healthy baby at
the end of treatment is lower than with a
single pregnancy. All the available research is
pointing towards the use of single embryo
transfers to reduce this risk.
Ectopic pregnancies can also occur. This is
uncommon but can be serious. If detected
early the major complications of
intra-abdominal/peritoneal bleeding, pain,
infection, and shock, can be reduced or
eliminated. It is vital therefore that all women
undergoing assisted conception treatment
perform a pregnancy test as instructed even
if they are bleeding. In an ectopic pregnancy
you can be bleeding even though the
pregnancy test is positive. A blood test can
sometimes also be used to confirm the
possibility of an early ectopic pregnancy as
the pregnancy hormone (hCG) levels are
much lower than usually expected. Ectopic
pregnancies are treated either medically or
surgically. A referral to your local hospital
will be made to ensure that you receive the
most appropriate treatment.
Ovarian hyperstimulation
syndrome (OHSS)
Development of OHSS in not always
predictable or avoidable. We will identify if
you have an increased risk and then monitor
your ovarian response to the stimulation
with extra ultrasound scans and blood tests
which will allow us to change your drug
dose to try and avoid overstimulation. It is
more common in younger women and
those with confirmed polycystic ovarian
syndrome (PCOS).
Occasionally, where the risk is too high,
we will recommend that the cycle is
postponed – in this case you do not take
the hCG injection which keeps the hormone
levels high. We will not collect the eggs
and may ask you to continue taking the
down regulation medicine until your
symptoms improve.
If we do collect the eggs, we may still
recommend that any embryos created are
frozen, for replacement in a future cycle
when the overstimulation symptoms have
subsided. If we were to replace the embryos
in this fresh cycle and you become pregnant,
your blood oestrogen level will start to rise
again and make your condition worse. A
frozen embryo replacement cycle will not
cause OHSS as the ovaries are not stimulated.
In OHSS, the ovaries enlarge more than
normal and blood oestrogen levels rise. The
blood protein level then drops which causes
fluid to leak out into the abdominal cavity or
around the lungs. This can result in problems
producing urine, mineral imbalances in your
blood, clotting and breathing difficulties.
Symptoms of OHSS are most common
around the time of egg collection or up to
and around ten days after embryo transfer.
You may find that things improve only to
worsen again nearer to the time of your
pregnancy test. Symptoms include:
• Abdominal (tummy) pain and swelling
• Passing small amounts of concentrated urine However, since it is not possible to sterilise
• Thirst
• Nausea and vomiting
• Diarrhoea
• Dizziness
• Shortness of breath
If you have any of these symptoms please
contact us immediately so we can give you
the necessary advice. Most cases of OHSS
are mild and are resolved by drinking three
litres of fluid a day and using mild pain
relieving medicine, such as paracetamol.
If we are concerned that you are at risk of
developing moderate or severe OHSS we
will keep you under regular review. If your
symptoms worsen we might have to admit
you to an NHS hospital for monitoring and
treatment. Very rarely, OHSS can be life
threatening.
Please also contact your LWC clinic if you
are admitted or attended a hospital for
advice or treatment even if it was not to do
with OHSS but related to your treatment.
We are obliged to report these events to
the HFEA and we may be able to assist your
hospital doctor by giving them a summary of
your relevant treatment if you require it.
29 – 30
Pelvic infection
Pelvic infection can very occasionally follow
an egg collection and, rarely, an abscess might
develop. We try to make sure this does not
happen by performing the collection under
clean conditions and giving antibiotics to
women who are at a higher risk of infection.
the vagina where there is always some
bacteria naturally present, it is not possible to
prevent all infections, despite preventative
measures. Symptoms of an infection include:
• Pain
• Bright red vaginal bleeding
• Smelly vaginal discharge
• Diarrhoea
• Fever
• Generally feeling unwell
In these cases, we will ask you to come
and see us in the clinic and you may be
prescribed antibiotic treatment.
Bowel, bladder or vessel
perforation
There is a very small risk that the needle
used for egg collection can puncture the
bowel or blood vessels. The needle used is
very fine and it is unusual to have any
complications. If there is a concern that a
tiny hole has been made in the bowel or
bladder, antibiotics will be given and a referral
to an appropriate specialist can be made.

Please contact us if you feel any of the
following symptoms:
• Pain in your tummy
• Shortness of breath
• Swelling/bloated feeling in your tummy
• Feeling feverish, shivery or generally unwell
• Nausea and vomiting – especially fluids
• Heavy or irregular vaginal bleeding
• Diarrhoea
• Dizziness
• Passing a small amount of urine or if your urine
seems concentrated or has an offensive smell
Adverse reactions to
the medications
Clomifene Citrate
(an oestrogen antagonist) tablets
The side effects of Clomifene therapy
include vasomotor symptoms such as hot
flushes, dizziness, blurring of vision, nausea,
headaches and occasionally, weight
gain, abdominal distension and breast
discomfort. There is an increased risk of
multiple pregnancy caused by multiple
follicular development, the vast majority
being twins. There is no evidence that the
possibility of miscarriage or the rate of
congenital abnormalities is increased with
Clomiphene citrate.
Human Menopausal Gonadotrophins
(hMG) such as Menopur injections
The most common side effect is a local
reaction at the injection site, occasionally
fever, joint pains and flu-like symptoms.
Sometimes excessive ovarian stimulation
can result in ovarian hyperstimulation
syndrome (OHSS).
Recombinant FSH such as Gonal F injections
The most common side effect is a local
reaction at the injection site, occasionally
fever, joint pains and flu-like symptoms.
Sometimes excessive ovarian stimulation
can result in ovarian hyperstimulation
syndrome (OHSS).
GnRH agonists such as Buserelin
(Suprecur) injections and Nafarelen
(Synarel) nasal spray
Side effects include hot flushes, headache,
vaginal dryness, emotional lability,
musculo-skeletal pain, dizziness, breast
tenderness and ovarian cyst formation
caused by the initial flare up effect of
initially stimulating the release of natural
gonadotrophins (the hormones FSH
and LH).
GnRH Antagonist such as
Orgalutran and Cetrotide injections
Side effects include injection site irritation,
nausea and headache.
Human Chorionic Gonadotrophins
(hCG) such as Ovitrelle
There are no serious side effects reported.
However, it may accentuate the problems
of ovarian hyperstimulation following use,
if too many follicles have developed.
Luteal support such as Cyclogest pessaries
No significant side effects have been reported
according to the manufacturer’s data.
Metformin tablets
Possible side effects with Metformin include
diarrhoea, nausea/vomiting, indigestion/gas,
abdominal discomfort and headaches.
Risks from ovulation
induction agents
There has been increasing interest in recent
years regarding a possible link between the
drugs used for ovarian stimulation and the
subsequent risk of cancers, particularly
ovarian cancer.
Case reports and epidemiological studies
examining ovarian cancer risk in relation to
the use of fertility drugs have shown
conflicting results, which may in part be
explained by methodological problems.
Reviews of these studies found insufficient
evidence to support a direct causal
relationship. The conflicting results may stem
from the interaction between nulliparity (no
previous births), infertility and ovarian cancer.
The risk decreased with the increasing
numbers of pregnancies and the use of the
oral contraceptive pill, in other words with a
reduction in the number of ovulatory cycles.
Recommendations
The National Institute for Clinical Excellence
(NICE) recommendations are that women
who are offered ovulation induction should
be informed that a possible association
between ovulation induction therapy and
ovarian cancer remains uncertain and that
References: 1.Quinn MJ, Babb P, Cancer
trends in England and Wales 1950 – 1999
Health Stat (2000), 8:5 – 19
31 – 32
practitioners should confine the use of
ovulation induction agents to the lowest
effective dose and duration of use.
Further research is needed to assess the
long-term health effects of ovulation
induction agents on women who have
undergone ovulation induction therapy for
their fertility problems.
Checklist
• Make sure that you fully understand
the risks before you start treatment
• Perform a pregnancy test when
instructed, even if you are bleeding
Be aware of:
• the symptoms of OHSS and contact
the clinic immediately for advice if
you think you are experiencing such
symptoms
• the symptoms of a pelvic infection
and of bowel, bladder or vessel
perforation and contact the clinic for
advice if you think you are
experiencing such symptoms
• the symptoms of adverse reactions
to your medication and contact the
clinic for advice if you are concerned
about any symptoms you may be
experiencing
• Contact the LWC if you are admitted
to or attend a hospital for advice or
treatment
 33 – 34

What happens to embryos that are not used? IVF 3 cycle package

Embryo Freezing
Any embryos that are of good enough
quality and ‘leftover’ from your treatment, can
be frozen for later use. Although the majority
of patients hope to have spare embryos for
freezing, in reality, this only happens for about
one in four patients. A frozen embryo, which
has been thawed, is slightly less likely to
implant into the lining of the uterus than a
fresh embryo, so we are very selective about
the embryos we choose to freeze. We will
freeze good quality embryos on day three or
blastocysts on day five or six of development.
If you have one or two good quality embryos
to transfer in a fresh cycle and spare
embryos, which are suitable for freezing, you
have an above average chance of conception
in the fresh cycle.
What is ‘vitrification’?
Embryos are frozen at an extremely low
temperature with the use of the vitrification
method. Even if you get pregnant in your
initial attempt at treatment you may wish to
use frozen embryos, if possible, to expand
your family at a later date.
Any embryos that are not of a good enough
quality to use in a fresh cycle or to be frozen
will be removed from the incubator and their
careful disposal witnessed. The same follows
for poor quality eggs and sperm.
Few women in the UK undertake more
than one cycle of in vitro fertilisation (IVF).
The main reasons are financial, as well as the
physical and emotional burden and the
commitment of time involved.
Here at the LWC we felt that IVF needed to
be simplified, to make it less stressful and
financially more affordable for most couples.
Our philosophy of keeping costs down to
a minimum is to encourage the idea of IVF
as a multiple cycle treatment.
Success is more likely to be achieved if
couples regard IVF as a course of treatment
rather than a one-off attempt.
In order to lessen the financial burden for
couples and hopefully to encourage them
to take advantage of the cumulative
pregnancy rate from multiple cycles, the
LWC offers a ‘three cycle package’.
The ‘three cycle package’ represents a
substantial saving on three IVF cycles. If
you can afford the time and expense, we
recommend that couples should plan on
the three cycles of treatment in order to
maximise their chances of taking home
a baby.
Success rates for IVF treatment vary with a
large number of factors, including the cause
of infertility, the age of the female, and the
grade of the embryos that are replaced.
Patients booking this form of treatment
will be treated for up to three cycles within
a period of one year, the end point being
an on-going pregnancy which at least reaches
20 weeks gestation.

Vitrification is a technique whereby embryos Mock IVF and FET cycles

are cooled at very fast rates (1,000 to
30,000°C/min) in higher than former
concentrations of permeating
This involves going through a particular
cryoprotectants/freeze-protecting solutions
treatment but without a real embryo
in order for the cell fluid/cytoplasm of the
transfer. It may/may not involve down
embryo to appear to be in a glass-like state
regulation. This will be discussed with you
i.e. it ‘vitrifies’. Vitrification avoids the
by your LWC Consultant or IVF Specialist.
formation of cell membrane-damaging ice
which was associated with the process that
This allows us to pin point any potential
used to be employed to freeze embryos
problems. Problems may include a thin
(‘Controlled rate slow cooling’).
endometrial lining or the need to use a
particular type of catheter for embryo transfer.