How is a patient prepared for IVF treatment?
Preliminary testing
When attending an IVF clinic for the first time, the doctor will conduct a consultation. He or she will review in depth the past medical history, conduct physical and internal examination and your doctor may perform a 'dummy' embryo transfer to make sure there is no technical problems with the procedure. The doctor may order some investigations before proceeding with treatment.
These usually include:
- Semen analysis to check for sperm number, swimming ability, shape, and survival. . For men who have difficulty in producing semen samples on demand, the doctor may recommend that semen is produced at a convenient time and then frozen and stored prior to IVF treatment as a 'back up' just in case the male partner is unable to perform on the day of egg collection.
- Blood hormone tests to assess the female partners response to fertility drugs (ovarian reserve). The commonly used tests include baseline levels of FSH, LH, estradiol, inhibin B and anti-Mullerian hormone (AMH). The ovarian reserve tests to date have only modest-to-poor predictive value (Broekmans et al 2006 Human Reproduction).
- Blood test to check for immunity to German measles.
- In some women, hysteroscopy or HSG may be ordered to inspect the uterine cavity.
- Screening for chlamydia infection is usually considered if the patient is at risk.
- Some clinics will require screening both partners for HIV, hepatitis B and Hepatitis C and only accept the couple for treatment if the tests results are negative. The European Union Tissue and Cell Directive (EUTCD) which came into effect in 2006 and each EU country is expected to adopt into local legislation require compulsory screening for blood born viral infections of all patients undergoing licensed treatments and planning to have samples frozen. The reasons for screening is that knowledge of infection allows measures to be taken to reduce risk of transmission between partners, and to the fetus or newborn as well as to protect healthcare professionals. In addition, knowledge of infection enables couples to make informed decision regarding proceeding with treatment. Infection of one or both partners with any of these infection is no longer precludes the couple from receiving fertility treatment.
- Transvaginal ultrasound scan for antral follicle count (AFC) and ovarian volume, this have only moderate to poor predictive value for assessing ovarian reserve. In addition Assesssing endometrial thickness, texture and any significant distortion of the uterine cavity by polyp or fibroid which may hinder embryo implantation.
- Check for health habits that may affect your chance of success such as medications, supplements you may be taking, along with any alcohol, smoking or excess caffeine or recreational drug use. Also he or she will check for medical conditions that you may have such as diabetes and ensure that that it is well controlled etc.
Does surgery have a role in optimising outcome of IVF treatment?
- If the Fallopian tubes are grossly distended with fluid (Hydrosalpinx). Salpingectomy (removal of the tubes) is the treatment of choice as it may results in a three-fold increase in delivery rates.The procedure is usually performed by a key hole surgery (laparoscopy). Proximal tubal occlusion is a suitable second line treatment in complex cases. Some infertility specialists aspirate the hydrosalpinx fluid under ultrasound scan guidance at the time of egg collection. However, the efficacy of aspirating the fluid is not clear.
- Myomectomy (Surgery to remove uterine fibroids). In general, the presence of fibroids reduces the success of IVF treatment in particular the sub-mucous fibroids which distort the endometrial cavity as it may interfer with embryo implantation. large intramural fibroid which are not distorting the cavity also results in reduction in IVF outcome. However, subserous fibroids appear not to affect the IVF outcome. Removal of sub mucous fibroid which are distorting the uterine cavity is is usually recommended. This is usually performed by hysteroscope under a general anaesthetic. .
- Endometrial polypectomy (removal of endometrial polyp). Despite the lack of clinical evidence, most specialists recommend hysteroscopic removal of the large polyp prior to IVF.
- hysteroscopy adhesiolysis (Division of intrauterine adhesions) is usually recommended prior to IVF and some women may require multiple procedures to achieve a satisfactory response .
- Septoplasty (removal of uterine septum). Women with uterine malformations such as uterine septum and bicornuate uterus) have por reproductive outcomes. Non randomised controlled studies reported that hysteroscopic septoplasty improves natural conception rates in women with otherwise unexplained infertility, it also improves the outcome in women with recurrent miscarriages and the success of IVF. The procedure is performed using hysteroscope under a general anaesthetic.
- Surgical treatment of endometriosis. Most specialists recommend surgical excision rather than drainage of large endometrioma (larger than 5 cm) prior to IVF as this will give a better access during egg collection and also reduces the risk of infection. However, it may also result in reduced ovarian reserve.