IVF Protocols

The Long Protocol  

This is the commonest protocol that is used in IVF. The suppressive effects of the initial injections(buserelin) seem to be beneficial for women with endometriosis which sometimes can be undiagnosed. Studies have shown that success rates with Long protocol are marginally better than the short protocol.

The first visit to the clinic is roughly about a week before the onset of the woman’s menses, which is usually Day 21 of her menstrual cycle. During this visit, she will undergo a scan to confirm that she has ovulated. Sometimes, the doctor may give her some oral contraceptive pills (OCPs) from the beginning of her menstrual cycle (usually Day 2 or Day 3) and she will commence injections on her own a few days before the last pill. Yes, if you didn’t know, IVF involves A LOT of injections. Self-administered injections.

The first type of injection is called buserelin (Suprefact) and is given as a daily dose in the morning before she goes about her usual daily activities. These injections are well tolerated though sometimes she may have hot flushes. She will still have a menstrual period though it may be lighter or prolonged.

After about 2 weeks of injections, she will be seen in the clinic for a repeat scan to confirm down regulation (ovaries that are quiet). The dose of busereline is subsequently reduced and approximately a week later, she will commence on stimulation of the ovaries. This involves the use of a daily hormonal injection called FSH (Gonal F or Puregon) for about 10 to 12 days. More injections, yeay!

In total, the Long protocol takes about 4 weeks plus involving around 50 self-administered injections. It is not for the faint-hearted. 

 Are you strong enough to give yourself shots?

 

 Buserelin (Suprefact)
 

 

 The needle

 

 Lots and lots of needles!
 



Gonal-F

The Short Protocol

This protocol is gaining prominence due to its shorter duration and less amount of injections. It is particularly useful in women with polycystic ovaries, as there is a lower risk of ovarian hyperstimulation syndrome.

The doctor may sometimes give several days (up to 3 weeks) of OCPs from the onset of the woman’s menses. Then on the second or third day of her withdrawal menses after the pill, she commences the daily FSH injections immediately. A scan would be repeated on Day 5 of injections after which another injection called GnRH antagonist (Cetrotide or Orgalutran) is commenced. This injection which is also done daily prevents premature release of the eggs. In total she will do about 10 to 12 days of injections. Much kinder to the body compared to 50 injections for the Long protocol.

 Gonal-F needle pen 

 



In-Vitro Fertilization (IVF)

It is now more than 34 years since the world’s first birth from IVF, a technique that mimics the process of human fertilization in the laboratory. Over this period of time, countless couples all over the world have benefited from IVF, the majority of whom would never have been able to have a child without it. While it is now readily and widely available, a high degree of knowledge, skill and attention to detail by the doctor and the laboratory is required before consistently high pregnancy rates can be achieved.

Couples are recommended to undergo IVF if they face one of the following problems:

·         tubal factors (tubal blockage or dysfunction)

·         endometriosis

·         male factor infertility

·         immunological infertility (anti-sperm antibodies)

·         repeated unsuccessful IUI

·         unexplained infertility

The wife undergoes controlled ovarian hyperstimulation (COH), either with long protocol or short protocol, depending on her condition. A hCG injection is given to mature the eggs when the leading follicles have reached 18mm. 34 hours later, oocyte pick up (OPU) or egg collection, will be done. OPU is the process of aspirating the eggs through the vagina.

 

The OPU is a minor procedure performed under sedation or general anaesthesia as a daycase. The OPU is performed in a specialized IVF Operating Theatre (OT). A very fine needle is inserted through the vagina under transvaginal ultrasound guidance. The needle punctures through the vaginal wall and into the ovaries to harvest the eggs. The eggs which are now in a test tube are handed over to the embryologist for processing. The laboratory is located next to the IVF OT to ensure minimal exposure to the external environment. The entire procedure takes only about 15 minutes and she will wake up immediately after that. She will be allowed to go home after 2 hours.

After the semen is produced by the husband, the laboratory technician or embryologist will process the semen by removing the seminal plasma, debris, residual cells, dead and sluggish sperm. This is done by a series of steps including adding sperm wash media and centrifuging. The final solution with live and motile sperm will be inseminated to the culture media containing eggs to allow fertilisation to occur. The mixture will be cultured in the Carbon Dioxide incubator.

The eggs are fertilized and are now called embryos. The embryos are cultured for between 2 to 5 days, depending on the number of fertilized eggs available. Embryo transfer (ET) is a minor procedure where the fertilized eggs are transferred into the womb through a very fine flexible catheter. the number of embryos to be transferred depends on several factors such as the age of the woman, the quality of the embryos and the wishes of the couple. Doctors will usually transfer the optimum number of embryos to achieve the best results with the least risk of multiple pregnancies. Good embryos that are not transferred will be frozen for use in the future.

3 day old embryos

 

Embryo transfer (ET) requires no sedation or anaesthesia and it is similar to that of IUI. However, ET requires ultrasound guidance. A speculum is inserted into vagina to hold it open. Ultrasound guidance enables the doctor to visualise the insertion of ET catheter into the uterus so that can ensure that the embryos will be place near the fundus and minimise the trauma to the endometrium. The whole procedure takes only 5 minutes to complete.

After ET, the wife will require some luteal support such as vaginal pessary or injection. She has to take extra care such as:

·         rest more and avoid excessive physical activities. Bed rest is not necessary.

·         remember to take progesterone medication daily

·         drink plenty of water

·         not take any medication without doctor consultation

·         avoid sexual intercourse for at least three months

A blood pregnancy test will be carried out approximately 2 weeks after the transfer. If she is pregnant, she will be required to continue the progesterone support for another month or so. If unfortunately she is not pregnant, the doctor will review the entire treatment with her and discuss her options if she would like to try again. If she has excess embryos frozen, she may undergo a Frozen Embryo Transfer (FET) about 2 months later.

Since the first IVF-ET carried out in 1978, over four million babies have been born using this method. It is an effective treatment for almost all causes of infertility. There is no increase in the risk of abnormality of the baby compared to a natural conception. 

6 week old twin IVF pregnancy

9 week old IVF pregnancy

12 week old IVF foetus

32 week old IVF baby

VF costs between RM 12,000 to RM20,000 per cycle in Malaysia and there is no 100% guarantee you will succeed on your first try. Due to the high cost, it is imperative for couples to do a thorough research in finding the right fertility specialist with vast experience and high success rates.