In Vitro Fertilisation (IVF)
What is IVF?
If the male's sperm parameters are normal, IVF may be the most
appropriate treatment option.
IVF involves artificial fertilisation of egg and sperm in the
laboratory. This may be done with husband or donor
sperm. The egg and sperm are mixed together and allowed to
fertilise naturally. A specific quantity of sperm cell
is mixed with each egg in an IVF fertilisation dish
(Petridish). The dish is placed in an incubator overnight to
aid fertilisation. Couples are notified of the number of
fertilised eggs the next morning.
Conventional IVF treatment is highly recommended for couples
diagnosed with unexplained infertility or cases of tubal blockage.
Usually all fertilised eggs (embryos) are cultured in the incubator
for possible (cleavage stage) embryo transfer on day 2, day 3 or
day 5 blastocyst embryo transfer.
IVF is a licensed treatment and is regulated by The Human
Fertilisation and Embryology Authority (HFEA) in the UK.
What does the treatment involve?
Click here to see
the Simplified IVF Process.
We currently use two IVF/ICSI cycle types. Click on
the links to find out more:
- Short Antagonist
protocol: uses GnRH Antagonist and Gonadotrophin
The team will decide which protocol best suits your individual
circumstances. The protocol for each cycle is tailor-made to the
individual based on various parameters, including hormone test
results, previous cycle response and associated medical history.
This will be discussed with you at your clinic appointment.
You will be given a 'teach' appointment in which the nurses will
show you how to inject yourself at home with the appropriate
Each treatment cycle lasts approximately 6-8 weeks.
Whichever protocol you are on, there are several stages that are
common to both:
1. Ovarian Stimulation
Stimulation phase of the cycle with gonadotropin
- You will need to have daily injections of gonadatropin.
The drug dose is decided based on Anti-mullerian Hormone (AMH - A
hormone test that ascertains the ovarian reserve of eggs) blood
test results. The dose of the drug might change during
treatment depending on response.
- Injections are subcutaneous (beneath the skin) - given through
the abdomen or thigh.
- The site of the injection should be altered daily - usually
from side to side (left/right).
- We recommend you do the injections at the same time every day
(between 4.00 pm-8.00 pm).
- You may experience a feeling of heaviness or pressure inside
the abdomen as the ovaries get bigger - this is normal.
- It is important to follow all instructions on drug dosage and
timing. You should inform us immediately if there are any
problems with this.
- The injections are normally given over 10-12 days, although
this may be extended if your response is suboptimal.
- An hCG injection is the last and final one before egg
collection is done.
- Timing of this injection is VERY CRUCIAL.
- The injection must be taken at the time advised by the Unit
(this is exactly 36 hours before egg collection and will therefore
be based on the expected time of your egg retrieval
- This is a late night injection (timing starts from 9.00 pm in
30 minute intervals).
- If you miss your allocated time slot, please DO NOT
inject at any other time as this can compromise your
- Ring the Unit first thing the next morning as we might be able
to provide a new time slot for you - occasionally this is not
feasible and could lead to cancellation of the cycle.
2. Support and Monitoring
You will be required to attend for scans and blood tests to
monitor how the follicles are developing.
Scanning is performed 3-4 times throughout each treatment
All scans during the treatment cycle are done vaginally and in
the morning along with blood tests - between 8.00 am and 10.00
- Pre-treatment scans are done within 3 months of the cycle
starting to rule out problems that can affect treatment success
such as polyps, fibroids, endometriosis and ovarian cysts.
- Down-regulation scans are rarely done following Buserelin
injections (long protocol). The scan will only be required if the
blood tests done following the menstrual bleed do not indicate the
desired effect on the lining of the womb (thin lining) and ovaries
('quiescent' - meaning there is no ongoing follicular activity in
the ovaries). 2-3 scans are usually done during the treatment
cycle to monitor the response to treatment - by way of growth of
follicles in the ovaries.
3. Egg Collection
- Egg collection is a vaginal procedure performed under
ultrasound guidance. The procedure lasts 20-30 minutes.
- You will need to starve from midnight before egg collection
(this means no food, drinks, water, sweets or chewing gum).
- The procedure can be performed under IV
sedation, although on occasions general anaesthetic (GA) can
- Please be aware that not all follicles seen on scan yield
- You may experience some pain and bleeding after the
Advice before and after egg recovery
Sedation for patients undergoing egg
4. Sperm on the day of egg collection
- On the day of egg collection, the male partner is asked to
provide a fresh sample of semen, produced on site in the Andrology Department.
- If you have difficulty producing, it is important that you
inform staff prior to start of treatment cycle.
- Some couples may have sperm frozen previously or may be using
- If sperm parameters on the day appear suboptimal, we
might consider ICSI rather than IVF treatment (this will be
discussed and agreed with you). For more information about
ICSI, please click
5. Egg Insemination
If the sperm parameters are normal then the egg will be
inseminated using IVF, whereby the embryologist will prepare the
eggs and sperm and mix them together in a
container (Petridish) and allow them to fertilise
If there are any concerns about the sperm, the ICSI method
will be used. This involves taking up a single sperm in a
fine glass needle and then injecting it directly into an
6. Embryo Development and Progress
During IVF, the embryos are cultured for up to six days and they
are graded when necessary.
Grading is necessary in order to evaluate your embryos to decide
which ones(s) should be selected and replaced into your uterus and
which ones, if any, to store.
There are a number of ways in which embryos can be graded.
At Saint Mary's we assess embryos by carefully evaluating and
scoring some aspects based on their morphological appearance. For
example, you can have 2 to 4 cells after 48 hours, and 7-10 cells
after 72 hours. The cells in an embryo are referred to as the
'blastomeres'. It is generally considered best if all these
blastomeres are even and similar in size or close.
When portions of the embryo's cell are broken and are separate
from the nucleated cells, these portions are referred to as
fragmentation. Ideally, there should be very little or no
fragmentation present. However, the occurrence of
fragmentation is quite common and several beautiful babies have
resulted from fragmented embryos.
The blastocysts are graded based on the expansion state (early,
expanding, expanded, and hatching) as well as the quality of the
other cell type in the blastocyst. The blastocyst consists of the
inner cell mass - which eventually forms the fetal tissues, and the
trophectoderm - which forms the placenta.
The pictures below show the development of a hatching blastocyst
from an egg to two cells, four cells, eight cells, blastocyst and a
We carefully assess the morphology of all the embryos and select
the best embryo(s) to replace for our patients considering every
individual patient's case.
The table below shows an example of the outcome from an IVF
cycle. These may vary significantly, and there are not always
embryos available to freeze.
This is a revolutionary new technique involving time lapse
imaging technology. At Saint Mary's we use this equipment to
record images of your embryos every 15 minutes. Embryonic
cells are normally programmed to divide at set time intervals and
the timing of these divisions is known to be of high clinical value
to optimise IVF outcomes. Time lapse videos of your embryos enable
our embryologists to enhance embryo selection for transfer by
studying these timelines of cell division. This novel and unique
application has shown to have a vast improvement in pregnancy
rates, as patterns of embryo development can be monitored to select
the most viable embryo(s) from a cohort. Recent reports
emerging about the use of this technology is very promising and can
also be used to reduce the number of embryos to transfer in order
to minimise the risks of multiple pregnancy.
7. Embryo Transfer Process
- Embryos are normally transferred back into the uterus either 2,
3 or 5 days after egg collection.
- The procedure involves introducing a speculum into the vagina,
as in a smear test.
- A fine tube is passed into the womb under ultrasound guidance
and the embryo(s) is replaced into the cavity of the womb.
- The procedure does not require an anaesthetic or fasting.
- No hospital admission is required.
- We recommend that after the procedure you carry on as
How to help yourselves getting through the days of
waiting following embryo transfer.
Day of embryo transfer: Day 2, Day 3 or Day
Our aim is to select the best one or two embryos for transfer to
maximise your chance of pregnancy, but minimise the risk of twin
- You must agree to be available for embryo transfer potentially
on day 2, day 3 or day 5.
- If there are 1 or 2 embryos, transfer is usually on day 2 -
this applies to around 1 in 4 patients.
- Around two thirds (2 out of 3) of patients will have transfer
on day 3, when we can select the best quality one or two
- Only patients with at least 4 top quality embryos on day 3 will
be selected for extended culture (approximately 1 in 12
Blastocyst culture to day 5 is a method of embryo selection, not
suitable for all couples/cycles, and involves some degree of extra
risk over culture of embryos to day 2 or day 3.
The blastocyst programme does carry the following additional
risks, although these risks are considered very small:
- There may be no blastocysts available for transfer.
- The risk to offspring of extended culture are slightly greater
than the risks with day 2/3 culture.
- Vitrification* used to cryostore spare embryos is
a new procedure in our unit, and it will take time to assess thaw
or defrosting outcomes.
- There is an increased risk of identical twins.
*Vitrification is a new method of embryo freezing and appears to
be most suitable for blastocysts, but success is not
guaranteed. Some increased risk is involved because of higher
concentrations of chemicals required.
- A pregnancy test is performed 14 days after embryo
- If positive - an ultrasound scan is booked 2-3 weeks later to
confirm the pregnancy.
It is imperative that you inform the unit of the outcome
of the treatment cycle - as it is compulsory for the unit to notify
the HFEA of all outcomes.