In this first phase, hormonal drugs (called gonadotropins) are administered to stimulate the growth of ovarian follicles. Gonadotropic hormones used are very similar to natural ones: in fact, they are the analogue substances (FSH –follicle-stimulating hormone-, LH-luteinizing hormone) produced by the pituitary gland in our body to stimulate the growth of ovarian follicles. Ovarian follicles are small sacs filled with fluid that are placed inside a woman’s ovaries and they contain the immature egg. The aim of ovarian stimulation is to promote the growth and the ovulation of multiple follicles to retrieve multiple eggs. Gonadotropins are administered by subcutaneous injections, in a simple and painless way, and they can be administered by the patient herself after a proper explanation by our Nursing team. During the natural ovulatory cycle, ovaries usually produce a single follicle, containing just one egg. On this basis, ovarian stimulation is performed to increase the number of mature eggs to retrieve and consequently the chances to obtain a pregnancy. Ovarian stimulation must start at the beginning of the menstrual cycle. During the second or third day of the cycle, a transvaginal ultrasound is performed to check the follicles. In addition, a blood test is often performed to determine certain hormone levels such as LH, to evaluate the ovary status. If the ovaries result at rest, the administration of the medication can begin. Four or five days after, a new ultrasound is performed to check the response of the follicles to the hormonal stimulation.

Once the follicles reach the proper growth, the following phase is the egg retrieval. During this procedure, an ultrasound probe is inserted into the vagina to identify follicles and a needle is guided through the vagina and into the follicles. The eggs are removed from the follicle through the needle, which is connected to a suction device. Once the content of the follicle (follicular fluid) is obtained, it is immediately delivered to the embryologists in the laboratory, who check under a microscope the presence of the eggs into the follicular fluid. The whole procedure lasts approximately 10 minutes, and usually the number of eggs obtained in each cycle range from 5 to 15. Patients are under mild sedation throughout all the procedure to not feel any discomfort of pain. Overall, it is a simple and safe procedure but, for some patients, could be stressful if they has never been in a surgery room before. Before the egg retrieval, the patient must be in a complete fasting state: she should not eat or drink for at least six hours before the procedure. After the procedure, it is advisable to rest for 1-2 hours to avoid possible side effects, which are usually rare. Typically, the patient does not suffer any discomfort after the intervention.

Once the eggs are obtained, there are two techniques to fertilize them: In Vitro Fertilization or Intracytoplasmic Sperm Injection (IVF or ICSI). In conventional IVF, the oocytes are placed in the same culture dish with a large number of spermatozoa (about 100,000 per oocyte) and incubated with the intention that the gametes themselves carry out the fertilization spontaneously as would happen in the female genital tract. To obtain a successful fertilization in conventional IVF it is required an adequate sperm quality: recovery of more than 5 million spermatozoa, with a minimum of 30% progressive motility. If these conditions are not satisfied, the chances of failure (fertilization failure) are higher. Thus, in cases of severe male infertility, ICSI would be the best choice. Intracytoplasmic Sperm Injection (ICSI) is a technique which involves injecting a one single good quality selected spermatozoa directly into the patient’s oocyte. The procedure is performed using very fine micro-manipulation equipment. ICSI is generally used in cases of low sperm quality, fertilization failures with conventional IVF, patients affected by infectious diseases transmissible by sperm, frozen oocytes or to perform pre-implantation genetic diagnosis of the embryo. Regardless of the technique used to fertilize the oocytes, the following day after the insemination embryologists check on the status of the fertilized eggs. Usually, 60-70% of the eggs are fertilized (either with IVF or with ICSI). The embryos are always kept in the incubators, to maintain strict culture conditions (controlling temperature, CO2 concentration, oxygen pressure, etc.). On the second day, the fertilized embryos with a normal evolution have divided and have between 2 and 4 cells; on the third day, they have between 6 and 8 cells and so on until the 5th-6th day when they should have already reached the blastocyst stage. The blastocyst stage is important because at this time the embryo start attaching to the uterus wall in the natural pregnancy, therefore it represents the last stage during which the embryo can be cultured outside the maternal environment. In Amnios we usually keep the embryos in culture in the laboratory until the fifth day. This is a procedure called blastocyst culture or long culture. In this way we obtain more information about their implantation potential, to increase pregnancy rates.

Embryo transfer is the last step of an in vitro fertilization cycle and is usually performed on the fifth or sixth day after ovarian pick-up. During this procedure, the embryo is loaded into a small catheter tube and eventually released in the uterus under ultrasound control. Embryo transfer is not painful: it is very similar to any gynecological examination and does not require sedation or analgesia. Once the catheter is withdrawn, the biologist checks the presence of the embryo, to assure that the embryos has been correctly released in the uterus). During the following 14 days, the woman undergoes a hormonal treatment (and sometimes with estrogen as well) that is introduced into the vagina to help the embryos implant. And 14 days after the transfer (earlier if we have transferred the embryos in the blastocyst phase), we can perform the blood pregnancy test. The decision of how many embryos to transfer is made by the specialists depending on each couple and current legislation, but it is advisable to transfer the embryos one by one. In the cases of non-transferred embryos, they can be vitrified to be used in subsequent cycles. Rest is not needed after embryo transfer. In vitro fertilization has no consequences on the health of the woman, and normal life can be led after it. It is possible to lead a completely normal life, although without great effort. It is not necessary to stay in bed or special care.