How many embryos to transfer?

The number of embryos transferred is crucial to your risk of a triplet pregnancy or higher. In Ghana there are no restrictions or regulations with regard the number of embryos to be transferred. Recently, there has been a drive toward single embryo transfer (SET). It is the policy of the Assited Conception Unit at Finney Hospital to transfer a maximum of 3  embryos. This however depends on individual circumstances. In order to improve the effectiveness of SET, selecting the embryo with the highest potential for implantation is important.

General advice after embryo Transfer

  • Take it easy for a few days, avoid any strenuous exercise such as aerobics and jogging.
  • Avoid douching, tampons and swimming in order to avoid undue contamination of the vagina.
  • Avoid unnecessary exposure to solvents and paints containing lead.
  • Avoid carrying or lifting heavy objects.
  • You should eat sensible and healthy diet, avoid consumption of excess alcohol,
  • Stop smoking.
  • Continue taking folic acid tablet.
  • Refrain from taking medication or drugs that are not necessary, and only after checking with your doctor. .
  • Avoid intercourse for two weeks.
  • Do not stop luteal phase support until you have both a negative pregnancy test and a period

Pregnancy Testing

  • Most IVF clinics will offer you a blood tests about two weeks after embryo transfer, to check the level of Beta hCG (pregnancy hormone) and may also check the level of blood progesterone.In the happy event that the pregnancy test is positive, the patient will be asked to repeat the blood tests at intervals between 2-5 days to check the rising levels of these hormones.

    HCG levels are the only way of monitoring early pregnancy. HCG levels which do not increase as rapidly as they should may indicate that there is a problem with the pregnancy such as ectopic pregnancy.

    An ultrasound scan is usually performed about 5 weeks after embryo transfer or earlier. The scan will check that the pregnancy is normally located, appears normal and viable, and to see if there is more than one fetus.

    The patient may have some vaginal spotting or bleeding prior to the pregnancy test. She may think that her period has already started and decline having the pregnancy test however it is recommended that the pregnancy test is done as it is the only way to determine whether there is a pregnancy. 

Cost of Treatment

  • Although a baby is priceless, you must be aware of the cost involved and you need to decide whether you can afford it. The cost of IVF treatment varies between different clinics

    You need not only consider the money you will be spending in pursuing the treatment but also the time and energy you will need to invest as well, including loss of earnings, traveling and accomodation.

Factors affecting the outcome

  • The Presence of hydrosalpingesThere is increasing evidence that the presence of hydrosalpinges adversely affects the live birth rates of women undergoing IVF treatment. The mechanism for reduced implantation in women with hydrosalpinges is not fully understood but it is possible that the leakage of the fluid from the tube into the womb wash off the embryos, or the fluid itself could have toxic effects on the embryos. Most specialists offer surgical treatment for hydrosalpinges before IVF treatment. The treatment usually inviolves removal of the tube (salpingectomy) preferably by laparoscope. An alternative is to occlude the tube at its uterine end again by laparoscopy or aspiration of the fluid from the tube.
  • Basal FSH and LH levels (ovarian reserve)Woman with a base FSH level of 12 or more IU/L or FSH/LH ratio more than 3 or women with an Inhibin level less than 80 pg/ml are unlikely to respond adequately to ovarian stimulation.
  • Uterine Fibroid: Fibroid that compress the cavity of the womb significantly reduce live birth rate
  • Lifestye: Obese women take longer to conceive and are at higher risk of miscarriage than normal weight women. 
  • Smoking reduce implantation and pregnancy rates .Smoking also adversely affects live birth rates equivalent to increased female age by 10 year.
  • Blastocyst embryo transfer: The first IVF human pregnancy was achieved by blastocyst transfer. Blastocyst transfer is claimed to be more physiological than pronucleate or cleaved-embryo transfer is as it mimics nature more closely. As the embryo advances in the development, after 5-6 days it becomes a blastocyst. This has an outer thin layer of cells which will later form the placenta, and an inner cell mass which will develop into the fetus. A blastocyst has about 120 cells. A blastocyst gives a better idea of the competence of an embryo and has a higher chance of implantation than a cleaved embryo. In conventional culture medium, about 20% of embryos will develop into blastocysts. Recently, the use of sequential culture medium (the embryos are cultured in different media according to their stage of growth) has enabled a larger number of embryos to develop into blastocysts. However, up to 40% of patients will not grow blastocysts and will not have blastocyst embryo transfer The rational behind a blastocyst transfer is that an embryo which has failed to reach the blastocyst stage, would be unlikely to have resulted in a pregnancy. However, if it reaches the blastocyst stage it has about 50% chance of implanting. So the improved implantation rates following blastocyst transfer is due to selection of the best embryos

Why then do 50% of the blastocysts fail to implant?

A defective blastocyst (e.g. chromosomal abnormalities) is a possible cause; a non-receptive endometrium is another cause. Blastocyst embryo transfer into the uterine cavity is performed about 5-6 days after egg collection. Transfer of one or two blastocysts is recommended to avoid high-order multiple pregnancies. Supernumery blastocysts can be frozen for future use.

For whom blastocyst transfer is recommended?

  • Patients who had repeatedly failed to achieve a pregnancy following the transfer of good quality cleaved embryos (If the embryo arrest and did not develop to blastocyst, this may indicate a potential egg problem)
  • Patients who wish to achieve a pregnancy without the risk of multiple pregnancy, here the transfer of one blastocyst will be recommended.
  • Patient who do not wish to have their spare embryos frozen for whatever reasons may be advised to have blastocyst transfer

What are the disadvantages of blastocyst transfer?

  • About 10% of the embryos that fail to develop to blastocyst in vitro may have done so if replaced inside the womb on day 2 or 3
  • Up to 40% of patients will not have blastocyst available for transfer
  • Freezing spare blastocyst is not as good as freezing cleaved embryos. 

Advice for men

  • Wear loose fitting boxer shorts and trousers.
  • Avoid hot baths and take showers instead.
  • Cut down smoking and alcohol drinking or stop altogether. Men who smoke heavily or drink too much appear to have lower sperm motility and a higher proportion of abnormal sperm.
  • If overweight they should loose weight.
  • They should avoid exposure to chemicals and radiations etc.

Surgical sperm retrieval (PESA and TESA)Surgical sperm retrieval is a technique for collecting sperm from the vas deferens, epididymis or testis. This is a minor procedure, usually carried as a day case surgery under a local or a general anesthetic.

To whom surgical sperm retrieval is advised?

There are selected groups of patients to whom surgical sperm retrieval is recommended.

  • Men with complete absence of sperm in their ejaculate when the sperm production by the testicles is normal but there is a blockage, which prevents sperm entering the semen (obstructive azoospermia). This may be due to a blockage of sperm transport tubules (epididymis or vas deferens) for whatever reasons, congenital absence of the vas deference, a previous vasectomy or failed vasectomy reversal. 
  • Men with complete absence of sperm from their ejaculate due to failure of sperm production by the testicles, about 50% of these men may have areas in their testicles producing sperm, which do not pass into semen although there is no obstruction (non-obstructive azoospermia). Testicular biopsy from these men may have some sperm. 

There are two methods of retrieving sperm surgically.

PESA (percutaneous sperm aspiration)

This is the first choice (if possible) to collect sperm. A fine needle is inserted through the scrotum into the epididymis and sperm are obtained by gentle suction. After each sample is collected, it is examined under the microscope to confirm the presence of sperm.

TESA (testicular sperm extraction)

A fine needle is inserted into the testis and sample of tissue are obtained by gentle suction and examined under the microscope. If sperm are not found, a small tissue sample (testicular biopsy) is taken through a small incision in the scrotum and testis, sperm can then be extracted from the tissue. The cut is stitched back together with a couple of stitches, which self dissolve in about 10 days. Finding sperm in the testicular tissue can be a laborious process.

Surgically retrieved sperm are immature and incapable of fertilization by conventional means. Fertilization is achieved using ICSI, this involve injecting a selected sperm into the cytoplasm of a mature egg.

After the operation, You may feel discomfort, bruising and tenderness of the scrotum for 24-48 hours.

Any spare sperm or testicular tissues may be frozen for later use, thus avoiding a repeat of surgical sperm retrieval procedure.

In case no sperm is found, the couple may either decide to cancel the egg collection and abandon treatment altogether, or proceed with the egg collection and inseminate the eggs with donor sperm if this has been discussed and agreed before hand as a ‘backup’.