Intra Cytoplasmic Sperm Injection (ICSI)

When do we need IVF/ ICSI?

1. Tubal block, tubal infections
2. Severe endometriosis / chocolate cyst
3. Low sperm count/ low sperm motility/ No Sperms
4. Failed IUI cycles (up to 3 to 4 Cycles failed)
5. PCOS (No/ delayed egg growth)
6. Low Egg/ ovarian Reserve AMH < 0.8, advanced maternal age > 35 years
7. Recurrent miscarriages/Anomaly in fetus / Genetic conditions.

What happens in ICSI?

In ICSI, the eggs are held by a holding pipette and the best selected sperm is injected into the egg. So, the fertilization chances are better

What are the steps of ICSI/ How many times should we visit hospital?
First Visit -Day 2/3:

➣ Scan
➣ Investigation - Husband and Wife
➣ Consent
➣ Counselling- Clinical and financial
➣ Injections and Tablets
➣ Semen freezing

Usually a semen sample is frozen as a backup in case of emergency on day 2
Then daily injections for 10 days either as self-injections / coming to A4 Fertility Centre only for injections

Second Visit on Day 7 /8 :

➣ Scan - To monitor the appropriate growth of eggs (follicles) and to prevent premature rupture of eggs,
➣ It increases success rate to 8-10 %.
➣ An injection is added after doing the scan.
➣ If semen freezing ( not given on day 2 ) , should be given at least on this day.

Third Visit on day 11 /12:

➣ Scan again to decide on egg collection / ovum pick up date.
➣ Blood test for hormones, to further assure Egg growth and to decide on fresh Embryo transfer.
➣ Trigger injection (Night Injection) timing will be informed and instructions for OVUM PICK UP will be informed.

Fourth Visit: for Ovum Pick Up on Day 13/14

➣ Fifth Visit: for Embryo Transfer (day3 or day5 embryos) on day 17 / 19

Hence need only five visits for an IVF cycle

What is the duration of a successful IVF treatment?

The duration of stimulation of eggs is usually 10 days, 12th day the egg collection happens. If the embryo transfer happens in the same cycle, then it happens 3 to 5 days post egg collection. After Embryo transfer 14 days later pregnancy blood test is done. So if fresh Embryo Transfer (ET) happens, the duration is 4 weeks. If the patient is not ready or fit for a fresh embryo transfer (ET), then Frozen Embryo Transfer happens after 30 to 45 days. In Frozen embryo transfer, there is no injections and only oral medications are given. Pregnancy tests is done as usual 14 days after FET.

Why is it important to take the trigger injection on time?

This is a very important step in ICSI cycle, the trigger timing is decided exactly 36 hours before Ovum Pick Up procedure. Hence, the timing has to be maintained and the concerned sister in charge is informed after the receipt of injections.

What is OVUM PICK-UP? How should we come?

Ovum Pick Up is egg collection procedure done for the female partner under anesthesia with vaginal ultrasound. Usually takes 20 to 30 minutes, no abdominal incision or scar happens. As it is done under anesthesia, hence 8 hours of fasting is absolutely necessary. Even water should not be taken for 8 hours before OPU. If thyroid or other medications are to be taken, this alone can be taken with sips of water as per instructions given by the doctor.

Steps on OVUM PICK UP day ?

Admission at 8am

➣ Not to take anything, even water for 8 hours before planned OPU
➣ To bring the OPD file for entering reports
➣ Husband to accompany and to give fresh semen sample with only 2 to 3 days abstinence. Usually 1 hour after OPU timing. Will be called by embryologist
➣ After OPU, to maintain nil by mouth for 3 hours.
➣ Later Soft diet.
➣ Discharge 4 hours after procedure, approximately

What is the time duration for the creation of embryos?

After Ovum Pick UP, the embryo is grown till - cleavage stage or day 3 / blastocyst or day 5. Day 5 transfer is most often recommended for patients. If fresh transfer is not planned then embryo is grown till day 5 and then frozen in that stage, when frozen embryo transfer is planned the embryo is thawed before 2 to 3 hours of procedure.

Is embryo transfer a painful process?

Most of the embryo transfers are done without anesthesia, as it is not painful at all, except for the discomfort caused by partially filled urine and the small vaginal speculum. But if the patient is worried, anesthesia can be given for embryo transfer but only with prior intimation and preparation.

When is Fresh Embryo Transfer planned?

If all the conditions are met
➣ Serum P4/ Progesterone normal levels,
➣ Endometrial thickness is good,
➣ no complaints S/o OHSS (Pain, bloatedness, vomiting) or less than 20 oocytes planned for Fresh Embryo Transfer on DAY 3 or DAY 5

What are the steps of embryo transfer procedure?

➣ No Anesthesia needed
➣ Normal food
➣ Husband preferred to accompany
➣ The procedure as such takes only 15 minutes. The duration of stay in hospital is 2 hours before and 3 hours after the procedure.

Do we need Night admissions?

All are day care procedures, no need for stay for whole day. Except if patients wants to stay after embryo transfer as they have long distance for travel.

Post transfer what are the important medications need to be taken? When is pregnancy test done?

Luteal Support
➣ Micronized Progesterone 400 mg two times a day to be inserted vaginally
➣ Oral Progesterone T. Duphaston 10mg twice a day
➣ Blood report Serum Beta Hcg/ Pregnancy test is done after 14 days of embryo transfer to confirm pregnancy.

Do’s and Dont’s after embryo transfer ?
Video Link : https://www.youtube.com/watch?v=gnbXSJlHjnk

The two weeks period after embryo transfer is the most stressful one.
Do’s:

➣ 1. Follow directions for your medications. Have enough of them
➣ 2. Travel: Your partner or an accompanying adult must drive you home after the procedure preferably in a car/ train.
➣ 3. Activity: We recommend to restrict your activities but not bed rest. Can do walking up to 30 minutes each day (regular walking). Can climb Stairs, Can sleep/ sit down. You can do simple cooking. As long as work is not stressful, you can resume work
➣ 4. Symptoms: There are no signs and symptoms that are indicative of pregnancy or no pregnancy: Some people who are pregnant have mild cramps, spotting and some don’t. To report or call if bleeding, severe pain, giddiness, fever or any other complaints. Our clinical coordinator will help you.
➣ 5. Diet: Can have regular healthy balanced diet as given in diet chart. Can take non vegetarian diet if you are already comfortable with it. Drink plenty of water, have regular bowel habits. Constipation is quite common, to avoid it, take lots of vegetables , fruits and liquids.

Don’ts:

1. No restriction of type of toilets. Can use Indian or Western Closets
2. Avoid junk foods, spicy oily foods, allergic foods.
3. Avoid intercourse, Swimming, Douching, Heavy exercises, Zumba
4. Don’t immerse yourself obsessively in Internet forums where other IVF patients pore over their signs, symptoms and feelings. Avoid talking to people who create negativity.

Do always have a positive attitude towards the treatment, it will bring in more happiness. Talk to patients become positive.
Is it necessary to do Cryopreservation / Vitrification/ freezing of Extra Embryos?

Benefits:

➣ If pregnancy is negative, cryo preserved embryos can be used for next cycle.
➣ If pregnancy is positive, cryo preserved embryos can be kept for 5 years for second pregnancy.
➣ Cost is approximately one fourth of a fresh cycle

Pregnancy Confirmation Test , Next step?

➣ Blood report B-hCG is done after 14 days of embryo transfer to confirm pregnancy.
➣ Do not stop medication till confirmation of result with doctor.
➣ If pregnancy test is positive- come for sonography after 1 week
➣ If pregnancy test is negative – do not stop medicines till advised by doctor.

We at A4 fertility center believe in shared decision making. Talk to our experts if you have fertility issues and you are planning for ICSI