In order for a couple to decide on the use of assisted reproductive technologies, the doctor mainly focuses on the age of the patient. If the patient is younger than 35 years old, then when certain factors of infertility are identified, other methods of treatment may be offered to her: stimulation of ovulation, artificial insemination, laparoscopy and hysteroscopy.
IVF is the most effective treatment for infertility and pregnancy. Elena Mladova, obstetrician-gynecologist, reproductologist, chief physician of the Remedi Institute of Reproductive Medicine, spoke about what you need to know about the testimony and the editorial procedure itself.
For example, if a thirty-year-old patient has obstruction of the fallopian tubes, then laparoscopy will be recommended to her first. However, if pregnancy does not occur after laparoscopy within a year, then she will need to do IVF.
In the event that a patient under 35 years old suffers from anovulatory infertility (she does not ovulate), she will be recommended to stimulate ovulation as the first therapy. If pregnancy does not occur after ovulation stimulation, the doctor will prescribe IVF.
Men who are identified with minor abnormalities on the part of the spermogram may be recommended conservative treatment with an andrologist for 6 months. IVF is recommended to a couple if treatment fails. If the partner in such a pair is older than 35 years old, then, in fact, the only method of infertility treatment is IVF. It turns out that IVF is a method of achieving pregnancy in the most difficult cases.
How long does it usually take between finding problems with conception before deciding on IVF and having a baby?
Problems with conception are spoken of if pregnancy does not occur within one year of regular sexual activity without contraception. This is an occasion to consult a reproductologist and conduct an examination to determine the possible causes of the absence of pregnancy.
A complete examination of the couple takes about two months. A woman is examined for patency of the fallopian tubes, the presence of ovulation is assessed, the uterine cavity is examined for the absence of pathologies, and the partner’s spermogram is checked. These are the main points that need to be evaluated.
If a decision is made on IVF, then, as a rule, the treatment process itself takes one month, and if it is successful, then after 8-9 months the baby is born.
Sometimes the IVF process takes place in segmented protocols. The essence of this method in two events: obtaining a married couple of embryos and choosing the time for transferring these embryos to the uterine cavity. And sometimes these events can be spread in time. For example, in January, a woman is stimulated, her eggs are taken from her, fertilized by sperm and receive embryos, and the embryos are transferred in February, March or April, depending on the woman’s readiness for transfer. Therefore, on average, a patient in a reproduction clinic is observed for 6 months until pregnancy occurs.
Has IVF really become more affordable?
Since 2012, the implementation of the IVF program has been available at the expense of the local health insurance funds. The number of medical procedures that are performed as part of the compulsory medical insurance grows exponentially every year. If in 2013 IVF procedures due to compulsory medical insurance for the whole country were about 10,000, then in 2017, according to the Minister of Health Veronika Skvortsova, up to 70 thousand procedures were performed. We believe that in 2017, 40% of all cycles were performed due to compulsory medical insurance.
Yes, from this point of view, the IVF procedure has become more accessible. But, unfortunately, MLA financing does not take into account many nuances, and therefore it is not always possible to effectively carry out an IVF program.
There are standards that WHO has indicated as “accessibility standards for infertility treatment in different countries.” The norm recommended by WHO is 2,000 treatments per million people per year. It is this indicator that indicates the availability of IVF as a treatment method. In our country, so far the number of IVF cycles per million of the population has not even reached 1000, that is, there is a significant shortage of treatment procedures.
For example, in Denmark about 3000 treatment cycles per million population are carried out, in Spain – 2800 treatment cycles per million population. On the one hand, help has become more affordable, but, on the other hand, the number of procedures that are carried out in our country is still insufficient to solve the problem.
In my professional opinion, this is due to two main reasons. Firstly, the lack of awareness of the patients themselves. Patients, unfortunately, believe that IVF is an extreme treatment, postpone it to a later age (41-42 years), when the treatment itself becomes less effective due to the age of the woman. Patients do not decide for a long time to start treatment with this method, because there are certain fears that are actually not justified.
The second point is the difficulty in working with primary care physicians. Usually, patients with difficulties with conception go to the obstetrician-gynecologist in the clinic, where doctors drag out the patients for IVF, spending valuable time on examination and conservative treatment.
Can we say that IVF is becoming more effective?
This year marks the 40th anniversary of the birth of the first child conceived using IVF. The method itself developed long before the first results were obtained and, in fact, a huge breakthrough occurred in these 40 years in terms of the quality of in vitro fertilization itself.
What do we have today? First, we have a completely flexible, patient-friendly, and safe protocol for stimulating follicular growth. It is now quite safe to receive eggs and the frequency of such complications as, for example, ovarian hyperstimulation syndrome is approaching zero, while in 2000 this number was 7-8%.
Since 2008, a very effective technique for freezing biological material called vitrification has been introduced throughout the world, and in Russia too. The freezing of biological material, in general, has existed for a long time. If we talk about sperm, they are frozen for more than 100 years. And if we talk about human embryos, the first human pregnancies after the transfer of thawed embryos occurred in 1983. But since 2008, a slightly different technology has been used, which allows very good preservation of embryos and, most importantly, eggs. The yield of embryos from defrosting is 99.9%, and therefore we can guarantee the patient that the embryo will not be damaged as a result of our intervention. The same applies to the eggs.
For women, effectiveness always depends on age. For example, the freezing of an egg has now allowed young women who are not planning a pregnancy yet, but are making a career, to save their eggs for future use. Although this sounds fantastic, in practice it looks like this: a woman makes a career, say, up to 36 years old, then decides to have a baby, realizes by the age of 37-38 that she has encountered difficulties and comes to perform in vitro fertilization at the age of 40. But the effectiveness of the IVF procedure at 40 years old is about 25% per cycle, while the effectiveness of the same procedure at 35 years old will be 50% per cycle. If this woman has eggs, which she froze at 30 years old, then it will be much easier for her to achieve pregnancy at an older reproductive age using these young eggs.
This is due to the quality of the eggs, because in women all over the world, starting from the age of 37, the ability to conceive independently decreases and the quality of the eggs decreases. That is why after 35 years, other methods than IVF are not recommended to achieve pregnancy.
It is also possible to preserve eggs in cancer patients. Quite a lot of young women suffer from breast cancer, leukemia. There are certain diseases that, unfortunately, young women can also get. Naturally, if the disease is detected at an early stage, then treatment is quite effective and 5-6 years after the disease, patients turn to the issue of reproductive function. And of course, the presence of frozen biological material that was taken before treatment facilitates the solution of the reproductive problem and in many cases allows these women to experience the joy of motherhood.
How has the approach to IVF changed?
At the dawn of the IVF procedure in the 80s, reproductologists transferred 2, 3, and 4 embryos into the uterine cavity. This was due to the desire to increase the frequency of pregnancy in the IVF cycle. Over the past 15 years, significant changes in the cultivation technology itself have occurred, good environments for embryo cultivation have appeared, laboratory technology has advanced, incubators have appeared that allow the most careful treatment of embryos. Thanks to this, we now have the opportunity to cultivate embryos up to the fifth day of development. This is the stage of development when the embryo should normally be implanted in the uterine cavity. These embryological technologies have led to the fact that now we never transfer more than two embryos, and in most cases we try to transfer one embryo, while having a high pregnancy rate.
And what does a multiple pregnancy mean for a woman? Multiple pregnancy is almost always a preterm birth and premature babies, which, as a rule, have a number of diseases. On the one hand, we treat, and on the other hand, we put a woman and her unborn children at risk. Therefore, this improvement in embryological technology has made it possible for a patient to become pregnant when one embryo is transferred, thereby significantly reducing the risk of multiple pregnancies.
There is also a technology called preimplantation genetic testing (preimplantation genetic screening, preimplantation genetic diagnosis). This is a method for genetic diagnosis of an embryo before it is transferred to the uterine cavity. When the embryo is still directly in the Petri dish, you can take several cells and conduct a genetic study for the presence of chromosomal pathology.
Genetic diagnosis is also possible for couples at high risk of having a baby with a monogenic genetic disease, for example, spinal amyotrophy. For such families, IVF is a way to give birth to a healthy baby.
There is an indicator of the frequency of pregnancy, and there is an indicator called Take Home Baby (came, did the procedure and gave birth to a baby). And this figure averages around 35% worldwide. So on average, every third IVF attempt ends with the birth of a living, healthy child. If the patient is 30 years old, and she has obstruction of the fallopian tubes, then such a patient has a 55% chance of pregnancy on the first try.
IVF allows you to become parents to those who, in principle, can not have children. For example, if a woman’s ovaries were removed as a result of surgical interventions for tumor-like formations, then she can take advantage of donated eggs, carry the baby and give birth. If a woman has had her uterus removed, or a congenital absence of the uterus, then a woman can get eggs, fertilize them and transfer them to the cavity of a surrogate mother. And already in this way you can give birth to your child genetically. Such technologies make it possible for mothers to find happiness for those who have no other way to become pregnant.
Is IVF used in male infertility?
A separate story in IVF is work with the male factor of infertility. Up to half of all non-pregnancy cases are related to male fertility problems. First, IVF is stimulated, then the eggs are fertilized with sperm and embryos are transferred to the uterine cavity.
Fertilization can be carried out by two methods. The first is when the egg is mixed with sperm. This is called classic IVF. The second method, when the sperm is introduced into the egg, is called the intracytoplasmic injection of the sperm into the egg or ICSI (from the English IntraCytoplasmic Sperm Injection). The ICSI method was first proposed in 1992, and it allowed men who have very few sperm to become fathers as well.
How many children are being born as a result of IVF in Russia?
There are no such data in Russia. I can say that in European countries, the proportion of children born after IVF in the overall structure is 7-8%. This is already open data. In Spain, 4-5% of children, in the Scandinavian countries it is 7-8%. Unfortunately, there are no such statistics in Russia. In Russia, there are only statistics on the number of treatment procedures, the number of IVF cycles. We calculated that the average annual growth rate of the number of IVF cycles in the Russian Federation in the period from 2007 to 2011 is 22%, and from 2012 to 2017 -17%. The frequency of IVF will continue to grow further. The main thing is that people understand that there is no need to be afraid, you need to go and do it. Because, the sooner you do, the earlier and more likely there will be a result.
In Russia, it is necessary to work towards greater accessibility of this type of treatment, including greater awareness of this method.
How do you feel about IVF from three parents – a procedure that is already allowed in the UK?
IVF from three parents can potentially help two categories of patients. The first is a very narrow group – patients with mitochondrial diseases. For such patients, replacing the egg cytoplasm increases the chances of having a healthy baby. And the second – patients over 40 years of age who have low quality eggs and embryos in IVF programs.
In my opinion, the future of IVF technology is to preserve reproductive material in a young return. In the future, the life expectancy of people will increase, and it will be possible to give birth at 45, and 50, and maybe later, from their eggs, but for this they must be frozen at 25 or 30 years. IVF is a safe method, but using high technologies and technologies, these will develop in the direction of the birth of a healthy child.