During a normal cycle, only one follicle is produced by your ovaries. The follicle is like a small bubble on the ovary which grows to 20mm diameter and contains one oocyte (egg) which is about 0.1 mm in diameter. When ovulation occurs, the follicle bursts and the oocyte is released into the end of the fallopian tube.

There are three basic regimes for ovarian stimulation for IVF treatments.
These are as follows :

All this is done to produce more eggs at the same time making sure that there is no Lh surge (the release of hormone from the pituitary gland in the brain which causes the egg to get released or to become postmature). This is because when in a natural cycle only one egg matures, the cycle is well co-ordinated to make the egg release exactly at the time when it is mature.

When multiple eggs are formed this co-ordination may get disturbed and hence to achieve control on the cycle a GnRH agonist or GnRH antagonist is used. Gonadotropins are the drugs which actually stimulate the ovaries to produce multiple eggs. The dosage of FSH or hMG will be determined by your consultant and can vary between individuals and between cycles.

It is normally performed on Day 2 and then these scans are done regularly to assess follicular development. When the probe is placed in the vagina, an image of the ovaries can be seen on the scanning screen and fluid filled follicles that contain the eggs can be observed.

The size of the follicle indicates the degree of egg maturity. When the egg is immature, the follicle is only a few millimeters in size, but when it is fully mature it grows to about 2 cms in size. When follicles are large in size, you may experience some discomfort in the region of the ovaries. Usually 5 - 15 follicles will develop but this varies considerably.

On the second day of the menstrual cycle or as determined by your doctor you will have to come for your first scan to determine that the ovaries are containing small follicles and that the uterine lining is as expected. If you are on the Long Protocol you may also have some scans off and on from the 21st day of your last menstrual cycle till you get your periods.

Usually on the second day the Gonadotropins, that is the drugs which stimulate the ovaries are started. The woman will have to come for a scan at regular intervals as advised by the consultant. You will be given an appointment for your scan . You should pass urine and have an empty bladder prior to the scan. These are all OPD procedures and there is no need for admission during this.

Egg (oocyte) Retrieval involves aspiration of the ovarian follicles under anesthesia in the operating theatre adjacent to the I.V.F. Laboratory at the IVFPune unit This is done by the transvaginal ultrasound technique. The anaesthetic for the ultrasound procedure is very light. For this procedure a probe is inserted into the vagina and this projects a picture onto a monitor which enables the doctor to direct a needle into each follicle to retrieve the eggs. The fluid filled follicles are aspirated under slight suction into a test tube which is passed on the the embryologist. The scientist or embryologist locates the eggs, places them into culture media and then into the incubator.

All the instructions prior to the oocyte retrieval or egg pick-up will be given on the day the woman receives her hCG injection. The hCG injection is usually given late evening or in the night so as to schedule the pick-up in the morning around 34-36 hours later. On the day after the woman receives the hCG injection no stimulation drugs are to be taken. This is the day before the egg pick-up. Do not do any strenuous activity and abstain from sex. In fact the doctor will advise you regarding abstinence before the hCG is given. On the night before the egg pick-up the woman can have her dinner, but should not eat or drink anything after 10pm. She will have to come to IVF Pune the next day morning on an empty stomach, that is fasting. The time of reporting will be told to you along with all the other instructions. The husband will also have to come along with the wife as he will have to give the semen sample. Unless it is an ICSI procedure which also involves surgical retrieval of sperms the husband need not be fasting.

A written informed consent will have to be signed by the couple. As mentioned above the procedure is done in the IVF theatre under light anaesthesia.

After the procedure the woman will have to rest in the hospital for a few hours and will then be allowed to go home after ascertaining that all is fine. You will also be allowed to drink something after the effect of anesthesia wears out and can have a light meal at night. You will be started on progesterone supplementation from the day of the pick-up. see luteal phase support). You will also be told when to contact the unit and when to come back for the embryo transfer procedure.

As obvious this is a day procedure and there is no requirement for admission under normal circumstances.

The sample is then processed by centrifuging or spinning the specimen in a test tube through a sterile solution which acts as a sieve to catch dead and abnormal sperm. Forward swimming sperm are able to pass through the interface and are collected from the bottom of the tube. These sperm are washed and used for IVF. Most patients are requested to have a "trial run" sperm preparation prior to their cycle to determine sperm quality and thus the best form of treatment.
Insemination
Oocytes are inseminated approximately 4 hours after egg pick-up using the microdrop technique. This involves suspending 100,000 sperm and one egg each in a tiny drop of culture media under sterile paraffin oil. This procedure confines the egg and sperm to a small volume, allowing more egg-sperm interaction. Thus the sperm and egg are fertilized outside the body, in the laboratory and cultured for 2-3 days.		Insemination
Fertilization
The eggs are checked for fertilization 18-20 hours after insemination has been performed. Those eggs which either have not fertilized or which are abnormally fertilized (polyspermy) are discarded. Normally fertilized eggs (called pronuclear-stage embryos) are cultured for a further 24-48 hours for subsequent embryo transfer. Embryo Development Embryos are assessed by looking at the stage of development (number of cells), the equality among the divided cells and the amount of fragmentation within the embryo. The embryos are graded. 2-3 embryos of a good grade are then used for transfer into the uterine cavity. Excess embryos can be frozen.

During embryo transfer, the woman's legs are rested on stirrups, a speculum is inserted in the vagina and the embryos are transferred into the uterine cavity by a very fine catheter which is passed through the cervical canal. Usually no anaesthetic is required. This is usually done approximately 2-3 days after Egg Pick-up and the procedure takes 5-10 minutes. We usually recommend bed rest for 2-6 hours, however, you will be allowed to get up to go to the toilet and have refreshments during this time. You should have 48 hours rest at home after the embryo transfer and then you may return to your everyday activities. However, it is suggested that any strenuous exercise be avoided, and that sexual intercourse not be resumed until 1 week after embryo transfer. For those wishing to return to work, you may do so 2 days after the embryo transfer.

You may have a vaginal discharge after an ultrasound pick-up and if this persists or becomes offensive, please contact the IVF Pune unit. Sometimes complications can arise from these procedures, relating either to the actual surgical procedure or to the anaesthetic and these can be further discussed with your consultant. The use of ovarian stimulation drugs and since more than one embryo is transferred the chances of multiple pregnancy are present. All this will be discussed with the couple during the counseling session.

ICSI pregnancy rates also depend on the quality of oocytes available from the woman and increasing maternal age and impaired oocyte quality can decrease ICSI-related pregnancy rates. Sometimes the scientists have to use the ICSI technique on patients who were previously considered appropriate for ordinary micro drop insemination. This can be due to factors such as poor quality semen or oocytes on the day of oocyte retrieval. Therefore all patients undergoing A.R.T. treatment are requested to sign a consent form for ICSI if they are agreeable to the procedure, even though the technique might not be performed.

Approximately five days after fertilization, the human embryo reaches a development stage termed the BLASTOCYST stage. The embryos have to be cultured in the laboratory for a longer period of 5 days for the embryos to reach this stage. This allows the good quality embryos to reach the is stage and helps in embryo selection. Presently studies do not support the routine use of Blastocyst transfer in all patients.

Patients should be aware that when the embryos are cultured for an extended period of time,the embryos may not survive this and may get arrested and there is a possibility that some patients by Day 5 will have no embryos for transfer.
The IVF Pune unit currently transfers embryos into the uterus after 2 - 3 days of cultre.