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In vitro fertilization (IVF process)
In vitro fertilization at the Gyn-Fertility Clinic Milenković is performed in cooperation with Gynecology Hospital Jevremova Belgrade.
Preparation and consultations are performed in the Clinic, while aspiration, embryo transfer and embryo freezing are performed at the Jevremova Gynecology Hospital.
IVF process at the Gyn-Fertility Clinic Milenković
Preparation includes:
- Detailed gynecological and ultrasound examination.
- Hormone evaluation (AMH, TSH), eventually other hormones;
- Tests for infections (Hepatitis B, Hepatitis C, HIV and syphilis);
- Cervical swab for chlamydia trachomatis and neisseria gonorrhoaea;
- Semen analysis for men and urin test’urthra swab for chlamydia trachomatis and gonococcus.
- Patency of fallopian tubes.
The IVF process consists of several steps:
Hormonal stimulation: stimulation of the ovaries with gonadotropins to produce more eggs.
Egg aspiration: collection of eggs under ultrasound control.
Fertilization: eggs are fertilized by sperm in the laboratory.
Embryo development: embryos are cultured and monitored in the laboratory for several days.
Embryo transfer: the best embryos are repalced to the uterus.
Pregnancy monitoring: pregnancy testing 12-14 days after embryo transfer.
- After egg aspiration, patients receive progesterone hormone.
- 12-14 days after embryo transfer, a pregnancy test (beta hCG hormone) is performed, from blood or urine.
Pregnancies are later controlled as well as spontaneous pregnancies.
When is in vitro fertilization (IVF) done?
IVF is done if after one year of unprotected sexual intercourses no pregnancy occurs in couples where the woman is younger than 35 years old or after 6 months where the woman is older than 35 years.
IVF can be done earlier if it is known that there is some infertility factor.
It goes without saying that some simpler methods should be done before the IVF, if there are possibilities for that. These can be ovarian stimulation with pills, insemination, treatment of infections and other diseases that negatively affect fertility, as well as surgical methods.
In which conditions is the IVF procedure performed?
IVF is recommended for couples facing problems such as:
- blocked fallopian tubes;
- polycystic ovary syndrome (PCOS);
- endometriosis;
- male infertility;
- in genetic diseases;
- in case of previous sterilization of the woman by tubal ligation;
- embryo freezing for social and medical reasons;
- after egg freezing;
- unexplained infertility (when the cause of infertility is not revealed during the examination);
- in malignant diseases before the start of therapy that is harmful to eggs and spermatozoa.
IVF procedure: step by step
*Each IVF cycle is carefully adapted to the individual needs of the patient, with the possibility of changes depending on the reaction to therapy. The doctor will lead you through all the stages, step by step, and adjust the treatment plan to ensure the best results.
Day 1- 10 - Hormonal stimulation of the ovaries
The ovaries are stimulated with hormones (injections and/or pills) to produce more eggs. There are THREE protocols:
- Short protocol – Stimulation starts day 2-3 of the cycle and from day 5-6, an injection is added that prevents premature maturation of the eggs.
- Long protocol – First of all, the work of the ovaries is blocked, and then hormone stimulation is started.
- Progestin prime ovarian stimulation (PPOS)-stimulation starts on day 2-3 of the cycle. Progesterone tablets are taken from the beginning of stimulation. With this protocol, embryos are always frozen.
Day 3-14–Follicular Monitoring
Ultrasounds are performed 2-3 times during stimulation in order to monitor the growth of the follicles and thus indirectly the maturation of the eggs. Once the follicles have reached the appropriate size, egg aspiration is planned. *Not all follicles produce eggs - e.g. out of 10 follicles, usually 6-7 eggs are obtained.
Day 10-14 – Stop injection
When the follicles are mature, an hCG or GnRH agonist injection ("stop injection") is given, which allows the egg to be released into the follicular fluid before aspiration.
(Day 12-16 of the cycle)
- Sperm collection: The partner provides a sperm sample, which is then prepared for fertilization. The sperm can be given before the start of the IVF cycle, with the possibility of freezing it for later use, or frozen donor sperm can be used.
- Egg collection: 34-36 hours after the stop/trigger injection, the doctor performs aspiration, a procedure by which the egg cells are collected from the ovary. This procedure takes about 5 minutes and is performed under mild anesthesia.
(usually up to 4 hours after aspiration)
- IVF or ICSI: In the laboratory, the collected eggs are combined with the partner's or donor's sperm (classical insemination) or the sperm is directly injected into the egg (ICSI method) under controlled conditions that mimic the condition in the body. Fertilization usually does not occur with all the obtained eggs.
- Embryo development: The fertilized egg cell becomes an embryo and its development is monitored in the following days. Some embryos stop developing.
(most often after the 12th day of the cycle)
- Embryo transfer: When the embryos reach the optimal stage of development, one or two embryos are carefully transferred to the uterus. The transfer itself is a technically demanding procedure, it is not painful and does not require anesthesia.
- Transfer of previously frozen embryo – cryo-embryo transfer (if applicable)
- If more quality embryos remain, they can be frozen (cryopreserved) for future attempts or additional IVF cycles. About 40% of couples have embryos for freezing.
- Three weeks after a positive beta hCG test, the first vaginal ultrasound examination is performed.
Success of the IVF procedure
- The duration of infertility and the age of the woman are the two most important predictive factors.
- The shorter the period of infertility, the greater the chances of pregnancy.
- In women up to 35-36 years of age, the success rate of IVF is about 50-60% per embryo transfer, and at the age of 44, 2-3% of women achieve pregnancy and give birth to a child.
- The result after the transfer of a fresh or previously frozen embryo is similar.
- It is more realistic to assess success based on the initiated IVF procedure and stimulation.
- A good result is considered if the overall success rate is 35% or more per initiated procedure, but the result must always be analyzed by age group.
- The success rate after IVF with donated eggs is about 50-60% per embryo transfer.
Potential complications
- During the procedure, side effects of the stimulant drugs, such as drowsiness, fatigue, bloating, abdominal pain and headache, may occur, but these disappear after the treatment. Egg aspiration can be painful, so it is performed under general or local anesthesia.
- There is no long-term risk of cancer or other diseases after IVF or the use of stimulation drugs.
- The risk of bleeding and infection after egg aspiration is less than 1%.
- The risk of ovarian hyperstimulation syndrome (OHSS) is between 5% and 10% and increases with the number of eggs retrieved.
- OHSS can cause abdominal pain, enlarged ovaries, fluid in the abdomen and chest, shortness of breath, and chest pain. When there is a high risk for OHSS, an "agonist" stop injection is used, and embryos that meet the criteria are frozen.
Frequently asked questions: expert advice
Odgovara Dr sci. med. Milan Milenković
How long does the IVF procedure take?
The IVF procedure lasts from 12-14 days and up to 4-5 weeks, depending on which protocol is used. Today, a short, antagonistic protocol is most often used, and generally everything is finished in 14-17 days.
How to behave after the transfer?
The patient can return to normal activities after the embryo transfer. Heavy physical activities and absolute rest are not recommended. Light physical training can be started a day or two after the embryo transfer. Jumping and sudden movements that can lead to stomach pain are not advised.
IVF has been performed since 1978 and there is no evidence that strict rest increases the success of the IVF procedure.
The patient can drive a car and travel by plane. If the flight is longer than 6 hours and the patient is traveling within two weeks after the transfer, therapy with low molecular weight heparin (fraxiparin) is advised before the trip. The usual diet that the patient had before IVF is advised. Check out our nutrition blog.
Sexual intercourses are not advised in the period from the stop injection to the transfer due to the risk of multiple pregnancies in case of premature or late ovulation after egg aspiration.
When can the IVF procedure be repeated?
If pregnancy does not occur, IVF is usually repeated after two or three months. In certain situations, however, it can be repeated immediately after aspiration, for example when embryos are frozen before treatment with cytostatics in malignant diseases or when the so-called "dual stimulation" protocol is applied.
How many times can IVF be repeated?
IVF can be done several times and how many times it will be done depends on the age of the patient, the quality of the embryo, fertilization and previous procedures. In any case, the assessment is individual.
How to prepare for the first consultation?
Both partners come to the first consultation. It is preferable that the couple already have AMH, TSH and semen analyses. Serological analyses of both partners for hepatitis B, hepatitis C, HIV, syphilis and rubella in the woman are also required.
What is the price of in vitro fertilization at the Gyn-Fertility Clinic Milenković?
See the price of in vitro fertilization in the regularly updated price list.
Is IVF available through the public Serbian insurance at the Gyn-Fertility Clinic Milenković?
The Gyn-Fertility Clinic Milenković performs IVF for couples financed through the public insurance of the Republic of Serbia. It is necessary that the couple at the commission chooses the Special Gynecology Hospital Jevremova. You can read more about the IVF process at the expense of the state here.
Does IVF increase the risk of cancer?
IVF or more precisely the drugs used for stimulation do not increase the risk of developing cancer. IVF has been performed since 1978 and no epidemiological studies have shown that IVF increases the risk of either cancer or any other disease.
What are the side effects of the drugs in the IVF process?
During the procedure, side effects of the stimulant drugs, such as drowsiness, fatigue, bloating, abdominal pain and headache, may occur, but these disappear after the treatment.
Does DHEA increase the chance of IVF success?
Dehydroepiandrosterone (DHEA) does not increase the chance of success of IVF. The idea of DHEA is about 20 years old, but so far no study has shown that DHEA increases the success of IVF. DHEA also has side effects by increasing testosterone levels in the blood and disrupting the ratio of good and bad cholesterol.
Do fraxiparin and aspirin increase the success of the procedure?
Low molecular weight heparin (Fraxiparin, Fragmin) and acylsalicylic acid (aspirin)/ do not increase the success of the IVF procedure. They are advised only if there is some other indication for it.
Does intralipid infusion increase the success of IVF treatment?
Some studies of lower quality and with a small number of patients have shown a slightly higher success rate in women after multiple unsuccessful embryo transfers, where the embryo was of good quality. There is still insufficient evidence to use intralipids in routine clinical practice.
Is pregnancy after IVF risky?
Pregnancy after IVF has a slightly increased risk for pregnancy complications.
The risk of preeclampsia (high blood pressure, protein loss, swelling) and diabetes in pregnancy occurs in 3% of pregnant women after spontaneous conception, while this percentage is 5-6% after in vitro fertilization. IVF carries a slightly increased risk for pregnancy bleeding, preterm birth, and low birth weight. Children born after the transfer of a previously frozen embryo have a slightly higher birth weight than children born after spontaneous conception.
Twin pregnancies have a several times higher risk for premature birth and complications in the child related to premature birth, especially when the birth is before 30 weeks of gestation. Pregnancies after IVF with a donated egg have a risk of preeclampsia of about 10%. Due to the aforementioned risks, pregnancies after IVF should be controlled in institutions with experience in monitoring risk pregnancies.
What is a follicle?
A follicle is a complex of cells in the center of which is an ovum that has 23 chromosomes, and around it are "somatic cells" that have 46 chromosomes each. When at a certain moment during the maturation of the egg cell, fluid appears between the somatic cells that surround it, an antral follicle is formed, which can be seen by ultrasound examination. The egg itself is 0.1 mm and cannot be seen on ultrasound.
During the stimulation in the IVF procedure, the follicle grows and thus the maturation of the egg cell is indirectly monitored. Follicular growth correlates with the level of estradiol in the blood. An egg cell is not found in every follicle, so a lower number of egg cells than the number of follicles is usually found during aspiration.
Does IVF reduce ovarian reserve and increase risk for early menopause?
IVF does not increase the risk of early menopause or reduce ovarian reserve.
Physiologically, about 1000 egg cells start a process of maturation and development that lasts about 6 months. Those eggs located in the antral follicles that we see on the ultrasound screen have reached the final stage. Since one egg cell has been released by ovulation, the others will perish, that is, enter the process of apoptosis - programmed cell death.
By stimulating the hormones FSH and LH, we help those cells to survive and continue the development and maturation process.
