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IVF: A Look At The In Vitro Fertilisation Process

IVF is an artificial procedure by which an egg and sperm are conjoined externally, in a specialised laboratory.

Belinda Kemp calls herself a practical person; a 'planner' who knows what she wants and how to get there. Until it came to having a baby.

"In the back of my mind, I have always had the thought that I was going to need help. But I never thought that it was going to be this difficult," Kemp told The Huffington Post Australia.

"For me this journey has been about accepting the help. We may not have our daughter otherwise."

Kemp's journey is a three-year one through various fertility treatments that led her and her partner to IVF -- a treatment option more Australians are now turning to when 'nature' seemingly fails them.

In the last 15 years, women have been given access to much more choice. Whilst this is wonderful, there is still a lack of knowledge about our biology. That hasn't changed – only our sociology has.Dr Juliette Koch

IVF is a growing industry. In spite of this, Australians fertility experts warn that there can often lie little chance of success.

"IVF is certainly becoming more streamlined these days. But people need to understand what it actually does and have realistic expectations from the outset," Dr Juliette Koch, obstetrician-gynaecologist and fertility specialist at IVF Australia, told HuffPost Australia.

What is it?

In 2014, 12,962 babies were born in Australia and New Zealand through in vitro fertilisation (IVF).

IVF is an artificial procedure by which an egg and sperm are conjoined externally, in a specialised laboratory.

Under micrograph: A single sperm is injected into the cytoplasm of an egg, via a microneedle.
Under micrograph: A single sperm is injected into the cytoplasm of an egg, via a microneedle.

In a stimulated treatment cycle, a woman will begin by moving through a series of daily hormone injections to stimulate fresh egg production.

"A woman can self-administer these injections at home and they do this for about ten days. During that time, we are performing blood tests and ultrasounds to see how they are responding," Koch said.

"After the stimulation has worked and we think they are ready for an egg collection, they have a final injection that matures the egg inside the ovary."

If all goes well, she will proceed onto egg collection, followed by fertilisation.

In a cycle of IVF, if you have ten free eggs, you may end up with an average of one or two good embryos. Depending on your age, if you're up to 40 years old, the chance of having a baby is at about 30 percent. Dr Juliette Koch

"A woman will then have a 20-minute procedure under ultrasound into the ovary, through the vagina, to collect the eggs. The rest of the process happens in the lab."

The fertilised embryo is then grown in a protected environment for multiple days before being transferred into the woman's uterus in the hope it will take hold.

Dr Koch explains the usual wait is five days.

"A good embryo will keep dividing. A lot of them will fall off the perch and show that they don't have the capacity to keep growing. By the fifth day, this becomes very obvious," Koch said.

"In the past we weren't able to culture them for that long. Now, we're able to choose the best one, and this, with the advent of embryo freezing, means that in Australia we're able to put one back at a time."

Reducing the number of embryos transferred in an IVF treatment cycle lowers the chance of multiple pregnancies and associated risks to mother and baby. This method, together with the increased use of frozen embryos, has contributed to higher success rates in Australia (more on these later).

Multiple embryos are rarely implanted because it poses a danger to the mother.
Multiple embryos are rarely implanted because it poses a danger to the mother.

This is a best-case scenario.

At every stage, something can go wrong. A woman's eggs may not fertilise and grow into embryos or they may fail to implant in the uterus.

This is a cycle Belinda knows all too well. When she first began treatment, she was 37.

"My partner and I were both a bit older when we decided to try for kids before marriage. I've always had problems along the way so I thought I would run into some issues," Kemp said.

Alternatives to IVF:

IVF is not a suitable treatment path for all couples. According to Dr Koch, treatment depends on an individual's circumstance, with procedures ranging from the very simple to the more complex.

Ovulation Induction (OI): a simple treatment that uses medication to stimulate hormones.

"For women who don't ovulate – and that's the reason why you're not falling pregnant – a simple tablet can help people to conceive," Koch said. "This option involves minimal side effects and very little cost."

Artificial Insemination (IUI): a technique that involves inserting prepared sperm into the female's uterus close to the time of ovulation.

"If sex is a problem for either partner, insemination can be successful," Koch said. "A lot of same-sex couples will pursue this option with donor sperm."

Six months in, Belinda was diagnosed with polycystic ovary syndrome (PCOS) before checking in to see a fertility specialist.

"We were told to start off with the tablets but this didn't work for me. When we were about to start our fifth round, I decided I wanted to try something else," Kemp said.

After changing doctors, Belinda and her partner attempted two rounds of IUI. "The first time it did work and we got pregnant. That ended up being a blighted ovum so I had to have a D&C at nine weeks," Kemp said. "Unfortunately the second time, it didn't."

We didn't want to mess around with anything else so we moved onto IVF.

With no eggs to freeze, Belinda moved through four full cycles of IVF -- the first a 'trial and error' round that she aptly describes as "daunting".

"Everything has to be done on time and at certain times. I actually liked that someone else was in control –- at least I knew there was some sort of plan and that we might have a chance," Kemp said. "Even so, it was incredibly nerve-racking not knowing."

Despite collecting seven eggs, her first transfer was unsuccessful.

"The second round felt different. I knew what I was in for and relaxed a bit ... that turned out to be a really terrible round for us," Kemp said.

"The third round was similar. We ended up only getting one egg, which we transferred early, and unfortunately that one didn't take either."

When the fourth round came around, one of two eggs stuck.

Women over 44 have a one in 100 chance of having a baby with their own fresh eggs.
Women over 44 have a one in 100 chance of having a baby with their own fresh eggs.

Not all success rates are created equal.

Now with a nine-month-old daughter, Belinda's success story started out as a statistical anomaly.

At 37 years old, she had approximately a 35-40 percent chance of clinical pregnancy (a pregnancy confirmed by a blood test and ultrasound at around six to eight weeks), according to rates from IVF Australia.

"There are various ways of defining success (and no standard definition). The most common approach is to report clinical pregnancy rates, but it's important to note that not all of these will lead to live births," Koch said. "Healthy live birth is another important measure."

According to the most recent report from the University of NSW's National Perinatal Epidemiology and Statistics Unit New South Wales --- one that collates the success rates of all IVF cycles in Australia -- the live birth rate per IVF cycle has increased from 18.1 percent in 2011 to 19.8 percent in 2014.

The study also showed a rapid drop-off with age.

Age: an inconvenient truth

"People often think that they can wait until they're 40 and have IVF if they need to. IVF doesn't do anything to the quality of a woman's eggs," Koch said.

"It is unable to fix the process of ageing and what age does to eggs."

According to the UNSW report, for women aged 30 to 34, using their own eggs, the birth rate per cycle was 26 percent or 28.6 percent depending on whether her eggs were fresh or frozen. For a woman over 44, this drops to 1 and 6.6 percent.

Second to age is carrying extra weight.

Professor Chris O'Neill, Head of the Human Reproductive Unit at the Kolling Institute of Medical Research labels obesity a significant stressor on the quality of embryos.

"Obesity is the most common source of chronic inflammation. Gametes -- the eggs and the sperm -- are particularly sensitive to inflammation and this can cause low-grade but measurable damage," O'Neill told Huffpost Australia.

"An egg in particular has large stores of fat-like material. It is clear when people have poor diet and are overweight or obese, the nature of the lipids within their eggs is different and can cause abnormalities in function."

This low-grade inflammation can pose a range of hurdles to conception.

"The first is getting the gametes to fertilise, the next is getting the embryos to implant in the uterus," O'Neill said.

And subsequent weight loss can help.

At what cost?

The financial burden of a treatment that has increasingly become corporatised is well known. What is less talked about is the emotional toll. A life put on hold.

"You find yourself constantly thinking, 'this hasn't worked again' or 'how many more times will I have to do this?'" Kemp said.

"I found myself pulling back from social scenes. I didn't have a drink for two years. You start to fear every little thing that could be the reason why this doesn't work. And a lot of people didn't understand that because I didn't tell them I was going through this."

I think people think this will just work. And that it will work first or second go. As amazing as IVF is, it doesn't work for everyone. It just doesn't.Belinda Kemp

Counselling countless partners, Koch sees varied responses throughout the process.

"There are studies showing that infertility causes stress equivalent to that of cancer. And yet there is minimal support from family and friends because there is a sense of shame and failure tied to this," Koch said.

"What I find most often is that women and men feel depressed for a period of a few days after a failed cycle and then they start to get more positive and hopeful for the next step."

Both Koch and Kemp are strong advocates for taking both physical and mental breaks between cycles.

"I'm a very practical person. I would have my breakdowns and take the time to get back into the right frame of mind. I think it's so important to let yourself be sad for as long as you need... And to trust the process," Kemp said.

"This is a long road to go down and it is normal to have times that feel more difficult," says Koch. "But it does bring huge amounts of joy for people who may not have a baby any other way.

"Be kind to yourself. And keep the rest of your life going as much as you can."


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