Homerton Fertility Centre, London

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1 Homerton Fertility Centre, London

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4 Overview Individualised care and protocols Medical aspects of IVF/ICSI Nursing support Embryology and laboratory aspects of IVF/ICSI Counselling support

5 Menstrual Cycle Growth of the egg and womb lining Ovulation and womb support Follicle Stimulating Hormone Luteinizing Hormone Oestrogen Progesterone

6 ZP Cumulus Egg Sperm Storage Site Fertilization Site Fallopian Tube Uterus Ovary

7 What is IVF/ICSI? IVF is a form of fertility treatment where we help assist you get pregnant using your egg and sperm outside your body with the help of technology ICSI technique is an extension of conventional IVF where a single sperm is injected in to the egg to assist you get pregnant

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9 IVF is performed When the tubes are damaged, blocked and not possible to repair at surgery Unexplained fertility problem where other methods have failed Ovulation problems where other methods have failed Female age is advanced Other issues such as endometriosis, fibroids or combinations of any of the above

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11 ICSI is performed Where sperm count is very low or sperm motility is very poor or a combination of both along with highly abnormal sperm Where man fails to produce sperm and needs a surgery to extract sperm Where frozen sperm are needed such as donor sperm with significant female problems Where IVF has failed to fertilise the eggs

12 Cycle timeline Approximately 8 weeks until the pregnancy test from the start Phone in with the D 1 of the period and leave a message on the nurse phone (this is a voic ) Nurses offer you the date to start (usually D 21 of period) supracure/suprafact injections to switch off the natural egg production

13 Cycle timeline Scan appointment in about 3 weeks - assess the lining of the womb/ovaries ( Down regulation scan) along with a possible hormone blood test A start date for stimulation is organised Stimulation of the ovaries with menopure/gonal-f injections for egg production started followed by scans (vary according to specific needs)-about 2-33 scan on an average over days

14 Cycle timeline Trigger ovulation with appropriate injections Egg collection hours later under sedation and local anaesthetic as a day procedure Male partner to produce the sperm sample on the day of egg collection at the fertility unit Fertilisation check and phone call to inform you before mid day on the day after the egg collection

15 Cycle timeline Embryo transfer on Day 2/3/5 after egg collection depending on individual circumstances Progesterone hormone support with pessary or gel until the pregnancy test Pregnancy blood test about 2 weeks after the Embryo transfer with the results available on the same day usually

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17 IVF/ICSI Cycle: 6 phases Preparation- switch off natural egg production and ovulation Stimulation- production of more than one egg Ovulation trigger Egg collection Embryo transfer Support to the womb lining and the pregnancy test

18 Preparation Aim-medical medical menopause (temporary) by hormones to prevent unplanned ovulation Long protocol is conventional with daily Suprafact/Supracure injections from the D21 of natural menstrual cycle- any time of the day as long as no more than a couple of hours apart Short/Antagonist protocol is being used more and more as we become more familiar and comfortable at using it. This does not include any preparation except a short course of the Pill to facilitate the convenience of scheduling

19 Preparation Short/Antagonist protocol also uses Cetrotide injection from Day of the stimulation to prevent unplanned ovulation Possible common side effects: headaches, hot flushes, night sweats, mood swings, period like bleeding Small selective group of patients may need individualised protocols such as flare protocol, short protocols without the Pill or estrogen priming protocol Dosages and protocols along with side effects are variable from a person to person

20 Un-stimulated Ovary

21 Stimulated Ovary

22 Stimulation Daily Menopure/Gonal-F F injections for about days Possible side effects: Soreness/bruising at the injection site, nausea, bloating in the tummy, pressure on the bladder or bowel Can be done any time of the day as long as it is done more or less the same time and no more than a couple of hours apart

23 Ovulation trigger To release the eggs Late night injection of Ovitrelle or Pregnyl or Superafact depending on the individual case Timed hours prior to the egg collection Timing is crucial and must be adhered to the given time otherwise you run the risk of unplanned ovulation or un able to collect the eggs

24 Egg collection No food or drink including water/tea/coffee/milk at least 6 hours before the procedure Lasts between minutes usually but depends on the number of eggs and varies from a patient to patient and generally you will go home in a few hours afterwards Pain relief during the procedure with Intravenous sedation and local anaesthetic followed by more pain relief in the form of suppositories and take home oral tablets

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26 Egg collection Performed under conscious sedation according to the NICE guideline for improved patient safety General Anesthetic is only offered if there is a medical reason as this is a riskier procedure when compared to the conscious sedation Partners are not allowed to be present due to the sterility issues in the theatres

27 Egg collection Some discomfort for up to a couple of days can be expected It is possible that you may get some discharge and mild bleeding for a day or two It is expected to have some hang over for several hours after the procedure and hence some one needs to take you home You should definitely not be driving on the day!

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29 Egg collection Serious side effects such as major bleeding or injury to the internal organs such as bladder, bowel or blood vessels are rare and are likely to occur in less than 1% of patients, thankfully If there is any major side effects, you may not be sent home and kept under observation for longer

30 Embryo transfer Usually takes place between days after the egg collection Does not require any pain relief for 99.99% of patients and is as quick as a smear test! Performed under ultrasound guidance and with a full bladder Partners are welcome and encouraged to be present at the procedure unlike egg collection

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32 Embryo transfer Discussions of final embryo quality, availability, number to transfer ( mostly 1 or 2 and rarely 3) as well as any to freeze It is a very delicate and a crucial step Performed by the senior specialists only Instructions for post transfer are handed out verbally and in written form

33 Embryo transfer

34 Support to the womb lining Progesterone hormone pessaries or gel to be taken daily as per the instructions- rectal/vaginal Possible common side effects- breast tenderness, bloating, vaginal discharge To continue for about 14 days until the pregnancy blood test and for longer if pregnant

35 Pregnancy test Blood test at the general blood collection centre for the hospital on the pre determined day in the morning Results phoned in to you by the same day late afternoon or early evening Pregnancy scan weeks later when pregnant

36 Failed treatment Period can start within 2 weeks but could be different from normal Appointment to see the doctors will be arranged as soon as possible after a recovery interval Counselling is available if required

37 Unexpected events Preparation: cyst formation, unable to suppress the normal cycle Stimulation: poor response, over response, total failure to respond Egg collection: no eggs, no sperm, major bleeding from needle entry site Post egg collection: fertilisation failure, failure to cleave, difficult embryo transfer, infection

38 Ovarian Hyperstimulation (OHSS) Mild OHSS is the aim of the IVF treatment Moderate to severe OHSS can occur and is unpleasant and can be potentially serious Patients with polycystic ovaries (PCOS) are more likely to develop-up to 10% Overall risk of severe OHSS needing intensive care is less than 1%

39 OHSS Bloated tummy Nausea Vomiting Diarrhea Shortness of breath-mainly due to fluid in tummy and lungs dehydration

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41 Prevention is better than cure OHSS Low dosage stimulation of ovaries in PCOS patients Cycle cancellation if over response Avoiding ovulation trigger Ovulation trigger with alternative medicines Special medications to reduce the intensity without affecting the treatment cycle Delaying or avoiding Embryo replacement and freezing all embryos Limiting the number of embryos being replaced

42 OHSS Management of most patients with OHSS as outpatients Some may need admission and tapping of tummy/lung fluid Unfortunate one with severe OHSS may need ITU care and close monitoring for a few days If pregnant, increased risk of early pregnancy loss

43 Multiple Pregnancy (MP) Fortunately triplets are rare (less than 5%) are the law does not allow more than 2 embryos to be transferred in women < 40 yrs Twins are more common than natural conception Most of the twin pregnancies in the UK come from assisted conception IVF/ICSI twins rates are on decline due to Single Embryo Transfer policy of HFEA Multiple pregnancy is risky for the babies and mum

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45 MP Risks to babies- 3x higher miscarriage, birth defects and premature delivery rates as compared to single baby with several fold increase (6x)in Cerebral Palsy due to prematurity Risk to mother- morning sickness, raised blood pressure, diabetes, interventions such as cesarean sections and its complications several times higher when compared with single baby Can be stressful for the family and increased cost to NHS and society

46 MP reduction strategy Complete prevention impossible Single Embryo Transfer (SET) in selected group of mothers to be- young patients below the age of 35 years, first treatment cycle, excellent quality embryos on D3 ord5 of replacement Patients who have had live births before are also advised to have SET if suitable SET is not a law as yet

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48 MP reduction strategy Advantages- less problems with pregnancy, increased chance of live birth, less cost to the society overall Disadvantages- reduce pregnancy rate marginally in unselected group, defies patient choice On a balance, One at a time is better than Two at once!

49 Ectopic Pregnancy (EP) 5% risk at IVF/ICSI treatment More likely in women with tubal problems Women who have swollen and blocked tubes which are beyond repair are thus advised to have their tubes clipped prior to the treatment to reduce EP and also to increase the pregnancy rates by up to 6x Ultrasound guided ET can help better position the embryos to reduce the EP rates

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52 EP Most EP need surgery by keyhole to remove them Small numbers can be managed conservatively by observation and appropriate medications Early pick up and diagnosis is crucial for successful management and hence a pregnancy scan at weeks when pregnant

53 Success national level % (1980/6922) for women aged under % (1205/4684) for women aged between % (496/2887) for women aged between % (262/2466) for women aged between % (25/513) for women aged between % (1/129) for women aged over 44

54 Success Homerton IVF /ICSI IUI USING DONOR SPERM (COMBINED STIMULATED AND NON STIMULATED DATA) IUI USING PARTNER SPERM *NATIONAL LIVE BIRTH DATA (LATEST HFEA DATA 2008) *NATIONAL LIVE BIRTH DATA (LATEST HFEA DATA 2008) NO AVAILABLE DATA FROM HFEA HOMERTON HOSPITAL CLINICAL PREGNANCY RATE HOMERTON HOSPITAL CLINICAL PREGNANCY RATE HOMERTON HOSPITAL CLINICAL PREGNANCY RATE Less than 35 years old 38% *32.3% 8% * % 11% years old 35% *27.3% 20% * % 9% years old 20% *19.1% 13% * % 10% 40+ years old 20% *11.9% 6% * % 0%

55 Nutritious diet Preconception Care Healthy body weight-bmi between and definitely below 30 at the time of treatment No smoking Alcohol- <6u/wk for woman and <10u/wk for man Up to date yr normal smear tests Folic Acid 0.4 mg/day to start 3 months prior to treatment ideally Rubella immunity

56 Opening times Monday - Friday: hrs Saturday and weekday evenings: Only by appointments Sunday- closed Out of hours: for patients having treatment cycle only, a facility to contact an on call team member for advice through the switchboard at the Homerton Please remember: the on call person has no access to your data or o file as they are at home!! Please be considerate when you call for advice if they do not immediately reply to your query - it takes several calls between switchboard and us before we can call you back!

57 Telephone Nurses usually reply to your phone messages left during the day only after 3pm on a weekday Messages left on the weekend can only be replied by late Monday afternoon Please do not turn up at the fertility unit without appointments as we are unable to deal with such situations If you prefer communication, please let us know As a matter of confidentiality and to avoid miscommunication, we do not generally give any results on the phone unless it has been agreed specifically We may ask you to confirm your personal details while having phone conversation, so please do not feel offended!!

58 Clinic timetable Please arrive no later than 15 minutes for your appointments- you may be refused to be seen and that upsets everyone! Allow plenty of time for travel and parking! Please ring or intimate in advance if you are late or are unable to attend- allows us to reschedule appointments When booking over the phone, please be as specific as you can as there are many different types of appointments to avoid wrong appointments Be sure you know what to do next before leaving the unit- this will avoid un necessary phone calls

59 Hormone injections Please consider who is going to do it- self or partner or someone else Nurses will show the process and give you the leaflets for the same You will not be able to come to the fertility centre to have injections Please ensure that you have the right amount and right type, syringes, needles, sharp disposal boxes Lack of hormonal injections can affect your treatment and since we do not store any at the centre it might be difficult to obtain out of hours.

60 At your initial appointment Please attend with your partner if seeking treatment as a couple Please provide us your up dated address and contact numbers and s for both partners Please provide us a photo ID such as passport or DVLA license for both partners

61 At a scan appointment Please empty your bladder immediately prior to scan You may normally have a chaperone accompanying a doctor/sonographer You may be asked to give a urine sample prior to the scan if needed All fertility scans are internal scans unless specified otherwise You may be asked to see the nurses prior to leaving the unit

62 At Embryo Transfer (ET) Please keep your bladder full by drinking adequate water and not going to the toilet This makes the procedure easier to perform for the doctor though not any easier for you! You can empty the bladder immediately after the ET You are welcome to have your partner or anyone else to accompany you at the ET-only 1 person though!

63 Consents Plenty of consents to understand and sign however boring they may sound! These are the HFEA (Human Fertilisation and Embryology Authority) mandatory requirements for safety, confidentiality and welfare of the unborn child Doctors will go through the consents for communication, research, your treatment, HFEA sperm and egg usage and storage as well as embryo storage and embryo transfer

64 Consents Nurses will help you understand the cost implications for those who pay for their treatments and organise the invoicing consents You may change these consents at any time after further discussion

65 Payment If you are paying for your IVF/ICSI treatment, the payment must be made prior to egg collection otherwise your treatment may get cancelled at the last minute Payment can be made by cash or credit cards only Cheque can not be accepted to pay towards your treatment Patients eligible to have NHS funded treatments will usually not pay for the IVF/ICSI treatment

66 Medications Fee paying patients will be contacted by the homecare company who delivers the medications at your home for payment Hospital does not charge you for medications Cost of medications once paid can not be refunded even if they are unused You can buy your own medications but we have usually specially negotiated rates with the pharma companies due to the number of cycles we perform

67 Contact us Fertility Unit Phone: automated service with options to contact administration, nurses and embryologists Postal address: Homerton Fertility Centre, Homerton Hospital, Homerton Row, London E9 6SR Website:

68 Embryology Embryologists are the scientists who deal with your eggs, sperm and embryos in the laboratory You may not see them until the egg collection and embryo transfer! Your partners may meet them early on when the sperm analysis is performed though

69 Sperm analysis Normal sperm count takes in to consideration generally three parameters Sperm count Sperm motility Sperm abnormal forms We do not check routinely for sperm antibodies

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71 Sperm Analysis Males will normally bring a sample from home at the pre booked appointment only Sperm sample should not be produced using lubricants or in normal condoms as this may give a false result Sperm sample once produced must arrive at the centre within 2 hours otherwise it may give false results

72 Sperm Analysis If you have difficulty producing a sample, please let the team know as soon as possible Sperm samples for the actual IVF/ICSI treatment cycle needs to be produced at the centre on the day of egg collection due to the HFEA regulatory requirements If you are unable to do so due to having difficulty producing a sample, please fore warn us if possible by discussing with a member of nursing/medical team On the day of egg collection, if you are unable to produce a sample, your whole treatment cycle may get cancelled

73 Egg Collection Fluid aspirated from your follicles in the ovary is checked for the egg one by one Approximately 60% your follicles may give eggs At the end of the egg collection all the eggs are promptly transferred in to an incubator at 37 degree C Meanwhile the sperm sample will be prepared by special technique for either IVF insemination or ICSI injection

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76 IVF Insemination Usually several hundred thousand sperm are required per egg for this process Insemination process is performed within hours from the time of ovulation trigger injection This is crucial as earlier or later insemination may result in to poor fertilisation as per standard practice

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79 ICSI Only mature egg is injected after removal of surrounding cell with single sperm thus one sperm per egg is the ratio within 42 hours of the ovulation trigger injection for optimum result Pregnancy rates are similar to IVF No major concerns are observed especially with regards to fetal malformations after several years of research if performed for the right indication

80 Fertilisation Check Approximately 60% of eggs may get fertilised with IVF/ICSI This check happens about hours after the insemination or injection, next day early morning Unfertilised eggs will be discarded as they can not be used. These eggs may also be used after your consent for the trainee embryologists to learn the ICSI technique using glass beads You will be called by an embryologists before mid day to inform about the fertilisation and book a date and time for the ET ET days can change depending on the embryo development and growth and you will be kept informed

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82 Witness process Every laboratory process from checking your identification from the time of egg collection till the embryo transfer and freezing as well as storage is witnessed by two people using your name and date of birth Soon we will be introducing a computerised witnessing system to ensure accuracy and confidentiality This is taken very seriously and we comply 100% with the HFEA standards

83 Embryo Development

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87 Embryo Transfer Majority of the ET we perform at Homerton are either Day 3 or Day 5 Small number of patients with fewer eggs have Day 2 ET Day 5 ET is also popularly known as Blastocyst transfer Number of embryos being transferred depend on the number, quality, patient age and of course patient choice where possible within the legal obligations

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90 Blastocyst ET Aim of doing the blastocyst transfer is to choose the best possible embryo or embryos to enhance the conception chances Depending on the individual patient circumstance hence the day of ET will vary

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92 Embryo Freezing Blastocyst grade Day 5/6 embryos of good quality are suitable for freezing Thus we can freeze the ones surplus to the requirement They are frozen now by a process called Vitrification or fast freezing to improve the chances of survival when thawed About 60% of embryos will survive freezing Embryo freezing may incur costs depending on your NHS funding and the duration of freezing

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94 Egg Freezing Vitrification or fast freezing ha improved the egg freezing technology but it still remins in its infancy We offer freezing eggs in cases of cancer patients who are single or when the male partner unexpextedly fails to produce a sperm sample Egg freezing also may incur charges depending on your circumstances We do not offer social egg freezing as yet

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96 Sperm Freezing We offer this service for patients who have undergone operations to obtain sperm by surgery or in male cancer patients needing treatments If we have to freeze sperm as a back up for the male partner for medical indication such as a very low sperm count, there is no charge involved Back up sperm freezing for male partner unable to attend on the day of egg collection will incur charge

97 Change of address When you have embryo, sperm or eggs stored with us at Homerton, please provide us with your most up dated address and phone/ contact details and change of personal circumstances. This will be your responsibility! We do appreciate that people move homes and even countries and hence If we are unable to contact you for renewal of your storage consents once they expire, we have no choice but to discard them as per HFEA regulations which are very strict

98 Counselling Counselling is available to all the fertility patients before and after the treatment as well as during the treatment cycle It is free of charge to all and we actively encourage you to meet up with our counsellor if necessary

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