✓ IVF, in vitro fertilization

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It was 1978 when the first "test tube" girl was born. Her name was Louise Joy Brown and she had come into the world thanks to in vitro fertilization, a procedure developed by the Englishman Robert Edwards. More than forty years have passed since then, but the in vitro fertilization technique continues to give hope to thousands of women and men who have the desire to become parents.

What is in vitro fertilization

IVF or better IVF or IVF (in vitro fertilization and embryo-transfer) is one of the most widely used techniques of medically assisted procreation (MAP). It is a defined "second level" technique which consists of egg retrieval from the ovaries of the woman who wishes to become a mother, or of an anonymous donor, and in their union in the laboratory with the spermatozoa of the partner or a donor. The aim is to obtain embryos to be transferred to the maternal uterus.

The techniques of MAP

Currently the different techniques of medically assisted procreation are divided into three levels:

1st level: they are techniques characterized by a relative simplicity of execution because they do not involve any or only minimal manipulation of the gametes (spermatozoa and oocytes). Fertilization takes place inside the woman's body, as in natural procreation;
2st level: they are instead more complex procedures that involve manipulation of the female and male gametes, and because they involve in vitro fertilization, that is, in a test tube, and the subsequent transfer of the embryo into the uterus. This is the case with in vitro fertilization;
3st level: they are less used because they involve a more invasive procedure. It is used only in cases where the first and second level techniques have proved ineffective

Read also: All medically assisted procreation techniques

When using in vitro fertilization

In vitro fertilization was originally developed for the treatment oftubal infertility, but today it is also used in other cases such as:

ovulation problems;
problems of interaction between the woman's oocytes and the spermatozoa;
advanced endometriosis;
major infections leading to pelvic inflammatory disease;
fertility problems of one or both partners (e.g. poor sperm quality, blocked fallopian tubes);
unexplained infertility;
failure of first level MAP techniques.

Furthermore, today the techniques of MAP such as in vitro fertilization offer the possibility of procreation even to those women who are over 38/40 years old and who therefore have suffered a decline in fertility.

Clearly, before starting an IVF course, the MAP specialists will have to perform clinical and instrumental investigations and laboratory tests to try to understand the causes of infertility.

Read also: First level medically assisted procreation techniques

The causes of infertility

Infertility (male, female or couple) is unfortunately a very widespread problem which, according to data from the World Health Organization, concerns about the 15% of couples of childbearing age living in Western countries. The causes can coexist with each other and the most common are:

endometriosis: a disease of which there is still too little talk and for which women are forced to wait many years before being diagnosed;
tubariche/pelviche: in the event that there is obstruction or closure of the fallopian tubes, or there are pelvic adhesions;
ovulatory / hormonal: when ovulation is missing or occurs irregularly, but also in case of hyperprolactinemia, irregular menstrual cycle, micropolicistic ovarian syndrome and reduced or absent ovarian reserve;
cervical: if due to infections, estrogen deficiency or previous surgical procedures that have compromised the cervical glands, the mucus present in the woman's cervix "obstructs" the passage of spermatozoa;
male: when the partner does not produce an adequate number of spermatozoa or if they have characteristics (shape, mobility) that make fertilization difficult;
uterine: caused by malformations of the uterus, myomas, or by adhesions present inside the uterine cavity;
unknown (idiopathic infertility): when the tests have not highlighted one or more causes that explain the infertility.

In vitro fertilization: how is it done?

In vitro fertilization involves 4 basic phases: ovarian stimulation, egg retrieval, in vitro insemination and, finally, embryo transfer. Let's see them in detail.

Ovarian stimulation

Ovarian stimulation involves the administration of some medications, such as FSH (follicle stimulating hormone), which stimulate a greater production of eggs. The woman produces a single egg each month, but with hormone treatment she causes one multifollicular growth. In this way, more eggs will develop which will be subsequently collected and fertilized.

The ovarian situation is checked through a series of transvaginal ultrasounds and hormone dosages to evaluate the growth of follicles. When the follicles reach the appropriate size and it is considered that they are mature, the pick up, or the extraction of the eggs, is scheduled.

The egg retrieval

To collect the eggs from the ovaries, they are accessed from the vaginal cavity and the follicular fluid which contains the eggs to be fertilized.

Before the blood collection, the woman is sedated and the procedure is completed within about 15-20 minutes. Already after a couple of hours the woman can go home and resume normal daily activities. Some women after the pick-up procedure may experience cramping and light vaginal bleeding as a side effect.

In vitro insemination

After taking the follicular fluid, it is sent directly to the laboratory where the MAP specialists identify the eggs and make an estimate of their quality. The oocytes are then placed on a culture plate and surrounded by the sperm in order to fertilize them with seminal fluid of the partner. However, if there are problems related to the quality of the partner's sperm, IVF can be performed with the sperm of a donor. In this case, or if the oocytes came from a donor, we speak of heterologous MAP.

In vitro fertilization is also used with a second technique, called ICSI (intracytoplasmic sperm injection), which consists of inserting a single sperm into each mature egg.

The transfer of embryos

The embryos obtained are then analyzed in the laboratory and classified according to their morphology and ability to cleave and only the "best" ones will be transferred to the woman's uterus.

It is a process fast and absolutely painless which occurs thanks to the use of a thin catheter and under ultrasound guidance. The number of embryos to be transferred is defined on the basis of certain parameters such as the woman's age, embryonic quality, etc. Generally, however, 1 or 2 embryos are transferred, at most 3 as required by law.

After the embryo transfer, the woman will stay still for about 15/20 minutes, after which she will be able to go home, avoiding sport and excessive effort for 3-4 days.

The embryos that are not used can be frozen with the vitrification technique for a subsequent cycle of in vitro fertilization.

Read also: Calculation of the weeks of pregnancy with medically assisted procreation

Probability of success and risks

With in vitro fertilization younger women have a higher chance of conception, which is lowered instead in donne about 40. On average, IVF can lead to a birth in 20-50% of cases.

The abortion rate, unfortunately, is quite high, around 20%, as is the risk of twin pregnancies. Also, in rare cases, drugs given for ovarian stimulation could lead to ovarian hyperstimulation syndrome (OHSS), resulting in enlarged ovaries and abdominal pain.

Read also: Artificial insemination. I would do it all again, it was worth it

What does the Del Paesena law provide?

In our country medically assisted procreation is regulated by law 40/2004 which provides for the use primarily of simpler treatment options and less invasive. The law also provides that:

access to MAP techniques is allowed only to couples made up of adults, heterosexuals, married or cohabiting, of childbearing age;
medically assisted procreation techniques can be used only if infertility cannot be resolved in other ways;
couples carrying transmissible genetic diseases can access the preimplantation diagnosis;
access to the techniques is also allowed to serodiscordant pairs, that is, in which one of the two partners is a carrier of sexually transmitted viral diseases such as HIV;
children born thanks to MAP are legitimate children of the couple.

In 2022 the law underwent an important change since, thanks to the Constitutional Court, the ban on heterologous fertilization, i.e. fertilization in which one or both gametes come from a donor outside the couple.

Cryopreservation of gametes and embryos

Finally, the Del Paesena law on assisted procreation now also allows the cryopreservation of gametes and embryos. It therefore means that when you pick up a large number of oocytes in a woman who has to perform in vitro fertilization, the oocytes that "move forward" can be stored for a possible second cycle. This is to avoid that the patient has to undergo again, in the event of a negative result, the induction of ovulation and the retrieval of oocytes.

In the same way, since 2009, with the sentence of the Constitutional Court, the cryopreservation of embryos has also been allowed, avoiding having to necessarily introduce all the embryos produced into the woman, as required by law, and thus reducing the risk related to multiple pregnancies.

Read also: MAP and children's health: how are the children of in vitro fertilization

Here is the list provided by the Istituto Superiore di Sanità with all the authorized centers in which the techniques of MAP are applied, including in vitro fertilization.

Sources used: information material from the Ministry of Health, information material from the World Health Organization, information material from the Society of the Paesena of Human Reproduction.

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