ICSI Treatment in PCMC

Agonist activation of luteal gonadotropin-releasing hormone

• GnRH-a should be started on day 21 of a normal menstrual cycle.
• A serum progesterone level of >4 ng/ml or the existence of a corpus luteum on a transvaginal scan confirms the luteal start. The risk of ovarian cyst formation is reduced by initiating GnRH-a in the luteal phase.
• 10-12 days following GnRH-a administration, expect spontaneous menses.
• Transvaginal scan to assess endometrial lining after menses began and serum estradiol to confirm down-regulation before initiating gonadotropin stimulation (rec-FSH,or urinary FSh or combination)
• The number and size of follicles, as well as the development of the endometrium and its shape, are all monitored with serial ultrasonography and E2 levels.
• Rec-hCG, typically 5000-10 000 IU, should be given once the follicular size reaches 18-22 mm.

GnRh antagonist protocol with multiple doses

• On day 2/3 of the period after oral contraceptive pretreatment, a transvaginal ultrasound and serum E2 are scheduled.
• SCrecFSH is started daily for ovarian stimulation after confirmation of sluggish ovaries and low E2 levels.
• The GnRH antagonist 0.25 mg daily is then given as a set protocol beginning on day 6 of the stimulation and continuing until the day of HCG injection.
• When leading follicles reach 18-20 mm and at least three mature follicles 16 mm are seen on an ultrasound examination, ovulation is triggered by a subcutaneous injection of 10 000 IU of hCG. This is followed by oocyte retrieval using transvaginal ultrasound 34-36 hours later.

BOOST GnRH agonist protocol or flare-up

• GnRH-a 0.05 mg/day starting on day 2 of the cycle.
• RecFSH began on day three.
• GnRh agonist is given subcutaneously on a daily basis until human chorionic gonadotropin (HCG) is given.
• When the leading follicle reaches 17-18 mm in diameter, a total of 10,000 units of rec-hCG 250 mcg is injected SC, followed by an ultrasound-guided transvaginal oocyte retrieval 34-36 hours later.
• Tifitacation

On day one of oocyte recovery an oocyte is implanted under general anesthesia or intravenous sedation in a surgery theatre under ultrasound supervision.

The patient is washed and draped before being placed in lithotomic postures. The Trans virginal probe with a needle guide is then placed into the vagina to see both ovaries and their follicles, while the aspiration system is set up and visualize pressures (100 mm Hg) are monitored using specially developed disposable needles.

The needle is placed under ultrasound guidance into the first follicle of the lower, more accessible ovary. The follicular fluid is then aspirated into a test tube that has been heated in a warming block and given over to the wafting embryologist in the adjacent IVF lab. The follicles on one side are systematically aspirated without flushing, taking care to avoid the neighbouring pelvic side-wall vascular at all times. After aspirating all of the follicles on one side, the needle is removed and used to aspirate warm culture material into a test tube to flush the system.

The needle is placed under ultrasound guidance into the first follicle of the lower, more accessible ovary. The follicular fluid is then aspirated into a test tube that has been heated in a warming block and given over to the wafting embryologist in the adjacent IVF lab. The follicles on one side are systematically aspirated without flushing, taking care to avoid the neighboring pelvic side-wall vascular at all times. After aspirating all of the follicles on one side, the needle is removed and used to aspirate warm culture material into a test tube to flush the system.

Before the surgery is considered complete, the vagina is cleaned with sterile guaze swabs and homeostasis is confirmed. The patient is observed in the recovery ward after surgery and assessed 2-6 hours later before being discharged. The embryologist empties the contents of the test tube containing the follicular fluid into a Petri dish and analyses them under a binocular dissecting microscope for the oocyte cumulus complex (OCC).

The OCC is promptly detected and transferred to a buffered medium. Before being put into a culture dish containing a culture medium, it is washed three times in the medium to eliminate red blood cells. The dish holding all of the OCCs is kept in the incubator until insemination, which occurs about 4 hours after the oocyte retrieval.

The oocytes are placed in the incubator until the next day after insemination or ICSI. 18 hours after insemination or ICSI, a fertilization check is performed. The presence of two pronuclei in the oocytes is verified. The fertilized oocytes are kept in the incubator until day 2, which is the next day. From day 2 to day 6, embryos are scored daily. The embryos should be in the four-cell stage on day two. Embryos on day 3 should be at the eight-cell stage, those on day 4 should be compacted, and those on days 5 and 6 should be blastocysts. The regularity of the blastomeres and the presence of pieces are used to grade embryos. Regular blastomeres with no fragmentation characterize high-quality embryos. Embryos of average quality have regular blastomeres and moderate fragmentation. Embryos of poor quality have uneven blastomeres with numerous fragments.

The oocytes are placed in the incubator until the next day after insemination or ICSI. 18 hours after insemination or ICSI, a fertilization check is performed.

The presence of two pronuclei in the oocytes is verified. The fertilized oocytes are kept in the incubator until day 2, which is the next day. From day 2 to day 6, embryos are scored daily. The embryos should be in the four-cell stage on day two. Embryos on day 3 should be at the eight-cell stage, those on day 4 should be compacted, and those on days 5 and 6 should be blastocysts.

The regularity of the blastomeres and the presence of pieces are used to grade embryos. Regular blastomeres with no fragmentation characterize high-quality embryos. Regular blastomeres with modest pieces characterize average-quality embryos. Embryos with poor-quality blastomeres have a lot of pieces.

IVF treatment success is mostly determined by embryo quality and endometrial receptivity. Embryo quality might be altered by the availability of oocytes or the quality of sperm in that month. The existence of appropriate subendonetrial blood flow and endometrial thickness are used to define endometrial receptivity. Minimal ovarian stimulation during IVF or normal ovarian stimulation followed by embryo vitrification and transfer of a thawed embryo in a frozen thaw embryo transfer cycle both boost IVF success rates.