INTRODUCTION:

In vitro fertilization (IVF) is a type of assistive reproductive technology (ART). It involves retrieving eggs from a woman’s ovaries and fertilizing them with sperm. This fertilized egg is known as an embryo. The embryo can then be frozen for storage or transferred to a woman’s uterus. The process involves monitoring and stimulating a person's ovulatory process, removing an ovum or ova (egg or eggs) from their ovaries, and letting sperm fertilize them in a culture medium in a laboratory. After the fertilized egg (zygote) undergoes embryoculture for 2–6 days, it is implanted in the same or another person's uterus, to establishing a successful pregnancy.^1-6

Two commonly used ARTs are IVF and intrauterine insemination (IUI). IVF involves the retrieval of multipleoocytes, which are subsequently combined with sperm in vitro and incubated.

Then the blastocyst is transferred into the uterus. It is recommended that couples with unexplained infertility, mild endometriosis, or mild ‘malefactor’ infertility should have tried to conceive naturally for 2 years before referral for IVF.^7-10

Primary Role and Responsibilities of Nurses:^11-14

1. To coordinate patient’s treatments and/or procedures, such as In Vitro Fertilization (IVF), Intrauterine Insemination (IUI), etc.

2. To manage patient’s waiting lists, maintenance, and scheduling cycles. i.e., Schedule’s embryo transfers, embryo retrievals, frozen Eggs cycles, and Intrauterine Insemination.

3. Assess patients: plan and implementation of care.

4. The nurse takes the client through the whole IVF treatment process step by step. She will repeat everything that she has told to make sure that the client understands everything that is going on.

5. The nurse must understand the basics of embryology, andrology, endocrinology, gynaecology, obstetrics, genetics, information technology, and of course psychology. They are the most important bridge between highly technical information and physician prescriptions and their patients’ ability to understand and implement the treatment.

6. The Nurse is always involved in the initial consultation and performs transvaginal scanning, when having proper training.

7. The nurse executes treatment plans that fertility doctors formulate with couples starting at the initial visit.

8. The nurse instructs patients on how to administer fertility medications, including how to administer subcutaneous and intramuscular injections. For many patients, this is the first time they have had to give injections to themselves. Understandably, this can create a certain level of anxiety, which nurses will skillfully help to reduce.

9. The Nurse should check the files before the IVF or Gyne procedures that all consents sign by the couple and ensure the couple that they understand the procedures.

10. The Nurse will do inventory once a week and maintains, monitors adequate stock control of supplies and drugs in the department.

11. The Nurse should make sure that the patient after any procedures, e.g., egg collection and embryo transfer that the patient should have a discharge instruction.

MANAGEMENT:^15-18

Conservative:

· Couples should be advised of the importance of regular sexual intercourse every 2 or 3 days, regardless of the woman’s cycle. Explore any reasons preventing this, such as vaginismus or antisocial working patterns. Offer lifestyle advice, including advice regarding diet, exercise, alcohol, and smoking. Current NICE guidance advises women to restrict themselves to one or two units of alcohol once or twice per week, whereas men should not exceed three or four units daily. NICE also advises checking the rubella status of women trying to conceive; those who are susceptible should be offered immunization and advised to wait at least a month before attempting to conceive. Recommend folic acid at an appropriate dose and prescribe where necessary. Ask about cervical screening tests and recommend screening if the woman is due or overdue a test.

· In both men and women, a BMI of greater than 29 kg/m2 is associated with reduced fertility. Patients who are above this level should be advised on weight loss, with a target BMI of 19–25 kg/m2. This alone may restore fertility and will also improve the probability of responding to fertility treatments. Additionally, encourage women with a BMI of below 19 kg/m2 to gain weight if their weight is associated with irregular or absent periods, and encourage people to exercise excessively to reduce this, where appropriate.

· Home ovulation kits are increasingly being marketed to the public as a means of demonstrating ovulation. They typically detect the pre-ovulatory LH surge and can help to demonstrate ovulation, although accuracy varies between products. They are not referred to by the most recent NICE guideline.

Infertility Treatments:

· First-line treatment in cases of persistent anovulation due to hypothalamic-pituitary dysfunction. It should not be used in cases of unexplained infertility. Ultrasound monitoring is recommended for at least the first month of clomifene treatment. This is to assess follicle growth (particularly when used at high doses) and to determine whether an appropriate dose is being used to avoid multiple pregnancies; clomifene is associated with multiple pregnancies in about 10% of the pregnancies in which it is used (NICE, 2013). It should not be offered for longer than 6 months. Alongside the common side effect, it can have on vision (e.g., blurring, spots or flashes) it can also cause hot flushes and abdominal cramps.

· Metformin is also recommended as a first-line treatment for women with hypothalamic-pituitary dysfunction. In comparison to clomifene, it offers a similar probability of live birth. It is also cheaper and less likely to result in multiple pregnancies but does have a higher rate of side effects, particularly gastrointestinal disturbance. also recommends that combined metformin and clomifene therapy can be offered, either as a first-line treatment or if patients do not respond to either drug initially.

· Combination treatment results in a higher proportion of live full-term singleton pregnancies than monotherapy. Gonadotrophins are used to restore fertility in men with hypogonadotrophic hypogonadism. They can also be used selectively in females; women with hypothalamic-pituitary failure can be offered pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins to induce ovulation. The use of gonadotrophins in women carries a risk of multiple pregnancies.

· Dopamine agonists such as cabergoline can be used to manage the hyperprolactinaemia caused by prolactinomas, thus improving fertility.

· Infertility treatments can be categorized into medical (e.g., drugs to induce ovulation), surgical (e.g., laparoscopy for ablation of endometriotic lesions), or ARTs. All are typically commenced in secondary care.

· Surgical treatment of mild to moderate endometriosis by ablation and adhesiolysis is thought to improve fertility, but there is no convincing evidence for the same effect in severe endometriosis.

· Laparoscopic cystectomy should be offered to women with ovarian endometriomas. In the presence of minor tubal disease-causing blockage, surgery including tubal cannulation can improve fertility rates. This is especially relevant for women who may be ineligible for NHS-funded IVF.

· men who are known to have obstructive azoospermia may benefit from treatment of epididymal blockage. Assisted conception Two commonly used ARTs are IVF and intrauterine insemination (IUI)

COMPLICATIONS:^18-23

Multiple births:

The major complication of IVF is the risk of multiple births. This is directly related to the practice of transferring multiple embryos at embryo transfer. Multiple births are related to increased risk of pregnancy loss, obstetrical complications, prematurity, and neonatal morbidity with the potential for long-term damage. Strict limits on the number of embryos that may be transferred have been enacted in some countries (e.g., Britain, Belgium) to reduce the risk of high-order multiples (triplets or more), but are not universally followed or accepted.⁵

Sex ratio distortions:

Certain kinds of IVF, in particular, ICSI (first applied in 1991) and blastocyst transfer (first applied in 1984) have been shown to lead to distortions in the sex ratio at birth. ICSI leads to slightly more female births (51.3% female) while blastocyst transfer leads to significantly more boys (56.1% male) being born. Standard IVF done on the second or third day leads to a normal sex ratio. Epigenetic modifications caused by extended culture leading to the death of more female embryos have been theorised as the reason why blastocyst transfer leads to a higher male sex ratio, however, adding retinoic acid to the culture can bring this ratio back to normal.⁶

Spread of infectious disease:

By sperm washing, the risk that chronic disease in the male providing the sperm would infect the female or offspring can be brought to negligible levels. In males with hepatitis B, The Practice Committee of the American Society for Reproductive Medicine advises that sperm washing is not necessary for IVF to prevent transmission unless the female partner has not been effectively vaccinated.^7,8. In females with hepatitis B, the risk of vertical transmission during IVF is no different from the risk of spontaneous conception.⁸ However, there is not enough evidence to say that ICSI procedures are safe in females with hepatitis B in regard to vertical transmission to the offspring.⁸

Other risks to the egg provider/retriever:

Risk of ovarian stimulation is the development of ovarian hyperstimulation syndrome, particularly if HCG is used for inducing final oocyte maturation. This results in swollen, painful ovaries. It occurs in 30% of patients. Mild cases can be treated with over-the-counter medications and cases can be resolved in the absence of pregnancy. In moderate cases, ovaries swell and fluid accumulated in the abdominal cavities and may have symptoms of heartburn, gas, nausea, or loss of appetite. In severe cases, patients who have sudden excess abdominal pain, nausea, vomiting and will result in hospitalization.

· During egg retrieval, there exists a small chance of bleeding, infection, and damage to surrounding structures such as bowel and bladder (transvaginal ultrasound aspiration) as well as difficulty in breathing, chest infection, allergic reactions to medication, or nerve damage (laparoscopy).

· Ectopic pregnancy may also occur if a fertilised egg develops outside the uterus, usually in the fallopian tubes, and requires immediate destruction of the foetus.

· IVF does not seem to be associated with an elevated risk of cervical cancer, nor with ovarian cancer or endometrial cancer when neutralizing the confounder of infertility itself.⁹

· Regardless of pregnancy results, IVF treatment is usually stressful for patients.^[6] Neuroticism and the use of escapist coping strategies are associated with a higher degree of distress, while the presence of social support has a relieving effect.¹⁰ A negative pregnancy test after IVF is associated with an increased risk for depression in women, but not with an increased risk of developing anxiety disorders.¹⁰ Pregnancy test results do not seem to be a risk factor for depression or anxiety among men.¹⁰

· Studies show that there is an increased risk of venous thrombosis or pulmonary embolism during the first trimester of IVF.¹¹

· Spontaneous pregnancy has occurred after successful and unsuccessful IVF treatments.¹¹

Psychosocial Health and Support for Patients:^24-33

Mental health professionals play an important role in reproductive medicine due to the complex psychosocial issues faced by fertility patients. As technological advances fertility treatment and the use of fertility services in diverse populations have increased, there is a growing need for the skills and services of trained fertility counselors to assist patients and staff.

Fertility counselling includes psychotherapeutic intervention and psychoeducational support for individuals and couples experiencing fertility problems, as well as those utilizing assisted reproductive technology to build a family or preservefertility.⁴

DISCUSSION:

In primary cases, patients should advise for improving diet, lifestyle, and exercise. Hospital nurses play an important role in the IVF cycle because they are close to the couple and have good knowledge of health criteria, worries, symptoms, drugs, and pregnancy complications that could arise. Given their unique position in cycle control, treatment and recording the problems of pregnancy, nurses are well placed to monitor the patient’s response to IVF treatments. After IVF needs more care to prevent complications such as multiple births, sex ratio distortion. Psychological support is also an important aspect of patient health.

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Received on 28.07.2022 Modified on 26.10.2022

Asian J. Pharm. Tech. 2023; 13(1):47-50.

DOI: 10.52711/2231-5713.2023.00009