GAMETE INTRA FALLOPIAN TRANSFER (GIFT)

Gift is a modification of the classic IVF technique where, instead of fertilisation occurring in the laboratory, it occurs within the fallopian tube, the normal site of fertilisation.

Only women who have at least one normal fallopian tube can be considered for treatment by GIFT since the fertilisation takes place in the tubes. There must also be a sufficient number of normal, healthy sperm to allow this method to be used.

The aim is to place two, or in some instances three eggs and a prepared sample of sperm into the fallopian tubes, allowing fertilisation to occur naturally. There are a number of reasons for this procedure to be used if possible, some of them are discussed below.

As conception occurs within the body there are fewer objections on religious or moral grounds as compared to the IVF programme.

As the tubes act as they would in natural conception, the embryo arrives at the uterus at a later stage in its development than it would with IVF procedures. The endometrium is also more receptive to embryo implantation due to the time the embryo takes to reach the uterus. Therefore, the prospects for a successful, full term pregnancy are significantly improved.

In reality, GIFT mimics the way a normal fertilised egg begins its journey to the uterus for implantation. The egg is allowed to fertilise in the natural environment of the fallopian tubes and then proceed on to the uterus for implantation according to natures own timetable.

MEDICATION

Fertility drugs are used to stimulate the ovaries to develop a number of eggs in the cycle. This is because the normal cycle usually only produces one egg, and pregnancy rates in IVF/GIFT are better if a number of eggs can be collected. The drugs used to stimulate egg production may be Clomiphene Citrate (Clomid), Serophene, Human Menopausal Gonadotrophin (HMG), Puregon or Gonal F. Lucrin or Synarel can be used to suppress the natural cycle allowing a controlled cycle. Clomiphene, if used, is taken for 5 days with HMG injections starting some time during the Clomiphene course and continuing through until approx 48 hours before laparoscopy or ultrasound guided egg pick-up. Most patients will have Lucrin or Synarel followed by HMG or similar hormone preparation injections and no Clomiphene tablets. Some patients may be treated with HMG or a similar hormone preparation only.

MONITORING EGG DEVELOPMENT

The eggs (or Ova) develop in follicles, which are like little cysts or bags containing fluid. These follicles produce increasing amounts of oestradiol (an oestrogen hormone) as they grow. The size of the follicles can be measured by ultrasound, although the eggs themselves are much too small to see.

Blood Test.

Blood may be taken at intervals from about day 8 of the cycle to measure oestradiol levels. Closer to ovulation, further blood tests may be required.

Ultrasound examinations.

Patients will have ultrasound examinations to measure the size, number and development of follicles growing. Ultrasounds are performed eithervaginally, where no full bladder is needed or abdominally, where a full bladder is needed. Sound waves are used to produce pictures of the growing follicles, so that they may be counted and measured. The number of eggs collected may differ from the number of follicles seen on ultrasound.

TIMING OF OVUM ASPIRATION

This will be undertaken at laparoscopy or an ultrasound guided pick-up about 36-38 hours after the HCG injection. The oestradiol levels (from the blood tests) and the number and the size of the follicles (from the ultrasound) are together used to assess the maturity of the eggs and the right time for egg collection. There is no "correct" oestradiol level to reach and there is enormous variation between patients. It is the whole pattern of blood and ultrasound results which determine whether the response to treatment is good.

In general, however, it is important the oestradiol level rises steadily until the eggs are collected. It is very important to realise that a wide range of individual treatments are used in the programme.

Please do not be alarmed if your treatment is different from someone else's. The aim is to design the best individual protocol for you.

For patients that do not have Lucrin or Synarel, LH, the hormone which normally triggers ovulation may be present. If it is detected, ovum pickup must be timed according to the results of the blood tests. If the start of LH production occurs before admission to hospital, further blood tests may determine the correct time for the operation. If the appropriate LH rise is detected in the blood tests, the operation will be performed some 36 hours after the start of the rise, depending on the levels of oestrogen and the number of follicles.

HCG INJECTION

HCG (Human Chorionic gonadotrophin) is a hormone which performs the function of LH, triggering the final maturing of the eggs and ovulation. This is given by injection 34-36 hours before the operation is planned, unless natural LH productions has started. A second injection may be given.

SPERM COLLECTION

In the GIFT programme it is necessary to obtain the husband's sperm sample before the wife goes into the operating theatre. This is different to IVF where the sample is obtained several hours after the operation. Husbands will usually be required about one and a half hours prior to the operation so the laboratory will have time to wash and separate out the best sperm for the procedure.

The sperm sample must be produced by masturbation at the clinic or by other means by special arrangement.

It can be very difficult for some to produce a sperm sample on request under these conditions. If you are worried about this aspect of the programme, please discuss it with the clinic at or before the start of the treatment cycle, so that arrangements can be made to freeze some semen if necessary - freezing must be done about a week before egg pick-up.

Abstinence from intercourse for 3 days prior to the producing of the sample is required, to allow the sperm to reach optimum quality.

If there are extra eggs left over after the GIFT procedure, which you would like fertilised and stored for a future attempt, a second semen sample will be required.

THE OPERATION

The procedure is divided into two parts:

Ovum retrieval

This is identical to egg pick-up in IVF patients. A needle is placed in a follicle and the egg sucked into a tube which is then sent through into the laboratory for identification and grading of the ova. Not all patients will have the procedure performed by laparoscopy.

In some patients this will be done using an ultrasound guide and needle introduced via the vagina. For both collection techniques a general anaesthetic will be administered and both parts of the procedure are done under the same anaesthetic.

The GIFT

Once the eggs are obtained the laboratory scientist will choose the best ones up to the number you have agreed to have replaced. The eggs and a measured amount of sperm will then be loaded into a thin catheter. This will be introduced into the abdomen and the Fallopian tube cannulated from its outer end just near the ovary. The sperm and eggs will then be gently flushed into the tube. A few patients will not get the preferred number of eggs due to a poor response to stimulation. In this case whatever eggs are obtained will be placed into the Fallopian tube.

SURPLUS EGGS

Some patients will have more than two or three ova retrieved. Patients will be asked what they would prefer done with excess ova. One option which is available is to attempt to inseminate the excess eggs and freeze all embryos suitable for transfer in a later cycle, should pregnancy not occur initially. Another option is to donate these extra eggs to women who cannot produce their own eggs, or these extra eggs can be destroyed.

A combination of these choices is also possible ie fertilise half of the excess eggs and freeze all suitable embryos; and donate the other half of the excess eggs.

Embryos which are no longer wanted can be donated or destroyed.

POST-OPERATIVE COURSE

Recovery time is no longer than for a normal laparoscopy. Patients will usually go home four hours after the operation. Gentle activities may be resumed at home, but it is important there is no sexual intercourse for four days after the operation. The main reason for this is that sometimes not all the eggs are collected and it might be possible to fertilize these eggs and a high order multiple pregnancy could result.

PREGNANCY BLOOD TEST

To maintain your progesterone levels either pessaries or injections may be required. Other blood tests, specific to your cycle which are ordered by your gynaecologist will also be on your post operative instruction sheet. Menstruation does not necessarily mean that a pregnancy is not developing. You must continue blood tests until a final outcome is known.

The blood test taken approximately two weeks after your operation will detect whether the pregnancy hormone (HCG) is present and check your blood progesterone. If the pregnancy hormone is detected it is too early to know whether there is a healthy continuing pregnancy. Further blood tests and an ultrasound examination may be needed.

Unfortunately GIFT/IVF, like natural conception, can lead to a biochemical pregnancy (Transient rise in pregnancy hormone followed by a late period);

miscarriage (needing curettage): or ectopic (tubal) pregnancy (requiring surgery), as well as the happier outcomes: so that even a positive blood test is not the end of the waiting.

Multiple pregnancy (twins or triplets) are more common with GIFT/IVF than with natural conception, because of the practice of transferring more than one ova/embryo. If you do not want to risk having twins or triplets please discuss this with your doctor and we will only replace one embryo/ova.

FURTHER STEPS

All patients are asked to notify us of their next period whether or not ovum pick-up and/or embryo transfer is performed. This information helps us plan future management.

REPEAT GIFT/IN VITRO FERTILISATION ATTEMPTS

If pregnancy is not achieved then a repeat attempt can be made approximately

1-3 months later, depending on findings at the most recent treatment cycle . Make an appointment to see your gynaecologist after your period.

PATIENT COOPERATION

Your cooperation in all aspects mentioned is vital to the success and smooth running of the programme. Please do not lose this information leaflet - it has been provided for instant reference. Further enquiries regarding management are best directed through the Co-Ordinator.