In Vitro Fertilization (IVF)
IVF is a procedure involving the stimulation of multiple ovarian follicles using gonadotropins. These follicles are then retrieved at the appropriate time. After fertilization in the lab, the subsequent embryos are transferred into the uterus where implantation can occur. This process bypasses the fallopian tubes and increases fertilization rates when there are problems with low sperm counts.
In vitro provides many people with the opportunity to attempt pregnancy in the face of one or more factors that may otherwise decrease their chances. There are several reasons why you may be better off with IVF. Reasons for undergoing IVF include:
- Significant adhesions (scar tissue)
- A history of damage to the fallopian tubes
- Unsuccessful attempts with other types of infertility treatment
- Low or abnormal semen assays Intra Cytoplasmic Sperm Injection
- Reduced risk of pregnancies greater than twins
Our facility does not select out patients or decline patients that may not be likely to conceive. There are no attempts to turn away couples in hopes of maintaining good statistics. With this said, however, realistic expectations need to be established. Your physician will need discuss your individual situation with you.
Prior to becoming eligible for treatment in an IVF cycle you will need to complete the tests recommended for you by your physician, have to have current infectious disease testing (good for 1 year), and your consent forms must be signed and returned before starting each cycle.
Prior to any type of treatment, Dr. Zeringue will meet with you and review your history and desires. You may need some further medical tests prior to starting treatment. When your evaluation is complete, the IVF nurses will provide you with a folder of information that discuss the IVF process. An IVF information session is conducted to discusses the IVF process and risks. You will also learn how to self-administer the medications you will be taking as part of the IVF process. The purpose of the medication class is to teach you about the process of preparing and injecting the medications. The class will also give you an overview of what will be happening during your treatment cycle. Individual instructions on the actual injection process will be provided. Please review the documents in your information folder and bring this folder with you to the medication class. If possible, bring your medications with you. We have found this is the best way to fully understand how to mix and administer medications.
Next, we will coordinate a date for a baseline ultrasound and pregnancy test. This is usually done on or about day 24 of your cycle. The baseline ultrasound is performed just like the monitoring ultrasounds. A vaginal ultrasound probe that is smaller and usually more comfortable than a speculum (used for gynecologic exams) is used for the monitoring. An empty bladder is preferred for trans-vaginal ultrasounds. The lining of the uterus is measured as are any cysts that may appear on your ovaries. These are usually cysts from follicles that formed in previous cycles and are rarely anything to worry about.
On the same day as your baseline ultrasound you will have a pregnancy test. We occasionally do have a positive pregnancy test which is always welcome news. If the pregnancy test is negative you will begin Lupron 10 units or 0.1 cc. Continue taking Lupron every morning until you are directed otherwise by someone from our clinic. If you have not had a menses after 14 days on the Lupron you will need to call the clinic. Instructions for the next step will be given. We will give you a date to begin taking your gonadotropins. On the same day you begin gonadotropins you will also decrease your Lupron dose to 5 units or 0.05 cc.
At the same time you are instructed to take gonadotropins and decrease the dose of Lupron you will be given a date for your first monitoring visit. The monitoring visit consists of a monitoring ultrasound, a sometimes a serum estradiol. Since this clinic is designed for monitoring progress, the discussions will focus on the findings and informing you what to do next and are often very brief. If you have questions about the overall management of your care you may wish to schedule an appointment with the physician or nurse. The monitoring phase of the IVF cycle usually requires 2-3 visits.
Estradiol (a type of estrogen) is released by the follicles. There is not a magic number your estradiol "should be". We like to see a rise in the values early in the cycle but do not want the value too high towards the end of the medications. A high estradiol level (>4500) can be a concerning indicator for the risk of ovarian hyperstimulation in some patients. The IVF cycle may be delayed or canceled if this becomes too great of a risk.
The ultrasound will be looking at the endometrial lining as well as growth of the follicles. The endometrium will preferably be greater than 6 mm. The target size for the follicles is 18-20 mm for the lead or largest follicle and > 14-15 for the other follicles. Once the follicles are thought to be mature we will instruct you to stop taking your Lupron and gonadotropins. You will be given written instructions on what to do for the retrieval. HCG will be administered approximately 36 hours before your scheduled retrieval. This injection is timed in conjunction with your retrieval so the oocytes will be "released" from the wall of the follicle but not "released" from the ovary into the abdomen. After you have been given instructions to take your HCG you'll not take anymore medications including Lupron and gonadotropins. You will still take Lupron the morning of your HCG injection. There will be no further injections until after the retrieval. Remember not to eat or drink anything after 11PM on the night before your retrieval.
On the day of the retrieval we will need a semen specimen which needs to be collected at the clinic. Due to the serious nature of identity, we will request photo identification and a signature before the specimen can be accepted. A collection room is available for privacy. Materials are available in the collection room to provide the appropriate visual stimulus that males often need.
When you arrive at the clinic you will be checked in and taken to the recovery and observation area. An identification band will be used once identities have been verified. An anesthesia provider will place in an intravenous catheter (IV) and administer sedatives when you're ready to go to the operating room. Additional sedatives and pain medication will be given as needed during the procedure. Women are not completely unconscious but will rarely remember anything from the procedure. While the procedure can provoke a great deal of anxiety, most women are pleasantly surprised how "easy" the procedure can be.
The retrieval procedure takes approximately 10-15 minutes, though you will be out of your recovery room for about 30 minutes. The procedure involves a transvaginal ultrasound with a needle guide that is used to aspirate the fluid from within the follicles under real time visualization. The oocytes are identified in the follicular fluid by an embryologist. The number of follicles will be known shortly after the completion of the procedure.
The recovery usually takes less than 30 minutes. You will be given discharge instructions by the nurse that was present at your retrieval. Because the medications used for the retrieval often cause memory impairment and drowsiness you should plan to have the remainder of the day free of any activities. Most importantly, do not plan to drive as you will not be allowed to drive yourself home.
The next day we will call you with fertilization results. Do not expect to have 100% of the oocytes retrieved to be fertilized. There is no good way to predict how many eggs will actually fertilize. Depending on several factors, including number of fertilized eggs and age, the embryos will be transferred into the uterus on either day 3 or at the blastocyst stage (5-6). Your retrieval is considered day 0.
Supplemental progesterone will be administered following the retrieval. Dosing instructions will be given to you along with your discharge instructions prior to leaving on the day of your retrieval. Progesterone is usually continued until approximately 1012 weeks into the pregnancy until the placenta has completely taken over the hormone production function.
A pregnancy test will be done 10 days following the embryo transfer. This test should be done even if menstrual bleeding occurs since there is still a good possibility of an ongoing pregnancy.
There are times when cycles will need to be canceled. A few examples are presented here for information purposes. If your cycle is canceled the doctor will discuss the reasons as well as the management plan. One of the possibilities for cancellation of a cycle is lack of adequate ovarian response. If you do not have a good number of follicles you may be better served by attempting pregnancy by timed intercourse or intrauterine insemination. For some patients this saves financial resources for future attempts at IVF where the follicular response may be improved. There are a good number of pregnancies that have resulted from "canceled" cycles. Other reasons your cycle may be canceled include ovarian hyperstimulation, and premature ovulation (very uncommon in patients taking Lupron).
Monitoring ultrasounds will give an estimate of the numbers of follicles. It is important to remember the number of oocytes retrieved is not always the same as the number of follicles seen on ultrasound. Sometimes there are very few oocytes retrieved when the number of follicles looks encouraging. There is always a possibility that no oocytes fertilize or no embryos survive to the day of transfer. Obviously if this occurs the embryo transfer would be cancelled.
With any cancellation, patients will only be billed for the services that have been provided.
ICSI and Other Techniques
Male-factor infertility occurs in approximately 40% of couples who are unable to achieve a pregnancy. Severe male-factor infertility accounts for 25% of infertility. Less than 10% of male infertility can be successfully treated with surgical or medical therapies. Fortunately, there are some other therapies for the remaining 90% of couples desiring pregnancy. Some will be helped by superovulation with drugs such as Follistim, Repronex and Gonal-F along with intrauterine insemination. Most couples will be better served by in vitro fertilization (IVF) combined with intracytoplasmic sperm injection (ICSI).
ICSI is indicated when there are not enough normal, motile sperm for intrauterine insemination or standard IVF. It is also used frequently when there are poor fertilization results in previous IVF cycles. It is a micromanipulation technique originally developed in Belgium. By using a powerful microscope we are able to isolate a single sperm, aspirate it into an extremely thin glass pipette and inject it into a single egg. This technique does not require large numbers of motile sperm and bypasses the need for the sperm to penetrate the egg by itself. With the help of ICSI, fertilization is achieved and embryos that continue to divide are ready for transfer into the uterus in several days. No increase in congenital anomalies (birth defects) have thus far been observed with ICSI.
To prepare for ICSI, couples follow the standard protocol for IVF up to the egg (oocyte) retrieval. Instead of incubating the retrieved eggs with sperm, the eggs are actually injected with sperm on that day. The day following egg retrieval and ICSI, you will receive a phone call with the fertilization results. If fertilization has been successful, some embryos will be transferred to your uterus a few days after the transfer, and any remaining will be frozen and stored (cryopreserved).
Assisted Hatching is a technique involving the removal of a small portion of the zona pellucida (outer layer of the oocyte or early embryo). This process is done prior to transfer. Age is the predominant determining factor for using assisted hatching. Assisted hatching is considered on an individual basis.
There are multiple risks involved with the medications and retrieval process. A brief summary is provided here. You should have a full understanding of these risks and ask questions regarding these risks prior to signing your consent forms.
Ovarian Hyperstimulation Syndrome (OHSS) -- this is a combination of symptoms that result from the elevated levels of hormones and other factors that result from excessive stimulation of the ovaries. There is a fine line that exists in many women between just the right amount of stimulation and OHSS. Click here to read more.
Multiple gestations -- the use of medications to stimulate increased numbers of follicles will also increased the rate of multiple pregnancies. Up to 20 percent of pregnancies conceived while taking gonadotropins. will be multiple gestations. Most of these will be twins, however, triplets and higher numbers of gestations are seen as well. This is in contrast to the one to two percent risk of multiple gestations in the general population.
Ectopic pregnancies (tubal) -- there is a very small increase in the incidence of ectopic pregnancies due to gonadotropins. The risk of ectopic pregnancy is not eliminated by IVF, though it is very uncommon.
Ovarian torsion -- with ovarian stimulation from gonadotropins., the size of ovaries is increased. This increase in size can lead to a twisting of the ovaries which interrupts the blood supply. Surgery is often required to alleviate the problem. Torsion occurs in less than 1% of patients.
Ovarian cancer -- there is much debate about ovulation induction agents increasing a woman's risk for ovarian cancer. The risk of ovarian cancer does have a correlation with the number of times a woman ovulates. Pregnancy and breast feeding has been shown to decrease the risk of breast cancer as do birth control pills.
Infection -- the retrieval process involves the passage of a needle into the abdominal cavity through the vagina. There is a risk of infection as a result of the oocyte retrieval. Prophylactic antibiotics are used to help prevent infections. The actual incidence of peritonitis is exceedingly rare.
Perforation -- Injury to intra-abdominal organs and vessels is always a concern during the retrieval process. Organs at risk include the bowel, bladder, and vessels. Because the needle is relatively small this complication is not as common as one would expect. Keep in mind needles are used to puncture vessels in order to draw blood. Punctures of intra-abdominal organs likely seal themselves in a similar fashion.
Following your procedure you may experience a moderate amount of abdominal discomfort due to enlarged ovaries and manipulation from the procedure. If you are experiencing increasing abdominal pain, fevers, or unexpected symptoms, contact the clinic.
In the event there are more embryos surviving than are needed at the time of transfer, you may choose to have your embryos frozen, or cryopreserved, for later transfer. The frozen embryo transfer (FET) process does not involve taking injectable gonadotropins. Coordinating the frozen embryo transfer can be done with or without medications. Cryopreservation allows for attempts at achieving pregnancy without the high-cost of a repeat IVF cycle. (Note you may be advised to complete other IVF cycles prior to attempting FET. This discussion will need to be individualized.)
Information provided here is intended as an overview only. Your treatment plan will be given to you and you should not use this as a substitute for medical advice.