Introduction
In vitro fertilization, or IVF, is a specialized procedure used to achieve pregnancy for patients when other fertility treatments have failed or are unavailable. IVF is most frequently offered to couples in cases with:
- Failed standard infertility treatment
- Long standing infertility
- Severely damaged or absent fallopian tubes
- Male factor infertility (low sperm count and/or low motility)
- Endometriosis (severe or failed prior treatment)
- Unexplained infertility
- Cervical factor infertility
- Prolonged infertility (more than 3 years)
The technique involves the collection of eggs from the ovaries, laboratory fertilization of the eggs with partner or donor sperm, and placement of developing embryos into the uterus.
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For more details on each phase, please follow the links below:
Criteria for Undergoing IVF
Before initiating an IVF cycle, a complete review of your medical and infertility history is needed. A thorough evaluation into the cause(s) of your infertility needs to be completed before couples can be considered candidates for IVF.
There are no firm age limits for undergoing IVF. Advanced maternal age does reduce the chances for conception, even if ovarian function appears normal. Women over age 42 who wish to use their own eggs or age 50 who wish to use donor eggs require special consideration before undergoing IVF.
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Procedure
The IVF procedure includes five steps:
- Induction of multiple ovulations (eggs)
- Egg retrieval
- Sperm preparation and fertilization of the eggs
- Embryonic growth in the laboratory
- Transfer of the embryos into the uterus
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Induction of Multiple Ovulations (Eggs)
In order to increase the effectiveness of IVF, most patients will be given medications to induce (bring on) ovulation of multiple eggs. Typically GnRH agonists will be started prior to your period to suppress your body’s own hormonal response so that we may directly control the ovarian production of eggs. Human Menopausal Gonadotropins (Gonal F, Follistim, Pergonal, Repronex, or Bravelle) will be used to induce multiple egg development and maturity.
These drugs will be given in a set sequence as determined by your physician. Lupron (a GnRH agonist) is given by daily injections under the skin. If Synarel (a GnRH agonist) is used, this requires twice daily nasal sprays. Human Menopausal Gonadotropins will be given daily by subcutaneous or intramuscular injections (it is not available in an oral form). These medications will be continued until it is time to induce ovulation. Human Chorionic Gonadotropin (hCG) (Gonal F, Follistim, Pergonal, Repronex, or Bravelle) will be given by subcutaneous or intramuscular injection at the time selected by your physician to complete the maturation of the eggs and induce the ovulatory response.
During the time you are taking medications to induce ovulation your response will be carefully monitored to ensure your safety and success with IVF. In addition to physical examinations, two other monitoring systems will be utilized:
- 1. Hormonal Monitoring
- Blood samples will be drawn for assessment of the hormonal response of the ovaries during ovulation induction. Blood will be drawn in the morning (between 8:00 and 9:00 AM) for estradiol (E2) levels at intervals determined by your physician.
- 2. Ultrasound Monitoring
- Ultrasound is a simple, noninvasive and safe technique which allows assessment of the ovarian response to stimulation, development and maturity of ovarian follicles, and of follicular number. Ultrasound will be performed with a vaginal probe. The ultrasound should take 5 to 10 minutes to perform. Ultrasonographic monitoring will be performed prior to the start of the Gonadotropin injections and at intervals thereafter as determined by your physician.
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Egg Retrieval
When two or more mature, preovulatory follicles have developed, as determined by both ultrasound and E2 levels, you will be scheduled for egg retrieval 32 to 36 hours after the injection of hCG has been given. Ultrasound-guided egg collection is almost always utilized.
Ultrasound-Guided Egg Collection
Using ultrasound to locate the follicles within the ovaries, a needle is passed either through the vagina or abdominal wall into the follicles, allowing the eggs to be collected. This technique takes from 20 to 30 minutes under a light anesthesia that allows the patient to recover quickly and have very little discomfort.
Potential risks do exist when ultrasound-guided egg collection is used. The most common risks include bleeding, either at the puncture site in the vagina or from the ovaries, infection, or failure to obtain eggs. If bleeding from the ovaries occurs, an extremely rare event, an operative procedure may be necessary.
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Sperm Preparation and Fertilization of the Eggs
Sperm Preparation
On the day of egg collection, it will be necessary to obtain a semen specimen. Abstinence for 48 hours is required prior to the specimen collection. In some situations, we will also ask that a sperm sample be collected prior to the IVF cycle and frozen as a back-up for use in the event of some problem on the day of egg collection. For certain cases, the man may be asked to collect two separate specimens prior to egg retrieval.
In the laboratory, the semen sample will be specially processed using the technique of sperm wash and “swim up”. These procedures allow the laboratory personnel to collect the most motile (active) sperm for the fertilization of the eggs.
Insemination of the Eggs
At the time the eggs are retrieved from the patient, they are examined by the gamete biologist for maturity and viability. In the laboratory the eggs will then be placed into a special incubation fluid and be allowed to complete the final steps of development necessary to allow fertilization. At a specific time, the specially processed sperm are added to the eggs.
When the man does not have normal sperm and in selected other patients, fertilization will be performed by a procedure called intracytoplasmic sperm injection (ICSI). ICSI involves the embryologist using a very fine needle to puncture the outer cell layer of the egg to inject a single sperm into each egg. This procedure has revolutionized treatment of male factor infertility.
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Embryonic Growth in the Laboratory
Fertilization of the Eggs
Approximately 24 hours after the retrieval, the Gamete Biologist will perform a fertilization check on the egg(s). If fertilization of the egg(s) has occurred, the zygote(s) or pre-embryo(s) will be checked at different times to determine adequate growth and development. Typically, the embryo(s) will be grown in the lab for three to five days after egg collection. All aspects of the embryo growth are carefully monitored and controlled.
If you have consented to cryopreservation (freezing) for a future frozen embryo cycle, this will generally be performed just after you have had embryos replaced back into your uterus (embryo transfer). The embryo transfer and freezing are usually done on Day 3 after the egg retrieval and fertilization day.
Assisted hatching is a laboratory procedure that weakens the outer cell wall of the embryo with a chemical solution to assist the embryo to implant in the uterus. This procedure is performed for embryos coming from older women, frozen embryos, and embryos with thickened cell walls with prior unsuccessful IVF cycles, and others. It is performed just before embryo transfer.
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Transfer of the Embryos into the Uterus
Once normal growth and development of the embryos occurs, the transfer of the embryos will be scheduled three days after the egg retrieval. At this time, we will transfer from 1 to 5 embryos back into the uterus.
The transfer is done by passing a very fine catheter through the cervix and into the uterus. The transfer is monitored by abdominal ultrasound which requires that you drink water to fill your bladder before the transfer. No anesthesia is required although a mild sedative may be given prior to the transfer. The embryos are then placed into the uterus through the catheter. After the transfer, you will be required to stay in bed for 2 hours and rest for the first 24 hours, with no exercising for 14 days after the transfer.
You will receive daily progesterone injections starting on the day of egg retrieval to ensure adequate development of the endometrium. The dosage and time of administration will be provided to you by our staff.
When Preimplantation Genetic Diagnosis (PGD) is performed an embryo biopsy is performed on Day 3 after the egg retrieval and embryo transfer is performed after the test results are known on Day 4 or Day 5. Transfer on Day 5 is called blastocyst transfer and is occasionally also performed for patients who do not do PGD.
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Results
There is over a quarter century clinical experience with IVF. The National success rate defined as number of retrievals resulting in a live birth is 30%. This ranges from 36% for age less than 35, 31% for age 35 – 37, 19% for age 38-40 and 10% for age 41-42. Known risks include:
- Ectopic pregnancy
The risk of ectopic (tubal) pregnancy may be increased with IVF. The overall ectopic rate with IVF is approximately 2%, as compared with approximately 1% in the general population. An ectopic pregnancy can usually be managed medically, but occasionally requires a minor or major surgical procedure.
- Spontaneous Abortion (Miscarriage)
With IVF, the spontaneous abortion rate of a clinical pregnancy is approximately 15%. This figure is comparable to the general population when matched for age and other factors.
- Multiple Pregnancy
Since more than one embryo is usually placed within the uterus, the risk for multiple pregnancy is increased. With IVF, the chance of twins is approximately 29% and triplets 4% or less. Each patient can choose how many embryos to replace to limit the multiple pregnancy rate even further.
- Birth Defects
While some studies have suggested, but not proven, an increase in some birth defects, overall data show that the great majority of IVF babies are healthy and not significantly different than comparable babies in the general population.
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Cycle Cancellation
It is infrequently necessary to cancel a treatment cycle, usually for one of the following reasons:
- Inadequate follicular development (size)
- Inadequate number of available oocytes
- Inability to collect eggs
- Complications of ovulation stimulation and/or egg retrieval
- Failure of egg fertilization
- Failure of embryo growth and/or development
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