In Vitro Fertilization -
IVF Program Summary
The following is a brief outline of the steps involved in IVF and related procedures, also referred to as Assisted Reproductive Technologies (ART). Due to individual needs, some steps may be changed for you, but the basic flow of steps remains the same for most patients.
The following steps are required in all IVF and related procedures:
1. Patient selection
2. Pre-cycle evaluation
3. Ovulation induction and monitoring
4. Egg retrieval
5. Sperm Processing
6. In-vitro fertilization
7. Embryo Transfer
8. Post transfer management
9. Cryopreservation
10. Related Procedures
1. Patient selection
A complete evaluation of fertility factors is important prior to considering ART. The following conditions can be successfully treated with ART.
Tubal Damage. Patients with tubal blockage or severe pelvic adhesions, or who have not conceived after tubal surgery are good candidates for IVF.
Female Sterilization. Women with a tubal sterilization not surgically reversible or who don't desire to undergo a sterilization reversal procedure are also good candidates for IVF.
Moderate to Severe Male Factor. The ability to treat sperm in the laboratory by various techniques, along with the ability to concentrate large numbers of motile sperm around eggs makes IVF a potential treatment for couples whose infertility is due to poor semen quality.
Vasectomy. Men with a vasectomy not reversible by surgery or who don't desire to undergo a reversal procedure can achieve pregnancies with their partners by means of IVF.
Endometriosis. As endometriosis often results in the distortion of the pelvic anatomy, the IVF procedure allows the egg and sperm to meet and fertilize in an environment free of endometriosis and be transferred directly into the uterus.
Immunologic Infertility. IVF allows fertilization outside the body, away from the destructive actions of anti-sperm antibodies.
Unexplained infertility. Couples that have not responded to other types of therapy can be successfully treated with ART. IVF can demonstrate the ability of the sperm to fertilize eggs. Rarely, unexplained infertility may be due to subtle defects in gamete function (fertilization).
Preimplantation Genetic Diagnosis (PGD). PGD consists of the biopsy (removal) of a single cell per embryo, followed by its genetic evaluation of this cell (testing). Those embryos classified by genetic diagnosis as normal are then transferred into the patient's uterus. PGD can help the following patients: (1) women with a prior history of repeated spontaneous abortions or chromosomally abnormal conceptions; (2) carriers of single gene disorders; (3) carriers of chromosome translocations, or other chromosome abnormalities; (5) patients with repeated IVF failure, and patient's who desire family balancing (gender selection).
2. Pre-Cycle Evaluation:
We partly attribute our success rates to our meticulous evaluation of three factors that contribute to a favorable outcome with ART.
A. The first of these is the woman's ability to respond to fertility drugs.
While age affects this parameter, measurements of FSH and Estradiol levels early in the menstrual cycle help us estimate a woman's ability to produce extra eggs in response to fertility drugs. In general, women with high FSH levels are more resistant to ovarian stimulation.
B. The second factor we evaluate is the uterine environment.
We recommend that the woman undergo evaluation of the uterine cavity before ART. This evaluation can be performed by means of a hysterosalpingogram (HSG), an office hysteroscopy, or a "fluid" ultrasound (hysterosonogram). These procedures allow us to evaluate the uterine cavity and make sure there are no fibroids, polyps, or scar tissue that could interfere with implantation. Also, women undergoing IVF/FET should have a "Mock Embryo Transfer" to carefully assess length of her uterine cavity, in order to accomplish an atraumatic embryo transfer in the IVF cycle.
Before commencing treatment cervical cultures are taken for ureaplasma/mycoplasma and aerobic organisms, and a DNA probe for chlamydia and gonorrhea is also obtained. Organisms such as ureaplasma have been associated with poor reproductive outcome and poor embryonic growth in the laboratory.
Finally, the uterine lining is evaluated prior to ovulation using a sonogram. Certain patterns of uterine lining development are associated with poor pregnancy rates. These sub-optimal patterns can sometimes be improved with estradiol supplementation or sildenafil citrate (Viagra) suppositories.
C. The third factor we look at is the male factor.
A complete semen analysis with strict morphology evaluation (Kruger Criteria) is performed at our laboratory. In addition, sperm antibodies are measured in both partners. High levels of sperm antibodies can interfere with fertilization in the laboratory, and special techniques are employed to correct this problem.
Couples undergoing ART at West Valley Fertility Center are screened for syphilis, hepatitis (B and C), Rubella, Varicella, CMV, HTLV-1/2 and HIV. We are unable to accept patients who have major medical, surgical, or psychological problems that may require in-patient management.
In addition to the above medical evaluation, couples contemplating ART are informed of the availability of a counselor. The licensed counselors are familiar with the emotional impact of infertility and infertility treatments, and can help the couple deal with this important aspect of their care. A medical acupuncturist is also available to patients who request this type alternative therapy as part of their ART treatment. Acupuncture is growing in popularity and it is believed that it may improve endometrial receptivity and increase blood flow to the pelvic area.
3. Ovulation Induction and Monitoring
ART success rates depend upon the numbers of eggs or embryos available for transfer. Additionally, the egg retrieval must be carefully timed so as to retrieve mature eggs. To accomplish these two goals, ovulation induction medications and careful monitoring are employed.
The start of the ovarian stimulation is timed using oral contraceptive pills (OCP). A woman takes OCP for two to four weeks prior to the beginning of the stimulation. Within 4 days after the last "active" pill is taken a baseline ultrasound is performed to make sure there are no ovarian cysts, and a blood estradiol level is measured. The fifth day after the last "active" pill is taken the woman begins injections of gonadotropins (Follistim, Gonal-F), according to a schedule that is provided by the clinic. We arbitrarily call this first day of gonadotropin administration Stimulation Day 1.
On Stimulation Day 5 the woman begins the administration of a GnRH antagonist (Ganarelix or Cetratide) to prevent premature ovulation. In order to monitor a patient's response to these drugs, frequent ultrasounds and serum estradiol levels are performed starting Stimulation Day 7. These help us determine when the eggs are ready for collection.
Once the follicles (containing the eggs) are deemed ready or mature, the patient stops taking the GnRH antagonist and the gonadotropins. About 35 hours prior to the anticipated egg retrieval, the patient takes an injection of human chorionic gonadotropin (hCG). This hormone replaces the woman's normal LH surge, and is necessary for the final maturation of the eggs so that sperm can fertilize them.
4. Egg Retrieval
At West Valley Fertility Center the egg retrieval is accomplished non-surgically using a vaginal ultrasound probe to guide a needle into the ovaries. The procedure does not require general anesthesia and is performed with intravenous sedation. An anesthesiologist administers the sedation to maximize your comfort and safety. As a result, the experience is not painful and recovery is rapid.
5. Sperm Processing
Freshly ejaculated sperm must undergo biochemical and structural changes called capacitation before they can fertilize an egg. In an IVF cycle, sperm are capacitated in the laboratory and the motile sperm are isolated prior to inseminating the eggs.
6. In Vitro Fertilization
In-vitro fertilization literally means "fertilization in glass". Follicular fluid removed from the ovaries is examined in our lab for the presence of eggs. These eggs are isolated and placed in culture media where they are allowed to further mature. A few hours later, the processed sperm are placed around each egg. Approximately 50 thousand sperm are needed for each egg. This is why men with low sperm counts can often fertilize eggs in the lab.
The eggs and sperm are left to incubate together in a carefully controlled environment. Approximately 16 hours following insemination, the eggs are inspected under the microscope to determine how many have been successfully fertilized. These embryos will be kept in the incubator as they continue to grow and develop until the moment of transfer.
The couple receives daily reports keeping them informed of the development of the embryos (fertilization, cell division and quality or grading). Three days after the egg retrieval, a decision is made about when to perform the embryo transfer (Day 3 embryo transfer or a blastocyst transfer). The decision to transfer at Day 3 or 5 (blastocyst) is based on the grading of the embryos.
7. Embryo Transfer
At West Valley Fertility Center all embryo transfers are performed under transabdominal ultrasound guidance. We have found that ultrasound-guided transfers are easier to perform and have resulted in higher pregnancy rates. The ultrasound allows for the accurate placement of the embryos approximately 1.5 centimeters from the top of the uterus. The embryos are transferred via a thin plastic tube and this catheter is carefully guided into the upper part of the uterus where the embryos are placed. After 20 seconds the catheter is gently removed. The transfer is generally a painless procedure and the patient remains resting for 1 hour, after which she is sent home. We instruct our patients to rest at home during the next two to three days after the transfer.
When to transfer Day 3 or Day 5 (Blastocyst)?
Depending on the quality of the embryos and the couple's preference, the embryos may be transferred into the woman's uterus either 3 or 5 days after egg retrieval. Three days after egg retrieval, the embryos have cleaved (divided) and contain 6 to 10 cells each. If an embryo transfer is performed at this time, approximately 1 to 4 embryos are transferred depending on the woman's age, the couple's desires and the quality (grading) of the embryos.
Currently, we offer couples that have embryos of exceptional quality the option to transfer their embryos 5 days after egg retrieval when the embryos are at a more advanced stage of development (blastocyst stage). These blastocysts have a higher implantation rate than embryos grown only three days, and as a result, only one or two blastocysts need to be transferred to have the same pregnancy rate usually seen when 2 or more embryos are transferred into the uterus on Day 3.
8. Post-Transfer Management
After the embryo transfer, the woman uses progesterone injections and progesterone/estradiol vaginal suppositories to enhance implantation. Fifteen days following the egg retrieval a blood pregnancy test is performed. If the test is positive, then approximately 8 days later, a second hCG level is obtained to confirm that the pregnancy is ongoing. The confirmation of a clinical pregnancy is made by ultrasound about 2 to 3 weeks later.
9. Cryopreservation
An option for couples with many embryos is to freeze the "extra embryos". This gives couples an additional opportunity to conceive without going through another stimulated cycle and egg retrieval. After a Day 3 embryo transfer, all remaining embryos are cultured for 2 to 3 more days. We then freeze the embryos that reach the blastocyst stage and are of good quality. Our pregnancy rate with the transfer of frozen blastocysts is almost double the expected pregnancy rate with the transfer of frozen Day 3 embryos.
A frozen embryo cycle can be used if the couple was not successful with the fresh embryo transfer or, if successful, when they wish for another child. Since the couple already has embryos to transfer, the uterus needs only to be prepared to receive the embryos. The success rate with frozen/thawed embryos is improved when the woman uses hormone replacement instead of her natural cycle. The woman takes oral contraceptive pills (OCP) for approximately one month. While she is on the OCP, she will begin a medication called Lupron (GnRH agonist) that is used to suppress ovarian function. Once the OCP has been discontinued the woman will be treated with biweekly injections of Estradiol Valerate to stimulate the lining of the uterus. Her Estradiol level in blood will be measured twice weekly and her dosage adjusted as needed. An ultrasound assessment of the uterine lining is performed to make sure an adequate endometrial thickness is present. When the uterine lining is not adequate (thin) the embryo transfer is cancelled. Four to six days prior to the embryo transfer, daily injections of progesterone are started, and the Lupron is discontinued. . The embryos are then thawed the morning of the transfer. If successful thawing of the embryo(s) occurs, an embryo transfer will take place as previously described. About half of the frozen embryos survive the defrosting process. Therefore, at least 2 blastocysts should be available for a frozen embryo transfer cycle.
10. Other related procedures
Intracytoplasmic Sperm Injection (ICSI) is a technique where the embryologist, under the microscope, captures a sperm in a very thin glass pipette and inserts it directly into the egg. All mature eggs are fertilized in this manner and the fertilized eggs are monitored for continued growth. The use of intracytoplasmic sperm injection allows the man with an extremely low sperm count or with a low number of normally shaped sperm to fertilize eggs.
"Assisted Hatching" is another procedure that involves thinning the shell around the fertilized egg to help facilitate implantation by the embryo. It is recommended for women who have had previously unsuccessful cycles, are older, or who have elevated FSH levels.
Testicular Sperm Extraction (TESE) is a simple and minimally invasive procedure where a small amount of testicular tissue is removed via a needle biopsy. It is an office procedure performed by an urologist under local anesthesia. The retrieved sperm is then inserted into each egg using the ICSI procedure. TESE allows for the retrieval of sperm from men who are unable to produce sperm in their ejaculate because of an obstruction (i.e. vasectomy) or absence of the vas deferens.
Couple Participation
We are well aware that infertility exacts a very heavy toll. The emotional, financial, and physical burden is often overwhelming. It is for this reason that we encourage both partners to be supportive of one another, and to participate in the treatment process together. The male partner should make every effort to accompany his partner with every visit. We understand this is not always possible, but is highly recommended.
For information on IVF costs, please click here. If you have any further questions or concerns regarding our program, please do not hesitate to contact our IVF coordinator or one of our qualified team members.
Last updated:
June 4, 2008
Reviewed by Dr. Vladimir Troche and his medical staff