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In Vitro Fertilization (IVF)

Beginning an IVF cycle is an exciting and anxious time for a couple. The following explanation is meant to simplify the process that occurs during various stages of IVF

Definitions

  • Ovarian Follicle - a small, fluid-filled structure in which eggs develop
  • Oocyte - an egg
  • Embryo - a fertilized egg that has undergone division cleavage

Stage I: Ovarian Follicle Development through Controlled Ovarian Stimulation

Fertility drugs that simulate the female partner and natural hormones are used to develop several normal follicles in the ovaries These medications are:

  • Clomiphene Citrate also called Siphene® or Ovofar®
  • Menogon (HMG), a 50:50 mixture of FSH and LH hormonal administered intramuscularly
  • Puregon® (POFSH): administered subcutaneously
  • Gonal-F (RecFSH)

Any excess Oocytes that fertilize and develop into embryos at fertilization may later be stored through cryopreservation.

Follicular growth, development, and maturity are evaluated through frequent hormone monitoring and by ultrasounds. Typically, the hormones estradiol, luteinizing hormone, and progesterone are measured through blood tests to evaluate ovarian response. Ultrasound is used several times during a cycle to measure accurately follicular growth and size.

These steps allow the team to modify the treatment in some cases and to stop the cycle if the response to stimulation is not satisfactory. Once follicular maturation is achieved, the patient receives an intramuscular injection of human chorionic gonadotropin (hCG), which triggers oocyte maturation and ovulation. Oocyte retrieval is performed approximately 36 hours later. In some the physician may elect to withhold the hCG injection and wait for spontaneous ovulation, referred to as a spontaneous LH hormone surge.

Stage II: Embryo Retrieval through Puncture/Aspiration

If the last hormone blood test and ultrasound evaluation indicates healthy growth of follicles, then aspiration of mature follicles takes place. This entire procedure takes approximately 30 minutes performed under short general anesthesia. The physician locates each follicle through ultrasonic guidance and carefully aspirates them. The contents of the follicles are immediately taken to the IVF lab. Patients usually recover for one to two hours following Oocyte retrieval and are then discharged. Progesterone supplementation initiated from the day of the retrieval.

Stage III: Oocyte Culture, Insemination, and Fertilization

In the IVF laboratory, follicular fluid is examined under a microscope to locate all eggs, which are then incubated in a special media. Generally, semen collection occurs at about the time of the egg retrieval but, in some cases, may be several hours later. They are then added to the eggs in culture and it is here that fertilization occurs. Any resulting embryos are stored in the incubator and maintained in culture until the time of embryo transfer and/or cryopreservation

Stage IV: Embryo Transfer

Usually, transfer of the embryos takes place on day two to three post retrieval. The embryos are examined under the microscope and carefully aspirated to a thin transfer catheter. The loaded catheter is introduced into the uterus through the cervix where the embryos are placed. This procedure takes a few minutes and does not require anesthesia. The physician administers a mild sedative to provide complete relaxation of the cervix and prevent cramping. The maximum number of embryos to be transferred at one time is 3-4.

After the transfer, the patient rests for two hours prior to discharge and complete bed rest for four days is required. On the sixth day following the transfer, the patient returns for a progesterone evaluation. Twelve days after the embryo transfer, a serum base pregnancy test is taken. During this period, patients are advised perform light activity. If pregnancy does not occur, our team reviews the IVF cycle and make specific recommendations for follow-up. The patient will speak with the clinical staff to review and if necessary, to discuss other options.

Cryopreservation

Embryos of sufficient quality that are not transferred can be cryopreserved. The embryologist will select embryos that are suitable for freezing. Embryos that are ideal for freezing have blastomeres of equal size and display minimal or no fragmentation.

A Word of Caution: There is approximately a 68% chance of survival following the cryopreserved embryos. The quality of embryos undergoing cryopreservation is a major determinant of survival. Depending on the stage of embryo development, frozen embryos are thawed for 2 days before the transfer. The patient is informed of the survival of the thawed embryos and posted for a frozen thawed embryo transfer (FET).

Frequently Asked Questions (FAQ’s)

The information presented below is only for informational purposes. Your surgeon will talk to you about details regarding your specific procedure.

What is infertility?

Infertility, whether male or female, can be defined as 'the inability of a couple to achieve conception or to bring a pregnancy to term after a year or more of regular, unprotected intercourse'.

Is infertility exclusively a female problem?

No. The incidence of infertility in men and women is almost identical. Infertility is exclusively a female problem in 30-40% of the cases and exclusively a male problem in 10-30% of the cases. Problems common to both partners are diagnosed in 15-30% of infertile couples. After thorough medical investigations, the causes of the fertility problem remain unexplained in only a minority of infertile couples (5-10%).

What are the most common causes of infertility?

The most common causes of female infertility are ovulatory disorders and anatomical abnormalities such as damaged fallopian tubes. Less frequent causes include, for example, endometriosis and hyper-prolactinemia. Causes of male infertility can be divided into three main categories: Sperm production disorders affecting the quality and/or the quantity of sperm; anatomical obstructions and other factors such immunological disorders. Approximately a third of all cases of male infertility can be attributed to immune or endocrine problems, as well as to a failure of the testes to respond to the hormonal stimulation triggering sperm production. However, in a great number of cases of male infertility due to inadequate spermatogenesis (sperm production) or sperm defects, the origin of the problem still remains unexplained.

What is the general progression for infertility treatments?

A variety of procedures can be used to diagnose the cause of infertility in a couple; these range from simple blood tests to more complicated analytical methods. In any case, diagnosis is a crucial first step to determine the appropriate therapeutic path that should be followed. In addition to the cause itself, other factors, such as the age of the woman, or problems shared by both partners, might also influence the choice of treatment.

What treatment options do infertile couples have?

Several options are offered to couples depending on the type of infertility that has been diagnosed. The vast majority of female patients are successfully treated with the administration of drugs such as clomiphene citrate, bromocriptine or gonadotrophins. Surgery can also be a means to repair damage to the reproductive organs, such as those caused by endometriosis and infectious diseases. Treatment options for male infertility also include the administration of drugs, surgery and assisted reproductive technologies, such as intracytoplasmic sperm injection (ICSI). Drug therapy and surgery have proved very successful for specific types of male infertility. However, in a great number of cases, the reason why men have fertility problems remains unexplained and the treatment methods applied are empirical. Some patients nevertheless require more complex medical intervention. Assisted reproductive technologies (ART) refer to several different methods designed to overcome barriers to natural fertilization such as anatomical problems (e.g. blocked fallopian tubes). One of these techniques, in-vitro fertilization (IVF), has now been practiced for more than 15 years. Overall, the estimated number of infertile patients currently treated by ART is around 20%.

How successful are infertility treatments?

When talking of success rates for any type of infertility treatment, one should bear in mind that the average chance to conceive for a normally fertile couple having regular unprotected intercourse is around 25% during each menstrual cycle. It is estimated that 10% of normally fertile couples fail to conceive within their first year of attempt and 5% after two years. Comparable to normal fertility rates, effective treatments can be expected to have, on average, up to a 25% success rate per cycle of treatment, and may therefore need to be repeated several times before a pregnancy is achieved. Simple ovulation induction to compensate for hormonal imbalances has a very high success rate; more than 80% of women suffering from such disorders are likely to conceive after several cycles of treatment with drugs such as clomiphene citrate or gonadotrophins.

Are there particular factors influencing the success of a treatment?

In any type of infertility treatment, important factors need to be taken into account when referring to success rates. The age of the woman and the duration of the couple's infertility are likely to influence the success of treatment. In women, fecundity decreases as age increases, particularly after 40 years of age. When the woman is being treated, her chances of conceiving can be lessened if her partner also has infertility problems (e.g. poor quality sperm).

How important is counseling to the patient undergoing infertility treatment?

The physician helps the infertile couple find the most appropriate therapeutic path to overcome barriers to conception, but, before a treatment is started, patients need to be aware of all its aspects, including its constraints. Beyond the medical expertise, infertile couples are also looking for counseling and support. From a psychological point of view, infertility is often a hard condition to cope with. During treatment and before a pregnancy is achieved, feelings of frustration or loss of control usually experienced by the infertile couple are likely to be exacerbated. Management of infertility includes both the physical and emotional care of the couple. Therefore, support from physicians, nurses and all people involved in treating the infertile couple is essential to help them cope with the various aspects of their condition. Offering counseling and contact with other infertile couples and patient associations can provide help outside the medical environment.

What are the success rates of IVF?

Overall, the success rates for IVF have steadily improved over the last ten years. Birth rates for IVF vary according to the expertise of the centers practicing this technique. However, centers in Europe have reported pregnancy rates after one cycle of IVF equal or superior to 25%. In 1993, the French IVF registry (FIVNAT) reported a pregnancy rate of 25.4% per embryo transfer on a total of 23,025 oocytes retrieved. Based on such results, after three to four cycles of IVF, a woman under 40 whose partner does not have any fertility problems could reasonably expect to give birth. Again, in general, success rates may vary from one center to another, since they are influenced not only by the level of expertise of the medical team but also by the characteristics of the patients treated. A clinic treating a large number of women over 40 is likely to report lower success rates than a clinic having a majority of patients under 35.

What is the duration of one IVF or ICSI cycle?

One complete IVF or ICSI cycle takes approximately six to eight weeks. First, the normal menstruation cycle of the woman is regulated by injection or nasal application of specific hormones each day. This part of the cycle can vary from a few days to several weeks. When the ovaries have become inactive as shown on ultrasound control and laboratory findings, the stimulation of the ovaries start by muscular or subcutaneous injections of hormones. The mean stimulation period is 12 days, depending on the reaction of the ovaries. The ovum pick up takes place within two days after stopping the stimulation. Now the real IVF or ICSI follows in the laboratory. When fertilization occurs, embryos are transferred into the uterus after two to four days and drugs supporting the uterus are given. After approximately 15 days a pregnancy test will show whether the IVF treatment has been successful or not.

Are there particular health risks for women undergoing infertility treatment?

Along with their intended benefits, drugs used to treat infertility may on occasion cause side effects. In ovulation induction, close monitoring of follicular growth is crucial to ensuring successful treatment. Monitoring techniques (such as ultrasound scan and blood tests) and adequate use of treatment protocols help the physician to avoid ovarian hyper-stimulation syndrome (OHSS) and minimize the risk of multiple pregnancy. Current treatment protocols have been designed to reduce the risk of multiple births and OHSS. OHSS Ovarian Hyper-stimulation Syndrome (OHSS) is a side-effect that can occur during infertility treatment with ovulation inducing drugs. Symptoms of this syndrome may include ovarian enlargement, accumulation of fluid in the abdomen and gastrointestinal disorders (nausea, vomiting, and diarrhea). Severe cases of OHSS are however very rare (1-2% of cases).