In Vitro Fertilization

In Vitro Fertilization (IVF) is the most widely used form of treatment for infertility. IVF is the process of collecting the eggs from a woman and the sperm from a man and combining them in a dish in the lab for fertilization to occur. Once fertilization has occurred the embryos are transferred back into the woman and hopefully implantation and a pregnancy will occur.

A Detailed Overview of the IVF Process

After completing the comprehensive screening, you will be placed on an oral contraceptive pills or daily Lupron shots or Luteal estrogen. This allows us to suppress your natural cycle and gives us control over when you are to start your injectable medication called gonadotropins. Gonadotropins work to stimulate the ovary to make numerous follicles, (which each contain an egg) during a single cycle. Typically, you will administer these shots for 8 to 11 days depending on your own response. Once enough follicles reach the mature range, which is approximately 15-20 mm, you will be instructed to take a subcutaneous shot of HCG that night. Approximately 36 hours later, you will be scheduled for your egg retrieval.

Egg Retrieval

You will be instructed not to eat or drink anything from midnight on the day prior, and arrive at our office one hour prior to the procedure. You will be given IV sedation for the procedure and will be recovering over the next hour to hour and a half. Your partner will be asked to produce an ejaculate at the time of your retrieval with him being abstinent for the prior 48-72 hours. Remember that no children are allowed in the recovery area and that you will need someone to drive you home and stay with you for at least the next 24 hours. You will know the total number of eggs retrieved prior to leaving and will be called the following day with the number of eggs fertilized. In preparation for the embryo transfer, you will be asked to use some form of progesterone supplementation.

Embryo Transfer

You will be asked to return either on the third or fifth day following your retrieval for your embryo transfer. The decision is based on both the number and the quality of embryos obtained. Basically, if you have many high quality embryos to choose from on day 3, then a day 5 transfer would most likely be scheduled. You will return several times for blood work, including a pregnancy test approximately two weeks after retrieval. An ultrasound is done approximately three weeks after retrieval and will be repeated several times throughout the first trimester, after which you will be discharged to your ob/gyn for the remainder of your obstetrical care at around 8 or 9 weeks estimated gestational age.

IVF Medications

There are a number of different types of medications that may be used to increase the number of eggs which develop to maturity in women undergoing in vitro fertilization (IVF). The specific medications, the dose of those medications, the times at which they are administered and the duration of the treatment vary markedly from patient to patient and are based on their individual needs.

An agonist that inhibits your pituitary’s production of FSH and LH. This medication is taken as an injection just beneath the skin. This allows some of the other medications to provide a very even and balanced stimulation to the developing follicles. Lupron will allow patients to produce greater numbers of higher quality eggs during a given treatment cycle. Additionally, it prevents a spontaneous mid-cycle hormonal surge which may result in cycle cancellation.

 An antagonist acts to inhibit your pituitary’s production of FSH and LH in an immediate fashion unlike Lupron which may take days to weeks to accomplish. This medication is taken as a daily injection just beneath the skin. This medication is given for only a few days prior to the HCG injection and is designed to prevent a spontaneous mid-cycle hormonal surge which may result in cycle cancellation.

These are synthetic recombinant DNA preparations of follicle stimulating hormone (FSH) which are taken as subcutaneous injections. The FSH provides the critical stimulation to the follicles containing the eggs that are developing during the stimulation phase of the cycle.

A highly purfied preparation of follicle stimulating hormone (FSH) and lutenizing hormone (LH) which is taken as a subcutaneous injection. It is similar to Gonal F and Follistim but it also contains some LH and HCG. This may allow some (but not all) patients to respond somewhat faster and produce somewhat higher estrogen levels.

This is synthetic recombinant human chorionic gonadotropin which is taken as a subcutaneous injection. This medication is used as a substitute for the mid-cycle hormonal LH surge which induces the final maturational changes in the eggs and prepares them for retrieval. NOTE: After receiving this medication you will have a positive pregnancy test for the following 7-8 days (whether you are pregnant or not). Do not be misled by the results of a home pregnancy test!

Natural progesterone normally used vaginally beginning one day following egg retrieval and continues until the placenta is making adequate amounts of progesterone.

Typical IVF Cycle

Call with date of onset of menses. This will allow the nursing staff to finalize your schedule.

Come to the office for baseline hormonal evaluation (bloodwork). You will be instructed to either return on day 19 for blood work to start estrogen OR begin birth control pills and instructed on Lupron start date.

 Come in to the office in the early morning to have blood drawn for a progesterone level to confirm ovulation. You will be contacted by one of the nurses later that afternoon to confirm that you are ready to start your Lupron or Estrace. The dose of the medication may be altered (typically reduced when stimulation begins). Estrace starts on cycle day 19 and is stopped on the 3rd day of stim.

Approximately 8 to 14 days after starting your Lupron or Estrace (it varies from patient to patient and even cycle to cycle), you will have a menstrual cycle. This will be counted as cycle day 1 for the remainder of the stimulation portion of your IVF cycle. Please contact the IVF team and let them know when you begin your cycle so they can tell you exactly when to come in and begin your stimulation (typically cycle day 2 to 4).

Come in to the office in the early morning (between 6:30-7:30 A.M.) for an ultrasound scan and to have your bloodwork done. This will confirm that your hormone levels are low as expected at baseline. The ultrasound confirms that the ovaries have appropriately small follicles which are ready to be stimulated and that the endometrium (lining of the uterus) has shed appropriately and is ready to begin a new development cycle. You will be contacted that afternoon to confirm that you are ready to begin your gonadotropins (Gonal F, Follistim, and/or Menopur). The dosing of the medications will also be reviewed at that time. You will be told when to return to the office for your next visit.

You will be told when to return for blood tests and ultrasounds, typically once every 1-2 days in order to monitor the development of the follicles. Each time you come in, your nurse will contact you in the afternoon with your instructions. If you do not get a call by 3:00 P.M., you must have the nurse on call paged for instructions.

Once your follicles have reached an optimal state of maturity, you will be directed to take your HCG (Pregnyl, Ovidrel) injection. Unlike the other medications you have taken up to this point, the timing of this injection is very specific (plus or minus 15 minutes). You will stop all other injections at this time (Lupron, Follistim, Gonal F, Menopur, Cetrotide, Ganerelix).

This will be the final morning for bloodwork monitoring. The IVF team will advise you of the time you must arrive at the office for retrieval and will answer any additional questions. You may not eat or drink after midnight on this day in preparation for retrieval.

Approximately 36 hours after your HCG injection, you will undergo aspiration of your follicles to obtain the eggs. This is done under ultrasound guidance using a specially designed needle. You will need to arrive at our office ½ hour prior to retrieval. During that time, you will be admitted by the nurse into the recovery room. You will also meet with the nurse anesthestist who will start an I.V. Your husband will be instructed when to produce his specimen. Generally, this is during retrieval. Following retrieval, you will remain in the recovery room for approximately 1 hour. The Progesterone suppositories begin the day after retrieval. You must have someone to drive you home after the procedure. Please do not bring your children with you today.

Sometime before 8:30 A.M. on the day following retrieval, you will be contacted by your physician regarding your fertilization results. Continue taking your medications unless otherwise directed.

3-5 days after retrieval your embryos will be replaced into the uterus. Embryo transfers are done in the late morning and under ultrasound guidance. You will be instructed to drink 2-3 glasses of water prior to the transfer, as your bladder must be full to be able to visualize the uterine cavity. Following the transfer, you will be allowed to use the restroom then get dressed and return home.

Return to the office in the early morning for blood work to check your progesterone and estrogen levels. We want to make sure that your progesterone and estrogen levels are staying high to maintain a pregnancy. This blood work does not tell us whether or not you are pregnant.

Return to the office in the early morning for a serum pregnancy test. (Testing may be done a day earlier or a day later). If you are pregnant, you will be instructed when to return to the office for additional monitoring (blood work and ultrasound scans). If you are not pregnant, you should stop all your medications and wait for a menses. This will occur within a few days. You should schedule a follow up visit to discuss the failed cycle and next options with the physician.

Intracytoplasmic Sperm Injection (ICSI)

In the case of the male factor infertility, standard insemination techniques may not be successful. In cases where sperm counts are very low or where fertilization has failed to occur with a prior IVF attempt, special egg insemination techniques may be used to help the sperm fertilize the eggs. Intracytoplasmic sperm injection (ICSI) is the most common specialized insemination technique.

The use of ICSI represents a major advance in reproductive medicine. From the patient’s perspective, the process is similar to a regular IVF cycle, while the difference is in the laboratory handling of the sperm and eggs. The scientist takes a single sperm and, using sophisticated instrumentation, places the sperm directly into the center of the egg. In many cases, ICSI offers couples the hope of conceiving a child without the use of donated sperm. ICSI is not for everyone, however. Your physician will determine if ICSI is appropriate for you.

Is ICSI Necessary? Unfortunately, there is no good test performed to determine that a sperm will function normally other than IVF. Most programs will use a standard semen analysis to determine the number, motility and morphology of sperm found in the ejaculate. Other tests, such as the sperm penetration assay and the hemizona assay have also found some correlation with sperm fertilization capability, however, they are not foolproof. At RMA we use the standard semen analysis along with strict morphology (Kruger) and 24 hour survivability to determine whether or not ICSI is required. In general, we recommend ICSI for those having the following conditions: low count, low motility, low percentage of normal forms, vasectomy reversal, prior ICSI, presence of antisperm antibodies, prior low percentage fertilization during IVF or sperm obtained from either a TESA or MESA. On the day of the retrieval, your partner’s sample is evaluated and it may be deemed necessary to proceed with ICSI considering that sperm samples can vary a great deal from day to day.