August 25th, 2011 by Hasham

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Follicular Stimulation and Monitoring

IVF requires numerous eggs compared to a natural cycle which only requires one. This is because some of the eggs used in an IVF cycle will be damaged during the ART procedures and others will not fertilize and develop.

To produce the number of eggs needed for IVF, and to appropriately time egg release, IVF patients are started on fertility drugs (Lupron, Antagon, Cetrotide) designed to suppress their own hormones (FSH and LH). FSH is administered by injection and directly stimulates the ovaries to recruit and develop numerous follicles, each of which contains an egg. Drugs like Lupron are critical to a successful cycle as they “block” natural ovulation.  Otherwise, ovulation may occur prior to egg retrieval resulting in a “lost IVF cycle”. While on these drugs, ovulation must be induced by the drugs hCG or LH.

The progress of the IVF cycle is monitored by ultrasound scans of the ovary. As the follicles develop, the number and size can be measured using transvaginal ultrasound. As healthy follicles develop in an IVF cycle they produce increasing levels of estrogen, which is monitored by blood tests. Estrogen levels are used to help determine the appropriate dosage of FSH and to avoid potential side effects, such as ovarian hyperstimulation syndrome.

Once the follicles, developed during the IVF cycle, are judged to be mature, an injection of hCG is given to initiate the final phase of egg development. Sufficient development and an adequate number of eggs must be present in order to proceed to retrieval.

Oocyte Retrieval

IVF oocyte retrieval is performed using intravenous sedation. A needle is inserted under ultrasound guidance through the vagina into the follicle on the ovary. The follicles, containing the eggs, are punctured and aspirated. If the procedure is successful, one or more of the eggs will be obtained.

Sperm are usually obtained by masturbation the same day. The eggs are inseminated with the processed sperm and fertilization is allowed to take place. Micromanipulation of the sperm and egg is sometimes required to achieve fertilization (ICSI – intracytoplasmic sperm injection).

Allowing the embryos to grow in an environment established by culturing other cells from the woman sometimes improves the quality of the embryos (co-culture).

Sometimes the sperm count, or quality are poor (male infertility) and an adequate sample cannot be obtained by masturbation. In some of these cases, the sperm may be withdrawn directly from the testicles (TESA) or other parts of the male reproductive tract (MESA).

Intracytoplasmic sperm injection, ICSI, is often employed in case of male infertility. Using ICSI, a single sperm is injected into each egg. ICSI can be performed with extremely small quantities of ejaculate or sperm retrieved from the reproductive track.
Embryo Transfer

Once the embryos mature, a number (determined by the fertility specialist, embryologist, and patient) of them are inserted through the cervix into the uterus by means of a small catheter.

In some IVF cycles, prior to transfer, some or all of the embryos may undergo assisted hatching to increase implantation rates. The embryo transfer is usually painless and no sedation is required. Most IVF patients will be given drugs, such as progesterone, after the embryo transfer to insure endometrial development.

Excess embryos may be frozen for possible transfer in a future cryopreserved IVF cycle. While cryopreserved IVF cycles produce lower success rates compared to fresh IVF cycles, their cost is much lower. This is because the embryos have already formed and their is no need for ovulation induction drugs or embryo culturing.

The Center For Human Reproduction’s New York IVF Center’s success rates significantly exceed the national averages.  Success rates for US clinics can be reviewed at the Centers for Disease Control Web site.  However, be careful when comparing IVF programs as the treatment populations may be different. For example, an IVF center that employs IVF on a large number of women under the age of 30 will appear to have better success rates than a clinic that treats an excess of women 35 yrs. of age and older. There is a direct correlation between female age and IVF success rates.

Description

Normally, an egg and sperm are fertilized inside a woman’s body. If the fertilized egg attaches to the lining of the womb and continues to grow, a baby is born about 9 months later. This process is called natural or unassisted conception.

IVF is a form of assisted reproductive technology (ART). This means special medical techniques are used to help a woman become pregnant. IVF has been successfully used since 1978. It is most often tried when other, less expensive fertility techniques have failed.

There are five basic steps to IVF:

Step 1: Stimulation, also called super ovulation

Medicines, commonly called fertility drugs, are given to the woman to boost her egg production. Normally, a woman produces one egg per month. Fertility drugs tell the ovaries to produce several eggs. During this step, the woman will have regular transvaginal ultrasounds to examine the ovaries and blood tests to check hormone levels.

Step 2: Egg retrieval

A minor surgery, called follicular aspiration, is done to remove the eggs from the woman’s body. The surgery is normally done as an outpatient procedure in the doctor’s office. The woman will be given medicines so she does not feel pain during the procedure. Using ultrasound images as a guide, the health care provider inserts a thin needle through the vagina and into the ovary and sacs (follicles) containing the eggs. The needle is connected to a suction device, which pulls the eggs and fluid out of each follicle, one at a time. The procedure is repeated for the other ovary. The woman may have some cramping after the surgery, but it usually goes away within a day. In rare cases, a pelvic laparoscopy may be needed to remove the eggs.

If a woman does not or cannot produce any eggs, donated eggs may be used.

Step 3: Insemination and Fertilization

The man’s sperm is placed together with the best quality eggs and stored in an environmentally controlled chamber. The mixing of the sperm and egg is called insemination. The sperm usually enters (fertilizes) an egg a few hours after insemination. If the doctor thinks the chance of fertilization is low, the laboratory staff may directly inject the sperm into the egg. This is called intracytoplasmic sperm injection (ICSI). Many fertility programs routinely do ICSI on some of the eggs even if everything is normal.

Step 4: Embryo culture

When the fertilized egg divides, it becomes an embryo. Laboratory staff will regularly check the embryo to make sure it is growing properly. Within about 5 days, a normal embryo has several cells that are actively dividing.

Couples who have a high risk of passing a genetic (hereditary) disorder to a child may consider pre-implantation genetic diagnosis (PGD). The procedure is done about 3 -4 days after fertilization. Laboratory scientists remove a single cell from each embryo and screen the material for specific genetic disorders. According to the American Society for Reproductive Medicine, PGD can help parents decide which embryos to implant, which decreases the chance of passing a disorder onto a child. The technique is controversial and not offered at all centers.

Step 5: Embryo transfer

Embryos are placed into the woman’s womb 3 – 5 days after egg retrieval and fertilization. The procedure is done in the doctor’s office while the woman is awake. The doctor inserts a thin tube (catheter) containing the embryos into the womans vagina, through the cervix, and up into the womb. If an embryo sticks to (implants) in the lining of the womb and grows, pregnancy results.

More than one embryo may be placed into the womb at the same time, which can lead to twins, triplets, or more. The exact number of embryos transferred is a complex issue that depends on many factors, especially the woman’s age. Unused embryos may be frozen and implanted or donated at a later date.
Why the Procedure is Performed

IVF is done to help a woman become pregnant. It is used to treat many causes of infertility, including:

* Advanced age of the woman (advanced maternal age)
* Damaged or blocked fallopian tubes (can be caused by pelvic inflammatory disease or prior reproductive surgery)
* Endometriosis
* Male factor infertility, including decreased sperm count and blockage
* Unexplained infertility

Risks

IVF requires a significant physical, emotional, financial, and time commitment. Stress and depression are common among couples dealing with infertility. A woman taking fertility medicines may have bloating, abdominal pain, mood swings, headaches, and other side effects. Many IVF medicines must be given by injection, often several times a day. (The health care team will teach the couple how to properly mix the medicines and give a shot.) Repeated injections can cause bruising.

In rare cases, fertility drugs may cause ovarian hyperstimulation syndrome (OHSS). This condition causes a build up of fluid in the abdomen and chest. Symptoms include abdominal pain, bloating, rapid weight gain (10 pounds within 3-5 days), decreased urination despite drinking plenty of fluids, nausea, vomiting, and shortness of breath. Mild cases can be treated with bed rest. More severe cases require draining of the fluid with a needle.

Medical studies to date have concluded that fertility drugs are not linked to ovarian cancer.

Risks of egg retrieval include reactions to anesthesia, bleeding, infection, and damage to structures surrounding the ovaries, including the bowel and bladder.

There is a risk of multiple pregnancies when more than one embryo is placed into the womb. Carrying more than one baby at a time increases the risk of premature birth and low birth weight. (However, even a single baby born after IVF is at higher risk for prematurity and low birth weight.) It is unclear whether IVF increases the risk of birth defects.

IVF is very costly. Some, but not all, states have laws that say health insurance companies must offer some type of coverage. But, many insurance plans do not cover infertility treatment. Fees for a single IVF cycle — including costs for medicines, surgery, anesthesia, ultrasounds, blood tests, processing the eggs and sperm, embryo storage, and embryo transfer — can quickly add up. The exact total of a single IVF cycle varies with each individual, but may cost more than $12,000 – $17,000.

A Year Without Pregnancy

diagram illustrating the process of fertilization Infertility is defined as the inability to conceive a child despite trying for one year. The condition affects about 5.3 million Americans, or 9 percent of the reproductive age population, according to the American Society for Reproductive Medicine.

Ironically, the best protection against infertility is to use a condom while you are not trying to get pregnant. Condoms prevent sexually transmitted diseases, a primary cause of infertility.

Even a completely healthy couple can’t expect to get pregnant at the drop of a hat. Only 20 percent of women who want to conceive become pregnant in the first ovulation cycle they try, according to Younger.

To become pregnant, a couple must have intercourse during the woman’s fertile time of the month, which is right before and during ovulation. Because it’s tough to pinpoint the exact day of ovulation, having intercourse often during the approximate time maximizes the chances of conception.

After a year of frequent intercourse without contraception that doesn’t result in pregnancy, a couple should go to a health-care professional for an evaluation. In some cases, it makes sense to seek help for fertility problems even before a year is up.

A woman over 30 may wish to get an earlier evaluation. “At age 30, a woman begins a slow decline in her ability to get pregnant,” says Younger. “The older she gets, the greater her chance of miscarriage, too.” But a woman’s fertility doesn’t take a big drop until around age 40.

“A man’s age affects fertility to a much smaller degree and 20 or 30 years later than in a woman,” Younger says. Despite a decrease in sperm production that begins after age 25, some men remain fertile into their 60s and 70s.