In Vitro Fertilization
Introduction
In vitro fertilization (IVF) is a complex procedure made up of many different steps. It can seem extremely overwhelming at first but if you read the information carefully and ask lots of questions (no question is dumb), you will feel much more comfortable with the process. Our goal is to help you become aware of all of the steps involved so that you know exactly what to expect. In addition, once you have read the material, you will have more realistic expectations of outcomes and success rates for your particular age and circumstances.Although we have incorporated all of the proven latest techniques into our treatment protocols, experience to date indicates that the average national success rates for pregnancy with IVF are as follows:
Ages < 35 43.1% Live birth < 35 37.3%
Age 35-37 36.2% Live birth 35-37 30.2%
Age 38-40 27% Live birth 38-40 20.2%
Age 41-42 18.5% Live birth 41-42 11%
These statistics are taken from the reported CDC (Centers for Disease Control and Prevention) and SART (Society for Assisted Reproductive Technologies) for 2003.
If your first attempt does not result in a pregnancy, we recommend that you wait for an interval of 2-3 months before making a second attempt. This allows each couple to recover fully, both physically and emotionally.
Patient Selection
Couples are selected for IVF on the basis of the following causes of infertility:- Absence, damage, or blockage of fallopian tubes due to previous inflammation or surgery.
- Endometriosis
- Unknown factors with normal evaluations
- Male factor infertility
- Ovulation disorders
Treatment Cycle
The single most important factor in improving the success rate of IVF has been better embryo quality. Advancements in the quality of embryo culture media as well as incubation techniques have led to higher implantation rates. Although a certain percentage of embryos do not implant following transfer, improved success rates of implantation has caused most programs to limit the number of embryos to no more than two. Depending on your age, egg maturity, embryo quality as well as other factors, your doctor may recommend replacing up to three. These decisions will be made between you, your significant other, Dr. Assad and the embryologist.You will receive three different types of medications during your stimulation. One medication, Lupron, is responsible for “shutting down” the pituitary gland so that the production of natural hormones will not affect the artificial stimulation cycle. Lupron is started before actual stimulation begins and is administered as a subcutaneous injection. Antagon is sometimes used in place of Lupron and is also designed to “shut down” the pituitary. The difference is that it is given on or about day 7 or 8 of the IVF cycle. Once the ovaries become suppressed, medications will be added that will stimulate the production of multiple follicles. The development of these follicles (the fluid filled sac that contains an egg) will take place over the period of 10-13 days. Brand names of these medications are; Repronex, Menopur, FolliStim, and Gonal-F. The injections begin on cycle day 3 and continue until the day of the final injection prior to egg retrieval. The last injection will be hCG. This is responsible for causing the final maturation of the egg in the follicle.
Oocyte or Egg Retrieval
Oocyte or egg retrieval is the surgical procedure that involves removing the eggs from the follicle. A thin needle is placed through the vagina into the ovaries and the eggs are removed by gentle suction. This is a very precisely timed procedure that is done 34½ to 36 hours after the hCG injection- just before ovulation would normally occur. At that time, we will attempt to collect all eggs that can be obtained safely. Most often, the aspiration is performed through the vagina with ultrasound guidance. Rarely is it necessary to do a laparoscopic retrieval of the eggs. Usually this is determined ahead of time based on the location of the ovaries in relation to the vaginal wall and uterus.DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT ON THE EVENING PRIOR TO THE PROCEDURE. A monitored anesthetic will be used to keep you comfortable during the procedure. Following the procedure, you may have a slight amount of bleeding or moderate cramping. Occasionally you may notice blood in your urine. None of these are serious problems and unless pain / bleeding become severe, they need not be reported to our office. Remote risks of trans-vaginal egg retrieval may include injury to the bowel, blood vessels, or bladder, infection or excessive bleeding. In the unlikely event that one of these complications occurs, emergency surgery may need to be performed to repair the injury.
Semen Collection and Embryo Development
Couples should abstain from having intercourse for 3-4 days prior to egg retrieval. At each visit, Dr. Assad will be giving an estimate of the date on which he predicts the procedure to fall. On the day of retrieval, the husband will be asked to collect the semen sample prior to the egg retrieval (if possible, the patient will be allowed to assist in the collection process). Of course, a private area will be provided for purposes of collection. Sometimes, circumstances may delay the collection until after the egg retrieval is completed. If that is the case, we will work with you to make the process as stress free as possible. As with all aspects of IVF, our goal is to help make you both feel comfortable and secure.In the hours following the aspiration, the embryologist will be working with and inseminating the eggs. An attempt is made to inseminate all eggs in order to increase the chance of obtaining several healthy appearing embryos. A fertilization check of the embryos is typically not performed until the day following egg retrieval. It is best to leave the embryos as quiet as possible in the incubator environment. We will inform you of the results of the embryo check and may or may not do a second check on Day 2 post procedure. Embryo transfer is typically done on day 3. The morning of the transfer, the embryologist will assess embryo quality and discuss the results with Dr. Assad. The embryos appearing to be the best quality will be chosen for transfer. In some instances, blastocyst transfer (Day 5) may be chosen over Day 3. This situation is usually decided beforehand and will be discussed with you by Dr. Assad.
Embryo Transfer and Post Transfer Care
The transfer portion of this process is also done at the hospital but requires no anesthesia. If at all possible, we would like your partner to be present. Before the transfer, we may prescribe an antibiotic or a mild sedative. A tiny catheter containing the embryos within a minute amount of fluid is gently inserted through the cervix and deposited into the uterus. Every patient will have had a “mock” transfer at some point prior to initiating an IVF cycle so you will have an idea what to expect at this point. We will have you rest for 20 minutes after the embryos are placed in the uterus. We will also encourage you to minimize activities for the two days following this procedure. You may get up to eat, use the bathroom, shower etc. but we would like you to rest and stay as quiet as possible.You may notice some slight spotting for a couple of days following the transfer, this is normal. You may gradually increase your activities but we do ask you to refrain from vaginal intercourse, orgasm and any strenuous activities which may cause the uterus to contract. Once a pregnancy is confirmed, you will be instructed by Dr. Assad which activities are OK for you to resume.
Progesterone supplementation will be started immediately following the egg retrieval and will continue for the first 9 weeks of pregnancy or until a negative blood pregnancy test is confirmed. The purpose of this medication is to prepare the lining of the uterus and support an early pregnancy. There are three preparations of progesterone, one is oral, one is injectable, and the other comes in the form of a vaginal gel. Dr. Assad will let you know which one he prefers you to take. Both formulas of the medication may delay the start of a period even if you are not pregnant but spotting may also occur even if you are pregnant. Two weeks post retrieval you will be asked to do a pregnancy test. Home pregnancy tests (urine tests) are acceptable, but a sensitive blood test will be required for all patients to confirm the diagnosis. The hormone levels measured by the blood tests (hCG) may be very low initially and it is important to monitor the progress of these numbers. If the blood test is positive, it will be repeated in 48 hours. If the results are negative, you will be instructed to stop your Progesterone.
In some instances, the first hCG level will be high initially then show a decrease in number at the second check. These are called “biochemical” pregnancies. In all cases when pregnancy does not occur or one that does not continue, expect that your period will be much heavier than usual. If your pregnancy progresses normally, remember that your Progesterone supplementation will continue. You will be scheduled for an ultrasound at about two weeks post positive pregnancy test. Approximately 2-3% of all pregnancies can be ectopic (tubal) and this complication will require immediate attention. With an intrauterine pregnancy, the normal rate of miscarriage is 20% in the first 12 weeks. One or more ultrasounds will be performed in the first twelve weeks to assess the progress of the pregnancy.
Prenatal Care
After the pregnancy has progressed to 8-10 weeks, you will be asked to return to your Obstetrician for prenatal care. We would expect that your pregnancy proceed as if you had conceived without going through this process. IVF has been in existence since 1978 and there has been no evidence of an increase in the rate of congenital abnormalities beyond the 1-2% seen in the general population. In order to further our understanding of the IVF process, it is important that you keep us informed of the progress and outcome of your pregnancy. A visit and/ or a birth announcement are always appreciated!!!!Reasons for Delay / Cancellation of a Treatment Cycle
Approximately 15% of patients fail to respond properly to the ovulatory medications. Some develop no follicles, some develop only one follicle and some develop far too many for a safe stimulation. These cycles will be cancelled prior to aspiration or egg retrieval. Blood estradiol levels are performed as an added measure beyond just ultrasound observation. There are levels which are considered normal depending on the number of follicles present. If the estradiol levels are significantly out of range (either high or low) the cycle may be cancelled.A small number of patients will ovulate prematurely before aspiration. This is usually prevented with the use of the medications (Lupron and/ or Anatgon) that act on the pituitary, but there are no guarantees. If this were to occur, the retrieval would be cancelled.
Our first choice is never to cancel a cycle but we must consider what is safest and most beneficial for a successful cycle. We strongly believe that no patient should be taken to egg retrieval unless they have optimum ovarian response. There will be no accumulation of charges for portions of the process that are not completed. We recommend that you wait at least one cycle before trying a second attempt.
Occasionally, there are problems with both trans-vaginal and laparoscopic attempts to retrieve the eggs. This would be in cases of the ovaries being entirely inaccessible due to scarring and adhesions caused by previous disease or surgery. Only very rarely might this occur.
Oocyte maturity varies considerably and not all eggs will fertilize. In rare cases, no eggs fertilize. Sometimes sperm (despite normal parameters) prove incapable of fertilization. This is sometimes related to a sperm problem but may also be an egg quality issue. Finally, cell division and embryo development may fail to occur. Despite what appears to be normal fertilization, embryos may not divide normally and develop as expected. Only embryos appearing to be good quality will be selected for transfer.
The CDC and SART statistics on cancellations are as follows:
Age <35 8.5%
Age 35-37 12.4%
Age 38-40 16.3%
Age 41-42 18.7%
Embryo Freezing
If more eggs are fertilized than are safe to be to replace at transfer, additional embryos may be frozen (cryopreserved) for replacement in the future. Frozen transfer cycles are much less involved than an original IVF procedure; however, some patients are not comfortable with the freezing of embryos. This option is one that should be thoroughly considered and discussed ahead of time.Once frozen, embryos can be maintained for several years in storage. We do however; encourage patients to consider replacing embryos within two years if possible. After two years, arrangements must be made to transfer the embryos to a center that provides long term storage.
Costs of the Treatment Cycle
Advanced fertility treatment cycles can be very expensive. They are very complex, technical and labor intensive procedures. We have worked hard to keep the costs as low as possible and are lower than all programs in the immediate area. In most instances, there is no insurance coverage for these procedures. You may want to check with your company to verify the extent of coverage (if any). Remember to keep names of any representatives that you speak with and document the information for your personal records. If they indicate that you have coverage, ask to have them send you verification in writing. Pre payment may still be required but we will provide you with all the documentation you need to file with your insurance company for reimbursement.In the event that you have no coverage- which is usually the case, keep copies of all payments you make for treatments. Most often, you will be able to deduct medical expenses on your tax forms. Many companies offer medical savings plans such as flex benefits or cafeteria plans. You may want to consult with your tax advisor in this regard.
