In vitro Fertilization

In-vitro fertilization ("IVF") is a sequential process in which eggs are retrieved from the ovaries, fertilized in the laboratory using the partner's sperm (or donor sperm) and cultured into the creation of embryos, which are then transferred to the uterus for initiation of pregnancy. The first IVF baby in the world was born in July, 1978 and today, many thousands of children are born as a result of this technique.

The choice of in-vitro fertilization (IVF) is most ideally suited for couples who have failed to conceive after one year of trying and who may or may not have one or more of the following conditions:

1. Blocked fallopian tubes or pelvic adhesions.
2. Women who have had tubal ligation and are considering tubal reversal surgery and/or men who are considering vasectomy reversal surgery.
3. Failed cycles (2–6) of ovarian stimulation with intrauterine insemination.
4. Advanced female age of > 38 years
5. Reduced ovarian reserve, which may also be treated with egg donation.
6. Severe endometriosis.

The IVF procedure is based on a six-step process, namely:

1. prepration for treatment
2. ovulation induction
3. egg retrieval
4. fertilization
5. embryo transfer
6. post-transfer support to pregnancy tests

Step 1 - Preparation for IVF Treatment

In the first step, preparing for in-vitro fertilization (IVF) treatment, the couple would be required to have a complete medical workup. Medical records should be forwarded to the clinic for review and assessment in order to rule out the possibility that procedures other than IVF might better address their needs.

The medical work up would include a physical exam; including an ultrasound to better assist the doctor to discover any abnormalities within the uterus, fallopian tubes and/or ovaries. Sometimes evidence of pelvic scarring can be discerned. The doctor can also obtain information regarding the woman's potential for adequate ovarian stimulation for infertility treatment cycles by counting antral follicles.

An assessment of ovarian reserve will be important to determine a woman's remaining egg supply. This is usually done with a Cycle Day 3 (CD3) FSH and estradiol testing along with the ultrasound assessment of ovarian volume and antral follicle counts. The FSH and estradiol is a blood test which can be performed at a lab local to the patient.

Another important test which should be done in the evaluation process is a semen analysis and sperm count. The purpose here is to ensure that the sperm is viable and motility is not abnormal and/or not to have changed significantly since the last sperm count/semen analysis was performed, which could dramatically affect the couple's expectation for a successful outcome. If a severe sperm defect is discovered, there are three options for sperm extraction available: Testicular sperm extraction ("TESE") and/or Percutaneous Epididymal Sperm Aspiration ("PESA") and Microscopic Epididymal Sperm Aspiration (MESA). Once Sperm is obtained ICSI (Intracytoplasmic Sperm Injection) will be used to fertilize the eggs.

Some blood tests needed for better assessment of the patient and her partner include the CD3 FSH, luteinizing hormone (LH), prolactin, estradiol (E2), progesterone (P4), thyroid stimulating hormone (TSH), HIV, HTLV-I and II and other possible tests as recommended before they head for in-vitro fertilization..

In checking for tubal factors, we have two tests to employ: an x-ray test called a hysterosalpingogram (HSG) and laparoscopy, an outpatient diagnostic surgery. The HSG usually does an adequate job of determining whether the tubes are open or not. It can miss scar tissue around the tubes. Laparoscopy gives the most information since it allows the gynecologist to actually see the tubes, uterus and ovaries through a small telescope inserted through the umbilicus.

The HSG x-ray, which outlines the uterine cavity is a useful test for checking for uterine factors, as is the saline sonogram, which is performed in our offices. The saline sonogram allows the doctor to see the muscular wall of the uterus where fibroids can develop. If a patient's history or sonogram findings are suspicious of a problem such as a polyp or scar tissue inside the uterus, a hysteroscopy would be recommended. This is a minor procedure involving the passing of a small telescope through the cervix so the doctor can directly visualize the uterine cavity and remove the abnormal tissue.

Prior to Step 2, the couple will be required to review and sign informed consents for the medical procedure involved in in-vitro fertilization treatment. The purpose of informed consents is to clearly explain the process and the associated risks.

Step 2 - Ovulation Induction

A woman undergoing in-vitro fertilization (IVF) treatment is given fertility drugs for two reasons: to enhance the growth and development of her ovarian follicles in order to produce as many healthy eggs as possible and to control the timing of ovulation so the eggs can be retrieved before they are ovulated. IVF success rates are strongly correlated to the number of eggs retrieved.

The ovulation of more than one egg caused by the administration of fertility drugs is known as "superovulation". The term "Controlled Ovarian Hyperstimulation" or "COH" is the concept of superovulation but also encompasses the production of an exaggerated hormonal response that favors implantation of the embryo into the endometrium. Thus, the terms stimulation, superovulation or controlled ovarian hyperstimulation can be used interchangeably. The degree to which a woman is stimulated depends on the concentration of the hormone estrogen as measured by the estradiol or E2 level and/or with the visualization of the developing ovarian follicles by ultrasound examination. The protocols set by the doctors specifically define the type, dosage and method of stimulation as well as the entire sequence and timing of the in-vitro fertilization (IVF) cycle.

Typically the patient starts on birth control pills, which may seem counterproductive when you are trying to get pregnant but it is a means of better controlling for the timing of the in-vitro fertilization cycle and in the case of a cycle being planned with an egg donor or gestational surrogate, it helps to synchronize the cycles of the intended parties.

When the protocol is set for the cycle there are typically three types of fertility drugs injected: (1) GnRH-agonist (e.g., Lupron, Synarel) or GnRH-antagonist (e.g. Antagon) to suppress the LH surge and ovulation until the follicles are mature; (2) FSH product (e.g., Follistim, Bravelle, Gonal-F, Repronex) to stimulate development of multiple follicles and (3) HCG (human chorionic gonodotropin) to cause final maturation of the eggs in the follicles. The purpose of the GnRH-agonist (or antagonist) is to suppress release of the luteinizing hormone ("LH") from the woman's pituitary gland during the ovarian stimulation process. An LH surge would cause premature ovulation (release) of the eggs.

Once the woman has been on the birth control pill for the minimally required amount of time, the next step is suppression of ovulation through the injection of a GnRH-agonist or a GnRH-antagonist. The injections are usually subcutaneous and occur daily at a specified window of time (usually in the morning). Prior to starting the next phase of injections, the patient will have her blood drawn to check her estradiol ("E2") and/or ultrasound to be sure her ovaries are now "quiet" prior to starting the stimulation phase with the FSH medications. These medications may be injected subcutaneously or intramuscularly.

The purpose of the FSH product is to stimulate development of multiple follicles in the ovaries. During the stimulation phase the ovarian response is usually monitored by serially performed blood tests and ultrasounds to follow the follicular development (size and number) and hormonal response (the estrogen level, primarily). As the follicles mature these tests may be performed daily over a 4–6 day interval.

Step 3 - Egg Retrieval

The final stages of follicular development and egg maturation following the administration of hCG ("Human Chorionic Gonadotropin") occur on a very tight time schedule based on the size and development of the follicles as determined by the blood tests and ultrasounds. We prefer that once the dominant follicle reaches 18mm in average diameter, hCG is injected to induce final egg maturation. The egg retrieval is then planned for 36 hours later, just before ovulation would occur.

The egg retrieval is performed using the same vaginal ultrasound equipment used to monitor the follicular development but with the addition of a sterile, long, small diameter needle inserted in a guide on the ultrasonic probe. The needle is connected to a suction pump and the fluid from each accessible follicle within the ovary is aspirated ("air suction"). The retrieval is usually performed with local anesthesia in the vagina and cervix with light intravenous sedation. The egg retrieval process takes about 15–30 minutes and then the patient is required to rest for an additional 30–60 minutes before being discharged from the clinic. Prior to being discharged, the couple will know how many eggs were retrieved. Also, because of the use of anesthesia, the patient is not allowed to drive or operate machinery but is encouraged to keep her schedule/activity light for the rest of the day.

Step 4 - Fertilization

Fertilization, the union of the sperm and egg, is a very complex process and the in-vitro fertilization (IVF) process takes place in the IVF laboratory. The laboratory is a crucial link in determining the success of in-vitro fertilization (IVF). Once retrieved, the oocytes (or eggs) must be isolated from the follicular fluid and then supported in an incubator with changes of medium all the while being handled so as to facilitate fertilization. A semen sample is produced at the time of the egg retrieval and handled using different lab techniques with the more vigorous, motile sperm being introduced into the medium containing the eggs. However, before the sperm can be introduced to the eggs, it must be washed by centrifuge to separate the sperm from the seminal fluid.

Although most men are able to produce a masturbation specimen at the time of the egg retrieval, some may be unable to produce a specimen under the stress of the situation. If it is thought this could happen, a back up specimen can be collected well in advance and frozen in liquid nitrogen. It is preferable to use a fresh specimen so even if the man has a frozen semen specimen available, he should attempt to produce a fresh specimen around the time his partner's eggs are to be fertilized. When sperm quality or sperm quantity are low, it may be necessary for the man to produce multiple specimens so they can be concentrated and frozen in case he cannot produce an adequate specimen for the day of the egg retrieval.

In situations with male factor, the embryologist in the lab may perform Intracytoplasmic Sperm Injection ("ICSI"), which is when the embryologist holds the egg under a microscope to inject a single sperm into the interior of the egg. ICSI is an exceedingly labor intensive procedure demanding great hand-eye coordination and dexterity on the part of the embryologist.

There is another situation which requires specialized handling by the embryologist, namely, assisted hatching ("AH"). This procedure is most commonly used in in-vitro fertilization (IVF) when the female partner is over the age of 37; there is an indication of lower egg quality or quantity as measured by CD3 FSH, lower embryo quality or for something called the Zona Factor. Assisted hatching may also be used for couples who have experienced previous IVF failures. In this procedure the embryo is held with a specialized holding pipette and a very delicate, hollow needle is used to expel an acidic solution against the outer shell or "zona pellucida" of the embryo. The zona pellucida is the outer most and toughest coating around the egg. A small hole is made in the shell by the acidic solution and the embryo is then washed and put back in the incubator. Shortly afterwards, the embryo transfer procedure is initiated.

The developing embryo must be cultured in an environment of constant temperature, with control of humidity and strict limitations of oxygen and carbon dioxide levels. The medium is altered and changed at intervals to promote cellular division. Each dish with developing embryos is carefully labeled with the couple's name, identification number, and coded to prevent against any mix-up.

It is important to understand that not all eggs retrieved will be mature or normal in appearance. The percentage of eggs achieving fertilization depends on many factors. Not all eggs exposed to sperm will go on to division or "cleavage".

Step 5 - Embryo Transfer

The decision as to how many embryos will be transferred will include a pre-transfer discussion with the doctor regarding the number and quality of embryos, how many embryos have cleaved, and how healthy they appear to be. A review of multiple pregnancy as well as selective reduction will also be revisited with the couple prior to the transfer.

After incubation for 48 to 72 hours, the dividing embryos are selected for placement in the uterus. Usually this occurs when the fastest-growing embryo reaches a four-to-eight cell stage. A pre-agreed upon number of embryos (usually between 2–4) are loaded by the embryologist into a soft, plastic catheter. Using a small volume of medium the embryologist loads the catheter and the doctor will pass it through the cervix well into the uterine cavity. This is the process of embryo transfer in the in-vitro fertilization treatment ("IVF-ET").

After the embryos have been transferred, the embryologist checks the catheter under the microscope to confirm that all embryos have been placed in the uterus and are not remaining in the catheter. The IVF-ET procedure is quick and usually painless—taking no more than 15 minutes. However, you are required to remain quiet and in a reclined position for at least 1 hour following the procedure. It is believed the resting encourages uterine relaxation. It is important that physical activities be limited for the remainder of the day and the following day or two.

Step 6 - Post-transfer Support to Pregnancy Tests

After ovulation has occurred, whether naturally or with hormonal stimulation as in an in-vitro fertilization cycle, the ovary shifts its emphasis to manufacturing progesterone rather than estrogen. Thus, it is important to add additional progesterone supplementation in the form of vaginal suppositories and/or injections. Progesterone levels in the blood are monitored by blood draws and supplemental doses adjusted accordingly.

Pregnancy testing is usually performed quite early—usually 10–12 days after the transfer. The blood test used to determine if the patient is pregnant is called a quantitative beta HCG. The purpose for the beta hCG test is to determine if there is a presence of the hormone hCG, which is produced in minute amounts by the implanting embryo(s). A rise in hCG from beta 1 to beta 2 usually suggests that an embryo is implanting and is a good indication of a possible pregnancy. A positive beta hCG is known as a chemical pregnancy. One would expect to see an approximate doubling of the value from beta 1 to beta 2. If the blood hCG levels continue to climb, the patient continues on hormone supplementation.

Three to four weeks after the embryo transfer and with rising beta hCG numbers, the patient will then have an vaginal ultrasound to confirm the existence of a pregnancy with observation of fetal heart motion and fetal sac. After pregnancy is confirmed by ultrasound, hormone injections continue for another 4–6 weeks and the patient will then start prenatal monitoring with her own primary care physician. If a viable pregnancy is confirmed at the 6th week, there is a 95% chance the pregnancy will proceed normally to term. Once the pregnancy has progressed beyond the 12th week, the chance of a healthy baby being born is upwards of 97%.

In the event the in-vitro fertilization (IVF) cycle is not successful, women should wait until they have had one unstimulated menstrual cycle before initiating the next procedure.

1. Female Partner
2. Male Partner
3. Egg Donor
4. Egg Donor's
5. Partner Surrogate
6. Surrogate's Partner