In Vitro Fertilization (IVF)
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.
Lupron (GnRH agonist)
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.
Ganerelix, Cetrotide (GnRH antagonist)
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.
Gonal F, Follistim Pen (recombinant gonadotropins)
These are synthetic recombinant DNA preparations of follicle stimulating hormone (FSH) which are taken as subcutaneous injections. The FSH provides the cr
Menopur (urinary gonadotropins)
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.
Ovidrel (recombinant HCG)
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!
Progesterone
Typical IVF Cycle
Pre-cycle Day 1
Pre-cycle Day 3
Pre-cycle Day 19
Cycle Day 1
Cycle Day 3
Cycle Day 6
Day of HCG
Day after HCG
Retrieval Day
Post Retrieval Day 1
Transfer Day
Post Transfer Day 14
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.