IVF/Assisted Reproduction

In vitro Fertilization (IVF)

Overview

Although it was originally developed to assist women with tubal disease, in vitro fertilization (IVF) has evolved into the definitive treatment for nearly all types of infertility, especially for couples who have not experienced success with less complex treatment approaches. Suitable IVF candidates may include patients who have:

• Blocked fallopian tubes
• Pelvic adhesions
• Endometriosis
• Polycystic Ovarian Syndrome (PCOS)
• Cervical abnormalities
• Male factor infertility
• Unexplained infertility
• Genetic diseases suitable for screening through preimplantation genetic diagnosis (PGD)

Many of our patients will become pregnant through other treatments, but IVF is the most effective method for achieving pregnancy in a single cycle. We suggest reviewing the information presented on our website and scheduling a consultation with our physicians before determining if IVF is the right option for you.

Preliminary Testing

Prior to undergoing IVF, our team will review your previous evaluation and/or fertility treatment—this is to ensure that we select a protocol that is not arbitrary (e.g. based upon age) but rather individualized to give you the best possible chance of success in a single cycle. Some of the testing that we will confirm includes:

Uterine Cavity Evaluation If you have not undergone a recent assessment of your uterus (e.g. hysteroscopy, saline-infusion sonogram, or hysterosalpingogram) or if you have a history of uterine abnormalities, we will often obtain repeat testing prior to IVF to rule out abnormalities that may interfere with successful implantation.
Genetic Disease Testing.

One example of this type of evaluation is carrier status screening of both partners for the pulmonary disease cystic fibrosis. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) recommend that all patients undergoing preconception counseling are offered cystic fibrosis testing. Although the population risk of having a child with this disease is less than 1 percent, obtaining this evaluation will allow our team to furnish you with the most complete counseling before beginning IVF. Testing for other genetic diseases may also be offered depending upon the background of male and female partners. We can also arrange for referral to a genetic counselor in the event of an abnormal result or for more detailed discussions regarding genetic disease risk.

Blood Borne Disease Screening

In certain instances, the Food and Drug Administration (FDA) requires that we obtain a specific panel of tests prior to embarking upon an IVF cycle. This is most often in cases involving third-party reproduction (e.g. donor egg). Among the majority of our patients utilizing their own eggs and sperm, we perform an abbreviated blood borne disease panel.

IVF Medications

Many of the medications we use in IVF are also used in other stimulation protocols. As previously mentioned, we will select a type/dose of medication and protocol that will optimize your response. Following a detailed injection teaching conference, you will be given a calendar that provides dates to start and stop each medication. Please keep in mind that the calendar is meant to serve as an estimate, since we frequently will need to adjust your doses and dates while we are monitoring your stimulation response. Finally, it is not uncommon for patients to need reassurance that they are taking their medicines correctly–we encourage you to call us anytime if you have questions.

Bravelle, Menopur (laboratory-purified gonadotropins)

These FSH preparations are packaged in a dried powder form that must be diluted with a small amount of saline before they are administered as a subcutaneous injection. Remember that Menopur contains both FSH and LH.

Follistim, Gonal F (laboratory-synthesized gonadotropins)

These FSH preparations are in a liquid form with cartridge/pen (Follistim) or pre-filled pen (Gonal F) delivery systems for subcutaneous injection.

Ganirelix, Cetrotide (GnRH antagonist)

If ovulation occurs before we are ready to perform your egg retrieval procedure, your chances of getting pregnant will be adversely affected. Therefore, IVF requires that we not only stimulate your ovaries with one or more of the FSH regimens above but also include a medication that will block your LH surge until your egg retrieval. With protocols that involve Ganirelix, we will instruct you to add this medication as a daily subcutaneous injection beginning a few days into your stimulation, and continuing until the day of hCG administration.

Lupron (GnRH agonist)

Lupron is another medication that prevents early ovulation. Since it takes longer to work, Lupron-based protocols require that this subcutaneous injection is begun at variable intervals and doses before you begin your stimulation with FSH.

Novarel, Ovidrel (hCG)

As mentioned elsewhere on this website, both of the above medications are preparations of human chorionic gonadotropin (hCG), the ‘pregnancy hormone,’ which can be used in place of the LH surge prompting the eggs to mature within the follicle. This can be administered as an intramuscular (Novarel) or subcutaneous (Ovidrel) injection. Please keep in mind that because these medications are present in your bloodstream for 10 to 12 days after they are given, taking a pregnancy test in that time can produce a false positive result.

Progesterone

Women going through IVF are given progesterone supplementation as support for embryo implantation and early ongoing pregnancy. Progesterone is available in intramuscular and vaginal (gel or tablet) regimens that are begun from the day of retrieval and continued until the mid to late first trimester.

Antibiotics

Some evidence suggests that administration of antibiotics to both the male and female partners around the time of embryo transfer reduces bacterial growth at the catheter tip, and may improve pregnancy outcome.

Anti-inflammatory medications (steroids)

Similar to the thought process behind administration of antibiotics, the use of steroids (prednisone, dexamethasone, or methyl-prednisolone) around the time of embryo transfer may reduce inflammation at the site of implantation.

Stimulation

Following either an induced or spontaneous menstrual period, a typical stimulation is begun on the second or third day of your menstrual cycle and continues for 8 to 14 days before hCG is administered and the egg retrieval is performed. The goal is to use the fertility medications to promote the simultaneous maturation of multiple follicles. During this time period, a woman’s progress is monitored with several hormone testing and/or ultrasound assessments. Dependent upon the observed response, the medication doses are modified or continued until the follicle sizes and estrogen level indicate maturity.

Retrieval

When the stimulation has been completed, hCG is administered and the egg retrieval is scheduled approximately 36 hours after this injection. You will need to arrive at our surgery center at least an hour before your scheduled procedure time to allow for registration and nursing assessment prior to your procedure. Once you are in the procedure room, an anesthesiologist will administer 2 or 3 different medications intravenously that will remove any pain or memory during the egg retrieval.

Using a transvaginal ultrasound probe and a needle with attached tubing to a suction device, the eggs are aspirated through 2 puncture sites in the vaginal wall, meaning that there is no incision. The procedure lasts between 20 to 30 minutes.

Transfer

Following introduction of egg and sperm on the day of retrieval and several days of embryo culture, one or more embryos are transferred into the uterine cavity under ultrasound guidance using a thin plastic catheter. Since this is accomplished with a speculum in place and with a full bladder to assist in visualization of the uterus on ultrasound, patients report pressure but minimal pain during the embryo transfer.