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In Vitro Fertilization (IVF)
The first steps of any assisted reproductive technology (ART) are similar. In vitro fertilization (IVF) is the original ART--the first IVF-assisted baby was born in 1978.
Candidates
The procedure was originally used for women with blocked fallopian tubes. Now, it is used to treat many other infertility problems. In couples with a severe male factor for the infertility, IVF with intracytoplasmic sperm injection (ICSI) can improve pregnancy rates.
Benefits
As the least invasive of the ART procedures, IVF is often the best way to achieve pregnancy for women with blocked fallopian tubes, couples with male factor infertility, and for couples with unexplained fertility who have not been successful with less advanced treatments. Additionally, it can help expedite time to conception for women in their late 30's to 40's.
Risks
Side effects of the medications Gonal-F and Follistim can include cysts on the ovaries, multiple births, and a condition called ovarian hyperstimulation syndrome. In this condition, the ovaries become very large and may cause significant discomfort and fluid in the abdomen. It is common in IVF cycles in its mild form. Although it is rare, the severe form could require admission to a hospital and careful monitoring.
The risks of the egg retrieval are less than that of a laparoscopy but can include infection (you'll take an antibiotic to help prevent infection), bleeding that could require a blood transfusion or major surgery, or a puncture that injures the bowel or the bladder. These are very rare events.
Procedure
These are the general steps we use for IVF. You will receive personalized instructions. The physician with whom you have your initial consultation may not be the same doctor who performs your IVF procedures. All of our physicians use the same techniques and have similar success rates.
To begin an IVF program, our physician will examine the female partner and use ultrasound to determine the depth and position of the uterus. The couple consults with their physician, who may also perform diagnostic tests. Then, the couple meets with our IVF nurse coordinator to plan the IVF cycle. You will attend an IVF injection class and overview where we will discuss details of the cycle, and you will be asked to sign consent forms.
IVF normally spans two menstrual cycles. The six major steps, described below, are:
- Prevention of ovulation
- Follicle stimulation and hormone adjustment
- Follicular Maturation Trigger
- Egg retrieval and fertilization
- Embryo transfer
- Pregnancy test
1. Prevention of Ovulation
Call the office prior to the first day of your period. You will begin taking the birth control pill on the 2nd or 3rd day of your period. After 2-3 weeks on the pill, your physician will use ultrasound to view the ovaries, and if they appear normal, you will be instructed to begin taking Lupron and stop the birth control pill. This medicine prevents your ovaries from releasing eggs early during your IVF cycle. Lupron is given as a subcutaneous injection at the same time each day. The most common side effects are hot flashes, headaches, and vaginal dryness. In some situations a medication called Antagon® or Cetrotide® may be used in place of Lupron, or a different formulation of Lupron called microdose Lupron may be used.
2. Follicle stimulation
Another ultrasound will be performed approximately one week after beginning Lupron. If there are no cysts on the ovaries we will tell you when to start taking the medicine Gonal-F or Follistim. You will also decrease the daily dose of Lupron (usually to half the original dose), and continue at this dose through the day of your hCG (human chorionic gonadotropin) injection.
Gonal-F or Follistim can stimulate the ovaries to produce many eggs. This is important because we wish to choose the highest quality embryos for transfer to give you the best chance for pregnancy. Either Gonal-F or Follistim is given daily as a subcutaneous injection in the abdomen, thigh, or upper arm. Your doctor will determine the appropriate dose for you.
Hormone adjustment. Schedule another appointment for your fifth or sixth day after starting Gonal-F or Follistim. We schedule these appointments for the morning, between 7:00 and 9:00 a.m. We'll test your blood estrogen level and perform a vaginal ultrasound.
Based on these tests, your physician may adjust your daily dose of Follistim or Gonal-F. We'll call you in the early afternoon to explain the new dosage for the next few days and schedule your next ultrasound and blood estrogen level test. Your doctor may adjust your dose again. We will call you with your dosage information and schedule another appointment. This process will continue until your follicles are mature.
3. Follicular Maturation Trigger
When your follicles are mature, we will instruct you when to inject the hCG, a hormone that gives the eggs their last growth spurt. You must inject the hCG within a few minutes of the time that you are instructed to take it in a subcutaneous fashion. We'll also schedule a pre-operative examination and your egg retrieval. At the pre-operative exam, we will explain what to expect during the egg retrieval. Do not eat or drink anything after midnight the night before the egg retrieval.
4. Egg retrieval
You will need to arrive 45 minutes before the actual egg retrieval. After you enter the operating room, an anesthesiologist will give you intravenous sedation to make you as sleepy as you want to be.
For the egg retrieval, your physician will place an ultrasound probe along with a needle into the vagina. The needle will be moved through the back of the vagina into each mature follicle of the ovaries. Since the eggs are retrieved through the vagina, there will be no cut or incision on your abdomen. The fluid from each follicle--and its egg--will be drawn through the needle. The egg retrieval procedure usually lasts 20 to 30 minutes, depending on the number of mature follicles you have.
Fertilization - On the day of the egg retrieval, the male partner will need to produce a sperm specimen to give to the IVF laboratory to fertilize the eggs. He should abstain from ejaculating for three to five days before the egg retrieval. (Some men may require microsurgery to get a sperm sample.)
The eggs will be mixed with the sperm on the day of the egg retrieval. (In cases of male infertility, the sperm may be injected into the eggs in an ICSI procedure.) We will call you the next day to tell you how many eggs have fertilized.
Recovery- After the egg retrieval, you'll rest in the recovery suite for one hour. You should be driven home, where you must rest for the remainder of that day. You may have light vaginal bleeding and lower abdominal pain. A heating pad or acetaminophen (Tylenol) can help ease this discomfort.
Progesterone supplement - Begin the progesterone injections (1 cc given in the hip daily) on the day after your egg retrieval. Continue the progesterone injections or gel at the same time each day until the day of your pregnancy test. Progesterone helps provide the best possible uterine lining for attachment of the embryos.
5. Embryo Transfer
If there are fertilized embryos, we will schedule an appointment for embryo transfer three days after the egg retrieval. If you are a candidate for blastocyst embryo transfer, we may schedule the transfer for five or six days after the retrieval. We will discuss the condition of your embryos and how many we will transfer. In general, we transfer two to four embryos, depending on the age of the patient and other factors.
Following the embryo transfer, you will remain in the embryo transfer suite for a few minutes. You should be driven home, and rest in bed for the remainder of the day. Following a 36 hours of bedrest, you can do normal daily activities. But do not do strenuous exercise or have intercourse until the day of your pregnancy test.
6. Pregnancy test
We will schedule a pregnancy test at our laboratory for 2 weeks after your egg retrieval, before 9:00 a.m. One of our doctors will call you with results by mid-afternoon the same day and give you further instructions if the pregnancy test is positive. If the pregnancy test is negative, please make an appointment to speak with your physician about the cycle.
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