The Alta Bates IVF Program

I. Introduction

In vitro fertilization (IVF) and the related procedures of ICSI-IVF and GIFT are collectively known as assisted reproductive technologies (ARTs). Each ART treatment is complex and consist of many different steps. You will feel much more comfortable with them if you take the time to read the following information carefully. When you are fully aware of all the aspects of ART, you will know better what to expect at each step and will have realistic expectations.

Even though a high percentage of patients achieve pregnancy in their first attempt, it is best to think of ART as an ongoing series of treatments which, we hope, will eventually allow you to conceive and deliver a healthy baby. Furthermore, depending on your age, type, complexity and severity of your infertility, it may take more than one attempt for you to conceive and deliver a healthy baby.

We recommend that ART treatments be undertaken at intervals of at least 2 to 4 months. This allows each couple to recover fully as well as to have the benefit of any new advances which might occur during the interval. There appears to be little if any decrease in the chance of success in repeat cycles up to 4.

In the course of your treatment you may meet other couples with similar problems. We realize that infertility can be a very stressful and frustrating experience. It often helps to know that you are not alone and to share your feelings.
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II. Patient Selection

Couples are selected for ARTs on the basis of the following causes of infertility:

Absence, damage or blockage of fallopian tubes due to previous inflammation or surgery (IVF)
Endometriosis (IVF or GIFT)
Unknown factors with entirely normal evaluation, including age-associated infertility (IVF or GIFT)
Poor cervical mucus (IVF or GIFT)
Male factor infertility (ICSI-IVF)

One of the universal findings in reproductive medicine has been the profound adverse effect of woman's advanced age upon the likelihood of successful outcome. For that reason, we generally do not recommend initiating ART treatments in women beyond their 43rd birthday if they use their own eggs. Older women are excellent candidates for pregnancy initiation with donated eggs. The presence of a uterus and at least one functioning ovary is a prerequisite for IVF and GIFT.

With severe decreases in the sperm count, IVF may be difficult if not impossible. In most cases of severe male factor, normal fertilization rate can be achieved through ICSI (intracytoplasmic sperm injection). In the presence of one of the above female factors and markedly abnormal semen analysis, IVF can be combined with the use of donor semen alone or in conjunction with the partner's sperm.
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III. Pre-Treatment Preparation

A. Initial Visit and Screening Tests

At the time of the initial consultation, the physician reviews your history, performs a physical examination and formulates the treatment plan. Past medical records, especially operative reports, results of semen analyses and tests of ovulation (such as FSH and progesterone tests) should be sent to our office in advance of the initial visit or brought with you.

If you have undergone ART at another program previously, please bring detailed records so that we can review them with you in an attempt to assess that treatment and to learn from it. A form for release of medical information needs to be sent to each doctor who tested or treated you for infertility in the past.

At the time of this visit a trial transfer is done by passing a fine plastic tube into the uterus (womb) in order to assess the direction of the passageway through the cervix (the neck of the womb) and to measure uterine depth. The trial transfer is usually painless and allows us to perform the actual embryo transfer with as little irritation as possible.

Screening blood tests are ordered at that time. We test the woman for evidence of past exposure to Chlamydia, the microorganism most frequently responsible for tubal damage. If she shows evidence of antibodies to Chlamydia, antibiotics may be prescribed before treatment. A hormonal profile (FSH/LH/Estradiol and DHEA-sulfate) is also frequently obtained to tailor the stimulation regimen to the individual patient.

Both partners are tested for carrier status for hepatitis B and C, exposure to the HIV virus (causative agent of AIDS) and HTLV virus and RPR. Additional tests include rubella and chlamydia antibodies, prolactin and thyroid hormone tests. As with all tests, there are occasionally misleading results (false positive and false negatives) which may necessitate confirmatory testing. Repeat semen analysis is scheduled unless a very recent one is available. Patients are scheduled for a baseline ultrasound survey, hysteroscopy or a hysterosalpingogram in order to evaluate the pelvic anatomy. If one or both tubes are closed at the distal end (near the ovaries, forming a hydrosalpinx) removal of the damaged tubes may be advisable, because closed tubes lower pregnancy rates even with IVF.

For patients residing very far away from the San Francisco Bay Area for whom a trip for the interview and examination would add greatly to the cost and inconvenience, arrangements can be made by telephone with the help of their primary physician. Couples in need of accommodations in the East Bay are referred to nearby hotels and motels.
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B. Injection Techniques

Shortly before the first treatment cycle the patient's partner or designee needs to learn the technique of intramuscular and subcutaneous injections. VHS tapes demonstrating the injection technique are available from the office. One of the nurses then supervises the first injection at which time additional questions can be answered.

Please make sure that you have medications well in advance of starting the treatment cycle. We provide you with prescriptions and a list of participating pharmacies where the medications you will need can be obtained. Comparative shopping can be worthwhile as the medication prices do vary. Since many of these medicines are injectable, they are generally not stocked by most pharmacies and may need to be ordered, which can take a few days.
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IV. Actual IVF and ICSI-IVF Treatment Cycle

A. Controlled Ovarian Hyperstimulation

The single most important factor in improving the early success rate of ARTs was the transfer of more than one embryo (fertilized dividing egg). This is because a high percentage of early embryos do not implant. Furthermore, the maturity of each egg collected may not be ideal and only about 65% of eggs fertilize normally. While placing more than one embryo markedly increases the success rate, it also increases the chance of multiple pregnancy. In our experience, one of every three pregnancies in women under the age of 40 years is multiple, with the majority being twins.

In order to stimulate development of multiple follicles, which are the fluid-filled sacs containing the oocytes (eggs), you receive ovulatory medications (gonadotropins). The medications currently available in the United States are human menopausal gonadotropins HMG (Humegon, Pergonal and Repronex are the brand names) and highly purified FSH (Follistim, Gonal-F, and Fertinex).

HMG is a purified extract of two natural hormones, FSH and LH, which are released by the pituitary gland to stimulate the development of follicles in the ovary. HMG has been used for many years to stimulate ovulation in women who do not ovulate regularly. Since FSH and LH would be digested if given orally, HMG has to be administered by intramuscular injection. Recently "pure" FSH has become available and may be used in conjunction with or in place of HMG. FSH hormone is the primary active ingredient in both preparations and their effectiveness is similar. The FSH preparations are given subcutaneously.

Both HMG and FSH can overstimulate the ovaries to produce cysts, but this is rarely a serious complication. Most cysts resolve spontaneously over a period of a few weeks. More extreme degrees of ovarian enlargement and tenderness represent the hyperstimulation syndrome which is usually treated with bedrest. In rare cases, ovarian hyperstimulation syndrome may be so pronounced that intravenous fluids or even hospitalization may be required. With close monitoring and experience, the severe degree of ovarian hyperstimulation can usually be avoided. Gonadotropins have been used for many years without any evidence of increase in birth defects or spontaneous miscarriage.

Recently, concern has been raised that the use of fertility medications by infertile women may increase their long-term risk of developing ovarian tumors including cancer. Delivery appears to confer protection from that increased risk but the magnitude of the risk remains to be established. While relatively uncommon, ovarian cancer has a high mortality rate. Whether or not there is an association between the use of fertility medications and ovarian cancer remains unsettled as some of the best studies have shown no such association.

Other medications often used before and during stimulation with gonadotropins are leuprolide (Lupron) and nafarelin (Synarel). They are modifications of the hypothalamic hormone which controls the pituitary gland which in turn influences the ovaries. By using these medications we can eliminate the influence of the pituitary gland on ovarian stimulation and achieve recruitment of a larger number of follicles (fluid-filled sacs containing the eggs).

Leuprolide and nafarelin are usually started before menses (long protocol) but in women, whose ovaries are less sensitive to stimulation, leuprolide may be started at a lower dose after onset of the period (short protocol). Leuprolide is given in the form of self-administered subcutaneous injections in the morning while nafarelin is given as twice-per-day nasal spray. When leuprolide is to be begun before the onset of menses, we recommend that a barrier method of contraception (condoms, diaphragm or spermicidal jelly) be used during that cycle. If your period is more than 2-3 days delayed, please call the office to schedule a sensitive blood pregnancy test. While there is little reason to expect that leuprolide would cause any congenital anomalies, it might interfere with implantation of the fertilized egg in the uterus.

Whereas leuprolide and nafarelin are GnRH agonists, recently a GnRH antagonist, ganirelix (Antagon) has become available in the US for prevention of premature ovulation in women undergoing ovarian stimulation with gonadotropins. Ganirelix has a more rapid onset of action than the agonists and is usually started later 5-6 days after the start of gonadotropins. Thus the total number of injections with ganirelix is less than with leuprolide.. Ganirelix is administered subcutaneously.

An individualized treatment plan will be discussed with you prior to starting and again at baseline ultrasound so you will know what to anticipate. It is of utmost importance that we have your current telephone numbers so that we can always reach you and/or your partner in case there is a change in the treatment plan.
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B. Monitoring of Ovarian Response

Gonadotropins are usually started 2-5 days after the onset of menses. Prior to beginning the gonadotropins, a baseline ultrasound is done to detect any preexisting ovarian cysts. A vaginal probe is used so a full bladder is not necessary. Simple ovarian cysts are common and they usually resolve on their own. However, if a large cyst is found, it may need to be aspirated first or the treatment cycle may be delayed. At the baseline ultrasound, the nurse will dispense your supplies -- syringes, extra needles, and alcohol wipes. After three to four days of gonadotropins, a blood test is usually done to assess your response by measuring hormone estradiol which is secreted by the growing follicles in your ovaries.

Once your estradiol reaches 200-300 pg/mL another vaginal ultrasound is scheduled to examine the size and number of the follicles. Most patients have 5-6 ultrasounds. Ultrasound is harmless to you and to the developing eggs. Depending on the growth of the follicles and estradiol levels, variable doses of gonadotropins are given for a total of 9-13 days. Unlike some other programs, we monitor your response closely and frequently adjust the dose of medications in the course of stimulation.

When the follicles are mature on the basis of ultrasound and blood tests, you receive a single injection of human chorionic gonadotropins (HCG; Pregnyl and Profasi are the preferred brand names). The HCG injection is in the evening (generally at 8 to 11 PM). HCG provides for the final phase of egg development. It is a natural hormone produced by the placenta during pregnancy and is similar to the LH hormone which is released by the pituitary gland to trigger ovulation in spontaneous cycles. HCG has been used for many years and has not been associated with any increase in congenital abnormalities.
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C. Egg Retrieval

Oocyte retrieval, i.e., removal of the eggs from your ovaries, takes place about 36 hours after the injection of HCG just before ovulation would occur. At that time we collect as many eggs as possible. In the majority of cases the aspiration is done transvaginally with ultrasound guidance.

Ultrasound-guided retrieval is usually performed with intravenous sedation. A thin needle is introduced through the vagina into the ovaries and the eggs are aspirated. Aspiration of ovarian follicles causes moderate discomfort. Following this procedure you may have a small amount of vaginal spotting. Rarely there may be small amount of blood in your urine immediately after the aspiration which usually clears rapidly. Rare risks of ultrasound-guided aspiration are injury to the bowel, a blood vessel or bladder, infection and excessive bleeding. In the highly unlikely event one of these complications occurs, emergency major surgery might have to be performed to repair the injury.

In occasional cases retrieval can be done by laparoscopy, in the course of which it is possible to examine the ovaries, tubes and uterus so that additional information can be obtained.
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D. Semen Collection

We suggest that prior to the retrieval, your partner refrain from ejaculation for two to three days. We will keep you informed as to the progress of follicular development to enable him to judge when abstinence should begin. The morning of the egg retrieval, your partner provides a semen specimen by masturbation in a private area in our office. We understand that he may feel under stress but we have allowed ample time to avoid any problem in providing the specimen.
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E. In Vitro Fertilization and Embryo Development

About 6-8 hours after retrieval, the eggs are inseminated with sperm prepared by washing in culture medium. We recommend that all the eggs be inseminated so that there will be an optimal chance of obtaining several healthy-appearing embryos. The day after the retrieval, the eggs are examined for evidence of fertilization. The eggs are reexamined three days after retrieval.

8-cell embryo
Eight-cell embryo 3 days after retrieval

While transfer of multiple embryos increases the chance of pregnancy, it also increases the risk of multiple pregnancy. The decision regarding the number of embryos to transfer can be difficult. In making a recommendation we take into account the woman's age, the appearance of the embryos, the couple's prior history, the advisability of embryo freezing and the couple's concern about multiple pregnancy and the potential need for multi-fetal pregnancy reduction. In general, we transfer 2-3 embryos in women under the age of 35, 3-4 embryos in women aged 35-39, and 5-6 embryos in women over 40 years of age. Some couples may choose a lower number of embryos to have transferred because of concern about the risks of multiple pregnancy.

The embryos not transferred are either frozen for future use or discarded. If you have embryos which will be discarded, you may either permit us to study them first for research or quality control or you may choose to discard them without any study.

If you do not plan to freeze additional embryos for future use, if you are healthy and under 30 years of age, you may consider donating some of the eggs before fertilization to an infertile woman who does not produce eggs of her own. If you are willing to do so, please inform Dr. Chetkowski well in advance of the treatment cycle so that appropriate screening and arrangements can be completed. Even if you agree to donate extra eggs, we will only do so if a large number of mature eggs are recovered so that your decision would in no way decrease your own chance of conception in that cycle. Donation of the extra eggs may reduce your total expenses significantly.
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F. Embryo Transfer and Post-Transfer Care

The embryo transfer is done in a room adjacent to the laboratory. The transfer requires no anesthesia. If at all possible, we would like your partner to be present. We use an abdominal ultrasound to confirm that the catheter is within the uterine cavity. Therefore it is best if you drink extra fluid 1-2 hours and stop voiding about 1 hour before the transfer. In the usual position for a pelvic examination, a tiny catheter containing minute amount of fluid with the embryos is gently inserted into the uterus and the fluid is deposited.

You then rest for 5-10 minutes before discharge. Following transfer you might notice light spotting for a couple of days. For five days after the transfer we recommend that you refrain from vaginal intercourse and orgasm which are associated with uterine contractions which in turn could expel the embryos from the uterus. Otherwise, we leave it up to your discretion to what extent you may want to modify your usual activities. Bedrest after transfer is not required for high pregnancy rate.

Progesterone supplementation begins in the morning three days after egg retrieval. Currently, progesterone can be given in the form of daily IM injections or as a vaginal gel (Crinone 8%).

Two weeks after the retrieval a sensitive blood pregnancy test (quantitative HCG) is performed to determine if implantation (attachment of the embryo(s) to the womb) has taken place. It is important to have the test done even if you are spotting or bleeding. If the test is negative, progesterone is stopped and a period follows within a few days. If the test is positive, it is repeated in a couple of days to determine whether there is normal growth. In the presence of pregnancy, progesterone is continued unless a blood test determines that your ovaries are producing sufficient quantity of this hormone.

In some instances the first HCG test is higher than the second or is followed by a delayed heavy period despite the progesterone. These cases are classified as "biochemical" pregnancies, which do not progress to the clinical state. Biochemical pregnancies are not included in the calculation of the success rate in our program. If your pregnancy progresses normally, you will be scheduled for an ultrasound examination about 4 weeks after the retrieval in order to visualize the pregnancy. About 5% have been ectopic, i.e., in the tube. This complication usually requires a laparoscopy to remove the ectopic pregnancy.

With intrauterine pregnancies there is still the risk of miscarriage which increases with advanced age. We usually perform a second ultrasound examination at 9-10 weeks to confirm normal development of the fetus. If multiple pregnancy greater than twins is found, we discuss with you the relative benefits and risks of the multi-fetal pregnancy reduction procedure.
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G. ICSI Micro-fertilization and MESA

Couples with male factor infertility can use a powerful technique called intra-cytoplasmic sperm injection (ICSI) to realize their aim of parenthood. The ICSI procedure was initially developed for severe male factor cases when the number and/or functional capacity of sperm is not sufficient for standard IVF. The first baby from ICSI at the Alta Bates IVF Program was born in April 1995. Recently the use of ICSI has been extended to couples with milder forms of male-factor as well as couples with unexplained or multi-factorial infertility in order to avoid the low or absent fertilization which occurs in some of these cases and which can severely reduce the chance of success. The tests for functional capacity of the sperm (such as semen analysis, strict sperm morphology and the hamster egg penetration assay) do no always predict low or absent fertilization in the laboratory. While uncommon, this can happen even with sperm of men who had previously achieved pregnancy naturally and who have normal semen characteristics. Failed fertilization markedly reduces the number of embryos available and the likelihood of successful outcome. For this reason, we have recently extended the use of ICSI on some or all eggs to IVF cycles without obvious male factor with men who did not previously demonstrate normal fertilization rate in vitro.

During ICSI, a single sperm cell is injected directly into the egg. The procedure is carried out under a microscope while the eggs are kept on a warm stage at 30°C. During thee injection procedures, micromanipulators are used to reduce hand movements to microscopic movements. The sperm injection pipette is used to immobilize and then to inject the sperm into the egg while it is kept stationary using a holding pipette. After egg retrieval, about 80 to 100% of the eggs are expected to be mature for sperm injection. A small percentage of the eggs may be damaged by the ICSI procedure. Not all eggs will fertilize after ICSI and some fertilized eggs may not divide into a cleavage stage embryo. Overall, however, the live birth rates with ICSI equal those achieved by conventional IVF. For most couples with severe male factor infertility, ICSI is the only option available to achieve parenthood with their own gametes.

ICSI Procedure

In cases where the ejaculate does not contain sperm, MESA (microsurgical epididymal sperm aspiration) is performed by a urologist specializing in infertility on the same day that the eggs are retrieved or in advance of the ICSI-IVF cycle. Epididymal and testicular sperm require ICSI for fertilization. During the MESA procedure it is common to obtain more sperm than needed for the ICSI treatment and the additional sperm can usually be frozen for future attempts.

The risk of genetic abnormalities in children born form ICSI has been of equal concern to patients and health professionals. Studies carried out world-wide showed that some forms of congenital abnormalities had a higher incidence in male babies born from ICSI but the most recent studies showed no difference between IVF with and without ICSI. Men with marked sperm abnormalities have a high chance of carrying mild genetic abnormalities which would then be transmitted to their offspring conceived through ICSI but would not be the result of the ICSI procedure itself. Specifically, men with very low sperm counts often have deletions or mutations in the long arm of the Y chromosome which would be passed on to their sons born from ICSI. Therefore, when the sons born form ICSI reach reproductive age, they may also find that they are sub-fertile or infertile due to the genes inherited from their fathers.
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H. Assisted Hatching

Assisted hatching is a laboratory procedure designed to facilitate implantation or attachment of the dividing embryos to the wall of the uterus. In order for implantation and pregnancy to occur, the embryo must "hatch" out of the zona pellucida (the egg's outermost membrane). In some patients, failure to establish a pregnancy after IVF may be related to the inability of the embryos to get out of the zona. On the day of transfer, a small opening is created in the zona pellucida under microscopic control, thus aiding the hatching process.

Our recent results indicate that most, if not all, patients may benefit from assisted hatching. Therefore, assisted hatching is currently done before all Day 3 transfers. On the day of transfer, a small opening is created in the zona pellucida under microscopic control. Assisted hatching is not currently done on blastocysts with Day 5 transfers.

Assisted Hatching Procedure
Assisted Hatching 3 days after retrieval

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I. Prenatal Care

After pregnancy has progressed normally to 10 to 11 weeks, you return to your obstetrician for prenatal care and delivery. There is no increase in the rate of congenital abnormalities after standard ART. While the number of infants born after ICSI is smaller, there is also no increase in the rate of congenital abnormalities with ICSI. Therefore, the rates of congenital anomalies in the general population, with standard ART and with ICSI are all equal at 2-3%.

Chromosomal abnormalities are detected through amniocentesis or CVS (chorionic villus sampling). Since amniocentesis and CVS are not risk free, we do not recommend them for all pregnancies established through IVF or GIFT. We believe they should be performed for the usual indications such as maternal age above 35 years or history of a previous anomaly. At this time, it may be appropriate to consider genetic testing in some pregnancies established through ICSI-IVF. In order to further our understanding of the IVF process, and to comply with reporting requirements, it is most important that you keep us informed of the progress and outcome of your pregnancy, especially if there are any problems. We count on you to ensure that your obstetrician will also provide us with all relevant medical information.
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J. Reasons for Delay or Cancellation of a Treatment Cycle

Infection of the male reproductive tract (prostatitis) may be evident on semen analysis or semen culture, even though the man may be entirely without symptoms. Since infection is associated with decreased fertilization rate and can introduce contamination into the laboratory, we attempt to first eradicate the infection with antibiotics before proceeding with IVF. Sometimes prolonged treatment is required.

If review of your past tests of tubal patency (HSG and/or laparoscopy) indicates that you have dilated distally closed tube(s) which are known as hydrosalpinx, removal of the tube(s) by laparoscopy will be discussed with you and may be advisable before starting IVF. Hydrosalpinx fluid interferes with embryo implantation decreasing pregnancy rate by as much as 60%. The presence of hydrosalpinges also increases the risks of severe pelvic infection and ectopic pregnancy.

About 10% of women fail to respond to the ovulatory medications adequately. Some develop no follicles and some develop only a single follicle. These cycles are canceled before egg retrieval. Evaluation of the hormones FSH and Estradiol on day 3 of the cycle permits identification of some of the patients who are likely not to respond to ovarian stimulation. It has been shown that falling values of estradiol are seen in unsuccessful cycles. Therefore, patients exhibiting a large fall in serum estradiol before hCG do not usually undergo retrieval. A small percentage of patients ovulate prematurely before retrieval because their pituitary gland initiates the process before we administer hCG. Occasionally patients develop such a large number of follicles with very high levels of estradiol that hCG needs to be withheld lest they develop severe hyperstimulation of the ovaries.

We believe that retrieval should be performed only after optimal ovarian response and that it is in your best interest not to proceed to retrieval under less than ideal conditions. If you are canceled before retrieval, we recommend waiting 2-3 months before starting another cycle of treatment with appropriate modification of the ovarian stimulation protocol. A follow-up visit in the interval is recommended.

The maturity of oocytes varies considerably and not all fertilize. The average fertilization rate is about 65%. In rare cases no eggs fertilize. Sometimes the sperm prove incapable of fertilization despite a normal semen analysis. In such cases, ICSI can be done the day after retrieval ("rescue ICSI"). While fertilization can usually be established, the pregnancy rate with "rescue ICSI" is lower than in cycles with timely fertilization. At other times the eggs are not as ready to be fertilized as they appear to be by ultrasound and blood tests. Finally, cell division and embryo development may fail to occur despite apparently normal fertilization. In some cases embryo quality may not be optimal or the embryos may stop developing.

Obviously the embryo transfer would have to be canceled if one of these problems arose, but fortunately they are quite uncommon and over 90% of patients in our program undergo transfer of fresh embryos.

Handling of the eggs, which are very minute, outside of the body is inherently hazardous and requires great skill and care. On occasion, an egg or an embryo, fresh or frozen, may get stuck to the side of a culture dish and cannot be found. These kinds of mishaps are rare but you need to be aware of their possibility.
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V. GIFT Procedure

GIFT (gamete intra-fallopian transfer) can be used by infertile women with entirely normal fallopian tubes. Candidates for GIFT include couples with unexplained and age-associated infertility, minimal endometriosis and poor cervical mucus who have failed inseminations. The national success rate has been higher with GIFT than IVF but in our own experience, the two procedures appear similar.

The initial steps, i.e., ovarian stimulation and monitoring, are similar in GIFT and IVF. GIFT requires laparoscopy. At the time of the GIFT laparoscopy eggs are placed together with previously prepared sperm in the end of the fallopian tubes so that fertilization occurs at its natural location. Therefore, no embryo transfer is necessary but progesterone supplementation would still be given. The ectopic pregnancy rate is about 5%.

One of the drawbacks of GIFT is that it provides less information about the fertilizing capacity of the sperm which can be deficient, even with a normal sperm count. Therefore, unless there is prior evidence of fertility in the man, the GIFT procedure is not generally performed in the first treatment cycle.

If the GIFT procedure cannot be performed due to technical reasons at the time of the laparoscopy (e.g. inability to cannulate the tubes), then IVF can always be done in the same treatment cycle.
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VI. Embryo Freezing

If more eggs are normally fertilized and divide to form healthy-looking embryos than is advisable to replace during the treatment cycle, the additional embryos can be frozen and stored for replacement in the future. However, the embryos may not survive the freezing process or may be incapable of resuming growth after thawing. Offspring born from frozen embryos have the same rate of congenital abnormalities as the general population. When damage occurs during the freezing process, the pregnancy usually does not ensue. The likelihood of establishing a pregnancy following transfer of frozen-thawed embryos is about 15-20% per transfer.

Once frozen, the embryos can be maintained in storage for several years, but we encourage replacement within 2 years of fertilization whenever possible. The consent form for embryo freezing requests that you indicate how you would like to dispose of the frozen embryo(s) in case of divorce and death. The options include donating the embryos anonymously for the benefit of another infertile patient or discarding them. While the embryos remain in storage, you need to pay an annual fee.
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Alta Bates IVF Program - 2999 Regent Street #101A - Berkeley, California 94705 USA
Telephone: 510-649-0440 - FAX: 510-649-8700 - E-mail: abivf@pacbell.net

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