IVF Information

The female partner is stimulated with medicine to make several eggs grow within the ovary. The eggs are then collected through the vagina using a sonogram-guided needle under sedation. Sperm is then added to the eggs to allow fertilization to take place. Fertilized eggs are then placed back in the uterus a few days later. IVF is effective for different types of infertility including tubal disease, male factor, ovulatory disorders, endometriosis and unexplained infertility.

What effect does female age have on getting pregnant and staying pregnant? Fertility rates decline with age. Although the average age of menopause is 52, most women are not very fertile after age 40. Miscarriage rates also rise with age. Lastly, pregnant women over 35 years have a higher rate of chromosome abnormalities such as Down Syndrome. Women over 35 years are encouraged to have a clomiphene citrate challenge test to determine egg quality before doing IVF.

Male Factor Procedures: If the husband has a normal semen analysis, then sperm are simply added to eggs and natural fertilization occurs. However, if the semen analysis is abnormal, then intracytoplasmic sperm injection (ICSI) is indicated. ICSI is a technique where a single sperm is injected directly into the cytoplasm (center) of the egg.

Risks associated with offspring born from ICSI procedures are still under investigation. While currently available data suggest that the risk of birth defects or major congenital defects in children born from ICSI is approximately that of the general population (approximately 3-4%), it is possible that such defects could occur as a result of the procedure. A higher incidence of abnormalities with the Y chromosome in male offspring (2-3% vs. 0.1-0.5%) from ICSI has been suggested. While the implications of such findings remain unclear, it is possible that male offspring may be at higher risk of fertility problems if such abnormalities occur. There also is a slight increased risk of sex chromosomal abnormalities from the ICSI procedure (0.8% vs. 0.23%) such as Klinefelter's Syndrome and Turner's Syndrome. Because ICSI is still a relatively new procedure, there may be additional risks that cannot be foreseen at present.

Assisted Hatching: Assisted hatching is a technique where a small hole is created in the zona pellucida (shell around the fertilized egg) by a needle or chemical solution to facilitate the embryo's release. Assisted hatching is performed just prior to embryo transfer. Patients who may benefit from this procedure include:

• Patients that are 38 years or older.
• Patients that have failed IVF in at least two previous attempts.
• Patients who are having frozen-thawed embryos transferred.
• Patients who have embryos with abnormally thick zonae pellucidae (shells).

Risks of the procedure include rarely destruction of the embryo and possibly increased chance for identical (monozygotic) twinning.

Which day should the embryos be placed back into the uterus? Initially, fertilized eggs were transferred back to the uterus after 1 day. Research then showed that transfer on day 2-3 was better. A few years ago, some studies showed that transfer back on day 5-6 was better still. On day 5-6, developing embryos are called blastocysts. However, more recent studies have shown that while blastocyst transfer is better in certain situations, day 2-3 transfer is better for most patients. The optimal day for your embryo transfer will be decided upon by the embryologist and your physician as the embryos develop. Extra viable embryos may be successfully frozen at different stages for later use.

Multiple gestation is a frequent complication of ART. If a pregnancy is achieved with ART, about 60% of the time there is only 1 baby, however, about 25-30% of the time there are twins, and the other 5-15% of the time triplets or more are present. While many couples are happy to have twins, the complications of pregnancy increase with the number of babies present. The most serious complication of multiple gestation is preterm labor with delivery of premature infants. Severe prematurity can result in the death or brain damage of a child. With proper prenatal care, the risks of premature labor can be lessened but not eliminated. Every effort is made to increase the chances for pregnancy with ART while minimizing the chances for multiple births. Though not offered in Kentucky, selective reduction is an option for some couples with high order multiples. The chance for complete pregnancy loss with selective reduction is between 10-25%.

Ovarian hyperstimulation syndrome occurs in 5% of patients. Approximately 5% of patients undergoing ART will develop ovarian hyperstimulation syndrome. This occurs when the ovaries are extremely sensitive to the fertility medication and become quite enlarged and swollen. If this occurs, most patients are successfully treated at home on bed rest, but rare patients have to be hospitalized. One value of the blood estrogen testing and vaginal sonograms is that individuals at high risk for developing this hyperstimulation syndrome can be identified. Rarely, enlarged ovaries can become twisted (ovarian torsion) which may require surgical removal.

ART babies may have more birth defects. The background risk for birth defects is 3-4%. IVF may increase the risk of birth defects as high as 6-8%. IVF pregnancies are high risk. There is an increased chance for pre-term delivery, low birth weight, birth defects, chromosomal abnormalities, brain damage and death. There may be an increased risk of genetic diseases. Increased maternal complications can also occur such as preeclampsia, placental abruption and need for C-section. Any patient over age 35 is at an increased risk for chromosomal abnormalities such as Down Syndrome and should consider a genetic amniocentesis if pregnancy occurs.

ART pregnancies may end in either a miscarriage or an ectopic pregnancy. The chance for miscarriage is slightly reduced with IVF since supplemental progesterone is used and certain non-viable embryo abnormalities are eliminated and not transferred such as triploidy. Overall, miscarriage rates increase with maternal age. The chance for a tubal or ectopic pregnancy is about 1-2%. Embryos circulate within the uterus for a few days prior to implanting and rarely can become lodged in a fallopian tube. Tubal pregnancies require either surgical or medical intervention.

The medications used in ART possibly are associated with ovarian cancer. An epidemiological study in the early 1990's suggested that Pergonal use might increase the chances for developing ovarian cancer later in life. However, many more recent studies do not agree. Patients who have infertility already have a higher chance of getting ovarian cancer on the basis of the infertility alone and it is difficult to separate out the various risk factors. Clearly, more study is needed on this matter before definitive conclusions can be made about Pergonal either way. Gonal-F, Follistim, Bravelle, Repronex and Humegon are very similar medications to Pergonal and these concerns may also apply to them.

Step By Step Instructions

Prior to starting an IVF cycle, basic preliminary tests are required on the female such as a uterine cavity study and preconception blood testing. The male partner also needs to have the preconception blood tests as well as a current Semen Analysis preferably within 6 months.

The month we will be initiating treatment, call the office on the first or second day of your menstrual cycle. If your menstrual cycle falls on a weekend call on Monday. We will be starting you on oral contraceptive pills the cycle prior to IVF to suppress ovarian androgen production as well as for scheduling purposes. Your nurse may have given you a written schedule to go by on when to start the oral contraceptives. If so, please follow the nurse's instructions.

Lupron injections are begun while on oral contraceptives. Lupron is given to prevent spontaneous ovulation during the IVF cycle. The usual starting dose of Lupron is 0.5 mg or 0.1 cc (with some syringes 10 units) daily.

Stop the oral contraceptives on the date indicated. When your period starts on the Lupron, continue the medication but decrease the dose to 0.25 mg or 0.05 cc (with some syringes 5 units) daily.

We will schedule a sonogram and a baseline estrogen level. If these are normal, we will begin the hormonal stimulation in addition to the Lupron injections. Typically, we start the hormonal injections (Gonal F, Follistim, Bravelle or Repronex or equivalent) on a Monday.

The hormonal injections are continued daily until the eggs are mature. Typically you are seen every 2-4 days during this time for ultrasound monitoring and blood estrogen levels.

When the eggs are mature, you will be instructed to take the hCG injection at a specific time. This injection is timed about 34 hours before the egg retrieval. The timing of the hCG injection is critical and if it is given at the wrong time, pregnancy may not occur. Husbands are asked to abstain from ejaculation for 3 days prior to the egg retrieval.

The day of the egg retrieval, you will be given IV sedation and will sleep through the egg retrieval. At the end of the egg retrieval, we will know how many eggs were retrieved.

Generally, the husband will collect his semen specimen at the Andrology Lab collection room while the wife is undergoing the egg retrieval. If this is not possible, other arrangements can be made but the semen has to arrive within one hour of collection and be kept body temperature warm.

Beginning after the egg retrieval, please take the progesterone, prednisone, antibiotic, pain medication and any other medication as directed.

We will know how many eggs are fertilized the day after the egg retrieval. The fertilized eggs (embryos) are generally placed back into the uterus 3-5 days later. The embryo transfer is a simple procedure and does not require anesthesia. Any extra embryos can be frozen for later transfer, however many couples will not have extra embryos to freeze.

Two weeks after the egg retrieval, a blood pregnancy test is obtained. If you are pregnant, we will continue the progesterone injections through the 1st 10 weeks of pregnancy.

When the cycle doesn't work. There are several reasons why conception may not occur during the Assisted Reproduction Cycle. The treatment cycle may be canceled prior to egg retrieval if follicular development is unsuitable. Some eggs may not be fertilized and some embryos may not implant when transferred to the uterus. Failures at IVF procedures are frustrating. We share in your success and disappointments. If at any time you feel undue stress or just need to talk, please let us know of your feelings.

If pregnancy does not occur in the first IVF cycle, is there reason to try again? Yes, several studies conclude that IVF pregnancy rates are constant throughout the first 6 attempts. In other words, your chances for pregnancy are not decreased in your third IVF attempt because the first 2 attempts did not work assuming that there were embryos each time to transfer. Unfortunately, since many insurance companies do not completely cover IVF costs, few couples are able to afford to go through more than 3 cycles.