In Vitro Fertilization
In vitro fertilization or “test tube baby” is one of the biggest advances in the field of infertility, bringing its inventor the Nobel Prize. The simple concept behind IVF is to “unite” the sperm and egg in a test tube dish, unimpeded by various factors causing infertility. These factors can include tubal blockage, pelvic scarring, very low sperm counts/motility or abnormally shaped sperm, advanced age/low ovarian reserve, endometriosis, unexplained infertility, ovulation problems not solved by ovulation induction or IUI, need for genetic testing on the embryo, fertility preservation and others.
While IVF can be performed without ovarian stimulation (called natural cycle IVF), to increase the success rates and number of eggs and embryos available, typically an ovarian stimulation protocol is needed. The ovarian stimulation can be performed with various ways but the two main types are “agonist” and “antagonist” cycles. To prevent your ovaries from ovulating during the stimulation, we need to administer certain drugs which are called GnRH agonists (e.g. lupron) or antagonists (e.g. ganirelix, antagon, orgalutron etc.). Because agonists have an initial stimulatory effect on the follicles and to minimize the risk of cyst formation due to this stimulatory effect, it is usually started before the menstrual period preceding the IVF cycle, typically 7-10 days prior. The antagonists on the hand do not have this “flare” effect hence they are started after your ovarian stimulation is under way and when your largest follicle reaches certain size where the risk of early ovulation is high. We generally prefer the antagonist cycle because of its ease on our patients and less need of medications. However, either protocol seems to be equally successful and antagonist protocol allows more timing flexibility. With the antagonist protocol, we have to start the stimulation by the third day of your menstrual cycle. In contrast, once you are suppressed on lupron, we can hold the start of your cycle for weeks, if needed, for scheduling or timing purposes.
Ovarian stimulation is generally performed with Follicle Stimulating Hormone (FSH) injections for IVF patients. This is a hormone your body naturally produces to support the growth and ovulation of one egg. To enable your ovary to grow multiple eggs, we supplement FSH hormone in the form of subcutaneous injections (e.g. Follistim, Gonal-F, Menopur, Repronex etc.). It generally takes 10-12 days for follciles (eggs) to reach the desired size before a final injection of hCG is given to initiate the ovulation process. Egg retrieval is scheduled 34-35 hours later, 1-2 hour before ovulation would normally occur. To determine the correct timing of the hCG shot and to ensure that you are receiving the right dose of FSH, we monitor you with ultrasound exams every 1-3 days depending on the situation.
Oocytes are collected in the office under light anesthesia via transvaginal ultrasound guided needle aspiration. Typical recovery is around 30 minutes and you will be able to leave the premises accompanied by an adult after that time.
Several hours after the egg retrieval, eggs are inspected and cleaned from the surrounding support cells and then either inseminated or injected with sperm (see ICSI). The next day, our embryologists check for signs of fertilization. Fertilized embryos are cultured for an additional 2-4 days to be transferred as cleavage stage (generally day 3) or blastocyst stage (generally day 5) embryos. We in general prefer blastocyst stage transfer as it gives us a longer opportunity to observe the embryos and make a better selection. Implantation rate of blastocyst embryos is higher, enabling us to perform a single embryo transfer in most cases. Of course each case is unique and we make our recommendations based on many other factors as well as following the American Society of Reproductive Medicine guidelines.
We perform embryo transfer under ultrasound guidance to ensure better precision. Embryo transfer is a painless procedure similar to IUI where embryo or embryos are passed into the uterus with a thin catheter without a need for anesthesia.
After the egg retrieval, you typically receive progesterone hormone supplementation, tailored to your case. Pregnancy test is performed 10-14 days after your embryo transfer, depending on the stage of embryo transfer. Progesterone treatment is generally continued until the fetal heart beat is detected.