In Vitro Fertilization (IVF-ET)
In Vitro Fertilization Pre-Embryo Transfer (IVF-ET) is a fertility procedure which first succeeded as recently as 1978 by Dr. Edwards (an embryologist) and Dr. Steptoe (a gynecologist) in England. Since then the technology has been further refined and developed by physicians and embryologists, with over 20,000 babies born worldwide.
The possibility of a continuing pregnancy being achieved by IVF has improved from practically nil to one chance in 4 to 6 at IVF centers worldwide.
The possibility of a pregnancy being achieved for any one patient cannot be predicted, as it depends on many variables - such as age and the reproductive health of both the wife and the husband. Although the chance of success varies from case to case, a thorough evaluation is required to predict the probability of pregnancy in any given situation.
IVF Without Surgery - Transvaginal Oocyte Retrieval
Due to improvements in ultrasound imaging, surgery is no longer necessary for most In Vitro Fertilization patients. A technique for recovery of eggs from the ovary is described below. It uses a sonographically-guided needle to replace the surgical procedure which previously was used to recover oocytes (eggs). This procedure, called Transvaginal Oocyte Retrieval, requires neither hospitalization nor general anesthesia.
In order to prepare a proper environment in the woman and to increase the chances of recovering several healthy and mature eggs, the woman will undergo about two weeks of intensive preparation. This will include hormonal therapy with "fertility drugs." Blood tests and ultrasound scans of the ovaries are used to determine the optimal time to retrieve the eggs from the ovary. This optimal time is just before ovulation when the oocytes are almost ready for fertilization.
At the proper time, an outpatient procedure under local anesthesia will allow the female's eggs to be visualized by ultrasound and retrieved from the ovary by placing a needle through the vaginal wall. The mild discomfort that the patient feels has been described as similar to a Pap smear or endometrial biopsy. After a short rest, the patient will be able to go home and resume normal activities.
The fluid from the follicles is examined under the microscope by the embryologist, who locates the eggs and keeps them in the laboratory under physiologic conditions. The embryologist will place the sperm with the eggs when they are ready for fertilization. Usually, the eggs will develop into cleaving pre-embryos, whose cells divide 2 or 3 times to become preimplantation embryos (pre-embryos). They are maintained in laboratory dishes, in a nutrient mixture which acts as a substitute for the environment that would otherwise have been provided by the fallopian tubes.
Using a special catheter, the couple's pre-embryos will be passed through the vagina and into the uterus at the time the pre-embryos would normally have reached the uterus (2+ days after retrieval).
After the pre-embryo placement in the uterus, the patient will lie quietly in a bed for about an hour, and then will return home.
IVF-ET- Questions and Answers
- Q: Will the IVF technique damage my ovaries?
- A: There is no evidence to suggest that either normal laparoscopy or ultrasound egg retrieval damages the ovaries. In fact, some reports in the medical literature suggest that following ovarian biopsy, pregnancies occur in couples with a long-term history of infertility.
- Q: Will scar tissue around my ovaries make it impossible to retrieve the eggs?
- A: Not ordinarily. The surgeon must be able to see the follicles in order to guide the needle to the proper spot for retrieval of the eggs whether by sonographic (ultrasound) or surgical methods.
- Q: What if I ovulate before oocyte (also called egg or ovum) retrieval?
- A: Once ovulation has occurred it is impossible to retrieve the eggs. The entire team of physician, nurse and embryologist will monitor your cycle very carefully to avoid premature ovulation.
- Q: If an egg is not retrieved or if the technique does not produce a pregnancy on the first attempt, how soon can the procedure be repeated?
- A: This depends on the individual. The primary reason for delay is to allow the patient's normal menstrual cycle to resume, which may take 2 to 3 cycles.
- Q: How many times will IVF be repeated per couple?
- A: There is no specific number. This is determined by the couple together with the physician.
- Q: Can we have intercourse during the two-week period before an IVF procedure is performed?
- A: Most definitely. We recommend that the husband refrain from ejaculation for at least 48 hours, but for no more than 5 to 6 days preceding egg retrieval. This precaution assures that the semen sample obtained for IVF will contain a maximum number of healthy, motile sperm.
- Q: After the IVF procedure, how long must we wait to have intercourse?
- A: Although a definite time of abstinence to avoid damage to the pre-embryo has not been determined, most experts recommend abstinence for two to three weeks. Theoretically, the uterine contractions associated with orgasm could interfere with the early stages of implantation. However, intercourse the night before pre-embryo transfer is acceptable. Some physicians will advise intercourse before transfer as they feel that this will improve the chances of a pregnancy.
- Q: What about other activities? How soon can I resume my normal routine?
- A: The IVF team recommends that the patient be sedentary for a full 24 hours following pre-embryo placement in the uterus. Strenuous exercises such as jogging, horseback riding, swimming, etc. should be avoided until pregnancy is confirmed. Otherwise, the patient is free to return to her regular activities.
- Q: How soon will I know if I'm pregnant?
- A: Pregnancy can be confirmed using blood tests about 13 days after egg aspiration. Pregnancy can be confirmed by ultrasound 30 to 40 days after aspiration.
- Q: I had my tubes tied (tubal ligation) several years ago. Would I be a candidate for IVF?
- A: Perhaps, in certain situations, IVF may be cheaper and physically less demanding than surgery to repair you fallopian tubes.
- Q: Is IVF covered by insurance companies?
- A: Unless your health insurance policy provides infertility coverage it is unlikely that IVF coverage is provided. Frequently insurance policies will cover infertility but exclude IVF. This has been successfully challenged in the legal system. Consultation with your lawyer may be necessary to review you insurance companies refusal to provide IVF coverage. If, however, IVF is combined with surgical procedures used for diagnosis, insurance carriers may pay for much of the procedure. However, coverage will depend on the terms of your policy. For infertility alone, most insurance policies will not provide
- Q: What drugs are given to stimulate the ovarian follicles and to maintain the lining of the uterus prior to implantation of the pre-embryo?
- A: Four to five medications normally are given:
1. Leuprolide acetate (Lupron), an injectable drug that blocks secretions of the pituitary gland, thereby optimizing the number of oocytes retrieved;
2. Human menopausal gonadotropin (Pergonal or hMG) or Follicle Stimulating Hormone (Metrodin or FSH), hormones that stimulate ovarian activity, are injected daily for about 6-10 days prior to the procedure;
3. Human chorionic gonadotropin (hCG), a hormone that mimics the action of the hormone which naturally induces ovulation, is injected 34 to 36 hours before retrieval and may be used after retrieval to supplement natural progesterone production;
4. Progesterone, a natural hormone that enables the uterus to support pregnancy, may be used as a daily injection after egg retrieval; and
- Q: What side effects, if any, can these drugs cause?
- A: No pronounced side effects have been associated with any of these drugs. However, the patient should inform the physician of ANY allergies she has or of any previous adverse reactions to drugs.
- Q: Will I have an egg in every follicle?
- A: It varies from patient to patient . As many as half of the follicles may not contain an egg in some patients.
- Q: Is there a possibility of multiple births with IVF?
- A: Yes, when multiple pre-embryos are transferred. 25%. of pregnancies with IVF are twins. (In normal population, the rate is one set of twins per 80 births.) Triplets are seen in approximately 2-3% of pregnancies.
- Q: Is there an increased chance of birth defects if I become pregnant through IVF?
- A: There are no known ill effects. Abnormal pre-embryos, even those produced through normal fertilization, do not seem to mature. However, any long-term effects of IVF remain to be determined.
- Q: How much time does the entire procedure require?
- A: Approximately three weeks (all as an outpatient). Fertility drugs are administered to stimulate the ovaries. Then during the four to six days prior to ovulation, the patient is monitored by ultrasound as well as by hormone levels.
- Q: What happens to any extra pre-embryos?
- A: A maximum of four pre-embryos will be transferred to the uterus for possible implantation. Patients will have several other options regarding the disposition of the remaining pre-embryos. One option is to freeze pre-embryos for your later use. Other options are to donate or simply dispose of them. Excess pre-embryos, if any, belong to you, and you will determine what is to be done.