In Vitro Fertilization (IVF)

IVF involves the removal of eggs from the woman’s ovaries, fertilizing them in the laboratory with her husband’s sperm and replacing the fertilized eggs (embryos) into her uterus. Most infertility problems can be treated with IVF. This procedure is usually reserved for patients who have failed to conceive with less invasive and less expensive forms of therapy. IVF is an expensive procedure that is not always covered by insurance. Arkansas does have somewhat favorable laws mandating IVF coverage, but they do not apply to all policies. You should check with your insurance to see if you have IVF coverage. A brief overview of the IVF process is summarized below.

Pre-IVF Evaluation

A detailed medical history and physical exam will be performed by the physician to determine whether or not IVF is indicated. All relevant medical records and previous infertility treatments are reviewed. An assessment of the capacity of the ovaries to produce sufficient numbers of eggs (test of ovarian reserve) is done early in the pre-IVF evaluation. There are several ways to evaluate ovarian reserve including cycle day 3 FSH/LH/estradiol levels, the clomiphene challenge test and ovarian antral follicle count. Transvaginal ultrasound of the pelvis is performed to determine if there are any abnormalities of the uterus or ovaries that might interfere with the IVF cycle. An evaluation of the uterine cavity, either with hydrosonography or hysterosalpingogram (HSG) is also performed. A trial embryo transfer procedure is performed to make sure there will be no difficulty placing the embryos in the uterine cavity. A comprehensive semen analysis on the male is performed to determine if he has adequate sperm for the IVF procedure. Finally, the couple will meet with the IVF nurse to review the stimulation protocol and receive instructions on how to administer the fertility drugs.

Controlled Ovarian Hyperstimulation

Fertility drugs are administered to stimulate the ovaries to produce multiple eggs. They are given by subcutaneous injection. The drugs most commonly used are Gonal-f or Follistim. Other stimulatory drugs including Repronex, Menopur and Luveris may sometimes be used. In addition to the stimulatory drugs another drug, lupron, is given to prevent a premature LH surge. Two other related drugs, ganirelix (Antagon) or cetrorelix (Cetrotide) may be used instead of lupron to prevent the LH surge. The stimulatory drugs are usually given for 7-10 days. During this time the patient will return to the office every few days for blood tests and ultrasounds to monitor the response of the ovaries. When these tests indicate the eggs are mature, an injection of hCG (Ovidrel) is given to induce final maturation of the eggs.

Egg Retrieval

Approximately 36 hours after the Ovidrel injection the eggs will be retrieved. This is performed transvaginally under ultrasound guidance. The procedure is performed in our clinic under intravenous (IV) conscious sedation. The patient is heavily sedated, but is not asleep. The egg retrieval usually takes about 30 minutes to complete. Afterwards the patient is allowed to recover and is sent home about two hours later. Progesterone injections are started the day after the egg retrieval.

Fertilization of the eggs and embryo culture

A sperm sample from the husband is obtained shortly after the egg retrieval. The sperm and eggs are then mixed together in the laboratory and incubated overnight. (If there is a severe male factor the sperm may be microscopically injected into the eggs by a procedure known as intracytoplasmic sperm injection) The eggs are then evaluated the next morning for signs of fertilization. It is uncommon for all of the eggs to fertilize. On average, approximately 60-70% of the eggs will fertilize normally. The fertilized eggs are then placed in new culture media and placed back in the incubator where they will remain until the day of embryo transfer.

Embryo Transfer

Embryos are transferred either on the 3rd or the 5th day after the egg retrieval. The benefits of a day 5 versus a day 3 transfer are the subject of ongoing debate. Numerous studies, and our own experience, suggest higher pregnancy rates with day 5 transfers. However, depending upon the number and quality of embryos, not all patients will be suitable candidates for day 5 transfer. The IVF physician will discuss this issue with each couple and a decision will be made regarding the best day to transfer the embryos.

Embryo transfer is usually a painless procedure and does not require any sedation. The embryos are loaded in a small catheter which is placed through the cervix and into the uterine cavity. This is performed under trans-abdominal ultrasound guidance to ensure proper placement of the embryos in the uterine cavity. The number of embryos that are transferred depends on several factors including the embryo quality and the age of the woman. The IVF physician will discuss this with each couple and a decision will be made as to the number of embryos to transfer. In our program we typically transfer two or three embryos. Any additional embryos may be frozen for later use. After the embryo transfer the women is allowed to rest in the clinic for 30 minutes. She is then discharged home with instructions to remain at bedrest for the next two days. A pregnancy test is performed two weeks later to see if implantation has occurred.