In Vitro Fertilization


Overview


In vitro fertilization (IVF) is a sophisticated series of procedures used to treat fertility or genetic problems and assist with the conception of a child. IVF is the most effective form of assisted reproductive technology.
During IVF, mature eggs are collected (retrieved) from your ovaries and fertilized by sperm in a lab. Then the fertilized egg (embryo) or eggs are implanted in your uterus. This process requires preparation and usually takes at least 8-11 days. The procedure can be done using your own eggs and your partner's sperm. Or IVF may involve eggs, sperm or embryos from a known or anonymous donor. In some cases, a gestational carrier — a woman who has an embryo implanted in her uterus — might be used.
While, in general, chances of success with IVF are excellent, your chances of having a healthy baby using IVF depend on many factors, such as your age and the cause of infertility. There are additional factors that must be considered including time, cost and the need for significant intervention. If more than one embryo is implanted in your uterus, IVF can result in a pregnancy with more than one fetus (multiple pregnancy). Your doctor can help you understand how IVF works, the potential risks and whether this method of treating infertility is right for you.

Why it's done


In vitro fertilization (IVF) is a treatment for infertility, significant genetic problems, and patients with recurrent pregnancy loss. While IVF is often not the first-line treatment for most patients, it is always the most effective treatment. Many patients will arrive at this choice after trying other treatments such as controlled ovarian hyperstimulation or and/or intrauterine insemination.

There are numerous reasons why IVF is used for patients. Age is often the single greatest factor, especially in women with diminished ovarian reserve, where chances become more limited. IVF can also be done if you have certain health conditions:

Tubal Factor:

Fallopian tube damage or blockage, whether because of infection, surgery or previous tubal ligation, makes it difficult for an egg to be fertilized or for an embryo to travel to the uterus.

Ovulation disorders:

If ovulation is infrequent or absent, fewer eggs are available for fertilization.

Endometriosis.

Endometriosis occurs when the uterine tissue implants and grows outside of the uterus — often affecting the function of the ovaries, uterus and fallopian tubes.

Genetic Anomalies:


If you or your partner is at risk of passing on a genetic disorder to your child, you may be candidates for preimplantation genetic diagnosis — a procedure that involves IVF. After the eggs are harvested and fertilized, they're screened for certain genetic problems. Embryos that don't contain identified problems can be transferred to the uterus.
Fertility preservation for age, cancer or other health conditions: If you're about to start cancer treatment — such as radiation or chemotherapy — that could harm your fertility, IVF for fertility preservation may be an option. Women can have eggs harvested from their ovaries and frozen in an unfertilized state for later use. Or the eggs can be fertilized and frozen as embryos for future use. Women who don't have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF, to allow for another woman to carry the pregnancy as a surrogate or gestational carrier

Male Factor:

Below-average sperm concentration, weak movement of sperm (poor mobility), or abnormalities in sperm size and shape can make it difficult for sperm to fertilize an egg. If semen abnormalities are found, your partner might need to see a specialist to determine if there are correctable problems or underlying health concerns.

Unexplained infertility:

Unexplained infertility means no cause of infertility has been found despite evaluation for common causes. IVF is universally accepted as the most effective treatment for unexplained infertility.

Uterine fibroids:

Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s and 40s. Fibroids can interfere with implantation of the fertilized egg and increase the risk of miscarriage.

Diminished ovarian reserve:

Premature ovarian failure is the loss of normal ovarian function before age 35. If your ovaries fail, they don't produce normal amounts of the hormone estrogen or have eggs to release regularly.

Risks


Specific steps of an in vitro fertilization (IVF) cycle carry risks, including:

Pain:

Despite what you may hear, the procedure itself is essentially painless as we use adequate anaesthesia to keep you comfortable. However, depending on the number of eggs retrieved, there can be mild and occasionally moderate discomfort after the procedure lasting one or two days.

Injury:

Injury at the time of IVF is extremely rare. We are pleased to report we have never had an injury in our program. We use every available safety precaution to avoid any chance of harm to patients.

Multiple births:

IVF increases the risk of multiple births if more than one embryo is implanted in your uterus. A pregnancy with multiple fetuses carries a higher risk of early labor and low birth weight than pregnancy with a single fetus does. Premature delivery and low birth weight. Research suggests that use of IVF slightly increases the risk that a baby will be born early or with a low birth weight.

Ovarian hyperstimulation syndrome:

Use of injectable fertility drugs, such as human chorionic gonadotropin (HCG), to induce ovulation can cause ovarian hyperstimulation syndrome, in which your ovaries become swollen and painful. Signs and symptoms typically last a week and include mild abdominal pain, bloating, nausea, vomiting and diarrhea. If you become pregnant, however, your symptoms might last several weeks. Rarely, it's possible to develop a more-severe form of ovarian hyperstimulation syndrome that can also cause rapid weight gain and shortness of breath. We use the most advanced techniques to essentially eliminate severe ovarian hyperstimulation syndrome.

Ectopic pregnancy:

About 2 to 5 percent of women who use IVF will have an ectopic pregnancy — when the fertilized egg implants outside the uterus, usually in a fallopian tube. The fertilized egg can't survive outside the uterus, and there's no way to continue the pregnancy. Birth defects: The age of the mother is the primary risk factor in the development of birth defects, no matter how the child is conceived. More research is needed to determine whether babies conceived using IVF might be at increased risk of certain birth defects. Some experts believe that the use of IVF does not increase the risk of having a baby with birth defects.

Cancer:

Although some early studies suggested there may be a link between certain medications used to stimulate egg growth and the development of a specific type of cancer, more recent studies do not support these findings.

Stress:

Use of IVF can be financially, physically and emotionally draining. Support from counselors, family and friends can help you and your partner through the ups and downs of infertility treatment.

How To Prepare For IVF


When choosing an in vitro fertilization (IVF) clinic, keep in mind that a clinic's success rate depends on many factors, such as patients' ages and medical issues, as well as the clinic's treatment population and treatment approaches. Ask for detailed information about the costs associated with each step of the procedure.

Before beginning a cycle of IVF using your own eggs and sperm, you and your partner will likely need various tests and investigations. These are the same tests we use to evaluate all fertility patients. To explore these tests click here. (hyperlink this to the list of tests that we’ve already outlined in the evaluation page) Before beginning a cycle of IVF, consider important questions, including:

How many embryos will be transferred? The number of embryos transferred is typically based on the age and number of eggs retrieved. Since the rate of implantation is lower for older women, more embryos are usually transferred — except for women using donor eggs.

Most doctors follow specific guidelines to prevent a higher order multiple pregnancy — triplets or more — and in some countries, legislation limits the number of embryos that can be transferred at once. Make sure you and your doctor agree on the number of embryos that will be transferred before the transfer procedure.

What will you do with any extra embryos? Extra embryos can be frozen and stored for future use for many years. Not all embryos will survive the freezing and thawing process, although most will. Cryopreservation can make future cycles of IVF less expensive and less invasive.

How will you handle a multiple pregnancy? If more than one embryo is transferred to your uterus, IVF can result in a multiple pregnancy — which poses health risks for you and your babies. In some cases, fetal reduction can be used to help a woman deliver fewer babies with lower health risks. This is critical when dealing with more than 3 fetuses simultaneously. Pursuing fetal reduction, however, is a major decision with ethical, emotional and psychological consequences. Have you considered the potential complications associated with using donor eggs, sperm or embryos or a gestational carrier? A trained counselor with expertise in donor issues can help you understand the concerns, such as the legal rights of the donor. You also may need an attorney to file court papers to help you become legal parents of an implanted embryo.

There are two different approaches to IVF: Natural Cycle IVF and multiple follicle IVF

Natural cycle IVF is ideal for patients who either desire to avoid medications, want a more natural approach, or for women with weakened ovaries. Numerous studies have demonstrated that patients undergoing natural cycle IVF have improved outcomes compared to multiple follicle IVF when they have previously failed standard IVF, have had prior poor fertilization or embryo development, or a history of diminished ovarian reserve. Natural cycle IVF is very simple. Patients are monitored with blood and ultrasound for the development of their natural monthly egg. When the egg develops to the size of 12-14mm, patients take a minimal amount of medication to continue egg growth and prevent premature egg release for just 3 – 4 days. At this point, patients use human chorionic gonadotropin injection to trigger egg release. Thereafter, they undergo a routine egg retrieval, ICSI to ensure fertilization and then either a day 3 or a day 5 embryo transfer. For patients wishing to undergo preimplantation genetic testing, this can still be done. Many patients will opt to undergo several natural IVF cycles, prior to beginning embryo transfers to collect a sufficient number of embryos. Natural cycle embryos can be frozen with the same success as multiple follicle IVF cycles.

Multiple Follicle IVF

Ovulation induction

If you're using your own eggs during IVF, at the start of a cycle you'll begin treatment to stimulate your ovaries to produce multiple eggs — rather than the single egg that normally develops each month. Multiple eggs are needed to improve your chances, maximize chances of a genetically normal embryo, and to improve the efficiency and value of the IVF process in some cases.

You may need several different medications, such as:

Medications for ovarian stimulation. To stimulate your ovaries, you might receive an injectable medication containing a follicle-stimulating hormone (FSH), a luteinizing hormone (LH) or a combination of both. These medications stimulate more than one egg to develop at a time. Medications for oocyte maturation. When the follicles are ready for egg retrieval — generally after eight to 14 days — you will take human chorionic gonadotropin (HCG) or a gonadotropin releasing hormone agonist (GnRHa) to initiate egg release. Medications to prevent premature ovulation. These medications prevent your body from releasing the developing eggs too soon. Typically, you'll need one to two weeks of ovarian stimulation before your eggs are ready for retrieval. To determine when the eggs are ready for collection, your doctor will likely perform: Vaginal ultrasound, an imaging exam of your ovaries to monitor the development of follicles — fluid-filled ovarian sacs where eggs mature Blood tests, to measure your response to ovarian stimulation medications — estrogen levels typically increase as follicles develop and progesterone levels remain low until after ovulation.

Sometimes IVF cycles need to be canceled before egg retrieval for one of these reasons:

Inadequate number of follicles developing

Premature ovulation

Excessive egg production

EGG COLLECTION


Egg retrieval will be done at our center 34 to 36 hours after the final injection and before ovulation. During egg retrieval, you'll be sedated and given pain medication. Transvaginal ultrasound guided retrieval is conducted, using a vaginal probe to visualize the ovaries, and then a very thin needle is passed through the vagina and into the follicles to retrieve the eggs. Multiple eggs can be removed in about 5-20 minutes. After egg retrieval, you may experience cramping and feelings of fullness or pressure. You will be kept in the procedure room till you meet discharge criteria. You will then be kept for up to one hour in a recovery area to ensure your wellness before you are discharged.

SPERM RETRIEVAL

If you're using your partner's sperm, he'll provide a semen sample at the IVF clinic at the time of the egg retrieval. This can be done through masturbation, or a sperm extraction procedure such as a percutaneous epididymal sperm extraction procedure, or previously frozen sperm can be used. Donor sperm also can be used. Sperm samples are carefully prepared through a gradient process in a centrifuge to remove protein, debris, and the semen itself, isolating only the sperm. The sperm are then placed in a solution that provides them with energy and are then ready to be used for IVF.

FERTILIZATION

Fertilization can be attempted using two common methods:

Insemination. During insemination, healthy sperm and mature eggs are mixed and incubated overnight. Mature eggs are placed in a nutritive liquid (culture medium) and incubated. Eggs that appear healthy and mature will be mixed with sperm to attempt to create embryos. However, not all eggs may be successfully fertilized. In general, approximately 50-60% of eggs will be fertilized and results can be seen 24 hours later. Intracytoplasmic sperm injection (ICSI). In ICSI, a single healthy sperm specifically chosen under a high-powered microscope, is injected directly into each mature egg. ICSI is often used when semen quality or number is a problem or if fertilization attempts during prior IVF cycles failed. In certain situations, your doctor may recommend other procedures before embryo transfer. In our program, our ICSI fertilization rate is extremely high, and we advise it for the vast majority of our cases and universally for our natural IVF cycles.

EMBRYO CULTURE


Embryos are grown in the lab for either 3, or 5-6 days. The choice is dependent on numerous factors. If the embryo number is low, and there is no desire for preimplantation genetic testing, the embryo(s) can be transferred on day 3, while in cases where numerous embryos are present, or if patients need genetic testing of their embryos, or in cases where only a single embryo is desired for transfer, day 5-6 blastocyst culture is considered the most appropriate method.

ASSISTED HATCHING

About five to six days after fertilization, an embryo "hatches" from its surrounding membrane (zona pellucida), allowing it to implant into the lining of the uterus. If you're an older woman, or if you have had multiple failed IVF attempts, your doctor might recommend assisted hatching — a technique in which a hole is made in the zona pellucida just before transfer to help the embryo hatch and implant.

Preimplantation genetic testing.



Embryos are allowed to develop in the incubator until they reach a stage where the portion of the embryo that will eventually become the placenta (trophectoderm) will extrude from the embryo and can be biopsied without any injury to the embryo(fetus) itself. These specimens can then be tested either for chromosomes (PGT-A) or for single gene abnormalities such as cystic fibrosis, BRCA mutations, or SMA mutations (PGT-M). Embryos that don't contain affected genes or chromosomes can be transferred to your uterus. While preimplantation genetic testing can reduce the likelihood that a parent will pass on a genetic problem, it can't eliminate all the risk. Prenatal testing may still be recommended.

Embryo transfer



Embryo transfer is done at the clinic in a very calm setting. The current recommendation is to consider first freezing embryos and then transferring the embryos into the patient as this improves success rates and results in a safer pregnancy, with less complications. However, in some cases embryos can be transferred fresh, such as when frozen embryo transfers have previously failed, or with natural IVF cycles. takes place two to six days after egg retrieval.

On the day of egg retrieval or several weeks prior to the time of embryo transfer, your doctor might recommend that you begin taking estrogen and progesterone supplements to make the lining of your uterus more receptive to implantation. Your doctor will work with you to determine which medications to use and when to use them.

The procedure is usually painless, although you might experience mild cramping. A speculum is first placed into the vagina and the cervix visualized. The cervix is then cleared of all mucous and an outer catheter is placed into the cervix. A syringe containing one or more embryos suspended in a small amount of fluid is attached to the end of the catheter. Using the syringe, the embryologist places the embryo or embryos into your uterus under careful ultrasound guidance. If successful, an embryo will implant in the lining of your uterus within 24 hours of transfer.

AFTER THE EMBRYO TRANSFER



After the embryo transfer, you can resume your normal daily activities. In general, we advise that you avoid extremes of stress, exertion, heat, or cold. We want you to find ways to minimize your stress as much as possible, so do whatever will result in the least amount of anxiety or concern.

RESULTS



About 12 days to two weeks after embryo transfer, your doctor will test a sample of your blood to detect whether you're pregnant. If you're pregnant, we will take care of you at VRC, or refer you to any specialist that you wish to see for your pregnancy. If you're not pregnant, you'll stop taking progesterone and likely get your period within a week. If you don't get your period or you have unusual bleeding, contact your doctor. If you're interested in attempting another cycle of in vitro fertilization (IVF), your doctor might suggest steps you can take to improve your chances of getting pregnant through IVF. The chances of giving birth to a healthy baby after using IVF depend on various factors, including:

Maternal age. The younger you are, the more likely you are to get pregnant and give birth to a healthy baby using your own eggs during IVF. Women age 41 and older are often counseled to consider using donor eggs during IVF to increase the chances of success. Embryo status. Transfer of embryos that are more developed is associated with higher pregnancy rates compared with less developed embryos (day two or three). However, not all embryos survive the development process. Talk with your doctor or other care provider about your specific situation. Reproductive history. Women who've previously given birth are more likely to be able to get pregnant using IVF than are women who've never given birth. Success rates are lower for women who've previously used IVF multiple times but didn't get pregnant. Cause of infertility. Having a normal supply of eggs increases your chances of being able to get pregnant using IVF. Women who have severe endometriosis are less likely to be able to get pregnant using IVF than are women who have unexplained infertility. Lifestyle factors. Women who smoke typically have fewer eggs retrieved during IVF and may miscarry more often. Smoking can lower a woman's chance of success using IVF by 80 percent. Obesity can decrease your chances of getting pregnant and having a baby. Use of alcohol, recreational drugs, excessive caffeine and certain medications also can be harmful. Talk with your doctor about any factors that apply to you and how they may affect your chances of a successful pregnancy.

Tubal Reversal


Overview



A tubal ligation reversal is a procedure to restore fertility after a woman has had a tubal ligation — a procedure that cuts or blocks the fallopian tubes to prevent pregnancy. A tubal ligation is commonly referred to as "having your tubes tied." During a tubal ligation reversal, the blocked segments of the fallopian tubes are reconnected to the remainder of the fallopian tubes. This may allow eggs to again move through the tubes and sperm to travel up the fallopian tubes to join an egg. Tubal ligation procedures that cause the least amount of damage to the fallopian tubes are the most likely to allow a successful tubal ligation reversal. Examples include sterilization with tubal clips or rings. Procedures that cause scarring to seal off the fallopian tubes, such as the Essure or Adiana systems, generally aren't reversible.

Why it's done

A tubal ligation reversal may allow a woman to get pregnant without further medical assistance. A tubal ligation reversal isn't appropriate for everyone. Your health care provider will consider several factors to determine if tubal ligation reversal is likely to be successful, such as: Your age and body mass index The type of tubal ligation The extent of the damage to your fallopian tubes Remaining tubal length Other fertility factors, such as sperm and egg quality The success of a tubal ligation reversal procedure depends on a variety of factors. It's more likely to be successful if you still have a large portion of healthy fallopian tube remaining. Tubal ligation reversal is more likely to be successful if your tubal ligation was originally done using clips or rings, rather than if segments of your fallopian tubes were burned in order to close them off (electrocautery).

Risks

Risks associated with a tubal ligation reversal include: An inability to get pregnant after the procedure. Pregnancy rates following reversal of tubal ligation vary greatly depending on a woman's age and other factors. Infection. Bleeding. Scarring of the fallopian tubes. Injury to nearby organs. Anesthesia complications. Ectopic pregnancy — when the fertilized egg implants outside the uterus, usually in a fallopian tube.

How you prepare


Before you have a tubal ligation reversal, your doctor will likely: Explain the details of the procedure Discuss the likelihood of success and your ability to get pregnant after the procedure Discuss other options for pregnancy, such as in vitro fertilization (IVF) What you can expect A tubal ligation reversal can be done as an inpatient or outpatient procedure. During the procedure During a tubal ligation reversal, your doctor may use robotic or laparoscopic surgical equipment — small tubes attached to tiny cameras and surgical instruments — to make a tiny incision on your abdomen, and reattach your fallopian tubes. Alternatively, your doctor may make a small incision in your abdomen (minilaparotomy) and expose your uterus, fallopian tubes and ovaries. The doctor will then: Remove blocked fragments of the fallopian tube Attempt to repair the tube with tiny absorbable stitches Your doctor may not be able to reattach one or both of your fallopian tubes if too much was removed during the tubal ligation.

After the procedure


You can slowly resume your normal activities as you begin to feel better, which usually takes one or two weeks. Your stitches will dissolve and won't require removal. Ask your doctor when to make a follow-up appointment so you can be sure you're healing properly.


Results

Success rates after a tubal ligation reversal can vary widely, depending on factors such as maternal age and the type of tubal ligation procedure that was initially done. While it's difficult to predict the odds of pregnancy after this procedure, younger women — particularly those 35 and under — tend to have much better success rates. In cases where tubal ligation reversal isn't successful, in vitro fertilization (IVF) may be an alternative option to assist you in becoming pregnant.

ELECTIVE SINGLE EMBRYO TRANSFER

ELECTIVE SINGLE EMBRYO TRANSFER (ESET)



DECIDING HOW MANY EMBRYOS TO TRANSFER


Many are familiar with the phrase, “To be or not to be—that is the question.” Though this sentiment originally appeared in William Shakespeare’s Hamlet, it is now an expression for situations in which there are difficult choices to make. One such situation that we experience regularly at Victory Reproductive Care is the patient’s decision regarding how many embryos to transfer during an in vitro fertilization (IVF) cycle. There was a time when IVF technology was in its infancy and fertility specialists routinely transferred multiple embryos, largely due to the uncertain ability of the individual embryos to implant. The outcome of this practice, when implantation did occur, was a significant increase in the conception of twins, triplets, and even higher-order pregnancies. Today, with improved clinical and embryology techniques, when transferring embryos in patients with a good prognosis for success, the rate of twins goes up to 43 percent among those receiving two blastocyst embryos (2BET). This is compared to 1 percent among those receiving a single embryo (this is the result of one embryo splitting, also known as natural twinning). This represents a 20-plus fold increase in the rate of twins. Similarly, the rate of triplets among patients doing a single embryo transfer is 0 percent and, because of natural splitting, goes up to 1 to 2 percent among the group receiving 2BET. Thus, when transferring two embryos, one of the embryos (and less frequently both embryos) can split to produce identical twins. This rate represents more than a 100-fold increase when compared to single embryo transfer.

THE GROWTH OF ESET

Over time, data have shown increased health risks associated with multiple pregnancies. With experience, careful observations of outcomes, and improvements in embryo culture techniques, elective single embryo transfer (eSET) has become a very good option for patients. Patients can now have a healthy singleton pregnancy—removing the risks commonly associated with multiple pregnancies—and their chances for success remain very similar. Despite the success of eSET, however, there remains a lot of hesitancy on this issue, which we hope we can alleviate here. The American Society for Reproductive Medicine (ASRM) has published transfer guidelines based on a variety of factors, including the: Age of the female partner (younger than 35 years old to older than 40 years old) Clinical outlook for a successful outcome (favorable and unfavorable) Developmental stage of the embryo (day 5 to 6 at the blastocyst stage) ASRM bases its recommendations, which include groups of patients for which physicians recommend eSET, on the best available national evidence. Since their publication, numerous other studies have supported these same findings. It’s no surprise that the majority of reputable fertility centers in the United States adhere to these guidelines, which intend to maximize success and minimize the incidence of pregnancies with multiple conceptions and their potential complications. Based on our own clinical excellence and published data, Victory Reproductive Care not only supports the ASRM guidelines, but we also have our own recommendations for patients beyond the ASRM, due to our higher rates of embryo implantation and success. Among couples being treated with IVF, there are many excellent candidates for eSET that we can identify before and/or as their treatment progresses. These patients are usually younger than 38 years old, going through their first IVF treatment cycle, or have had a pregnancy in a previous IVF cycle. They also may have one or more top-quality embryos (usually blastocysts) available for transfer, or those patients using donor eggs. We’ve found that the pregnancy rate after an embryo transfer is similar if we transfer one embryo (eSET) or two embryos (2BET). These success rates are incredibly important in light of the risks associated with multiple pregnancies.

RISKS INVOLVED IN MULTIPLE PREGNANCIES

The higher the rate of multiple pregnancies (twins, triplets, etc.), the greater the frequency and severity of risk for both the mother and the babies. The increase in risk translates into higher rates of complications for the mothers, including miscarriages, bleeding, bed rest, and obstetrical complications (such as gestational diabetes or pregnancy-induced hypertension) and the need for more cesarean sections. The babies in multiple pregnancies can also be adversely affected by smaller sizes, growth of one twin at the expense of the other (twin-twin transfusion syndrome), premature delivery, need for intensive care after birth, developmental disabilities, cerebral palsy, and even increased mortality rates. Therefore, for those patients who meet the recommended guidelines for eSET, the only difference in transferring one or two embryos is an increased risk for the mother and the child(ren). This situation then raises the question: Why not opt for an eSET when such an option is present? For some patients who have been trying for a long time without success, their hope is that transferring more embryos will increase pregnancy rates. As mentioned previously, however, this is not accurate since eSET provides very similar success rates as transferring multiple embryos, but without the many risks associated with multiple pregnancies. For some patients, a single embryo transfer might be medically necessary (i.e., not a matter of patient choice or preference). But for others at Victory Reproductive Care, they can choose to transfer two embryos—but this decision should follow a discussion of the advantages and disadvantages of each option with their physician based on the data and the risks above. Victory Reproductive Care is proud to acknowledge that the rate of patients selecting eSET in our practice is among the highest in the nation, thereby lowering risks to patients and their offspring without significantly compromising success. Based on solid data collected from thousands of treatment cycles over many years of experience at Victory Reproductive Care—and confirmed by many other studies in the United States and Canada —when one faces a choice between eSET or multiple embryo transfers, the best and safest answer is often eSET