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In vitro fertilization (IVF) is a complex series of procedures used to help with fertility or prevent genetic problems and assist with the conception of a child.
During IVF, mature eggs are collected (retrieved) from ovaries and fertilized by sperm in a lab. Then the fertilized egg (embryo) or eggs (embryos) are transferred to a uterus. One full cycle of IVF takes about three weeks. Sometimes these steps are split into different parts and the process can take longer.
IVF is the most effective form of assisted reproductive technology. 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.
Your chances of having a healthy baby using IVF depend on many factors, such as your age and the cause of infertility. In addition, IVF can be time-consuming, expensive and invasive. If more than one embryo is transferred to 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.
In vitro fertilization (IVF) is a treatment for infertility or genetic problems. If IVF is performed to treat infertility, you and your partner might be able to try less-invasive treatment options before attempting IVF, including fertility drugs to increase production of eggs or intrauterine insemination — a procedure in which sperm are placed directly in your uterus near the time of ovulation.
Sometimes, IVF is offered as a primary treatment for infertility in women over age 40. IVF can also be done if you have certain health conditions. For example, IVF may be an option if you or your partner has:
Risks of IVF include:
The Centers for Disease Control and Prevention and the Society for Assisted Reproductive Technology provide information online about U.S. clinics’ individual pregnancy and live birth rates.
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 screenings, including:
Before beginning a cycle of IVF, consider important questions, including:
IVF involves several steps — ovarian stimulation, egg retrieval, sperm retrieval, fertilization and embryo transfer. One cycle of IVF can take about two to three weeks, and more than one cycle may be required.
If you’re using your own eggs during IVF, at the start of a cycle you’ll begin treatment with synthetic hormones to stimulate your ovaries to produce multiple eggs — rather than the single egg that normally develops each month. Multiple eggs are needed because some eggs won’t fertilize or develop normally after fertilization.
You may need several different medications, such as:
Your doctor will work with you to determine which medications to use and when to use them.
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:
Sometimes IVF cycles need to be canceled before egg retrieval for one of these reasons:
If your cycle is canceled, your doctor might recommend changing medications or their doses to promote a better response during future IVF cycles. Or you may be advised that you need an egg donor.
Egg retrieval can be done in your doctor’s office or a clinic 34 to 36 hours after the final injection and before ovulation.
If you’re using your partner’s sperm, he’ll provide a semen sample at your doctor’s office or a clinic through masturbation the morning of egg retrieval. Other methods, such as testicular aspiration — the use of a needle or surgical procedure to extract sperm directly from the testicle — are sometimes required. Donor sperm also can be used. Sperm are separated from the semen fluid in the lab.
Fertilization can be attempted using two common methods:
In certain situations, your doctor may recommend other procedures before embryo transfer.
Embryo transfer is done at your doctor’s office or a clinic and usually takes place two to five days after egg retrieval.
If successful, an embryo will implant in the lining of your uterus about six to 10 days after egg retrieval.
After the embryo transfer, you can resume normal daily activities. However, your ovaries may still be enlarged. Consider avoiding vigorous activity, which could cause discomfort.
Typical side effects include:
If you develop moderate or severe pain after the embryo transfer, contact your doctor. He or she will evaluate you for complications such as infection, twisting of an ovary (ovarian torsion) and severe ovarian hyperstimulation syndrome.
About 12 days to two weeks after egg retrieval, your doctor will test a sample of your blood to detect whether you’re pregnant.
The chances of giving birth to a healthy baby after using IVF depend on various factors, including:
Talk with your doctor about any factors that apply to you and how they may affect your chances of a successful pregnancy.
Because the IVF process bypasses the fallopian tubes (it was originally developed for women with blocked or missing fallopian tubes), it is the procedure of choice for those with fallopian tube issues, as well as for such conditions as endometriosis, male factor infertility and unexplained infertility. A physician can review a patient’s history and help to guide them to the treatment and diagnostic procedures that are most appropriate for them.
While some research suggests a slightly higher incidence of birth defects in IVF-conceived children compared with the general population (4 – 5% vs. 3%), it is possible that this increase is due to factors other than IVF treatment itself.
It is important to recognize that the rate of birth defects in the general population is about 3% of all births for major malformations and 6% if minor defects are included. Recent studies have suggested that the rate of major birth defects in IVF-conceived children may be on the order of 4 to 5%. This slightly increased rate of defects has also been reported for children born after IUI and for naturally-conceived siblings of IVF children, thus it is possible that the risk factor is inherent in this particular patient population rather than in the technique used to achieve conception.
Research indicates that IVF-conceived children are on par with the general population in academic achievement as well as with regards to behavioral and psychological health. More studies are under way to further investigate this important issue.
Compared with the general population, women who have never conceived appear to have a slightly increased risk of ovarian cancer (about 1.6 times the rate). Because it is thought that many of these women have also used fertility medications, it has been hypothesized that a link might exist between fertility medications and this particular cancer. A number of studies have been conducted since 1992 when this concern was first raised. None have found an association between fertility medications and higher risk of ovarian or between IVF treatment itself and higher risk of ovarian cancer. Preliminary results from an ongoing National Institutes of Health study likewise suggest no association between fertility medications and ovarian, uterine or breast cancer.
It is possible that this association is due not to the use of fertility medication, but to the fact that this population of women has never undergone childbirth. Findings from the National Institutes of Health and others suggest that pregnancy or some component of the childbearing process may in fact protect directly against ovarian cancer.
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The prospect of daily injections can be overwhelming. While injections are a necessary part of IVF treatment, we have designed our medication schedules and injection type to minimize discomfort and stress; and our nurses carefully instruct and support every patient throughout this process. Medications that once had to be injected into the muscle have been replaced by medications given as a small injection under the skin (subcutaneous). Such injections are most commonly taken over a 10-12 day period, followed by one intramuscular injection of hCG, a hormone that triggers ovulation at the conclusion of the stimulation cycle. The hCG injection, previously only available in an intramuscular form, is now available in a subcutaneous form (Ovidrel) for patients that wish to avoid intramuscular injection. Although the recombinant subcutaneous form of hCG in Ovidrel has not been around as long as intramuscular hCG, all indications are that it is just as effective.
After egg retrieval, patients are given a progesterone hormone supplement in order to prepare the lining of the uterus for the embryo transfer. For most patients, progesterone may be taken in a vaginal tablet or vaginal suppository form rather than an injection. In this way, injections may be avoided entirely during the second half of the IVF cycle. Progesterone vaginal tablets and suppositories have been proven to be as effective as progesterone injections.
Because anesthesia is used for egg retrieval, patients feel nothing during the procedure. Egg retrieval is a minor surgery, in which a vaginal ultrasound probe fitted with a long, thin needle is passed through the wall of the vagina and into each ovary. The needle punctures each egg follicle and gently removes the egg through a gentle suction. Anesthesia wears off quickly once egg retrieval is concluded. Patients may feel some minor cramping in the ovaries that can be treated with appropriate medications.
Many of our patients at PFC come from other parts of the US, and throughout the world. Medical, nurse coordinator and financial consultations for IVF all can be done by telephone; many of the required screening tests and procedures, including initial fertility stimulation treatment, can be coordinated with a patient’s local gynecologist or reproductive endocrinologist. Those who have started stimulation treatment at home will travel to our clinic about 5-7 days later. Most patients need to be in San Francisco for 10 days to three weeks. Our staff is always available to help and counsel out of town patients throughout treatment, via telephone or e-mail.
Most of our out of town patients return home the day after the embryo transfer — there is no medical reason to stay in San Francisco after IVF treatment. All types of travel are safe. Sitting for an extended period of time will not affect chances of pregnancy. We recommend that patients traveling by air drink plenty of fluids, as circulated air can be quite dry, and dehydration should be avoided.
A woman’s ovaries house hundreds of potential eggs. Each month, during the natural ovulation cycle, the ovary selects just one egg from a pool of 100-1,000. Those eggs which are not selected undergo a natural cell death process called atresia. When a woman uses fertility medication, the body’s natural selection process is overridden, and a number of these otherwise unused eggs are allowed to grow. As many as 20 eggs may be stimulated in a given cycle. Thus when using fertility medication in the IVF process, not only is the woman not using up all of her eggs, but she is ‘rescuing’ eggs that otherwise would have undergone atresia.
In general, the success of frozen-thawed embryo transfer procedures depends on three factors:
The quality and survival of the frozen-thawed embryos. In general, we only freeze good quality embryos so the current rate of survival is greater than 90%. The age of the woman who produced the eggs. In patients under the age of 37, the chances of pregnancy with frozen-thawed embryos are similar to a pregnancy with fresh embryos. In patients 37 years or older, pregnancy chances with frozen-thawed embryos decline in conjunction with declining fertility in general, but still can be quite good. As always it is best to discuss a woman’s individual situation with their physician. The status of the uterus in the woman receiving the embryos. A healthy endometrial lining free of any interfering fibroids or polyps provides a sound environment for embryo implantation.
Previously frozen embryos may be transferred during a woman’s natural cycle or in a controlled (artificial) cycle, depending on a number of factors:
Controlled cycle transfer. In a controlled cycle, hormone medications are given to prepare the uterus for transfer. This method is recommended for patients who have irregular cycles. Because the controlled cycle can be precisely timed, it is also advised for those who are on a set travel schedule. The medications commonly used for a controlled cycle are estrogen (either in an injectable or oral form) and progesterone (in either an injectable or vaginal form).
Natural cycle transfer. Patients who have a regular menstrual cycle may have the option of using their natural cycle for transfer of frozen-thawed embryos. In this case, there is no need for hormone treatment, as the body’s natural cycle will prepare the uterus for pregnancy. In cases where natural cycle transfer is possible, this option allows for less medication and monitoring and thus is often relatively affordable for patients. We typically will monitor the natural cycle using home urinary ovulation predictor kits as well as ultrasounds. When the kit changes and/or a nice pre-ovulatory follicle is seen on ultrasound, we administer a single injection of Ovidrel (recombinant subcutaneous hCG) and the patient starts progesterone vaginal suppositories a couple of days later. The embryo transfer will occur 5-7 days after ovulation/hCG injection, depending on whether the embryos are frozen at a Day 3 or Day 5 stage.
For the transfer procedure itself, the embryo is thawed at room temperature, and then warmed to body temperature (37° C). As with a fresh embryo transfer, embryos are placed inside a special catheter (a very thin tube), which is guided through the cervix and into the uterus. Embryos are gently injected into the uterus and the catheter is removed. This procedure requires no anesthesia, and is done in a position similar to a pelvic examination for a Pap smear. After transfer, the woman rests for 15 minutes and then is able to go home, where a day of rest or very gentle daily activity is recommended.
The ability to use a donor egg has enabled thousands of women to become pregnant when they otherwise might not have had this opportunity. While a woman’s eggs may not be viable, very often the uterus is completely healthy and capable of supporting a pregnancy. In these cases, egg donation with IVF has high success rates. This procedure follows the same protocol as IVF, except the intended parents select a donor and use the donor’s egg to create the embryo. Patients may seek egg donation services at Pacific Fertility Center’s Egg Donor Agency or at an outside agency.
Various medical conditions may make it impossible for a woman to carry a pregnancy. Reproductive medicine provides the option of enabling another woman, known as a gestational carrier (formerly called a surrogate) to carry the child of a woman who cannot sustain a pregnancy.
There are two types of gestational carriers:
A gestational carrier may be appropriate for those in the following situations:
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One cycle of IVF takes about two months. Women younger than age 35 will get pregnant and have a baby with their first IVF egg retrieval and subsequent embryo transfer(s) about half the time.
Women who don’t get pregnant following the first IVF cycle still have very good chances of getting pregnant on second, third and even more cycles of IVF. There are many factors that affect your ability to get pregnant and have a healthy baby using IVF. Your doctor can usually give you reasons why you are not getting pregnant and explain your chances to have a baby with IVF.
Age is the factor that most affects IVF success rates. According to the Society for Assisted Reproductive Technology (SART) Clinic Report, the average percentages of live birth from IVF by age are:
In addition to these statistics, it’s important to note that the cumulative success rate for a live birth increases with additional IVF cycles for all women. However, the success rate still remains lower for older women. Also, the Centers for Disease Control (CDC) recently observed that the IVF success rate for every age category has been increasing in the last few years as techniques and experience advance,
You should also be able to ask any fertility clinic about their IVF success rates. Keep in mind, clinic success rates vary based on the characteristics of their patients and individualization of patient care so this should probably not be the only factor you consider when selecting a fertility clinic.
Many couples are not successful the first time going through IVF and continuing with additional IVF cycles often involves purchasing a separate cycle of treatment each time it doesn’t work. While most patients choose to finance their treatment one cycle at a time, selecting a multicycle plan offers more chances for IVF success and at a lower cost per cycle.