IVF and Assisted Reproductive Technologies
Getting
Started
In
Vitro Fertilization (IVF)
Gamete
Intra-Fallopian Transfer (G.I.F.T.) and Zygote Intra-Fallopian Transfer
(Z.I.F.T.)
Assisted
Hatching
Blastocyst
Transfer
If a patient has already had an initial
consultation with Dr. Selub, she may start
Assisted Reproductive Technologies (A.R.T.) treatment whenever she wishes to
do so. It does not matter when her last menstrual period started, since the
medication we use will temporarily alter the patient’s own menstrual rhythm.
Generally, an initial A.R.T. visit should be scheduled by telephone with the patient coordinator, Debbie
Carmichael, no later than about six weeks before you wish to have
your eggs retrieved. It is good to give us about two months lead time to fit you
into the A.R.T. treatment cycle schedule. We generally have 11 cycles, or groups of
IVF patients, during a given year, so there is always a group starting treatment
within 2 or 3 weeks from the time you call (for
IVF schedule, please click here). It takes about 4 weeks of medication
to prepare a patient for egg retrieval.
During the A.R.T. initial
visit, we
will discuss details of the treatment and answer any further questions. If you
do not already have your medication ready, you will be given prescriptions.
Details of any drug regimens will be thoroughly reviewed and follow-up visits
will be scheduled. Any screening tests that still need to be done will be
arranged.
Male partners will need to give a semen
sample for analysis in our laboratory, if this has not yet been done. You may
want to schedule this test the same day of your initial
A.R.T. interview. Please
let us know if you wish to have your A.R.T.
semen analysis done on the day of your
initial A.R.T. interview, so the laboratory will be prepared to accept the
specimen. All male partners and patients entering treatment are asked to have
infectious disease blood work done before starting medication. This is for the
protection of yourselves and your potential child.
Remember, the medication used for A.R.T.
is
costly. We advise you to find out about how much medication you will need and
how much it will cost before you schedule your initial
A.R.T. appointment. Please
contact our patient coordinator, Debbie
Carmichael, to get detailed information
on how best to obtain your medication. This will help you plan for your cycle
financially. Payment for A.R.T. cycles is due in full on the day of your
initial A.R.T. interview.
In vitro fertilization is fertilization of
the egg by sperm that occurs outside the body in a glass dish. In vitro
means “in glass”, in Latin. This technique is used if the sperm and egg
cannot meet in the fallopian tube as a result of blocked or absent tubes or, if
the quality or quantity of the sperm is insufficient to fertilize the egg.
Originally, IVF was designed to treat women with blocked tubes, but its use has
expanded to include the treatment of infertility resulting from of other
conditions, such as endometriosis, male factor infertility and unexplained
infertility.
There are several different drugs and drug
regimens used during IVF therapy. Because each patients problems are unique,
treatment is individualized and you may find that your particular regime differs
from that of others. This is normal and reflects our goal of providing the right
treatment for your particular problem.
Before IVF is recommended, tests are
performed to ensure that the ovaries are capable of producing eggs and that the
male’s sperm can fertilize them. When ready to begin an IVF cycle, you will
receive a medication that turns off temporarily the normal monthly maturation of
egg follicles in the ovary. After a blood test ensures that this has been
successful, a drug is administered that stimulates the ovaries to produce more
eggs than usual. The progress of this stimulation is monitored by blood tests as
well as ultrasound examinations of the ovaries. When a sufficient number of eggs
containing follicles has reached the proper size, another medication, hCG, is
administered to ripen the eggs and prepare them for retrieval.
Approximately one and a half days after hCG
administration, the eggs are ready for retrieval. The egg retrieval is performed at
the Outpatient Surgery Center of the Weston
Regional HealthPark, part of the North
Broward Hospital District, rather than in a physician's office. As a
result, our patients receive a comprehensive and exceptional care from prior to
their procedures until after they recover. Depending on the number of ripe follicles, the
procedure takes 15-30 minutes. During the retrieval, you are medicated with
Versed and Demerol to achieve what is known as conscious sedation. The use of
these medications minimizes any discomfort you may experience and diminishes
your recollection of the procedure.
The procedure itself is performed by
passing a thin needle under ultrasound guidance through the vaginal wall into
the ovarian follicles. The follicular fluid is suctioned out and passed to the
embryologist who separates the egg from the fluid under a microscope. The number
of eggs retrieved varies from patient to patient; not all follicles contain eggs
and not all eggs retrieved are mature enough for fertilization.
The eggs are then carefully washed and
placed in an incubator for several hours to permit further maturation. The male
partner produces a semen specimen which is processed to obtain a concentrated
sample rich in healthy sperm. After 3-6 hours, the eggs and the sperm are
combined in a laboratory dish and placed in an incubator overnight for
fertilization. The eggs are observed the next day to see if fertilization has
occurred.
If fertilization has been successful, the
resulting embryos are transferred into the uterus on the second or third day when they are
at the two-to-eight cell stage. During this procedure, the embryos are drawn up
into a fine tube called a catheter; the tip of the catheter is then passed
through the cervical opening into the uterus and the embryos are placed in the
uterine cavity. The process takes a short time and is generally no more
uncomfortable than undergoing a Pap smear.
The number of embryos transferred depends
on several factors. If more embryos are produced than can be safely transferred,
the remaining embryos may be frozen for future transfer.
Two weeks after transfer, a pregnancy test
is performed . If you become pregnant, ultrasound examinations are done at four
weeks and six weeks after transfer to monitor the number of fetuses. At six
weeks, if the pregnancy appears normal, you will be referred to your
obstetrician for further prenatal care.
Regardless of the outcome of the pregnancy
test, our staff is available for counseling and support. If the cycle has been
unsuccessful, we will discuss with you possible reasons and, if needed, plan
changes for future cycles. One of our primary goals is enable our patients to
have a realistic appreciation of their prospects of success.
In these forms of therapy, the woman
undergoes ovulation induction as in IVF. When the eggs are mature, they are
retrieved under ultrasound guidance and mixed with sperm. In G.I.F.T., the specimen
containing the eggs and sperm is then placed into the fallopian tube with a thin
catheter. This requires laparoscopic surgery under general anesthesia. We
perform this procedure at the Weston Regional HealthPark Outpatient Surgery
Center. Z.I.F.T. is similar to G.I.F.T.; however, in Z.I.F.T., the eggs and sperm are
incubated together overnight and only fertilized eggs (zygotes) are transferred
to the fallopian tube. At present these techniques, while available at F.I.R.S.T.,
are used infrequently as they have been rendered less important by therapeutic
advances in IVF, such as ICSI, assisted hatching, and blastocyst transfer.
G.I.F.T. and Z.I.F.T. may be advantageous for
certain patients. These procedures have been consistently associated with higher
pregnancy rates per cycle in many studies. This may be because of the more
natural environment in a healthy fallopian tube compared to that of an embryo
developing in media in a laboratory incubator. The tubal environment may render
the embryo better able to implant in, or adhere to, the uterine lining. These
procedures may be more helpful in women with normal fallopian tubes and only
minimal endometriosis, unexplained infertility, or age over 35 years. G.I.F.T. seems
to be more efficient as a first step in treatment for many of these patients,
especially if a patient has not already had a diagnostic laparoscopy as part of
her infertility work up.
To perform this procedure, the embryologist
creates a small hole in the zona pellucida, the protective layer that surrounds
the egg, and subsequently, the
embryo. Before an
embryo can implant, it must
escape, or hatch, from the zona. There is some evidence that in older women the
zona becomes harder, decreasing the embryo’s ability to hatch. Some believe
that laboratory conditions may affect the zonae of some women, making the layer
tougher. This may result in a decreased ability to conceive with IVF. For this
reason, we use this technique at F.I.R.S.T. routinely for women age 37 or
older and those with a history of repeated and/or unexplained IVF failure.
Perhaps with assisted hatching, we make it easier for the embryo to escape the
zona and adhere to the uterus.
Until
recently, eggs fertilized by IVF or
ICSI were transferred to the uterus after
two or three days, when the embryos were at the two-to-eight cell stage. With
recent advances in laboratory techniques, embryos may be transferred after five
or six days when they have reached a more advanced stage of development known as
a blastocyst. To date, it seems that the only advantage of this technique is to
be able to limit the number of healthy-appearing embryos transferred following
IVF and thereby decreasing the rate of high-order multiple pregnancy. Typically,
if a patient’s embryos successfully reach the blastocyst stage, two
blastocysts are transferred. By lowering the risk of multiple gestation, the
likelihood of a successful term pregnancy is increased.
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