IVF and Assisted Reproductive Technologies
If a patient has already had an initial consultation with Dr. Selub, she may start Assisted Reproductive Technologies (ART) 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 ART 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 ART 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 ART 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 ART interview. Please let us know if you wish to have your ART semen analysis done on the day of your initial ART 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 ART 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 ART 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 ART cycles is due in full on the day of your initial ART interview, or at the time you begin any kind of medication to prepare for the cycle, including oral contraceptives.
In Vitro Fertilization (IVF)
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. Do not necessarily expect that your medication protocol will be the same as a friend's whose procedure was successful, or the same as a during a succesful procedure you may have had a few years earlier. Each patient presents with unique problems, goals, or issues, so treatment is individualized and you may find that your particular regime differs from that of others or what you did before. This is normal and reflects our goal of providing the right treatment for your particular problem at the right time (desired timing of your procedure may affect your protocol, as well).
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 may simply be instructed to start oral contraceptive pills for a set period of time. Some patients may not need to take pills and may just be instructed to let us know when a period begins. In this case, the patient should be ready to come in to the office on cycle day 1,2, or 3 to start injections to stimulate the ovaries to mature several eggs at once.
Other protocols may involve your injecting a daily medication that temporarily turns off the normal monthly maturation of egg follicles in the ovary. After a blood test and/or an ultrasound exam ensures that this has been successful, a drug is administered that stimulates the ovaries to produce more eggs than usual.
The progress of the ovarian stimulation part of any regimen is monitored by several sequential blood tests, as well as ultrasound examinations of the ovaries. When a sufficient number of egg-containing follicles have reached a certain size, if, before starting the ovarian stimulating medication, you have not used a preliminary medication to "down-regulate' your ovarian function (so you do not ovulate on your own, too early, before your eggs are completely mature), you will be instructed to start taking another injectable daily medication, in addition to your stimulating injections, known as a GnRH antagonist. The antagonist will block you from triggering ovualtion, too early, before your harvesting procedure is scheduled. Finally, hCG is injected in a single dose, or an injection of a GnRH agonist is administered at a set time, to ripen the eggs and prepare them for retrieval at the designated time.The timed injection to trigger ovulation is given approximately one and a half days (36 hours) before your egg retrieval procedure.
For FIRST's patients, the egg retrieval is performed on the second floor of our office building (our office is on the third floor), at the Surgery Center of Weston, LLC. Unlike other South Florida IVF centers, where retrievals are performed in a room in a physician's office, patients at FIRST receive the benefits of a comprehensive, exceptional, private outpatient surgical facility, equipped with full service operating rooms. The Surgery Center of Weston employs a full time anesthesia and nursing staff. There, the experienced, hand-picked personnel are dedicated to caring for patients from before procedures until after each patient is fully recovered, ensuring a comfortable and safe experience.
Depending on the number of mature follicles you have, the egg retrieval procedure takes between 15-30 minutes. During the retrieval, you are medicated intravenously, through a tiny hollow tube inserted with a needle into your vein (an "IV"), to achieve conscious sedation, sometimes called "twilight sleep." The use of thes IV medications prevents discomfort during the procedure and usually erases or diminishes your recollection of the procedure.
The egg retrieval 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 using a microscope. The number of eggs retrieved varies from patient to patient; not all follicles contain eggs and not all eggs retrieved are in proper condition or mature enough for fertilization.
The eggs are then carefully washed and placed in an incubator, sometimes for several hours, to permit further maturation. The male partner produces a semen specimen either before or after the eggs are collected, or a frozen specimen may be thawed. Generally, there is no difference in success rates whether a frozen or fresh specimen is used. In either case, the specimen is processed to obtain a concentrated sample rich in healthy sperm.
Next, the eggs and the sperm are combined in a laboratory dish and placed in an incubator overnight for fertilization. If a frozen sperm specimen is used, if there are only very few eggs, if there is a history of a poor fertilization rate, or if there is any question regarding the quality of the sperm sample, intracytoplasmic sperm injection (ICSI), a procedure involving micromanipulation, will be employed to enhance the chance of fertilization taking place. The eggs are then checked 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, third, or fifth day following the retrieval. Thus, at the time of transfer, depending on your individual circumstances, and the number of seemingly good quality embryos you have formed, your embryos may be anywhere from the two-cell stage to an expanded, or even hatching, blastocyst at the time Dr. Selub places them in your uterus.
Embryo transfers are performed in our office using abdominal ultrasound for guidance. During this procedure, the embryos are drawn up into a fine tube called a catheter. The tips of the catheters we use are specially marked to be more easily seen on the ultrasound screen. Having urine in your bladder, also helps to make the catheter more visible with ultrasound. The catheter is then passed through the cervical opening into the uterus and the microscopic embryo(s), suspended in a tiny droplet of fluid, are placed in the uterine cavity. The process takes a short time, usually a few minutes, 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 viable embryos may be frozen for future transfer. The decision regarding the number of embryos transferred is always fully discussed with IVF patients before the procedure is performed, when it is known exactly how many embryos are actually available.
Your pregnancy test, a blood test, will be scheduled two weeks after the egg retrieval was performed. Whether or not your period has started after an IVF procedure, it is important to do a pregnancy test at the designated time because vaginal bleeding does not always indicate the procedure failed.
If you do become pregnant through an IVF procedure, further pregnancy tests will be ordered to monitor whether or not your pregnancy is continuing to grow properly. It is not uncommon to see a positive pregnancy test as the result of IVF turn negative over several days' or weeks' time. This is referred to as a "chemical" pregnancy, which is a very early miscarriage, occurring after implantation, but before a pregnancy can be visualized by ultrasound examination.
If the pregnancy appears to be progressing properly through blood tests, an ultrasound exam will be scheduled to take place about four weeks from the time of your embryo transfer to monitor the viability of the pregnancy and determine the number of embryos that implanted. If your pregnancy is properly sized for dates and an early fetal heartbeat can be visualized, you will then 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 you are very happy or very sad, take some time after receiving your results to collect your thoughts and emotions. You will be given an opportunity to speak with Dr. Selub about your outcome and whether or not you should, or wish to, proceed further with a particular treatment plan. It helps to write down your thoughts and questions following a negative (or even positive) result before talking with our staff so you can make clear, informed decisions about your next step.
One of our primary goals is enable our patients to have a realistic appreciation of their prospects of success. If the cycle has been unsuccessful, of course we will discuss possible reasons for failure, but, keep in mind that, for many cases, a definite reason usually cannot be pinpointed. Often, how you will respond to certain protocols cannot be known before you go ahead and try IVF. Based on a failed treatment cycle at FIRST, or anywhere else, Dr. Selub can adjust your regimen accordingly to increase your chance for a live birth or advise you that your chances to have a baby will depend on whether or not you are willing to take a very different approach. Studies have shown that, with persistence, and without long breaks or periods of "giving up" on therapy, most fertility patients can achieve a successful pregnancy!
Until several years ago, 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.
Intra-Cytoplasmic Sperm Injection (ICSI)
Male factor infertility results when the sperm count is extremely low or the sperm quality is very poor. It is a common reason couples present for treatment; around 40% of infertility cases are attributed to male factor. When there is no reason for poor semen parameters identified, which is usually the case, there is no treatment that can be recommended to normalize semen parameters when male factor infertility is unexplained. Lifestyle changes may help to improve sperm quality, such as increasing exercise, improving one's diet, eliminating obesity and quitting smoking and/or use of recreational drugs. No vitamins or supplements have been shown to reverse male factor infertility, though some may offer general health benefits.
Conventional IVF without ICSI, it turns out, often ends in disappointing results for patients experiencing male factor infertility, such as no fertilization of eggs or a low percentage of eggs fertilized in vitro, with no or few embryos available for transfer. Until the 1990s, the only available treatment was the use of donor sperm. With the development of ICSI in Belgium, a powerful tool became available for what had been an intractable problem. IVF with ICSI is the best treatment for male factor infertility and has been employed at FIRST for almost two decades, so we've had vast experience with this technique! And IVF/ICSI is always necessary when sperm is obtained by surgical means (see below).
The steps leading to ICSI are identical to IVF until just after the eggs are retrieved. Instead of mixing the sperm and eggs in a dish and waiting for fertilization to occur naturally, individual eggs are isolated and, with the use of sophisticated micromanipulation techniques, a single sperm is injected into each normally formed, mature egg. The fertilized eggs resulting from the ICSI procedure, identified 24 hours later, are then incubated as in IVF until they are ready for transfer. Note that not all eggs subjected to ICSI will necessarily fertilize.
Percutaneous Epididymal Sperm Aspiration (PESA) and Testicular Sperm Aspiration/Extraction (TESA/E)
Some men have no sperm in their semen because of vasectomy, previous infection or trauma, or a congenital defect. In such instances, sperm may be obtained by extracting it through a needle placed in the testicle or epididymis under local anesthesia. Sometimes, the scrotum is opened surgically, and a small piece of testicular tissue is excised in an attempt to obtain sperm. Sperm obtained by these means must be used in conjunction with ICSI because such sperm cells are too immature to fertilize eggs on their own.
We do not perform these procedures at FIRST, but we do collaborate closely with specialists who have extensive experience with surgical sperm extraction.