The following is a brief description of the steps involved in IVF. Based on individual needs, some steps may be changed for you, but the basic flow of steps remains the same for most patients.
Steps in an IVF cycle:
Conditions which can be successfully treated with IVF.
Tubal Damage. Patients with tubal blockage or severe pelvic adhesions, or who have not conceived after tubal surgery are good candidates for IVF.
Female Sterilization. Women with a tubal sterilization not surgically reversible or who don't desire a sterilization reversal procedure are also good candidates for IVF.
Moderate to Severe Male Factor. For men with poor sperm quality (low numbers, low motility or small amounts of normally shaped sperm) IVF is the treatment of choice.
Vasectomy. Men with a vasectomy not reversible by surgery or who don't desire a reversal procedure can achieve pregnancies with their partners by means of IVF.
Endometriosis. As endometriosis often results in the distortion of the pelvic anatomy, the IVF procedure allows the egg and sperm to meet and fertilize in an environment free of endometriosis and be transferred directly into the uterus.
Unexplained infertility. Couples who have not responded to other types of therapy (such as IUI or intra-uterine insemination) can be successfully treated with IVF.
Preimplantation Genetic Diagnosis (PGD) or Screening (PGS). PGD/PGS consists of the biopsy (removal) and genetic evaluation (testing) of a few cells of the embryo. Those embryos classified by genetic diagnosis as normal are then transferred into the patient's uterus. PGD/PGS can help:
We partly attribute our success rates to our meticulous evaluation of three factors that contribute to a favorable outcome with IVF.
A. The first factor we evaluate is Ovarian Reserve.
Ovarian reserve is a term used to determine the capacity of the ovary to provide eggs capable of fertilization. Evaluation of certain hormones (AMH, FSH, and Estradiol) and an ultrasound evaluation (AFC) of the ovary are the means we utilize to determine a woman’s ovarian reserve. AMH (Anti-Mullerian hormone) is a substance produced within the developing follicles in the ovaries and is believed to provide insight into the size of the woman’s remaining supply of eggs. Measurement of FSH (Follicle Stimulating Hormone) and Estradiol levels early in the menstrual cycle help us estimate a woman's ability to produce multiple eggs in response to fertility medications. The Antral Follicle Count (AFC) is the number of follicles starting to develop on each ovary early in the menstrual cycle as seen via ultrasound. Combining the information of the hormone levels (AMH level, FSH and Estradiol) and AFC number helps indicate the ovarian reserve.
B. The second factor we evaluate is the Uterine Environment.
We recommend an evaluation of the woman's uterine cavity before IVF. This evaluation can be either a Sonohystogram (SHG) or “fluid” ultrasound, or hysterosalpingogram (HSG). These brief office procedures allow us to evaluate the uterine cavity and ensure there are no fibroids, polyps, or scar tissue that could interfere with implantation. Additionally the HSG allows visualization of the fallopian tubes for patency (openness) or abnormality such as a hydrosalpinx (dilated tube) that might affect the outcome of the IVF cycle. A "Mock Embryo Transfer" is also performed to carefully assess the length of the uterine cavity, in order to accomplish an atraumatic embryo transfer in the IVF cycle.
C. The third factor we look at is the Male Factor.
A complete semen analysis with strict morphology evaluation (Kruger Criteria) is performed at our laboratory. The semen analysis evaluates the concentration or number of sperm, how many are moving (motility), their forward motility (swimming ability), and morphology (amount of normally shaped sperm). Each factor is used to evaluate the sperm’s ability to fertilize an egg and identify if fertilization in the IVF cycle may be compromised or normal.
Other Pre-cycle Testing.
In keeping with federal regulations, couples and individuals undergoing IVF at Troché Fertility Centers are screened for HIV, hepatitis (B and C) HTLV-1/2, CMV (cytomegalovirus), syphilis, gonorrhea and chlamydia. Additionally we look at factors which may impact a woman’s ability to become pregnant such as Vitamin D levels, thyroid and prolactin hormone levels. The woman is also tested for immunity to Rubella (German measles), and Varicella (chicken pox) to maximize a healthy pregnancy.
IVF success rates depend upon the number of eggs to be fertilized and/or embryos available for transfer. Additionally, the egg retrieval must be carefully timed to retrieve mature eggs. To accomplish these two goals, ovarian stimulating medications and careful monitoring are employed.
The start of the ovarian stimulation is timed using oral contraceptive pills (OCP). A woman takes OCP for 2-4 weeks prior to beginning the stimulation. After the last "active" pill is taken a baseline ultrasound is performed to ensure there are no ovarian cysts present and a blood estradiol level is measured. Once cleared, the woman begins daily subcutaneous (SQ) injections of fertility medications called gonadotropins (Follistim, Gonal-F, Menopur), according to a schedule that is provided by our Center. We arbitrarily call this first day of gonadotropin administration Stimulation Day 1.
On Stimulation Day 5 the woman begins the daily SQ administration of a GnRH antagonist (Ganirelix or Cetrotide) to help prevent premature ovulation. In order to monitor a patient's response to these fertility medications, additional ultrasounds and serum estradiol levels are performed starting Stimulation Day 5 or 7. Frequent monitoring occurs to help us determine when the eggs are ready for collection.
Once the follicles (containing the eggs) are deemed ready or fully developed, the woman stops the stimulation medications and takes a SQ injection of human chorionic gonadotropin (hCG). This “trigger shot” replaces the woman's natural LH surge, and is necessary for the final maturation of the eggs so they can be retrieved and fertilized by sperm.
As follicles are monitored for growth during the cycle, we also evaluate the uterine lining (endometrium) during the ultrasounds. We measure the thickness and characteristics of the endometrium. In the rare event the endometrium does not develop adequately by the time of egg retrieval and/or embryo transfer, the embryos can be cryopreserved and transferred in a subsequent frozen embryo transfer (FET) cycle.
At Troché Fertility Centers the egg retrieval is accomplished using a vaginal ultrasound probe to guide a needle through the vaginal wall and into the ovaries. The egg retrieval takes approximately 30 minutes to complete and sedation is provided by an anesthesiologist for your comfort and safety. After the retrieval the woman wakes from a rather nice nap (intravenous sedation), and will stay for a recovery period of 45-60 minutes. Once we ensure she is doing well, she is released to go home and rest the remainder of the day.
Before sperm can fertilize an egg, it must undergo biochemical and structural changes called capacitation. Freshly ejaculated sperm are capacitated in the laboratory and the motile sperm are isolated prior to injecting or inseminating the eggs. While freshly obtained sperm is preferred, frozen samples of sperm or tissue may also be used and are prepared before use.
In-vitro fertilization literally means "fertilization in glass". Follicular fluid removed from the ovaries is examined in our lab for the presence of eggs. These eggs are isolated and placed in culture media where they are allowed to further mature. A few hours after the eggs are retrieved, the embryologist using a microscope, captures a sperm in a very thin glass pipette and inserts it directly into the egg. This technique of injecting an individual sperm into each mature egg is called Intracytoplasmic Sperm Injection (ICSI). All mature eggs are fertilized in this manner and the fertilized eggs are monitored for continued growth. The use of intracytoplasmic sperm injection allows the man with an extremely low sperm count or with a low number of normally shaped sperm to fertilize eggs and maximizes fertilization rates in all patients.
Alternately, for couples who do not wish to use ICSI for fertilization, conventional IVF (insemination) can be used. Approximately 50 thousand capacitated sperm are placed in the culture medium around each egg for fertilization to occur on its own.
Approximately 16 hours following injection or insemination, the eggs are inspected under the microscope to determine how many have successfully fertilized. These embryos will remain in the incubator as they continue to grow and develop until the moment of transfer.
The couple receives regular reports keeping them informed of the development of the embryos. Two days after ICSI (sperm injection) or insemination, normal embryos have divided into about 4 cells. Three days after ICSI or insemination, normally developing embryos contain about 8 cells. Five days after insemination or ICSI, normally developing embryos have developed to the blastocyst stage, which is typified by an embryo that now has 80 or more cells, an inner fluid-filled cavity, and a small cluster of cells called the inner cell mass. The decision of when to perform the embryo transfer is based on the grading of the embryos.
At TFC, we plan for an embryo transfer on day 5 or at the blastocyst stage of embryo development. Blastocysts have a higher implantation rate than embryos incubated only 3 days. Three days after injection or insemination, the embryologist will evaluate the embryos for their quality and provide a grade. If there are at least 2 grade “A” or good quality embryos, the decision is made to continue to blastocyst transfer and the embryos are cultured an additional 2 days. At day 5 the best looking blastocyst stage embryo or embryos are transferred into the woman’s uterus. Any viable and good quality embryos not transferred into the woman’s uterus may be cryopreserved for future use if the couple wishes. Our pregnancy rate with the transfer of frozen blastocysts is almost double the expected pregnancy rate with the transfer of frozen Day 3 embryos.
At Troché Fertility Centers all embryo transfers are performed under transabdominal ultrasound guidance because higher pregnancy rates are noted. Use of the ultrasound allows for the accurate placement of the embryo(s) approximately 1.5 centimeters from the top of the uterus. The embryo is transferred via a thin plastic tube and this catheter is carefully guided into the upper part of the uterus where the embryo is placed. After 20 seconds the catheter is gently removed and inspected microscopically to ensure the embryo(s) were not retained in the catheter. The transfer is generally a painless procedure and the patient remains resting for 1/2 hour, after which she goes home. We recommend she rests at home through the next day before resuming her activities.
After the embryo transfer, the woman uses progesterone supplementation (vaginal gel or IM injections and suppositories) to enhance implantation. Fifteen days following the egg retrieval a blood pregnancy test is performed. If the test is positive, a second level is obtained 8 days later to confirm the pregnancy is ongoing. The ultrasound confirmation of a clinical pregnancy (presence of a heart beat) is performed about 2 to 3 weeks later. The progesterone supplementation continues until the pregnancy can sustain itself at 12 weeks.
An option for couples with remaining embryos that are not immediately transferred into the uterus is to freeze (or cryopreserve) the embryos. After the embryo transfer on Day 3 or 5, any untransferred embryos are placed in culture until they progress to the blastocyst stage. The blastocyst stage embryos, which are of good quality, are then frozen. Cryopreserved embryos can be used in the event the woman doesn’t conceive in the “fresh” IVF cycle or for later use to attempt for a sibling. Most patients (approximately 75%) will have 1 or more embryos to cryopreserve. Approximately 80-90% of cryopreserved embryos survive the thawing process.
Endometrial “Scratching” is a procedure which is performed approximately 1 week before starting the Frozen Embryo Transfer (FET) cycle. It involves the insertion of a small pipelle (tube) through the cervix into the uterus and taking a small sample of endometrial tissue (uterine lining). This brief office procedure, also known as an endometrial biopsy, or EMB, causes some cramping that resolves quickly. While not entirely understood, it is believed the “scratching” or disruption of the uterine lining releases growth factors that help to improve embryo implantation in the subsequent FET cycle. This procedure may prove helpful for those who have failed IVF cycles and studies suggest it may increase pregnancy by up to 70% compared with no treatment.
Endometrial Receptivity Analysis or (ERA) is an evaluation of endometrial factors at the molecular level to determine if the endometrium (uterine lining) is receptive to an embryo implanting. It is a personalized genetic test that looks at the expression of 238 genes to diagnose the state of endometrial receptivity to an embryo during the “window of implantation”. This test is performed during a “mock frozen embryo transfer cycle”. ERA may prove useful for those who have failed IVF (fresh and frozen) cycles when good quality embryos have been transferred.
Assisted Hatching is a common laboratory technique in which an embryologist uses a precise laser to make an artificial opening in the shell of the embryo to facilitate implantation by the embryo. The hatching is performed immediately before loading the embryo into the transfer catheter. It is recommended for women who have had previously unsuccessful cycles, are older, who have elevated FSH levels, and with all FET (Frozen Embryo Transfer) cycles.
Testicular Sperm Extraction (TESE) is a simple and minimally invasive procedure where a small amount of testicular tissue is removed via a needle biopsy. It is an office procedure performed by an urologist under local anesthesia and is performed before the planned IVF cycle. The tissue is then frozen until needed during the IVF cycle when it is thawed and the sperm retrieved from the tissue. The retrieved sperm is capacitated (processed) and one is inserted into each egg using the ICSI procedure. TESE allows for the retrieval of sperm from men who are unable to produce sperm in their ejaculate because of an obstruction (i.e. vasectomy) or absence of the vas deferens.
Acupuncture information (medical acupuncture and acupuncturists) is available to patients who request this alternative therapy as part of their IVF treatment. Acupuncture is growing in popularity and is believed it may improve endometrial receptivity and increase blood flow to the pelvic area. Treatments usually involve 1-2 sessions with the acupuncturist before the egg retrieval and then a session immediately before and after the embryo transfer. The sessions surrounding the embryo transfer may occur at the clinic for your convenience.
We are well aware that infertility can exact a heavy toll. The emotional, financial, and physical burden may seem daunting. It is for this reason we encourage both partners to be supportive of one another, and to participate in the treatment process jointly by attending all appointments together. We understand this is not always possible, but is highly recommended. Names of licensed counselors are available for individual’s and couples wanting additional support before, during, or after the cycle. These counselors are familiar with the emotional impact of infertility and infertility treatments, and can help the couple manage this important aspect of their care.
When an individual or couple has frozen embryos, an FET cycle can be used to prepare the woman's uterus to receive the thawed embryos. As with the IVF cycle, the woman takes oral contraceptive pills (OCP) for 2-4 weeks followed by medication (Estrace or Estradiol Valerate) to stimulate the lining of the uterus to thicken. An ultrasound assessment of the uterine lining is performed to ensure an adequate endometrial thickness is developing before the embryos are thawed. Five days before the embryo transfer, progesterone supplementation is started to facilitate implantation. The designated number of embryos are then thawed the morning of the transfer and the embryos transferred.
How Much Does Fertility Treatment Cost?
Review our competitive pricing information for fertility treatment.
Fertility Sucess Rates
IVF success rates show you the chances for successful fertility treatment.
Patient Success Stories
We measure our success not only with numbers, but with thank you cards from our patients.