IN VITRO FERTILIZATION
IVF is a procedure where mature eggs are collected from the ovaries and fertilized with sperm in the lab. The resulting fertilized eggs (embryos) are transferred into the uterus where implantation can occur.
The following is a brief description of steps involved in an IVF cycle:
OVARIAN STIMULATION AND MONITORING
Troché Fertility Centers’ 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.
Before the stimulation begins, birth control pills are used to quiet the ovaries. An ultrasound exam and blood (estradiol) test confirms this and the woman begins the fertility medications according to a schedule provided by TFC. The medications (Follistim, Gonal-F and/or Menopur) are injected subcutaneously (SubQ) daily to stimulate multiple follicles to grow. A follicle is a fluid-filled sac in which an egg can develop. Another medication (Ganirelix or Cetrotide) is added to help prevent premature ovulation (release) of the eggs.
The eggs are microscopic and can’t be seen directly, therefore we track their development by measuring the size and number of follicles and measuring the level of hormone (estradiol) produced by the follicles. Together the measurements of follicle sizes and blood tests indicate when the follicles are likely to contain a fully developed egg. When the follicles are ready a medication (hCG and/or Lupron) is taken to cause the final maturation of the eggs prior to retrieval.
At Troché Fertility Centers (TFC), the egg retrieval is performed using ultrasound to guide a needle through the vaginal wall 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, you’ll stay for a recovery period of 45-60 minutes before going home to 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
Follicular fluid removed from the ovaries is examined in our lab and the eggs are isolated and placed in culture media where they continue to mature.
A few hours after the egg retrieval – the embryologist using a microscope – captures a sperm 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 to maximize fertilization. ICSI is especially helpful for men with low sperm counts or low numbers of normally shaped sperm.
Alternately, for individuals/couples who do not wish to use ICSI for fertilization, conventional IVF (insemination) is used. Approximately 50 thousand capacitated sperm are placed in the culture medium around each egg for fertilization to occur on its own. Conventional IVF is used when there are no sperm issues or male factor infertility.
Approximately 16 hours following injection/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.
Regular reports are provided regarding the development of the embryos. Generally, at two days normal embryos are four cells, at three days they are eight cells, and at five days they have over 80 cells with an inner fluid-filled cavity and a small cluster of cells called an inner cell mass (blastocyst stage). The decision of when to perform the embryo transfer is based on the grading of the embryos.
At TFC, our doctors plan for an embryo transfer on day 5 (at the blastocyst stage of embryo development). Blastocysts have a higher implantation rate than embryos incubated only three days. Three days after injection/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, day 5 transfer is confirmed and the embryos remain in culture to develop further. On day 5, the best looking blastocyst stage embryo(s) are transferred into the woman’s uterus. If there are not 2 grade “A” embryos, a day 3 embryo transfer is planned. Any viable and good quality embryos not transferred into the woman’s uterus may be cryopreserved for future use if desired.
All embryo transfers are performed using ultrasound guidance as it allows for accurate placement of the embryo in the optimal location in the uterus. The embryo is transferred via a thin plastic tube (catheter) which is carefully guided into the upper part of the uterus and the embryo is placed. The transfer is a painless procedure and the woman remains resting for 1/2 hour, after which she goes home. We recommend she rests at home the next day before resuming her activities.
With the goal of decreasing the incidence of multiple births (twins or triplets) TFC utilizes the American Society of Reproductive Medicine (ASRM) guidelines for the number of embryos to transfer. With information about the embryo number and quality, and mindful of the ASRM recommendations, Dr. Troche and the woman/couple will determine the number of embryos to transfer.
AFTER THE EMBRYO TRANSFER
Progesterone supplementation (vaginal gel or IM injections and suppositories) is used to enhance the implantation of the embryo and support an early pregnancy. Fifteen days following the egg retrieval a blood pregnancy test is performed. If the test is positive, an ultrasound confirmation of a clinical pregnancy (presence of a heart beat) occurs about three weeks later. The progesterone supplementation continues until the pregnancy can sustain itself at 12 weeks.
An option for individuals/couples with remaining embryos that are not immediately transferred into the uterus is to freeze (or cryopreserve) the embryos. After the embryo transfer, any untransferred embryos are placed in culture until they progress to the blastocyst stage. All good quality blastocyst stage embryos 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 one or more embryos to cryopreserve. Approximately 80-90% of cryopreserved embryos survive the thawing process.
Assisted Hatching is a common laboratory technique in which an embryologist uses a precise laser to make an opening in the shell of the embryo to facilitate implantation by the embryo in the uterine lining. The hatching is performed immediately before loading the embryo into the transfer catheter. It is recommended if embryo quality is less than optimal, for all Frozen Embryo Transfer (FET) cycles, and cycles where cryopreserved eggs are used. Here is a picture of an embryo starting to hatch
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 are 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.
Information (medical acupuncture and acupuncturists) is available to patients who request this adjunct therapy as part of their IVF treatment. Acupuncture may improve endometrial receptivity and increase blood flow to the pelvic area which can increase pregnancy rates. Treatments usually involve 1 or 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.
Endometrial Receptivity Analysis or (ERA)
An 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”. An ERA may prove useful for those who have failed IVF (fresh and frozen) cycles when good quality embryos have been transferred.
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 individuals 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.