Many couples and individuals that suffer from infertility are unable to achieve pregnancy after first line therapy such as ovulation induction, intrauterine insemination, or reproductive surgery. For these persons, the unique solution is to use Assisted Reproductive Technologies (ART) and especially IVF - In vitro fertilization and other assisted laboratory techniques designed to improve fertilization. These procedures have excellent success rate but require significant effort and can be expensive. For all of these reasons, advanced treatment options can be stressful. These natural stresses can be minimized if you understand all peculiarities of ART procedures.
Step One - Ovulation Induction
Hormone injections (as prescribed by the embryologist) are given to stimulate multiple egg production. This is because a normal cycle usually produces one egg only, and pregnancy rates in IVF are better if a number of eggs can be retrieved and fertilized. These injections are usually given subcutaneously (under the skin) and are much less uncomfortable than the previous generations of medication. Your embryologist monitors the progress of ovulation induction with ultrasounds and blood estrogen levels over several days.
Step Two - Egg Retrieval
An egg retrieval is performed by placing a special needle into the ovarian follicle and removing the fluid that contains the egg. This procedure is performed by visualizing the follicles with a vaginal ultrasound probe. A needle is directed alongside the probe, through the vaginal wall, and into the ovary. To avoid any discomfort, strong, short acting intravenous sedation is provided.
Step Three - Fertilization and Embryo Culture
Once the follicular fluid is removed from the follicle, the eggs are placed into an incubator. The eggs are fertilized with sperm later the same day. The male partner will provide a semen sample by masturbation from which the healthiest sperm will be extracted. If no sperm are available in a natural way, your embryologist may schedule a sperm retrieval procedure such as testicular biopsy, microdissection, testicular sperm extraction (TESA) or percutaneous sperm aspirations(PESA) around the time of egg retrieval. During conventional insemination approximately 50,000 sperm are placed with each egg in a culture dish and left together overnight to undergo the fertilization process.
The eggs also might be fertilized by Intracytoplasmic Sperm Injection (ICSI). ICSI is most commonly recommended as part of the IVF procedure when there is a problem with the sperm or egg, including sperm low motility, low sperm count or abnormally shaped sperm. Previous poor fertilization in IVF or low egg number may also prompt the use of ICSI.
Until recently, embryos were cultured for three days and then transferred to the uterus and/or cryopreserved (frozen). Now it's recommended to grow the embryos for five or six days until they reach the blastocyst stage. For some couples these blastocysts may have a greater chance of implantation, allowing the embryologist to transfer fewer embryos and lower the risk of multiple birth while increasing the chance of pregnancy. On day two or three after fertilization, the embryos will be evaluated for blastocyst culture. If there is a sufficient number of dividing embryos they will be placed in a special solution and grown for two or three additional days. A special blood test will be performed in 12-14 days to determine if the patient is pregnant.
Step Four - Embryo Transfer
Embryos may be transferred on day 3, 5, or 6 after egg retrieval. Transfers on day 5 or 6 are called Blastocyst Transfers. They are placed through the cervix into the uterine cavity using a small soft catheter. This procedure usually requires no anesthesia.
Additional Advanced Technologies
(AH) is a procedure performed prior to transfer in selected cases. An embryo needs to escape or "hatch" from it's protein shell, called the Zona Pellucida, before it can implant in the uterus. In AH, a chemical or a laser can be used to dissolve part of the zone, to facilitate the hatching process later. This technique is often used with prior failed IVF cycles, female age over 38, and with abnormally thick zone.
Percutaneous Epidydimal Sperm Aspiration and Testicular Sperm Extraction (PESA and TESE)
Some men have no sperm in the ejaculate but still produce them in the testicles. This may occur due to a vasectomy, to a congenital obstruction of the sperm ducts leaving the testicles, or to inadequate development of the sperm such that they cannot leave the testicles. In these situations, a urologist can remove sperm by placing a needle into the testis or the tubes that drain it. These procedures are done under anesthesia and can be very effective when combined with ICSI.
Embryos that are not transferred but continue to thrive in the laboratory can be cryopreserved (frozen). We'd recommend freezing for any high quality embryos that survive to the blastocyst stage. These embryos are stored in liquid nitrogen and can be thawed at a later date. While the pregnancy rates with frozen embryos are not as high, the procedures involved in preparing for a frozen embryo transfer are much simpler and less expensive. Freezing only embryos that survive to the blastocyst stage maximizes the chance for success in a thaw cycle.
In many situations, especially when a female patient is in her late 30's and early 40's, infertility may result from a decrease in ovarian function and a consequent fall in egg quality. In the event of a severe compromise in ovarian function, successful pregnancy is very unlikely. A treatment that often offers an excellent chance of success is to use eggs from a donor who is capable of producing good quality eggs. This is a complex treatment option from medical and psychological points of view, but one that provides a very good chance for pregnancy.