Before Starting the IVF
cycle
The IVF-ET
Process at C.A.R.S.
1. Ovarian Preparation and Stimulation
2. Follicle Aspiration
3. In Vitro Fertilization and Culture
4. Embryo Transfer
5. Implantation Support
IVF Model Cycle (requires
Acrobat Reader)
Questions and Emergencies
Financial Arrangements
IVF
success rates at C.A.R.S.
A complete medical history of both partners
is taken on the first visit. Physical examination is usually
postponed until a later visit. We may perform blood tests
to exclude hormonal problems known to lower the response to
ovarian stimulation and pregnancy rates. A pap smear should
have been performed within the past year. You should have
had a mammogram if you are over age 35. The screening process
is usually performed one to several months before the first
treatment cycle is scheduled. Screening always includes a
"baseline" ultrasound to exclude pelvic pathology.
Testing for AIDS and hepatitis should be current. Please advise
us of any health issue, or past medical history you feel might
impact on your therapy or chances of success. We make an earnest
attempt to keep screening tests, and therefore cost, to a
minimum. (Please review preconception-counseling
recommendations) General information about the science and
practice of IVF is available as an info
sheet in The
Learning Center
To the
Male Partner - We encourage you to accompany your partner
as much as possible during all visits and procedures at C.A.R.S.
It is essential that you accompany your partner for at least
one consultation because IVF is an important issue that affects
both of you. This is an opportunity for us to answer questions
you may have regarding the IVF procedure.
It may be necessary for you to learn the techniques to give
injection(s) of the medicines used for ovarian stimulation.
These injections are simple and safe procedures.
Please let us know of any changes in health or medications.
Tobacco use is strongly discouraged.
An absolute requirement is a recent semen sample from you
prior to the beginning of the IVF cycle. This sample permits
a check on the number and movement (motility) of the sperm.
If a problem is diagnosed or suspected, a more detailed examination
may be in order before proceeding. We do not routinely perform
more complex sperm function tests, such as hamster egg penetration
or sperm antibody tests, due to the expense and their failure
to alter course of therapy.
In some cases we may "bank"
your sperm by freezing to provide convenience, or in select
cases, a greater chance of fertilization. In cases of previous
fertilization failure, we may suggest assisted fertilization
(ICSI). where the oocyte coverings are manipulated and fertilization
rate possibly improved. With advance notification and planning,
donor sperm is also available through several certified sperm
banks, all of which meet certification standards of the American
Society of Reproductive Medicine. You may also want to read
our information on male
infertility in The
Learning Center.
The science of IVF is presented in our
IVF-ET INFO SHEET
on this subject. Financial matters are discussed in IVF
finances. Let’s now review how each of the steps
of the IVF cycle is accomplished at C.A.R.S. You will also
receive a copy of written instructions covering each step
of the procedure. You will be given well in advance an informed
consent form that outlines the risks that may be associated
with the IVF and provided ample time to answer questions or
address any concern.
The objective of ovarian stimulation is to increase the possibility
of successful initiation of pregnancy by synchronizing the
ovary and increasing the number of eggs available for IVF.
There are countless different regimens that have been tried
and in fact, most are much more similar than different. At
C.A.R.S., we do not have a fixed method. We do not believe
that “one size fits all.” We try to design a treatment
regimen that fosters the best egg quality and the greatest
chance of pregnancy, remaining ever mindful of the inconvenience
and cost of therapy. While we want to maximize the chances
of pregnancy, we want to minimize the chances of over-stimulation
of the ovaries and resulting cyst formation. All of this can
be a tall order to fill.
In cases where there is a high probability of pregnancy, such
as a woman under age 30 who has had previous tubal sterilization,
fertility pills (clomiphene) rather than injections may be
adequate. Some women may require very large dosages of medication
and prolonged therapy to achieve an adequate number of eggs
to fertilize. You have our guarantee that if a superior method
for ovarian stimulation is found, we will use it.
An example of the most commonly used
stimulation regimen has been included as an IVF
cycle model (requires Adobe Acrobat Reader). While this is similar, if not identical,
to the most commonly used regimen in the world today, individual
response will still vary. The rationale and plans for your
therapy will be presented in detail and please ask questions.
Traditionally we use A GnRH analog (the commonly recognized
brand is Lupron) beginning around cycle day 21 of the in the
cycle before IVF is anticipated. This helps synchronize egg/follicle
development and helps prevent and unwanted ovulation before
aspiration.
If your periods are irregular we often use oral contraceptives
or progestins to help regulate and time bleeding.
Various regimens are used to stimulate the ovary to develop
multiple follicles, but most involve the use of injectable
fertility medications, gonadotropins. The purpose of these
injections is to cause more than one follicle to advance toward
ovulation. The injections are safe and easy to administer.
For time, cost and convenience, your
partner will be taught how to give the injections when you
are using an injectable form of therapy. In our experience,
partners are the best of all “shot givers.” We
have videotapes and written instructions to guide this process.
It is important to know that there is very little chance for
mistake if a few simple guidelines are followed. The risk
of injury (other than an occasional bruise or complication
of the injection procedure is very rare. If there are ever
any problems or questions, please ask.
Monitoring
of Follicle Growth - An initial screening ultrasound
scan is usually scheduled on day 2 or 3 of the cycle in which
IVF will be attempted. Ultrasound examinations are painless
and are usually performed vaginally. This early screening
is to ensure that the ovary and uterus are at the necessary
low level of stimulation and that there are no ovarian cysts.
Cysts, while generally not serious, may cause the ovary to
respond less well and lessen the chance of pregnancy. If cysts
are found, it may be necessary to postpone your IVF cycle.
Follicular growth will be monitored
using ultrasound scans and blood samples. Monitoring is performed
in either our Johnson City or Asheville offices or in any
one of our several satellite
offices. Careful monitoring of response to stimulation
helps to ensure that adequate stimulation is occurring and
over- and under-stimulation is avoided. With ultrasound scans,
the number of follicles can be determined and their growth
followed. Blood samples measure the level of estradiol, the
principle hormone produced by the growing follicle, and possibly
LH, luteinizing hormone, and progesterone. This ensures that
ovulation has not occurred. Together these tests help to determine
the number, size and quality of developing follicles.
Follicle
Maturation - When the follicle(s) is judged to be mature,
both by size (usually 16-22 mm) and estradiol level (above
400 pg/ml or 200 pg/ml per preovulatory follicle), you will
receive an injection of human chorionic gonadotropin (hCG)
to ensure the final maturation of the oocyte. The injection
of hCG also sets the time for follicular aspiration. This
injection is usually given in the evening between days 10
and 13 of the stimulation cycle. Follicle aspiration is scheduled
35-37 hours after this injection. If left alone you would
probably ovulate at about 40 hours after the hCG injection.
It is common to worry about ovulation occurring before the
eggs can be removed. Ovulation is certainly not impossible,
but very unlikely because of the medications discussed above
used to block ovulation. It is common to feel considerable
pressure and have a large amount of cervical mucus in the
last several days, especially right before, the aspiration
procedure.
Follicle aspiration is performed at
our Johnson City office.
We know this is much less convenient for some, but it offers
considerable cost savings and improved quality control to
have a “central” laboratory. Before the aspiration
procedure, a speculum is placed and the vagina cleansed with
large amounts of sterile water. It is impossible to completely
disinfect the vagina and we do not want to use strong antiseptic
agents as that might kill the eggs. As a safeguard, you will
be given an injectable antibiotic to reduce the chance of
infection. Please let us know if you have any drug allergies.
Since this is an outpatient office procedure and we are trying
to minimize intervention, complications and cost. We do not
routinely start an intravenous infusion (IV). We use mild
oral sedation (Valium or Ativan)/pain medication (usually
a combination of Demerol and phenergan. Most patients are
interested and like to see the eggs as they are isolated form
the follicular fluid be the embryologist. Your partner is
strongly encouraged to be with you during the procedure. The
procedure is not painless, but is quick and generally well
tolerated. The pain is often described as pressure, or a severe
menstrual cramp or ovulation pain. After several thousand
procedures using this method we are convinced that it is superior
to all others.
An ultrasound scan, just like those used in monitoring is
performed, but this time a needle will be attached to the
ultrasound probe (transvaginal approach). The ovary, which
is naturally positioned very close to the top of the vagina
and the tip of the ultrasound probe, is usually easily accessible.
In the procedure of follicle aspiration, the needle is passed
through the upper vaginal wall and while watching on the ultrasound
screen the follicle is entered and fluid removed with gentle
suction.
With the fluid comes the egg, which is often floating freely
in the follicle fluid at the time of the aspiration. The nurse
who will be assisting passes the fluid into the adjacent mobile
incubator (we call it the “egg mobile”). All culture
dishes will have your name on them. The attending embryologist
will empty the fluid into a small dish where the egg and its
associated follicle cells can be seen through the microscope.
He will move then move the egg into a culture medium and later
the sperm will be introduced. Each culture dish is carefully
labeled with your name.
We aspirate all follicles possible. Some
follicles, especially small ones, may not have eggs capable
of collection. All eggs may not be healthy eggs capable of
being fertilized; some of fertilized eggs will not continue
their development into embryos capable of establishing a pregnancy.
The procedure may last from several to about 10 minutes, with
few exceptions. You will be in the procedure room for another
10-15 minutes before and after the procedure;. Immediately
after aspiration of a follicle, the oocyte is isolated from
the follicular fluid and placed in a culture dish containing
nutrient media and transferred to the incubator. Each culture
dish is carefully labeled with your name.
After the aspirations are completed, we let you rest a short
while and usually permit you to go home within one hour.
For the Male Partner
Shortly before or after the aspiration procedure, the sperm
are isolated from the semen obtained earlier. During this
procedure, the most active sperm are selected and transferred
to a culture dish for completion of the changes necessary
for fertilization.
All specimen and culture containers are carefully labeled
with the couple's name and isolated from all other patient
material.
You must be available to give a semen specimen on the day
of the follicle aspiration. You should abstain from ejaculation
for at least 2 days, but no more than 7 days prior to the
aspiration procedure. This timing has been judged to produce
an optimal specimen. Too long or too short period of abstinence
can be detrimental to sperm quality.
The specimen used for fertilization
should be obtained in as clean a manner as possible. Wash
the genital areas thoroughly with soap and water on the morning
the sample is required. Use no lubricants in production of
the specimen. A sterile container will be given to you. The
specimen must be obtained by masturbation. A quiet and isolated
room is provided for production of the sample. Your partner
may accompany you. If you think there may be any problem in
producing a specimen, please discuss this well in advance.
Oocytes and sperm are placed together in a culture dish, which
is placed in a controlled environment inside an incubator.
There they are left undisturbed until the next day when they
are examined. If fertilization has occurred, you will be notified
and the transfer time confirmed. If fertilization cannot be
determined the eggs may be re-inseminated, or reexamined,
before a decision to cancel the cycle is made. If there are
more than four embryos after fertilization, you will be notified
and given the option of cryopreservation for future embryo
transfer cycles.
Usually on the third day following follicular aspiration,
you will return to the clinic to receive the conceptuses ("embryo[s]"),
which have developed in culture to the 2-12 cell stage. The
transfer takes only a few minutes. This procedure involves
placing a speculum into the vagina and transferring the embryo(s)
through a small plastic tube placed through the cervix into
the uterine cavity. No anesthesia is required and usually
only minimal, if any, discomfort is felt.
You will remain in one of our procedure lounges for 1-2 hours
after the transfer. During that period you will be lying down
as a possible aid in retention and implantation of the embryos.
If you want, bring something to read or music.
It is unknown when implantation takes place or what can be
done to ensure the best chance of implantation. Common sense
should prevail. Avoid guilt in deciding on activities.
In some cases either progesterone (suppositories or injections)
or hCG injections may be given to help prepare and possibly
support, the uterus. Whether or not they are prescribed depends
on the type of ovarian stimulation and your response to this
stimulation.
As the embryo attaches to the uterine wall, it produces hCG.
This hormone can be measured in maternal blood and urine and
is the basis of pregnancy tests. The hormone may be detected
as early as 10 days after transfer by sensitive quantitative
blood testing and should be seen by 12 days after transfer
by home testing of urine. A rising level of ß-hCG indicates
successful implantation and pregnancy. We do not routinely
do blood testing, but wait for a missed menses. Early testing
can possibly be misleading, but more importantly, the results
will not change or therapeutic course or intervention. Normally,
all residual hCG for injections has been cleared by 7-10 days
after the last injection but it is possible, that there may
be a very small amount that could falsely affect pregnancy
test. Generally, if a pregnancy test is positive 10 days from
hCG, you are pregnant, regardless of what future testing might
show.
A large number of pregnancies, both
normal and after IVF-ET, are lost very early. Generally, hCG
and progesterone levels are followed until an intrauterine
pregnancy can be identified. If progesterone is used for luteal
support, it is tapered relatively quickly depending on blood
levels. Ultrasound scans are performed weekly until fetal
heart activity and the number of embryos has been determined.
If there is spotting during this time--rest and call. If a
pregnancy does not occur, menses will usually start 10 to
14 days after embryo transfer.
Specific
charges for each portion of the IVF cycle are presented in
IVF
Cycle Fees.
You should feel free to ask any questions as you progress
through your IVF cycle. You will be given time during your
office visits to discuss your concerns. If you have additional
questions or should problems arise, you may contact us at
423-461-8880; in Asheville, 828-285-8881. When calling our
office please identify yourself as an IVF patient. If a nurse
is not available, leave a message. Please call again if your
call has not been returned in a reasonable length of time.
If it is before regular office hours,
at night, or during the weekend, please leave a message on
our voice mail at the above number. If it is a question that
needs to be addressed immediately, please page your primary
C.A.R.S. physician. If the call is not returned within 15
minutes page again. If the after the second try there has
been no answer, page one of the other C.A.R.S. physicians.
You may page Dr. Thatcher at 412-8880, or Dr. Kennedy at 412-8888.
Asheville patients may call the Asheville office where pager
numbers will be given (828-285-8881). If the call is not returned
within a reasonable time, page Dr. Thatcher or one of the
Johnson City physicians.
If there is a true medical emergency
and you have been unable to reach your C.A.R.S. physician
or you feel that you cannot wait for a return call, go directly
to the nearest emergency room. In Johnson City, go to Johnson
City Medical Center and identify yourself as a patient of
your primary C.A.R.S. physician. In Asheville, go to Mission
emergency room and identify yourself as a patient of Dr. Holman.
If you have an obstetrician or gynecologist, or live a considerable
distance away, you may use this person for calls when your
C.A.R.S. physician is not available.
We are very interested in your medical care and please keep
us informed of any significant health changes.
Do not let a question go unanswered.
Also see C.A.R.S.
IVF success rates and Dr. Thatcher's article on interpreting
success rates.
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