In Vitro Fertilization

invitro

Medications

Each patient’s medication plan is individualized, but most IVF regimens include one or more of the following:

A medication that prevents ovulation. These medications are called GnRH analogues because they are similar to GnRH, a naturally occurring human hormone that controls the function of the ovaries. They can be started before or after ovarian stimulation, and they allow us to stimulate the ovary harder, without running the risk of spontaneous ovulation, that can cause the loss of all the oocytes prior to the oocyte retrieval. Such medications are Cetrotide, Antagon, Ganerelix and Lupron and are given by subcutaneous (under the skin) injections usually daily.

Medications to stimulate the ovaries. These invariably contain the hormones FSH and LH, although at AFS we also use protocols that indirectly cause the release of FSH and LH by the patient’s own pituitary, such as the pill Clomid. FSH and LH can be given via subcutaneous (under the skin) injections, and these injections are daily. Brand names for these medications are: Gonal-f, Follistim, Menopur, and Bravelle among others.

The trigger injection. This is an injection that is absolutely necessary in order to start the process of oocyte maturation, i.e. to prepare the oocyte so that at the time of retrieval the oocytes are mature. Almost all IVF cycles are triggered with an injection containing hCG, the natural human placental protein that acts by imitating the LH surge. [The LH surge is an event that occurs during the normal monthly cycle in every woman. It is a rapid release of high levels of the hormone LH by the pituitary and is in fact the hormone detected by commercially available ovulation predicting tests]. Such medications are Ovidrel, hCG, and Novarel. On occasion, we use a special characteristic of Lupron (see above), one of the ovulation blocking medications that triggers ovulation. This is occasionally useful she we are trying to avoid the ovarian hyper stimulation syndrome (OHSS). Irrelevant to what specific medication is used, the timing of the trigger is very important because it correlates with the timing of the oocyte retrieval (egg harvesting).

The Process

Monitoring visits. When undergoing IVF, a patient will need to be seen in the office a number of times, during which visits she will have blood tests and ultrasounds. These monitoring visits start usually before the stimulation, and will be necessary every 2 to 3 days until the time when the patient’s ovaries are ready for the final “trigger” shot.

Oocyte retrieval. The procedure is usually done under intravenous anesthesia, using a very safe medication called Propofol, administered by a Board Certified Anesthesiologist. The patient experieoccasion, for cycles where only one or two oocytes are present, such as in natural or minimal cycles, it can be done without an anesthesiologist. The day of the retrieval the patient cannot eat or drink anything. As the patient’s partner will need to provide his semen on the same day, it is necessary to abstain from sex for two to three days prior to the retrieval. Oocyte retrieval is performed using a transvaginal ultrasound probe that has a “needle-guide” attached to it. This makes the procedure very safe and fast. Following the procedure the patient will need some time to recover, and it is best that she is escorted home. Some cramping, vaginal staining and dizziness can be expected. However such side effects are short-lived. A painkiller such as Tylenol can be used.

Embryo transfer. A few days after the oocyte retrieval, the patient usually undergoes the embryo transfer. This is a fairly simple procedure that usually does not require anesthesia. Using a fine catheter, the embryos are deposited in the uterine cavity while a transabdominal ultrasound confirms proper placement.

Pregnancy test. This is scheduled 9 to 11 days after the embryo transfer. As the patient has been given an hCG injection (the usual trigger), performing the test earlier may show confusing results. In other words, it is possible to detect low levels of hCG 6 days after the embryo transfer but cannot be sure if that represents residual hCG from the injection, or a lively pregnancy. It is therefore necessary to wait for the proper time for the test.

Reproductive Biology – The Lab

During the IVF process, an important part of the procedure happens within the embryology lab. At AFS, our experienced and compassionate staff will be directly interacting with you, communicating about outcomes and expectations. These are the relevant Laboratory steps.

Oocyte retrieval. After the follicular fluid is aspirated via a needle our Embryologists aspirate the oocyte out of that follicular fluid. They then transfer the oocytes in a defined culture medium, which imitates the normal human fallopian tube, where the oocytes would otherwise be.

Fertilization. A few hours after the retrieval, the oocytes are fertilized with the partner’s sperm. This can be done with traditional high concentration insemination, (the sperm is put next to the oocyte and the process occurs by itself) or using intracytoplasmic sperm injection, where a normal spermatozoon is injected directly into the oocyte, ensuring a higher probability of fertilization.

Embryo culture. Following fertilization, the oocytes (now called zygotes) are again kept in defined culture medium under very strict conditions. The embryos are observed for cell division and growth, until it is time for their replacement to the uterine cavity.

Embryo transfer. Immediately prior to the embryo transfer, the embryos are kept sequestered in the laboratory. When the physician has prepared for the embryo transfer, the embryologist “loads” the embryo transfer catheter and passes it to the physician who advances it inside the uterus.