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Understanding Infertility


 

IVF Basics - How does IVF work?

In vitro fertilization, or literally "in glass" fertilization, is the process by which a woman's egg is fertilized with sperm outside of her body in a lab setting. This fertilized egg, now called an embryo, is then transferred back into her uterus for pregnancy.

This procedure is a common infertility treatment for women who have viable eggs, but have damage to their fallopian tubes or another fertility factor which prevents the possibility of pregnancy without assistance. IVF is also used when other infertility treatments have been unsuccessful.

The IVF procedure has five different parts: hormone suppression, ovarian stimulation, egg retrieval, fertilization, and transfer.

 Step 1

Step 1: Hormone Suppression

A few days after the egg retrieval occurs, the female patient will come back to the center for the embryo transfer. The embryos are suspended in fluid and inserted directly into the uterus through a long flexible tube. The process is generally quick and painless; however, the woman will be advised or rest for a short period of time.

 Step 2

Step 2: Ovarian Stimulation

Once a woman's own hormonal cycle is suppressed, medications are given to help stimulate the ovaries to encourage the development of multiple eggs. In a normal reproductive cycle, a women typically matures one egg. However, for an IVF procedure, multiple eggs are created in order to increase the chances of a successful pregnancy. Once the eggs are almost mature, a second medication is administered to help give a final "push" in preparation for retrieval and to trigger ovulation.

 Step 3

Step 3: Egg Retrieval

In egg retrieval, eggs are aspirated from the ovaries. In this procedure, a thin needle is guided by ultrasound through the vagina and to the ovaries where eggs are retrieved. This procedure is usually done under light sedation, and takes only 10 to 15 minutes.

 Step 4

Step 4: Fertilization

Using the partner's sperm or donor sperm, the retrieved eggs are fertilized in a lab setting either by mixing the eggs with the sperm or by injecting a single healthy sperm directly into each mature egg (this procedure is called ICSI). Once the eggs are fertilized, they become embryos. These embryos are allowed to mature for several days. The fertility expert will then decide which embryos are the healthiest and select those to be transferred back into the uterus for pregnancy.

 Step 5

Step 5: Transfer

A few days after the egg retrieval occurs, the female patient will come back to the center for the embryo transfer. The embryos are suspended in fluid and inserted directly into the uterus through a long flexible tube. The process is generally quick and painless; however, the woman will be advised or rest for a short period of time.

Once the IVF procedure is complete the couple will need to wait approximately 2 weeks before taking a pregnancy test.

How likely am I to become pregnant with IVF?

The success rate of IVF depends on multiple factors, including age and endometrial lining. However, the Society for Assisted Reproductive Technology reported that the average successful live birth rate after IVF in the US was 41% (for women under the age of 35). Because CHR treats older women with complex infertility cases, our IVF pregnancy rates cannot be directly compared to the national average or those of other centers.

Watch Dr. Barad explain the crucial importance of tailoring IVF treatment for each patient

IVF - Why Individualization is Crucial


 

Fertility medications for IVF and ovarian stimulation

Many fertility medications are used in fertility treatment. The list below contains typical fertility medications used. Although many fertility centers use the same small set of medications, the protocols that the fertility experts prescribe to each patient can be very different (and can make all the difference between a successful IVF cycle and a failed one). There are exceptions, of course, such as CHR's innovative use of dehydroepiandrosterone (DHEA) supplementation in women with diminished ovarian reserve. When taking fertility medications, follow your fertility doctor's instruction carefully, as timing can be very important for some medications, such as hCG.

Estrogen Patch 

Estrogen patches are used in IVF cycles to thicken your uterine lining (endometrium), so that your uterus is ready to welcome the transferred embryo(s).  

Clomiphene Citrate 

Clomiphene citrate (called Clomid, by its brand name) is often the first fertility medication that reproductive endocrinologists prescribe for infertility patients. Clomid is most often used with intrauterine insemination (IUI) to induce ovulation. 

Leuprolide Acetate 

In IVF cycles, Leuprolide Acetate (often called Lupron, even though it's a brand name--a bit like Band Aid and Hoover) is used to prevent premature ovulation. Because Leuprolide Acetate does this by suppressing the estrogen production in your body, you will need Follicle Stimulating Hormone (FHS) and/or Human Menopausal Gonadotropin (hMG) to encourage follicular development. 

Follicle Stimulating Hormone (FSH) 

Follicle Stimulating Hormone (FSH) is used in IVF cycles to stimulate your ovaries to produce multiple mature eggs. 

Human Menopausal Gonadotropin (hMG) 

hMG contains natural follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In IVF cycles, hMG is used to regulate ovulation and encourage growth of multiple eggs when clomiphene citrate did not work well.

Ganirelix Acetate (GnRH Antagonist)

In IVF cycles, Ganirelix Acetate (often called Antagon, even though it's a brand name--a bit like Band Aid and Hoover) is used to prevent premature ovulation. Ganirelix Acetate suppresses Luteinizing Hormone, which would normally let your ovary to release the mature egg (i.e., ovulation). 

Human Chorionic Gonadotropin (hCG)

hCG is similar to LH. In an IVF cycle, one-time injection of hCG is used to trigger ovulation to get your mature eggs ready for insemination.

Progesterone

Progesterone is used to thicken your endometrium (lining of the uterus) so that the implantation of fertilized egg(s) will be easier. Medications used in ovarian stimulation can suppress progesterone levels in your body, so it is important to supplement it with exogenous progesterone. You will be taking both Progesterone injections and Prometrium vaginally.

Micronized Estradiol

Micronized estradiol helps maintain and build your uterine lining so that the transferred embryos will find a comfortable environment there.

Micronized DHEA

DHEA is a hormone naturally produced in the body. Introduced into fertility treatments by CHR, DHEA improves the quality of eggs and embryos, improves pregnancy chances, and reduce miscarriage rates. 

Baby Aspirin

Aspirin helps increases blood supply to your uterus and ovary. It also prevents clotting. 

Prenatal Vitamins

Prenatal vitamins, such as Folate, will help prevent neural tube defects. Iron will build up your blood count. Calcium helps build your babies' bones and will help you maintain yours.

Prednisone

Prednisone suppresses male hormones and immune function.

Doxycycline

Doxycycline is an antibiotic used to prevent infection after the egg retrieval.

How to interpret IVF success rates

IVF success rates represent the number of times a fertility clinic achieves a favorable outcome from a in vitro fertilization procedure. Success rates are published by individual clinics, and CDC/SART provides this information to the public. For patients, it is important to know that there are two different types of IVF success rates: "clinical pregnancy rate" and "live birth rate." Knowing the difference between the two can help you understand major variations in success rates between different fertility clinics.

Clinical Pregnancy Rate

A clinical pregnancy rate is the percentage of women that have a positive pregnancy test following an IVF treatment, regardless of whether or not the pregnancy results in a live birth. Because miscarriage rates are often high among women seeking fertility treatment (25% or more), the clinical pregnancy rate is usually higher than the live birth rate. However, in many cases, clinical pregnancy rates are the only available success rates for fertility clinics.

Live Birth Rate

The live birth rate is the percentage of IVF procedures at a fertility clinic that result in a live birth of a baby. Since this is the desired outcome for couples, this is the type of success rate that is often sought by patients. For many reasons, however, live birth rates are often not available (one difficulty that fertility centers face is the length of time it takes for a pregnancy to reach full term).

In addition, patients should be cautioned that there are many factors that may influence an IVF center's IVF success rate, including their practice specialty or if there are exclusion criteria for IVF patients. For example, clinics that specialized in IVF for the older women will have a lower IVF success rate than clinics that treat a younger patient population. In addition, many clinics artificially keep their IVF success rates high by excluding patients who are less likely to have a successful IVF treatment (criteria includes age, FHS levels, number of follicles, etc.). We don't!

Read more: How to interpret IVF success rates

Mini IVF: Is it really cheap?

Low-cost IVF, also often called "Mini IVF," has recently gained popularity as an attractive alternative to regular IVF. These programs may run as low as $5,000, a huge savings compared to standard IVF programs which usually charge upwards of $10,00 per cycle. However, this does not make them cheap. Unlike regular IVF, low-cost IVF cycles have significantly reduced success rates and on average require more cycles to achieve a pregnancy. In other words, couples may wind up spending much more than they would have had they invested in a regular IVF program. In addition, needing more cycles to get pregnant means that you'll have to spend more time trying, a stressful proposition. Unless your primary motivation is to use as little medication as possible for ovarian stimulation, Mini IVF may not be the best option! Although we do offer a type of low-cost IVF called EcoIVF (with proper informed consents), we strongly encourage you to discuss your options thoroughly with your IVF physician before option for Mini IVF cycles.

Read more: Weighing Mini IVF and Regular IVF

IUI vs IVF

Intrauterine insemination (IUI) and in vitro fertilization (IVF) are two of the most common infertility procedures prescribed.

Intrauterine Insemination (IUI)

Often considered a first-line treatment, IUI is one of the least complicated and most cost-effective options available for some fertility patients. In an IUI procedure, the male partner's sperm is "washed" in a lab setting to create a highly concentrated sample of healthy sperm. Then, a woman's cycle is monitored to determine when she is most likely to ovulate and become pregnant. At the time of ovulation, the sperm sample is inserted directly into the uterus through a long thin catheter.

The success rates for IUI depend on the couples' individual factors such as infertility diagnosis, age, etc. Typically, IUI success rates are lower than IVF; however, the cost of the procedure is much less and therefore younger couples who can afford to "wait and see" may undergo more rounds before deciding whether or not to advance to a more complex and expensive treatment options. IUI is generally a good option for couples with regular ovulation, open tubes and mild male factor infertility, who can afford to "wait and see."

In Vitro Fertilization

In vitro fertilization (IVF) is the process by which a woman's egg is fertilized with sperm outside of her body in a lab setting. This fertilized egg, or an embryo, is then transferred back into her uterus for pregnancy.

This procedure is a common infertility treatment for women who have viable eggs, but have damage to their fallopian tubes or another fertility factor which prevents the possibility of pregnancy without assistance. IVF is also used when other infertility treatments have been unsuccessful, or when patients' reproductive time frame doesn't allow for trying less costly but less reliable treatments like IUI.

Read more: IUI vs IVF

Tubal Reversal vs IVF

One reason a couple may need fertility treatment is the past use of tubal ligation as a form of permanent birth control. When life circumstances change, some of those who had tubal ligation realize that they want more children. Without permeable fallopian tubes, a fertilized egg cannot travel to the uterus and therefore pregnancy cannot occur.

Pregnancy After Tubal Ligation

Women who have undergone a tubal ligation but later decide they desire more children have two options to try and become pregnant again: tubal reversal or IVF.

Tubal reversal is an attempt to surgically repair the fallopian tubes. However, the availability of this option depends on the amount of healthy tubes left. When surgery is not possible or the likelihood of a natural pregnancy after tubal reversal is low, IVF is an alternative, often more reliable, option. In an IVF procedure, the need for healthy fallopian tubes is bypassed by extracting mature eggs out of the ovaries, fertilizing them in a lab setting, then implanting them back into the uterus for pregnancy.

Some considerations in deciding which procedure is right for you may include financial factors (many insurances do not cover the cost of this surgery, which can be very expensive), methods used for tubal ligation, or the likelihood of a natural pregnancy after a tubal reversal.

Read more: Tubal Reversal vs IVF

Want to learn more?

Our infertility experts offer free email consultation to help you decide whether treatment at our center is right for you.

 

Norbert Gleicher, MD

Norbert Gleicher, MD, FACOG, FACS

Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.

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