This procedure was first successfully used in humans in 1977 in England by Drs. Steptoe and Edwards. The scientific importance of this discovery was recently recognized with the awarding of the Nobel Prize in Medicine to Dr. Edwards. To date, millions of babies have been delivered worldwide as a result of this treatment. The procedures to achieve IVF pregnancy have become increasingly simpler, safer, and markedly more successful.
To achieve pregnancy as a result of IVF, several steps are necessary and each one of them will be described in detail to help you better understand the treatment as it will occur.
Hormonal suppression or ‘down-regulation’ of your menstrual cycle with birth control pills or other drugs.
Stimulation of the ovaries to produce several eggs.
Retrieval of the eggs from the ovaries
Fertilization of the eggs and cultivation of the embryos in the laboratory
Biopsy and Cryopreservation of Embryos
Placement of the embryos into the uterus
This process allows us to take charge of your ovaries so that there is no follicular growth occurring at all, and helps to synchronize your follicles to allow multiple eggs to develop at once. Depending on the medications used, there is a chance you will temporarily undergo some of the symptoms of menopause, but these symptoms will go away during the stimulation phase. This will then make sure that during the next stage of the treatment we have full control of the stimulation.
During this phase of your treatment cycle you need to continue the drugs that ‘switch off’ your bodies own control of your ovaries and also start taking medication that will stimulate them. The reason for continuing the suppression medications is to stop the chance of you ovulating before we get to the egg retrieval, so it is very important that you keep taking those drugs. The stimulation is carefully controlled to allow for the most optimal follicle recruitment possible – the dosage is decided based on all of the workup that you did before starting the cycle.
You will be monitored during this phase of your treatment to make sure that you are responding appropriately by doing blood draws to check your estradiol levels and by vaginal ultrasound scans to measure the follicle sizes. There are times when we either increase or decrease the drug dosage depending on what we see, and you will be informed accordingly.
It is very important that you continue to follow your calendar very closely during this period and to follow any and all changes that we may make depending on your response. You will need to make sure that you are flexible to allow for appointments at short notice and that you are available via phone each day.
Once it has been determined that your follicular growth is optimal then we will schedule your egg retrieval. This is achieved by the administration of a carefully timed ‘trigger shot’ that allows for the final maturation of the follicles and readies the eggs for release. The exact nature of the shot depends on your response to stimulation and you will be given full instructions at the time. You will be given a precise time for the trigger and it is very important that you stick with this time.
You will be under deep sedation anesthesia for the egg retrieval procedure, under the care of a MD anesthesiologist. The anesthesiologist will keep you asleep for the procedure. You will be given instructions as to when we need you to arrive at the clinic and how to prepare for the case.
The retrieval itself utilizes the same vaginal probe ultrasound that was used during the monitoring phase of treatment, but with a guide attached to it. That guide allows a needle to be passed through the back of the vagina and into the ovary under direct visualization. The needle itself allows both the contents of the follicle to be aspirated, and then media to be pushed back into the follicle to ‘rinse it out’. Then the fluid is passed to the embryologist in order to look for the egg. They are very visible within the fluid from the follicle, and they can be separated and placed into culture media.
This step also utilizes the IVF Witness RFID tagging system which allows us to allocate your name to the tag that has been placed on the dish for chain of custody monitoring of the identity of all samples. This ensures that the right eggs, sperm, and embryos are used for every procedure we do.
Once we get the eggs back into the laboratory they are placed into new culture media and are placed into the incubator. We also need to process the sperm sample that we are going to be using for the insemination later that day. In most cases we will use an ejaculated sample that has been produced at some point during the morning. The sample is processed to remove all the seminal plasma and to concentrate the motile sperm. On occasion we can use a frozen sample; the process is very similar in that the sample is washed, this time to remove the cryoprotectants as well as the seminal plasma.
The insemination procedure is carried out during the afternoon – timed to take place 6-8 hours after the scheduled retrieval start time. There are two different methods that can be used to inseminate the eggs, and the decision of which to use is dependent on the quality of the semen sample and also the couple’s history. For the most part we will have made the decision prior to the cycle as to which method we will be using, either conventional IVF when the sperm is simply added to the dish with the eggs, or Intra Cytoplasmic Sperm Injection (ICSI) where individual sperm are injected into each egg.
The morning after the egg retrieval (Day 1) is when we check the eggs to see which ones have fertilized, and you will be given a call that morning to update you about the status. After this point the embryos are left in the incubator, evaluated at specific times and moved into fresh culture media as their developmental requirements change.
The embryos are then cultured in the incubators until day 5 of development. This allows biology to filter out which embryos are more likely to be normal. In other words, a higher proportion of day 5 embryos will go on to be a successful pregnancy than earlier stage embryos.
Here at ORH, we are quick to adopt cutting edge ideas and approaches when it is clear it is better. In freeze-all protocols all suitable embryos obtained from a “fresh” IVF cycle are frozen on either day 5 or 6 with no embryos being transferred that cycle. The transfer will then be planned for a later date in a separate FET cycle.
Emerging research is indicating that freeze all protocols significantly increase pregnancy outcomes over traditional fresh cycles where the embryo is transferred back during the same cycle as it was retrieved.
There are many likely reasons for this:
First, hormone values and inflammation are vastly different in a fresh IVF cycle than in a FET / non-IVF cycle. During a fresh cycle the women’s ovaries are hyper-stimulated with hormones to allow for more mature eggs to be retrieved. These hormones/medications alter the woman’s normal biochemistry for the duration of their cycle. Until recently, this was thought to be of no consequence, but strong evidence is starting to show the opposite. Waiting to transfer the fertilized embryo(s) back into the uterus during an unstimulated cycle (FET cycle) results in increased pregnancy outcomes in all age groups as well as increased birth weights of around 200 grams.
Another important reason that ORH has gone to a “Freeze-All” approach is that emerging research is showing that approximately 20% of uterine linings in a fresh cycle are NOT ready for the embryos, even when the lining looks excellent by ultrasound.
Appropriate embryos can be biopsied for PGS/PGD at the day 5/6 day of development before they are frozen.
Once we have all decided on the number of embryos that are going to be replaced then we will make sure that we have selected the most appropriate ones to transfer based on their grade.
The first part of the transfer is where the physician finds the best route into the uterus through the cervical canal, and places the outer sheath of the catheter into your cervix under abdominal ultrasound guidance. The embryos are then quickly loaded into the catheter, that is threaded through the outer sheath that is already in place and the embryos are expelled into the uterus. After they have been transferred we will carefully check the catheter to make sure that they have not been left behind before the procedure is complete.
After the transfer you will be asked to remain lying down for about 15-20 minutes and then you are free to go about the rest of your day. You will be given full follow up instructions regarding what activities should be avoided and what new medications you will take.
All of the procedures that are carried out in the laboratory here at Overlake Reproductive Health utilize the IVF Witness system. This allows us to use Radio Frequency Identification tags (RFID) on every single culture dish or test tube to safely identify the contents – eggs, sperm, or embryos – as the ones that belong to you.
Learn more about IVF at ORH
IVF offers hope for couples who might not be able to conceive through natural means alone. Technological advancements and constantly improving techniques continue to make IVF a safer, simpler, and more successful procedure. You can read more about our world class IVF success rates. If you would like to learn more about IVF or want to discuss your options with one of our highly trained fertility specialists please contact us.