Faq's Related to In Vitro Fertilization - IVF.

When is IVF Needed?

Because the IVF process bypasses the fallopian tubes (it was originally developed for women with blocked or missing fallopian tubes), it is the procedure of choice for those with fallopian tube issues, as well as for such conditions as endometriosis, male factor infertility and unexplained infertility. A physician can review a patient’s history and help to guide them to the treatment and diagnostic procedures that are most appropriate for them.

Are there risks to having a baby through IVF?

While some research suggests a slightly higher incidence of birth defects in IVF-conceived children compared with the general population (4 - 5% vs. 3%), it is possible that this increase is due to factors other than IVF treatment itself.
It is important to recognize that the rate of birth defects in the general population is about 3% of all births for major malformations and 6% if minor defects are included. Recent studies have suggested that the rate of major birth defects in IVF-conceived children may be on the order of 4 to 5%. This slightly increased rate of defects has also been reported for children born after IUI and for naturally-conceived siblings of IVF children, thus it is possible that the risk factor is inherent in this particular patient population rather than in the technique used to achieve conception.
Research indicates that IVF-conceived children are on par with the general population in academic achievement as well as with regards to behavioral and psychological health. More studies are under way to further investigate this important issue.

Do fertility hormones pose long term health risks?

Compared with the general population, women who have never conceived appear to have a slightly increased risk of ovarian cancer (about 1.6 times the rate). Because it is thought that many of these women have also used fertility medications, it has been hypothesized that a link might exist between fertility medications and this particular cancer. A number of studies have been conducted since 1992 when this concern was first raised. None have found an association between fertility medications and higher risk of ovarian or between IVF treatment itself and higher risk of ovarian cancer. Preliminary results from an ongoing National Institutes of Health study likewise suggest no association between fertility medications and ovarian, uterine or breast cancer.
It is possible that this association is due not to the use of fertility medication, but to the fact that this population of women has never undergone childbirth. Findings from the National Institutes of Health and others suggest that pregnancy or some component of the childbearing process may in fact protect directly against ovarian cancer.

Are IVF injections painful?

The prospect of daily injections can be overwhelming. While injections are a necessary part of IVF treatment, we have designed our medication schedules and injection type to minimize discomfort and stress; and our nurses carefully instruct and support every patient throughout this process. Medications that once had to be injected into the muscle have been replaced by medications given as a small injection under the skin (subcutaneous). Such injections are most commonly taken over a 10-12 day period, followed by one intramuscular injection of hCG, a hormone that triggers ovulation at the conclusion of the stimulation cycle. The hCG injection, previously only available in an intramuscular form, is now available in a subcutaneous form (Ovidrel) for patients that wish to avoid intramuscular injection. Although the recombinant subcutaneous form of hCG in Ovidrel has not been around as long as intramuscular hCG, all indications are that it is just as effective.
After egg retrieval, patients are given a progesterone hormone supplement in order to prepare the lining of the uterus for the embryo transfer. For most patients, progesterone may be taken in a vaginal tablet or vaginal suppository form rather than an injection. In this way, injections may be avoided entirely during the second half of the IVF cycle. Progesterone vaginal tablets and suppositories have been proven to be as effective as progesterone injections.

Is the egg retrieval procedure painful?

Because anesthesia is used for egg retrieval, patients feel nothing during the procedure. Egg retrieval is a minor surgery, in which a vaginal ultrasound probe fitted with a long, thin needle is passed through the wall of the vagina and into each ovary. The needle punctures each egg follicle and gently removes the egg through a gentle suction. Anesthesia wears off quickly once egg retrieval is concluded. Patients may feel some minor cramping in the ovaries that can be treated with appropriate medications.

Is IVF using up all a woman’s eggs?

A woman’s ovaries house hundreds of potential eggs. Each month, during the natural ovulation cycle, the ovary selects just one egg from a pool of 100-1,000. Those eggs which are not selected undergo a natural cell death process called atresia. When a woman uses fertility medication, the body’s natural selection process is overridden, and a number of these otherwise unused eggs are allowed to grow. As many as 20 eggs may be stimulated in a given cycle. Thus when using fertility medication in the IVF process, not only is the woman not using up all of her eggs, but she is ‘rescuing’ eggs that otherwise would have undergone atresia.

What are the chances of pregnancy with frozen embryos?

In general, the success of frozen-thawed embryo transfer procedures depends on three factors:
The quality and survival of the frozen-thawed embryos. In general, we only freeze good quality embryos so the current rate of survival is greater than 90%.
The age of the woman who produced the eggs. In patients under the age of 37, the chances of pregnancy with frozen-thawed embryos are similar to a pregnancy with fresh embryos. In patients 37 years or older, pregnancy chances with frozen-thawed embryos decline in conjunction with declining fertility in general, but still can be quite good. As always it is best to discuss a woman’s individual situation with their physician.
The status of the uterus in the woman receiving the embryos. A healthy endometrial lining free of any interfering fibroids or polyps provides a sound environment for embryo implantation.
How are frozen embryos transferred?
Previously frozen embryos may be transferred during a woman’s natural cycle or in a controlled (artificial) cycle, depending on a number of factors:
Controlled cycle transfer. In a controlled cycle, hormone medications are given to prepare the uterus for transfer. This method is recommended for patients who have irregular cycles. Because the controlled cycle can be precisely timed, it is also advised for those who are on a set travel schedule. The medications commonly used for a controlled cycle are estrogen (either in an injectable or oral form) and progesterone (in either an injectable or vaginal form).
Natural cycle transfer. Patients who have a regular menstrual cycle may have the option of using their natural cycle for transfer of frozen-thawed embryos. In this case, there is no need for hormone treatment, as the body’s natural cycle will prepare the uterus for pregnancy. In cases where natural cycle transfer is possible, this option allows for less medication and monitoring and thus is often relatively affordable for patients. We typically will monitor the natural cycle using home urinary ovulation predictor kits as well as ultrasounds. When the kit changes and/or a nice pre-ovulatory follicle is seen on ultrasound, we administer a single injection of Ovidrel (recombinant subcutaneous hCG) and the patient starts progesterone vaginal suppositories a couple of days later. The embryo transfer will occur 5-7 days after ovulation/hCG injection, depending on whether the embryos are frozen at a Day 3 or Day 5 stage. For the transfer procedure itself, the embryo is thawed at room temperature, and then warmed to body temperature (37° C). As with a fresh embryo transfer, embryos are placed inside a special catheter (a very thin tube), which is guided through the cervix and into the uterus. Embryos are gently injected into the uterus and the catheter is removed. This procedure requires no anesthesia, and is done in a position similar to a pelvic examination for a Pap smear. After transfer, the woman rests for 15 minutes and then is able to go home, where a day of rest or very gentle daily activity is recommended.

What are the options if a woman’s own eggs are not producing a pregnancy?

The ability to use a donor egg has enabled thousands of women to become pregnant when they otherwise might not have had this opportunity. While a woman’s eggs may not be viable, very often the uterus is completely healthy and capable of supporting a pregnancy. In these cases, egg donation with IVF has high success rates. This procedure follows the same protocol as IVF, except the intended parents select a donor and use the donor's egg to create the embryo. Patients may seek egg donation services at Pacific Fertility Center's Egg Donor Agency or at an outside agency.

What if a woman is not capable of carrying a pregnancy?

Various medical conditions may make it impossible for a woman to carry a pregnancy. Reproductive medicine provides the option of enabling another woman, known as a gestational carrier (formerly called a surrogate) to carry the child of a woman who cannot sustain a pregnancy. There are two types of gestational carriers:
A traditional gestational carrier becomes artificially inseminated with the sperm of the intended father and uses her own eggs to fertilize the embryo. Many fertility centers, including Pacific Fertility Center do not offer traditional surrogacy. The legal issues and complicated past history of parental rights with traditional surrogacy have led us to discourage this option.
A gestational carrier with IVF does not contribute any of her own genetic material. In this case, the egg as well as sperm are extracted from the prospective parents, fertilized in the laboratory with IVF and then implanted into the uterus of the surrogate.
A gestational carrier may be appropriate for those in the following situations:
No uterus
Abnormal uterine cavity
Several recurrent miscarriages
Recurrent IVF cycles have not produced a pregnancy Medical conditions would make pregnancy dangerous for the mother or her baby

Faq's Related to Intrauterine Insemination - IUI.

What is an IUI and how is it done?

An IUI — Intrauterine Insemination — is performed by threading a very thin flexible catheter through the cervix and injecting washed sperm directly into the uterus. The whole process doesn’t take very long. It usually requires the insertion of a speculum and then the catheter, a process that maybe takes no more than a couple of minutes (60-90 seconds to introduce the catheter, then sperm injection, and another 60 seconds or so to remove catheter — going slowly helps reduce discomfort).

Where is the sperm collected? How long before the IUI?

The sample is collected through ejaculation into a sterile collection cup. If you are collecting at home, HFI requires that the semen be delivered to the office within an hour of ejaculation. Otherwise, we provide a collection room in the office for the male to use.
There is a delay between when the semen sample is dropped off and when it is inseminated to allow for washing of the sample. The amount of time depends on the washing technique used, which takes 30 minutes to two hours, as well as on the clinic’s scheduling. In most cases, we will perform the IUI as soon after washing is completed as possible.

When is the best timing to an IUI?

Ideally an IUI should be performed within 6 hours on either side of ovulation. When timing is based on an hCG injection, the IUI’s are usually done between 24 and 48 hours later. If two IUI’s are scheduled, they are usually spaced at least 24 hours apart.

What does an IUI feel like?

Most women consider IUI to be fairly painless due the thin flexible cathetar — along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is ovulation-related rather than from the IUI.

Do I have to lie down after an IUI?

Our doctors recommend patients lie down on the table for 15 – 30 minutes after the procedure.

Do I need to take it easy after an IUI?

We recommend patients take it easy for a while following IUI. Some people reduce their aerobic activity and heavy lifting during this time in hopes that it will increase the chance of implantation.

How long before an IUI should the male abstain from intercourse or ejaculating?

This depends on your individual situation, but it usually should not be more than 72 hours since his last ejaculation in order to ensure the best motility and morphology. If low sperm count is the reason for IUI, it is generally best to wait 48 hours between ejaculation and collecting sperm for the IUI.

How long after IUI should implantation occur?

Implantation generally takes place 6-12 days after ovulation — so 6-12 days after a properly timed IUI.

What kind of monitoring is usually done for an IUI cycle?

This depends mostly on how the female is being treated. A natural cycle is often timed with over-the-counter ovulation prediction kits. The use of Clomid can increase the monitoring, but usually only requires a handful of visits. Gonadotropins (injectable medications) increase the necessity of ultrasounds and bloodwork, requiring more frequent office visits

What does "sperm washing" mean?

It is sometimes also called sperm preparation or spinning. It is a laboratory technique for separating sperm cells from other supporting cells and fluid, and the separating motile sperm from non-motile sperm, for use in assisted reproduction (IUI, IVF).
The washing technique for near normal specimens is mixing the ejaculate after liquefaction with the appropriate washing medium followed by centrifugation (a centrifuge is a machine that separates materials with different densities by spinning them at high speed) The supernatant is discarded and the sediment (sperm rich fraction) is re-suspended in more washing medium. This process is repeated 2-3 times maximum. In the final wash, the sediment is re-suspended in 0.5 cc of medium, loaded into a syringe and deposited in the uterus.

Faq's Related to Intracytoplasmic Sperm Injection - ICSI.

What is ICSI?

Intracytoplasmic sperm injection, or ICSI, involves injecting a single live sperm directly into the center of a human egg. The technique was developed to help achieve fertilization for couples with severe male factor infertility or couples who have had failure to fertilize in a previous in vitro fertilization (IVF) attempt. The procedure overcomes many of the barriers to fertilization and allows couples with little hope of achieving successful pregnancy to obtain fertilized embryos.
The procedure requires that the female partner undergo ovarian stimulation with fertility medications so that several mature eggs develop. These eggs are then aspirated through the vagina using vaginal ultrasound, and incubated under precise conditions in the embryology laboratory. The semen sample is prepared by centrifuging, or spinning the sperm cells through a special medium. This separates live sperm from debris and most of the dead sperm. The embryologist then picks up the single live sperm in a glass needle and injects it directly into the egg.
ICSI was first used at UCSF in 1994, and our first successful birth achieved with ICSI assistance was in February of 1995. UCSF was the first San Francisco Bay Area program to achieve a pregnancy and birth with this procedure.

Who should consider ICSI?

ICSI is considered absolutely necessary is in the case of male factor infertility with an abnormal semen analysis. In the Bay Area, however, about 75 percent of all IVF cases are now ICSI. Patients are electing to undergo ICSI for reasons other than male factor infertility, including:
Previous poor fertilization with IVF
Variable sperm counts
Unexplained infertility
Many patients choose to undergo the ICSI procedure in order to maximize their success even when the procedure is not clearly indicated.
If you have been told that there are abnormalities with any sperm test results, you should give serious consideration to ICSI. If the male partner has had a vasectomy reversal, we also recommend ICSI regardless of the sperm quality because of the presence of sperm antibodies that may affect fertilization.
The decision to proceed with ICSI is particularly difficult if there is no prior evidence of male factor infertility. Some couples choose ICSI because they want to do everything possible to maximize fertilization. However, it is important to understand that for many couples with normal sperm parameters, maximal fertilization can be achieved with standard insemination during IVF without the use of ICSI.

Who should consider split ICSI?

For couples interested in knowing about their own fertilization capability, we offer split ICSI. This option involves performing ICSI on a majority of all mature eggs and incubating the remainder with sperm. In effect, split ICSI can provide a safety net against failed fertilization with standard insemination.
The fee charged for split ICSI is the same as ICSI. One requirement for split ICSI is a minimum number of mature eggs. We must be able to identify at least eight mature eggs on the day of your egg retrieval in order to proceed with split ICSI. If this requirement is not met, we will inject all of your mature eggs.

How successful is ICSI?

Through the ICSI procedure, many couples with difficult male factor infertility problems have achieved pregnancy at UCSF. Fertilization rates of 70 to 80 percent of all eggs injected — equivalent to fertilization with normal sperm — are currently being achieved, and pregnancy rates are comparable to those seen with IVF in couples with no male factor infertility.
The most important indicator of ICSI success appears to be the fertilization rate achieved with the ICSI procedure. The fertilization rate in the UCSF IVF laboratory is exceptional — currently 80 to 85 percent. That is to say, on average, eight out of every 10 eggs will fertilize normally.

What are the risks associated with ICSI?

There are several risks. First, during the ICSI procedure, a small number of eggs — usually less than 5 percent — can be damaged as a result of the needle insertion. Second, the overall risk of having a baby with a chromosomal abnormality in the X or Y chromosomes is 0.8 percent, or eight per 1000, which is four times the average seen with spontaneous conception. At present, we do not know the reason for this increased risk. It is important to understand that the following problems can be associated with sex chromosome abnormalities:
  • Increased risk of miscarriage
  • Heart problems for affected infants that may require surgery
  • Increased risk of behavior or learning disabilities
  • Increased risk of infertility in your children during their adulthood
  • The risk of having a chromosomal abnormality like Down's syndrome is not increased with ICSI but increases with maternal age.
Several studies have addressed the issue of developmental delays in children born of ICSI. However, there is no conclusive evidence that this is the case.

Will all of our eggs be injected?

If you decide to proceed with ICSI, we will make every effort to inject as many eggs as possible. It is important for you to understand that only eggs that are mature can be injected with sperm. Our IVF laboratory can easily tell if an egg is mature or immature. Although the immature eggs are incubated with sperm, the likelihood of fertilization is very low. On average, we are able to inject 75 percent to 80 percent of the eggs that are recovered.

Faq's Related to Donor Oocyte IVF

If I use donor eggs, will the baby look like me?

When matching an egg donor to a recipient, fertility clinics take into account that there is compatibility between them and that they share as many phenotype and immunological characteristics as possible. So, theoretically, yes, a baby conceived with donor eggs is likely to look like the birth mother.
However, it is important to note that the biological mother of the baby will be the egg donor, so in terms of genetic inheritance, the answer to this questions is no, the baby will not look like the recipient, since he or she does not share the genetic load with her.

Does a donor egg have my DNA?

No, donated eggs contain the DNA of the donor. The fact that it is later fertilized in the laboratory and transferred to the recipient’s uterus does not modify the original genetic code of the egg. The embryo, therefore, contains the donor’s genetic material.

Do babies from egg donation share genes with the birth mother?

As explained above, egg donor babies do not share the genetic load of the birth mother, but that of the egg donor, who is in fact the biological mother.
Nevertheless, recent studies have shown that recipients of donor eggs still pass some traits of their DNA through a phenomenon called epigenetics, a branch of Biology that studies the influence of a person’s lifestyle on who he or she is, regardless of the gene expression.
So, factors such as the mother’s diet during pregnancy could affect the development of the baby-to-be’s gene expression.

What does an IUI feel like?

Most women consider IUI to be fairly painless due the thin flexible cathetar — along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is ovulation-related rather than from the IUI.

If I use donor eggs, will the baby be mine?

Absolutely. Having a child is not only about sharing your DNA with him or her, but about educating, bringing up and enjoying life together as a family. Women who become mothers via egg donation love the baby exactly as any other female who got pregnant naturally with her own eggs would do. Having a child, no matter how you do it, is one of the most gratifying and rewarding experiences in life.
So, those women who are afraid of developing feelings of regrets once pregnant or after the birth of the child should know that this idea will disappear eventually.

Who will the baby look like in cases of egg donation?

As mentioned earlier, fertility clinics make sure that egg donors share similar physical characteristics with the recipient, so that they resemble the future child in spite of not sharing their DNA with him or her, and the same applies in cases where donor sperm is used. If the baby is conceived using your partner’s or husband’s sperm, then he or she will resemble him as well.

How can I prepare for IVF with donor eggs?

From the medical point of view, the recipient has to get her body ready to receive the embryo that has been created using donor eggs in order to maximize the chances of implantation.
If fresh donor eggs are used, then synchronization between the cycles of the donor and the recipient is required. Inversely, this step is not needed when frozen donor eggs are used.
The recipient has to prepare her body for donor-egg IVF by means of endometrial preparation, which makes the uterus to grow its lining so that it is prepared for the embryo to implant successfully after the transfer (ET). To this end, the patient has to follow a strict drug protocol.

How successful is IVF with donor eggs?

In general, the use of donor eggs makes an IVF treatment more likely to succeed, as the oocytes have been donated by young, healthy girls who enjoy a good ovarian reserve, features that make the quality of the eggs they produce optimal.
In comparison, if the normal pregnancy rate of IVF with own eggs stands at 35-34% on average, with donor eggs it increases to up to 55-63% approximately. These figures, however, depend on the uterine receptivity of the patient.
Visit the following article to learn more: Pregnancy success rates with donor eggs.

How many embryos should be transferred with donor eggs?

Specialists do recommend everyone undergoing IVF, whether it is done using own or donated eggs, to transfer one embryo in order for a multiple pregnancy to be prevented. There exist certain cases where transferring two embryos would be justified, including poor embryo quality and previous failed IVF attempts with a single embryo.
Also, given that the final decision is in the hands of the patient, sometimes younger patients who wish to have twins request a 2-embryo transfer from the beginning. The older the woman is, the higher the number of risks associated with a multiple pregnancy.

What are the success rates with donor eggs in women over 40?

With donor eggs, the chances of getting pregnant stand at 50-70% per cycle for women in their forties. It should be kept in mind that uterine receptivity might decline with advanced age. The reasons behind it might include biochemical and/or molecular aberrations of the endometrial lining, incidence of pathological conditions in the uterus (e.g. polyps, myomas…), hypertension, etc.