In Vitro Fertilization
In vitro fertilization (IVF) and other "high tech" procedures are now referred to as the assisted reproductive technologies (ART). These procedures all involve collecting the oocytes (eggs) and placing them in direct contact with sperm. Together they form an alphabet soup of techniques including: IVF, GIFT, ZIFT, ICSI, FET.
In its simplest term, IVF is simply the uniting of egg and sperm in vitro (in the lab). Subsequently the embryos are transferred into the uterus through the cervix and pregnancy is allowed to begin. IVF was the first of the ART techniques to be developed. The first birth was in 1978 in England. The procedure was pioneered by a Gynecologist and a Ph.D. ( Drs. Steptoe and Edwards). Next came GIFT which stands for gamete (egg and sperm) intrafallopian transfer. This procedure requires laparoscopy which is small incision surgery and requires a general anesthetic. With existing technology, pregnancy rates are similar with IVF and GIFT. Since IVF does not require surgery, it has supplanted GIFT.
ZIFT (zygote intrafallopian transfer) involves IVF and then a laparoscopic surgical procedure to transfer the embryos into the fallopian tube. Since transferring embryos through the cervix with IVF gives the same pregnancy rate as ZIFT, and is nonsurgical, IVF has also supplanted ZIFT.
As the years have passed, IVF has become the dominant ART technology due to its simplicity, efficacy and lack of invasiveness. A typical IVF cycle begins with shutting down the ovaries. This is done with a medication known as a GnRH agonist or a birth control pill. The most common drug that is used is Lupron. Lupron is given for approximately two weeks after which the ovaries are shut down temporarily. The reason for ovarian shut down is so that the follicles when stimulated will all ripen at approximately the same time. The next phase involves stimulation of the ovaries with potent ovulation medications such as Pergonal, Bravelle, Repronex, Gonal-f or Follistim. These are basically potent ovulation medications given to stimulate the development of several eggs. For a full description of these agents go to the page on ovulation medication. These injections are given for approximately 10 days. When the eggs are ready for harvesting, a final step is to give hCG to induce final maturation. The eggs are then harvested by a process called ultrasound guided vaginal retrieval. Under moderate sedation, and with ultrasound guidance, a thin needle is passed a short distance into the ovaries and the eggs are suctioned from the follicles. Typically 5-15 eggs are collected. Typically the eggs are fertilized by adding approximately 100,000 motile sperm to each egg. If the sperm will not fertilize the eggs naturally we can perform intracytoplasmic sperm injection (ICSI). This procedure involves injecting one sperm directly into the egg:
The day following retrieval, we can document fertilization under the microscope. We then observe the embryos for 3-6 days. Typically 1-2 embryos are then placed in a catheter and transferred through the cervix into the uterus 3 days following egg retrieval. The number of embryos to be transferred depends on the age of the woman. Women in the twenties have fewer and women in the thirties have more embryos transferred. An embryo transfer is a simple procedure much like a pap smear. At the present time, embryos can be transferred either 3 or five days following retrieval. A 3 day embryo is usually at the 6-8 cell stage:
For some photos of the IVF retrieval area and the embryo lab please go to IVF photo gallery.
It is also possible now in some cases to perform advanced stage or blastocyst embryo transfers.
Blastocyst transfer is appealing because of its ability to decrease multiple pregnancy rates. It does have its drawbacks. It can only be attempted if there are a high number of rapidly dividing embryos. This is because the majority of embryos cannot with existing technology make it to this final stage. We have been working with blastocyst transfer for greater than 10 years and have been able to achieve excellent results with both fresh and frozen blastocysts. In March of 1999 channel 9 aired a story about 2 tristate couples. One had conceived with fresh and the other with frozen blastocysts. We find the technique to be helpful for many couples. All patients at the present time are considered for blastocyst transfer if they have 4 or more high quality embryos at 72 hours. At the present time, approximately 50% of our transfers are advance blastocyst transfers. Almost all of our embryo cryopreservation (freezing) is done at the blastocyst stage.
Two weeks after embryo transfer a pregnancy test can be obtained. Two weeks after the pregnancy test, an ultrasound can be performed and the fetal heart beat can be seen.
The image on the top is of a single pregnancy 6 weeks after egg retrieval and the one on the bottom is of a twin pregnancy. If more embryos were generated than can be replaced, these additional embryos can be saved by freezing (cryopreservation). Frozen embryos can be stored for future replacement at much lower cost than the original IVF cycle.
As the years have passed, IVF has improved greatly. Today it is arguably the most effective technique to treat infertility when compared with others on a month by month basis. IVF is not a perfect technology. First ,it is expensive. An IVF cycle can cost $8,000 to $9,000. It may not work on the first cycle. Multiple pregnancies can result. The truth is that it is a powerful technology and must be used carefully. Some patients may have very high odds of success: 50 - 55% chance per attempt. Others may, due to their situation, have only a 20% chance of success. Age of the wife is the single most important variable controlling pregnancy rates. Women in the twenties and early thirties have the best chance of success. The multiple pregnancy risk varies from 20% - 35% depending on clinic practices. Most multiples contrary to popular opinion are twins. Younger patients need fewer embryos to be replaced, and older patients need more. The worst thing that has happened with IVF is the various centers entering into a race to see who can get "the best statistics". This has encouraged centers to transfer high numbers of embryos to get the stats while accepting too high a risk of multiple pregnancy. Also in order to get the best stats, some patients will be refused care in order to " protect the statistics".
Our data is contributed in great detail annually to the Center for Disease Control (CDC). The 2010 data have just been released. To see this information please click on the following CDC link: ivf data
Date reporting typicall lags by 1 to 2 years to allow time for delivery of a given pregnancy. Our most recent review of our data from Oct 2011 to March 2012 showed the following clinical pregnancy rate per egg retrieval (52%). A clinical pregnancy is defined as a pregnancy that can be seen on ultrasound. Most such pregnancies will continue on to a live birth but some will miscarry.
The age < 37 Clinical pregnancy rate was 52%. Age of the egg is a major factor in predicting pregnancy rates. It is known that rates will decline with age. Another interesting statistic is our IVF money back program. This program is available for selected individuals lees than or equal to 38 years of age. Our live birth rate for this program is 80%. Money back program allows up to 3 fresh and 3 frozen cycles.
Our center was the first in the tristate area to report the birth of 1,000 IVF babies as of June of 1998. As of early 2012 we have now experienced more than 7,000 births. We were able to achieve these landmarks without refusing treatment to patients who were less likely to succeed. Our center has been successful with a variety of techniques including IVF, GIFT, frozen embryos, and egg donation. We have also been pleased with the ability of ICSI to help patients with very few sperm become parents. ICSI allows us to treat cases that were untreatable five years ago. We continue to improve the results of our program by participating in national and regional research trials. We also strive to improve clinical and laboratory techniques through implementation of promising new technologies.