Reproductive Endocrinology & IVF
Reproductive Endocrinology & IVF
WHAT IS INFERTILITY?
Infertility is a condition of the reproductive system that prevents the conception of children. The diagnosis of infertility is usually given to couples who have been attempting to conceive for at least 1 year without success.
- the production of healthy sperm by the man
- healthy eggs produced by the woman
- unblocked fallopian tubes that allow the sperm to reach the egg
- the sperm’s ability to fertilize the egg when they meet
- the ability of the fertilized egg (embryo) to become implanted in the woman’s uterus
- sufficient embryo quality
Is Infertility Primarily A Woman’s Problem?
What Causes Infertility In Men?
What Causes Infertility In Women?
When Should Someone Get Tested For Infertility?
How Early Can You Get Tested?
How Is Infertility Diagnosed?
How Is Infertility Treated?
What Is In Vitro Fertilization (IVF)?
Is In Vitro Fertilization Expensive ?
Does In Vitro Fertilization Work?
FERTILTY & INFERTILTY FAQ
When is a woman’s most fertile time?
- A woman’s most fertile time is during ovulation. Ovulation typically occurs within day 11 through day 21 of a woman’s cycle.
- Counting from the first day of a woman’s last period, day 1 is the first day a woman starts bleeding, and the 11th day is most likely the earliest day a woman will ovulate. The 21st day is most likely the last. A woman’s period comes between the 28th and 32nd day of the cycle. This pattern may differ slightly with each woman depending on a variety of factors.
Is infertility a medical problem related to the woman only?
- Infertility is a medical condition that is found in both men and women, and men and women are affected almost equally.
- With men, declining sperm counts, testicular abnormalities, and decreased reach of climax are common causes of infertility. Shop Products to Help Increase Sperm Count
- With women, the most common causes are tubal blockage, endometriosis, PCOS, and advanced maternal age which affects egg quality/quantity. Shop Products to Help Female Reproductive Health
How common is infertility?
- Infertility is a growing issue for many couples. Infertility affects 6.1 million American couples (approximately 10% of American couples of childbearing age).
- 25% of infertile couples have more than one cause of infertility.
- The current increase in infertility might be the result of more women choosing to delay starting a family until later in life, when their reproductive health can be affected.
- The increase of some STD’s such as Chlamydia can result in conditions such as blocked tubes, preventing pregnancy from occurring.
How long should a couple try to conceive before going to the doctor?
- The American Society of Reproductive Medicine recommends that a woman consult her health care provider if she is: 1) under 35 years old and has been trying to conceive for more than 12 months, or 2) over 35 years old and has been trying to conceive for over 6 months.
Can you find out earlier if you have fertility issues?
- You always have the option of asking your health care provider to conduct a complete examination to determine if either partner has possible fertility issues. You can also choose to do at-home fertility testing, available for both men and women.
Does the position chosen for intercourse affect fertility?
- After ejaculation, enough sperm will remain inside the woman to fertilize an egg. Therefore, there is no significant advantage of one intercourse position over another.
What about fertility treatments?
- Fertility treatments can increase the likelihood of getting pregnant.
- Treatments can include lifestyle changes, vitamins and supplements, surgery, medication, or assisted reproduction. Shop Fertility Supplements Now
- There are several treatments under assisted reproduction such as in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT). All these procedures involve harvesting a number of eggs in the hope of fertilizing at least one egg, and then insert the fertilized egg(s) into the uterus.
Types of Infertility Medications
Medications are a regular and normal part of infertility treatments and the in vitro fertilization (IVF) procedure. These medications are used to prepare the body for treatment and to increase the probability that more healthy eggs are released from the ovaries.
A reproductive specialist can evaluate your situation to determine the most appropriate medications for your situation.
The Following Medications Are Used For Ovarian Stimulation:
Clomiphene citrate (CC): There are two types of medications, Clomid® and Serophene®. These medications work by increasing the amount of FSH the pituitary gland secretes. These are often used to stimulate ovulation in women who have absent periods, infrequent periods or long cycles.
The dosage is usually started at 50mg a day, for a certain amount of days. Dosage may be increased if ovulation still does not occur, although the chances of side effects increases as the dosage increases. The American Society for Reproductive Medicine (ASRM) recommends that clomiphene be prescribed for only 3-6 cycles.
Potential side effects include:
- Increased incidence of multiple birth
- Increased incidence of miscarriage
- Hot flashes, nausea, and breast tenderness
- Headaches or blurred vision
- Depression and mood swings
- Ovarian cysts and pelvic discomfort from over stimulation of the ovaries
Synthetic Human Chorionic Gonadotropin (hCG): Intra-muscular injections used to trigger ovulation. Often used when other medications have been taken to induce ovulation. Common human chorionic gonadotropin (hCG) medications include: Pregnyl®, Profasi® Novarel® and Ovidrel®. There are no known side effects if ONLY taking hCG.
Follicle Stimulating Hormone (FSH): An injection given just below the skin (subcutaneous injection) that bypasses the hypothalamus and pituitary glands to directly stimulate follicle growth in the ovaries.
Common FSH medications include:
Potential side effects include:
- Increased incidence of multiple birth
- Increased incidence of miscarriage and premature delivery
- Breast tenderness, swelling, or rash at injection site
- Mood swings and depression
- Hyper stimulation syndrome which includes enlarged ovaries, abdominal pain and bloating
Human Menopausal Gonadotropins (hMG): An injection that contains equal parts of FSH and LH (luteinizing hormone), given to stimulate the ovaries to produce multiple eggs during one cycle.
Common hMG medications include:
These are the most potent ovulation medications currently used today. Potential side effects include the same as noted above for FSH.
Bromocriptine and Cabergoline: Oral medications used to reduce the amount of prolactin released by the pituitary. The brand name for bromocriptine is Parlodel® and the brand name for cabergoline is Dostinex®. Potential side effects include:
- Nausea, vomiting, nasal congestion
- Headache, dizziness, fainting
- Decreased blood pressure
Gonadotropin-Releasing Hormone (GnRH): An injection used to stimulate the pituitary gland to secrete LH and FSH. Common names for GnRH medications include: Factrel® and Lutrepulse®. Potential side effects include:
- Slight chance of multiple births
- Mild hyper stimulation which includes enlarged ovaries, abdominal pain, and bloating
- Headaches and nausea
The Following Medications Are Used to Prevent Premature Ovulation:
GnRH Agonists (Analogs): There are two types of medications. Lupron® and Zoladex® are injections given below the skin and Synarel® is a nasal spray. These medications are used to enable the body to produce a higher number of quality eggs. These medications are also designed to prevent the mid-cycle hormonal surge which can result in a cancelled cycle.
Potential side effects include:
- Hot flashes
- Mood swings
- Vaginal dryness
- Decreased breast size
- Painful intercourse
- Bone density loss
GnRH Antagonists: These medications, Ganirelix Acetate® and Cetrotide®, are injections administered for three to four days. These medications operate as antagonists of the gonadotropin causing the hormone (GnRH) to be released to help prevent premature ovulation. Potential side effects are the same as GnRH.
Other Medications Used to Enhance Fertility Treatments:
Medrol: A steroid provided daily for four days during the cycle to assist with pre-embryo implantation.
Doxycycline: An oral antibiotic provided to the male partner during the female’s stimulation cycle to reduce the levels of bacteria which may be found in semen. This medication is also given to the female partner to decrease the risk of infection after aspiration of the follicles at the time of egg retrieval.
Progesterone: Intra-muscular injections provided daily beginning two days after retrieval and finishing when the placenta is creating appropriate amounts of Progesterone. Progesterone may be administered through a vaginal gel, suppository or in a pill.
Fertility Supplements: Many couples opt for natural, non-prescription fertility supplements containing vitamins, minerals, antioxidants and/or herbs to help improve their reproductive health.
INFERTILITY AND ACUPUNCTURE
Acupuncture is the insertion of ultra-thin, sterile needles into specific acupuncture points on the body which reside on channels or meridians; these are pathways in both the exterior and interior of the body. These points, when needled, can regulate the way in which the body functions.
Acupuncture helps by addressing problems that affect fertility such as an under-functioning thyroid (hypothyroidism) or over-functioning thyroid (hyperthyroidism).
Can acupuncture be used to treat infertility?
Acupuncture, frequently combined with herbal medicine, has been used for centuries to treat some but not all causes of infertility. For example, acupuncture and herbs will not work to address tubal adhesions which can occur as a result of pelvic inflammatory disease or endometriosis.
However, in this situation, an individual could still benefit from acupuncture and herbs because of the potential effect of improved ovarian and follicular function. Additionally, acupuncture can increase blood flow to the endometrium, helping to facilitate a thick, rich lining.
When should acupuncture treatment begin?
Acupuncture is similar to physical therapy in that it is a process-oriented method of medical intervention. It is better to do more than less. Patients are commonly treated for three to four months before progressing to insemination, in vitro fertilization (IVF), or donor-egg transfer. This pacing of treatment seems to have a therapeutic effect.
In a study by Stener-Victorin et al from the Departments of Obstetrics and Gynecology Fertility Centre, Scandinavia and University of Gothenburg, women are encouraged to receive acupuncture treatments pre and post embryo transfer.
Clinical observations from the Berkley Center for Reproductive Wellness suggest that the most effective fertility treatments involve a combination of acupuncture, herbal medicine, and traditional medicine. However, conception occasionally occurs when acupuncture and herbal medicines are used without traditional medical interventions.
When should I stop?
Typically most miscarriages occur within the first 3 months of pregnancy. Consequently, treatment of patients may often last through week twelve to help prevent miscarriage.
Are the acupuncture points different after an insemination, IVF, or donor-egg transfer than before?
Acupuncturists should not place needles in the abdomino-pelvic area after insemination or transfer. There are 6 contraindicated acupuncture points which should be avoided when the patient is pregnant or pregnancy is suspected. These include Gallbladder 21, Stomach 12, Large Intestine 4, Spleen 6, Bladder 60, Bladder 67 and any points on the lower abdomen.
What are the risks of using acupuncture with infertility?
There are minimal risks in using acupuncture for fertility treatment. The risk of miscarriage may increase if incorrect acupuncture points are used during pregnancy. This is one reason why those choosing to include acupuncture in their treatment regimen should only be treated by an acupuncturist who specializes in treating fertility disorders. Acupuncture is generally safe regardless of a person’s medical history.
Who make up typical patients?
Acupuncture can be used to treat any type of fertility disorder including spasmed tubes. Spasmed tubes are often de-spasmed with acupuncture, though blocked tubes will not respond to acupuncture. Acupuncture is often combined with herbal remedies to treat elevated follicle stimulating hormone (FSH), repeated pregnancy loss, unexplained (idiopathic) infertility, luteal phase defect, hyperprolactinemia (when not caused by a prolactinoma), polycystic ovarian syndrome (PCOS) with annovulatory cycles and male factor including men affected with sperm-DNA-fragmentation.
Is acupuncture a licensed profession?
In most states acupuncture is a licensed profession. You can visit www.nccaom.org to find a licensed and Board certified acupuncturist in your area. However, it is important to understand that being licensed and Board certified does not guarantee expertise in reproductive disorders.
Male Infertility: Causes, Treatment and Prevention
Infertility affects approximately 1 out of every 6 couples. An infertility diagnosis is given to a couple who are unable to conceive over the course of one year. When the problem lies with the male partner it is referred to as male infertility. Male infertility factors contribute to approximately 30% of all infertility cases, and male infertility alone accounts for approximately one-fifth of all infertility cases.
What causes male infertility?
There are four main causes of infertility in males:
- A hypothalamic or pituitary disorder (1-2%)
- Gonad disorder (30-40%)
- Sperm transport disorder (10-20%)
- Unknown causes (40-50%)
Much research remains to be performed on the topic of male infertility, as many cases still receive an “unknown cause” diagnosis. Male infertility usually occurs because of sperm that are abnormal, because of inadequate numbers of sperm, or problems with ejaculation.
Sperm can be considered abnormal for two possible reasons: unusually short life span of the sperm and/or low mobility.
Sperm abnormalities may be caused by one or more of the following:
- Inflammation of the testicles
- Swollen veins in the scrotum
- Abnormally developed testicles
Reasons for a low sperm count or lack of sperm include one or more of the following:
- A pre-existing genetic condition
- Use of alcohol, tobacco or other drugs
- Severe mumps infection after puberty
- Hernia repairs
- Hormone disorder
- Exposure to poisonous chemicals
- Exposure to radiation
- Blockage caused from a previous infection
- Wearing restrictive or tight underwear
- Injury to the groin area
Male infertility can also occur when there are problems with ejaculation.
Ejaculation problems may include any of the following:
- Premature ejaculation
- Retrograde ejaculation, which occurs when the semen is forced back into the bladder
- Erection dysfunctions
- Complications from radiation therapy or surgery
Other causes of male infertility can include:
History of STD’s
- Urinary tract infections
- Use of certain types of medications
How is male infertility diagnosed?
Potential male infertility will be assessed as part of a thorough physical examination. The examination will include a medical history regarding potential contributing factors.
Your healthcare provider may use one or more of the following tests to assess fertility:
- Semen analysis to determine the number and quality of sperm
- Blood test to check for infections or hormone problems. Hormone levels are just as important in male fertility as they are in female fertility
- Making a culture of fluid from the penis to check for infections
- Physical examination of the penis, scrotum and prostate
Semen analysis is the most important part of male fertility testing. Some men find it more comfortable to do semen analysis testing in the privacy of their own homes. In-home testing kits are available.
What are they looking for in the testing?
When semen analysis is done, your health care provider will be looking for some specific markers to access fertility.
Total amount or volume of semen – 2 milliliters is considered normal. A lower amount may indicate an issue with the seminal vesicles, blocked ducts or a prostate gland issue.
- Sperm count – 20 million to 300 million per milliliter is considered in the normal range for sperm counts. Below 10 million is considered “poor.”
- Morphology – the size and shape of the sperm affect the sperms ability to reach and fertilize an egg. 30% is considered a good amount of sperm that are shaped “normal.” And “strict” testing shows an even lower percentage as normal.
- Motility – movement and number of active cells. Movement is rated from 0-4, with score over 3 considered good. The amount of active cells is rated in percentages from 1-100%, with 50% considered the minimum.
How is male infertility treated?
Male infertility is most often treated by conventional methods that include one or more of the following:
- Taking medications to help increase sperm production
- Taking antibiotics to heal an infection
- Taking hormones to improve hormone imbalance
- Avoiding taking long hot showers, using hot tubs or saunas
- Wearing looser underwear such as boxer shorts versus jockey shorts
Sperm production may also improve by taking clinically proven supplements. Anything that increases the number of healthy sperm increases the chances of conception. Many health food stores and vitamin shops offer male fertility supplements. Shop for male fertility supplements.
Artificial insemination is an option if the man’s sperm count is low. In this procedure, sperm is collected through multiple ejaculations. They are then manually placed in the female’s uterus or fallopian tubes.
In vitro fertilization is another option that can be used to overcome male infertility factors. In this procedure, the sperm and egg are fertilized in a laboratory after which the fertilized egg is placed in the female’s uterus.
If tests show that there is no sperm production or that other related problems are present, donor sperm can be used to help facilitate conception. In this procedure, donor sperm are obtained from a sperm bank and placed inside the female’s uterus or fallopian tubes through artificial insemination.
Can male infertility be prevented?
There is usually nothing that can be done to prevent male infertility caused by genetic problems or illness. However, there are actions that men can take to decrease the possibility of infertility.
- Avoiding sexually transmitted diseases
- Avoiding illicit drugs
- Avoiding radiation when possible
- Avoiding exposure to toxic substances
- Avoiding heavy or frequent use of alcohol
- Observing good personal hygiene and health practices
- Avoiding long, hot baths, hot tubs or saunas
- Wearing loose-fitting underwear
What causes female infertility?
The most common causes of female infertility include problems with ovulation, damage to fallopian tubes or uterus, or problems with the cervix. Age can contribute to infertility because as a woman ages, her fertility naturally tends to decrease.
Ovulation problems may be caused by one or more of the following:
- A hormone imbalance
- A tumor or cyst
- Eating disorders such as anorexia or bulimia
- Alcohol or drug use
- Thyroid gland problems
- Excess weight
- Intense exercise that causes a significant loss of body fat
- Extremely brief menstrual cycles
Damage to the fallopian tubes or uterus can be caused by one or more of the following:
- Pelvic inflammatory disease
- A previous infection
- Polyps in the uterus
- Endometriosis or fibroids
- Scar tissue or adhesions
- Chronic medical illness
- A previous ectopic (tubal) pregnancy
- A birth defect
- DES syndrome (The medication DES, given to women to prevent miscarriage or premature birth can result in fertility problems for their children.)
Abnormal cervical mucus can also cause infertility. Abnormal cervical mucus can prevent the sperm from reaching the egg or make it more difficult for the sperm to penetrate the egg.
How is female infertility diagnosed?
Potential female infertility is assessed as part of a thorough physical exam. The exam will include a medical history regarding potential factors that could contribute to infertility.
Healthcare providers may use one or more of the following tests/exams to evaluate fertility:
- A urine or blood test to check for infections or a hormone problem, including thyroid function
- Pelvic exam and breast exam
- A sample of cervical mucus and tissue to determine if ovulation is occurring
- Laparoscope inserted into the abdomen to view the condition of organs and to look for blockage, adhesions or scar tissue.
- HSG, which is an x-ray used in conjunction with a colored liquid inserted into the fallopian tubes making it easier for the technician to check for blockage.
- Hysteroscopy uses a tiny telescope with a fiber light to look for uterine abnormalities.
- Ultrasound to look at the uterus and ovaries. May be done vaginally or abdominally.
- Sonohystogram combines an ultrasound and saline injected into the uterus to look for abnormalities or problems.
Tracking your ovulation through fertility awareness will also help your healthcare provider assess your fertility status.
How is female infertility treated?
Female infertility is most often treated by one or more of the following methods:
- Taking hormones to address a hormone imbalance, endometriosis, or a short menstrual cycle
- Taking medications to stimulate ovulation
- Using supplements to enhance fertility – shop supplements
- Taking antibiotics to remove an infection
- Having minor surgery to remove blockage or scar tissues from the fallopian tubes, uterus, or pelvic area.
Can female infertility be prevented?
There is usually nothing that can be done to prevent female infertility caused by genetic problems or illness.
However, there are several things that women can do to decrease the possibility of infertility:
- Take steps to prevent sexually transmitted diseases
- Avoid illicit drugs
- Avoid heavy or frequent alcohol use
- Adopt good personal hygiene and health practices
- Have annual check ups with your GYN once you are sexually active
When should I contact my healthcare provider?
It is important to contact your healthcare provider if you experience any of the following symptoms:
- Abnormal bleeding
- Abdominal pain
- Unusual discharge
- Pain or discomfort during intercourse
- Soreness or itching in the vaginal area
SELECTING YOUR (ART) PROGRAM
The Questions You Need to be Asking
- Does the program adhere to the guidelines set forth by the American Society for Reproductive Medicine (ASRM)?
- Is the program a member of the Society for Assisted Reproductive Technology (SART)?
- Is the IVF lab accredited by the College of American Pathologists and SART or by the Joint Commission on Accreditation of Healthcare Organizations?
- Are the physicians board certified in reproductive endocrinology and infertility?
- Does the program report its results to the SART Registry and the Centers for Disease Control and Prevention?
Regarding Cost and Convenience:
- What pre-cycle screening tests are required, what are their costs, and will insurance cover the tests?
- How much does the ART procedure cost, including drugs per treatment cycle?
- Will I be required to pay in advance? If so, how much, and what payment methods are acceptable?
- If applicable, whose responsibility will it be to submit any bills to the insurance company?
- What is my financial obligation if the treatment cycle is canceled prior to egg recovery or embryo transfer?
- What are the costs of embryo freezing, storage and embryo transfer?
- How much work am I and my partner likely to miss?
- If necessary, what kind of help is available for low-cost lodging?
Regarding Details About the Program:
- How many physicians will be involved in my care?
- To what degree can my own physician participate in my care?
- What types of counseling and support services are available?
- Whom do I call (day or night) if a problem surfaces?
- Do you freeze embryos (cryopreservation)?
- Are donor sperm, donor eggs or embryos available in your program?
- Do you have an age or basal follicle stimulating hormone (FSH) limit?
- Do you consider ICSI? If so, when, and what is the cost?
- Do you do assisted hatching? If so, when, and what is the cost?
- How many eggs/embryos are normally transferred?
The Centers for Disease Control and Prevention (CDC) is a good source of information to obtain ART outcomes for each reporting program in the United States.
It is important to find out if there have been any significant changes in the program since the initial release of this information in 2000, including:
- Personnel changes
- Changes in the approach to ovarian stimulation, egg retrieval, embryo culture, or embryo transfer
- Change in the number of cycles
- Change in the miscarriage rate, live birth rate per cycle started, or the multiple pregnancy rate
SELECTING YOUR ASSISTED REPRODUCTIVE TECHNOLOGY PROGRAM
Intrauterine insemination (IUI): Uses Risks and Success Rate
Intrauterine insemination (IUI) is a fertility treatment that involves placing sperm inside a woman’s uterus to facilitate fertilization. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization.
IUI provides the sperm an advantage by giving it a head start, but still requires a sperm to reach and fertilize the egg on its own. It is a less invasive and less expensive option compared to in vitro fertilization.
When is IUI used?
The most common reasons for IUI are a low sperm count or decreased sperm mobility.
However, IUI may be selected as a fertility treatment for any of the following conditions as well:
- Unexplained infertility
- A hostile cervical condition, including cervical mucus problems
- Cervical scar tissue from past procedures which may hinder the sperms’ ability to enter the uterus
- Ejaculation dysfunction
IUI is not recommended for the following patients:
- Women who have severe disease of the fallopian tubes
- Women with a history of pelvic infections
- Women with moderate to severe endometriosis
How does IUI work?
Before intrauterine insemination, ovulation stimulating medications may be used, in which case careful monitoring will be necessary to determine when the eggs are mature. The IUI procedure will then be performed around the time of ovulation, typically about 24-36 hours after the surge in LH hormone that indicates ovulation will occur soon.
A semen sample will be washed by the lab to separate the semen from the seminal fluid. A catheter will then be used to insert the sperm directly into the uterus. This process maximizes the number of sperm cells that are placed in the uterus, thus increasing the possibility of conception.
The IUI procedure takes only a few minutes and involves minimal discomfort. The next step is to watch for signs and symptoms of pregnancy.
What are the risks of IUI?
The chances of becoming pregnant with multiples is increased if you take fertility medication when having IUI. There is also a small risk of infection after IUI.
How successful is IUI?
The success of IUI depends on several factors. If a couple has the IUI procedure performed each month, success rates may reach as high as 20% per cycle depending on variables such as female age, the reason for infertility, and whether fertility drugs were used, among other variables.
IN VITRO FERTILIZATION: IVF
In Vitro Fertilization (IVF): Side Effects and Risks
In Vitro Fertilization is a one assisted reproductive technology (ART) commonly referred to as IVF. IVF is the process of fertilization by manually combining an egg and sperm in a laboratory dish, and then transferring the embryo to the uterus. Other forms of ART include gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT).
Why is IVF used?
IVF can be used to treat infertility with the following patients:
- Blocked or damaged fallopian tubes
- Male factor infertility including decreased sperm count or sperm motility
- Women with ovulation disorders, premature ovarian failure, uterine fibroids
- Women who have had their fallopian tubes removed
- Individuals with a genetic disorder
- Unexplained infertility
What is involved with in vitro fertilization?
There are five basic steps in the IVF and embryo transfer process:
Step 1: Fertility medications are prescribed to stimulate egg production. Multiple eggs are desired because some eggs will not develop or fertilize after retrieval. Transvaginal ultrasound is used to examine the ovaries, and blood test samples are taken to check hormone levels.
Step 2: Eggs are retrieved through a minor surgical procedure that uses ultrasound imaging to guide a hollow needle through the pelvic cavity to remove the eggs. Medication is provided to reduce and remove potential discomfort.
Step 3: The male is asked to produce a sample of sperm, which is prepared for combining with the eggs.
Step 4: In a process called insemination, the sperm and eggs are mixed together and stored in a laboratory to encourage fertilization. In some cases where there is a lower probability of fertilization, intracytoplasmic sperm injection (ICSI) may be used. Through this procedure, a single sperm is injected directly into the egg in an attempt to achieve fertilization. The eggs are monitored to confirm that fertilization and cell division are taking place. Once this occurs, the fertilized eggs are considered embryos.
Step 5: The embryos are usually transferred into the woman’s uterus three to five days following egg retrieval and fertilization. A catheter or small tube is inserted into the uterus to transfer the embryos. This procedure is painless for most women, although some may experience mild cramping. If the procedure is successful, implantation typically occurs around six to ten days following egg retrieval.
Side effects of in vitro fertilization
Although you may need to take it easy after the procedure, most women can resume normal activities the following day.
Some side effects after IVF may include:
- Passing a small amount of fluid (may be clear or blood-tinged) after the procedure
- Mild cramping
- Mild bloating
- Breast tenderness
If you experience any of the following symptoms, call your doctor immediately:
- Heavy vaginal bleeding
- Pelvic pain
- Blood in the urine
- A fever over 100.5 °F (38 °C)
What are the risks associated with in vitro fertilization?
As with most medical procedures, there are potential risks. Fertility medications can have various side effects including headaches, mood swings, abdominal pain, hot flashes, and bloating, amongst other side effects. Although it is rare, fertility medications may cause ovarian hyper-stimulation syndrome (OHSS). Symptoms of OHSS may include abdominal pain or a feeling of being bloated. More severe symptoms include the following:
- Nausea or vomiting
- Decreased urinary frequency
- Shortness of breath
- Severe stomach pains and bloating
- Ten pound weight gain within three to five days
If you experience any of these symptoms above, contact your doctor right away.
Additional risks of IVF include the following:
- Egg retrieval carries risks of bleeding, infection, and damage to the bowel or bladder.
- The chance of a multiples pregnancy is increased with the use of fertility treatment. There are additional risks and concerns related to multiples during pregnancy including the increased risk of premature delivery and low birth weight.
- Assisted reproductive technology (ART) involves a significant physical, financial, and emotional commitment on the part of a couple. Psychological stress and emotional problems are common, especially if in vitro fertilization (IVF) is unsuccessful.
- IVF is expensive, and many insurance plans do not provide coverage for fertility treatment. The cost for a single IVF cycle can range from at least $12,000-$17,000.
How successful is in vitro fertilization?
The success rate of IVF clinics depends on a number of factors including reproductive history, maternal age, cause of infertility, and lifestyle factors. It is also important to understand that pregnancy rates are not the same as live birth rates.
In the United States, the live birth rate for each IVF cycle started is approximately:
- 41-43% for women under age 35
- 33-36% for women ages 35 to 37
- 23-27% for women ages 38 to 40
- 13-18% for women ages over 40
What if I don’t produce healthy eggs or my husband is sterile?
You may choose to use donor eggs, sperm, or embryos. However, make sure to talk with a counselor experienced with donor issues. You will want to be informed about various legal issues related to gamete donation including the legal rights of the donor.
How many embryos should be created or transferred?
The number of embryos transferred typically depends on the number of eggs collected and maternal age. As the rate of implantation decreases as women age, more eggs may be implanted depending on age to increase the likelihood of implantation. However, a greater number of eggs transferred increases the chances of having a multiples pregnancy. Make sure to talk with your doctor before the procedure so you both agree on how many embryos to implant.
How do I choose an infertility clinic?
There are a number of questions to ask regarding the cost and details of specific centers and fertility programs. Some suggested questions are available online in Selecting Your ART Program.
INTRACYTOPLASMIC SPERM INJECTION: ICSI
How is ICSI performed?
There are basically five simple steps to ICSI which include the following:
- The mature egg is held with a specialized pipette.
- A very delicate, sharp, and hollow needle is used to immobilize and pick up a single sperm.
- The needle is then carefully inserted through the shell of the egg and into the cytoplasm of the egg.
- The sperm is injected into the cytoplasm, and the needle is carefully removed.
- The eggs are checked the following day for evidence of normal fertilization.
Once the steps of ICSI are complete and fertilization is successful, the embryo transfer procedure is used to physically place the embryo in the woman’s uterus. Then it is a matter of watching for early pregnancy symptoms. The fertility specialist may use a blood test or ultrasound to determine if implantation and pregnancy has occurred.
Are there specific situations where ICSI might be recommended?
ICSI may be recommended when there is a reason to suspect that achieving fertilization may be difficult. ICSI is most often used with couples who are dealing with male infertility factors. Male infertility factors can include any of the following: low sperm counts, poor motility or movement of the sperm, poor sperm quality, sperm that lack the ability to penetrate an egg, or azoospermia.
Azoospermia is a condition where there is no sperm in the male’s ejaculation. There are two types of azoospermia: obstructive and non-obstructive.
Obstructive azoospermia may be caused by any of the following:
- Previous vasectomy
- Congenital absence of vas
- Scarring from prior infections
Non-obstructive azoospermia occurs when a defective testicle is not producing sperm. In the case of azoospermia, the probability of obtaining usable sperm is low, and the possibility of using donor sperm may be considered.
How is sperm retrieved for use in ICSI?
For men who have low sperm count or sperm with low mobility, the sperm may be collected through normal ejaculation. If the man has had a vasectomy, the microsurgical vasectomy reversal is the most cost-effective option for restoring fertility.
Needle aspiration or microsurgical sperm retrieval are good alternatives when a competent microsurgical vasectomy reversal has failed, or when the man refuses surgery. Needle aspiration allows physicians to easily and quickly obtain adequate numbers of sperm for the ICSI procedure. A tiny needle is used to extract sperm directly from the testis.
Needle aspiration is a simple procedure performed under sedation with minimal discomfort; however, there is the potential for pain and swelling afterwards. The sperm obtained from testis is only appropriate for ICSI procedures when testicular sperm is not able to penetrate an egg by itself.
What health concerns are there when considering ICSI?
There have been studies indicating that developing babies from pregnancies achieved through artificial insemination, and particularly ICSI, may face an increased risk for some birth defects, such as imprinting defects. Imprinting refers to the phenomenon in which certain genes function differently depending on whether they involve a particular chromosome passed on by the father or by the mother.
Reproductive researchers are concerned that manipulation of either gametes or zygotes may affect the imprinting process or the subsequent release. Other researchers believe that the incidence of these birth defects occurring is similar to those in natural pregnancy, and therefore should not be a deterrent in using them.
The potential risks or complications from doing ICSI is something that you should discuss with your reproductive specialist at length about.
ZYGOTE INTRAFALLOPIAN TRANSFER: ZIFT
What is zygote intrafallopian transfer (ZIFT)?
ZIFT is an assisted reproductive procedure similar to in vitro fertilization and embryo transfer, the difference being that the fertilized embryo is transferred into the fallopian tube instead of the uterus.
Because the fertilized egg is transferred directly into the tubes, the procedure is also referred to as tubal embryo transfer (TET). This procedure can be more successful than gamete intrafallopian transfer (GIFT) because your physician has a greater chance of insuring that the egg is fertilized. The woman must have healthy tubes for ZIFT to work.The main difference between ZIFT and GIFT is that ZIFT transfers a fertilized egg directly into the fallopian tubes while GIFT utilizes a mixture of sperm and eggs.
How is ZIFT performed?
ZIFT is an assisted reproductive procedure that involves the following steps:
- A woman’s ovaries are stimulated with medications to increase the probability of producing multiple eggs.
- Eggs are then collected through an aspiration procedure.
- Those eggs are fertilized in a laboratory in a procedure identical to IVF, with the exception of the time frame. During the ZIFT procedure, fertilized eggs are transferred within 24 hours, versus 3-5 days as used in a regular IVF cycle.
- The fertilized eggs are then transferred through a laparoscopic procedure where a catheter is placed deep in the fallopian tube and the fertilized eggs injected.
- The final step is to watch for early pregnancy symptoms. The fertility specialist will probably use a blood test to determine if pregnancy has occurred.
- Who should be treated with ZIFT?
ZIFT is an assisted reproductive procedure which may be the selected form of treatment for any infertility problems except the following:
- Tubal blockage
- Significant tubal damage
- An anatomic problem with the uterus, such as severe intrauterine adhesions
- Sperm that are not able to penetrate an egg
ZIFT is commonly chosen by couples who have failed to conceive after at least one year of trying and who have failed five to six cycles of ovarian stimulation with intrauterine insemination (IUI).
What are the similarities and differences between ZIFT and in vitro fertilization (IVF)?
- ZIFT and IVF both tend to be favorable treatments for women who have more severe infertility issues such as damaged fallopian tubes.
- ZIFT and IVF both involve embryo culture.
- ZIFT and IVF both provide the physician with the opportunity to select only the best quality embryos for transfer.
- ZIFT transfers the fertilized embryo into the fallopian tube whereas the IVF and embryo transfer procedures result in the fertilized embryo being placed into the uterus.
- The ZIFT procedure differs from IVF in that the transfer of embryos into the tube requires an extra surgical procedure called laparoscopy.
PREIMPLANTATION GENETIC DIAGNOSIS: PGD
Preimplantation Genetic Diagnosis (PGD) Benefits & Concerns
Preimplantation genetic diagnosis (PGD) is a procedure used prior to implantation to help identify genetic defects within embryos created through in vitro fertilization to prevent certain diseases or disorders from being passed on to the child.
How is the PGD performed?
Preimplantation genetic diagnosis begins with the normal process of in vitro fertilization that includes egg retrieval and fertilization in a laboratory. Over the next three days the embryo will divide into eight cells.
Preimplantation genetic diagnosis involves the following steps:
- First, one or two cells are removed from the embryo.
- The cells are then evaluated to determine if the inheritance of a problematic gene is present in the embryo.
- Once the PGD procedure has been performed and embryos free of genetic problems have been identified, the embryo will be placed back in the uterus, and implantation will be attempted.
- Any additional embryos that are free of genetic problems may be frozen for later use while embryos with the problematic gene are destroyed.
Who can benefit from PGD?
Preimplantation genetic diagnosis can benefit any couple at risk for passing on a genetic disease or condition.
The following is a list of the type of individuals who are possible candidates for PGD:
- Carriers of sex-linked genetic disorders
- Carriers of single gene disorders
- Those with chromosomal disorders
- Women age 35 and over
- Women experiencing recurring pregnancy loss
- Women with more than one failed fertility treatment
PGD has also been used for the purpose of gender selection. However, discarding embryos based only on gender considerations is an ethical concern for many people.
What are the benefits of PGD?
The following are considered benefits of PGD:
- PGD can test for more than 100 different genetic conditions.
- The procedure is performed before implantation thus allowing the couple to decide if they wish to continue with the pregnancy.
- The procedure enables couples to pursue biological children who might not have done so otherwise.
What are the concerns of PGD?
The following are considered concerns or disadvantages associated with the use of PGD:
- Many people believe that because life begins at conception, the destruction of an embryo is the destruction of a person.
- While PGD helps reduce the chances of conceiving a child with a genetic disorder, it cannot completely eliminate this risk. In some cases, further testing is needed during pregnancy to ascertain if a genetic factor is still possible.
- Although genetically present, some diseases only generate symptoms when carriers reach middle age. The probability of disorder development should be a topic of discussion with the healthcare provider.
- Keep in mind that preimplantation genetic diagnosis does not replace the recommendation for prenatal testing.
When does the embryo transfer procedure occur?
Embryos are generally transferred to the woman’s uterus at the 2-8 cell stage. Embryos may be transferred anytime between day 1 through day 6 after the retrieval of the egg, although it is usually between days 2 -4. Some clinics are now allowing the embryo to reach blastocysts stage before transferring, which occurs around day 5.
What is the procedure for embryo transfer?
The patient returns to the clinic to have the embryos transferred. Anesthesia is often not necessary, although a sedative may be used. An ultrasound may be used to help guide the physician as he transfers the embryos. A predetermined number of embryos are loaded into a fine transfer catheter that passes through the vagina and cervix, into the uterus.
The embryos are deposited from the catheter into the uterus. Following this procedure, the patient usually remains in a recovery room resting on her back and is discharged 4-6 hours after the procedure. The couple will then wait and optimistically watch for early pregnancy symptoms.
What medications may be given along with the procedure?
Progesterone is often the main medication that a woman will continue to take after the embryo transfer. Taking supplemental progesterone will not only help increase the chances of pregnancy, but progesterone is also vital to sustain a pregnancy. Progesterone is often discontinued once a pregnancy has been confirmed and is producing adequate amounts of progesterone on its own.
What risks are there with embryo transfer?
There are minimal risks associated with the embryo transfer procedure. They include the loss of the embryos during transfer or implanting the embryos in the wrong place such as the fallopian tubes. Although some women experience mild cramping, the procedure is usually painless.
Are there any instructions following the embryo transfer procedure?
Once embryos are transferred, there is nothing a patient can do to influence the outcome of her cycle. Currently, there is no documented evidence as to whether bed rest or continuing normal activities following the procedure make a difference in the outcome.
Some physicians encourage the patients to rest for twenty four hours. Others suggest returning to normal activities as soon as possible. Some patients choose to rest because they think that by doing so they are improving their chances. Additional rest also gives them an opportunity to think about the potential baby.
Other women elect to return to normal activities to help them avoid worrying about things that could go wrong. Together with counsel from the doctor, the state of your body and mind should help you decide your course of action.
Again, there is no documented evidence showing that physical activity has any impact upon embryo implantation or conception. Conception is a natural event that depends primarily upon the genetic quality of the eggs.
How many embryos should be transferred?
The number of embryos that should be transferred during any single IVF cycle is subject to debate. Medical experts and writers seem to agree that transferring no more than four embryos per IVF cycle will yield optimal results.
WORKING THROUGH THE EMOTIONS OF INFERTILITY
What impact does infertility have on emotional well-being?
Infertility often creates one of the most distressing life crises for couples. Struggles with conception can cause deep feelings of loss to surface. Dealing with the multitude of medical decisions and the uncertainties that infertility brings can create great emotional upheaval for many couples. So if you find yourself feeling anxious, depressed, out of control, or isolated, you are not alone.
How do I know if I could benefit from psychological counseling?
It is normal to experience a wide variety of emotions in the process of pursuing infertility treatment. However, if your experience includes any of the following symptoms over a prolonged period of time, you could benefit greatly from spending time with a mental health professional.
The symptoms include:
- Loss of interest in normal activities
- Depression that doesn’t seem to go away
- Strained interpersonal relationships (with partner, family, friends, or colleagues)
- Difficulty thinking about anything other than your infertility
- High levels of anxiety
- Diminished ability to focus upon completing tasks
- Difficulty concentrating
- Change in sleep patterns (difficulty falling asleep or staying asleep, early morning awakening, sleeping more than usual)
- Change in appetite or weight (increase or decrease)
- Increased use of drugs or alcohol
- Thoughts about death or suicide
- Social isolation
- Persistent feelings of pessimism, guilt, or worthlessness
- Persistent feelings of bitterness or anger
In addition, there are certain points during infertility treatment when discussion with a mental health professional can help clarify thoughts and help with decision making.
For example, consulting with a mental health professional may be helpful to you and your partner if you are:
- At a treatment crossroad
- Trying to decide between alternative treatment possibilities
- Exploring other family-building options
- Considering third party assistance (gamete donation, surrogacy)
- Having difficulty communicating or if you are in conflict with others about what direction to take
How can psychological treatment help cope with infertility?
Mental health professionals who have experience with infertility treatment can be very helpful. Their primary goal is to help individuals and couples learn how to cope with the physical and emotional changes associated with infertility, as well as with medical treatments that can be painful and intrusive.
Some professionals might choose to focus primarily on how to deal with a partner’s response. Others might spend time discussing how to choose the right medical treatment or how to explore and evaluate other family building options.
Some couples might need help controlling stress, anxiety, or depression. Mental health professionals can help individuals work through grief, fear, and other negative emotions related to infertility. A good therapist has the ability to help others sort out their feelings, strengthen existing coping skills and develop new ones, and communicate with others more effectively.
Many have found that their crisis of infertility became an opportunity for life-enhancing personal growth.
How can I find a mental health professional experienced in working with infertility?
Make every effort to find a mental health professional who is familiar with the emotional experience of infertility.
The professional should have:
- A graduate degree in a mental health profession
- A license to practice and state registration
- Clinical training in the psychological aspects of infertility
- Experience in the medical and psychological aspects of reproductive medicine
It may prove beneficial to interview more than one professional. Ask the person for his/her credentials, especially regarding their experience with infertility issues and treatments. It could also be helpful to ask if they are currently seeing other people with infertility problems. Although the process of finding a professional can be stressful, it can also be a highly rewarding experience.
DEFINITIONS OF MEDICAL TERMINOLOGY
ART cycle: The process includes 1) an ART procedure, 2) ovarian stimulation, or 3) frozen embryos thawed for transfer into a woman. This process begins when a woman starts fertility medications or has her ovaries monitored for follicle production.
Canceled cycle: An ART cycle in which ovarian stimulation was carried out but was stopped before eggs were retrieved, or in the case of frozen embryo cycles, before embryos were transferred. The reasons a cycle may be have been cancelled include: undeveloped eggs, patient became ill, or the patient chose to stop treatment.
Combination cycle: An ART cycle which uses more than one ART procedure. Combination cycles usually combine IVF with either GIFT or ZIFT.
Concentration of motile sperm: A measurement of the sperm that can readily swim to fertilize the egg. According to the World Health Organization (WHO), there should be a minimum of 10 million motile sperm per milliliter of semen.
Cryopreservation: The process of freezing extra embryos from a couple’s ART cycle for potential future use.
Diminished ovarian reserve: A diagnosed condition which means the ability of the ovary to produce eggs is reduced. The reasons may either be congenital, medical, surgical causes or advanced maternal age (older than 40).
Donor egg cycle: An embryo is formed from the donor egg of one woman (the donor) and then transferred to another woman who is unable to use her own eggs (the recipient). All parental rights are relinquished by the donor.
Donor embryo: An embryo that is donated by a couple who previously underwent ART treatment and had extra embryos available. All parental rights are relinquished by the donor couple.
Ectopic pregnancy: A pregnancy in which the fertilized egg implants in a location outside of the uterus, usually in the fallopian tube, the ovary, or the abdominal cavity.
Egg: A female reproductive cell, also called an oocyte or ovum.
Egg retrieval (also called oocyte retrieval): A procedure to collect the eggs contained in the ovarian follicles.
Egg transfer (also called oocyte transfer): The procedure of transferring retrieved eggs into a woman’s fallopian tubes through laparoscopy; this procedure is used only in GIFT.
Embryo: An egg that has been fertilized by a sperm and undergone one or more divisions.
Embryo transfer: The procedure of placing an embryo into a woman’s uterus through the cervix after in vitro fertilization (IVF). During the process of zygote intrafallopian transfer (ZIFT), the embryos are placed in a woman’s fallopian tube.
Endometriosis: A medical condition that involves the presence of tissue similar to the uterine lining in abnormal locations. This condition can affect both fertilization of the egg and embryo implantation.
Fertilization: The penetration of the egg by the sperm and the resulting combining of genetic material that develops into an embryo.
Fetus: The unborn offspring from the eighth week after conception to the moment of birth.
Follicle: A structure in the ovaries that contains a developing egg.
Follicle-Stimulating Hormone (FSH): A hormone produced by the pituitary gland that helps an egg mature and be released. High levels of FSH indicate ovarian reserve is low and chances of conception are poor.
Fresh eggs, sperm, or embryos: Eggs, sperm, or embryos that have not been frozen. However, fresh embryos may have been conceived using either fresh or frozen sperm.
Frozen embryo cycle: An ART cycle in which frozen (cryopreserved) embryos are thawed and transferred to the woman.
Gamete: A reproductive cell, either a sperm or an egg.
GIFT (gamete intrafallopian transfer): An ART procedure that involves removing eggs from the woman’s ovary, combining them with sperm, and using a laparoscope to place the unfertilized eggs and sperm into the woman’s fallopian tube through small incisions in her abdomen.
Gestational carrier (also called a gestational surrogate): A woman who carries an embryo that was formed from the egg of another woman. The gestational carrier usually has a contractual obligation to return the infant to its intended parents.
Gestational sac: A fluid-filled structure that develops within the uterus early in pregnancy. In a normal pregnancy, a gestational sac contains a developing fetus.
Home fertility screening: Over-the-counter fertility testing kits that allow for screening for both men and women.
ICSI (intracytoplasmic sperm injection): A procedure in which a single sperm is injected directly into an egg; this procedure is most commonly used to overcome male infertilityproblems.
Induced abortion: A surgical or other medical procedure used to end a pregnancy.
IUI (intrauterine insemination): A medical procedure that involves placing sperm into a woman’s uterus to facilitate fertilization. IUI is not considered an ART procedure because it does not involve the manipulation of eggs.
IVF (in vitro fertilization): An ART procedure that involves removing eggs from a woman’s ovaries and fertilizing them outside her body. The resulting embryos are then transferred into the woman’s uterus through the cervix.
Laparoscopy: A surgical procedure in which a fiber optic instrument (a laparoscope) is inserted through a small incision in the abdomen to view the inside of the pelvis.
Live birth: The delivery of one or more babies with any signs of life.
Male factor: Any cause of infertility due to low sperm count or problems with sperm function that make it difficult for a sperm to fertilize an egg under normal conditions.
Miscarriage (also called spontaneous abortion): A pregnancy ending in the spontaneous loss of the embryo or fetus before 20 weeks of gestation.
Multi-fetal pregnancy reduction: This procedure is also known as selective reduction. A procedure used to decrease the number of fetuses a woman carries and improve the chances that the remaining fetuses will develop into healthy infants. Multi-fetal reductions that occur naturally are referred to as spontaneous reductions.
Multiple factors, female only: This diagnostic category means that more than one female infertility cause was diagnosed.
Multiple factors, female and male: A diagnostic category used when one or more female/male infertility causes are diagnosed together.
Multiple-infant birth: A pregnancy that results in the birth of more than one infant.
Multiple-fetus pregnancy: A pregnancy with two or more fetuses, determined by the number of fetal hearts observed on an ultrasound performed early in pregnancy.
Oocyte: The female reproductive cell, also called an egg.
Other causes of infertility: These include immunological problems, chromosomal abnormalities, cancer, chemotherapy, and serious illnesses.
Ovarian monitoring: The use of ultrasound and/or blood or urine tests to monitor follicle development and hormone production.
Ovarian reserve: Refers to a woman’s fertility potential in the absence of problems in her reproductive tract (fallopian tubes, uterus or vagina).
Ovarian stimulation: The use of medications to stimulate the ovaries to develop follicles and eggs.
Ovulatory dysfunction: A diagnostic category used when a woman’s ovaries are not producing eggs normally. It includes polycystic ovary syndrome (PCOS) and multiple ovarian cysts.
Pregnancy (clinical): A pregnancy documented by ultrasound that shows a gestational sac in the uterus. For ART data collection purposes, pregnancy is defined as a clinical pregnancy rather than a chemical pregnancy (i.e., a positive pregnancy test).
Pregnancy Symptoms: A group of physical changes that occur in a woman’s body related to pregnancy and the increased levels of the hCG hormone.
Sperm: The male reproductive cell.
Sperm motility: The sperm’s ability to readily swim forward to fertilize the egg. Also referred to as sperm mobility.
Stillbirth: Fetal death that occurs after 20 weeks gestation.
Stimulated cycle: An ART cycle in which a woman receives oral or injected fertility drugs to stimulate her ovaries to produce more follicles.
Thawed embryo cycle: Same as frozen embryo cycle.
Tubal factor: A diagnostic category used when the woman’s fallopian tubes are blocked or damaged, making it difficult for the egg to be fertilized or for an embryo to travel to the uterus.
Ultrasound: A technique used in ART for visualizing the follicles in the ovaries, the gestational sac, or the fetus.
Unexplained cause of infertility: A diagnostic category used when no cause of infertility is found in either the woman or the man.
Unstimulated cycle: An ART cycle in which the woman does not receive drugs to stimulate her ovaries to produce more follicles. Instead, follicles develop naturally.
Uterine factor: A structural or functional disorder of the uterus that results in reduced fertility.
ZIFT (zygote intrafallopian transfer): An ART procedure in which eggs are collected from a woman’s ovary and fertilized outside her body. A laparoscope is then used to place the resulting zygote (fertilized egg) into the woman’s fallopian tube through a small incision in her abdomen.