Assisted Reproductive Technologies (ART) including In Vitro Fertilization (IVF)
The IVF process can be broken down into 5 general steps:
Intra-Cytoplasmic Sperm Injection (ICSI)
Pre-Implantation Genetic Diagnosis (PGD)
PCOS
Many women with PCOS have difficulties conceiving because they do not ovulate. Drugs can be used to induce ovulation, including clomiphene citrate (oral medication) and injectable hormones(FSH ). Clomid (Clomiphene Citrate, a sister medication to Tamoxifin) therapy is a safe and long standing therapy for infertility. It is best used on patients under the age of 38. Clomid acts on the brain as an anti-estrogen, tricking the brain into thinking it does not have any estrogen, so the brain makes FSH, hence stimulating the ovaries to develop follicles. Some women are resistant to Clomid and do not develop follicles even on high doses of clomid.
Ovulation induction is carefully monitored by the physician and is often coupled with timed intercourse or Intra-Uterine Insemination (IUI).
Ovulation Induction / IUI
Intra-Uterine Insemination (IUI) is generally coupled with ovulation inducing fertility drugs. The effectiveness of the medication(s) is monitored by transvaginal ultrasound, allowing the physician to check the endometrial lining and follicular development. When the physician feels that the thickness of the endometrial lining and follicles have developed correctly, the patient will be given an injection of hCG, or human chorionic gonadotropin, to stimulate ovulation 36 hours later. A semen sample will then be placed into the uterus at the expected ovulation time.
Endometriosis
Endometriosis may be treated with hormone therapy, surgery, or both. A physician may decide to remove the tissue during the laparoscopy, or first have a biopsy analyzed by the laboratory. Hormone therapy, including oral contraceptives, may also be used alone or in combination with surgery to manage the disease.
Uterine Fibroids
Some types of uterine fibroids do not require treatment. However, if the fibroids are causing pelvic pain, infertility, painful menstrual periods, and/or heavy bleeding the fibroids may be treated with hormone therapy and surgery. Myomectomy is the surgical removal of fibroids from the uterus allowing the uterus to be left in place to preserve future fertility. Hormone therapy can be used to shrink the fibroid(s) before surgical removal.
Assisted Reproductive Technologies (ART) including In Vitro Fertilization (IVF)
ART is a term used to describe advanced inertility therapies, most commonly IVF (In Vitro Fertilization) and GIFT (Gamete Intrafallopian Transfer), but it also includes other techniques such as ZIFT (Zygote Intrafallopian Transer) and FET (Frozen Embryo Transfer). These procedures all involve the removal of a woman's eggs from her ovaries, processing these eggs with sperm, and returning the eggs to the woman, sometimes already fertilized, in order to achieve pregnancy. The differences in these procedures are centered around where the eggs become fertilized, and how far along the fertilization process has progressed before they are returned to the woman's uterus.
During IVF, the eggs and sperm are taken to the laboratory and allowed to incubate together for several days. The fertilized eggs, or embryos, are returned to the woman's uterus through the cervix. GIFT requires the immediate return of the eggs and sperm (gametes), (or Zygotes or embryos for ZIFT) to the woman's fallopian tubes, and it is here that fertilization takes place. The embryos will proceed down the fallopian tubes into the uterus in the usual manner. This procedure is on the decline because of lower success rates compared to IVF and because of the additional costs due to the need for a laparoscopic surgery required at the time the sperm and eggs are transferred.
The IVF process, from the start of medication until egg retrieval, takes approximately 4-6 weeks. Monitoring your response to these medications will require several office visits prior to your procedure.
In Vitro Fertilization is an alternative treatment for some infertility problems. These conditions may be due to pelvic endometriosis, absence or blocked fallopian tubes, male factors such as low sperm counts, women who are 35 years or older who fail to conceive naturally, or unexplained reasons that have not been responsive to other forms of treatment.
The IVF process can be broken down into 5 general steps:
1. Administration of hormone medications, which stimulate egg production in the woman’s ovaries. Egg development is monitored by hormone blood studies and ultrasound.
2. The developed eggs are removed from the ovaries in a minor procedure called transvaginal ultrasound-guided egg retrieval.
3. The husband/partner’s sperm is collected on the day of the retrieval. The sperm is specially prepared to increase the probability of fertilization.
4. The eggs and sperm are placed together and are carefully monitored in incubators to allow for fertilization.
5. Some of the resulting embryos are selected to be transferred into the woman’s uterus approximately 3-5 days later. Blood hormone tests will be done 8-10 days after the transfer, to determine if pregnancy has been achieved.
Intra-Cytoplasmic Sperm Injection (ICSI)
ICSI is a form of micromanipulation in which a single sperm is selected and injected into an egg under a microscope to help assure fertilization. ICSI is an effective option for male factor infertility.
Pre-Implantation Genetic Diagnosis (PGD)
PGD or Pre-implantation Genetic Diagnosis, a relatively old technology that has recently increased in popularity. PGD can test for either a specific gene abnormality such as Tay Sachs or Cystic Fibrosis, or it can test for an irregular arrangement in the normal chromosome count, known as aneuploidy. Normally our genetic material is arranged on chromosomes. We each have 23 pairs of chromosomes. When we are conceived, each of the two cells, the sperm and egg, contributes a single set of chromosomes. When the sperm penetrates the egg, the job of the egg is to bring these chromosomes together to create 23 pairs. As we get older, the architecture inside the egg gets older and is not as proficient in bringing these two sets together as when it was younger, so there is an increased chance of having an irregular number of chromosomes in the developing embryo. (SEE CHART)
We call this irregular number of chromosomes Aneuploidy. Down’s Syndrome is the most famous form of aneuploidy, when there is a normal compliment of chromosomes, or 23 pairs, plus an additional number 21 chromosome, resulting in “trisomy,” or three sets of Chromosome 21. PGD testing can test for 9 to 12 of the most common forms of aneuploidy, reducing the chances for aneuploidy by up to 90%.
PGD is usually performed on the third day after egg retrieval. At this stage, there are usually between 4 and 8 cells in the developing embryo. Our embryologist delicately removes one cell from each of the developing embryos,
which is fixed to a slide and sent via courier to our affiliate Reprogenetics, the most experienced cytogenetics laboratory in the world. At Reprogenentics, the cells are stained for the 9 most common chromosome abnormalities, which make up 90 % of aneuploidies. Not all of the chromosomes are tested.
This is an example of the staining technique called FISH, or Florescent In Situ Hybridization, which allows us to determine which embryo has an irregular number of the tested chromosomes.
That information is relayed back to us and the good embryos are then used for embryo transfer.
Stillbirth, the number one cause of infant deaths in the U.S. has genetic implications. (2001, Data from National Center for Health Statistics, CDC). 7% of stillbirths and neonatal deaths have chromosomal abnormalities. (Patients Fact Sheet, Genetic Screening for Birth Defects, ASRM 2002).
Recurrent miscarriages and repetitive failed IVF may be due to genetic abnormalities. Preimplantation genetic diagnosis (PGD) can be used as a diagnostic procedure to identify embryos that carry genes for certain diseases.
According to a report from the American Society of Reproductive Medicine (ASRM), “The advantage of accurately diagnosing these genetic abnormalities in the embryo obviates the 25% to 50% risk of transferring an affected embryo with the specific abnormality in question.” (A Practice Committee Report: Preimplantation Genetic Diagnosis, ASRM. June 2001).
Egg donation
At The Advanced Reproductive Center of Hawaii, our egg donation success is the star of our program. We are proud to have an egg donor pregnancy rate of over 75 percent over the last five years, and we are currently over 90% for the year 2007.
Donated eggs can lead to successful pregnancies for women with premature ovarian failure; women whose own eggs are of poor quality; women in the older reproductive age group (under age 50); and women with chromosomal translocations or genetic diseases that they wish to avoid passing on to their offspring. Donors may be a family member or friend of the woman desiring a pregnancy, or an anonymous volunteer screened by our program.
The egg donor process involves fertility drugs to stimulate the development of multiple follicles/eggs, just like in an In Vitro Fertilization cycle. At the same time, the recipient is coordinated with the egg donor’s cycle with estrogen and progesterone to prepare the uterus to receive the donated embryos. Sperm from the husband, partner, or sperm donor is used to fertilize the donor’s eggs, which are then incubated and placed into the recipient’s uterus a few days after egg retrieval.
All egg donors are screened before they are accepted into the program. Anonymous egg donors are healthy women between the ages of 21-32 who go through the following testing procedures before being accepted:
- Medical history and physical examination
- Testing for infectious diseases per FDA guidelines
- Screening for inheritable diseases through family health questionnaire
- Psychological assessment through the Minnesota Multiphasic Personality Inventory and interview with a psychologist
Many recipient couples have a large number of embryos available through egg donation, which allows the possibility of freezing some for future use. The approximate cost of donor egg IVF in our program with donor work-up, medications, and an anonymous egg donor cycle is approximately $27,000-$33,000, which includes the fees to the donor and donor agency, stimulation of both the donor and recipient, medications, egg retrieval and embryo development, and transfer of the embryos.