In Vitro Fertilization technically mean "fertilization outside of the body." While considered an experimental procedure for years, IVF is a procedure used by couples that have difficulty conceiving on their own. IVF is a safe, medically supervised procedure that has given many hope to many couples with fertility problems.

Retrieved eggs are fertilized and monitored in the lab for 1-3 days, or 4-5 days for blastocyst transfer. Typically one or two of the best embryos are selected for transfer, and are placed via an ultrasound-guided catheter into the uterus. Sensations during the procedure are similar to those of a Pap smear.

The IVF program is made up of four steps:
1) Use of fertility medications to develop oocytes or "eggs."
2) Collection of the oocytes (eggs).
3) In Vitro Fertilization of the egg and growth of the embryo.
4) Transfer of the embryo into the uterus.

Screening tests required prior to IVF program
Female:

1. Blood test for: CBC, Blood Group, Rh Group, Anti HIV, VDRL, HBsAg, Anti HCV, Rubella IgG
2. Blood test for: FSH, LH, Prolactin and Estradiol on day 2 or day 3 of menstrual cycle
3. Pap smear result within one year
4. Transvaginal ultrasound scan of uterus, endometrium, and ovaries on day 2-3 of menstruation

Male:

1. Blood test for: CBC, Blood Group, Rh Group, Anti HIV, VDRL, HBsAg, Anti HCV.
2. Semen analysis (Sperm count)

Developing and Monitoring Follicles
To assist in follicle growth, you will be started on a program of medication. These medications shut off pituitary stimulation to the ovaries. By shutting down the pituitary, the ovaries are isolated so that oocyte (egg) development is stimulated by medication alone. These medications are used together to help stimulate multiple follicles so that several eggs can be collected at the time of egg retrieval. This increases the number of eggs that have an opportunity to fertilize and develop into embryos.

After starting these medications, you will be monitored for follicle growth with both transvaginal ultrasounds and a blood test for estradiol (E2). The size of the follicles and amount of E2 present tells if the follicles have reached optimal maturity. This may require 8-12 days of treatment, with several ultrasounds and blood tests. When the follicles are mature, you will receive an injection of human chorionic gonatotropin (hCG) to begin the final maturation of the eggs. Eggs are collected 36 hours after the medication is given.

Collection of the Eggs
Mature eggs will be collected by ultrasound-directed needle aspiration. Follicles are located by ultrasound and then a needle is guided through the top of the vagina into the ovary to aspirate the eggs from the follicles.

Fertilization of the Egg and Growth of the Embryo
Once the eggs are retrieved, they are transported to the in-house Assisted Reproduction Technology (ART) laboratory where they are placed in a special liquid culture medium and allowed to remain there for approximately 2-3 hours. A semen specimen collected by masturbation is given to the lab within one hour of collection on the morning of your procedure. You must abstain from intercourse for 2 days prior to the IVF procedure. This ensures optimal sperm quality. The sperm are prepared and a small number of active sperm are placed in the medium with each egg. If Intracytoplasmic Sperm Injection (ICSI) is to be done, it will be performed approximately 4 hours after the oocyte retrieval.

The eggs will be examined for the first time approximately 18 hours after the time of insemination to determine if they have fertilized. You will be informed about the outcome of fertilization the day after your retrieval. If fertilized, the eggs will be kept in the incubator for an additional day or possibly two for further development before they are transferred to your uterus.

Embryo Transfer (ET)
In consultation with your Dr. Wiwat, you will decide the number of embryos to be transferred into you. The risk of multiple pregnancy must be considered carefully in this decision. You will need to decide before the IVF procedure what will be done with the remainder of the embryos. Your choices include the following:

      1) discarding the extra eggs before fertilization
      2) freezing extra embryos for future pregnancy attempts for yourself
      3) donating the unfertilized eggs to another infertile couple.

Information regarding these choices is included in the packet of information you will receive from the IVF team. It is critical that you make your decision known regarding the disposition of any extra eggs and/or embryos before the cycle begins.

The embryo replacement procedure is very simple and requires no anesthesia. The embryos are picked up into a very fine catheter, which is inserted into the uterus through the cervix, and the embryo(s) are placed into the uterine cavity.

You will need to stay in a reclining head down position for approximately 2 hours after the embryo(s) have been placed in your uterus. Activities after embryo replacement should be minimal for the first 72 hours. After that, you may resume your normal activities, albeit no sports activities and no intercourse until your pregnancy test results are known. You will receive progesterone injections until pregnancy test results are known. Progesterone is given to assist successful embryo implantation. If you are pregnant, further instructions related to activity level and progesterone supplementation will be given.

Embryo Freezing
Cryopreservation, also known as "freezing," involves storing embryos at a very low temperature so that they can be thawed and used later. Cryopreservation is often done when there are more embryos than are needed for a single in vitro fertilization (IVF) cycle. The extra embryos are saved and potentially used during later cycles.

IVF success rates are generally lower with frozen embryos than with freshly fertilized embryos, although pregnancy rates with frozen embryos have been improving in recent years. The survival rate after thawing often depends on the quality of the embryos at the time of freezing.

Risks
You will be taking strong medications to stimulate egg production. While these medications have been proven safe to use, there are some possible side effects of which you need to know.

These side effects may include:
Ovarian Hyperstimulation - the ovaries become too stimulated and can become very large with cysts. In severe cases, fluid collects in the abdomen and lungs, blood clotting problems may occur, fluid and electrolyte imbalances can occur and rarely, life-threatening complications may ensue. Deaths have occurred with severe hyperstimulation syndrome (OHSS.) Your procedure may be canceled if the risk for hyperstimulation is high. Ovarian hyperstimulation may require hospitalization. Severe hyperstimulation occurs in less than 1% of cases.

Ovarian Torsion - the ovary twists around its blood supply causing blood flow to be shut off; this is rare (less than 1% of all assisted reproduction procedures), but if it occurs, it may require removal of the affected ovary.

Multiple Gestation - multiple gestations (twins, triplets, quadruplets) are more common with this procedure, occurring about 25% of the time. Most of these multiple gestations are twins. As with any multiple gestation, there is an increased chance of preterm birth. Some of the major problems associated with preterm birth may include respiratory distress, brain hemorrhage, and nervous system problems such as blindness and cerebral palsy. It is your decision in consult with your physician as to how many embryos are returned to the uterus. If a multiple pregnancy does happen, the option of selective fetal reduction (aborting some of the fetuses while still carrying some) is available.

Egg Retrieval/Laparoscopy Risks - if you have a transvaginal egg retrieval, laparoscopic egg retrieval or embryo transfer, the risks are very low (about 3 in 1,000) and may include: injury to the intestines, blood vessels, and bladder (if this does occur, it would be repaired during surgery, but would require a larger incision), infection and bleeding. In the unlikely event of physical injury resulting from your participation in this procedure, it is important to understand that the costs of such treatment will be at your own expense and that financial compensation from your insurance carrier may not be available.

Ectopic Pregnancy - the risk of ectopic (tubal) pregnancy is slightly higher than in natural pregnancy, approximately 5% (5 out of 100.)

Ultrasound - ultrasound has been used in obstetrics and gynecology for many years with no cases of fetal abnormalities or maternal complications directly related to its use.

Blastocyst Culture
Recently, there is a remarkable development in the laboratory methods used to allow the embryos to develop for up to 5-6 days after egg recovery and that embryo stage so called "Blastocyst". The advantages of blastocyst culture are to eliminate those embryos with little developmental competence and to facilitate the synchronization of embryonic stage with uterine endometrial development. This means that we can expect the higher implantation and pregnancy rates from a blastocyst transfer. However, there is still is considerable patient-to-patient variation, which means that on the same day using the same medium, one patient may get 90% blastocyst development while another patient will get 10%. Additional research data has found that about 5% of patients will not have at least one embryo develop to the blastocyst stage so they end up with no transfer.