Oak Brook Fertility Center - In Vitro Fertilization/Embryo Transfer (IVF/ET)

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Approach 1 (COH/AIH) | Approach 2 (IVF/ET)

About In Vitro Fertilization/Embryo Transfer (IVF/ET)

What is IVF/ET?
IVF/ET is an ART technique during which human eggs are fertilized in the laboratory ('in vitro') rather than in the fallopian tube ('in vivo'). For this purpose, the eggs are removed from the woman's ovaries with a fine needle; after maturing in the laboratory, they are fertilized with the husband's sperm; and after fertilization, the dividing embryos are transferred into the wife's reproductive system.

What are the indications?
IVF/ET was introduced in the late 1970's and early 1980's to bypass diseased fallopian tubes and it has revolutionized the management of infertility. It allows couples who otherwise would remain childless, a good chance for a biological child. Indications for the procedure, in addition to diseased fallopian tubes, include: endometriosis, pelvic adhesions, male-factor infertility, and unexplained infertility as well as other irreversible causes of infertility.

What are the contraindications?
IVF/ET will not be successful if the uterus is unhealthy or there are factors preventing embryo implantation. Endometrial polyps, intrauterine adhesions, uterine fibroids, uterine infections, and other congenital or acquired uterine anomalies can prevent implantation of healthy embryos. Careful evaluation of the uterus is therefore mandatory before the IVF/ET procedure. Occasionally, abnormal expression in the endometrial molecules that participate in embryo attachment/implantation (such as integrins) can prevent embryo implantation. If uterine problems cannot be corrected, use of a gestational surrogate (see below) may be required. Diseased fallopian tubes may occasionally accumulate fluid which is toxic to embryos. Such a condition is referred to as hydrosalpinx. If hydrosalpinx (either unilateral or bilateral) is present, chances for pregnancy with IVF/ET are decreased by about 50%. It is generally recommended that hydrosalpinges be removed before the IVF/ET attempt.

In Vivo vs. In Vitro Fertilization

What are the procedures involved?
IVF/ET consists of several phases. During the suppression phase, a hormone (GnRH agonist) is administered to suppress ovarian function and to allow for the development of several eggs at the same time. During the stimulation phase, FSH or FSH with LH are administered to stimulate development of ovarian follicles. When the follicles reach maturity, an hCG injection is given. About 36 hours later, oocyte retrieval is performed. The eggs are aspirated transvaginally under ultrasound control. The procedure is performed under conscious sedation with intravenous medication and with local anesthesia. After a brief maturation in the laboratory, the eggs undergo in vitro fertilization with specially prepared husband's sperm. Fertilized eggs or pre-embryos are cultured in the laboratory for 3-5 days. Then, embryo transfer (ET) of between one to three healthy embryos is performed. Uterine embryo transfer (UET) is a simple office procedure performed under a mild sedative. Ultrasound guidance is used to properly place the embryos in the uterus. A pregnancy test is performed about 10-14 days later.

There may be several modifications to this protocol. The suppression phase may be omitted or combined with the stimulation phase using GnRH antagonist. In some patients, the ovaries may not be accessible transvaginally and laparoscopic retrieval of the eggs may be necessary. After embryo transfer, various protocols may be used for luteal phase support to increase the chance for embryo implantation. Other modifications of IVF/ET protocol are listed below.

What are the success rates?
The success rates are reported as the number of live births per number of attempted IVF/ET cycles as recommended by the Society for Assisted Reproductive Technology/Center for Disease Control (SART/CDC). There are, however, other ways of reporting. In some women, because of a decrease in the ovarian reserve, there is no response to stimulation and there are no eggs retrieved. Such cycles are typically cancelled. To account for this, success rates may be reported per oocyte retrieval rather than per attempted cycle. In some couples, eggs are retrieved but there is no fertilization because of egg or sperm factors or there are no healthy embryos and, therefore, there is no transfer. To account for this, success rates may be reported per embryo transfer. Furthermore, some pregnancies do not progress and end up as early implantation failures, miscarriages, or premature losses. Accordingly, success rates may be reported as the number of chemical or clinical pregnancies or live births per initiated cycle, per oocyte retrieval, or per embryo transfer. Transfer of more than one embryo increases chances for pregnancy but also introduces the risk of multiple pregnancy. Accordingly, you may see reports of success rates expressed as an implantation rate per embryo transfer. The probability of pregnancy and live birth during the first cycle of IVF/ET is over 40% in the leading centers, as reported by SART/CDC. Cumulative probability of pregnancy after three IVF cycles exceeds 70%.

Supranumerary embryos not transferred during the IVF/ET cycle may be cryopreserved for future transfer, thus increasing the success rate of IVF/ET. The SART/CDC report does not account for pregnancies achieved with cryopreserved embryos transferred during subsequent cycles.

Additional benefits of IVF/ET
IVF/ET is not only therapeutic but is also a diagnostic procedure. Data from the embryology laboratory can provide information about the quality of a woman's eggs, fertilizing potential of her husband's sperm, and the quality of the resulting embryos. RE/I specialists have learned during the past two decades that poor quality of gametes and embryos is one of the most frequent causes of infertility - especially in couples of advanced age. IVF/ET is the only way to obtain this information.

Risks and complications
Multiple pregnancy and OHSS are two potential complications of IVF/ET. Multiple pregnancies can be prevented by limiting the number of embryos transferred. It is a common misconception that IVF/ET leads to high-order multiple pregnancies. In general, the number of fetuses cannot be larger than the number of embryos transferred and most IVF programs transfer no more than 2-3 embryos. By transferring two embryos in the blastocyst stage when chances for implantation are higher and by cryopreserving the supranumerary embryos, high success rates with low risk of a multiple pregnancy can be achieved. It is quite likely that with further advances, only one or two embryos will be transferred during each IVF/ET attempt. OHSS can be prevented by using less aggressive stimulation protocols and through other preventive measures.

Additional procedures on gametes and embryos
If more than two or three healthy embryos are available for transfer, cryopreservation of the supranumerary embryos can be performed. Cryopreserved/thawed embryo transfer during a subsequent cycle gives the couple another chance for pregnancy or the possibility for two or more consecutive pregnancies from the same IVF attempt. If the sperm have low or no fertilizing capacity or if their numbers are low, fertilization can be achieved through micromanipulation and intracytoplasmic sperm injection (ICSI). To improve embryo quality and chances for pregnancy, embryo co-culture with endometrial cells to the blastocyst stage may be recommended. Healthy blastocyst transfer increases the chance for implantation and pregnancy and lowers the risk of multiple pregnancy. Assisted zona hatching (AZH), another micromanipulation technique, facilitates embryo hatching from sometimes overly thick or hardened zona pellucida. Prior to transfer, embryos can be analyzed for abnormal chromosomes or adverse genetic traits and only healthy embryos of either male or female sex are then transferred. The procedure is referred to as preimplantation genetic diagnosis (PGD).

IVF vs. GIFT

Modifications of the IVF/ET approach
Occasionally, to improve chances for pregnancy, embryos may be transferred into the fallopian tube rather than into the uterus. These procedures are referred to as zygote intrafallopian transfer (ZIFT) or tubal embryo transfer (TET), depending on the stage of the embryos transferred. Both ZIFT and TET require laparoscopy. Gamete intrafallopian transfer (GIFT) is another variant of ART performed for specific indications. For this purpose, eggs are retrieved from the ovaries and placed laparoscopically with sperm in the fallopian tube. Typically, not more than four eggs are transferred and fertilization occurs 'in vivo' - not 'in vitro'. This approach is more acceptable to some religions but does not supply any information on the egg-sperm interaction and early embryonic development.

Occasionally, absence of eggs in the ovary or their poor quality may be the cause of infertility. This occurs in women approaching 40 years of age but is also seen in women with premature menopause (ovaries destroyed by endometriosis or surgically removed). In such cases, as long as there is a healthy uterus, the woman can conceive with Donor Egg IVF. Donor eggs can be obtained from the woman's healthy female relatives or from unrelated known or unknown donors. Chances for pregnancy with Donor Egg IVF are high - dependent on the age of the donor rather than age of the recipient.

Occasionally, a woman may have healthy ovaries but her uterus is either diseased or previously removed. In such cases, a woman's eggs can be removed and fertilized 'in vitro' with her husband's sperm and the resulting embryos can then be transferred to the uterus of a gestational surrogate. Gestational surrogacy for such couples may be the only way to have a biological child. CLICK HERE FOR TO CONTACT US.