In Vitro Fertilization (IVF)

Dr. Witten is a board certified Reproductive Endocrinologist and director of Reproductive Endocrinology in the Department of Obstetrics and Gynecology at St. John’s Mercy Medical Center. Once all avenues of infertility treatment have been pursued and IVF is being considered, we will provide you with professional guidance and supervision through this very important decision process. You will be treated with warmth and hospitality throughout your IVF experience.

Over one million children have been conceived through in vitro fertilization. In vitro fertilization (IVF) is a procedure first developed in 1978 in which a woman’s ovaries are stimulated with fertility medications to produce multiple mature eggs, which are then removed from her body and are fertilized in the laboratory with her partner’s (or donor) sperm. The resulting embryos are cultured for three or five days and the best two or three are then transferred back into her uterus in the hope that one will result in a full-term pregnancy.
IVF is a complex process with many steps that must be successful in order to maximize the chance of conceiving. The steps are as follows:

Pre-treatment

Before any treatment is begun, you will meet with Dr. Witten and complete a thorough screening. The initial examination will include a full medical history and prescriptions for a variety of tests: blood tests for hormone levels and infectious diseases, ultrasound, and uterine imaging (hysteroscopy or sonohysterogram). These tests are done to detect fibroids, endometriosis, tumors, infectious disease, hormone levels and other potential problems. The male partner will also be asked to undergo semen analysis to assess sperm count and health.

We will also tell you about ways to increase your chance of conceiving during the initial IVF stages. This includes instructions about diet, nutritional supplements, exercise and weight loss, and sexual behavior as well as a recommendation to avoid tobacco, alcohol, caffeine, and certain medications.
When preliminary testing is completed, we will meet to discuss cycle dates and finances.

Ovulation Induction

A woman’s body normally produces one egg per ovulation cycle. However, if more eggs can be collected and fertilized in one cycle, there will be more viable embryos to select from, and thus a greater chance of conception. For this reason, prior to egg retrieval the ovaries are carefully stimulated to produce more eggs than usual. This process is known as superovulation.
Superovulation is achieved through a series of injections of special medications that regulate the menstrual cycle by adjusting the levels of certain chemicals in the body. These include:

  • GnRH agonists, or gonadotropin-releasing hormone agonists – Stimulate high-quality egg production and help prevent mid-cycle increases in estrogen levels. (Lupron)
  • GnRH antagonists – Prevent premature ovulation. (Ganirelix, Cetrotide, Cetrorelix, Orgalutron))
  • FSH, or follicle stimulating hormones, and LH, or luteinizing hormones – Stimulate egg-producing follicles in the ovaries. (Follistim, Bravelle, Menopur, Gonal-F, Repronex)
  • hCG, or human chorionic gonadotropins – Prepare eggs for harvesting. (Pregnyl, Profasi, Novarel, Ovidrel)

Other medications that may be used to support the success of the cycle are:

  • A prenatal vitamin to give the developing egg, and later the embryo, all of the nutritional support necessary for growth
  • Dexamethasone, a hormone to suppress your immune system, is given to improve the survival of an embryo after it is transferred
  • Estradiol (injected, administered vaginally, or applied transdermally) may be recommended if you’ve got a history of poor response to gonadotropins
  • Viagra (and similar medications) may be used to improve blood flow to the uterus if there is a history of certain uterine factors contributing to your infertility
  • Folgard (folic acid) is a medication often prescribed to women with certain inherited risk for blood clot
  • Heparin and/or intravenous immunoglobulin (IVIG) may be prescribed for immunologic factors that could be contributing to your infertility
  • Progesterone may be prescribed to support embryo implantation
  • Antibiotics are often prescribed to prevent infections following the embryo transfer

There are some risks associated with these treatments, including side effects from the injection itself (bruising, swelling, tenderness or infection), allergic reaction, and excessive or insufficient response from the ovaries. Increased estrogen levels may cause fluid retention, weight gain, nausea, diarrhea, breast tenderness, moodiness, headache or fatigue. A rare but possible complication is ovarian hyperstimulation syndrome (OHSS), in which estrogen levels rise sharply and the ovaries produce too many eggs, potentially causing excessive fluid retention, thrombosis and enlarged ovaries.

Egg Retrieval

The next step in IVF is the retrieval of the eggs (oocytes) from the ovaries. Retrieval takes about 30 minutes under IV sedation. An ultrasound-guided needle is inserted into the ovary, where one or more eggs and fluid are removed. The sample is brought to the laboratory. Some soreness, cramping or spotting is normal after the procedure but recovery is quick – usually only about two hours. After retrieval the woman may be asked to take progesterone supplements to compensate for hormone-producing cells removed during the procedure.

Fertilization & Transfer

Sperm, usually obtained by ejaculation is prepared for combining with the eggs. The sperm and eggs are placed in incubators located in the laboratory which enables fertilization to occur. In some cases where fertilization is suspected to be low, 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. The embryos will be allowed to incubate for from 3-6 days. During this time they are graded and may undergo further testing such as preimplantation genetic diagnosis (PGD) or comparative genomic hybridization (CGH). The embryos are usually transferred into the woman’s uterus from three to six days following egg retrieval. Embryos not used in the cycle may be frozen for future use. The transfer process involves a speculum which is inserted into the vagina to expose the cervix. A predetermined number of embryos are suspended in fluid and gently placed through a catheter into the womb. This process is often guided by ultrasound. The procedure is usually painless, but some women experience mild cramping.

Pregnancy

About two weeks after retrieval and transfer, a blood sample is taken to measure levels of the “pregnancy hormone” hCG and determine whether the pregnancy has been successful so far. A second blood test two days later is required to confirm a positive result. Ultrasound images taken three weeks and four weeks later indicate whether a gestational sac has formed in the uterus around the developing embryo. Patients will be referred to their OB/GYN if all looks well.

Pregnant patients will continue to take progesterone supplements and follow an individualized treatment plan. If the test is negative, progesterone is stopped and the patient should have a regular period within 5 days. Follow-up visits will be scheduled with Dr Witten so couples can discuss their feelings and options.

Mini-IVF vs. Traditional IVF

Traditional IVF involves stimulating the ovaries with injectable hormones to make them produce multiple eggs which can then be harvested and fertilized to produce viable embryos. With more eggs produced, there is a better chance of getting good quality embryos for transfer. Mini-IVF uses the oral drug Clomid and a small amount of injectable hormones that will result in the production of fewer eggs than traditional IVF.
The eggs are harvested and fertilized the same manner as traditional IVF. Both options are available to our patients.

Recently, there has been some controversy over the advantages of doing low stimulation or mini-IVF versus traditional IVF. Low stimulation IVF protocols have been around for many years. With the advent of injectable medications, Clomid based cycles were largely abandoned due to the overall poorer success rates. Some clinics are suggesting that Clomid can actually improve the quality of the eggs, especially in older women. This is simply not true.

With low stimulation protocols, less medication is taken and therefore costs will be lower. The result will be fewer follicles and fewer eggs retrieved. This will impact the probability of success of IVF in any given cycle. It may take three or more low stimulation cycles to retrieve the same amount of eggs obtained in one traditional IVF cycle. Patients need to be aware of this multi-cycle concept and the effect of this on the overall cost savings.

It is important to evaluate each couple to help them choose the method that will be of maximum benefit to them. What is optimal for one couple may not be the best option for another couple. The good and bad points of different cycle options need to be considered, as well as personal circumstances such as finances, religious or ethical beliefs, and family dynamics. Together, we can come up with a plan that fits your personal circumstances and offers the best chance for success.