Wilford Hall where we will be doing our IVF has a booklet with some great info that helps explain IVF. I will copy some for you to read in case you are interested in how IVF works.
http://www.sammc.amedd.army.mil/patient/departments/ob_gyn/sammc_south/in_vitro/docs/IVFPatientBooklet.pdf
INTRODUCTION
In order for pregnancy to occur, an egg has to be released from the ovary and unite with a sperm. Normally this union, called fertilization, occurs within the fallopian tube. When this process cannot take place in the body, it can be accomplished in the laboratory by using the in vitro fertilization (IVF) technique. The technique, as currently practiced, involves uniting an egg(s) collected from a woman's ovary with sperm collected from her partner under laboratory conditions. The resulting normal embryo(s) may be transferred to the uterus (womb) for continued growth. The benefit of IVF and ET is that it gives a couple who may be unable to achieve a pregnancy an opportunity to attempt to overcome their infertility.
WHO WILL BENEFIT FROM IVF?
1.
IVF is of demonstrated value for patients with absence or blockage of the fallopian tubes.
2.
IVF is also recommended to those where corrective surgery has either failed and/or is deemed inadvisable.
3.
Couples with infertility related to severe male factor, e.g., lowered sperm counts or motility or antisperm antibodies.
4.
Those who have other causes of infertility such as: endometriosis, unexplained infertility, or couples that have experienced repetitive intrauterine insemination (IUI) therapy failure.
WHAT ARE YOUR CHANCES OF SUCCESS?
The probability of conceiving a child and delivering a healthy baby is very individual to each couple. Success has many variables such as: age, cause of infertility, the woman's response to fertility medications, the rate of the sperm's ability to fertilize the egg, the couple's willingness to undergo multiple embryo transfers, and the expertise of the chosen IVF program. Available at this website link SART (Society for Assisted Reproductive Technology) http://www.sart.org/ are the success rates for the IVF program at Wilford Hall Medical Center over the past five years. Look for our center under Texas and Lackland AFB.
DEVELOPMENT OF OOCYTES (EGGS)
It is necessary to stimulate the ovary with medications that develop multiple follicles (the cysts that contain the eggs), in order to improve your chances of a successful outcome from an IVF cycle. The IVF coordinator will meet with you and discuss the medication regimen and review the method and manner of medication administration. There are many different medication protocols that the physician may prescribe for you. This decision is based on factors such as your age, infertility history, past response to these medications, and baseline FSH level or CCCT results. The fertility medications that are necessary to stimulate the ovary are all injectable medications (except for Clomiphene Citrate, which is rarely used).
FERTILITY MEDICATIONS:
Follitropins:
This type of medication has been created using DNA recombinant technology. The hormone Follicle Stimulating Hormone (FSH) is now being produced in the laboratory. This is a relatively new class of drugs. In addition to consistency of dose, this medication may be given by the subcutaneous route (short needle).
Menotropins:
This type of medication is a purified preparation of the hormones Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). The hormones FSH and LH are naturally occurring in the urine of postmenopausal women. Some of these medications must be administered by the intramuscular injection (long needle), but others can be given subcutaneously.
Side Effects of Fertility Medications (Follitropins and Menotropins):
1. Overstimulation of the Ovary: The risk of Ovarian Hyperstimulation Syndrome (OHSS) increases as the estradiol levels in the blood increase and the number of follicles rises. OHSS can occur to varying degrees: mild, moderate or severe.
Signs & Symptoms:
Mild/Moderate - Abdominal bloating, ovarian enlargement, abdominal discomfort, weight gain (up to 10-15 pounds of fluid weight), nausea.
Severe -Large distended abdomen, severe abdominal pain, excessive weight gain (more than 20 pounds), shortness of breath, decreased urination, nausea and vomiting. Hospitalization is sometimes necessary for monitoring, fluid administration and administration of pain medication.
Cases of severe OHSS are more common and the condition lasts longer if pregnancy results from the IVF cycle. It is for this reason that based on your clinical situation (estradiol level, number of eggs retrieved, symptoms of severe OHSS) the physician may require that after all the eggs are retrieved and fertilized into embryos, all the embryos be frozen for future transfer. We understand that delaying the embryo transfer may be upsetting to you. The physician must consider all facts when making the decision that is best for your health. One comforting fact to remember is that the Wilford Hall Medical Center has an agreement with the Fertility Center of San Antonio to allow patients to freeze embryos for an additional charge. The Fertility Center of San Antonio's Frozen Embryo Pregnancy Rate is very similar to the Fresh Embryo Pregnancy Rate.
Careful and frequent monitoring of blood estradiol levels and ultrasound measurements of the number of
follicles will assist the physician to prevent the occurrence of severe OHSS. Unfortunately, due to an unpredictable ovarian response, the risk of severe OHSS will still exist with the administration of fertility medication, despite the most vigorous monitoring efforts.
2. Multiple Births: The risk of conceiving a multiple pregnancy during an IVF cycle is dependent upon many factors. Factors such as your age, response to the medications, the quality of the embryos, the number of embryos replaced into the uterus and other unforseen factors are considered when judging your specific risk of multiple births. In the year 2006, 27 % of the women going through IVF had more than one live born infant. However, the percentage of women with a triplet pregnancy was 0%. We have not had any live birth quadruplet or higher order multiple pregnancies in over 12 years of IVF at our center.
3. Common complaints: Pain at the injection site, headaches, and fatigue.
A special note: You may have read reports that fertility drugs increase the risk of ovarian cancer.
To date there are no conclusive studies that identify an association between taking fertility drugs
and ovarian cancer. Ovarian cancer is the fifth most common type of internal organ cancer
diagnosed in women. The average age of diagnosis is between 50 and 59 years of age.
Certain factors may be associated with an increased risk of ovarian cancer:
• Family history: For women with a family history of ovarian cancer, the increased risk may be as
high as 50%.
• Pregnancy: Women that have successfully conceived a child-even if they have not had a successful
birth- appear to have a lower incidence of ovarian cancer.
• Breast feeding and the use of oral contraceptives have been reported to be associated with a
reduced risk of ovarian cancer.
• Environmental factors: The incidence of ovarian cancer is much higher in industrialized countries,
leading to speculation that ovarian cancer may be associated with exposure to industrial byproducts
in the environment.
B. GnRH AGONIST (Lupron) or ANTAGONIST (Ganirelix, Cetrotide)
This medication is administered by subcutaneous injection. It is given to prevent premature release of the
oocytes (eggs). Side effects may include: localized skin reaction, allergic reaction, headaches, hot flashes and mood swings. If your scheduled menstruation is late while on Lupron, you should have a pregnancy test.
C. HCG (HUMAN CHORIONIC GONADOTROPIN)
You will be given instruction on the exact time this injection of medication should be taken. It is generally taken 34-36 hours prior to the egg retrieval. This medication should be injected into the muscle using a 1-1/2" needle. This medication completes the maturation of the egg. For mixing instructions, see the patient instruction sheet.
D. PROGESTERONE
You will begin taking this naturally occurring hormone the day after the egg retrieval. This medication causes the lining of the uterus to mature making implantation of the embryo possible. The side effects that have been reported with progesterone include: breast tenderness, headache, nausea, fluid retention, fatigue, mood swings, depression, and pain at the site of injection.
In 1977 the Food and Drug Administration (FDA) issued a warning that the use of progesterone may increase the risk of birth defects. As evaluated in our own research data, experience in our practice and the work of other researchers, there does not appear to be any increased risk of birth defects following use of progesterone. Moreover, the progesterone we use is the same formulation as the hormone that is naturally produced by a woman's own body each month after ovulation.
OOCYTE (EGG) RETRIEVAL
The egg collection process (egg retrieval) is usually accomplished using the ultrasound-guided trans-vaginal method. Other methods of retrieving oocytes that are rarely utilized in our practice but are sometimes necessary, include laparoscopy or a trans-abdominal approach.
The ultrasound-guided trans-vaginal method of egg retrieval allows this procedure to be done in an out-patient setting. A vaginal ultrasound allows for visualization of both ovaries. A needle is inserted through the vaginal wall into the ovary. Each follicle is punctured individually and the fluid containing the egg is drained and examined by the embryologist under the microscope until the egg is found. The duration of this procedure is usually less than 45 minutes.
A practice (mock) embryo transfer will normally be done after the egg retrieval. For the practice transfer, the physician inserts a tiny plastic catheter into the uterus. This allows the physician to measure the depth and direction of your uterus. For patient comfort, sedation is required. Conscious sedation is discussed below.
Conscious Sedation:
Conscious Sedation is administered by a Registered Nurse under the guidance and supervision of the physician. The patient is given a combination of two medications intravenously (IV): Versed which is in the valium family and Fentanyl which is in the morphine family. This type of sedation generally produces a "twilight sleep". The patient may be aware of her surroundings and the ongoing procedure. Response to sedation is very individual and therefore your comfort level with this type of sedation is difficult to predetermine.
INCUBATION AND FERTILIZATION OF OOCYTES (EGGS)
The eggs and sperm will be placed together in a special culture fluid and kept in incubators in our laboratory. This process is called insemination. The eggs will be examined 16-20 hours after insemination for signs of fertilization. If fertilization occurs, the fertilized eggs are now described as pre-embryos or zygotes. When they divide to at least 2 cells they are called embryos. The laboratory environment is conducive for fertilization to occur, however, it cannot be guaranteed that fertilization will occur. Typically, 60-80% of the eggs retrieved will be fertilized. This percentage may be higher or lower depending on each couple.. Sometimes the eggs will have to be injected with a single sperm to ensure fertilization. This process is called intracytoplasmic sperm injection (ICSI).
EMBRYO TRANSFER
Embryo Transfer (ET) usually occurs three days after the egg retrieval. The time of the transfer will be designated by the IVF staff. The embryos that are assessed to be developing normally will be considered for transfer. Although a recommendation of the number of embryos to transfer will be made by your physician (usually, 1-4 embryos depending on the woman’s age and prior history), the final decision resides with the couple and the physician. Transferring multiple embryos may result in the growth of more than one fetus. If you have extra embryos after the transfer, they will be cryopreserved if they have demonstrated appropriate development and you have signed the consent for cryopreservation. Cryopreservation is an additional fee. Should transfer of the cryopreserved embryos be desired in the future, all cryopreserved embryos are thawed and transferred at the Fertility Center of San Antonio, by the Fertility Center of San Antonio’s medical staff, not at Wilford Hall Medical Center.
The method used for transferring embryos is similar to that of the practice transfer. You will need to drink fluids to fill your bladder before the actual transfer so that we may visualize the uterus by ultrasound during the transfer. An embryo transfer is performed by inserting a small catheter through the cervical opening into the endometrial lining of the uterus. The embryo transfer is usually a painless procedure. There is a recommended rest period after the transfer. You will be given specific instructions prior to the transfer regarding your medications, future testing dates, and activity restrictions.
Within twelve days post-transfer, a pregnancy test will be done. If your pregnancy test is positive, further blood-work and an ultrasound will be required to assess progression of the pregnancy. Patients are generally followed in the infertility clinic throughout the first two months of the pregnancy and then referred to an Obstetrician.
CRYOPRESERVATION (FREEZING) PROGRAM
The military does not permit us to store frozen embryos. The Fertility Center of San Antonio has graciously allowed our patients this service. All future activity with embryos frozen at Wilford Hall (thawing, transferring, etc) will be done at the Fertility Center of San Antonio.
The purpose of the Embryo Freezing Program is to give a couple participating in the IVF program the best
chance to achieve a pregnancy with a maximum of safety. At the end of an IVF cycle there are often multiple embryos available for transfer. It has been found that transferring more than two embryos carries a significant risk of multiple pregnancy, while it does not increase the singleton pregnancy rate proportionately. The advantage of cryopreservation is that there may be an increased chance of pregnancy without the necessity of multiple stimulation cycles and oocyte retrievals. There are other advantages to embryo cryopreservation which include, but are not limited to: avoiding acute illness immediately following oocyte retrieval or other unforeseen conditions that would either prevent or make a fresh embryo transfer less than optimal. For example, if ovarian hyperstimulation syndrome seems likely to occur, all of the embryos should be frozen to prevent exacerbation of the condition, which may require hospitalization.
There are various stimulation protocols available to make a frozen transfer successful. You will be instructed by the physician which method may be best for your individual case. The frozen embryo transfer takes place in an identical manner to a fresh embryo transfer.
It must be realized that there is only minimal worldwide experience with prolonged human embryo storage. Currently, the longevity of embryos at -196°C is unknown. Extrapolating from information from other mammalian species, embryos that become healthy offspring can be stored up to ten years.
Embryos selected for cryopreservation will be frozen five to six days after the egg retrieval when they reach the blastocyst stage. The embryos will be placed in a cryopreserved media and frozen in a step-wise manner. At the end of the cryopreservation procedure the embryos will be stored frozen in tanks filled with liquid nitrogen. These cryopreserved embryos can be thawed and transferred at a future date. There is no guarantee of the survival of human cryopreserved thawed pre-embryos. If they have not survived, (as seen at the time of thawing), they will not be transferred. The Fertility Center of San Antonio, however, does have a very high survival rate for frozen embryos. We are pleased to offer our patients years of expertise in the area of cryopreservation. We are considered by many to have one of the most successful cryopreservation programs in the country.
ICSI - INTRACYTOPLASMIC SPERM INJECTION
This technique was developed in Brussels, Belgium at the Center for Reproductive Medicine in 1991. ICSI involves the injection of a single sperm directly into the cytoplasm of the oocyte (egg) using a technique called micromanipulation. This technique has revolutionized the treatment of male infertility. It is useful to couples where the male has a low sperm count, low sperm motility, high levels of anti-sperm antibodies or abnormal sperm morphology. In the case of testicular obstruction (ie: vasectomy), the sperm are aspirated from the epididymis or testes by the urologist and then the ICSI procedure is performed by the embryologist to fertilize the oocytes.
Careful follow up of all pregnancies are done and to date the rate of birth defects appears to be no higher than in naturally conceived children. It has been noted that men that have extremely low sperm counts may have a condition known as micro-deletion of the y-chromosome. This is a genetic condition that can account for why these men have a very low sperm count. This condition (micro-deletion of the y-chromosome) may be genetically passed down to the male offspring of this specific group of men. It has been shown that men with a condition called congenital absence of the vas deferens have a higher incidence of carrying the gene for cystic fibrosis and should have genetic testing done for cystic fibrosis.
Candidates for ICSI:
ICSI is useful for patients suffering from male factor infertility, which includes low count, low motility, abnormal sperm, high anti-sperm antibodies, or poor fertilization by conventional insemination in past cycles. ICSI requires very few total motile sperm, so even males with severe male factor infertility have a chance at producing a genetically related child. If there is an obstruction in the sperm ducts, a successful pregnancy can be achieved by collecting the fragile sperm from within the sperm duct behind the obstruction or from a testicular biopsy. Aspiration of the sperm from the male is performed by the Urology service at the Wilford Hall Medical Center on the same day that the eggs are retrieved.
Assisted Hatching
Assisted embryo hatching is a technique used in some IVF centers in women with a history of failed IVF cycles. A number of studies have suggested that some human embryos fertilized in-vitro lack the ability to "hatch" out of the embryo covering (zona pellucida). On the other hand, a number of studies suggest that assisted hatching is of no benefit in achieving pregnancy. This procedure is rarely recommended at WHMC.
EXPECTATIONS OF SUCCESS
Despite the encouraging statistics, it must be emphasized that successful conception and childbirth for any specific couple cannot be guaranteed by any IVF program, even if the couple undergoes multiple attempts. The probability of success depends on many factors, including, but not limited to, the patients age, the cause of infertility, and the skills and experience of the IVF team. (While almost all children resulting from human IVF have been normal, the possibility cannot be excluded that IVF could involve some unknown or increased risk to children who are conceived by this method.) Most infants who have been born following human in vitro fertilization have appeared healthy at birth. Animal offspring have usually been healthy following in vitro fertilization and/or embryo transfer. Yet, congenital abnormalities, birth defects, genetic abnormalities, mental retardation, and/or other possible deviations from normal may occur in children born following in vitro fertilization (as they may occur in children resulting from natural fertilization). At present there does not appear to be any increased risk of birth defects, though multiple births may be complicated by prematurity.
A pregnancy following IVF usually has a successful outcome but like any other pregnancy, may end in miscarriage or still birth. There is no evidence that the frequency of these events are increased by IVF. Even a tubal pregnancy is possible following IVF. There is also a greater chance of heterotropic pregnancy ie: one in the uterus and one in the fallopian tube. In this situation, the ectopic pregnancy will need to be surgically removed while every effort is made to preserve the intrauterine pregnancy.
