IVF

The Assisted Reproductive Technologies (ART) is a group of treatment options used for couples with infertility that cannot be treated using simpler methods. These procedures have excellent success rates but require significant effort and might be expensive. For all of those reasons, advanced treatment options of infertility can be stressful, but worthful. This natural stress can be minimized if you understand the nuances of the various procedures. I encourage you to learn more, to watch and read additional educational sources listed in the web site and to freely ask any question. Understanding the purpose of each procedure will help you obtain the appropriate treatment and maximize your chance of success. The unknown is always stressful. Knowing what is awaiting you, will minimize the stress. 

There are a number of different types of treatments belonging to the ART methods. The main treatment of infertility is In Vitro Fertilization or IVF. 

While every clinic's protocol will be slightly different and treatments are adjusted for individual needs, here is a summary of what generally takes place during an IVF treatment cycle.

Conventional IVF:

Conventional or traditional IVF is frequently used in cases such as blocked fallopian tubes or unexplained infertility. The embryologist isolates the healthy sperm which are then exposed to each egg inside the embryology laboratory where fertilization occurs naturally. In conventional IVF, 50,000 or more swimming sperm are placed next to the egg in a laboratory dish. Fertilization occurs when one of the sperm enters into the cytoplasm of the egg. There is one main condition for conventional IVF to work is that the sperm has to have a normal count and normal motility and normal morphology and they have to be able to penetrate the egg by themselves.

Intra-cytoplasmic Sperm Injection (ICSI):

The procedure of ICSI is the part of IVF where egg fertilization by the partner's sperm takes place in the IVF Laboratory. The embryologist selects a single best looking healthy sperm and injects it directly into the center of each egg. The ICSI technique is used to fertilize mature eggs with the best looking sperm. Under the microscope, the embryologist picks up a single sperm, the best looking one and injects it directly into the cytoplasm of the egg using a small glass needle called a micropipette.

ICSI is used in cases when the quantity or quality of sperm is poor and therefore unable to effectively penetrate the egg on its own. Since fertilization only requires one healthy sperm, ICSI has become one of the most incredible advances in treating severe male factor infertility.

ICSI allows even couples with very low sperm counts or poor quality sperm to achieve high fertilization and pregnancy rates.

It is also recommended for couples who have not achieved fertilization in prior IVF attempts.

Usually in the traditional way, before a man’s sperm can fertilize a woman’s egg, the head of the sperm must attach to the outside of the egg. Once attached, the sperm pushes through the outer layer to the inside of the egg (cytoplasm), where fertilization takes place.

Sometimes the sperm cannot penetrate the outer layer, for a variety of reasons. The egg’s outer layer may be thick or hard to penetrate or the sperm may be unable to swim. In these cases intra-cytoplasmic sperm injection (ICSI) can be done along with in vitro fertilization (IVF) to help fertilize the egg.

Who needs ICSI?

ICSI helps to overcome fertility problems, such as:

1. The male partner produces too few sperm to do artificial insemination (intrauterine insemination IUI) or conventional IVF.
2. The sperm does not move in a normal way.
3. The sperm may have trouble attaching to the egg.
4. A blockage in the male reproductive tract that may keep sperm from getting out.
5. Eggs were not fertilized by traditional IVF, even if the sperm is in good condition.
6. In vitro matured (IVM) eggs are being used.
7. Frozen eggs are being used.

IVF indications or when to use IVF?

In case of problems of the Fallopian tubes, especially if they are blocked, IVF is the 1st line of treatment to bypass the tubes. IVF is also the 1st line of treatment to avoid hereditary and genetic problems or in case of family planning for sex selection by using PGD + IVF or in case of female age factor (advanced age) or in case of egg donation. In other cases, IVF is recommended if simpler treatments fail.

Indications for IVF treatment:

1) Fallopian Tube Damage/Tubal Factor:

The fallopian tubes might get damaged or blocked after some pelvic infections or after previous abdominal surgeries such as C - sections for example. The only option for treating significant tubal damage, especially if both tubes are blocked is by bypassing the tubes with IVF. This decision must be carefully individualized in each situation.

The Fallopian tubes might be damaged and filled by a liquid. This is called a hydrosalpinx. In case of hydrosalpinx of the tubes, it is advised to remove or close the damaged tubes by Laparoscopy before doing an IVF procedure to increase the success rate.

2) Male Factor Infertility:

IVF is used in case of a decreased sperm count or sperm motility or sperm morphology using Intra Cytoplasmic Sperm Injection (ICSI). One of the most advances in the treatment of infertility has been to obtain fertilization and pregnancy in the IVF lab with severely abnormal sperm samples by using IVF + ICSI (Intra Cytoplasmic Sperm Injection). ICSI is recommended if there is any suggestion of a sperm problem. If sperm are obtained surgically in case of obstructive Azoospermia, or if there has been a prior failure of fertilization, ICSI is used.

3) Endometriosis:

Endometriosis may be treated by a combination of surgical and medical therapy. But it’s better to stay away from surgery or to postpone the surgery to treat endometriosis as it damages the ovarian reserve and leads to a decrease in the ovarian reserve, which makes the chances of pregnancy more difficult. It is advised to use surgery to treat endometriosis only after having had children, then the reserve will not matter anymore if damaged. IVF is considered a very effective and successful treatment of infertility caused by the endometriosis.

4) Female age related Infertility:

In normal reproductive life, a woman's ovarian function is decreased with age. As a woman grows older, especially after the age of 35, her ovarian reserve and egg quality decreases, making the chances of a successful pregnancy more difficult and increases the number of miscarriages. Age is the biggest factor affecting a woman's chance to conceive and have a healthy baby. A Woman's fertility starts to decline in her early 30s, with the decline speed increasing after the age of 35. In many cases, this reduced function of the eggs can be overcome through the use of IVF alone or in conjunction with techniques such as Assisted Hatching and ICSI.

Fertility preservation by freezing their own eggs until later use is also a perfect solution for women to keep the conceiving abilities as the woman gets older. After freezing her eggs, a woman can use them later using IVF. The quality of the frozen eggs depends on the age of the woman at the time when it was done.

IVF + Egg donation might also be a solution for women above 40 years old or for those who have premature ovarian failure before the age of 40.

5) Anovulation / Irregular menstrual cycle:

The majority of patients with anovulation will get pregnant using simpler treatments. However, those patients requiring IVF are typically "high responders" to gonadotropin therapy and have a good prognosis, because they usually have good ovarian reserve especially those suffering from polycystic ovaries (PCO).

6) Unexplained Infertility:

Approximately 20% of couples will have no known cause of infertility after completing a fertility evaluation. IVF is often successful even if more conservative treatments have failed, especially that some of those couples have some block to fertilization.

7) Pre-implantation Genetic Diagnosis (PGD) or Pre-implantation Genetic Testing (PGT) or PGS:

PGT or PGD technology reduces the potential for adverse pregnancy outcomes for couples ‘at risk’ by testing the embryos for certain genetic abnormalities before they are chosen for transfer. 

Genetic testing or diagnosis on pre-implantation embryos may be indicated for patients who are at risk for genetic disorders such as Thalassemia and for patients with infertility related to chromosomal abnormalities such as recurrent pregnancy loss or repeated unsuccessful IVF or for gender (sex) selection (to choose boys or girls). 

Pre-implantation genetic testing (PGT) or PGD is a procedure used in conjunction with in vitro fertilization (IVF) to select embryos free of chromosomal abnormalities and specific genetic disorders before transfer to the uterus. PGT improves the likelihood of a successful pregnancy and birth for two distinctly different groups of patients; couples with infertility related to recurrent miscarriage or unsuccessful IVF cycles and couples who are at risk for passing on an inherited genetic disease to their offspring.

Pre-implantation genetic testing may be recommended by your physician when there is a possibility, indicated by your medical history or advanced maternal age, which could affect your embryos by a genetic disease. PGD can only be performed during an IVF cycle where eggs and sperm, united in the laboratory, then develop into embryos. On the 3^rd day or 5^th day a biopsy is done on each embryo to make a chromosomal study and after the testing results on day 5, only the normal embryos would be selected for embryo transfer, reducing the possibility of miscarriage or birth defects.

We can also use PGD for gender selection. We choose the required embryos upon their sex, boys or girls before doing the embryo transfer for family planning. We can freeze the healthy embryos that were not chosen for the transfer.

8) Gender or sex selection / Family planning:

IVF + Pre-implantation genetic diagnosis (PGD) is an excellent tool to choose the sex of the embryo before uterine embryo transfer. 3 or 5 days after fertilization in the IVF lab a cell biopsy is done from each embryo using laser and under a special microscope. It is 99% precise in detecting the gender of the embryo. After the embryo biopsy, a chromosome study will be done on the Y and X chromosomes to determine the exact sex, a boy or a girl. 

The women will start on the 2nd or 3rd day of the period injections for about 8 - 12 days before making the egg retrieval and fertilization. The embryo transfer of the desired embryos depending on their sex will be done on day 5 after the fertilization. The embryos that were not transferred could be frozen for later use or if not frozen they will stop growing on day 5 - 7 because the embryos cannot live in the culture media of the IVF Lab more than that.

9) Cancer patients and IVF:

All young cancer patients willing to have children in the future have to freeze their eggs in case of women or their sperm in case of men before starting any cancer treatment.

Frozen eggs or frozen sperm procedures are done before starting cancer treatments to preserve female and male fertility after recovery from cancer. The frozen eggs and frozen sperm are used later by their owners to have children using IVF.

10) Egg donation:

Egg donation is the best solution for women after the age of 40 or in case of premature ovarian failure before 40 years.

We use donated eggs from young and healthy donors instead of using a woman's old eggs. In the IVF laboratory, healthy and young donated eggs (donors 18-27 years old) are fertilized with the husband's sperm. Then, on day 3 or day 5 after fertilization the embryos are transferred into his wife's uterus. Pregnancy success rate of egg donation is at least 70%. Once the woman gets pregnant from donor eggs, her pregnancy continues normal development as any other normal pregnancy.

IVF Treatment Step One: The Menstrual Cycle Before Starting The Treatment

Sometimes birth control pills are prescribed to regulate the cycle for time management and to prevent ovarian cyst formation before the IVF treatment begins.

During the menstrual period before your IVF treatment is scheduled to start, you may be put on birth control pills. This may seem awkward – because you’re trying to get pregnant. Using birth control pills before starting a treatment IVF cycle has been shown to decrease your risk of Ovarian Hyper Stimulation Syndrome and ovarian cysts.

In case you rarely get menstrual cycle on your own, or if your cycle is irregular, progesterone is given, to make your period come before starting.

The doctor might ask you to take an injection about 4 – 5 days before taking the last birth control pill, depending on the protocol of ovarian stimulation he’ll use later. Always follow the doctor's instructions.

IVF Treatment Step Two: When You Get Your Period

The first official starting day of your treatment cycle is the day you get your period. Spotting is not considered day one of the period. On the second day of your period, the doctor will likely order blood exams and a vaginal ultrasound. (A vaginal ultrasound during your period isn't exactly pleasant, but it’s necessary). This is referred to as your baseline blood exam and your baseline ultrasound.

The ultrasound is to check the size of your ovaries, and count how many small follicles you have, and look for ovarian cysts. If there are cysts, the doctor may just postpone the treatment to the next menstrual period, as most cysts will resolve by their own with time or by taking birth control pills. In some cases, your doctor may aspirate the cyst with a needle before starting the treatment to stimulate the ovaries. The doctor will check also the thickness or the lining of the endometrium to evaluate its receptivity and ability for embryo implantation. If everything looks good, treatment moves on to the next step.

IVF Treatment Step Three: Ovarian Stimulation and Ultrasound Monitoring

The next step is ovarian stimulation with fertility drugs. Depending on your treatment protocol, hormone injections either IM (intramuscular) or subcutaneous for approximately 8 – 12 days to stimulate multiple egg production rather than the single egg normally produced by the female body each month. This ovary stimulation process needs daily gonadotropin injections to stimulate the development of the eggs and requires injections to suppress the ovaries to prevent ovulation before the desired time. The staff of our clinic will teach you how to make the injections before your treatment begins.

During the ovarian stimulation, the patient has to visit our clinic several (3 - 4) times before the egg retrieval because the physician will monitor the growth and development of the follicles by vaginal ultrasound. This will include blood tests to measure Estradiol, LH, and progesterone levels and vaginal ultrasounds, to monitor the egg growth and size. Monitoring the cycle is important, as it helps the doctor decide whether or not the medications need to be increased or decreased in dosage. Once your largest follicle is 16 to 18 mm in size, the doctor will start a new phase.

IVF Treatment Step Four: Final Egg Maturation

The next step in your IVF treatment is triggering the eggs to go through the last stage of maturation, before they can be retrieved. This last growth is triggered with human chorionic gonadotropin (Hcg). Timing of this shot is critical. If it's given too early, the eggs will not be mature enough. If given too late, the eggs may be empty, because they already ovulated. The daily ultrasounds at the end of the last step are meant to time this trigger shot just right. Usually, the Hcg injection is given when 3 or more follicles have reached 17 to 20 mm in size and your estradiol levels are not less than 1,000 pg/ML.

The timing of the trigger shot will be based both on your ultrasounds and blood tests and when the doctor schedules your egg retrieval at the clinic. The egg retrieval takes place approximately 35 - 37 hours after the trigger shot is done.

If the doctor concludes that you're at risk of ovarian hyper stimulation syndrome, he might recommend you to freeze all the embryos without making an embryo transfer this cycle. The frozen embryo transfer might be done next cycle.

And if the treatment is cancelled because your ovaries didn't respond well to medications, the doctor may recommend different medications to be tried on the next cycle.

Because of the risk of Ovarian Hyper Stimulation, if you experience unusual cramping + difficulty in breathing, be sure to contact your doctor right away.

IVF Treatment Step Five: Egg Retrieval

You have to stop eating or drinking anything 7 - 8 hours before the egg retrieval procedure. Even smoking and chewing gums are not allowed during this period of fasting. This means that you have to make an overnight fasting before coming to the IVF center for the procedure.

The egg retrieval is done under a quick anesthesia (light sedation) in the operation room of an IVF clinic. Usually, a light sedative is used, which will make you "sleep" through the procedure. This isn't the same as general anesthesia, which is used during surgery. Side effects and complications are less common.

The egg retrieval will take place about 34 - 37 hours after doing the trigger shot. It's normal to be nervous about the procedure, but all women go through it without any trouble or pain.

The doctor will use a trans-vaginal ultrasound to guide a needle which is fixed alongside the vaginal probe through the back wall of your vagina, up to your ovaries. He will then use the needle to aspirate the follicular fluid gently from the follicles into the needle to a tube. There is one egg in each follicle. Not every follicle contains an egg. The follicles might be empty or containing non mature eggs. Only the mature eggs are injected by the sperm to be fertilized. All the aspirated follicles will be transferred to the embryology lab to search for the mature eggs for fertilization.

The number of eggs retrieved varies but can usually be estimated before retrieval via ultrasound. The average number of eggs is 5 - 15.

After the egg retrieval procedure, you'll be kept for a few hours in a private room in the clinic to make sure all is well. Light spotting is common, as well as low abdominal cramping, but most women feel better on the next day after the procedure. You'll also be told to watch for signs of ovarian hyper-stimulation syndrome, a side effect from fertility drug use during IVF such as unusual cramping + difficulty in breathing.

Instructions after egg retrieval in IVF:

The process of egg retrieval is done through the vagina using a vaginal ultrasound, under light anesthesia, during about 15 minutes.

1- You stay at the center for about 2 hours after the egg retrieval procedure.

2 - It is normal to feel some abdominal cramps after the operation.

3 - You can start eating food or drinking water 4 hours after the end of the egg retrieval process.

4 - Use any pain killer medicine about 4 hours after leaving the center.

5 - You may see some blood from the vagina for a few days after the procedure. If the bleeding is severe after leaving the center or during the next day, contact the center or the doctor.

6 - Start taking the treatment as prescribed by your doctor.

7 - Do not put the vaginal progesterone suppositories on the morning of embryo transfer.

8 - Your doctor tells you the expected day of embryo transfer.

9 - If you feel severe pain, difficulty in breathing, difficulty in urinating, nausea and vomiting, call the center or the doctor immediately.

10 - On the day of embryo transfer:

 # Do not put perfumes or oils.

 # You should shower well before coming to the center.

 # You should arrive 30 minutes before the scheduled time of embryo transfer.

 # You have to drink 5 - 6 large cups of water 1hour before reaching the center so that the bladder will be full before the procedure. This allows us to see clearly using an abdominal ultrasound that will guide us during the embryo transfer.

 # You can have light breakfast before the embryo transfer procedure.

IVF Treatment Step Six: Egg Fertilization

While you’ll be recovering from the retrieval, the follicles that were aspirated will be searched for oocytes, or eggs. Not every follicle will contain an oocyte.

Once the oocytes are found, they'll be evaluated by the embryologists and places in an incubator. If the eggs are overly mature, fertilization may not be successful. If they are not mature enough, the embryology lab may be able to stimulate them to maturity in the lab.

The eggs will be at different stages of maturity. Not all the stages are good for fertilization:

The eggs are classified into: M2 (Metaphase 2), M1 (Metaphase 1), GV (Germinal Vesicle). The M1 can be developed to M2 in the lab. Also the GV oocytes can undergo IVM (In Vitro Maturation) in the lab. Only the M2 eggs can be fertilized.

The eggs are fertilized with sperm later that day either by conventional insemination or by Intra-cytoplasmic Sperm Injection (ICSI). When the sperm has a very low normal morphology, Intra-cytoplasmic morphologically selected sperm injection (IMSI) might be used. The ICSI technique is used to fertilize mature eggs with the best looking sperm.

During conventional insemination approximately 50,000 sperm are placed with each egg in a culture dish and left together overnight to undergo the fertilization process.

ICSI allows even couples with very low sperm counts or poor quality sperm to achieve fertilization and pregnancy rates equal to traditional IVF. It is also recommended for couples who have not achieved fertilization in prior IVF attempts.

Sperm collection for the fertilization: The male partner enters a special room in the IVF center to give a fresh sperm sample by ejaculating in a sterile cup on the same day of egg retrieval. Or we can use previously frozen sperm samples if available.

In case the male partner doesn't have sperm in his ejaculate or in case he cannot have erection, a surgical sperm collection will be attempted at the IVF clinic operating room.

Surgical sperm collection procedures: (TESA, TESE, PESA, and MESA) are available for the cases where it is difficult to obtain sperm or for men with no sperm in the ejaculate.

The eggs will be checked the following day after fertilization to document fertilization and to evaluate early cell division. They are now called embryos and are placed in a solution called media to promote growth. The embryos are then placed in incubators in the IVF Lab. Until recently, embryos were cultured for three days and then transferred to the uterus and/or cryopreserved (frozen). We now have the ability to grow the embryos for five to six days until they reach the blastocyst stage. On day two or three after fertilization, the embryos will be evaluated for the possibility of a blastocyst culture. If there is a sufficient number of dividing embryos they will be placed in special blastocyst media and grown for two or three additional days to reach the blastocyst stage.

There are two ways that fertilization can occur:

1-     Conventional Fertilization: Is frequently used in cases such as blocked fallopian tubes or unexplained infertility. The embryologist isolates the healthy sperm which are then exposed to each egg inside the embryology laboratory where fertilization occurs naturally. In traditional IVF, 50,000 or more swimming sperm are placed next to the egg in a laboratory dish. Fertilization occurs when one of the sperm enters into the cytoplasm of the egg. There is one main condition for conventional IVF to work is that the sperm has to have a normal count and normal motility and normal morphology and they have to be able to penetrate the egg by themselves.

2-     Intra-cytoplasmic Sperm Injection (ICSI): The embryologist selects a single best looking healthy sperm and injects it directly into the center of each egg. The ICSI technique is used to fertilize mature eggs with the best looking sperm. Under the microscope, the embryologist picks up a single sperm, the best looking one and injects it directly into the cytoplasm of the egg using a small glass needle called a micropipette.

ICSI is used in cases when the quantity or quality of sperm is poor and therefore unable to effectively penetrate the egg on its own. Since fertilization only requires one healthy sperm, ICSI has become one of the most incredible advances in treating severe male factor infertility.

ICSI allows even couples with very low sperm counts or poor quality sperm to achieve high fertilization and pregnancy rates.

It is also recommended for couples who have not achieved fertilization in prior IVF attempts.

Usually in the traditional way, before a man’s sperm can fertilize a woman’s egg, the head of the sperm must attach to the outside of the egg. Once attached, the sperm pushes through the outer layer to the inside of the egg (cytoplasm), where fertilization takes place.

Sometimes the sperm cannot penetrate the outer layer, for a variety of reasons. The egg’s outer layer may be thick or hard to penetrate or the sperm may be unable to swim. In these cases intra-cytoplasmic sperm injection (ICSI) can be done along with in vitro fertilization (IVF) to help fertilize the egg.

Who needs ICSI?

ICSI helps to overcome fertility problems, such as:

              1-  The male partner produces too few sperm to do artificial insemination (intrauterine insemination IUI) or conventional IVF.

2-  The sperm does not move in a normal way.

3-  The sperm may have trouble attaching to the egg.

4-  A blockage in the male reproductive tract that may keep sperm from getting out.

5-  Eggs were not fertilized by traditional IVF, even if the sperm is in good condition.

6-  In vitro matured (IVM) eggs are being used.

7-  Frozen eggs are being used.

The decision about which method to use is based on the quality of the sperm. Sperm analysis is completed as part of the initial basic fertility work-up for diagnosis before the treatment and again when the semen sample is provided on the day of the egg retrieval. If the results from this analysis do not meet the parameters required for conventional fertilization, the embryologist will make the decision to switch to ICSI so that the cycle can still produce embryos and increase your chances of success. The clinical team will let you know if an unplanned ICSI procedure is recommended.

Once fertilization occurs, the embryos begin to develop. Every morning for the next 3 to 6 days, an embryologist examines the developing embryos and adds notes in your record regarding each individual embryo. A daily follow-up concerning your fertilization will take place updating you on the status of each growing embryo and the recommendations for either a day 3 or a day 5 embryo transfer.

IVF Treatment Step Seven: Embryo Transfer

 Embryos may be transferred on day 2, 3, 5, or 6 after egg retrieval and fertilization. Transfers on day 5 or 6 are called Blastocyst Transfers. The procedure of intra-uterine embryo transfer is usually done without anesthesia. A speculum is inserted in the vagina to visualize the cervix. The doctor cleans the cervix from mucus and remaining suppositories then prepares the path through the cervix by using a small, soft catheter which is inserted inside the cervix into the cavity of the uterus. The embryologist gives the embryos to the doctor in a special long thin and soft catheter that will be inserted inside the path previously prepared to reach the uterine cavity. Then the doctor softly and with high precision injects the embryos inside the cavity. Through the catheter, the doctor will transfer the embryos, along with a small amount of fluid. This procedure is not painful at all. You may experience very light cramping but nothing more. The number of embryos transferred will depend on the quality and quantity of the embryos and on the age of the woman and on the previous discussion with the doctor.

After the embryo transfer, you'll stay lying down for a couple hours at the clinic and then go home.

If there are "extra" high-quality embryos left over, you may be able to freeze them. This is called "embryo cryopreservation." They can be used later if this cycle isn't successful.

You’ll need bed rest at home for 3 days after the embryo transfer.

An important variable that is often overlooked is the embryo transfer technique. A smooth transfer with no trauma to the endometrial lining is essential to give the embryos the best chance for implantation and continuation of normal development.

Most IVF clinics "grade" each embryo using one of many scoring systems. Unfortunately, there is no agreement at all as to which system to use.

Patients often ask whether embryos that were given a "low grade" by the embryologist would result in a problem with the baby. As far as we know, the children born from low grade embryos are just as cute, intelligent, strong, etc. as those born from high grade embryos. The only difference seems to be with the chance for the embryo(s) to result in a pregnancy.

Embryo quality, to a great extent, is determined by the quality of the egg from which it started. If we could improve the quality of the eggs that we start with in IVF, we would have a better chance of having a successful outcome. However, for the most part egg quality is predetermined and "we get what she gives".

Most of the egg quality is determined by the chromosomal and genetic competence of the individual egg. There is no treatment that can fix chromosomal or genetic defects - so we do our best with the eggs that we retrieve.

By getting numerous eggs, we have a better chance of having one or more with "high egg quality" - in other words, an egg that is fully competent and capable of fertilizing, developing normally, implanting and going on to become a healthy baby.

Blastocyst culture and transfer is an important technique developed for in vitro fertilization (IVF) that maximizes pregnancy success rates while minimizing the risk of multiple pregnancies. The ability to grow embryos for five or six days to the blastocyst stage of development in the laboratory, rather than the traditional three days, allows to determine, with greater certainty, which embryos are really the "best" for implantation.

Blastocyst culture and transfer:

Culture media now are designed to take into account the myriad and changing needs of the developing embryo in vitro inside an incubator in the IVF Lab.

After five days of growth, the cells of the embryo should have divided many times over, and have begun to differentiate by function. The embryos that survive to this stage of development are more likely to be strong, healthy, and robust. They are now called blastocysts.

Are there benefits of blastocyst transfer with IVF?

Let's use an example. Historically, if a woman has 15 eggs retrieved, an average of 10 eggs will fertilize by day one of observation. It is impossible to determine at this point which of these 10 are most likely to implant and develop into a baby. Perhaps all will, but perhaps not. On the traditional day of embryo transfer (day three), 5 of the 10 embryos may be developing into vibrant, growing embryos. The others may have slowed or stopped their development altogether as naturally many eggs and embryos are abnormal.

In this example, we are left with several embryos that still look like they may have excellent potential. Which ones to transfer? Which ones are really the "best"? Two additional days in the blastocyst culture medium allows the natural winnowing process to continue. Thus, after 5 or 6 days of growth in the laboratory, only 2 or 3 of the original ten embryos may remain viable, showing their inherent potential. We now know the best embryo(s) to transfer.

Embryos transferred at the blastocyst stage have made it through key growth processes and typically offer a greater chance of implanting. Without compromising pregnancy rates, we need to return only 1 or 2 blastocysts to the mother instead of the typical 2 or 3 early embryos. In addition, the fewer embryos transferred the more may be available for cryopreservation for future use.

A significant benefit of blastocyst culture and transfer is the reduction of multiple births that can result from in vitro fertilization. This means that the many obstetrical complications that may arise from multiple pregnancies can be minimized. It is especially important in helping patients avoid having to make the difficult personal and ethical decisions regarding selective embryo reduction.

Is IVF with blastocyst transfer right for everyone?

No, blastocyst transfer is not good for everyone. Patients having few oocytes retrieved, fewer fertilized or fewer dividing embryos by day three in culture have no advantage using blastocyst culture, since little is to be gained in further embryo "self-selection".

Unfortunately the new blastocyst culture media does not improve the health or viability of an individual embryo which is not otherwise able to sustain five days of growth and then implant; rather it allows embryos capable of sustained growth to continue in culture and reach their maximum inherent capability.

However, a large proportion of patients with fewer eggs and/or fewer embryos do very well with a transfer day 3 when we can recommend to them which embryos for transfer earlier. Many patients undergoing Day 3 embryo transfer still have very good pregnancy success rates.

Be sure that whether day 3 or day 5 or 6 transfer is recommended for you, it is a decision made by the experienced and expert clinical and laboratory teams aligned to give you the best individualized advice for a safe and successful outcome.

Patient instructions after the embryo transfer during IVF

1) After embryo transfer you will need 72 hours, or 3 days of bed rest.

2) Continue taking all medications prescribed for you after the egg retrieval at least until the result of the pregnancy test after 14 days.

3) Make a blood pregnancy test two weeks after the embryo transfer and inform the result to the doctor.

4) In case you are an international patient, you can travel back home 3 days after the embryo transfer.

5) No intercourse until you’ll get the pregnancy result 2 weeks later.

6) It is normal to feel some abdominal cramps.

7) You can feel some liquid secretions due to washing the cervix during the embryo transfer. And you might see some blood spotting in the following days. Don't be afraid. This is normal.

8) Avoid smoking, alcohol, raw meat, and unwashed fruits and vegetables until you know the pregnancy result.

9) Contact your doctor if you feel nausea, swollen abdomen, and difficulty in breathing.

10) If the blood pregnancy test is positive, you have to continue the same treatment that the doctor prescribed after the egg retrieval and after the embryo transfer for 55 days. You do also a 1st vaginal ultrasound after about 7-10 days to determine how many gestational sacs are present and to confirm if the pregnancy is inside the uterus.

11) It is only allowed to use an ammonium-free hair dye until the pregnancy result is known.

12) If the blood pregnancy test is negative, you should stop all the treatments prescribed for you and wait for the menstrual period to come within 10 days. Then go to the doctor to explain to you your options in order to improve the result and get a pregnancy in the next attempt.

IVF Treatment Step Eight: Luteal Support

Progesterone support and two weeks of waiting for the result of the blood pregnancy test beta Hcg to know if you’re pregnant or not.

On the 1^st day or the next day after your egg retrieval, and before the embryo transfer, you'll start taking progesterone supplements. Usually, the progesterone during IVF treatment is given as intramuscular or subcutaneous injections or tablets, or vaginal gel or vaginal suppositories or rectal suppositories or a combination.

Two weeks after the embryo transfer you have to do a blood test for pregnancy. If you are pregnant, we will follow your progress with blood work and ultrasounds. And you will be advised to continue most of the treatment for 55 more days. The vitamins and anticoagulants have to be taken at least until delivery.

It takes about two weeks from the time an embryo implants in the uterine wall to start emitting enough of the hormone Hcg (human chorionic gonadotropin) to be detected by a blood test. This period of time is referred to as the two week wait. The blood test - officially called a beta Hcg blood test– detecting the Hcg is the most accurate indication of pregnancy.

In case of a positive Beta Hcg pregnancy test, you have to visit a gynecologist to make a vaginal ultrasound 7 - 10 days later to be sure that the pregnancy is inside the uterus and to see how many intra gestational sacs are found to exclude multiple pregnancy in cases where more than 1 embryo were transferred.

In case it's a multiple pregnancy (3 or more babies), the doctor may discuss the option of reducing the number of fetuses in a procedure called a "multifetal pregnancy reduction." This is done to increase the chances of having a healthy and successful pregnancy.

If the IVF Treatment Fails

If the pregnancy test is negative 12 to 14 days post-transfer, you have to stop taking the progesterone, and book an appointment with the doctor to discuss why the IVF failed and how to improve the outcome of a possible next IVF, and you'll wait for your period to start. The next step will be decided among you, your partner and the doctor.

Don’t surrender. Don’t lose hope.

The failure of a treatment cycle is never easy. It's heartbreaking. It's important, however, to keep in mind that having one cycle fail doesn't mean you won't be successful if you try again.