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ART collectively refers to procedures that have the common denominator of egg retrieval for the purpose of improving reproductive capabilities. ART has provided new options for treatment of infertility and has significantly improved the pregnancy success rate.
Typical candidates for ART include infertile patients with damaged or blocked fallopian tubes, scarred ovaries, pelvic adhesions, endometriosis, presence of anti sperm antibodies, ovulation dysfunction, low sperm count or motility, unexplained infertility, or combinations of above. With the present excellent pregnancy rates, any infertile couple that has not conceived through conventional means is considered a candidate for ART.
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Common ART procedures are:
- Gamete Intra-fallopian Transfer (GIFT): Retrieval of eggs and transfer of unfertilized eggs and sperms into the fallopian tubes by laparoscopy at the same settings.
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- Assisted Hatching (AH): Making a microscopic opening in the embryo wall to facilitate hatching of the embryo.
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Embryo Freezing (Cryopreservation).
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Blastocyst Culture: The growth of embryos continues in the lab up to 5-6 days after retrieval.
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Egg donation.
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Embryo donation.
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Gestational carrier: Someone else carries the pregnancy for the patient.
- Preconception genetic diagnosis (PGD): Biopsy of the embryo for genetic testing before transfer.
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A typical IVF cycle includes preparation, induction of superovulation, egg retrieval, sperm preparation and uterine embryo transfer (UET).
Preparation:
Previous infertility work-up and tests performed at other places such as semen analysis, hysterosalpingogram, lab tests, etc., will not be repeated unless absolutely necessary. |
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The patient is seen with partner, is examined and necessary basic lab tests are ordered.
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Assessment of sperm, uterus, tubes, hormones, ovarian reserve and others are carried out as applicable.
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The couple will attend a one-session class and consultation with nurse to go through the medications, injection teaching, time schedule of blood tests, ultrasounds, the overall cycle in general and ask any other questions they might have.
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A consultation with the doctor is set up to discuss superovulation, multiple births in relation to number of embryos to be transferred, ovarian hyperstimulation syndrome, embryo freezing (cryopreservation), pregnancy and other health issues, to answer questions and sign consent forms.
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A mock embryo transfer will be performed to prepare a cervical map for easy access on the day of the real transfer. This is a painless trial run performed in the office using a catheter with no embryos.
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Screening tests for HIV, hepatitis etc. if indicated will be conducted.
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Prescriptions will be given and the couple may be initiated on birth control pill or Lupron to maintain the reproductive system in baseline ready state.
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IVF Involves Five Steps:
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Induction of superovulation: This involves the use of injectable fertility medications in order to produce mature follicles. Other medications called GnRH agonists or antagonists are usually used along to prevent premature ovulation. Well-timed ultrasounds and blood tests are used to monitor the cycle. When follicles reach certain size an injection of Human Chorionic Gonadotropin (HCG) is given to trigger ovulation. Eggs are retrieved prior to their release.
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 Egg retrieval: This is done as outpatient with the help of an ultrasound through the vagina with a needle without the need for an incision. The patient is usually able to go home on the same day. Anesthesia or pain control and relaxing medications are used. The patient generally sleeps comfortably through the procedure. Vaginal spotting and bleeding is expected for a few days.
- Sperm preparation: Abstinence from sexual relations for about two days prior to sperm collection is required. For GIFT, sperm is collected about one hour before egg retrieval. For IVF, ZIFT, TET, and ICSI, sperm is collected after eggs are collected. The sperm is examined, washed and processed using special techniques. If the couple expects a problem with sperm collection, they should notify the doctor well ahead of time so sperm can be frozen for backup. For men who have had a vasectomy, sperm may be collected with a needle from the tubes around the testicles (percutaneous epididymal sperm aspiration or PESA) or from the testicles (testicular sperm extraction or TESE). This will eliminate the need to have a reversal of a vasectomy.
- Fertilization of eggs: For IVF, the washed sperm is added to the egg in a dish. This is called insemination of eggs. For ICSI, a single sperm is injected into each mature egg under a microscope. In either case, eggs are examined the next day to find out if fertilization has occurred.
- Uterine embryo transfer (UET) or blastocyst transfer: At 1-6 days after retrieval, fertilized eggs are injected into the uterus with the help of a thin soft tube and ultrasound guidance during a standard pelvic examination. This is painless and does not require anesthesia. Patients with large number of embryos may be candidate for blastocyst transfer. This means the embryos are cultured an extra 2-3 days in the lab. This allows the transfer of only 1 or 2 best embryos, thus reducing the risks of multiple births.
The patient will be instructed about other medications and progesterone to help with implantation and retention of pregnancy. The details will be explained and depend on the procedure that is performed. After embryo transfer the patient is advised to maintain low to normal physical activities and to refrain from strenuous activities or exercise until she is seen for follow up ultrasound and a pregnancy test in about two weeks.
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