Common Fertility Treatments
Once a diagnosis has been made, we have specific treatment plans that will overcome every cause of infertility. While there are common elements, each plan is customized to the individual patient. A vital concept to remember while undergoing treatments is to know what to expect. For example, the normal ability for a couple to conceive approximates only 20% per month. It is not as easy as most people think. Only 1 in 5 couples are pregnant per month when everything functions correctly. It takes an average of 3 to 6 months for most to conceive. Thus, if a treatment effectively overcomes the barrier causing infertility, then we typically expect only 20% to get pregnant. This is the reason why all treatments extend over a 3 to 6 month time frame. The second concept that is equally important is to know when to quit a certain treatment plan. Too many people quit too soon or extend ineffective treatments too long leading to further frustration and hopelessness. It is crucial to see a skilled physician properly trained in treating infertility for the highest rate and least cost of achieving a successful pregnancy.
Controlled Ovarian Hyperstimulation
Controlled ovarian hyperstimulation (COH) is a process in which the ovaries are stimulated by fertility medication to produce ovulatory follicle(s). Typically, a combination of oral fertility medication (clomiphine citrate) and injectible fertility hormones (follicle stimulation hormone) are used to stimulate the ovary to produce 2 mature follicles. Each mature follicle contains 1 egg that is capable of being fertilized. In women who have irregular periods and do not normally ovulate, the goal is to produce 1 mature follicle and restore normal ovulatory function. In women who have regular menses and ovulate each month, controlled ovarian hyperstimulation is used to “superovulate” women in hopes of increasing pregnancy rates by producing 2-3 mature follicles per month. With controlled ovarian hyperstimulation, the goal is to increase monthly fertility rates back to that of a 20 year old woman, approximately 20% per month. Multiple pregnancy rates account for 1-30% of these pregnancies, based on the age of the egg and the number of mature follicles obtained. The goal of controlled ovarian stimulation is to achieve a healthy singleton pregnancy. During controlled ovarian hyperstimulation, ultrasound monitoring is performed in order to safely stimulate the ovaries. Intrauterine insemination (IUI) is also recommended in conjunction with controlled ovarian hyperstimulation (COH) in couples with unexplained infertility and couples affected by mild/moderate endometriosis. The success rates of COH and IUI approximates the normal of 20% per month that is seen in fertile couples. However, the age of the woman and the fertility diagnosis can affect the success rate. If couples are not successful after 3-6 cycles of COH/IUI, a consultation is recommended to review the causes and possibly come up with a new plan.
Intrauterine insemination (IUI)
Intrauterine insemination (IUI) is a common fertility procedure in which the sperm are washed, concentrated, and placed directly into a woman’s uterus. Artificial insemination (AI) is similar, but the sperm is placed in the vagina artificially. It is performed commonly in animal husbandry. By placing the sperm into the uterus, a greater number of motile sperm have a better chance to fertilize an egg. Not only is the distance less for them to swim, but they also bypass many of the natural barriers in the vagina and the cervix. With natural intercourse, very few of the sperm make it to the upper reproductive tract because they are hindered by the cervical mucus. The process is similar to having a pap smear performed. Minimal discomfort is typically experienced with an IUI, which usually is completed within a few minutes. Intrauterine insemination is the treatment plan if there is mild male factor infertility such as decreased sperm concentrations and/or sperm motility. Intrauterine insemination is also recommended in conjunction with controlled ovarian hyperstimulation (COH) in couples with unexplained infertility and couples affected by mild/moderate endometriosis. The success rates of COH and IUI approximates the normal of 20% per month that is seen in fertile couples. However, the age of the woman and the fertility diagnosis can affect the success rate. If couples are not successful after 3-6 cycles of COH/IUI, a consultation is recommended to review the causes and possibly come up with a new plan.
The following is a example summary of an Invitro Fertilization Cycle: Step 1 – Evaluation A full evaluation confirms the need for IVF and prepares for the cycle, which includes extensive patient education and a few diagnostic tests. This preparation may take 1-2 months. Step 2 – Ovulation stimulation Beginning with the onset of a woman’s menstrual cycle, two hormonal medications are given, one to control when a woman will ovulate and the other to stimulate production eggs. These daily hormonal injections occur over 10 to 12 days. Two or three transvaginal ultrasounds are performed to assess the growth and maturity of the follicles containing the eggs. Once mature (ready to ovulate), a third hormone is given to trigger the eggs’ release (ovulation). This is usually cycle day 10 – 12. Step 3 – Oocyte retrieval One hour prior to the eggs releasing from the ovary, they are aspirated through a needle into a test tube. Anesthesia provides no pain, while the transvaginal ultrasound guides the needle into the separate follicles to aspirate the eggs. An average egg yield is about 15, but varies widely from 1 to 92. Once the patient awakes from her sleep, she only feels the sensation of ovulation. Step 4 – Laboratory The eggs are mixed or injected (ICSI) with the husband’s sperm. The lab is equipped with state-of-the-art instruments, microscopes, incubators, airflow hoods, and room filters to ensure the highest quality outcomes. Typically 60-70% of eggs retrieved will become fertilized (the same as in nature). These fertilized eggs are incubated over 3 to 5 days, until ready to enter the uterus.Step 6 – Luteal phase monitoring The patient takes progesterone daily while waiting for the pregnancy test. We typically wait 10 days after the embryo transfer to determine whether an embryo implanted. Once it takes hold, the hormone it produces is detected in the mother’s blood stream. This confirms an early pregnancy. Step 7 – Implantation Successful implantation marks the beginning of a 9-month gestation. The mother-to-be will return to her personal physician at 9 weeks gestation for prenatal care. If an embryo did not implant, the patient can use the frozen embryos or begin a new treatment cycle. Risks of Invitro Fertilization It is very rare to have a complication from your infertility medications and/or your IVF treatment cycle. However, as with most medical treatments, there are potential problems that can occur. Rarely, infection and significant bleeding can occur as a result of the egg retrieval. Ovarian hyperstimulation syndrome (OHSS) can occur whenever women use ovarian stimulation medications, especially injectable gonadotropins. This complication occurs in less than 1 percent of women who have egg retrievals with IVF. When severe, OHSS can cause severe dehydration with fluid accumulation in the abdominal and lung cavities, and blood-clotting disorders. OHSS symptoms typically last 1-2 weeks and the majority of cases resolve without treatment. Often pain medication and antinausea medication are needed to help alleviate the pain and nausea associated with OHSS. IVF cycles may be cancelled or embryo transfers may be postponed in order to prevent ovarian hyperstimulation syndrome. The risk of multiple gestations is more common in women who undergo IVF and fertility treatments. The rate of having twins is approximately 25% and the rate of high order multiples (three or more babies) is less than or equal to 2%. Our goal is to have one, healthy baby. Multiple gestation pregnancies have more risks associated with them including: premature labor, premature delivery, maternal hemorrhage, pregnancy-induced high blood pressure, cesarean section delivery, and gestational diabetes. The risks involve both the babies and the mother. The risk of ectopic (tubal) pregnancy is 1-2% with invitro fertilization.
Step 5 – Embryo transfer Three to five days after the egg retrieval, following evaluation of the quality of the developing embryos, a decision is made by the patients and the physician as to how many to transfer to the uterus. Your doctor will discuss the number of embryos to transfer that will provide the highest probability of the success of a healthy pregnancy, while still trying to minimize the probability of a high order multiple pregnancy. You will receive information on your embryos and a picture of your embryos. Usually, patients decide to transfer 1 to 3 embryos. In an atraumatic catheter, embryos are transferred through the cervix into the uterus under ultrasound guidance. The procedure is pain-free. It is often a very reverent experience to see the embryos placed into the womb. Spare embryos can be cryopreserved on this day and stored for future attempts.
Frozen Embryo Transfer
Often couples have excess embryos after an invitro fertilization (IVF) cycle that have been cryopreserved for future use. Embryo cryopreservation is a routine practice within advanced reproductive technology (ART) clinics. During a frozen embryo transfer cycle, the uterus is prepared with both estrogen and progesterone hormones to make the uterus receptive. This hormonal preparation typically takes 3-4 weeks of time. During this 3-4 week time period, both hormone levels and the uterine lining are monitored to ensure optimal uterine receptivity. Cryopreserved embryos are then thawed and transferred back into the uterus. Approximately 80% of embryos typically will survive the freeze-thaw process. Embryos are dehydrated prior to freezing to minimize ice crystal formation in the embryo which causes intracellular damage. Pregnancy testing typically occurs 8 and 10 days after the embryo transfer. If high quality embryo(s) are transferred, approximately 40% pregnancy rate is achieved per frozen embryo transfer. Embryo cryopreservation techniques and capabilities have become an increasingly important therapeutic strategy in assisted reproduction. About 20% of all offspring born worldwide from IVF cycles are from embryo cryopreservation and frozen embryo transfer procedures.
In vitro fertilization with donor eggs successfully treats women with age-related infertility, premature ovarian failure, egg factor infertility, women who are carriers of genetic diseases, and women who have had multiple failed cycles of IVF. Success rates are very high with an ovum donation cycle, often achieving 70% pregnancy rate and 60-65% take home baby rate with a fresh embryo transfer. Most commonly, there are supernumerary embryos that can also later be transferred during a frozen embryo transfer cycle (FET). A typical pregnancy rates with a frozen embryo transfer cycle is 45-50% success per transfer. Miscarriage rates and genetic risks are minimized because young, healthy eggs are fertilized. During the ovum donation cycle, the egg donor takes fertility medication to cause superovulation. Typically, egg donors will produce 15-40 eggs. With standard IVF techniques, the eggs are retrieved and fertilized with the sperm from the recipient couple. We will synchronize your uterine receptivity to the egg donor’s cycle. Egg donor IVF offers some possible advantages over adoption. The first benefit is that the egg donor recipient carries the pregnancy and, thereby, remains in control of the prenatal environment. The intended parent can be sure to get excellent prenatal care and avoid alcohol, tobacco, or illicit drug use. The second benefit is that the child is biologically related to the male partner. We also offer pre-genetic screening (PGS) on the embryos. Donors at the Idaho Center for Reproductive Medicine
Donor Egg Bank, USA (DEB USA) As a founding member of the Donor Egg Bank, USA, ICRM is excited to offer our patients a cutting edge treatment option. Donor Egg Bank, USA is a complete package of eggs and donor egg treatment afforded through network medical practices. One price includes the donor fee, the donor’s screening and cycle, and the recipient cycle with subsequent embryo transfer. Donor Egg Bank, USA is a culmination of more than 50 fertility specialist practices collaborating together to achieve success rates nearly equivalent to a fresh donor cycle. The convenience is unsurpassed. Frozen eggs are ready and available when it is convenient to the recipient to cycle. For more information and pricing, please visit the website of DEB, USA at www.donoreggbankusa.com.
ICRM has a reputable ovum donor program, with many in-house ovum donors. Because we have our own in-house ovum donor list, there is not an ovum donor agency cost if you choose one of the donors on our list. Additionally, you have the option to have a known ovum donor, such as a sister or a friend. Our ovum donor coordinators can assist you in choosing the most suitable ovum donor for you. Personalized care is given when you are going through an ovum donor cycle. Once the ovum donor has been chosen, we will meet with the ovum donor and make sure she is screened appropriately. Screening procedures include health maintenance testing, infectious disease testing, genetic testing, and psychological counseling. Both you and the ovum donor will have separate psychological evaluations and counseling to address potential psychosocial issues that may arise as a result of third party reproduction. The ovum donors sign detailed consent forms, relinquishing any rights to the eggs, embryos, and offspring.
Gestational Carrier IVF Cycle
Boise and its surrounding areas provide a “family friendly” environment. Boise has many gestational carrier agencies and available gestational carriers who are altruistic and wholesome. Because of Idaho’s lower cost of living, often gestational carrier compensations are lower than rates quoted in larger metropolitan areas. Gestational carrier cycles are ideal for women with contraindications to pregnancy, women born without a uterus or have an abnormal uterus, and for women who have had either high risk pregnancies or recurrent pregnancy loss. If you are undergoing a fertility cycle consisting of IVF with a gestational carrier, we will coordinate both your cycle and your gestational carrier’s cycle. Both you and your gestational carrier will be screened for health maintenance, infectious diseases, and have a psychological assessment with an opportunity to receive counseling. We will refer you to a lawyer who has expertise in reproductive law so that a contract can be obtained between the intended parents and the gestational carrier. The gestational carrier will also have a hydrosonogram to evaluate her uterus and make sure there are no uterine causes of diminished uterine receptivity and/or implantation. We will synchronize the uterine receptivity of the gestational carrier’s uterus to the the egg maturity in order to maximize the chance of pregnancy. The intended parent or egg donor will take birth control pills, followed by leuprolide and follicle stimulating hormone (FSH) injections. The gestational carriers will take birth control pills, followed by leuprolide and estrogen and progesterone supplementation. With standard IVF techniques, the eggs are retrieved and fertilized with the sperm from the recipient couple. The lab is equipped with state-of-the-art instruments, microscopes, incubators, airflow hoods, and room filters to ensure the highest quality outcomes. We offer pre-genetic screening (PGS) on the embryos also. Three to five days after the egg retrieval following evaluation of the quality of the developing embryos, the embryo(s) are transferred into the gestational carrier with a traumatic catheter under ultrasound guidance. Typically 1-2 embryos are transferred. Our goal is to have one, healthy baby.
Preimplantation Genetic Screening/Diagnosis (PGS/PGD)
How does PGS/PGD work? For patients who are at high risk of having offspring with chromosomal or genetic abnormalities, they may elect to undergo PGS/PGD. PGS is a way to generally screen embryos to transfer only those found genetically normal; PGD targets a specific gene or disease. This level of analysis can only be performed as part of an in vitro fertilization(IVF) cycle. When embryos are created during IVF and reach a particular stage of development (usually at the day 5 blastocyst stage), they can be biopsied. The biopsy consists of the removal of a small number of cells from the embryo so that these cells can be tested. The embryo is then frozen while testing is performed. Results are typically available in approximately one week, and the unaffected embryos are then selected to be transferred back to the uterus. What types of genetic or chromosomal testing can be done on embryos? There are currently several hundred single genes that can be tested depending on the gene of interest. Examples of such genetic mutations include cystic fibrosis and muscular dystrophy. In a normal embryo, there are 23 pairs of chromosomes, either 46XX or 46XY. As women age, the risk of having chromosomal abnormalities in the embryo increases. One of the most common abnormalities is Down’s syndrome, a condition having 47 chromosomes including an extra chromosome 21. The current technology allows us to evaluate an embryo and confirm that there is a normal number of chromosomes prior to placing it back into the uterus. Miscarriage rates are thereby lowered due to the transferring of genetically normal embryos. Is there an additional charge for PGS/PGD? Although the biopsy is performed at our center, the testing of the cells is performed elsewhere at a special laboratory. The outside laboratory does charge an additional fee for their services and this fee varies depending on the type of testing being performed.
The choice of having a boy or girl was first made possible for patients who suffer from sex-linked diseases that can harm their child. More recently, parents are choosing a certain gender to balance their families. The use of preimplantation genetic diagnosis (PGD) makes gender selection possible. Please be sure to discuss this option with your physician to learn more and see the section on PGD here.
Embryo Donation/Frozen Embryo Transfer Cycle
Often, couples have been successful with their fertility treatments and donate excess embryos to ICRM after their family is completed. Other couples suffering from infertility can adopt these embryos and undergo a frozen embryo transfer procedure. ICRM does not charge for the embryos, only the frozen embryo transfer cycle. The embryo adoption program at ICRM is an anonymous program. The embryo adoption program offers a lower cost option to couples suffering from infertility. Intended parents can review the medical history of the embryos prior to adopting them. After the intended parents have selected their desired embryos, they can proceed with a frozen embryo transfer cycle. Embryo cryopreservation is a routine practice within advanced reproductive technology (ART) clinics. During a frozen embryo transfer cycle, the uterus is prepared with both estrogen and progesterone hormones to make the uterus receptive. This hormonal preparation typically takes 3-4 weeks of time. During this 3-4 week time period, both hormone levels and the uterine lining are monitored to ensure optimal uterine receptivity. Cryopreserved embryos are then thawed and transferred back into the uterus. Approximately 80% of embryos typically will survive the freeze-thaw process. Embryos are dehydrated prior to freezing to minimize ice crystal formation in the embryo which causes intracellular damage. Pregnancy testing typically occurs 8 and 10 days after the embryo transfer. If high quality embryo(s) are transferred, approximately 40% pregnancy rate is achieved per frozen embryo transfer. Embryo cryopreservation techniques and capabilities have become an increasingly important therapeutic strategy in assisted reproduction. About 20% of all offspring born worldwide from IVF cycles are from embryo cryopreservation and frozen embryo transfer procedures.
Reproductive Surgery and Tubal Reanastomosis
Surgery can be performed to increase the likelihood of a successful pregnancy. Such surgeries are including, but not limited to, removal of fibroids, polyps, and scar tissue that involve the endometrial cavity, removing endometriosis and scar tissue in the pelvic cavity, and microscopically reconnecting fallopian tubes after tubal ligation has occurred. Laparoscopy is a minimally invasive outpatient surgery in which a laparoscope (a narrow instrument with a camera lens) is inserted into the pelvic cavity so that diagnosis and/or treatment of fertility problems can occur. Hysteroscopy is a minimally invasive, outpatient surgery, where a long narrow camera is inserted vaginally into the uterus. It does not involve an incision. Polyps, fibroids, and uterine cavity scar tissue can easily and safely be removed through the hysteroscope. Myomectomy refers to a surgical procedure in which uterine fibroids are removed from the uterus. Fibroids only need to be removed if they are causing pain, pressure, or bleeding problems. Fibroids that involve the uterine cavity and not just the uterine musculature are recommended to be removed if future fertility is desired. Tubal reanastomosis surgery involves microscopically reconnecting the fallopian tubes after they have been ligated. Women are hospitalized on average for 1 day. Over 90% of the time, 1 or 2 of the fallopian tubes can be successfully reconnected. Subsequent monthly pregnancy rates are dependent on the age of the woman. Ectopic pregnancy rate after tubal reanastomosis is approximately 4-10% of pregnancies.
Egg freezing provides the opportunity for patients to preserve their fertility until they are ready to start a family. Typically, these women are between the ages of 25 and 40. This could be for several reasons, including: – Women who have been diagnosed with cancer, prior to beginning chemotherapy or radiation treatment – Women with a family history of premature ovarian failure or early onset of menopause – Women who wish to limit the number of eggs they wish to fertilize during an IVF cycle due to ethical or religious reasons – Women who wish to delay childbearing because of personal, economic, or professional reasons Fertility in females begins to decline in their late 20s and declines increasingly rapidly after the age of 35. This decrease in fertility is also associated with increased miscarriage rates and increased rates of chromosomal abnormalities. The freezing of eggs enables female patients to pause their biological clock, whether for health or personal reasons, and preserve their eggs at an optimal point in time. When they choose to use those eggs in the future, they will be using younger eggs that can decrease the rates of miscarriage and genetic problems. Egg freezing is no longer considered to be an experimental form of assisted reproductive technology, according to the American Society of Reproductive Medicine (ASRM), and excellent pregnancy rates are being achieved at ICRM with this technology.