IN VITRO FERTILIZATION
In vitro fertilization (IVF) is the joining of a woman's egg and a man's sperm in a laboratory dish. In vitro means outside the body. Fertilization means the sperm has attached to and entered the egg.
Description
Normally, an egg and sperm are fertilized inside a woman's body. If the fertilized egg attaches to the lining of the womb and continues to grow, a baby is born about 9 months later. This process is called natural or unassisted conception.
IVF is a form of assisted reproductive technology (ART). This means special medical techniques are used to help a woman become pregnant. It is most often tried when other, less expensive fertility techniques have failed.
There are five basic steps to IVF:
step 1: Stimulation, also called super ovulation
- Medicines, called fertility drugs, are given to the woman to boost egg production.
- Normally, a woman produces one egg per month. Fertility drugs tell the ovaries to produce several eggs.
- During this step, the woman will have regular transvaginal ultrasounds to examine the ovaries and blood tests to check hormone levels.
Step 2: Egg retrieval
- A minor surgery, called follicular aspiration, is done to remove the eggs from the woman's body.
- The surgery is done in the doctor's office most of the time. The woman will be given medicines so she does not feel pain during the procedure. Using ultrasound images as a guide, the health care provider inserts a thin needle through the vagina into the ovary and sacs (follicles) containing the eggs. The needle is connected to a suction device, which pulls the eggs and fluid out of each follicle, one at a time.
- The procedure is repeated for the other ovary. There may be some cramping after the procedure, but it will go away within a day.
- In rare cases, a pelvic laparoscopy may be needed to remove the eggs. If a woman does not or cannot produce any eggs, donated eggs may be used.
Step 3: Insemination and fertilization
- The man's sperm is placed together with the best quality eggs. The mixing of the sperm and egg is called insemination.
- Eggs and sperm are then stored in an environmentally controlled chamber. The sperm most often enters (fertilizes) an egg a few hours after insemination.
- If the doctor thinks the chance of fertilization is low, the sperm may be directly injected into the egg. This is called intracytoplasmic sperm injection (ICSI).
- Many fertility programs routinely do ICSI on some of the eggs, even if things appear normal.
Step 4: Embryo culture
- When the fertilized egg divides, it becomes an embryo. Laboratory staff will regularly check the embryo to make sure it is growing properly. Within about 5 days, a normal embryo has several cells that are actively dividing.
- Couples who have a high risk of passing a genetic (hereditary) disorder to a child may consider pre-implantation genetic diagnosis (PGD). The procedure is most often done 3 to 5 days after fertilization. Laboratory scientists remove a single cell or cells from each embryo and screen the material for specific genetic disorders.
- According to the American Society for Reproductive Medicine, PGD can help parents decide which embryos to implant. This decreases the chance of passing a disorder onto a child. The technique is controversial and not offered at all centers.
Step 5: Embryo transfer
- Embryos are placed into the woman's womb 3 to 5 days after egg retrieval and fertilization.
- The procedure is done in the doctor's office while the woman is awake. The doctor inserts a thin tube (catheter) containing the embryos into the woman's vagina, through the cervix, and up into the womb. If an embryo sticks to (implants) in the lining of the womb and grows, pregnancy results.
- More than one embryo may be placed into the womb at the same time, which can lead to twins, triplets, or more. The exact number of embryos transferred is a complex issue that depends on many factors, especially the woman's age.
- Unused embryos may be frozen and implanted or donated at a later date.
IVF is done to help a woman become pregnant. It is used to treat many causes of infertility, including:
- Advanced age of the woman (advanced maternal age)
- Damaged or blocked fallopian tubes (can be caused by pelvic inflammatory disease or prior reproductive surgery)
- Endometriosis
- Male factor infertility, including decreased sperm count and blockage
- Unexplained infertility
IVF involves large amounts of physical and emotional energy, time, and money. Many couples dealing with infertility suffer stress and depression.
A woman taking fertility medicines may have bloating, abdominal pain, mood swings, headaches, and other side effects. Repeated IVF injections can cause bruising.
In rare cases, fertility drugs may cause ovarian hyperstimulation syndrome (OHSS). This condition causes a buildup of fluid in the abdomen and chest. Symptoms include abdominal pain, bloating, rapid weight gain (10 pounds or 4.5 kilograms within 3 to 5 days), decreased urination despite drinking plenty of fluids, nausea, vomiting, and shortness of breath. Mild cases can be treated with bed rest. More severe cases require draining of the fluid with a needle and possibly hospitalization.
Medical studies have shown so far that fertility drugs are not linked to ovarian cancer.
Risks of egg retrieval include reactions to anesthesia, bleeding, infection, and damage to structures surrounding the ovaries, such as bowel and bladder.
There is a risk for multiple pregnancies when more than one embryo is placed into the womb. Carrying more than one baby at a time increases the risk for premature birth and low birth weight. (However, even a single baby born after IVF is at higher risk for prematurity and low birth weight.)
It is unclear whether IVF increases the risk for birth defects.
IVF is very costly. Some, but not all, states have laws that say health insurance companies must offer some type of coverage. But, many insurance plans do not cover infertility treatment. Fees for a single IVF cycle include costs for medicines, surgery, anesthesia, ultrasounds, blood tests, processing the eggs and sperm, embryo storage, and embryo transfer. The exact total of a single IVF cycle varies, but may cost from approximately $12,000 to $17,000.
After embryo transfer, the woman may be told to rest for the remainder of the day. Complete bed rest is not necessary, unless there is an increased risk for OHSS. Most women return to normal activities the next day.
Women who undergo IVF must take daily shots or pills of the hormone progesterone for 8 to 10 weeks after the embryo transfer. Progesterone is a hormone produced naturally by the ovaries that prepares the lining of the uterus (womb) so that an embryo can attach. Progesterone also helps an implanted embryo grow and become established in the uterus. A woman may continue to take progesterone for 8 to 12 weeks after becoming pregnant. Too little progesterone during the early weeks of pregnancy may lead to miscarriage.
About 12 to 14 days after the embryo transfer, the woman will return to the clinic so that a pregnancy test can be done.
Contact your provider right away if you had IVF and have:
- A fever over 100.5°F (38°C)
- Pelvic pain
- Heavy bleeding from the vagina
- Blood in the urine
Statistics vary from one clinic to another and must be looked at carefully. However, patient populations are different in each clinic, so reported pregnancy rates cannot be used as an accurate indication of one clinic being preferable to another.
- Pregnancy rates reflect the number of women who became pregnant after IVF. But not all pregnancies result in a live birth.
- Live birth rates reflect the number of women who give birth to a living child.
Outlook of live birth rates depend on certain factors such as mother age, prior live birth, and single embryo transfer during IVF. Success rates have changed over the years in part due to the increasing use of single embryo transfers. IVF clinics have encouraged single embryo transfers to reduce the risk of twin pregnancies, which have higher risk for complications than singleton pregnancies. Embryos not transferred may be frozen and saved. The cycles in which those frozen embryos are thawed and transferred are called frozen embryo transfer cycles (FET).Today, in vitro fertilization (IVF) is practically a household word. But not so long ago, it was a mysterious procedure for infertility that produced what were then known as "test-tube babies." Louise Brown, born in England in 1978, was the first such baby to be conceived outside her mother's womb.
Unlike the simpler process of artificial insemination -- in which sperm is placed in the uterus and conception happens otherwise normally -- IVF involves combining eggs and sperm outside the body in a laboratory. Once an embryo or embryos form, they are placed in the uterus. IVF is a complex and expensive procedure; only about 5% of couples with infertility seek it out. However, since its introduction in the U.S. in 1981, 1.9% of all babies in the U.S. are born through IVF and other assisted reproductive technologies (ART).
What Causes of Infertility Can IVF Treat?
When it comes to infertility, IVF may be an option if you or your partner have been diagnosed with:
- Endometriosis
- Low sperm counts
- Problems with the uterus or fallopian tubes
- Problems with ovulation
- Antibody problems that harm sperm or eggs
- The inability of sperm to penetrate or survive in the cervical mucus
- Poor egg quality
- Genetic disease of mother or father
- An unexplained fertility problemIVF is never the first step in the treatment of infertility except in cases of complete tubal blockage. Instead, it's reserved for cases in which other methods such as fertility drugs, surgery, and artificial insemination haven't worked.
If you think that IVF might make sense for you, carefully assess any treatment center before undergoing the procedure. Here are some questions to ask the staff at the fertility clinic:
- What is your pregnancy ratio per embryo transfer?
- What is your pregnancy rate for couples in our age group and with our fertility problem?
- What is the live birth rate for all couples who undergo this procedure each year at your facility?
- How many of those deliveries are twins or other multiple births?
- How much will the procedure cost, including the cost of the hormone treatments?
- How much does it cost to store embryos and how long can we store them?
- Do you participate in an egg donation program?
What Can I Expect From IVF?
The first step in IVF involves injecting hormones so you produce multiple eggs each month instead of only one.You will then be tested to determine whether you're ready for egg retrieval.
Prior to the retrieval procedure, you will be given injections of a medication that ripens the developing eggs and starts the process of ovulation. Timing is important; the eggs must be retrieved just before they emerge from the follicles in the ovaries. If the eggs are taken out too early or too late, they won't develop normally. Your doctor may do blood tests or an ultrasound to be sure the eggs are at the right stage of development before retrieving them. The IVF facility will provide you with special instructions to follow the night before and the day of the procedure. Most women are given pain medication and the choice of being mildly sedated or going under full anesthesia.
During the procedure, your doctor will locate follicles in the ovary with ultrasound and remove the eggs with a hollow needle. The procedure usually takes less than 30 minutes, but may take up to an hour.Immediately following the retrieval, your eggs will be mixed in the laboratory with your partner's sperm, which they will have donated on the same day.
While you and your partner go home, the fertilized eggs are kept in the clinic under observation to ensure optimal growth. Depending on the clinic, you may even wait up to five days until the embryo reaches a more advanced blastocyst stage.
Once the embryos are ready, you will return to the IVF facility so doctors can transfer one or more into your uterus. This procedure is quicker and easier than the retrieval of the egg. The doctor will insert a flexible tube called a catheter through your vagina and cervix and into your uterus, where the embryos will be deposited. To increase the chances of pregnancy, most IVF experts recommend transferring up to three embryos at a time. However, this means you could have a multiple pregnancy, which can increase the health risks for both you and the babies.Following the procedure, you would typically stay in bed for several hours and be discharged four to six hours later. Your doctor will probably perform a pregnancy test on you about two weeks after the embryo transfer.
In cases where the man's sperm count is extremely low or there is poor motility (movement of the sperm), doctors may combine IVF with a procedure called intracytoplasmic sperm injection. In this procedure, sperm is taken from semen -- or in some cases right from the testicles -- and inserted directly into the egg. Once a viable embryo is produced, it is transferred to the uterus using the usual IVF procedure.
What Are the Success Rates for IVF?
Success rates for IVF depend on a number of factors, including the reason for infertility, where you're having the procedure done, whether eggs are frozen or fresh, whether eggs are donated or are your own, and your age. The CDC compiles national statistics for all assisted reproductive technology procedures performed in the U.S., including IVF, GIFT, and ZIFT, although IVF is by far the most common; it accounts for 99% of the procedures.
The latest report, from 2018, shows that 50% of IVF procedures in women ages 35 and under resulted in a live birth. For women ages 42 and older, 3.9% of the egg transfers resulted in a birth.
Are There Other Issues With IVF to Consider?
Any embryos that you do not use in your first IVF attempt can be frozen for later use. This will save you money if you undergo IVF a second or third time. If you do not want your leftover embryos, you may donate them to another infertile couple, or you and your partner can ask the clinic to destroy the embryos. Both you and your partner must agree before the clinic will destroy or donate your embryos.
A woman's age is a major factor in the success of IVF for any couple. For instance, a woman under age 35 who used her own eggs had a 37.6% chance of having a singleton (one baby) using IVF in 2018, while a woman between ages 41 and 42 had an 11% chance. The success rate climbs with more egg transfers.
The CDC reports that the success rate of IVF is increasing in every age group as the techniques are refined and doctors become more experienced.
What Are The Costs of IVF?
The average cost of an IVF cycle in the U.S. costs $12,000 to $17,000, according to the National Conference of State Legislatures. This price will vary depending on where you live, the amount of medications you're required to take, the number of IVF cycles you undergo, and the amount your insurance company will pay toward the procedure. You should thoroughly investigate your insurance company's coverage of IVF and ask for a written statement of your benefits. Although some states have enacted laws requiring insurance companies to cover at least some of the costs of infertility treatment, many states haven't.
Also be aware that some carriers will pay for infertility drugs and monitoring, but not for the cost of IVF or other artificial reproductive technology. Resolve: The National Infertility Association publishes a booklet called the "Infertility Insurance Advisor," which provides tips on reviewing your insurance benefits contract.
ike all medications and medical procedures, IVF has some risks and possible side effects. These include:
bloating
cramping
breast tenderness
mood swings
headaches
bruising from shots
allergic reaction to medicines
bleeding
infection
Your doctor can talk with you about any questions or concerns you have about IVF risks and side effects.
IVF can also be difficult emotionally, both for the person having the procedures and for their partner and/or family. Many people doing IVF treatments struggle with depression and anxiety throughout the process.
Talking with people who’ve been through fertility struggles and IVF can be really helpful if you’re feeling overwhelmed or discouraged. Online and in-person communities are also good places to meet people who understand what you’re going through and can offer advice and support. Counselors and therapists can also be sources of comfort.
You can find more information on support groups and coping with the stress of fertility treatments at RESOLVE: The National Infertility Association. Your doctor, fertility specialist, or local Planned Parenthood health center may also be able to offer you other resources and tips on finding therapists or support groups in your area.
