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In Vitro Fertilization (IVF) Process

In Vitro Fertilization And Uterine Embryo Transfer To A Surrogate Mother (IVF/UET)

IVF/UET is a widely accepted assisted reproductive treatment for infertile couples worldwide. This technique has been utilized since its inception in the late 70's. In the United States of America, IVF/UET began in early 1980 and it has been well received within the medical community and with infertile couples. In the mid 1980's, the dimension of a third party (Surrogate Mother) was added for those couples who could produce embryos through IVF, but the wife could not carry the pregnancy.

The criteria for consideration for IVF/UET is based on the woman's reproductive ability, her general health, history of medical problems and the husband's reproductive abilities, as well.

As you may anticipate, this procedure is physically and emotionally demanding as well as very expensive. In view of these complexities, here is the general background of the procedures.

The process is divided into 5 steps:

1. Follicle Development
2. Oocyte (Egg) Collection
3. Oocyte Culture and In Vitro Fertilization
4. Uterine Embryo Transfer to Intended Mother
5. Luteal Phase Monitoring and Support

• Steps 1 & 2 are completed by the Natural Mother
• Step 3 occurs in the medical laboratory
• Steps 4 & 5 are completed by the Surrogate Mother

Step 1: Follicle Development

IVF can be accomplished by using the natural mother's cycle without the use of fertility drugs, however the disadvantages in terms of the number of eggs retrieved, fertilized, transferred and frozen are great. Therefore, most commonly, the IVF process includes the use of fertility drugs. The physician's office will supply a list of the fertility drugs and the possible side effects at the screening appointment.

There are certain medications that are utilized to induce several follicles to develop. The monitoring of the follicle development is usually accomplished by:

1. Ultrasound - to actually view the follicle growth
2. Blood and/or Urine Tests - determine level of estrogen, progesterone, LH
3. Treatment cycle data

The ultrasound equipment, like a radar, sends out a very high frequency sound wave that reflects off the pelvic structures and return back to the equipment. These echoes are instantly transformed by a computer and an image is projected. The video images are visualized in different intensities of grays; outlining the actual female anatomy.

The ultrasound procedure is usually done with the use of a trans-vaginal probe. The bladder does not need to be full and, in addition, there are several studies that have shown that the ultrasound procedure is not harmful to the egg within the developing follicle or even to an early pregnancy.

Although the ultrasound gives a profile of the follicle development, the blood and/or urine tests assist further in determining the maturing level. Several office visits are necessary to monitor the progressive follicle growth. The physician evaluates the data from each visit to determine the appropriate time to administer the medication to trigger the final stages of ovulation.

Step 2: Egg Collection

The egg retrieval is done by a trans-vaginal ultrasound aspiration and is usually performed under mild anesthesia. This procedure is an ultrasound guided technique whereby a long, thin needle is passed through the vagina into the ovarian follicle and suction is applied to retrieve the egg.

Step 3: Egg Culture and In Vitro Fertilization

Once the eggs are retrieved, they are examined in the laboratory and each one is graded for maturity. The maturity of an egg determines when the processed sperm will be added to it. The processed sperm is placed together with each retrieved egg in a separate laboratory dish to allow the fertilization process to occur. The dishes are placed in an incubator set at the same temperature as the woman's body.

After a period of time, the eggs are examined under a microscope for the first signs of fertilization. When the embryos have reached the expected stage of development, any embryos in excess of the number agreed upon for the embryo transfer, are frozen for future use. The Natural Mother will receive written instructions of care and notice of when she may resume her normal activities. The recovery period is generally very short.

Step 4: Uterine Embryo Transfer to Intended Mother

The Surrogate Mother is seen several times during the treatment cycle for the purpose of monitoring her endometrium (lining of the uterus). Prior to the embryo transfer, she takes several medications that prepare the endometrium to receive the embryos. The physician will determine when she must begin the daily progesterone injections and she is to continue them until ordered to stop by the physician.

The embryo transfer is performed with the Surrogate Mother in a gynecological position and requires no anesthesia. After the proper cleansing procedures, a tiny plastic catheter is introduced into the uterus through the cervix and the embryos are transferred into the endometrial cavity. The Surrogate Mother is required to stay in this position for a short period of time, then the nurse will reposition her per the physician's instructions and monitor her for the required time.

Step 5: Luteal Phase Monitoring and Support

When the Surrogate Mother is released after the embryo transfer, she will be be taken to a hotel for complete bedrest; getting up only to use the bathroom. This regiment is continued for 2 more days. After this time, the Surrogate Mother may resume her normal activities with the limitations provided to her by the physician at the time of the embryo transfer. Some of the limitations are:

1. Complete Pelvic Rest
2. No douching or sexual intercourse
3. Showers only - no tub baths
4. No strenuous activities - no exercising, running, heavy lifting including children, groceries, luggage, etc.

A pregnancy test will be performed two weeks following the embryo transfer. If a pregnancy occurs, the Surrogate Mother will have several visits to the clinic to monitor the hormone level and the progress of the embryo(s). This monitoring is done by blood tests and ultrasound. If pregnancy does not occur, the physician will instruct the Intended Mother when to stop the medications and when to expect her menstrual period.

The pregnancy test (BhCG) is performed on the 14th day following the IVF Embryo Transfer and the results are reported in numeric form. There is a direct correlation between this test result and the prediction of the IVF pregnancy outcome. The following chart** is based on a study examining 305 IVF/GIFT pregnancies at our center in Redondo Beach:

When we receive a low positive result, we believe that we should be cautious about stopping hormonal support until we are certain that the pregnancy is not viable. During the initial period of evaluation, if there is any uncertainty, serial blood tests and ultrasound examinations can be performed. The moral is never to make a major decision based on one result, unless the one result is clear-cut. Occasionally, we see results that seem to have a poor prognosis, but eventually evolve into happy outcomes.

Notes:

*Portable Document Format. View using free Adobe Acrobat Reader.

**SINGLE QUANTITATIVE BhCG LEVEL CAN PREDICT IVF/GIFT PREGNANCY OUTCOME?
JS Heiner, K Hainsworth, RJ Kiltz, DR Meldrum, Div. of Reproductive Endocrinology, Harbor-UCLA Medical Center and the Center for Advanced Reproductive Care, Redondo Beach, CA.

Cycle Cancellation

The physician establishes the acceptable level of response to the treatment during the cycle. If at any point, the Natural Mother's or the Surrogate Mother's response to the treatment falls below that established level, the physician will most likely cancel the cycle.