PREPARING FOR CONVENTIONAL IVF
Sher Institute for Reproductive Medicine
The objective with In Vitro Fertilization is to consistently transfer several good quality embryos into an optimal uterine environment. This requires an individualized and meticulous approach to the evaluation and treatment of the following factors that are known to influence IVF outcome:
(1)THE NUMBER AND QUALITY OF THE EMBRYOS/BLASTOCYSTS FOR TRANSFER:
The number of embryos/blastocysts: The number of eggs a woman produces is influenced by her ovarian responsivity to gonadotropin fertility drugs such as Follistim, Gonal-F, Pergonal, Humagon or Repronex. This responsivity in turn relates to her proximity to menopause. Ovarian responsivity can be assessed by measuring FSH and estradiol (E2) and Inhibin B, on the 3rd day of a prior menstrual cycle. If the plasma FSH level is greater than 9.0MIU/ml in association with a plasma estradiol level of greater than 70pg/ml by EIA, and/or the plasma inhibin B level is less than 45 pg/ml, it would point to the likelihood that the woman would be relatively resistant to ovarian stimulation.
The quality of embryos/blastocysts: Clearly, the quality of the ivf laboratory is pivotal in ensuring that quality embryos are produced following IVF Highly technical procedures such as intracytoplasmic sperm injection (ICSI), assisted hatching (AH) and embryo biopsy, should only be performed by embryologists with the necessary experience and rehearsed skill, lest fertilization rates and embryo quality be severely compromised
2) THE INTEGRITY OF THE UTERINE CAVITY AND THE QUALITY OF THE UTERINE LINING:
The integrity of the uterine cavity: Hysterosonography (Fluid ultrasonography-FUS) is a simple office procedure performed under mild sedation, where a sterile salt/water solution is injected into the uterus and an ultrasound exam is performed. The procedure permits a detailed inspection of the inside of the uterus for surface lesions such as polyps or fibroid tumors that may be protruding into, encroaching upon, or distorting the uterine cavity. Such lesions compromise the ability of the embryo to attach to the uterine wall, and as such should be removed before initiating fertility treatment.
Sometimes, direct visualization of the uterine cavity is needed. This calls for the performance of hysteroscopy, a procedure where a thin, telescope-like instrument is inserted through the cervix into the uterus for visual inspection of the cavity. Diagnostic hysteroscopy can readily be performed in the doctor's office using local anesthesia and mild sedation.
Evaluation of the uterine cavity by FUS or hysteroscopy is an essential part of the screening process at SIRM.
A dye X-Ray test or Hysterosalpingogram (HSG) is NOT sufficiently sensitive or specific to exclude the presence of small lesions in the uterine cavity.
Evaluating the uterine cavity for infection: It is important to exclude infection with microorganisms such as Ureaplasma urealyticum; which, if present, may compromise fertilization and implantation. Ureaplasma infection is usually asymptomatic, and can be eradicated through appropriate concurrent antibiotic treatment of both partners. There is evidence that when Ureaplasma is present in semen, fertilization rates are reduced.
Evaluating the uterine lining: An additional uterine factor that can affect the success of IVF is the thickness and consistency of the endometrial lining following administration of fertility medications. This can be evaluated through the performance of an ultrasound examination prior to egg retrieval.
Evaluating for immunologic dysfunction: In more than 30% of cases where the cause of infertility resides with the woman, or is ”unexplained” there is an underlying contributing immunologic problem that interferes with embryo attachment. The high emotional, financial and physical toll associated with IVF, mandates that these immunologic problems be addressed early on. Accordingly we require that an immunologic evaluation be performed prior to IVF in the following situations:
- "unexplained " infertility or prior recurrent miscarriages
- underlying female organic pelvic disease
- a history of prior IVF failures
- a history of recurrent miscarriages, or ….
- Whenever there is a personal or family history of immunologic disease such as lupus erythematosis, Hypo/hyperthyroidism, rheumatoid arthritis, etc.
(3) SPERM QUALITY AND FUNCTION:
Until the advent of IVF, treatment of moderate and severe male factor infertility yielded dismal results. The introduction of IVF yielded offered the first ray of hope but results were still disappointing. The advent of ICSI, a high-tech procedure, where a single sperm is directly injected into each egg, changed all that. Now, as a result of ICSI, IVF birth rates in selected centers of excellence even exceed those achieved with conventional IVF performed for indications other than male infertility.
In Vitro Fertilization exacts an emotional, physical and financial price and no one gets through the process without paying the toll. Accordingly, all couples should learn what they can reasonably expect before committing to IVF. Simply put, it is important to shape realistic expectations and to plan this trip before embarking on the journey.
Accordingly, at SIRM we require that all of our patients be fully informed of the services contemplated, through a detailed medical consultation with one of our physicians, a clinical coordinator, and/or with a psychological counselor. We also require that relevant consent forms and agreements be carefully reviewed and signed prior to initiating a cycle of treatment at SIRM
The following is a list of the tests that are selectively performed in preparation for a cycle of IVF at SIRM. Those tests that have been performed within 18 months need not necessarily need to be repeated. Please ask the clinical coordinator for clarification. Many of the blood and diagnostic tests listed below may be performed by your Ob/Gyn or internist.
If done within 18 months do not repeat unless specifically ordered by SIRM’s physician.TYPE OF TEST/PROCEDURE / TIME / COMMENTS TESTS PERFORMED IN PRECEDING 18 MONTHS, IF NORMAL NEED NOT BE REPEATED! / DATE
FSH,E2, / CD 3
TSH / Anytime
CERVICAL CULTURES/ Any time
UTERINE ASSESSMENT/ CD 6 -13 / Not to be done during menstruation
Fluid Ultrasonography or
Uterine Measurement (US)Uterine Lining
EXAMINATION/ *Only for patients over the age of 40
and/or past history of systemic
disease or previous medical/surgical
EKG, Blood Chem*
If done within 18 months do not repeat unless specifically ordered by SIRM’s physicianBLOOD TESTS / Anytime / DATE
FSH/LH/Testosterone/Prolactin / Selectively ordered
Anti-sperm antibodies / Selectively ordered
SPERM DNA INTEGRITY T(SDI) TEST ( SYN: SCSA/ selectively ordered ( if never initiated a pregnancy that went beyond 12 weeks
SEMEN ANALYSIS/ 3-4 days of abstinence
CULTURES/ Any time
EXAMINATION of MALE/ SELECTIVE
We are very familiar in working with couples at a distance, and it is rarely necessary for out-of-town patients to spend more than 2 weeks at an SIRM center. Many patients treated at SIRM come from out-of-state or out-of-country. Accordingly, we have developed a system of working with patients and their primary care physicians at a distance.
Please keep in mind that the way we prepare couples for IVF at SIRM using a combination of the Oral Contraceptives (OC's), enables us to plan and schedule each cycle, often months in advance, with precision. This allows patients/couples to conveniently schedule IVF at SIRM, around their own calendars.
Patients/couples should inquire as to eligibility for acceptance to Outcome-based Pricing (OBP) plan, where if an IVF procedure at SIRM, does not result in the birth of a baby, most of the financial obligation to SIRM, fall away. Also, most couples who are eligible for OBP, will also be eligible for Medical Financing of their IVF, at SIRM.
IF YOU HAVE ANY QUESTIONS PLEASE DO NOT HESITATE TO CONTACT US AT. SIRM DURING REGULAR OFFICE HOURS (FROM 9:00AM TO 4:00PM)
PREP FOR CONVENTIONAL IVF AT SIRM (2) - 1 -