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If you have no medical or gynecologic problems that need to be treated before undertaking IVF, and if you respond appropriately to stimulation, the entire IVF process, from pre-IVF testing to the first pregnancy test, usually takes 2-3 months.
Some patients may be advised low-dose IVF or natural cycle IVF instead of standard IVF, especially if they had failed IVF cycles with standard stimulation.
Fertility medications are kept to a minimum. Clomid may be used for five days, followed by two injections of gonadotropins. In most patients, this results in 3-4 follicles from which eggs may be retrieved for IVF.
The patient will rely on the single egg that she ovulates naturally, and she must be monitored closely with ultrasound and blood values in the days preceding expected ovulation. Before her natural LH surge, she will be given an HCG injection to help mature the egg, and 32-36 hours later, the egg will be retrieved, inseminated and cultured in the laboratory.
Women older than 37 who wish to have their own biological child but have had more than one failed IVF cycle may choose to use donated eggs from an anonymous donor or a designated donor (a friend or relative) aged 30 or less, who must be appropriately screened by the fertility center following New York state criteria for egg donors. Donor-egg IVF, even for recipients as old as 45, has a 50-60% pregnancy rate with the first cycle.
The availability of frozen donated eggs has greatly widened the use of donor-egg IVF. It is cheaper because the fertility center charges a flat fee per donated egg, obtained from donors that were previously screened for suitability and stimulated to produce multiple eggs that were subsequently retrieved and frozen.
If the patient opts for fresh donor eggs, it means that her cycle must be synchronized with that of the chosen donor – a procedure that requires close monitoring and coordination of both the donor and the recipient, after which the donor will then be stimulated for an IVF cycle. Cycle synchronization requires time and may not always be achieved at the first try.
Fresh donor eggs are also costlier because the recipient pays for the medication and monitoring of the donor’s stimulation, her egg retrieval and anesthesia, as well as the embryo culture and transfer to the recipient uterus.
The expense for a fresh donor egg cycle may be reduced if the donated eggs are shared by two or three recipients, so that each recipient will only pay half or one-third of the donor’s medication and stimulation cost.
Women who wish to delay motherhood until they have achieved certain career goals may now freeze and bank their own eggs for future use, but are advised to do so before they reach age 30.
After age 37, a woman’s fertility potential begins to decline rapidly because her remaining eggs are older and therefore more likely to have chromosome abnormalities. This also explains the increased risk of miscarriage in older women. For this reason, it is not advisable to attempt egg freezing after age 35, because the very same risks will apply.
Egg-freezing patients must undergo standard IVF stimulation to maximize the number of eggs that they can bank. They may do more than one cycle of egg freezing. The only difference from standard IVF is that after egg retrieval, the eggs are frozen (cryo-preserved) and may be stored until the patient is ready to use them.
Egg freezing is also an option for reproductive-age women desiring to have children if they have ovarian tumors or ovarian cancer which require surgery or other treatment such as chemotherapy and radiation, which generally render the ovaries infertile. For this reason, egg freezing must be done before treatment is undertaken.
In the past 25 years, micro-manipulation techniques have been developed using specially designed microscopes to perform highly delicate operations on sperm, egg cells and embryos. Initially, these were used for intra-cytoplasmic sperm injection (ICSI) – injecting a single sperm into each mature egg retrieved at IVF – and for assisted hatching, when a tiny hole is made in the protective covering of each embryo before it is transferred to the uterus, in order to facilitate hatching out to implant in the uterine lining .
Eventually, micro-manipulation skills led to the possibility of embryo biopsy – in which a cell is detached from a viable embryo (usually at the 8-cell stage) for genetic analysis. This is called pre-implantation genetic diagnosis (PGD) which has become commonly used in the past 15 years to screen embryos for chromosome abnormalities, for the presence of gene mutations linked with specific diseases, or for sex selection - in order that only chromosomally normal embryos which do not contain a specific disease screened for, and/or which are male or female, are selected for embryo transfer.
Since a number or serious diseases are linked with the X chromosome, PGD can determine the sex of each viable embryo by identifying the sex chromosomes present in each embryo (XY chromosomes if male, XX if female).
The first condition for successful PGD outcome is that the patient must get pregnant. If IVF/PGD is performed on a normal healthy woman younger than 37, who has no infertility problems, her chances of pregnancy are 60% or more. Chances are lower for women with infertility problems and for women older than 37.
In the past, when the male partner in a couple desiring to have children together has had a vasectomy, he would require surgery to reopen the two tubes delivering sperm into the seminal stream that were cut and sealed off at vasectomy. Alternatively, the couple could consider using donor sperm or adoption.
With the advent of intra-cytoplasmic sperm injection (ICSI) to inseminate eggs retrieved at IVF – in which only as many sperm cells are needed as the number of eggs – various techniques were developed to recover sperm from the testes or epididymis of men who had undergone vasectomy.
In percutaneous epididymal sperm aspiration (PESA), a fine needle is injected through the skin to aspirate the sperm. MESA (microsurgical epididymal sperm aspiration) involves a microsurgical approach: a small incision is made over the epididymis, and sperm is identified with the aid of a microscope.
In TESE (testicular sperm extraction), an incision is made to access the sperm-bearing testicular tissue; this is best done with a microscope to identify biopsy sites that are most likely to yield sperm cells, which will be isolated in the laboratory from the tiny tissue samples taken. Sperm retrieval procedures in conjunction with IVF are performed by an experienced urologist.
Post-vasectomy patients who had a normal semen analysis before vasectomy usually will have enough sperm recovered not just for immediate use but also for cryopreservation.
Testicular or epididymal sperm retrieval is also used for patients with non-obstructive azoospermia or obstructive azoospermia not due to vasectomy, provided their urologist has reasonable expectation of recovering some sperm.