Overview
In vitro fertilization (IVF) involves the retrieval of developing eggs from the ovary, joining them in a culture dish with concentrated sperm, and transferring the fertilized eggs (embryos) into the uterus to establish pregnancy. The first successful IVF cycle occurred in 1978 with the subsequent birth of Louise Brown. Damaged or absent fallopian tubes has been a classical indication for IVF therapy. There is now a wide range of diagnoses that may warrant IVF treatment including couples with male factor infertility, couples with longstanding infertility who have failed other methods, and unexplained infertility. A successful cycle of IVF depends upon the completion of a series of steps. These include:

1. Stimulation of the ovaries - Medicines will be used to stimulate the development of multiple follicles (cysts in the ovaries that contain eggs). The follicle growth is monitored by transvaginal ultrasound measurements and by following blood hormone levels.
2. Retrieval of the eggs - Eggs are retrieved by a transvaginal ultrasound-guided needle that goes through the vaginal wall and into the follicles in the ovary. The fluid from the follicles is withdrawn and given to the embryologist who will identify the eggs.
3. Culture of sperm and eggs in vitro - The eggs will be placed with specially prepared sperm about four to six hours after retrieval. They are carefully incubated overnight and the next day are checked for signs of fertilization.
4. Fertilization of the eggs to produce embryos - The eggs that fertilize become embryos. In selected cases, fertilization may be assisted by direct sperm injection (Intracytoplasmic Sperm Injection or ICSI). The embryos are placed in special growth medium in the lab for three days. The embryos that have normal cell division are readied for transfer back into the uterus. If necessary, a small opening in the tough outer covering around the embryo can be created to help implantation (assisted hatching).
5. Transfer of the embryos into the uterus - The embryo transfer is done using a soft flexible catheter that can be placed through the cervical canal back into the uterus. The patient and her doctor will decide how many embryos to transfer back to the uterus. Selective assisted hatching of the embryos (making a small hole in the shell of the embryo) may be recommended to assist in embryo implantation.
6. Support of the pregnancy with medication administration - After retrieval, medications will be given to support implantation of the embryos.
7. Detecting the implantation of the embryos(s) with pregnancy testing - A pregnancy test is done 14 days after egg retrieval. If the test is positive it will be repeated and then an ultrasound will be performed in approximately three weeks to establish the presence of an ongoing pregnancy.

Other Services Related to IVF
Assisted reproductive techniques that complement or enhance the success rates of IVF are offered by the Program for Assisted Reproduction. Your special circumstances may require these services.

• ZIFT (Zygote Intrafallopian Transfer)
• Micromanipulation
• ICSI (Intracytoplasmic Sperm Injection)
• Assisted hatching
• Donor Egg Program
• Donor Sperm Program
• Cryopreservation of embryos
• Team approach to medical and surgical treatment of male infertility
• Electroejaculation
• TESE (Testicular Sperm Extraction)
• MESA (Microepididymal Sperm Aspiration)

Getting Started

Initial Consultation
The focus of the initial consultation prior to beginning your cycle will be to assess in detail your infertility history and other medical factors impacting general health. Having previous medical records, including pertinent X-rays, lab reports, operative notes and records of previous cycles of ovarian stimulation is important. After a history is obtained and a physical examination performed, the general treatment protocols will be reviewed with you. A video is available to acquaint you with the IVF cycle and show you the locations of services within the medical center. The costs of the IVF cycle can be estimated with our financial coordinator.

Nursing Care Coordination
You will receive instruction from our nurses on how to coordinate cycle events including medication schedules, injection teaching, scheduling of laboratories and ultrasounds. It is very important to call us on the first day of your menstrual cycle in the months preceding the IVF cycle. This will allow us to schedule testing and cycle events. Nurses are available by phone between 8 a.m. and 3 p.m. daily at 704-355-3149. Messages may be left with the recording or answering service to be returned later.

IVF Precycle Tests
Several tests need to be completed prior to the actual IVF cycle. The following may be used as a checklist to ensure that these labs are completed prior to the initiation of medicine for your IVF cycle. If some of these tests have been recently completed, they may not need to be repeated.

Female

• FSH and Estradiol - This blood test, drawn on the third day of the menstrual cycle, may give us an idea of how you respond to medication and determine the amount of medicine we should give to you. Call us when you start your period to arrange an appointment for the third day of your cycle to have blood testing.
• IVF Blood Panel - This panel includes Hepatitis B, Hepatitis C, HIV, and VDRL tests for the husband and the wife. Antisperm antibody tests can also be obtained at this time. Please schedule this test at Carolinas Medical Center's Women's Institute.
• Hysterosalpingogram (HSG) or Hydrosonography - The purpose of this test is to visualize the uterine cavity to insure there are no abnormalities that may hinder implantation of the embryos. If this test has been done within six months prior to your IVF cycle and films are available to review, this test may not be necessary.
• Trial Transfer - This simulates the embryo transfer and measures the depth and configuration of the uterine cavity. After a speculum is placed in the vagina, a small flexible transfer catheter is placed through the cervix. This will ensure that the actual embryo transfer is done as gently and carefully as possible. We prefer to do this in the cycle preceding your IVF cycle.
• Other lab testing - including genetic screening - may be required for some women on an individual basis.

Male
Semen Analyses - Several tests on the semen will need to be performed prior to IVF cycle. All semen specimens should be obtained at least two days, but usually no more than four days, of abstinence from the last ejaculation, and within two months of the IVF cycle. Some patients may receive instructions to abstain for more than 4 days. The specimen will be checked for total number of motile, morphologically normal sperm cells and antisperm antibodies. A trial preparation will be performed in order to determine the best method for the day of IVF. You will need to call the Andrology Laboratory at 704-355-3460 to schedule an appointment. Please be sure to tell the Andrology staff that the specimen is for an IVF work-up. The combination of IVF and assisted fertilization technique (ICSI- intracytoplasmic sperm injection) has helped many couples achieve a pregnancy. ICSI is performed by directly injecting a single sperm into an egg using microsurgery and may be recommended based on the results of the semen analysis.

• IVF Blood Panel - Blood for Hepatitis B, Hepatitis C, VDRL, antisperm antibodies and HIV will be obtained by appointment at Carolinas Medical Center's Women's Institute.
• Frozen Sperm Backup - Although a fresh semen sample on the day of retrieval is preferred, a sample may be frozen in advance if necessary to serve as a back-up. The Andrology Lab will notify individuals if more than one semen sample is needed.

Medications for the IVF Cycle
A detailed list of medications necessary for the IVF cycle need to be reviewed prior to the IVF cycle. Your IVF nurse will provide you with this prescription. You should carefully inventory this list of medications prior to your cycle. This list consists of oral and injectable forms of medication. Your IVF nurse will review your medication cycle with you in detail.

Injection Training Class
Injectable medications will be administered at home by you, your partner or your person of preference. You may need to complete an injection training class prior to your medication cycle. If you feel this is necessary, call the nurses to schedule a class.

Frozen Embryo Transfer
Extra embryos may be cryopreserved (frozen) with the intent of thawing and transferring them later. Cryopreservation provides a method to enhance the overall success of the initial assisted reproduction technology (ART) procedure. Future ART cycles with cryopreserved embryos tend to be less expensive and less invasive than the initial IVF cycle, since the woman does not require ovarian stimulation or egg retrieval. Once frozen, the embryos may be stored for several years. However, not all embryos survive the freeze and thaw process and the live birth rate is lower with cryopreserved embryo transfer. The couple should decide if they wish to cryopreserve surplus embryos before the initiation of the cycle.

Frozen embryos may be transferred in a hormonally controlled cycle or in a natural cycle. Your physician will determine which approach is best for you. In a controlled cycle, Lupron, estrogen and progesterone are administered to prepare the uterus for the embryo transfer. If pregnancy occurs in a controlled cycle, estrogen and progesterone must be continued throughout the first trimester of a pregnancy or a miscarriage will occur. If embryos are replaced during a natural cycle, ovulation will be monitored closely and embryo transfer will be scheduled after ovulation is confirmed by ultrasound, blood and urine tests.

Preimplantation Genetic Diagnosis (PGD)
We provide preimplantation genetic diagnosis (PGD) to our patients to test embryos for specific genetic disorders. One or two cells are removed from embryos obtained by in vitro fertilization. During PGD, the embryos are tested for either specific gene abnormalities such as cystic fibrosis or chromosomal abnormalities such as Down syndrome before placing the embryo into the uterus. Couples may consider PGD if they have a family history of a specific genetic disease such as hemophilia, Duchenne muscular dystrophy, fragile-X, Tay-Sachs disease, retinitis pigmentosa, sickle cell anemia or numerous other familial genetic conditions. PGD may also be considered on an individual basis for those couples with a history of other fertility issues or recurrent miscarriages. Your physician will review your history to determine if PGD may be beneficial to you.

Embryo Donation
Embryo donation, also referred to as "embryo adoption," provides infertile couples a possibility to become parents even when there are severe problems with a woman's eggs or a man's sperm. The embryos come from couples who have donated their excess frozen embryos after completing IVF. Rather than discard the excess embryos, the embryos may be donated to an infertile couple.

There are two types of donation: anonymous and known. In known donation, the couples with excess frozen embryos directly donate their embryos to an infertile couple, and identity of the donors and recipients are known. In anonymous donation, our center helps match a recipient couple with a donating couple; however, there is no contact between the couples. The donor couple receives no compensation for donating their embryos, although the recipient couple is responsible for fees associated with embryo donation.