IVF Clinic Primer for Patient – Alta Bates IVF Program – California, USA

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http://www.abivf.com IVF has become a most versatile therapy applicable to all forms of infertility. You can get enough of required information from Alta Bates Clinic and also interact with some of the would-be mothers and share your experience for more knowledge.

Transcript of IVF Clinic Primer for Patient – Alta Bates IVF Program – California, USA

  • IVF PRIMER

    I. Introduction In vitro fertilization (IVF) and related procedures are collectively known as assisted reproductive technologies (ART). Each ART treatment is complex and consists of many different steps. Even though a high percentage of patients achieve pregnancy in their first attempt, more than one cycle may be required to conceive and deliver a healthy baby. < Madison

    In the course of your treatment you may meet other couples with similar problems. Infertility can be a very stressful and frustrating experience. It often helps to know that you are not alone and to share your feelings. II. Indications for IVF Whereas IVF was originally developed for tubal factor infertility, it has since become a most versatile therapy applicable to all forms of infertility. One of the universal findings in reproductive medicine has been the profound adverse effect of woman's advanced age upon the likelihood of successful outcome (What is Age Factor?). For that reason, we generally do not recommend starting IVF with the womans own eggs beyond their 43rd birthday. Older women are usually excellent candidates for pregnancy initiation with donated eggs (Donor Egg Program). The presence of a uterus and at least one functioning ovary is an absolute prerequisite for traditional IVF. In the presence of male factor, normal fertilization rate can be achieved through ICSI (What is ICSI?) or the use of donor semen.

    The Tang Twins > III. Pre-Treatment Preparation A. Initial Visit At the time of the initial consultation, the physician elicits your history, reviews past records, performs a physical examination and formulates the treatment plan. A major goal of the evaluation is to define as precisely as possible what is your individual likelihood of success with different therapies. If you have undergone evaluation or treatment at another program, please bring detailed records including the results of screening tests, the stimulation and laboratory summaries so that we can review them with you in detail. A form for release of medical information should be signed by you and your partner and sent to each doctor who tested or treated you for infertility in the past. A trial embryo transfer is usually done by passing a thin catheter into the uterus (womb) in order to assess the ease of passage and direction of the cervical canal and to measure uterine depth. The trial transfer is usually painless and allows us to perform the actual embryo transfer with as little irritation as possible.

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    B. Standard Screening Tests The usual blood tests for the woman include Blood type and Rh Factor, Rubella and Varicella Antibodies, prolactin, TSH , Hepatitis BsAntigen, Hepatitis C Antibody, HIV Antibodies and RPR. FSH and estradiol are measured on cycle day 3 (How Do We Test for Ovarian Reserve?) and an ultrasound is done to check the number of antral follicles in the ovaries (AFC) and uterine anatomy. We try to avoid repeating previously completed tests.

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    The male partner is required to have a 5-test STD panel (Hepatitis Bs Antigen, Hepatitis C Antibody, HIV Antibody, HTLV Antibody and RPR) required by Health and Safety Code. As with all tests, there are occasionally misleading results (false positive and false negatives) which may necessitate confirmatory testing. A semen analysis is scheduled unless a very recent one is available. Additional evaluation includes an HSG (dye study of uterus) and a saline infusion sonohysterogram (SIS) for evaluation of the uterine cavity. If one or both tubes are closed at the end near the ovaries, forming a hydrosalpinx, removal or ligation of the damaged tubes is recommended before IVF, because such closed tubes lower pregnancy rates (What Is a Hydrosalpinx?). C. Injection Training Shortly before the first treatment the patient and her partner are instructed in the techniques of injections by one of the nurses in our office. At that time the medications you will use are reviewed and additional questions can be answered. Please make sure that you have medications well in advance of starting the treatment cycle. We provide you with prescriptions and a list of participating pharmacies where the medications can be obtained. Comparative shopping can be worthwhile as prices do vary. Since many of these medicines are injectable, they are generally not stocked by neighborhood pharmacies and may need to be ordered from specialized pharmacies. IV. Controlled Ovarian Hyperstimulation The single most important factor in improving the success rate of IVF in its early days was the transfer of more than one embryo (fertilized dividing egg). The reason is because a high percentage of early embryos do not implant. Furthermore, the maturity of each egg collected may not be ideal and only about 65% of eggs fertilize normally. While placing more than one embryo markedly increases the success rate, it also increases the chance of multiple pregnancy (The Dilemma of Twins). In our experience, one of every three pregnancies in women under the age of 40 years is multiple, with the majority being twins.

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    A. Gonadotropins, or injectable fertility drugs (Follistim, Gonal-F, Bravelle, Menopur).

    In order to stimulate development of multiple follicles, which are the fluid-filled sacs containing the oocytes (eggs), you receive gonadotropins the active ingredient of which is the FSH hormone. Menopur also contains the LH hormone or LH-like activity. LH is a hormone that may work with FSH to increase the production of estrogen and growth of the follicles. Luveris, recombinant LH, can also be given as a separate injection in addition to FSH or alternatively, low-dose hCG can be used. These medications are given by subcutaneous injection. Proper dosage of these drugs and the timing of egg recovery require monitoring of the ovarian response, usually by way of frequent blood tests and ultrasound exams.

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    B. Risks of Gonadotropins

    As with all injectable medications, bruising, redness, swelling, or discomfort can occur at the injection site. Rarely, there can be an allergic reaction to these drugs. Most women experience some bloating and minor discomfort as the follicles grow and the ovaries become temporarily enlarged. Mild hyperstimulation usually responds to bedrest. < Adrianne and Family

    About 2% of women develop more severe Ovarian Hyperstimulation Syndrome (How to Avoid OHSS). Other risks and side effects of gonadotropins include fatigue, headaches, weight gain, mood swings, nausea, and clots in blood vessels. Some research suggested that the risk of ovarian tumors may increase in women who take any fertility drugs over a long period of time. These studies had significant flaws which limited the strength of the conclusions. More recent studies have not confirmed this risk. A major risk factor for ovarian cancer is infertility per se, suggesting that early reports may have falsely attributed the risk resulting from infertility to the use of medications to overcome it. In these studies, conception lowered the risk of ovarian tumors to that of fertile women. Human chorionic gonadotropin (hCG) (Profasi, Novarel, Pregnyl, Ovidrel) is a natural hormone used in IVF to induce the final maturation of eggs. The timing of this medication is critical to retrieve mature eggs. Potential side effects include, but are not limited to, breast tenderness, bloating, and pelvic discomfort. Gonadotropins have been used for many years without any evidence of increase in birth defects or spontaneous miscarriage. C. GnRH Analogs: Agonists and Antagonists Leuprolide acetate (Lupron) is a potent agonist of GnRH, the hormone which controls the release of FSH and LH by the pituitary gland. It is usually taken as a daily subcutaneous injection. Its primary role is to prevent a premature LH surge, which could result in the release of eggs before they are ready to be retrieved. Since GnRH-agonists initially cause a release of FSH and LH from the pituitary, they can also be used to start the growth of the follicles or initiate the final stages of egg maturation (see Flare Protocol). Though leuprolide acetate is an FDA (Federal Drug Administration) approved medication, it has not been approved for use in IVF, although it has routinely been used in this way for more than 20 years. Potential side effects usually experienced primarily with use for over 6 weeks include but are not limited to hot flashes, vaginal dryness, bone loss, nausea, vomiting, skin reactions at the injection site, fluid retention, muscle aches, headaches, and depression. Few side effects are experienced with short-term use as is usually the case in IVF. Ganirelix and cetrorelix (Antagon, Cetrotide) are antagonists of GnRH hormone and are also used to prevent premature ovulation. As they have a rapid onset of action, they tend to be started later during the stimulation and used for just a few days. They are given subcutaneously. The potential side effects include, but are not limited to, abdominal pain, headaches, skin reaction at the injection site, and nausea.

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    D. Treatment Plan An individualized treatment plan will be discussed with you prior to starting and again at baseline ultrasound so you will