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Reproductive Endo/Infertility
In Vitro Fertilization

The Missouri Center for Reproductive Medicine and Fertility has expertise in each of the following Assisted Reproductive Technologies:

Blastocyst Culture
Assisted Hatching
Embryo Cryopreservation
Donor Egg IVF
Gestational Carrier
Ovarian Tissue Freezing for Cancer

IVF (in-vitro Fertilization)
The term Assisted Reproductive Technologies (ART) is frequently used and simply refers to all fertility treatments in which both egg and sperm are handled. Types of ARTinclude IVF, GIFT (gamete intrafallopian transfer), and ZIFT (zygote intrafallopian transfer). IVF is the most common ART procedure that is used in the United States, as GIFT and ZIFT do not increase pregnancy rates and require a second procedure (laparoscopy).

In Vitro Fertilization (IVF) Success

  • Depends primarily on the age of the female partner
  • Highest pregnancy and live birth (take-home baby) rates reported in women age <35.
    • In 2008, we reported a60% pregnancy rate and a 40% live birth rate in women age <35. (Caution: Patient characteristics vary among programs; therefore, these data should not be used for comparing clinics.)
  • Although pregnancy and live birth rates decrease after age 35, IVF remains a viable option for women up until their early 40s.
  • Other factors which will affect these rates include the use of fresh or frozen embryos, and the use donor eggs.

Multiple Pregnancy and IVF

  • Increased risk for multiple gestation of about 30%; most multiple pregnancies are twins.
  • General guidelines are followed to limit the number of embryos transferred based on the age of the woman, particularly in those age <35 who are at highest risk for multiple gestations.
    • The use of blastocyst transfer may also be used to achieve this goal.
  • We manage each case individually, and will attempt to be responsive to the needs of the couple, while balancing the number of embryos transferred with the risk of higher order multiple pregnancy.

The IVF Process

  • Injectable medications are used to stimulate the woman's ovaries to produce multiple eggs.
  • Patients are closely monitored through ultrasound and blood tests in order to optimizeegg development while minimizing the incidence of hyperstimulation of the ovaries.
  • Eggs are then surgically retrieved during a brief outpatient procedure in which the woman is sedated using medicines given through an intravenous (IV) line.
  • Oocytes (eggs) are surgically retrieved from a woman's ovaries and fertilized in the laboratory.
  • The fertilized eggs are then allowed to grow into embryos
  • Embryos arethen transferred to the woman's uterus through the vagina and cervix; ultrasound may be usedto aid invisualization
    • Embryo transfer is very similar to aninsemination in that it usually takes less than 5 minutes to perform, and requires no anesthesia
    • Embryo transfer is typically performed day 3 or day 5-6 following retrieval

Micromanipulation of Embryos
Microscopic procedures using the sperm, eggs, and/or embryos that are designed to improve fertilization, implantation, or reduce the risk of genetic disease in the offspring

  • Blastocyst Culture
    • The blastocyst represents the final maturation stage of embryo prior to implantation
    • Grow embryos an extra 2-3 days prior to transfer (day 5-day 6 following retrieval)
    • May allow for fewer transferred embryos and decrease risk of multiple pregnancy
  • Intracytoplasmic Sperm Injection (ICSI)
    • Direct injection of a single sperm into a mature egg. This procedure is selectively used in cases involving significant decreases in sperm counts, motility, or morphology. This procedure may also be used in cases where there is a history of previous failed fertilization despite normal sperm testing
    • Required for sperm obtained via microepididymal Sperm Aspiration (MESA)/Testicular Sperm Extraction (TESE) when there is little or no ejaculated sperm
      • For these procedures, sperm are aspirated or microscopically extracted by a urologist (with specialized expertise in male infertility) from the male reproductive tract (testes or epididymis)
      • Retrieved sperm are frozen by an experienced andrologist
  • Assisted Hatching (AH)
    • Making a small hole in the zona pellucida (sugar-protein membrane) that surrounds the pre embryo at the 6-8 cell stage prior to embryo transfer, making it easier for the embryo to "hatch" out of its shell
    • May improve implantation in cases with a thickened zona pellucida, patients >35 y/o, or patients undergoing frozen embryo transfer
  • Preimplantation GeneticDiagnosis(PGD)
    • Genetic evaluation of an embryo before transfer and subsequent implantation
    • Offered to carriers of single-gene disorders such a cystic fibrosis, patients with a family or personal history of inheritable disorders, and carriers of abnormal chromosomes
    • More controversial is its use for recurrent pregnancy loss (RPL), increased reproductive age of the female partner, repeated implantation failure (i.e. multiple failed IVF cycles) and HLA matching
    • Always used in conjunction with IVF
    • PGD involves removal of a single cell from a 6-8 cell embryo to analyze for genetic abnormalities
    • Biopsied embryos are allowed to grow to blastocyststage.
    • Those embryos that are genetically "normal" can be selected for transfer back into the uterus
    • Limitations
      • Requires adequate numbers of embryos to allow transfer at the blastocyst stage
      • Often, no additional embryos are available for freezing
      • Risk of no embryos for transfer
      • Misdiagnosis
      • Low risk of damage to the embryo during biopsy
  • Cryopreservation (Freezingof Excess Embryos)
    • Embryos are frozen at either the fertilized egg stage or the blastocyst stage
    • Frozen embryos can be used for transfer in a subsequent cycle
    • Frozen embryo transfer (FET) cycles require less medication, minimal monitoring and are much less expensive than a fresh IVF cycle, while still providing good pregnancy rates.

Donor Eggs (from known or anonymous donor, typically < age 33)

  • Used for women who are unable to achieve a pregnancy with their own eggs
  • Donor eggs are fertilized with the sperm of the recipient's partner (or with donor sperm as indicated), with subsequent embryos transferred to the recipient's uterus

Gestational Carriers (a woman who carries the pregnancy for the couple but has no genetic link to the child)

  • Used for patients desiring pregnancy who have severe damage to their uterine cavity or who have had their uterus removed
  • In our program, couples provide their own gestational carrier

OvarianTissue Freezing for Cancer Patients(Oncofertility Consortium)

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