Download IVF - Main Line Fertility

IVF Orientation
IVF Definition
• IVF – In Vitro Fertilization
• In Vitro – outside the natural environment*
• Fertilization – the joining of egg and sperm
• Literally – In Vitro Fertilization = the joining of egg
and sperm outside of the body
*
source – dictionary.com
What Is IVF?
With the IVF process the woman takes injectable medication to
increase egg production.
• Eggs are retrieved from the biological mother (who may or may not
be the intended parent) during a short surgical procedure under
anesthesia.
• Eggs are exposed to sperm in the laboratory.
• Embryologists check the egg for fertilization the following day.
• Fertilized eggs are referred to as embryos.
• A few days after fertilization, the best embryo or embryos are
transferred to the mother or (gestational carrier’s) uterus.
• The embryo transfer is completed by loading the embryo(s) into a
thin catheter, passing it through the cervix into the uterus, using
ultrasound guidance, and depositing the embryo(s) into the uterus.
Requirements before an IVF cycle. The tests, all paperwork
and consents should be completed before starting on any
medications.
Female:
• Standard IVF female lab tests (at lab facility approved by your insurance)
• PAP smear results from your PCP or Gynecologist
• Fax results to: 484.380.4866.
• Injection teaching and hysteroscopy:
• Call 484.380.4890 to schedule appointments.
• Call financial coordinator to verify insurance coverage: 484.380.4883
• Medical clearance letter from specialist, if being followed for medical condition.
• If Pre-Implantation Genetic Diagnosis (PGD) planned, consult embryologist:
• Call 484.380.4871
Male:
• Standard IVF Male lab tests (at lab facility approved by your insurance)
• Semen analysis on-site at MLFC: call 484.380.4863 for appointment
All paperwork and consents submitted to the Center before a cycle start
Mail to:
Main Line Fertility Center
825 Old Lancaster Ave, Suite 170
Bryn Mawr, PA 19010
IVF Orientation Appointment
Nurse will review all paperwork previously submitted, as well as lab results on
both partners (if applicable)
If applicable, the male patient will produce a specimen for semen analysis
onsite.
• If male is unable to produce specimen onsite please notify the andrology lab
in advance to arrange to produce specimen at home and transport to the lab:
484.380.4863.
An IVF nurse will explain the IVF process and answer patient questions.
Carrier (genetic) screening will be offered
• Carrier screening provides information on your reproductive risks, which may
be used to help minimize the chance of having a child with a particular
genetic disease.
• 1-2 tubes of blood will be drawn.
• If carrier screening is not desired a waiver will need to be signed.
A Typical IVF Cycle Takes Up To 6 Weeks:
• 3 weeks of birth control pills (if applicable)
• Approximately 10-14 days of injectable medications involving
up to 8 appointments.
• Appointments include blood work to measure hormone
levels, and vaginal ultrasounds to count and measure
follicles and thickness of uterine lining.
• Egg retrieval
• A surgical procedure performed under anesthesia
• Embryo transfer 3 to 5 days after the retrieval
• Hormone level check one week post embryo transfer
• Pregnancy test two weeks post embryo transfer
IVF CYCLE
Progesterone
Estradiol
Possible Birth Control Pills
Embryo
Transfer
Day 3
Post Retrieval
Lupron
or
Day 1 Menses
Call
Monitoring **
HCG
Ovulation
Stimulation Meds
7 days
----------------------------
Day 1
Menses
** Cycle Start
Schedule Blood Draw,
Hysteroscopy
&
Injection Teaching
Ganirelix/ Cetrotide
Egg
Retrieval
Hormone
Check
Pregnancy Test
1 week
2 weeks
Post Transfer Post Transfer
Blastocyst
Transfer
Day 5 or 6
Post Retrieval
The IVF cycle begins with day one of the menstrual cycle. Please call
the IVF Monitoring Team on the first day of full flow: 484.380.4890
IVF Monitoring Appointments:
First appointment (cycle day 2 or 3):
• Blood work and possible ultrasound
• Some patients are started on birth control pills and some on injectable
medications.
• If your doctor prescribes birth control pills, a hysteroscopy may be scheduled at
this time.
• Verbal and written instructions for your next steps and next appointment date.
Throughout cycle appointments
• Blood work for hormone levels
• Ultrasound to count and measure follicles, as well as thickness of uterine
lining.
• Expect call back from IVF Monitoring team nurses with next step, after they
have reviewed the cycle with your doctor.
• If you plan to create embryos, your partner should have ejaculations every
2-3 days to assure the freshest sperm will be available on retrieval day.
Stimulation
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•
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•
This is an ultrasound image of follicles in the
process of growing during a stimulation
cycle.
Follicles are fluid filled structures ranging in
size from 10-20 mm.
Eggs are retrieved from follicles.
Not every follicle contains an egg.
Follicles grow in response to fertility
medications and secrete estradiol (E2).
• While your follicles are
growing your uterus is
also being prepared to
accept the embryos
that are to be
transferred.
• This is an ultrasound
image of a uterus.
.
,
hCG Instructions: hCG is used to assist in the final maturation of eggs.
• when follicles have reached adequate size and hormone levels correlate….you are
ready for egg retrieval!
• Have pre-retrieval instruction sheet ready to fill in the blanks.(Right click on this link to
open hyperlink: hCG instructions 2013.doc)
• Make sure you have your hCG (Pregnyl, Profasi, Novarel, chorionic gonadotropin) or
Ovidrel available.
• Prepare the medication a few minutes before the dose is due.
• Inject the medication at the EXACT time instructed.
• Egg retrieval will occur approximately 36 hours after the injection.
Egg Retrieval Day
•
•
•
•
•
•
•
•
You will be asked to arrive approximately one hour before the egg retrieval. Please be on time to
allow proper preparation.
Please shower in the AM of your retrieval but do not use scented products(shampoo, soap and
deodorant are fine).
Brush your teeth but do not swallow any water.
Do NOT have anything to eat or drink, including candy, mints or gum.
Do NOT bring valuables or jewelry with you to the retrieval. Bring only necessary items, which can be
stored in a small locker.
Please do NOT wear contact lenses.
Plan to spend up to 2 ½ hours at the Center. You will need a driver to take you home.
Your partner will be expected to produce a sperm specimen upon arrival to the Center, IF you plan to
create embryos. A 2-3 day abstinence is recommended. Photo ID is required.
During the 20-30 minute egg retrieval procedure, eggs are retrieved under anesthesia using transvaginal
ultrasound guidance (to visualize the follicles)** see next slide. A needle attached to the ultrasound probe
penetrates the vaginal wall into the ovaries, suction is applied and the follicular fluid is aspirated into a tube.
The fluid is checked by an embryologist to isolate the egg. Not every follicle contains an egg. Eggs are
“cleaned up” then exposed to sperm in the lab, if embryos are desired. If eggs are to be frozen, they are
frozen on retrieval day.
Patients are usually discharged home within an hour after the retrieval, with minimal complaints.
Risks of egg retrieval may include, but are not limited to: abdominal cramping, loss of blood, infection, loss
of fertility, injury to pelvic or abdominal organs, nausea/vomiting or adverse reactions to anesthesia
medications.
Egg Retrieval Room
Prep-Recovery Area
Egg Retrieval
• Eggs are removed
from your follicles
along with follicular
fluid. Eggs are
surrounded by
cumulus cells when
they are first isolated.
Veek, L
• This is a mature
oocyte (egg) without
the surrounding
cumulus cells. The
outside wall is the
zona (z). The small cell
(f) is the polar body,
and the large cell (o) is
the oocyte itself.
Veek, L
Sperm
Veek, L
• A normal sperm cell
contains a head, neck,
and tail.
• During the semen
analysis the count,
%motility (% of
swimming sperm) and
morphology (shape)
will be evaluated.
ICSI (Intra-Cytoplasmic Sperm Injection)
• ICSI is a micro-surgical
technique where a
single sperm is manually
injected into each egg.
• This is an egg
undergoing sperm
injection.
• ICSI is typically used if
sperm count, motility
and/or morphology are
not within normal
range.
Embryo Observation
• Fertilization of the eggs is
observed the morning after
your retrieval(day 1)
• This is a typical newly fertilized
embryo known as a zygote.
• Two pronuclei (2PN) are seen in
a fertilized egg.
Veek, L
Main Line Fertility & Reproductive Medicine, LTD.
And The Center For Reproductive Medicine,
Bryn Mawr Hospital
Embryo Observation
• The embryos are
commonly 2 to 4 cells
the day after
fertilization check (day
2, or 2 days after
retrieval).
Veek, L
• This is an example of a
4 cell embryo.
Main Line Fertility & Reproductive Medicine, LTD.
And The Center For Reproductive Medicine,
Bryn Mawr Hospital
Embryo Observation
• The third day of
culture (day 3, 3 days
after retrieval) the
embryos are mostly 6
to 8 cells.
• This is an example of
an 8 cell embryo.
Veek, L
Embryo Observation
• The fifth day (day 5, 5
days after retrieval)
some embryos typically
reach blastocyst stage.
Not all embryos are
capable of reaching the
blastocyst stage.
Veek, L
• This is an example of a
blastocyst.
Embryo Transfer
• Embryos are loaded
into the catheter by
the embryologist and
are inserted through
the cervix into the
uterus by your
physician using
ultrasound guidance.
Wallace/Cook OB?GYN
Embryo Freezing
•
1)
2)
•
Embryos are frozen if:
There are more good quality
embryos produced from your
IVF cycle than your physician
feels you should have
transferred.
Your uterus is not ready for
implantation or for an
embryo transfer procedure
Your embryos are frozen and
stored in a tank filled with
liquid nitrogen.
Cryo tank
Ovarian Hyperstimulation Syndrome (OHSS)
Medications used to stimulate ovaries may cause side effects ranging from mild to severe. Please keep in touch with the IVF
staff if you develop moderate to severe symptoms.
Mild
You may experience:
- Abdominal bloating and feeling of fullness
- Nausea
- Diarrhea
- Slight weight gain
This may be due to:
- Ovaries are larger than normal, tender and fragile
- High level of estrogen (E2) and progesterone in the
bloodstream may upset your digestive system and
fluid balance causing bloating.
Recommended treatment:
- Avoid sexual intercourse
- Do not have a vaginal (pelvic)
exam other than by one of our
physicians.
- Reduce activities, no heavy
lifting, straining or exercise
- Drink clear fluids, flat coke,
ginger ale, cranberry juice,
Gatorade or Ensure
Moderate
You may also experience:
- Weight gain of greater than 2 lbs. per day (excessive weight gain)
- Increased abdominal measurement causing clothes to feel tight
- Vomiting & diarrhea
- Urine is darker and amount is less
- Skin/hair may feel dry
- Thirst
This may be due to:
- High levels of hormones in the bloodstream upset the
digestive system
- Fluid imbalance causes dehydration because body
fluids collect in the abdomen and other tissues
- This fluid collection causes severe bloating
As noted above plus:
- Call MLFC nurses
- You may need to be seen by a
physician who will do an
ultrasound
- Record your weight daily
- Record the number of times
you urinate each day
- Contact our office if you note a
five pound weight gain over the
previous 24 hours, note a drop
in the frequency of urination
(~50%), or increasing pelvic pain
Severe
You may also experience:
- Fullness/bloating up above the belly button
- Shortness of breath
- Urination has reduced or stopped and become darker
- Calf pains and chest pains
- Marked abdominal bloating or distention
- Lower abdominal pain
This may be due to:
- Extremely large ovaries
- Fluid collects in lungs and/or abdominal cavity, as
well as in tissues
- The risk of abnormal blood clotting increases
As noted above plus:
- Notify the physician on call
- You may need to be assessed
by our physicians at the hospital
or our clinic
- Excess fluid may need to be
removed from your abdominal
cavity
Risks of oocyte (egg) retrieval may include, but are not limited to, the following:
• Potential reactions from the drugs and procedures used in the administration of
anesthesia.
• Risks associated with the passage of the needle through the vagina into the
ovaries (including infection, bleeding, inadvertent damage to adjacent structures
including, but not limited to, the bowel, bladder, blood vessels, ureter, uterus or
ovary(ies), and adhesion formation (internal scarring) following the procedure.
Although uncommon, significant bleeding or damage to the bowel may occur,
and surgery may be required to repair such damage; this is a very uncommon
event. Rarely, infection may become severe enough to require hysterectomy
and/or removal of one or both ovaries.