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Smoking: Stop smoking before ovulation induction begins. It is best to discontinue
tobacco at least 2 months prior to an IVF cycle. If you cannot stop “cold
turkey”, make an effort to stop at least two weeks prior to the egg
aspiration. By products of tobacco have been demonstrated to be toxic to the
oocyte (egg). Numerous studies have also demonstrated that smoking during
pregnancy results in reduced birth weight and fetal compromise. There is
some data that smoking can also lower pregnancy rates. We strongly recommend
that all women, especially those undergoing fertility treatment, cease smoking.
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Drinking: Alcohol is a drug, and should be avoided during infertility
treatment and pregnancy. Please do not drink alcohol from the time fertility
medications are initiated until the pregnancy test.
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Medications: If you are taking any medication, prescription or
over-the-counter, please inform your physician. Some medications may
interfere with the fertility medications prescribed, some are not safe
to use before an operation or medical procedure, and others might interfere
with ovulation or pregnancy implantation. A prenatal or multivitamin will
be prescribed; if you are not taking a vitamin with folic acid, please
inform the ART nurses.
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An IVF cycle can be an emotional and stressful time for you and your partner. It
may be helpful to have supportive personnel to speak to, such as friends
and family, a clergy member, or a psychologist/therapist.
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Heavy exercise such as aerobics, jogging, weight lifting etc. are prohibited
during ovarian stimulation and until the pregnancy test results are known.
2. How does the ART laboratory operate and what safety measures are taken? What will happen to the eggs and sperm after retrieval?
On the day before the oocyte (egg) retrieval, oocyte culture dishes are labeled with
the patient’s name, date of birth, and ART identification number. The number
and size of the ovarian follicles determines the number of dishes prepared
(one dish for each large follicle). The dishes are filled with a rinsing
fluid in the outer well for removing blood and other extraneous cells from
the egg, and a nutrient fluid for the culture of the egg is in the center well.
The dishes are then placed in the embryology incubator for warming to body
temperature. The incubator also adjusts the pH of the culture media to the
human body. A large amount of rinsing media is equilibrated in the
incubator. The fluid is used by the physician to wash the oocyte from the
ovarian follicle if it is not found in the initial aspirations. Media is also
equilibrated in the andrology laboratory for processing of the sperm.
One of the more important and useful IVF laboratory instruments is the mobile IVF chamber. It
is a pediatric isolette (incubator) on wheels that has been modified to
contain a scanning microscope. Prior to the egg retrieval it is warmed to
body temperature and put at the normal neutral pH of the culture dish
media. These conditions avoid any abrupt changes the eggs might encounter
outside the body. The chamber has two small doors on each side. The
embryologists place their hands on one side to identify eggs and move
dishes. The OR nurse uses the opposite doors to pass test tubes containing
the follicular fluid to the embryologist.
Upon arrival in the operating room the patient’s identity is verified by the embryologist,
physician, and safety nurse. They also verify that the culture dishes are
correctly labeled. At the time of surgery the mobile chamber is loaded
with the equilibrated large dishes for receiving the follicular fluids, and
a sterile pipette (similar to a large eye dropper) for picking up the eggs. It
is then moved from the embryology laboratory to the adjoining operating room.
The physician aspirates the fluid from the ovarian follicles into a test tube. A nurse
passes the test tube, through the IVF chamber door, to the embryologist. The
embryologist then dispenses the fluid into a large dish and rapidly scans it
under the microscope. The egg complex is usually visible to the naked eye,
but microscopic verification is always done. The oocyte is removed from the
large dish by pipette, rinsed in the outer well of the culture dish and placed
in the center well for culture and the addition of sperm (insemination). The
presence of an egg in the follicular fluid is immediately reported to the
physician. The physician will then discontinue washing that particular
follicle.
After all of the eggs have been aspirated, the mobile chamber is moved to the
embryology laboratory for a more critical assessment of the oocytes,
insemination with sperm, and culture. The embryologist uses fine needles
to spread the cumulus mass that obscures the oocytes.
The maturity and health of oocytes can be more accurately assessed by thinning this
mass. Oocytes are graded as mature, intermediate, immature, or degenerate.
Oocytes judged mature are incubated 1 to 4 hours before insemination. Less
mature oocytes are incubated until they reach maturity, and then
inseminated. 100,000 motile sperm are added to the media surrounding the
oocyte in the center well of the culture dish. Dishes containing egg and
sperm are then returned to the main embryology incubators for culture.
The male will be asked to collect a semen sample after the oocyte aspiration. The
andrologist escorting him to the collection room will identify the patients
partner from his identification bracelet prior to collection and will write
both names on the outside of the specimen container after collection. The
partner will be asked to verify that both names are correct.
Approximately 30 minutes after collection, when the semen liquefies, a semen analysis is
performed. The sperm is prepared for insemination, usually by “swim-up.” The
swim-up procedure begins with two centrifugal washings of the semen to
remove the seminal fluid. The seminal fluid is an excellent media for
the sperm, but extended exposure is detrimental. The concentrated sperm
is then covered by a layer of the equilibrium preparation media and placed
in an incubator. The sperm are allowed to swim-up in the upper layer for
one to two hours.
Twenty to twenty-four hours after retrieval, the oocytes are transferred to
fresh dishes that were equilibrated on the day of retrieval. This pipette
procedure and all future transfers to fresh dishes are done in the mobile
IVF chamber.
Oocytes are then microscopically examined for pronuclei formation, the sign of
fertilization. The pronuclei are the decondensed DNA of sperm and egg
nuclei. They appear microscopically as two light spheres within the
egg. Polyspermic oocytes, those possessing more than two sperm pronuclei, are
discarded. These abnormal fertilizations are typically naturally aborted.
Fertilized oocytes in excess of those needed may be cryopreserved at this time or in the
next two days of culture. Fertilized oocytes for uterine transfer are
returned to the main embryology incubator for 24 hours. At that time the
embryos are transferred to fresh dishes where the cell stage and overall
health of the embryos are microscopically evaluated. The embryos are then
returned to the main embryology incubator for the final 24 hours before
uterine transfer.
3. When is the pregnancy test performed?
The blood pregnancy test is performed 14 days after the embryo transfer.
4. What happens if I become pregnant?
If pregnant, the patient is asked to return to the office for repeat blood work
and ultrasounds to ensure an ongoing successful pregnancy. After a fetal
heartbeat has been confirmed, patients are referred to an obstetrician for
the remainder of the pregnancy.
5. If I am not pregnant, when can we try again?
Usually we ask that patients wait one or two complete menstrual cycles before
beginning another ART cycle. Sometimes tests are required that may delay
subsequent cycles.
6. Will I need a high risk OB because I conceived with an ART procedure?
A high risk OB is only needed when there are complications that put the
mother or baby at increased risk, or in the case of multiple births. Other
than a higher incidence of multiple births, ART does not increase the risk
to the fetus.
7. Is there a higher miscarriage rate for ART patients?
The miscarriage rate is about the same for ART as the general population. Many times
older females undergo ART and their miscarriage rates are naturally
higher. Since pregnancy testing is done two weeks after embryo transfer, we
often know about spontaneous miscarriages in the very early stages of
pregnancy. These miscarriages would probably go unnoticed in the general
population.
8. What can be done to improve sperm quality?
Sperm quality on the day of egg retrieval is often related to what happened
in the male’s body 3 months ago. This is because sperm development takes
3 months. Listed below are guidelines to help ensure the semen specimen is
of the best possible quality.
v
A fever of 101 degrees Fahrenheit or higher within 3 months prior to ART treatment may
adversely affect sperm quality. Sperm count and motility may appear normal,
but fertilization may not occur. If you become sick during the ART cycle,
please notify the ART nurse, and take Tylenol to keep your temperature below
101 degrees Fahrenheit.
v
Keep the use of alcohol and cigarettes to a minimum before and during ART treatment. Do not use any “recreational” drugs.
v
If any prescription medication has been taken during the last 3 months, notify the ART nurse.
v
Do not sit in hot tubs, spas, Jacuzzis, or saunas during or 3 months prior to the ART cycle.
v
Do not begin any new form of endurance exercise during or 3 months prior to the
ART cycle. Physical activity at a moderate level is acceptable and encouraged.
v
Avoid all testosterone, DHEA, and Androstenedione/Androstanediol hormone containing supplements.
v
Tell your infertility physician if you have ever had genital herpes, or suspect
you may have been exposed to genital herpes in the past. Also tell your
physician if you have pre lesion symptoms, develop a lesion, or have healing
lesions before or during the ART cycle.
v
Refrain from ejaculation for 2-3 days, but not more than 5 prior to collecting the
semen sample for the ART cycle. The ART nurse will have your specific
instructions from the Andrologist.
9. How do we decide how many embryos to transfer?
Your physician will discuss this with you at the time of consent signing, but
we usually follow the recommendations of The Society for Reproductive
Medicine guidelines:
v Under 30 years old = 1-2 embryos
v 30-35 years of age = 2-3 embryos
v 35-40 years of age = 3 embryos
These numbers may vary depending on individual diagnosis and clinical circumstance.
10. Am I depleting my store of eggs by undergoing an ART cycle?
A woman is born with a full complement of eggs. There are far more
eggs than will ever be used during a normal lifetime and ART procedures
have no measurable “lowering” effects.
Copyright © 2005 Reproductive Medicine Group. All Rights Reserved.