DR. PABON’S IVF PATIENT GUIDE
“In vitro” fertilization (IVF) is the process by which female gametes (eggs or oocytes) are brought together with the male gametes (sperm) in the laboratory in order to achieve fertilization of the egg and pregnancy. Dr. Pabon’s IVF Process Patient Guide should help prepare you for your appointments. The IVF process patient guide begins by reviewing some basics about indications and tests and concludes with the treatment steps.
A blockage or abnormal function of the fallopian tubes in transporting sperm, eggs, and embryos are among the more common problems leading to IVF. Patients with tubal problems may have a history of a prior infection like chlamydia or gonorrhea. Some patients may have endometriosis or post surgical scarring of the fallopian tubes. Some patients may have suffered with ectopic pregnancies as a consequence of tubal disease. In the past it was more common to try to treat patients with tubal problems with invasive surgeries, but since the success of IVF has improved, it is now more common to “bypass” the problem. An exception to this is the patient that had a conservative tubal ligation procedure. These patients certainly have the option to consider an outpatient microsurgical tubal ligation reversal procedure.
In nature, the sperm must “swim” through the cervix, uterus and into the fallopian tubes to reach the egg in the far ends of the fallopian tube. This is in a place called the ampulla of the fallopian tube. That is where fertilization usually occurs. Subsequently, the fertilized egg (“zygote”) proceeds down the fallopian tube into the womb (uterus). During its travel, the fertilized egg or zygote becomes a one cell pre-embryo and then a two cell pre-embryo and continues to divide into four cells, and so on until it becomes a microscopic mass of cells called a compact pre-embryo or morula. A compact pre-embryo or morula is made of hundreds of individual cells that fuse their intercellular borders as the pre-embryo “readies itself” to begin the initial differentiation into a blastocyst. The cells or “blastomeres” set up communication channels that allow for initial differentiation. The compact pre-embryo or morula begins to “cavitate.” That is, it starts to make a fluid filled cavity among the compact cells called the blastocyst cavity. In humans, the pre-embryo is about to reach the uterine cavity or womb at this time. This is usually five to six days after fertilization. By bypassing the fallopian tube, the IVF clinic carries out the function of the fallopian tube during these early stages of development of the pre-embryo.
Male factor problems:
Large numbers of sperm are needed to achieve fertilization. Abnormal sperm development or function also causes fertilization problems under natural circumstances. About 35% of couples that seek consultation for infertility/subfertility have a problem in the quantity or quality of sperm. The basic sperm count or “semen analysis” should be done in a facility specializing in the treatment of infertility and this usually means that the facility should perform IVF. The physicians and technicians that work in these facilities usually are more attentive to the subtleties of the clinical implications of a semen analysis. The initial step in evaluating a couple is a routine consultation, but very soon after that, a semen analysis should be done. The most important parameters of a basic semen analysis are the volume, concentration, motility, and morphology. The normal parameters that are considered the lowest of the low normal numbers in a fertile population represent the lowest 5th percentile of the fertile populations studied. This is called the World Health Organization’s Semen parameters guidelines. The lowest normal sperm count is 15 million cells (sperm) per milliliter or cc of seminal fluid. The other lowest numbers are a volume of 1.5 cc’s, a motility of 40%, and a normal appearing cell percent of 4%. There are many patients that have counts in the lower ranges that experience subfertility and require either artificial inseminations, IVF, and even intracytoplasmic sperm injections (ICSI). A patient with a low sperm count should have both a hormonal evaluation as well as a physical exam with a urologist. Be careful to seek a second or third opinion if a urologist discovers a “varicocele” and recommends surgery. Many varicoceles (distention of veins around the testicle) are present without being the cause of a problem. If you have a very low sperm count, less than 5 million per cc., you should also have a test for cystic fibrosis and a Karyotype (chromosome analysis). Patients with counts less than 5 million per cc., should consider sperm banking frozen sperm just in case their count lowers to zero in the future and also as a “backup” for the IVF procedures just in case the day of the IVF the count is much worse.
One of the important things to know about male factor infertility is that it may be a dynamic process. A patient may present with a “lowish” sperm count and a year or two later, the count may be worse or even zero. It is never a bad idea to bank a couple of specimens for the future. Patients with very low counts should always bank sperm even during the evaluation. Sometimes the evaluation can take several months. Some patients with subtle hormonal problems may be treated with a trial of Clomiphene citrate, hCG, or even gonadotropins (FSH/hCG) for several months prior to repeating the count. Dr. Pabon will determine if the patient is going through primary testicular failure (irreversible) or pituitary or hypothalamic insufficiency. Patients with pituitary or hypothalamic insufficiency will reflect this in their hormone profiles and may be candidates for Clomiphene Citrate, hCG, FSH, or a combination of these.
Another important issue with male factor infertility is that the male children of men with severe sperm count problems may inherit that same trait. The genes that carry the information for making sperm are on the Y chromosome. These genes are closely linked to genes responsible for the normal descent of the testicle from the abdomen into the scrotal sac during fetal development as well as the normal development of the penis. Patients with severe male factor problems have been shown to have an increased incidence of “urogenital anomalies” in their male offspring. It is believed that this is a result of the genetics of the patient and not caused by the treatment (IVF and ICSI). Some patients may ask about a test called the “Y chromosome microdeletion assay”. This is a sophisticated test that goes beyond a chromosome analysis. It actually “stretches” the Y chromosome so we can detect abnormalities in small regions of the chromosome. Clinically, this has not been a routine test because it is expensive and doesn’t change treatment. The only practical clinical application for this test is for patients that do not have any sperm in the ejaculate and are being prepared for a surgery called a microsurgical sperm aspiration. Patients with multiple deletions in the Y chromosome have a high probability of not having a successful surgical sperm aspiration. So, the Y chromosome microdeletion is more of a pre-surgical counseling tool. If a patient would consider using a donor sperm specimen or not having children at all because of Y chromosome deletions, then it would be ordered more routinely. Now, in the age of pre-implantation genetic diagnosis (PGD) there may be patients that would use the information to choose to have only female children (46XX) with no Y chromosome.
Other reasons to consider IVF are secondary infertility, advancing maternal age, artificial insemination failures, known genetic disease, a need for either an egg donor or a gestational carrier, or simply a desire to have control over the gender of the next child (family balancing).
The process of IVF involves several steps as follows:
Please note that this guide reviews some of the most common protocols. Depending on your medical history and many variables such as age and prior treatments, Dr. Pabon may modify your treatment.
Consultation with the Physician:
During the initial consultation with Dr. Pabon, he will review all your pertinent medical history and may perform a physical exam. This time is spent reviewing the indication for “in vitro” fertilization, the pre-cycle tests, the IVF procedures, the available technology and the limits of the technology. Dr. Pabon will also review your age specific risk of chromosomal problems (like Down’s syndrome) in the baby. If you have extensive records for Dr. Pabon to review, it is important to make these available several days before your consult so he can have time to review them prior to your consultation. Some patients with chronic medical problems or very significant past histories may be informed of the possibility of a very high risk pregnancy as well as the option of not seeking treatment or considering the gestational carrier program (surrogacy). If you are at significant increased risk to either yourself or your baby, then Dr. Pabon will usually refer you to have further counseling from a high risk pregnancy or Maternal/Fetal medicine specialist (MFM) so you can be established as a patient and so both you and your partner can hear about your possible risks from a different perspective. This can be seen by some patients as an inconvenient step, but it is an important part of our informed consent process. Dr. Pabon often says: “just because we can do something, it does not mean that we should do it”. Another very common discussion at the time of the initial consultation will revolve around the general health of the patient. Unfortunately, the whole western world and especially the United States is in the midst of an obesity epidemic. In the recent years much scientific literature has been published regarding the much increased risk in the pregnancies of obese women. Obesity is defined as a BMI above 30. There are many BMI calculators available online as well as phone “apps”. The risk is present both for the mother and the baby. Maternal complications in pregnancy are significantly increased with increased blood pressure and the possible resulting pre-eclampsia/eclampsia, diabetes, increased risk of surgical deliveries as well as complications from the surgical delivery. The pre-eclampsia complication is very worrisome because it can lead to the failure of the liver and kidneys in pregnancy and result in fatal seizures. The diabetes complication can lead to an increase in the risk of congenital anomalies as well as large babies that fail to deliver naturally. The increased risk of Cesarean delivery results for unknown reasons, but in obese patients there is an increased risk from such surgeries. Complications like lung clots, strokes, and infections are more common. The risks to the baby come mainly from problems associated with being born too early. The above complications of pre-eclampsia and diabetes often result in a pre-term birth that can leave a very small baby at risk of breathing problems, feeding problems, and even bleeding in the brain. All these can result in significant morbidity, chronic afflictions, and even death. That is why Dr. Pabon will most likely counsel you about your weight if need be. In addition, IVF can be quite a journey. You want to optimize your chance of success. Obesity has been shown to lower the chance of success with IVF. At the initial consultation Dr. Pabon will also review your genetic history and will most likely order a Counsyl genetic test. The Counsyl genetic test will test for cystic fibrosis, spinal muscular atrophy, fragile X, as well as many recessive diseases that can be prevented with Pre-implantation genetic diagnosis or at least give the patient the option of testing the early pregnancy. These pre-pregnancy tests are recommended because the cost has decreased significantly while the accuracy and the ability to do more tests has increased. It is estimated that all humans carry at least eight recessive diseases in their genetic information. When a couple just happens to carry the same recessive gene out of the millions of genes, then that couple has a one in four chance of having a baby with a serious problem. Please understand that even the Counsyl blood test does not test for all possible problems, just the most common ones. Please read more about this at Counsyl.com. Humans have an expected rate of congenital anomalies of 3-4%. Some recent studies have mentioned that patients that are treated with IVF may have a slightly increase in the risk of congenital anomalies. Most critics of these studies (including Dr. Pabon) emphasize the fact that most such studies are only studying infertility populations. Some better done studies that looked at the risk of what are called imprinting genetic disorders like the Angelman syndrome have been properly controlled by not only studying infertility patients but also fertilie populations. After careful analysis, these studies found that it likely that the slight increase in these problems are more likely due to an inherent predisposition within the infertility patients. They found that infertility patients that did not seek treatment and eventually conceived also had a slight increase in some of these congenital problems. The most significant noted increase in congenital anomalies after IVF has been noted in Twin pregnancies. Twin pregnancies may have a 2-3 times higher risk of severe cardiac anomalies. That is why most great clinics go to great lengths to try to avoid multiple pregnancies.
The Physical Exam:
Dr. Pabon will usually postpone the physical exam until the time of the ultrasound evaluations (saline sonogram and practice embryo transfer). Sometimes when patients are trying to rush to get into the IVF schedule, they may come into the consult expecting to complete the entire pre-IVF evaluation. This is most common with out-of-town patients or patients that are seen in our satellite office in Bonita Springs. At the physical exam you will usually have a complete pre-surgical examination that will include a pelvic exam and a breast exam. If you will be completing all the pre-IVF tests in one visit, then make sure that you have a medium bladder as it is needed as a window for the abdominal ultrasound. Don’t overdo, a medium or slight bladder is enough. During the physical exam, Dr. Pabon will also do a cervical/vaginal culture to rule out any potential bacterial overgrowth that may interfere with the embryo transfer procedures.
The pre-IVF uterine evaluation:
It is important for all patients to have an ultrasound, radiological (HSG), or hysteroscopic evaluation of the uterus before attempting to conceive with IVF. There are different options for this pre-ivf evaluation. What is important is that it should be done within six months of the treatment and perhaps closer to the treatment if there are any new sypmptoms like changes in the pattern of menstruation. Some patients that are referred may have had a hysterosalpingogram (HSG) as part of their infertility evaluation by their Ob/Gyn physician. This test would be acceptable if it has been done within six months. Please try to bring pictures and or a CD file so Dr. Pabon can look at the actual images instead of just a report. Not all HSG’s give an adequate view of the endometrial cavity.
Alternatevely, patients may have had a surgical evaluation called a hysteroscopy. This is also acceptable. Please bring photos and surgical notes.
More commonly now is the use of ultrasound to assess the uterine cavity. This can be done in the office. It involves a physical exam and the placement of a small catheter through the cervix and into the uterus. Although it sounds uncomfortable, most patients report no discomfort with this procedure. It gives images of the inside of the uterine cavity as well as the uterine walls, and the ovaries.
Patients traveling from out of the country may have an easier time scheduling a hysterosalpingogram instead of a saline enhance ultrasound. We recommend that you try the saline enhanced ultrasound, if possible, as it can be an easier procedure. There are some patients for whom Dr. Pabon will perform an HSG. These are patients in whom he suspects a hydrosalpinx or a uterine anomaly that may be more easily discerned with the HSG. Sometimes the recommendation for the HSG follows the saline enhanced ultrasound.
The practice embryo transfer or “mock transfer” and endometrial aspiration (biopsy):
This is a test that is usually done at the same visit after the saline enhanced ultrasound. The purpose of this test is to map the entry point in the cervix, note details of the “twists” of the cervical canal, measure the length of the cervix, and the depth of the uterus. Patients are asked not to void prior to the saline enhanced ultrasound (unless the bladder is very full). The mock transfer and endometrial biopsy begin with a multifrequency trans-abdominal ultrasound. Measurements are taken. Then, a vaginal exam is performed. A small catheter with measurement markings is slowly and gently inserted into the cervix while an assistant monitors with the trans-abdominal ultrasound. Measurements are taken. After the mock transfer is completed, an aspiration of the lining of the uterus is taken in order to obtain a small amount of endometrial tissue for analysis. This tissue is submitted for pathologic examination. Abnormalities of the endometrium such as chronic inflammation or hyperplasia may require treatment prior to IVF. Recent studies have shown that implantation rates may be improved in the months following these procedures.
Some patients may have severe narrowing of the cervix. This can make the embryo transfer very difficult and significantly decrease the chance of pregnancy. Patients with cervical stenosis will usually be treated with in office cervical dilatation and cervical stent placement 2-3 weeks before they start their IVF meds. This procedure is usually done under deep sedation with the assistance of one of our anesthesiologists.
For your appointment for either an HSG, a saline enhanced ultrasound, or the mock transfer/endometrial biopsy, you may take Ibuprofen 600-800mg approx one and a half hour before your appointment. If you have allergies to Ibuprofen, Tylenol is an alternative. Don’t let this recommendation make you nervous. The great majority of patients don’t experience discomfort.
Evaluation of Ovarian Reserve and Pre-IVF Labs:
Ovarian reserve is a term given to a patient’s ability to respond to fertility medications (gonadotropins). If a patient has normal ovarian reserve, then it implies that usually this patient will respond well to average doses of fertility drugs. That means that the patient will be able to recruit 7 or more egg follicles using average doses of gonadotropins (FSH, LH, hCG). If a patient has diminished ovarian reserve, then it implies that the patient will require high doses of gonadotropins and will make one, two or a small number of ovarian follicles depending on how low the ovarian reserve is. If a patient has an increased ovarian reserve, then it implies that she may respond excessively to average doses of the gonadotropins and care needs to be taken to avoid severe hyperstimulation. Patients with high ovarian reserve may either be very young, very healthy, or have the polycystic ovary syndrome.
The most common way that ovarian reserve is checked is by blood tests and ultrasound. The blood tests are the early follicular phase (blood draw done menstrual cycle day 2 or 3) Follicle stimulating hormone test (FSH) and Estradiol (E2) as well as a random Antimullerian hormone (AMH) test. The FSH and E2 check the way the pituitary and the ovary are communicating with each other. A high FSH implies that the pituitary gland is “shouting” at ovaries that are being “stubborn” or have diminished ability to respond (diminished reserve). A low FSH implies that the ovary is responsive to smaller amounts of the hormone in order to make egg follicles. There are exceptions to these general statements. A patient that is under a lot of physical and/or psychological stress may have a low FSH despite having a low ovarian reserve. The estradiol test is used to sort these out, but more frequently now we are relying on a combination of AMH, resting follicle (antral follicle) counts, FSH and the estradiol. These are listed in diminishing order of importance.
The vaginal ultrasound that can be done separately or at the time of the saline enhanced ultrasound allows measurement of the ovaries and the number of small resting or antral follicles. Patients with small ovaries and few resting follicles will usually respond with fewer egg follicles and require higher doses of gonadotropins to stimulate them. Patients with larger ovaries and many resting follicles will usually require lower doses of gonadotropins and respond more generously.
The levels at which patients face terrible news are relative. If a patient is young (less than 34) and is found to have severely diminished ovarian reserve with an FSH above 14 but not higher than 20, an AMH between 0.1 -0.5, a normal E2, and 0 to 1 resting follicles, she will be informed that she has a diminished chance of pregnancy because she may only make one or two oocytes per stimulation. In addition, she will require an aggressive and expensive ovarian stimulation. She should be aware that she should consider the annonymous egg donor program, but will be allowed to proceed with IVF if she wishes and understands the above. Ovarian reserve is separate from egg genetic quality. If a patient recruits one egg follicle and it is a normal egg (genetically) then she has a fair chance of pregnancy even with diminished ovarian reserve.
If a patient is closer to 40 or above and has severely reduced ovarian reserve, she will be strongly adviced to consider the egg donor program because older patients make many more genetically abnormal eggs than younger patients. Therefore, the odds of a pregnancy are much lower.
Other pre-IVF blood tests are routine health check tests and pre-natal blood tests. These include infectious disease screening tests (HIV, HepBSurface antigen, HepC antibody, CMV, and RPR), a complete blood count (CBC), Rubella and Varicella titers, Thyroid Stimulating hormone and antithyroid antibodies, in addition to the Counsyl genetic test described above. The infectious disease tests are required to be completed within six months of treatment. They are needed so that the IVF team can isolate potentially infectious tissues both in time and space in order to avoid problems with contamination. The infectious disease tests are required prior to the freezing and storage of sperm, eggs, and embryos since products from patients with infections need to be completely isolated in separate cryotanks.
Patients involved in treatments with gestational carriers will have to be screened for infectious diseases with special FDA approved laboratories at specific times before conception. It is most advisable for the male patients in a gestational carrier treatment to have their complete FDA tests in the months before the IVF treatment and to submit a sperm sample for freezing within seven days of the FDA blood test. This assures complete compliance with the FDA and avoids last minute errors in screening during the busy IVF stimulation phase of the treatment.
If you are keen to enter the IVF program, please let us know so that the staff can order the menstrual cycle specific blood tests (FSH and E2) even prior to your initial consult. You may also wish to have the sperm test done prior to your initial consultation.
The Pre-IVF Sperm Test:
Prior to IVF you will be asked to submit a specimen for a complete semen analysis. Dr. Pabon accepts semen analyses only from our own andrology labs or other IVF centers as they are the most reliable for this. The semen analysis should be repeated if it has not been done within six months. In addition, the pre-IVF semen analysis should include an anti-sperm antibody test. The antisperm antibody test is important in deciding whether to inseminate the eggs more naturally by bathing the eggs with about 100,000 sperm per egg or whether the insemination should be done with single sperm using intracytoplasmic sperm injection (ICSI). Anti-sperm antibodies develop if men have had testicular trauma, inguinal or groin surgeries, testicular surgeries, vasectomy reversals, or sometimes without any obvious history. In the testicle, the manufacturing of sperm is normally kept separate from the blood system within the seminiferous tubules. If there is a breach of the “seminiferous tubule-blood barrier”, the white blood cells can mount an autoimmune respose than can result in excessive levels of antibodies that appear in the seminal fluid and can effectively block fertilization by blocking the sperm-egg interaction. Patients that are found to have anti-sperm antibodies in the seminal fluid will be treated with ICSI as standard IVF insemination would usually yield low fertilization.
All cases of pre-implantation genetic diagnosis require ICSI. Therefore, patients planning PGD/PGS do not need to do the antisperm antibody test.
When submitting a specimen for semen analysis, the patient must have abstained from ejaculation for 2 days and no more that 7 days. You may request a collection kit and collect at home if you wish. Try to drop the specimen within 45 minutes of collection and close to your appointed time.
Here Begins the IVF Process….
The Down Regulation Phase:
Most IVF treatment cycles require a preparatory phase called the down regulation phase. During this phase, the ovarian follicles are synchronized in order to assure a more cohesive ovarian response. The down regulation can be achieved with a simple low dose oral contraceptive pill or an estrogen and progesterone combination. Some patients cannot use a birth control pill for medical reasons and in this case the down regulation can be achieved with a brief period of estrogen after ovulation or with the use of Lupron.
The most common entry into the IVF program is as follows:
The day 2-3 FSH and E2 blood test usually done menstrual day 2-3 (day 4 is fine if day 2-3 is a weekend or holiday). Please inform the nursing staff if the blood draw was on a day other than day 2-3.
Begin the low dose oral contraceptive (Desogen or generic equivalent) on menstrual cycle day 5.
Come in for the pre-ivf tests while taking the oral contraceptive pill
Meet with the nurse or medical assistant to go over the IVF medications and the injection techniques and also to review that all the pre-ivf blood tests have been done.
If you will be using Lupron for your down regulation, you may also have to be on the oral contraceptive from the 5th day of the menstrual cycle before.
If you cannot use an oral contraceptive due to intolerable side effects or because of a medical reason, then you will usually be scheduled for a blood test around menstrual cycle day 20 or 21. This blood test will check your progesterone level as well as a pregnancy test. If the tests are in order, then you will be instructed to begin the Lupron injections at the prescribed doses or the estradiol/progesterone supplement.
Remember: continue to take active birth control pills until the pill stop day. If your protocol leads in with birth control pills, you must know that the first 21 pills in the pack are “real” pills while the last 7 are “fake sugar pills.”. If you have been instructed to stay on pills, you should know that means to stay on active “real” pills. If your pill stop day is, for example, 26 days away, then you will take 21 “real” pills from one pack and have to discard the last 7 “fake sugar pills” and start a fresh new pack in order to make it to your pill stop day. Also, the birth control pills should be taken at bedtime. The protocols are designed for this.
The Medication Instruction:
This is an appointment with the nurse or medical assistant. If you do not speak English, please bring your translator with you. If you live far away and are unable to come to the office for this, you can do this appointment over the internet with Video SKYPE. Our nurse’s skype name is FCAGOG Nurse Station. During this appointment you will review the planned dates of treatment as well as make sure that all labs and consents are in order. IVF meds require subcutaneous injection. The final trigger injection can either be subcutaneous or intramuscular. You will be taught the techniques for safe and efficient injections. If you will be having someone else do the injections, they should come to the appointment even if they are a physician or nurse. The most common medications used in our treatments are birth control pills, Lupron, Follistim, minidose hCG, Pregnyl, and progesterone supplements. There are other medications that may be used in place of the above depending on individual needs or insurance coverages.
The Ovarian Stimulation Phase:
The ovarian stimulation begins after the oral contraceptive pill or estrogen/progesterone supplement has stopped. Remember that the oral contraceptive pill needs to be taken at bedtime. The most common protocol involves taking the last active birth control pill at bedtime on a Monday night. Patients would have had a “baseline” ultrasound in the weeks before the pill stop. The following Sunday evening the first injectable FSH will start. Some patients will also inject the mini hCG injection at the same time. Another injection of FSH will be given Monday night. On Tuesday morning the patient will have a blood test for Estradiol and LH. Dr. Pabon will review the results and the staff will call the patient with the adjusted doses for the next few days. Patients should expect an appointment for ultrasound and a blood test the following Thursday or Friday. After that patients will probably be seen on Monday. There may be a need for further appointments on Tuesday or Wednesday. The oocyte retrieval or follicular aspiration will usually occur that Wednesday, Thurday, Friday, or Saturday depending on patient’s individual responses.
There are some patients that may fail to respond adequately. This may lead to cancellation of the treatment. When this happens, it is for the best as subsequent stimulation usually results in a better response. There are some patients that over-respond unexpectedly and may be cancelled for safety reasons due to a very high risk of severe ovarian hyperstimulation syndrome. Some patients that respond aggressively may already be planning an “all freeze protocol”. Alternatively, the “all freeze protocol” may be required if the patient is at risk of ovarian hyperstimulation syndrome or has a high progesterone level on the final day of stimulation. Please review the “all freeze protocol” information. Each visit of the stimulation phase requires an assessment of adequacy and safety. Fortunately, only about 10% of patients have to be cancelled. Pregnancy rates in the cycle following a cancellation are quite good.
The Oocyte Retrieval or Follicular Aspiration:
The ovarian follicles will reach maturity after about nine to twelve days of stimulation. The final maturation of the eggs or oocytes will be triggered by high dose hCG at a dose of 5,000 to 10,000 units intramuscularly, with Ovidrel subcutaneously, or with an agonist trigger of Lupron 80 units subcutaneously sometimes combined with a small dose of hCG subcutaneously. The exact type of trigger is individualized for each case. The trigger injection must be given at the exact time that you are told so that the egg retrieval will be 36-37 hours later.
The oocyte retrieval is most commonly done in the office. Patients are asked not to wear perfumes or scented body lotions. In addition, patients must not eat or drink anything the morning of the procedures. Even chewing gum is a problem. Try to be punctual as the timing of the procedures is important. The anesthesiologist will interview the patient in a consultation office. After the interview, a female staffperson will escort you to the procedure room. The anesthesiologist will start the IV and begin intravenous hydration. Patients also are given a preventative IV antibiotic at this time. The embryologist and Dr. Pabon carry out a “time out” at this time to comfirm the patient’s identification and allergies. The patient is positioned for the trans-vaginal ultrasound guided procedure. The ultrasound is started as the anesthesiologist starts to give the patient the sedatives. Once the patient is sleeping comfortably, Dr. Pabon tests with added pressure with the ultrasound and if the patient appears to be quite sleepy, he proceeds with the insertion of the aspiration needle while being guided by the ultrasound image. The egg follicles are sequentially aspirated and the follicular fluid is immediately passed to the laboratory. An oocyte aspiration usually takes about ten minutes. The sedatives are stopped and the patient wakes up and usually feels no discomfort. Some patients may experience menstrual like cramping. If the discomfort is significant, additional IV pain medications can be given. The patient is then taken to the recovery room where vital signs are monitored under the supervision of Dr. Pabon and the anesthesiologist. The total time in the office is usually about 45-90 minutes.
The male partner may bring a fresh semen sample from home if the time to the office is less than 45 minutes or alternatively, the patient can collect in the office collection room. Male partners are also asked to not wear cologne as the rooms used are close to the IVF tissue culture laboratory.
These procedures are extremely safe in our center. Dr. Pabon has been performing these procedures routinely since 1993. There has been only one complication. One patient developed an infection in one of her ovaries many years ago. This required antibiotics and an eventual surgery to drain an ovarian abcess. Prior to this infection, patients were prepared for the procedures with oral antibiotics. Since then our routine is to use both oral antibiotics as well as IV antibiotics just prior to the egg retrieval. No infections have happened since. As the consents state, there can be complications from the oocyte retrieval. These are extremely rare; especially in very experienced hands.
After Egg Retrieval:
Patients will receive detailed instructions and handouts regarding post retrieval instructions. The day after the retrieval patients receive a phone call about the fertilization results. Dr. Pabon will have made decisions regarding the embryo transfer day (day 2, 3 or 5) depending on all the details of the case. Patients who are doing PGD will usually receive the “normal” embryo on day 6 of culture. Patients doing an “all freeze” protocol or those that have a high risk of ovarian hyperstimulation require freezing of embryos. In that case the transfer will usually be the next month.
The Embryo Transfer:
Most embryo transfers require a medium to full bladder. Note that Dr. Pabon will not do a transfer if the patient is uncomfortable. Feel free to partially empty your bladder if you feel too full. Patients will have been instructed on bladder training exercises leading up to the IVF. That is, empty the full bladder for 20 seconds and then stop. Then empty the rest 10 minutes later. This exercise will prepare patients for the requirements of the embryo transfer.
Prior to the embryo transfer, Dr. Pabon will review the embryology and explain the results of the culture and genetic testing results of embryos if PGD was done. Dr. Pabon will review the risk of multiple pregnancy depending on the age of the patient and discuss if one, two, or more embryos should be considered for transfer. The patient is then brought to the procedure room. An abdominal ultrasound is performed to assure that the bladder is just right. If not, the patient will be asked to empty a bit or wait to fill.
The the rest of the embryo transfer is like a very gentle and careful gyn exam. A speculum is inserted, the cervix is thoroughly cleansed, the transfer catheter guide is placed through the cervix and then the embryos are loaded and transferred into the uterus according to past and concurrent ultrasound and mock transfer measurements.
The patient is asked to remain quiet for five minutes. The patient is allowed to empty her bladder 5 minutes after the transfer and is discharged home. Post transfer instructions are reviewed and plans are made for the initial pregnancy test.
After The Embryo Transfer:
After the embryo transfer patients should rest. Absolute bed rest is not necessary. Just take it easy. Patients should pretend that they hurt their back and are “taking it easy”. Most importantly, continue the progesterone supplements and the estradiol patch (if prescribed). Some patients may also be taking a tapering dose of medrol.
Patients may experience mild cramping or even some vaginal bleeding. Don’t be frightened. Vaginal bleeding is quite common at this stage. Please notify the office. Some patients will do home pregnancy tests a day or two before the scheduled blood test and should call if it is positive. Please don’t be distressed if the test is negative. The urine tests are not as sensitive as the blood tests at this stage.
Please prepare for both possibilities. There are no absolute guarantees. Just because the embryos looked good, it does not guarantee that they are normal genetically. Also, the genetic tests with PGS/PGD have their limits. Not every gene or gene switch is checked. So even so called “euploid” or “normal” embryos by PGD may not develop normally.
Our clinic is quite rare for the personal care that we provide. We assure you that we will celebrate when you are happy and will grieve if your treatment is not successful.
This guide is meant to serve as an outline. The policies and procedures change as science and medicine changes. Our web documents will never be as up to date as we are.