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In Vitro Fertilization or fertilization "in glass" is a treatment for infertility due to a variety of diagnoses including, but not limited to, ovulatory dysfunction, tubal blockage, endometriosis or low sperm count. Eggs and sperm are placed together in a nutrient- rich medium and are kept in an incubator that controls temperature, humidity, carbon dioxide and oxygen concentrations to closely mimic the environment of the Fallopian tube, the organ in which fertilization normally occurs.
In Vitro Fertilization is only one assisted reproductive technique that may be recommended to treat infertility. Before any treatment occurs, a couple should have a multi-step diagnostic workup to determine which infertility treatment is most likely to be effective.
Ovarian Stimulation. Typically, your physician will prescribe a regime of medications that are taken daily for a period of 10-12 days to stimulate your ovaries to produce more eggs than the single egg you normally produce without medications. This treatment phase is called controlled ovarian stimulation and requires frequent monitoring of hormonal blood levels as well as vaginal ultrasounds to track follicular growth. From these tests, your physician will know when you are ready for the egg retrieval. Thirty-six hours before your egg retrieval is scheduled, you will take a medication to induce the final "ripening" of your eggs.
Ultrasound-guided Egg Retrieval. Egg retrieval is an outpatient surgical procedure. You will receive conscious sedation for this procedure. You may have your partner or other support person with you for the egg retrieval. Your physician will insert an aspiration needle through the vaginal wall to reach the ovaries. Your physician will "retrieve" the eggs from your ovaries into a sterile tube that is then passed to the embryologist, who identifies and washes each egg. The egg retrieval is normally completed within 20-40 minutes. The embryologist quickly transfers each egg to a nutrient-rich growth medium. You will typically be discharged after two to three hours' rest in recovery.
Insemination. The eggs are combined with sperm (insemination) by the embryologist. Typically, the semen sample is provided by the partner the day of the egg retrieval. Sometimes, cryopreserved semen from the partner is used for insemination. Some patients may choose to use an anonymous donor from a commercial semen bank or a known (directed) donor for the insemination. Anonymous and directed-donors are required to undergo rigorous infectious disease testing and six-month quarantine and retesting before the specimen can be used for insemination. The semen sample is prepared for the insemination by a multi-step processing procedure that includes a semen analysis. Semen processing for in vitro fertilization may include thawing the specimen if it was cryopreserved. A small portion of this optimized semen sample with each egg. Eggs and sperm are then cultured in an incubator overnight. The next morning, the eggs are examined microscopically to determine if normal fertilization has occurred.
Determination of the fertilization status of the egg is one of the most critical steps of the procedure. A normally fertilized egg will contain structures inside the egg called pronuclei and polar bodies that can be observed with a microscope. The presence of two pronuclei in the egg and two polar bodies outside the egg is indicative of normal fertilization. Greater numbers of pronuclei can occur if the egg is abnormally fertilized by more than one sperm (polyspermy) or if the egg fails to complete its removal of the second polar body (polygyny). It is important to separate normally fertilized from abnormally or unfertilized eggs at this step so that only embryos developing from normally fertilized eggs are used for embryo transfer to produce a pregnancy. Your physician is given a fertilization report the same day so that you can be updated.
The fertilized egg begins to divide (cleave) within a few hours after fertilization. Cell division continues to the multicellular stage (8-12 cells) by day three and the resulting embryo can be transferred to the uterus at this stage. However, it is often desirable to continue culture for two additional days to allow the embryo to reach the more mature blastocyst stage of development. In vivo, the embryo is normally at the blastocyst stage when it arrives in the uterus, so achievement of this embryonic stage at the time of uterine transfer is most similar to the naturally occurring situation. Culture of embryos to the more advanced blastocyst stage provides additional information for choosing embryos with the greatest potential to start a pregnancy.
The embryo transfer typically occurs on day 3 or day 5. The physician and patient are given an update by the embryologist on the progress of the embryos in culture. Based on the embryology report and the couple's personal medical histories, the physician will make a recommendation to the couple regarding the appropriate number of embryos to transfer to optimize the likelihood of pregnancy, but minimize the risk of a multiple gestation. The couple can accept their physician's recommendation or decide to be more or less aggressive with their treatment by having more or fewer embryos transferred. The embryologist then prepares the embryos for transfer by placing the embryos in a uterine catheter. The physician uses ultrasound to guide the placement of the catheter containing the embryos into the uterine cavity. When placement is correct, the embryos are expelled from the catheter into the uterus. The embryologist checks the catheter to make sure no embryos are retained within the catheter. After rest in recovery for an hour, the patient is discharged to her normal routine. The patient begins taking progesterone supplements to support the pregnancy the night of the egg retrieval and continues until the physician recommends discontinuation. The pregnancy test is performed at about fourteen days after the embryos are transferred to the patient's uterus.
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