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Center for Advanced Reproductive Care: CARC

In Vitro Fertilization (IVF) Program

Introduction

The University of Iowa's Center for Advanced Reproductive Care In Vitro Fertilization (IVF) program was established in 1987. Over the years, the highly skilled and innovative team of reproductive health professionals has provided over 2,000 infertile couples with the most advanced reproductive therapies (ART). While we have seen many changes in methods used to diagnose and treat infertility, the financial, emotional and ethical decisions that must be made before a couple attempts to overcome their infertility through IVF remain the same. The Center for Advanced Reproductive Care IVF health care professionals are dedicated to helping couples work through the personal and emotional issues that are encountered before, during and after treatment. The combination of experience and expertise offered at the University of Iowa Center for Advanced Reproductive Care provides couples with a caring and ethical delivery of assisted reproductive services.

• Questions to ask
• Treatment process
• Services offered
• Donor Oocyte Program

Questions to ask

You should ask three questions before pursuing ART.

1. Have appropriate methods of treatment been attempted?
2. Is there a reasonable chance of achieving pregnancy with one of the ART procedures?
3. How can we best choose a program that fits our special needs?

If you have difficulty answering these questions by yourselves, you may request information outlining specific treatment guidelines, program success rates, and a brochure entitled "Questions to Ask of an ART Program." These and other issues can be explored further during a preliminary appointment in our clinic.

Services offered

• In Vitro Fertilization (IVF)/Embryo Transfer (ET)
• Donor Oocytes
• Donor Sperm
• Embryo Donation
• Intracytoplasmic Sperm Injection (ICSI)
• Microsurgical Sperm Retrieval
• Preimplantation Genetic Diagnosis

Treatment Process

1. Preliminary Appointment

• Both partners must be present for this initial appointment.
• As a couple, your visit will include a review of medical records, complete history and physical examination. You will meet with the financial advisor and the nursing staff to view educational materials and schedules.
• The male partner will be asked to provide a semen sample for analysis and sperm cryopreservation. Based on the results of the semen analysis and the couple's unique situation, the IVF team may recommend further evaluation by our male infertility specialist.
• The female partner may be required to undergo additional tests before a treatment plan is finalized. However, it is often not necessary to repeat testing that has been done locally. Sending us your local records prior to your appointment will reduce duplication of effort.

2. Team Review

Your CARC team physician will present your history at the weekly team meeting. The CARC team will develop a treatment plan that is appropriate for you. The complex processes of ART procedures are carried out by a team of professionals. Included on this team are: physicians with specialty training in the areas of infertility; nurses with special IVF training; the IVF Lab Director, who is a gamete biologist, and her assistants, trained in ART procedures; health psychologists experienced in working with infertile couples; a financial counselor; ultrasound technicians; endocrinology lab, pharmacy and operating room personnel.

3. Treatment Cycle Scheduling

Once testing is completed and a treatment plan has been developed you are welcome to schedule a treatment cycle. When planning an in vitro fertilization procedure, you will be asked to be in Iowa City one day in the middle of your menstrual cycle and again when your follicles are large enough to trigger ovulation. The actual number of visits required of you will depend upon the availability of monitoring in or near your home community. The IVF team will work with you to coordinate local care when possible. Male partners must be present on the day of egg retrieval to provide a fresh semen sample. An adult must be available to drive you home on the day of oocyte retrieval and on the day of embryo transfer.

The Treatment Cycle: Controlled Ovarian Stimulation

Fertility drugs which mimic the body's natural hormones are given daily by injection in hopes that three or more eggs will develop during the treatment cycle - the more eggs fertilized, the better the chance for pregnancy. Fertility drugs commonly given in this program include the following:

1. Gonadotropin Releasing Hormone (GnRh) agonist
2. Gonadtropin Releasing Hormone (GnRh) antagonist
3. Follicle Stimulating Hormone (FSH)
4. Human Menopausal Gonadotropins (hMG)
5. Human Chorionic Gonadotropin (hCG)

In all cases, timing of egg retrieval is determined by careful monitoring of blood estrogen levels and/or ultrasound imaging of the size and number of ovarian follicles.

Ultrasound Guided Egg Retrieval

When blood hormones reach the desired levels and/or the ultrasound shows ovarian follicles to be the desired size and number, hCG hormone is administered and egg retrieval is scheduled thirty-six hours later. With the help of ultrasound images, a needle is passed through the back of the vagina and into ovarian follicles. The eggs are drawn out of the follicles with gentle suction. Approximately 70 percent of all follicles contain a retrievable egg. Usually intravenous (IV) medication is used for sedation and to maintain comfort. Spinal anesthesia is another option for keeping you comfortable during retrieval.

Embryo Transfer

For an IVF-ET procedure ovaries are stimulated to produce multiple eggs, which are retrieved with ultrasound guidance. The eggs are inseminated in the culture dish and fertilization is confirmed the next day. Resulting embryos are incubated in the laboratory for an additional two to four days. Dependent upon your age, two to four embryos will be selected for transfer. Under certain circumstances, we may elect to transfer only one embryo. Good quality embryos in excess of those transferred may be cryopreserved if the couple has consented to embryo cryopreservation.

The non-surgical embryo transfer is accomplished by loading the embryos into a small catheter, threading the catheter through the cervical canal and depositing the embryos into the uterus. No anesthetic is required for the transfer.

Although pregnancy rates improve to a point with transfer of multiple oocytes or embryos, IVF carries a risk of multiple gestations (twins, triplets, etc.) associated with the number of embryos transferred. Multiple pregnancies are high-risk pregnancies. The best way to prevent multiple pregnancies is to limit the number of embryos transferred. Our program guidelines for embryo transfer are shown below:

Donor Oocytes

The University of Iowa's Center for Advanced Reproductive Care has an anonymous oocyte (egg) donation program. Our program also will facilitate directed egg donation to an identified recipient. Oocyte donors are evaluated for psychological, medical and genetic health and are tested for sexually transmitted diseases. Efforts are made to match anonymous recipient and donor characteristics according to the recipient's priorities. Anonymous oocyte donors must be 21-34 years of age in order to participate in the Univeristy of Iowa Center For Advanced Reproductive Care's anonymous oocyte donor program.

Donor Sperm

The clinical staff at the University of Iowa's Center for Advanced Reproductive Care will assist couples with preparation of the documents required for the purchase of anonymously donated sperm from a commercial sperm bank. Once the sperm arrives at the University of Iowa, the Reproductive Testing Laboratory will store the specimens in liquid nitrogen until the time of your procedure. Our program also will facilitate the testing and sperm cryopreservation for directed sperm donors.

Donor Embryos

In situations when more than the desired number of eggs to be transferred fertilize, many couples opt to cryopreserve their non-transferred embryos for future transfers. For a variety of reasons couples may ultimately choose not to transfer their cryopreserved embryos. Our Embryo Donation Program gives couples an alternative to discarding these embryos. Embryo donors are evaluated for psychological, medical and genetic health and are tested for sexually transmitted diseases. Couples receiving anonymously donated embryos are prioritized based on need for donor gametes, previous childbearing, and previous infertility therapy.

Embryo Cryopreservation (Freezing)

The use of cryopreservation technology for preservation of early human embryos has been shown to enhance the efficiency and cost-effectiveness of establishing pregnancy through in vitro fertilization. When in vitro fertilization yields more good quality embryos than the desired number to be transferred, the excess, good quality embryos may be cryopreserved.

Advantages of embryo cryopreservation include:

• The elimination of the pressure to transfer a greater number of embryos that increases the risk of multiple pregnancy.
• It gives patients the option to attempt to conceive in a frozen embryo transfer cycle at approximately 1/5 the cost of a fresh in vitro fertilization cycle.

Intracytoplasmic Sperm Injection (ICSI)

A technique called intracytoplasmic sperm injection (ICSI) is used to assist fertilization for couples with male-factor infertility that is unresponsive to other clinical and laboratory forms of treatment. The procedure involves injecting a single, live sperm directly into a mature oocyte. We recommend ICSI for couples who have no or very low rates of fertilization during previous treatment cycles or when the number of normal motile sperm available is less than that required for traditional in vitro insemination.

Microsurgical Sperm Retrieval

With the advent and improvement in intracytoplasmic sperm injection (ICSI), the options available for retrieval of sperm from the male have increased tremendously. Sperm may be obtained from the epididymis or directly from the testicle. Microsurgical sperm retrieval is indicated in men who have an obstruction that cannot be repaired, such as absence of the vas deferens, congenital obstruction, or failed vasectomy reversal and for men who have untreatable testicular failure.

Preimplantation genetic diagnosis (PGD)

Preimplantation genetic diagnosis involves the removal of a single cell from a three-day old embryo and testing the cell for certain inherited diseases (such as cystic fibrosis and muscular dystrophy). This service is available for couples that are at risk for passing on a genetic disease to their children.