IVF Frequently Asked Questions
- What is IVF and why aren’t pregnancy rates 1oo%?
- How does age affect the success of IVF?
- How does the ovarian rejuvenation procedure impact the success of IVF?
- What is Dr M’s ovarian stimulation protocol?
- What happens in the lab?
- What happens during the embryo transfer?
- Is genetic testing worth the added expense?
- Why would egg freezing be needed?
What is IVF and why aren’t pregnancy rates 1oo%?
IVF is a process that bypasses the usual way in which an egg and a sperm meet in the body. Bypassing the earliest steps in the fertilization process by putting the sperm and egg together in the laboratory should give a couple the optimal chance of conceiving. Unfortunately, as statistics show, the pregnancy rates are far below that. This is because there is one crucial part of the process of conception that cannot be bypassed. The problematic step is the way the chromosomes from the sperm and the egg combine. This is a very complex process which nature only gets right, at best, 33% of the time. If the chromosomes from the sperm and egg combine properly, an embryo ends up having 46 chromosomes. When there are 46 matched chromosomes which is a genetic blueprint for the development of a healthy baby. If an embryo has too many or too few chromosomes after fertilization, a condition called aneuploidy exists. Embryos with aneuploidy cannot develop into a healthy baby because their genetic blueprint is flawed. Embryos with aneuploidy, although indistinguishable from genetically perfect embryos, will either fail to implant in the uterus or end up as an early miscarriage. It seems that “ mother nature” can recognize unhealthy embryos at a very early stage of development and does not allow them to survive to be born. This process is called natural selection. It protects the species by allowing only the strongest babies to survive. The process of natural selection, in protecting the health of the species, limits the success rates of IVF.
How does age affect the success of IVF?
IVF tends to be more successful in women under the age of 34, because the younger the woman, the better the genetic quality of her eggs. With advancing age, pregnancy rates are lower because embryos from older women’s eggs have a much higher rate of aneuploidy. When the issue preventing pregnancy is poor egg quality, and there is nothing else preventing pregnancy other than poor egg quality, IVF may not give higher pregnancy rates than having sex at home. However, many women with advanced maternal age do opt to try IVF in the hope that they will beat the unfavorable odds.
There are options available for those women rendered infertile by advanced maternal age. The use of donor eggs from young women is the best option, producing high pregnancy rates, up to 60-70% per embryo transfer.
How does the ovarian rejuvenation procedure impact the success of IVF?
A more recent procedure, called ovarian rejuvenation, is the injection of the patient’s own white blood cells and platelets, called platelet rich plasma (PRP) into her ovaries to liberate tissue growth factors that cause the growth of new cellular elements in the ovaries. PRP treatment has been used successfully in other areas of medical treatments, such as in orthopedics and in skin grafting, for many years. Dr. Melnick has had one menopausal and one perimenopausal 45 year old conceived naturally and delivered healthy babies. He has also observed that some menopausal women regained their periods for up to nine months after treatment with PRP. Nearly 50% stopped having hot flashes and had improved vaginal lubrication and sex drive.
What is Dr M’s ovarian stimulation protocol?
Dr. Melnick uses a unique approach to IVF that differs from that used at most IVF clinics. He has developed a protocol to stimulate the production of the maximal number of mature eggs that a woman is capable of for harvest for an IVF treatment cycle. Dr. Melnick has modified the original IVF stimulation protocol that produced the first “test tube baby” which is quite different from the standard protocol used today. However, it produces the same numbers of eggs as does the standard protocol in approximately 95% of cases. Dr. Melnick’s ovarian stimulation plan eliminates many of the major issues that make the IVF process so difficult and costly.
Initially, Dr. M evaluates each woman for her potential to make eggs, using blood tests and an ultrasound examination of the ovaries, to see if she is a good candidate for his protocol or would do better with another stimulation protocol. His experience makes his predictions of potential egg yield very accurate. Dr. M evaluates each patient on an individual basis to determine their ideal method of ovarian stimulation. He does not believe in “one size fits all, cookie cutter” medicine.
The initial part of the IVF process is the stimulation of multiple eggs using injectable fertility drugs. The tiin of the egg retrieval is very important because the patient’s eggs must be mature and not immature (under ripe) or post mature (over ripe). To a certain point, up to 12 eggs, the more eggs, the better. After that point, when too many eggs are stimulated, many eggs are under ripe and cannot be fertilized. Dr. Melnick uses a unique approach to egg stimulation for women who he judges to be good egg producers. Most women do produce similar numbers of eggs, whether his special protocol or the standard protocol, is used. All things considered, Dr. M’s stimulation protocol is of great advantage to patients because they save a great deal of money and undergo much less stress during the course of a treatment cycle. Because they have less visits to the fertility clinic, many less sonograms and blood tests as well as fewer injections, patients experience less anxiety during all stages of the treatment.
What happens in the lab?
Patients seldom see the laboratory staff, but they are the real heroes of the IVF process. The lab is where the magic of IVF occurs as the miracle of life begins. Skilled embryologists identify and capture the eggs under a microscope, which are so small that 100 of them will fit on the head of a pin. In order to make sure that the process of fertilization gets off to a proper start, the embryologists can inject a single sperm, each one four hundredth the size of a human egg, into the egg, using a special robotic microscope fitted with needles having tips so fine that they can only be seen under the scope.
The embryologists carefully monitor the sophisticated incubators in which the fertilized eggs are kept. Incubators tightly control the environment that embryos need to grow and develop for a period of 5-6 days out of the human body, at which time some reach the 100 cell size called the blastocyst stage. Not all embryos reach the blastocyst stage. Many stop developing prior to becoming blastocysts, indicating that they were not genetically perfect enough to become a healthy pregnancy. Only a fraction of healthy looking blastocysts will actually be genetically perfect enough to end up as a viable full term pregnancy. Only genetically perfect embryos survive to become babies. Embryo development is the perfect example of the “survival of the fittest!”
These amazing laboratory technicians are also the ones who remove cells from a 100 cell embryo to check if they have the correct genetic material to allow the birth of a healthy baby and determine its sex!! Without their amazing skill sets, IVF would not be possible.
What happens during the embryo transfer?
The embryo transfer appears to be the simplest part of the procedure, but it really is the one that requires the most skill and experience. The process requires an extremely deft touch so as not to set off contractions of the uterus which could cause the embryo to be expelled. The embryo transfer is virtually painless so it does not require anesthesia. The embryo transfer, in which the one or two of a woman’s blastocysts are returned to her womb, is the most important part of the IVF process. It requires an experienced physician who has a delicate touch to place an embryo gently into the cavity of the uterus using ultra fine soft catheter so as not to disturb the lining of the uterus that has been prepared for the embryo’s implantation.
The implantation is performed using ultrasound guidance so that the position of the embryo is precise. The procedure resembles a pap smear and does not require anesthesia. It is quite normal for a woman to feel heightened levels of anxiety and muscular tension prior to and at the time of embryo transfer. Dr. Melnick suggests that if a woman anticipates even the slightest degree of anxiety, she should request an anti-anxiety/muscle relaxant pill such as Valium to take prior to the procedure. A single Valium pill taken several hours prior to embryo is safe for the mother and will not affect the early embryo and will make the transfer more comfortable for the woman. It will also prevent muscular contractions of the uterus that could potentially expel an embryo prior to its implantation.
It is unwise to transfer more than two embryos for fear of causing a multiple pregnancy. Multiple pregnancies greater than twins are risky for both mother and babies, so if there are additional embryos, they may be frozen safely in liquid nitrogen for future transfer.
Why would egg freezing be needed?
Egg freezing is an expensive, but sometimes necessary, insurance policy. Delaying childbearing too long is tragic for women who want to have a baby, but are not in a situation to do so at a point in their lives when they are young enough to be fertile. Any woman on a career track or who is unlikely to marry before the age of 35, should think about freezing their eggs just in case ‘prince charming” enters her life a few years too late. Dr. Melnick strongly believes in screening all young women in their early 20’s by doing a blood test, the AMH (antimullerian hormone), which is an indirect measurement of the number of eggs currently in the ovaries. This is especially true for young women with a history of thyroid problems, especially those with Hashimoto’s thyroiditis.
If a young woman has a relatively low AMH level, indicating low numbers of eggs, makes her a likely candidate for premature menopause. These women should definitely freeze their eggs. The good news is that even if they produce low numbers of eggs, their eggs are of prime biologic quality and are more likely to produce a pregnancy than are eggs from a woman in her mid 30’s.
The bottom line is that screening for egg reserve is simple. Women with low egg reserve can be easily identified by their relatively low AMH values for their age. Since a woman’s egg supply is reduced naturally over time and no new eggs are ever made, menopause will inevitably be early when the egg supply is already low when a woman is in her twenties or early thirties. The current technology for egg freezing is good. Eggs can be kept frozen in a viable state for many years. “forewarned is forearmed.” If only more physicians were aware of the need for early fertility screening, many women could be saved from the anguish of finding that they are irreversibly infertile at a young age.
Is genetic testing worth the added expense?
The answer is both yes and no. The simplest form of genetic testing is to examine each embryo to eliminate the ones with aneuploidy. But there are complicating factors in this approach. You would think that if only embryos with 46 chromosomes were transferred, there would be close to a 100% pregnancy rate. Wrong- the pregnancy rate is more like 70% and not even close to 100%. There are obviously other unidentified genetic factors that affect an embryo’s ability to develop into a baby.
There is another factor that can affect the results of genetic testing. It is called genetic mosaicism. That is when an individual has two distinct cell lines in their bodies. An example of mosaicism is an individual who has one brown eye and one blue eye. It is unknown how an embryo gets two cell lines instead of one, but if present, could give false positive or false negative results when embryos undergo genetic testing.
Nature does a far better job sorting out unhealthy embryos, in many cases, physicians should transfer healthy embryos into the prospective mother’s uterus and let nature sort everything out. Of course, no more than two embryos should be transferred at a time, to avoid complications of triplet pregnancy. Dr. Melnick has had the experience of transferring two embryos and getting three babies! Man plans…. God laughs!!!
Genetic testing of embryos is a “must do” in cases when one or both parents are carriers of a genetic disease.