IVF Treatment Cycle

Pre-cycle testing

Once all the pretreatment testing has been performed you will have a consultation with Dr Sharara to review the results and decide on a time frame to proceed with the IVF cycle. It is the patient's responsibility to complete these tests in a timely manner! Failing to do so will result in the postponement of the IVF cycle.

It usually takes 4-5 weeks to do all the tests required. Some of these tests might not have to be repeated if performed recently. Other tests such as the infectious screening (HIV, Hepatitis B, etc…) might be repeated if they are more than 6 months old.

Once all of the tests are completed, you will be given a medical calendar. The calendar will include the following information:

• Type of medications to be taken
• Dates when these medications are to be taken
• The patient's visits for blood tests and ultrasound examination
• Other pertinent instructions

It is crucial that the patient follows these directions carefully. Any mistake could jeopardize the success of the treatment.

Ovarian Stimulation

Stimulation refers to the initiation of the fertility medications. The goal is to "stimulate" the ovaries to produce eggs. In order to do so, the patient has to take fertility drugs such as Follistim, Bravelle, Gonal-F and/or Repronex.

Birth control pills (BCP)

Except in rare cases, the treatment cycle starts with the patient taking birth control pills. This is for scheduling purposes. By putting the patient on BCPs, we are able to manipulate her menstrual cycle to make it predictable. In this manner we are able to better plan ahead and provide the patient with specific treatment dates that can be set well in advance. The patient will usually take these pills for a period of 3-5 weeks. This will in no way harm the patient's chances of conceiving.

Lupron

Roughly 4 days before the last BCP, the patient starts taking daily Lupron injections. The dose will be indicated on the Calendar. Lupron will suppress the pituitary-ovarian axis (i.e. it will put the ovaries to "sleep") so that we can control them with fertility medications. If Lupron is not taken, then there is significant risk that the eggs might be released before we are ready to "harvest" them.

Lupron is administered as a subcutaneous injection (under the skin) with a small needle.

The patient will take daily Lupron injections until otherwise indicated.

Fertility Medications

The day fertility drugs are started as marked on the Calendar. These medications will stimulate the ovaries to produce multiple eggs. The response to these drugs varies according to the patient's age, her FSH hormone levels, the size of the ovaries, and the amount of drugs given. The dose should be clearly indicated on the Calendar.

These drugs are given once (usually in the evening) or twice daily (morning and evening). Mixing and injection instructions will be given to the patient prior to treatment initiation. The patient will be told when to stop taking these drugs. If the patient stops taking these medications prematurely, it might lead to the cancellation of the cycle.

These drugs are usually taken for 10 to 14 days. Some patients might need a longer period of time to have a successful stimulation. This is common in older patients or women with elevated FSH levels. A vaginal ultrasound examination will be performed 4-5 days after the start of these medications.

Ganirelix Acetate Injection

Some patients will be taking Ganirelix Acetate Injection instead of Lupron. They both do the same thing, which is preventing premature ovulation. The difference being in that Ganirelix Acetate Injection is given after the initiation of ovarian stimulation when the lead follicle is 12-14 mm in diameter. Ganirelix Acetate Injection is given every night for about 3-5 days. It is extremely critical to take the Ganirelix Acetate Injection shot every night until told to stop by Dr Sharara. Failure to do so may result in premature release of the eggs and cancellation of the IVF cycle!

Additional Medications

Often patients are placed on Dexamethasone and Baby Aspirin. These drugs are also started the same day the fertility drugs are started. Some women with elevated prolactin levels will be given Parlodel or Dostinex. Further instructions will be given to the patient as to when to continue or discontinue these medications.

Folic acid is a vitamin that every patient attempting to conceive should take prior to conception. It has been shown to reduce the incidence of serious birth defects (neural tube defects such as spina bifida) when taken during the first 50-70 days after conception. Adequate doses of folic acid are found in prenatal vitamins.

Monitoring

First Monitoring Visit

Four to five days after the start of the fertility drugs (Follistim/Bravelle/Gonal-f or Repronex), the patient will come in for her first appointment at VCRM. This date is referred on the Calendar.

During this appointment (which will take 30-40 minutes), the following will be performed:

• A blood test for the hormone Estradiol (E2): As the follicles (containing the eggs) mature, the eggs secrete the Estradiol hormone. Therefore measuring the level of this hormone in the blood gives us a good idea as to how the ovaries are responding to the drugs. The level increases over the next several days as the eggs are maturing and the follicles growing. The more eggs or follicles a patient has the higher the Estradiol level.
• A vaginal ultrasound examination: The purpose of this examination is to visualize the ovaries and count the number of follicles present. A follicle is the fluid-filled sac that contains the egg. Each follicle usually contains one egg. By counting the number of follicles we can determine how well the woman has responded to the fertility drugs. We will also measure the follicles. The size of the follicle gives a good idea about the maturity of the egg. As the woman continues to take the fertility drugs, these follicles will grow (about 3 mm in 2 days); and at a certain point in time they will be ready to be harvested. We usually like to retrieve the eggs when the majority of the follicles are between 17 and 20 mm in size.

After evaluating the number and size of the follicles, the thickness and pattern of the uterine lining will also be evaluated. This is a crucial part of the examination because a poor lining is unlikely to sustain a pregnancy.

Follow-up Visits

Following the initial visit, the patient will be told when to return for follow up visits. Usually another visit will be made 2-3 days after this date.

During this follow-up visit, a blood test for Estradiol and an ultrasound examination to evaluate the growth of the follicles will be performed. The patient will again be given further instructions on what to do on a daily basis. A total of 4-5 visits are usually required during the IVF cycle.

HCG injection

When Dr Sharara decides that the follicles are ready to be aspirated (to remove the eggs), the patient will be given instructions to take an HCG injection 35 hours prior to the Egg Retrieval. This medication is crucial. It will "push" the eggs through their final stages of maturation and will release them from their attachments to the walls of the follicles to float inside the follicular fluid. If HCG is not taken correctly and at the exact time specified, the eggs will not be mature and will not be able to be aspirated.

The patient will be given written instructions on how and when to administer this medication. She will also be given a instruction sheet on how to mix and administer the HCG injection under the skin, as well as the time the patient has to report for Egg Retrieval two days later. Since HCG injections are given at night (usually between 9 PM and 11 PM), the Egg Retrieval is scheduled 35 hours after the injection, which falls two days later in the morning between 8 AM and 10 AM.

Egg Retrieval

When the size of the leading follicles reaches 17 to 20 mm in average diameter and the estradiol hormone level is appropriately elevated, then it is time for the eggs to be "harvested". The HCG injection (described in the previous section) will be administered in the evening usually between 9 PM and 11 PM. The egg retrieval will be scheduled 35 hours after the HCG injection. For instance, if the HCG is given on a Monday at 9 PM, then the egg retrieval will be performed on Wednesday at 8 AM.

The couple needs to be at VCRM at least 30 minutes prior to the scheduled time of Egg Retrieval (ER). The patient should not eat or drink anything after midnight, the night before the ER day. (Please see Pre-Retrieval Instructions).

The ER is performed under "general anesthesia" but without intubation. The patient will not feel any discomfort during the procedure and will wake up within 10 to 15 minutes after the procedure. Depending on the number of follicles present, the ER will usually last 10 to 15 minutes.

The ER is performed under ultrasound guidance similar to the vaginal ultrasound examination that the patient has during follicular monitoring. A needle guide is attached to the ultrasound probe, a long needle is introduced through the guide, and under direct visualization each follicle is punctured and the fluid (along with the egg floating in it) is aspirated. The fluid is then immediately sent to the laboratory where the embryologist searches for the eggs, isolates them and place them in incubators. At the completion of the ER, the patient is taken to the recovery area where she will stay for about an hour. Pain medications might be administered at this time as needed. Some discomfort is expected for a few hours following ER and Tylenol can be taken by the patient at home as needed every 4 hours (please avoid Motrin/Alleve/Ibuprofen). Occasionally, some nausea might also occur which usually dissipates within a few hours.

After about 20-30 minutes when the patient is fully awake and relatively pain-free, instructions are given by the recovery nurse and the patient is discharged home. The patient must be accompanied by someone who can drive them home and should not be left alone for the rest of the day.

(Please see Post-Retrieval Instructions).

After the egg retrieval, the partner is asked to provide us with a semen sample. The semen is then washed and prepared to inseminate the eggs 3-4 hours later.

In cases where the male partner has to undergo the testicular biopsy (TESE) procedure for sperm recovery, he will be the operating room and the urologist will perform the needle biopsy under local anesthesia. This procedure will usually last 15-30 minutes and the patient will be discharged home with an ice pack placed over the testicles to prevent swelling.

Pre-Retrieval Instructions

• The day before egg retrieval, DO NOT EAT OR DRINK ANYTHING after midnight. You can brush your teeth the morning of egg retrieval.
• Do not wear any jewelry. Notify the anesthesiologist if you are wearing
• Wear comfortable clothing.
• Make sure to be at VCRM at least 20-30 minutes before your appointment.
• A fresh sperm sample will be needed if your partner's sperm is to be used, unless otherwise noted.
• Expect to be at VCRM for at least one hour. You will need someone to drive you home.
• Call us with any questions at (703) 437-7722.

Post-Retrieval Instructions

When you get home following egg retrieval, you should rest. Mild abdominal discomfort is very common. This will subside over several hours. You can and should use the restroom as needed.

• Eat or drink anything you would like as tolerated. Some nausea is common for a few hours.
• You can shower the night of egg retrieval and thereafter. You might be a little lightheaded, so be careful standing up!
• Expect some vaginal spotting.
• No heavy lifting
• No intercourse
• No hot tubs or baths, showers only
  
• No heavy or impact exercises

Call your physician immediately if you have any of the following symptoms:

• Fever (>101 F or 38.0 C).
• Bleeding (i.e, soaking a pad every 1-2 hours).
• Severe abdominal pain and tenderness.
  
• Difficulty breathing.

Embryo Transfer

Three to five days following the Egg Retrieval the patient will have the Embryo Transfer (ET). During this time the fertilized eggs (embryos) have been allowed to grow and divide in the incubator. The patient would have also been started on Progesterone injections and suppositories the day of HCG injection to prepare the uterine lining for implantation.

The day before ET the patient will be contacted and given a specific time to come to VCRM for ET the next day. (Please see Pre-Transfer Instructions).

About 30 minutes before the transfer, Dr Sharara will meet the couple and discuss the number and quality of the embryos at hand. A decision will be made by the couple and Dr Sharara as to the number of embryos that will be transferred, and the number to be frozen or discarded. The embryos will be separated into a separate dish and then transferred to the transfer catheter. Meanwhile the patient is taken to the operating room for the ET. This is very similar to an artificial insemination procedure except that embryos are transferred to the uterus instead of sperm. A speculum is inserted in the vagina, the cervix is washed and cleansed. The embryologist will then deliver the catheter to the physician who introduces it through the cervical canal into the uterine cavity where the embryos are released. The embryologist will then check the catheter to make sure none of the embryos are in the catheter.

The whole procedure takes approximately 15 minutes. The patient will remain in a supine position for about 20 minutes. She will then be discharged home. (Please see Post-Transfer Instructions). It is recommended that the patient rests at home for 1 or 2 days following the transfer.

Post-Transfer Instructions for Conventional IVF

• The day of transfer, you should go directly home or to your hotel and rest for 24 hours. You can use the restroom but do not shower. You may have some watery discharge. This is from the vaginal wash and not the embryos "coming out".
• The day after your transfer, you may resume light normal activities although we prefer that you rest one more day.
• No intercourse. No high impact activities. No lifting more than 10 pounds.
• Please follow your Calendar's instructions for all your medications!
• Call if you have a fever greater than 101º F or 38.1º C
• Call VCRM at (703) 437-7722 with any questions and at any time!