Programs and Services

In Vitro Fertilization

In vitro fertilization (IVF), a method of assisted reproduction, is an option for many couples who have not been able to conceive.

In vitro (“in glass”) fertilization is the fertilization of a woman’s eggs outside of her body — in a petri dish. Sperm provided by the male is mixed with eggs that have been aspirated from the woman’s ovaries. A few days later, one or more fertilized eggs are transferred to the woman’s uterus (womb), with the hope that pregnancy will occur.

More Information

To learn more about in vitro fertilization, or to schedule an appointment, call 414-805-3666 or 800-272-3666, or contact us.

Depending on the fertility problem, the eggs used in IVF may be the woman’s own eggs, or donor eggs from another woman. Likewise, the eggs may be fertilized with sperm provided by the woman’s male partner or by donated sperm.

The birth of the first baby achieved through IVF occurred in England in 1978. Since then, the procedure has helped hundreds of thousands of couples to conceive and have healthy babies.

When to Consider IVF

IVF may be used as a treatment option for the following reasons:

A women’s fallopian tubes are absent or blocked (and cannot be repaired), preventing the sperm and eggs from meeting
A man has very poor sperm counts
A women has exhausted her own supply of quality eggs (requires a donor egg)
A woman has severe endometriosis
A man has immunologic infertility, which occurs when antibodies to sperm prevent normal motility and function
Other fertility methods, such as artificial or intrauterine insemination, have not been successful
Unexplained infertility

Members of our staff — experts in male and female infertility — guide the couple through every step of the IVF process. If professional counseling with a psychotherapist is requested, we also can facilitate this service for couples. (Couples using donor eggs or sperm are required to go through professional counseling.)

The IVF Fresh Cycle

In a fresh IVF cycle, eggs are retrieved and placed, along with sperm, in a special culture medium that encourages fertilization and growth of the embryos. (This compares to a “cryopreserved frozen embryo transfer cycle,” described below, that uses frozen embryos.)

The entire IVF fresh cycle takes about one month — from the time the woman begins taking hormones to stimulate egg production to the time she is tested to determine if she is pregnant. This cycle is often preceded by a month on birth control pills.

IVF medications include a medication to prevent premature ovulation as the follicles (eggs grow within follicles) are growing and then various stimulation hormones are used to achieve the actual growth of the follicles. Once the follicles are mature, the women takes another medication to bring about final maturation of the eggs prior to retrieval. After retrieval, progesterone is given to support the lining of the uterus for implantation.

During the stimulation part of the cycle, frequent ultrasound exams are performed to evaluate the growth of the follicles. Hormonal monitoring with blood tests may also be performed to evaluate the follicles. Adjustments will be made to the stimulation medication doses based on these findings.

When the follicles and the eggs within them are judged to be mature, the eggs are retrieved by needle aspiration. This is a procedure in which the physician uses ultrasound to guide a needle through the vagina and into the ovaries. An anesthesiologist is present to provide pain medication and sedation so the woman does not feel pain. All follicles are aspirated to maximize the number of eggs collected.

Once the eggs have been collected, the male provides a semen sample. Sperm and eggs can be joined in one of two ways. They can be mixed in a laboratory dish, or a single sperm can be injected into each egg using special microscopes, needles and other equipment. (This is called intracytoplasmic sperm injection, or ICSI.)

The following day, eggs are examined to check for fertilization. Fertilized eggs become embryos. Typically, about 75 percent to 80 percent of the eggs may become fertilized. Three to five days after fertilization, embryos will be selected and placed in the woman’s uterus.

About two weeks after the retrieval, a blood test is performed to check for pregnancy. If it is positive, it is usually repeated 48 hours later to assess the pregnancy. We expect the level to about double in 48 hours. If all looks good, an ultrasound is planned for about seven weeks of gestational age (about five weeks from egg retrieval) to assess the location and number of pregnancies.

Progesterone, a female hormone that prepares the uterus to receive and sustain an embryo, is given to the woman after egg retrieval and is continued until 10 weeks of pregnancy (eight weeks after retrieval). The women would then continue prenatal care with her obstetrician.

The remaining embryos (those not placed in the uterus) can be frozen through a special technique of cryopreservation and used in the future if the fresh IVF cycle does not succeed. They can also be used years later for another pregnancy if desired by the couple.

Ovarian Reserve

Ovarian reserve may be thought of as a health check of the ovaries and the eggs (oocytes) they contain. Measurement of ovarian reserve, an important factor in female fertility potential, can only be approximated, because precise tests are not currently available. Testing for diminished ovarian reserve gives couples the advantage of a more realistic estimate of the likelihood of fertility with treatment. Older women with diminished ovarian reserve may be counseled to consider donor eggs or adoption.

Ovarian reserve decreases with age. Further complicating the situation, as fertility declines, the incidence of miscarriage rises. Estimates for miscarriage rates are 7 percent to 15 percent for women under age 30, 9 percent to 21 percent for ages 30-34, 17 percent to 28 percent for ages 35-39, and about 35 percent to 52 percent for women over age 40. Other causes of impaired ovarian reserve include endometriosis and multiple surgeries on the ovary and conditions resulting in the removal of one ovary. Patients with unexplained infertility also show a higher rate of diminished ovarian reserve.

No perfect markers exist for ovarian reserve but follicle stimulating hormone (FSH) levels that are more than a specific level provide an estimate. The brain senses the hormones the ovary is making and if it judges these to be deficient, it tries to stimulate the ovary more by sending a higher signal to the ovaries (higher FSH level). Therefore, a high FSH indicates the brain does not think the ovary is working well. Sometimes, this is tested by looking at the level of FSH on cycle day 3 (cycle day 1 is the first day of menstruation) along with an estrogen level. In some cases, a more provocative test, the clomiphene citrate challenge test (CCCT), is used. This test looks at the day 3 levels and then the woman takes the fertility medication clomiphene citrate, 100mg a day, for cycle days 5-9. The FSH is then repeated on cycle day 10. Clomiphene blocks hormone receptors in the brain, the brain increases the FSH in response and, due to the elevated FSH, the ovary makes more hormones. These hormones override the clomiphene blockade and the FSH should come back down. An elevated level on day 3 or 10 — or both days — indicates diminished ovarian reserve.

Some important concepts must be kept in mind when considering testing:

High FSH levels predict low fertility, but they do not accurately predict high fertility when normal
The specific FSH assay system used in any laboratory affects the level used to indicate diminished ovarian reserve
Diminished ovarian reserve does not mean a woman cannot become pregnant —only that she is less likely to be successful if she uses her own eggs
There is no need to repeat an abnormal test; the available evidence suggests that fertility estimates are more reliably based on the worst FSH value, not the best

Some programs will not allow women with diminished ovarian reserve to undergo treatment with their own eggs. Sometimes this may be done to protect a clinic’s success rates. We take an individual approach to these patients. If, after counseling about poorer prognosis, a patient wants to proceed in order to get closure, we generally allow her to go through a cycle.

Day 3 versus Day 5 (“blast”) transfers

Traditionally, transfers have been done on embryos three days after the eggs have been retrieved. Recently, advances in the culture media in which embryos grow have allowed the extended growth of embryos to the day 5 or blastocyst stage. This has advantages and disadvantages.

Potential advantages of blast transfers include:

Transfer occurs closer to the natural time an embryo enters the uterus when the uterine lining may provide a better environment for the embryo
Allowing embryos to develop in the laboratory for a longer period of time allows for selection of the hardier embryos that are more likely to survive
Because of this selection, fewer embryos can be transferred which allows for a reduction in the risk of multiple pregnancies (twins, triplets)

Potential disadvantages include:

The main risk for blast transfer is that some embryos will die in the laboratory; while we think these embryos have reduced potential, some may have survived if transferred at an earlier stage
There is a risk that no embryos will survive to day 5, so there may be no embryos for transfer
There may be fewer embryos for freezing and subsequent cryo cycles

At the Froedtert & the Medical College of Wisconsin Reproductive Medicine Center, we look at individual cases and offer blastocyst transfer to patients with a large number of quality embryos to try to avoid having a situation where no transfer occurs due to the loss of all embryos. Patients undergoing preimplantation genetic diagnosis (PGD) also have blast transfers due to the fact that the embryo biopsies occur on day 3 and the processing takes two days.

Assisted Hatching

A few days (six to seven) after fertilization, the thin shell surrounding the embryo — the zona pellucida — should erupt. This “hatching” occurs to allow the embryo’s cells to come in contact with the uterus, allowing implantation (pregnancy). Without hatching, implantation cannot take place.

In some women, the zona (shell) becomes toughened, preventing the embryo from hatching. Therefore, “assisted hatching” may be necessary in certain IVF procedures. Three days after egg retrieval, eggs are viewed under high magnification and a small hole is mechanically made in the zona. We typically recommend hatching for women who have repeated implantation failures, older women and situations where the embryologist notes a thickened zona.

Frozen Embryos (Cryopreservation)

If a fresh IVF cycle fails, (the woman does not become pregnant) or she desires another child some time later, subsequent IVF attempts can be made using the frozen embryos that remain. The process does not require ovarian stimulation. Rather, the woman takes oral estrogen in increasing doses followed by progesterone to prepare the uterus for implantation. At the right time, embryos are thawed and placed in the uterine cavity.

Success Rates

Success rates for IVF depend on the woman’s age. At the Reproductive Medicine Center, women under age 35 generally have from 40 percent to 50 percent success in becoming pregnant and giving birth following a fresh IVF cycle. The success rate declines as a woman ages and rates for frozen cycles are slightly lower than those for fresh cycles. In older women, the success rate is higher if she uses donor eggs from a younger woman.

Risks

The main risks associated with IVF are:

Over-stimulation of the ovaries (ovarian hyperstimulation syndrome or OHSS), causing body fluid to collect in the abdomen; severe OHSS, requiring hospitalization, occurs in less than 1 percent of women who undergo IVF
Multiple births — because two embryos are usually placed in the uterus during an IVF cycle, 20 percent to 25 percent of births will result in twins; in older women, more than two embryos may be replaced, which will slightly increase the rate of higher order multiples
Egg retrieval complications — egg retrieval is a minor surgical procedure and has the same risks as other surgical procedures; complications are uncommon, but may include infection, bleeding and injury to surrounding tissues

Costs

Fertility testing may be covered by health insurance. Fertility treatment typically is not covered.

For More Information

To learn more about in vitro fertilization, or to schedule an appointment, call 414-805-3666 or 800-272-3666, or contact us.

The America Society of Reproductive Medicine has many articles about in vitro fertilization.

Glossary

Assisted hatching — a laboratory procedure that involves thinning or making a small hole in the zona pellucida (shell) that surrounds the embryo to increase the likelihood of the embryo implanting in the uterus. Useful in some, but not all patients.
Cryopreservation — the process of freezing and storing cells, tissues, or organs to maintain viability.
Embryo — the fertilized egg in the early stages of growth and differentiation from fertilization to the beginning of the third month of pregnancy, when it is called a fetus.
Endometriosis — a growth of endometrial cells outside of the uterus. Endometrial cells are normally only seen inside the uterus. The cells attach themselves to tissue outside the uterus and are most often found on the ovaries, the fallopian tubes, outer surfaces of the uterus or intestines, and on the surface lining of the pelvic cavity. Endometriosis can be a cause of infertility.
Fallopian tube — one of the two tubes that transport the egg from the ovary to the uterus (the womb). Fertilization normally takes place within the tube.
Fertilization — the successful of combining of a male’s sperm with a female’s egg to form an embryo.
Follicle — a small fluid sac (cyst) in the ovary. Normally, an egg matures inside the follicle and the follicle then bursts open and releases the egg in the process of ovulation. In IVF, many follicles are made to grow.
Follicle-stimulating hormone (FSH) — a hormone from the brain that stimulates hormone and egg production in the ovary.
Hormones — chemical substances produced in the body that control and regulate the activity of certain other cells or organs.
Intracytoplasmic sperm injection (ICSI) — an assisted fertilization procedure in which a single sperm is injected directly into an egg to achieve fertilization.
Immunologic infertility — infertility in a man due to antibodies to sperm that prevent normal motility and function.
Ovarian hyperstimulation syndrome (OHSS) — a potentially serious complication of ovarian stimulation. The ovaries over-respond to hormonal medication, becoming enlarged and causing fluid to accumulate in the abdomen, which makes breathing difficult.
Progesterone (progestational hormone) — a female hormone that prepares the lining of the uterus to receive and sustain the fertilized egg.
Ultrasound — an imaging device that uses high-frequency sound waves. Ultrasound waves are bounced off of tissues and the echoes are converted into a picture. Ultrasound allows physicians to view soft tissues and body cavities without using invasive procedures.