In Vitro Fertilization

IVF is the uniting of egg and sperm in vitro (in the lab). Typically involving ovarian stimulation, egg retrieval, fertilization, and embryo transfer, IVF is a treatment for infertility commonly employed once other methods of assisted reproductive technologies have failed.

Chinese medicine and IVF

Chinese medicine, including acupuncture, herbs, dietary and nutritional therapy, stress reduction techniques, and reproductive organ massage, provides a safe and effective complementary therapy for IVF. Many research articles suggest an increase in IVF success of around 50% with acupuncture alone, and the application of a more comprehensive Chinese medical program may offer even greater improvement. A number of different treatment options are prescribed, depending on the specific presentation involved for each patient:

IVF Acupuncture

Acupuncture is able to increase implantation and ongoing pregnancy rates when used in conjunction with IVF. Research shows improved blood flow to the reproductive system through the uterine arteries after acupuncture treatments, which may over time enhance egg quality, thickness of the endometrium (uterine lining), and reduce the chance of miscarriage post-IVF. Other benefits of acupuncture when used with IVF include hormonal regulation, immune system balance, reduced stress and cortisol levels, reduced side effects of medications, better response to medications, reduced risk of ovarian hyperstimulation syndrome, and decreased contraction of the uterus post-IVF.

Herbal formulas are prescribed to help enhance egg quality and sperm parameters, to improve implantation rates, and to prevent miscarriage post-IVF. They are also useful when used prior to IVF to control many of the underlying causes of infertility, including endometriosis, PCOS, fibroids, high FSH, poor egg quality, blocked Fallopian tubes, and immune system imbalance. Much research has been done on the effect of herbs on these individual disorders. Herbal medications are generally not used during the ovarian stimulation phase of an IVF cycle; patients with multiple failed cycles of IVF who have responded poorly to their medications may be an exception to this rule.

Massage and physical therapy can be used to correct structural imbalances caused by fibroids, endometriosis, blocked Fallopian tubes, scar tissue from prior surgeries, and adhesions restricting function and mobility of the reproductive organs caused by trauma or injury, when performed prior to IVF. Reproductive organ massage is also effective in improving blood flow to the reproductive system. In a 2004 peer-reviewed study, manual physical therapy was shown to improve pregnancy rates in infertile women.

Nutritional and dietary therapy improve pregnancy rates, and can be used by both male and female partners to enhance fertility. Use of nutritional supplements prior to and during pregnancy has been proven via numerous research articles to improve the health of both mother and baby. Certain foods and supplements regulate hormone balance, and contain factors beneficial to egg and sperm health and development; they are prescribed according to the needs of the individual patient.

Mind-body techniques such as meditation, yoga, and qigong excercises are often useful for patients struggling with infertility, because they reduce stress and cortisol levels, and allow the body to prioritize reproduction.

Therapy and support groups can help deal with the psychological stress and feeling of isolation experienced by many patients undergoing fertility treatment. A 2000 Harvard Medical School study showed higher pregnancy rates in patients who attended support groups and cognitive behavioral therapy.

Ovarian stimulation

IVF treatment cycles are typically started on the third day of menstruation, and begin with a protocol of fertility drugs, based on a woman’s age, hormone levels, history of response to fertility drugs, and individual reproductive issues. This drug protocol, typically injectable gonadotropins, stimulates the development of multiple follicles in the ovaries. Frequent monitoring is required during ovarian stimulation (usually around ten days) to measure follicular growth via ultrasound, and estradiol testing of the blood. Medications called GnRH (gonadatropin-releasing hormone) agonists or antagonists are used during this time to inhibit the natural surge of LH (luteinizing hormone) and prevent ovulation. Side effects often occur during ovarian stimulation, or in the phase preparing for stimulation.

Common side effects of IVF:

• Abdominal and pelvic pain
• Bleeding
• Nausea and vomiting; usually 24 hours after egg collection
• Hyperstimulation
• Abdominal distension and bloating
• Mood swings
• Headaches
• Ovarian cysts
• Bruising
• Egg retrieval (transvaginal oocyte retrieval)

When the follicles have reached their optimal maturation, human chorionic gonadotropin (hCG) is given. The eggs are then retrieved from the patient using an ultrasound-guided needle piercing through the vaginal wall to reach the ovaries. Follicles (containing eggs and follicular fluid) are then aspirated and the embryologist identifies the ova. The retrieval procedure takes about 20 minutes and is usually done under conscious sedation or general anesthesia.

Fertilization

After egg retrieval, the sperm and the eggs are incubated together in a nutrient-rich culture media for about 18 hours. The eggs are then checked for the presence of two pronuclei, which indicates that fertilization has occurred. In situations where the sperm count is very low or of poor quality, a single sperm is injected directly into the egg using intracytoplasmic sperm injection (ICSI). The fertilized egg is incubated in a special growth medium until it is time for embryo transfer.

Selection and grading of embryos

Grading methods have been developed by embryology labs to judge oocyte and embryo quality, based on the number of cells, evenness of growth, and degree of fragmentation.

Numeric grading systems for multi-cell embryos usually have four levels:

Grade 1 Even cell division, no fragmentation
Grade 2 Even cell division, small fragmentation
Grade 3 Uneven cell division, moderate fragmentation
Grade 4 Uneven cell division, excessive fragmentation

Embryo transfer

Embryos are often transferred at the 6–8-cell stage three days after retrieval. If embryo quality and number are sufficient on day three, they may be placed into an extended culture medium with a transfer done at the blastocyst stage (typically on day five). Blastocyst stage transfers have been shown to result in higher pregnancy rates.

The embryos judged to be of the highest quality are transferred to the patient’s uterus through a thin plastic catheter, which enters through her vagina and cervix. The number of embryos transferred is based on age, embryo quality, response to previous treatment, and overall reproductive health. The goal is to maximize the chances of implantation and pregnancy while reducing the risk of multiple pregnancies.

Embryo development

The following is an approximate timetable of fertilization and embryo development:

Day 0 Egg retrieval, sperm collection, and preparation insemination
Day 1 Check eggs for fertilization (the presence of two pronuclei (PNs))
Day 2 Embryos at the 4-cell or more stage of development
Day 3 Embryos at the 8-cell or more stage of development
Day 4 Embryos at the compacted morula (16–32 cell) stage
Day 5 Embryos at the blastocyst stage of development

Critical points in development are (1) fertilization, (2) 4- to 8-cell stage and (3) morula to blastocyst stage.

Blastocysts are graded differently, with a number and two letters.

Pregnancy rates

With enhanced technology, the pregnancy rates are substantially higher today than they were in the past. In 2006, average pregnancy rates were 35% per embryo transfer.

Success rates for ART (assisted reproductive technology)

from a 2002 SART (Society for Assisted Reproductive Technology) report:

IVF   31.0%
ICSI   28.6%
GIFT   24.5%
ZIFT   29.2%

Other useful terms in assisted reproduction:

PGD (preimplantation genetic diagnosis) can be performed on embryos before the embryo transfer, to test for genetic disorders present in the embryos.

ICSI (intracytoplasmic sperm injection) is used when sperm numbers are very low, or when sperm have difficulty penetrating the egg. ICSI allows for a single sperm to be injected into the egg, resulting in fertilization.

ZIFT (zygote intrafallopian transfer) is a procedure similar to IVF, except that the embryos are placed in the Fallopian tubes instead of into the uterus.

In the GIFT (gamete intrafallopian transfer) procedure, eggs are removed from the woman and placed in one of the Fallopian tubes, along with the man’s sperm. This allows fertilization to take place inside the woman’s body.