Step
7-Transvaginal oocyte retrieval
Oocyte retrieval is performed about 36
hours after HCG is given. The Transvaginal Oocyte Retrieval is performed in the
ARTS lab at the Margot Perot Building at Presbyterian Hospital of Dallas .You should arrive one hour prior to your scheduled surgery time.
During this time the anesthesiologist will meet with you to review your medical
history, complete a preoperative evaluation, and answer any questions. During
the retrieval, the anesthesiologist administers intravenous medications ( pain
relievers and sedatives) in order to minimize the discomfort that may occur .
The egg retrieval is performed via vaginal ultrasound (similar to the
ultrasound used for monitoring your follicles during your stimulation). Once
you are comfortable and relaxed, Dr. Goldstein will place the ultrasound
transducer in the vagina. A needle attached to the transducer is then placed
through the wall of the vagina and into each follicle in the ovaries. The
oocytes and follicular fluid will be aspirated into a test tube and examined in
the embryology lab.
The embryologist examines the follicular fluid,
identifies the egg, and then transfers each egg to a special culture media.
Sometimes there are ovarian cysts that contain no eggs but appear identical to
follicles that do contain eggs. Also, follicles of smaller size may not yield
eggs. The number of follicles seen with ultrasound, therefore, may not
correspond to the number of eggs retrieved. Ultrasound provides only an
approximation of the number of oocytes that one can expect to
recover.
Step 8-Insemination of Oocytes
Later, the sperm is prepared and placed with the eggs. In some
cases, the embryologist will need to  identify
normal, motile sperm and inject them individually directly into
each egg. This procedure is called Intracytoplasmic Sperm Injection
(ICSI). Once the eggs are inseminated or placed with the sperm,
they are placed into an incubator overnight. Semen samples for
use in IVF procedures will be required on the day of egg retrieval
and should be collected in the ARTS center. On rare occasion,
the laboratory staff may request a second semen sample. The
specimen should be obtained by masturbation after 3-5 days of
abstinence. More than 5 days of abstinence is NOT recommended.
It is important not to use any lotions or lubricants for sperm
production as it may harm sperm motility. If you anticipate
any collection difficulties, please notify Dr. Goldstein or
the IVF nurse coordinator, Linda.
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A normal
2-PN embryo on Day 1
Normal fertilization is characterized by
a pronucleus of the egg and sperm that can be visualized
under a microscope.
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Embryo
on day 3 of development. |
Blastocyst embryo on Day 5
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Step 9-Embryo Transfer
The embryo
transfer (ET) is usually performed three days or five days after the oocyte
retrieval. The procedure takes approximately 10-15 minutes, and is very similar
to the uterine measurement taken at your baseline appointment. Please arrive at
ARTS 30 minutes prior to scheduled transfer time. Embryo transfers are
typically scheduled between 12:00p.m. and 2:00 p.m. on weekdays, and 9:00 a.m.
- 12:00 p.m. on weekends. You will not need anesthesia on this day, so there is
no need to abstain from eating or drinking before your ET. Please do not apply
perfume, or scented lotions on the day of your embryo transfer.
Once
you, the embryologist and physician have confirmed the plan for the embryo
transfer, the physician will insert a speculum. An abdominal ultrasound will be
used to visualize the uterine cavity. The embryologist will load the embryos
into a small catheter which is then gently inserted through the cervical
opening into the uterus, and the embryos are placed into the uterine cavity
along with an extremely small amount of fluid. The catheter is then carefully
removed.
Following the Embryo Transfer you will remain lying down for
approximately one hour, then we would like for you to rest at home for at least
24 hours. You must have someone accompany you and drive you
home.
Step 10-Progesterone Supplementation
You will take
progesterone injections beginning the evening after the oocyte retrieval and
continue daily until your serum pregnancy test. If pregnant, progesterone will
be administered for a total of 8 weeks. Ordinarily, the granulosa cells in the
folllicle will produce progesterone following ovulation, but some of these
cells are removed during the oocyte retrieval. Therefore, supplemental
progesterone is needed to help maintain the uterine lining for
implantation.
Progesterone is a hormone normally produced by the ovarian
corpus luteum during the last two weeks of the menstrual cycle and during early
pregnancy. After the seventh or eighth week of pregnancy the placenta takes
over progesterone production. Natural progesterone is prescribed in many
fertility treatments for luteal phase support of implantation and early
pregnancy. Natural progesterone is also prescribed to support the luteal phase
for patients in virtually every IVF program today. The progesterone prescribed
is derived from natural sources and is identical to that produced in the
body.
Do NOT discontinue your Progesterone until directed by our
office.
Step 11-Pregnancy Follow-up
Please call our office
after the embryo transfer to schedule your pregnancy test 14 days after the egg
retrieval. The pregnancy test is obtained before 10:00 a.m. and the results
will be called to you the same afternoon. Positive tests are repeated in one
week and a sonogram will be scheduled. Once we document a heartbeat on
sonogram, we will return your care back to your obstetrician. If your pregnancy
test is negative, we ask that you schedule a follow-up visit to review your
cycle and discuss options.
Questions and Answers
What
are possible reasons for cycle cancellation?
- The follicles are not developing properly
- An inadequate blood estrogen level
- Excessive estradiol level, indicating an increased
risk for ovarian hyperstimulation
- Less than 5 maturing follicles seen on
ultrasound
- If a cycle is cancelled, medication may be modified
in subsequent cycles in an attempt to improve your response.
What are side effects of gonadotropins?
- Multiple Births: While most multiple pregnancies
are twins, some are composed of triplets or more. High order multiple gestation
pregnancies are associated with increased risk of pregnancy loss, premature
delivery, infant abnormalities, handicaps due to the consequences of a very
premature delivery, pregnancy induced hypertension, hemorrhage, and other
significant maternal complications.
- Ovarian Hyperstimulation Syndrome (OHSS): OHSS is
uncommon, occurring in only 1-5 % of cycles and is more frequently seen in
women who have the diagnosis of Polycystic Ovarian Syndrome (PCOS). It is
characterized by rather sudden ovarian enlargement and abdominal fluid
retention. If your monitoring indicates that you may develop hyperstimulation,
we will bring this to your attention as soon as possible. Treatments most
likely will consist of bed rest and careful monitoring of fluid levels.
Hyperstimulation may be aggravated if pregnancy does occur. In such cases, we
may either cancel the cycle or proceed with the egg retrieval but then
cryopreserve (freeze) all embryos and transfer a month or two later.
In severe cases, OHSS can result in blood clots,
kidney damage, ovarian twisting, and chest and abdominal fluid collections.
During these times hospitalization may be required, usually for monitoring
purposes, although a surgical procedure may be called for in some
instances.
I had my tubes tied (tubal ligation) several years ago.
Should I have a tubal reversal or IVF?
Depending on the method of tubal
ligation, you may or may not be able to have a tubal reversal. Factors such as
the age of the women or in couples with male factor infertility become
important considerations in determining whether tubal reversal is reasonable.
If tubal ligation reversal has been attempted and has failed, IVF-ET represents
the best option.
Is there a possibility of multiple births from
ART?
Yes, any time more than one embryo is transferred, there is a
chance for multiple pregnancies. It appears that the rate of twin births is
greater than in the normal population (1 in80). We follow the guidelines
established thru the American Society of Reproductive Medicine regarding the
number of embryo's to transfer.
Is there an increased chance of birth
defects if I become pregnant through ART?
No. Numerous studies have
reported no increased risk of birth defects in children conceived through ART
compared to those conceived in the general population.
Can we have
intercourse while taking the hormone medications?
Yes. However, it is
recommended that the male abstain from ejaculating for 3 -5 days preceding the
egg retrieval. This precaution assures that the semen sample on the day of egg
retrieval contains the maximum number of motile sperm. You may find that near
the time of egg retrieval your ovaries will be markedly enlarged and tender,
possibly making intercourse very uncomfortable.
What activity
restrictions are recommended during my stimulation?
As your ovaries
begin to stimulate, they will become enlarged and tender. Limited activity
reduces the risk of ovarian torsion and/or rupturing the follicles on the
ovaries. As a general rule, it is advised that you stop any activity that
involves bouncing, or jarring the pelvis by the time you are returning for your
first ultrasound to monitor your stimulation.
What if I ovulate
before the retrieval?
On the day of the egg retrieval, a vaginal
ultrasound will confirm that the follicles are still intact. If they are, it
can be assumed that ovulation has not occurred and oocyte retrieval will be
attempted. The medications Lupron, Antagon, or Cetrotide also help to assure
that ovulation does not occur before egg retrieval has been
performed.
How much activity is recommended after Embryo Transfer
(ET)?
Strenuous exercises, like running or heavy lifting, etc. should
be avoided until a pregnancy test has been performed.
If an embryo
transfer takes place, how long must we wait until we have intercourse without
risk to the embryo?
Nobody really knows for sure if intercourse aids or
impedes implantation. Theoretically, uterine contractions result from
intercourse,
so to be safe, we recommend not having intercourse until after
the pregnancy test.
Can I have a glass of wine or alcohol during the
cycle up until the pregnancy test?
No alcohol after the
procedure
Can I travel more than 4 - 6 hours in a car after my
transfer or fly in an airplane?
Yes, but not recommended until the day
after the transfer.
The following list of immunizations or injections
are OK during a cycle:
- Flu shot
- Hepatitis Vaccine
- Chicken pox immunoglobulin
- TB Test
- Tetanus shot
- Allergy shots
- Novocaine (dental procedures)
The following is a list of medications that are
OK to take before or after embryo transfer:
- Cold medications (Sudafed, Robitussen)
- Amoxicillin, Ampicillin, Erythromycin
- Bactrim - OK before pregnancy test
- Flagyl - OK before pregnancy test
- Doxycycline, Tetracycline (OK before pregnancy
test)
- Nasal spray decongestants
- Tylenol Cold or PM
- Claritin D
- Valium, Prozac, Zanax, Ativan
- Benadryl
- MOM, Colace, Senekot, Immodium, Pepcid
- Headache meds: Fiuricet, Fiorinal
Do NOT take the following medications:
- Echinacea, St. John's Wort, Gingko Biloba
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If the baseline ultrasound
shows no significant cysts, we start ovarian stimulation after menstrual
bleeding begins. Ovarian stimulation medications are preparations of naturally
occurring hormones, which are used to develop and mature multiple follicles by
directly stimulating the ovaries. Gonal-F, Follistim, and Bravelle are the
brand names for a group of medications known as gonadotropins which contain
only FSH (follicle stimulating hormone). Repronex and Menopur are the brand
names for another group of medications known as human Menopausal Gonadotropins
containing both FSH and LH (luteinizing hormone). Many protocols use a
combination of both medications.
