In vitro fertilization for infertility

Treatment Overview

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During in vitro fertilization (IVF), eggs and sperm are brought together in a laboratory glass dish to allow the sperm to fertilize an egg. With IVF, you can use any combination of your own eggs and sperm and donor eggs and sperm.

See an illustration of the female reproductive system .

Ovulation and egg retrieval. To prepare for an assisted reproductive procedure using your own eggs, you will require hormone treatment to control your egg production (ovulation). This is done to prevent unpredictable ovulation, which would make it necessary to cancel that in vitro attempt. This is generally done using one of two similar types of gonadotropin-releasing hormone analogue (GnRH agonist or GnRH antagonist). The following are two examples of how ovulation can be controlled:

• Having about 10 days of nasal or injected GnRH agonist that "shuts down" your pituitary. Next, you undergo daily ovary-stimulating hormone injections and close monitoring for 2 weeks before egg retrieval. At home, you or your partner injects you with gonadotropin or follicle-stimulating hormone (FSH) to make your ovaries produce multiple eggs (superovulation).
• Starting treatment with FSH injections and adding GnRH antagonist injection after about 5 days, which stops the production of luteinizing hormone (LH) within an hour or two.

After the first week, your doctor checks your blood estrogen levels and uses ultrasound to see whether eggs are maturing in the follicles. During the second week, your dosage may change based on test results, and you are monitored frequently with transvaginal ultrasound and blood tests. If follicles fully develop, you are given a human chorionic gonadotropin (hCG) injection to stimulate the follicles to mature. The mature eggs are collected 34 to 36 hours later by needle aspiration guided by ultrasound. You will usually have pain medicine and sedation for this procedure.

Sperm collection. Sperm are collected by means of masturbation or by taking sperm from the scrotum through a small incision. This procedure is performed when a blockage prevents sperm from being ejaculated or when there is a problem with sperm development.

Fertilization and embryo transfer. The eggs and sperm are placed in a glass dish and incubated with careful temperature, atmospheric, and infection control for 48 to 120 hours. About 2 to 5 days after fertilization, the best fertilized eggs are selected. Two to four are placed in the uterus using a thin flexible tube (catheter) that is inserted through the cervix. Those remaining may be frozen (cryopreserved) for future attempts.

Pregnancy and birth. Any embryos that implant in the uterus may then result in pregnancy and birth of one or more infants.

What To Expect After Treatment

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Overall, in vitro fertilization (IVF)-related injections, monitoring, and procedures are emotionally and physically demanding of the female partner. Superovulation with hormones requires regular blood tests, daily injections (some of which are quite painful), frequent monitoring by your doctor, and harvesting of eggs.

These procedures are done on an outpatient basis and require only a short recovery time. You may have cramping during the procedure. You may be advised to avoid strenuous activities for the remainder of the day or to be on bed rest for a few days, depending on your condition and your doctor's recommendation.

Why It Is Done

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In vitro fertilization may be a treatment option if:

• A woman's fallopian tubes are missing or blocked.
• A woman has severe endometriosis.
• A man has low sperm counts.
• Artificial or intrauterine insemination has not been successful.
• Unexplained infertility has continued for a long time. How long a couple chooses to wait is influenced by the female partner's age and other personal factors.
• A couple wants to test for inherited disorders before embryos are transferred.

IVF can be performed even if a:

• Woman has had a tubal ligation reversal surgery that was not successful.
• Woman does not have fallopian tubes.
• Woman's fallopian tubes are blocked and can't be repaired.

IVF can be done using donor eggs for women who cannot produce their own eggs due to advanced age or other causes.

How Well It Works

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The number of women who give birth to a live infant after in vitro fertilization varies depending on the cause of infertility. The success rate for IVF can be as high as 40% for women under 30.¹ However, IVF success varies widely depending mostly on the woman's age, the cause of the couple's infertility, and pregnancy history.

The aging of the egg supply has a powerful effect on the chances that an assisted reproductive technology (ART) procedure will result in pregnancy and a healthy baby. Many women over age 40 choose to use donor eggs, which greatly improves their chances of giving birth to a healthy child.

Age. Birth rates resulting from a single cycle of IVF using women's own eggs are about 30% to 40% for women age 34 and younger, then decrease steadily after age 35.¹

Pregnancy history. A woman who has already had a live birth is more likely to have a successful ART procedure than a woman who hasn't given birth before. This "previous birth advantage" gradually narrows as women age from their early 30s to their 40s.¹

Own eggs versus donor eggs. Birth rates are affected by whether ART procedures use a woman's own eggs or donor eggs. Per cycle of in vitro fertilization:¹

• Using her own eggs, a woman's chances of having a live birth decline from over 40% in her late 20s, to 30% at about age 38, and to 10% by about age 43.
• Live birth rates are the same among younger and older women using donor eggs. Women in their late 20s through mid 40s average about a 50% birth rate using fresh (not frozen) embryos.

Donor frozen IVF embryos from a previous IVF cycle that are thawed and transferred to the uterus are less likely to result in a live birth than are donor fresh (newly fertilized) IVF embryos.¹ However, frozen embryos are less expensive and less invasive for a woman, because superovulation and egg retrieval aren't necessary.

You can consult the Centers for Disease Control and Prevention (CDC) national database for the latest ART success rates. See the complete CDC listing of U.S. infertility clinics online in the latest Assisted Reproductive Technology Success Rates report at http://www.cdc.gov/reproductivehealth/art.htm. Success rates in different programs can vary; couples are advised to talk to their health professional and seek the most current information from the programs they are considering.

Risks

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In vitro fertilization (IVF) increases the risks of ovarian hyperstimulation syndrome and multiple pregnancy.

• Severe ovarian hyperstimulation syndrome, which rarely is life-threatening, develops in 0.5% to 2% of all IVF cycles.² Your doctor can minimize this risk by closely monitoring your ovaries and hormone levels during superovulation.
• Approximately 35% of births in the United States that result from assisted reproductive technologies such as IVF produce pregnancies with twins or more.³ Multiple pregnancies are high-risk for both mother and fetuses.

Your doctor will help you decide how many embryos to transfer, with the goal of having a healthy pregnancy with one fetus. You should discuss this decision before your treatment cycle begins, and again before embryo transfer. Depending on your age and other factors, you may decide to limit the number of embryos transferred to one, two, or three. If more than two embryos implant and grow in your uterus, you will probably be counseled about multifetal pregnancy reduction to increase the chances of a healthy pregnancy and infant survival.

Embryo transfer success versus the risk of multiple pregnancy

For a woman over age 35 to maximize her chances of conceiving with her own eggs and carrying a healthy pregnancy, she may choose to have more embryos transferred than a younger woman would. However, this increases her risk of multiple pregnancy.

Because of the risks of multiple pregnancy to the babies, the American Society for Reproductive Medicine recommends that women under age 35 have no more than two embryos transferred, women age 35 to 37 have no more than three, women 38 to 40 have no more than four transferred, and women who have had repeated failed cycles or are over age 40 have no more than five embryos transferred.⁴

Women over 40 have a high rate of embryo loss when using their own eggs. As an alternative, older women can choose to use more viable donor eggs.

What To Think About

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Smoking has a damaging effect on fertility and pregnancy. Smokers usually require more cycles of IVF to become pregnant than nonsmokers.³ Smoking also endangers the health of the fetus. As a result, some doctors do not provide infertility treatment to women who smoke.

In vitro fertilization provides diagnostic information about fertilization and embryo development (which is not the case with a GIFT or ZIFT procedure).

Using ultrasound to help collect eggs from the woman's ovaries is less expensive, less risky, and less invasive than egg collection by laparoscopy.

Although the underlying causes are not yet fully understood, babies conceived with assisted reproductive technology have slightly higher rates of low birth weight and birth defects than do babies conceived naturally.^{5, 6} Babies conceived using intrauterine insemination (IUI) also have an increased risk of low birth weight.⁷

In vitro fertilization costs approximately $10,000 to $15,000 per cycle in the United States.

If you and your doctor are concerned about passing on a genetic disorder to your child, preimplantation genetic diagnosis might be available. Some genetic disorders can be identified with specialized testing before an embryo is transferred, increasing the chances of conceiving a healthy child.

Complete the special treatment information form (PDF) (What is a PDF document?) to help you understand this treatment.

References

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Citations

1. Centers for Disease Control and Prevention (2004). 2002 Assisted Reproductive Technology Success Rates: National Summary and Fertility Clinic Reports. Available online: http://www.cdc.gov/reproductivehealth/ART02/index.htm.

2. Duckitt K (2004). Infertility and subfertility. Clinical Evidence (11): 2427–2458.

3. Speroff L, Fritz MA (2005). Assisted reproductive technologies. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 1216–1274. Philadelphia: Lippincott Williams and Wilkins.

4. American Society for Reproductive Medicine (2004). Guidelines on number of embryos transferred. Fertility and Sterility, 82(3): 773–774.

5. Schieve LA, et al. (2002). Low and very low-birth-weight in infants conceived with use of assisted reproductive technology. New England Journal of Medicine, 346(10): 731–737.

6. Ludwig M, Katalinic A (2002). Malformation rate in fetuses and children conceived after ICSI: Results of a prospective cohort study. Reproductive Biomedicine Online, 5(2): 171–178.

7. Gaudoin M, et al. (2003). Ovulation induction/intrauterine insemination in infertile couple is associated with low-birth-weight infants. American Journal of Obstetrics and Gynecology, 188(3): 611–616.

Credits

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Author	Shannon Erstad, MBA/MPH
Author	Lila Havens
Editor	Kathleen M. Ariss, MS
Associate Editor	Michele Cronen
Associate Editor	Pat Truman
Associate Editor	Terrina Vail
Primary Medical Reviewer	Joy Melnikow, MD, MPH - Family Medicine
Primary Medical Reviewer	Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer	Kirtly Jones, MD - Obstetrics and Gynecology
Last Updated	April 7, 2006