What are Blastocysts?

From the fertility booklet The A.R.T. of Fertility: A patient guide
by the Fertility & IVF Center of Miami

Blastocysts are embryos that have developed for 5 to 6 days after fertilization. A healthy blastocyst is ready to hatch from its outer shell by the end of the 6th day and implant into the endometrial lining within 24 hours. Currently only about 20-40% of embryos mature into blastocysts, but those that do survive have a better chance to implant and develop into a baby. Why transfer blastocysts? Blastocyst culture can provide a natural selection of the best embryos instead of random selection among good quality embryos on "day 3". Blastocysts are a viable option whenever a good number and quality of embryos exist. When only a limited number of embryos are available on the third day, there is no advantage to continue culture to a blastocyst.

Since blastocysts have a higher potential for implantation, fewer of them are transferred, generally two. Transferring fewer embryos translates into a lower risk for multiple pregnancy, and this is paramount for those couples that want to avoid selective reduction.



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What is TESA/PESA?

From the fertility booklet The A.R.T. of Fertility: A patient guide
by the Fertility & IVF Center of Miami

PESA (percutaneous epidydimal sperm aspiration) and TESA (testicular sperm aspiration) are procedures that are performed to obtain sperm in certain cases of male infertility. PESA or TESA can be performed on men that have zero sperm counts due to either a sperm production problem or a blockage in their reproductive tract, such as the result of a vasectomy, congenital absence of vas deferens, or infection.

Once a diagnosis of azoospermia (zero sperm count) has been made, we work closely with a urologist with specialized training in male infertility who will retrieve the sperm. The urologist will first perform an exam and further testing which may involve blood work and/or a testicular biopsy. The result of these studies determine which procedure is more appropriate and more likely to yield sperm.

While PESA is usually performed in our Center the morning of the egg retrieval, TESA may be done the day prior to the egg retrieval to allow in vitro maturation of immature sperm. With PESA, a small needle is placed into the epidydimis, which is a reservoir of sperm that sits atop each testicle, using local anesthesia. During TESA, sperm is obtained by means of a biopsy of the testicle. The sperm obtained from these procedures is then injected directly into the eggs (ICSI).

The Fertility and IVF Center of Miami is proud to have announced on August 12, 1997, the birth of the first baby in Florida conceived with the aid of PESA.



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Egg Donation Program

Becoming an Egg Donor

The Fertility & IVF Center of Miami continuously recruits donors from Miami and neighboring areas. Recruitment is limited to areas reasonably close to Miami as we are not able to cover the costs of travel and lodging.

Donors must be between 21 to 31 years of age; however, we do accept applications from donors that are 20 years old. They must be a non-smoker, in good health, have a healthy weight/height ratio, reliable, and mature.

Donors are initially screened by phone and receive further information and an application through the mail. The complete initial screening includes:

  •     Written psychological screening test (MMPI)

  •     Consult and exam with our physicians

  •     Hormonal blood test on the third day of menses

  •     Consult with a psychologist

Donors are admitted into the donor pool based on these evaluations. Once in the pool, donors await to be selected by a recipient couple. The length of time between admission into the pool and an egg donation can be just a couple of weeks or one year or more depending on the donor’s characteristics and the type of donor the recipient couple are searching for.

Once a recipient couple chooses a donor, further blood tests are performed on the donor for infectious diseases and genetic abnormalities. The egg donor is taught to self-administer injections and is fully counseled on the donation process.

Donors take fertility drugs that stimulate the ovaries to produce eggs for a period of approximately 10 days. They must also take daily injections of a drug to prepare them to donate, so donors take medications for approximately 3 weeks in total. It is during those 10 days of stimulation that donors attend the office frequently for ultrasounds and blood work to determine the day of egg retrieval.

The egg retrieval is performed under intravenous sedation administered by an anesthesiologist. The eggs are harvested using an ultrasound-guided needle placed in the back of the vagina. The procedure lasts for approximately 15-30 minutes. Donors recover for about an hour and then return home the same morning.

Donors are given an honorarium of $5,000 to $6,000 for a completed egg donation as compensation for the time and effort invested during the treatment.

If you are interested in becoming an egg donor,
please contact us or complete our Information Request Form.
 

What is IVF?

From the fertility booklet The A.R.T. of Fertility: A patient guide
By the Fertility & IVF Center of Miami

An understanding of natural conception is important in order to understand in-vitro-fertilization (IVF). Normally, a woman will produce a mature egg each month. The egg (oocyte) is released from the ovary at the time of ovulation and transported to the fallopian tube. Usually, it is in the fallopian tube that it will encounter sperm and be fertilized. The fertilized egg develops into an embryo that will travel to the womb where it attaches and grows.

In IVF, the egg is collected directly from the ovary before ovulation and is fertilized with sperm in the laboratory. The fertilized egg will be incubated for a period of 3 to 5 days. The resulting embryo is then transferred into the uterus (womb) passing through a small canal, called the cervix, which can be accessed through the vagina.

There are also variations in the timing and method of transfer that may be appropriate for certain patients. How is IVF performed? The following are step-by-step descriptions of the IVF process.

Down-regulation

In order to begin the egg production (follicular recruitment) the pituitary gland, which controls the ovary, must be "quieted", so as not to "interfere" with the fertility drugs. There are two types of medications used for this purpose: GnRH (Gonadotropin Releasing Hormone) agonists and GnRH antagonists.

GnRH agonist

Lupron is an injectable drug that creates this state of suppression, medically termed "down-regulation". Lupron's immediate action is to stimulate the pituitary gland to release hormones that regulate the ovary, called follicle stimulating hormone (FSH) and luteinizing hormone (LH). With continued use of Lupron, the pituitary exhausts itself and a state of suppression is created.

Patients start daily injections of Lupron about 7 to 10 days before their expected period. To avoid an unexpected pregnancy while taking Lupron, it is very important to abstain from intercourse or use protection.

To avoid an unexpected pregnancy while taking Lupron, it is very important to abstain from intercourse or use protection the month before starting medications. You can discuss issues regarding abstinence with your physician.

In some patients, Lupron may be started on the second day of their period, to take advantage of the initial release of FSH and LH, in a technique called "Flare up". In both techniques, Lupron is continued daily in conjunction with gonadotropins until the follicular recruitment phase is over.

The cycle of IVF treatment begins with the onset of the menstrual flow. Patients attend the office for a baseline ultrasound and blood work. The ultrasound evaluation ensures the absence of cysts in the ovaries, and the blood work verifies low levels of the hormone estradiol. These results indicate to the physician that Lupron has achieved its goal of down-regulation.

GnRH antagonists

An alternative method of down-regulation involves the use of GnRH antagonists (Antagon or Cetrotide) . Shortly after the initial injection of Antagon or Cetrotide, a state of down-regulation is immediately achieved, in contrast with Lupron which takes several days to produce this effect. Therefore, GnRH antagonists are started after initiating stimulation of the ovaries with fertility drugs, rather than prior to menses. The purpose is to block the potential premature release of LH, which precipitates ovulation, thus allowing the gonadotropins to continue to stimulate the follicles to grow. Often, an oral contraceptive is utilized in the cycle prior to initiating a GnRH antagonist.

Follicular Recruitment

Eggs develop within a small sac of fluid within the ovary, called a follicle. While eggs are so small that cannot be seen without a microscope, follicles are easily visualized with the use of ultrasound imaging.

Once down-regulation has been ascertained, daily injections of gonadotropins will begin to start follicular recruitment. Examples of human-derived gonadotropins are Pergonal, Fertinex, Repronex, and Humegon; they contain a mixture of FSH and LH. A synthetic form containing pure FSH is most often used called Gonal-F or Follistim. Follicles respond to FSH by growing and producing the hormone estradiol. Typically, patients use daily injections of gonadotropins for approximately 10 to 12 days.

The goal of fertility drugs is to recruit as optimal a number of eggs as possible without over-stimulation of the ovaries. Therefore, careful monitoring of the patient's response to the medications is required. Monitoring involves ultrasounds performed through the vagina to visualize the number and size of the follicles. Blood is also drawn to assess the level of estradiol. This information allows the physician to modify the medication dosage, if needed, and to determine the extent of stimulation. Such monitoring visits start on the fourth or fifth day of gonadotropin injections, and continue throughout the course of medications.

Once the doctor determines that the follicles have grown sufficiently and estradiol levels are appropriate, Lupron and gonadotropin injections will stop. In preparation for egg harvest, the patient receives a single injection of a hormone called hCG (human chorionic gonadotropin), also called Ovidrel, Profasi, or Pregnyl. This injection is given at a specific hour since egg retrieval must be coordinated approximately 36 hours later.

Egg harvesting

Egg harvesting or retrieval is performed under sedation in a special suite in the Center . An anesthesiologist is present during the procedure to administer anesthesia into the patient's vein, similar to that which a dentist might use for wisdom teeth extraction. Once the patient is asleep, a needle, guided by an ultrasound, is inserted in the back of the vagina and into the ovary. All the visible follicles are aspirated, and the fluid obtained is taken to the laboratory. It is in the laboratory, that the embryologist will examine the follicular fluid to locate the eggs, and place them in the incubator. After the procedure, the couple is informed of the number of eggs retrieved. Recovery from the sedatives usually takes approximately one hour depending on the individual.

That same morning of the procedure, the male partner will provide the semen sample. He prepares by keeping a period of abstinence of at least 2 days but no more than 5 days. He provides the sample in the privacy of specially designed rooms in the Center furbished with printed material and movies. Once the semen sample is collected, it is analyzed, washed, concentrated, and later mixed with the eggs.

The interior of the uterus (endometrial lining) is prepared for the embryo transfer using Progesterone injections. Progesterone is a steroid hormone that prepares and maintains the endometrial lining in optimal condition to receive an embryo, and support a pregnancy. The daily injections of Progesterone begin in the evening the next day following the egg retrieval and continue until the 10th or 12th week of pregnancy.

Fertilization and Incubation

The following day ("day 1"), the embryologist examines the eggs under a microscope to verify that fertilization has taken place. Some eggs may not have fertilized. The fertilized eggs are kept in a special fluid called culture media. They will remain undisturbed in the incubator where they grow and divide into many cells. On "day 3" (three days following the retrieval of the eggs), the embryologist will examine the embryos and check the degree of development. This information will help the embryologist and the physician determine whether to transfer the embryos that same day, or wait two additional days until the embryos reach the blastocyst stage.

Embryo transfer
The embryo transfer takes place in a comfortable room while the patient lies on a special bed with stirrups. Anesthesia is not needed since only temporary, mild period-like cramping or no discomfort might be experienced. The partner or a family member can keep the patient company during the procedure. Use of strong perfumes should be avoided since it might be toxic to the embryos.

The morning of the transfer the embryologist and the doctor discuss with the patient the status of the embryos: the number of developed embryos, their quality, and number of cells of each one. A photograph of the embryos might be provided. At this point, the physician makes a final recommendation based on the patient's past history, age, status of the embryos, and the patient wishes regarding selective reduction. Then the couple and the doctor make a joint decision regarding the number of embryos to be transferred.

Prior to the transfer an ultrasound is performed through the vagina to chart the position of the uterus and measure the length of the cervix and the endometrial cavity.

The doctor begins the transfer by placing a speculum in the vagina to help him/her visualize and thoroughly cleanse the cervix. First, a very thin catheter or tube is introduced through the cervix and into the uterus to assess any difficulties placing the catheter. This trial gives the doctor an opportunity to choose a technique for the smoothest transfer. Once the trial is completed, the embryos are brought from the laboratory inside a similar catheter and then placed gently inside the uterus.

Following the transfer, the patient lies for approximately one hour and then is sent home to rest. Intense activities, strenuous exercises, extreme temperatures and intercourse should be avoided until pregnancy tests results are known. Two weeks following the retrieval of the eggs a blood pregnancy test is performed. If pregnant, the patient continues Progesterone injections and returns for a pregnancy ultrasound two and a half weeks later. Once the ultrasound confirms a pregnancy inside the uterus, the patient is then referred back to their obstetrician for continued care and delivery.



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Assisted Hatching (AH)

From the fertility booklet The A.R.T. of Fertility: A patient guide
by the Fertility & IVF Center of Miami

What is Assisted Hatching?
When the embryo is ready to implant, it hatches out of the outer shell and begins to burrow in the uterus. Assisted hatching is a procedure performed by the embryologist under the microscope which involves making a small tear in the protective outer coating of an embryo to facilitate hatching. In older patients and in cases of previously failed IVF attempts, assisted hatching may improve the chances of the embryo implanting into the womb. Assisted hatching is not performed on "fresh" (not previously frozen) blastocysts.

Patients prepare for assisted hatching by taking antibiotics and steroid pills starting a day before the transfer and continuing for a total of 4 days. These measures are taken to protect the embryo from possible immune or bacterial assaults once they are transferred.

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