Frequently Asked Infertility and IVF Questions, Richmond, Virginia

What happens in an ART (Assisted Reproduction Technology) cycle?

The goal of ovulation induction is to produce multiple follicles on the ovaries from which eggs are retrieved. In an ART cycle it is optimal to retrieve and fertilize as many eggs as possible to increase the chance of pregnancy.

To increase the chance of collecting multiple eggs and to control the eggs from being released too early, fertility drugs such as Lupron, Humegon, Follistim, or Gonal-F and hCG are administered. An ovulation induction protocol, which includes the dose and timing of medications, is selected for each individual patient by her physician. Most of the medications used are for the female; however, the male is asked to comply with a regimen of antibiotic therapy to prevent and treat certain organisms in the semen.

Transvaginal ultrasound examinations and blood hormone levels are used to monitor egg development. Ultrasound allows the physician to visualize the ovaries and ascertain follicle size. Blood is drawn numerous times during a stimulation cycle. As the follicles in the ovaries begin to grow, they produce estrogen. The physician compares the estrogen level with the ultrasound results to determine how much medication to prescribe prior to egg aspiration.

A baseline ultrasound and estrogen level are obtained prior to beginning any stimulation medications. A repeat ultrasound and estrogen level will be obtained approximately six days after medication has begun. Eventually, ultrasound examinations and blood tests may be necessary on a daily basis.

Ovulation induction ends when the physician estimates an appropriate number of eggs are likely to be mature and of good quality. This determination is made by follicle size and estrogen level. All fertility drugs will be discontinued at this time. An hCG (Profasi or Pregnyl) injection will be administered at the time specified by the ART nurse. Oocyte (egg) aspiration will be scheduled 34 hours from the hCG injection.

About 10 to 15% of patients who begin taking medications for ovulation are canceled before any procedures are done. The reasons for this can include an insufficient number of mature follicles, an inadequate blood level of estrogen, or an exaggerated response leading to hyperstimulation syndrome. If an ART cycle is canceled medications may be modified in subsequent attempts in order to try to improve the response.

What are my chances of becoming pregnant?

This is a frequently asked question of us. Please visit our Statistics section for the most accurate information.

Are the chances of the child having birth defects increased?

There is no reported correlation between babies conceived with medical intervention and birth defects. The risk is no greater than in the normal population. These are real and natural babies conceived with a little assistance.

Are the chances greater for multiple births?

There is a higher rate of multiple births for women treated with fertility drugs than in the general population. The actual rate depends on the type of drugs used and the chosen procedure. There are many strategies to minimize the risk of multiple births, but it is always a risk to some degree.

What tests are required prior to starting a cycle?

Tests are ordered based upon the individual needs of each patient. In general, all patients will receive semen analysis (for the male), hysteroscopy or hysterosalpingogram, pap smear, and hormone assays (for the female).

How much does medication cost?

The average cost of medication for an ART cycle is between $2,000 and $2,500. The majority of this cost is attributable to FSH administered as Follistim, Fertinex, or Gonal-F. Repronex is a generic version of Pergonal currently available in the United States. The cost of Repronex is roughly ½ that of the other preparations. Some patients respond better to pure FSH than Repronex. You and your physician will decide which medication best suits your particular situation.

Where can I purchase my medications?

Medications can be purchased at most pharmacies, however, it is best to choose a store that routinely supplies fertility products. There are wide variations in price, and it is best to obtain quotes from several stores in your area. Do not assume that all pharmacies will have the fertility medications you will need.

You must also be absolutely sure that the pharmacy will carry a backup supply of all products you are taking. If the doctor decides to increase your dosage it is essential that you obtain the additional medication on the day needed.

It is also very important to purchase hCG (human chorionic gonadotropin: Pregnyl, Profasi) well in advance of when you will need it. We recommend that you keep an additional vial on hand in the event you break the first. The injection of hCG must be given at the precise time prescribed or an entire ART cycle could be lost. Again, explain clearly to your pharmacist what your treatment regimen will involve. Many pharmacists are not familiar with infertility treatment protocols. Our staff will be happy to speak with your pharmacist if necessary. The most important factor is that the medication be available on the day needed in the appropriate quantities.

Are there any restrictions on physical or personal activities during an ART cycle?

Yes, there are a number of them.

Smoking: Stop smoking before ovulation induction begins. If you cannot stop "cold turkey," make an effort to stop at least two weeks before the egg aspiration or laparoscopy. The GIFT and ZIFT procedures, and sometimes aspiration, require general anesthesia. General anesthesia temporarily changes the normal function of the lungs. Smoking cessation insures that the lungs are in the best possible shape for surgery, and it also insures better tolerance of anesthesia.
Numerous studies have demonstrated that smoking during pregnancy can lead to reduced birth weight and fetal compromise. There is some data to suggest smoking can also lower pregnancy rates. New medications are available that can help many people overcome the smoking habit. We strongly recommend that all women, especially those undergoing fertility therapy, cease smoking.
Drinking: Alcohol is a drug and, in general, should be avoided during infertility treatment and pregnancy. There is no reason to consume alcohol and it can introduce another "unknown" factor into treatment. If you drink socially, you may continue to do so during ovulation induction. Two to three alcoholic beverages per week is acceptable. Please do not drink alcoholic beverages from approximately 4 days before egg aspiration until the pregnancy test.
Medications: If you are taking any medication, prescribed or over the counter, please inform your physician. Some medication should not be taken before an operation, some may interfere with those prescribed during your cycle, and others may interfere with ovulation or pregnancy implantation.
Your physician will prescribe a multivitamin.
Inform your physician of any changes in your health even minor colds or infections. This is especially important prior to surgery.
Any kind of surgery, or ART cycle, can be stressful physically and emotionally. Avoid becoming tired in the days before and after a procedure. Eating correctly, and getting proper rest and exercise, become even more important before an operative procedure.
An ART cycle can be an emotionally stressful time for you and your partner. You need to consider supportive relationships, for example; friends, clergy, family members, and psychologists.
Heavy exercise such as aerobics, jogging, weight lifting, roller blading, etc. will be prohibited during ovarian stimulation and until the pregnancy test.

When is the pregnancy test performed?

The blood pregnancy test is performed 14 days after the embryo transfer or 16 days after GIFT.

What happens if I become pregnant?

If pregnant, you are asked to return to the office for repeat blood tests and ultrasounds to insure an ongoing successful pregnancy. After 8-9 weeks you are referred to an obstetrician for the remainder of the pregnancy.

If I am not pregnant, when can we try again?

Usually we ask the patient to wait one or two complete menstrual cycles before beginning another ART cycle. Sometimes tests are required that can delay subsequent cycles

Will I need a high risk OB because I conceived with an ART procedure?

A high risk OB is only needed when there are complications that put the mother or baby at increased risk, or if there are multiples. Other than a higher incidence of multiple births, ART does not increase the risk to the mother or fetus.

Is there a higher miscarriage rate for ART patients?

The miscarriage rate is about the same for ART pregnancy as for the general population. Because women are often older when they undergo ART, their miscarriage rates are naturally higher.

Pregnancy testing is done two weeks after embryo transfer, so we often know about spontaneous miscarriages in the very early stages of pregnancy. These miscarriages would probably go unnoticed in the general population.

What can be done to improve sperm quality?

Sperm quality on the day of egg retrieval is often related to what happened in the male’s body 3 months ago. This is because sperm development takes almost 3 months. Listed below are guidelines to help insure the semen specimen is of the best possible quality.

A fever of 101 degrees Fahrenheit or higher within 3 months prior to ART treatment may adversely affect sperm quality. Sperm count and motility may appear normal, but fertilization may not occur. If you become sick before or during the ART cycle, please notify the ART nurse, and take Tylenol to keep the temperature below 101 degrees F.
Keep the use of alcohol and cigarettes to a minimum before and during ART treatment. Do not use any "recreational" drugs.
If any prescription medication has been taken during the last 3 months, notify the ART nurse.
Do not sit in hot tubs, spas, Jacuzis, or saunas during or 3 months prior to the ART cycle.
Do not begin any new form of endurance exercise during the 3 months prior to the ART cycle. Physical activity at a moderate level is acceptable and encouraged.
Do not wear tight pants or underwear during or 3 months before the ART cycle.
Tell your infertility physician if you have ever had genital herpes or suspect you may have been exposed to genital herpes in the past. Also tell your physician if you have pre lesion symptoms, develop a lesion, or have healing lesions before or during the ART cycle.
Refrain from ejaculation for 2-3 days, but not more than 5 days, before collecting the semen sample for the ART cycle. The ART nurse will have your specific instructions from the andrologist.

How do we decide how many embryos to transfer?

Your physician will discuss this with you, but we usually follow the American Society for Reproductive Medicine Guidelines: under 30 years old - 2 embryos; 30-35 years old - 3 embryos; 35-40 years old - 3 or 4 embryos The number may also vary depending on each individual clinical circumstance.

Am I depleting my store of eggs by doing an ART cycle?

A woman is born with a full complement of eggs. There are far more eggs than will ever be used during a normal lifetime and ART has no measurable "lowering" effect.

What is Endometriosis?

The formal definition of endometriosis is endometrium in an ectopic location that contains endometrial glands and stroma. In other words, it is uterine-like tissue that is growing outside the uterus causing pain and/or infertility. Its cause is unknown. There are many theories, but every answer has contradictions. It could be genetics. It could be retrograde menses, menstruation that goes backwards through the tubes into the abdomen. It could be congenital. It could be all of the above or none of the above. We simply don't know.

Endometriosis is common. The generally accepted percentage of women with Endometriosis is 5% to 15%. However, many women have Endometriosis and don't have the symptoms (usually pain) or the pressing need to be diagnosed (usually infertility). Additionally, Endometriosis can be diagnosed as very mild to severe. There are likely many more people with very mild Endometriosis, which does not cause infertility.

The only way to diagnose Endometriosis with complete accuracy is to see it. The only way to see it is through surgery (laparoscopy). There are symptoms and tests that can give a physician clues, but Endometriosis is a very elusive disease. The adage "seeing is believing" is the safest and most effective route to pursue diagnosis and ultimately treatment.