IVF Orientation

1. IVF Orientation

2. IVF Definition • IVF – In Vitro Fertilization • In Vitro – outside the natural environment* • Fertilization – the joining of egg and sperm • Literally – In Vitro Fertilization = the joining of egg and sperm outside of the body *source – dictionary.com

3. What Is IVF? With the IVF process the woman takes injectable medication to increase egg production. • Eggs are retrieved from the biological mother (who may or may not be the intended parent) during a short surgical procedure under anesthesia. • Eggs are exposed to sperm in the laboratory. • Embryologists check the egg for fertilization the following day. • Fertilized eggs are referred to as embryos. • A few days after fertilization, the best embryo or embryos are transferred to the mother or (gestational carrier’s) uterus. • The embryo transfer is completed by loading the embryo(s) into a thin catheter, passing it through the cervix into the uterus, using ultrasound guidance, and depositing the embryo(s) into the uterus.

4. Requirements before an IVF cycle. The tests, all paperwork and consents should be completed before starting on any medications. • Female: • Standard IVF female lab tests (at lab facility approved by your insurance) • PAP smear results from your PCP or Gynecologist • Fax results to: 484.380.4866. • Injection teaching and hysteroscopy: • Call 484.380.4890 to schedule appointments. • Call financial coordinator to verify insurance coverage: 484.380.4883 • Medical clearance letter from specialist, if being followed for medical condition. • If Pre-Implantation Genetic Diagnosis (PGD) planned, consult embryologist: • Call 484.380.4871 • Male: • Standard IVF Male lab tests (at lab facility approved by your insurance) • Semen analysis on-site at MLFC: call 484.380.4863 for appointment • All paperwork and consents submitted to the Center before a cycle start • Mail to: Main Line Fertility Center • 825 Old Lancaster Ave, Suite 170 • Bryn Mawr, PA 19010

5. IVF Orientation Appointment • Nurse will review all paperwork previously submitted, as well as lab results on both partners (if applicable) • If applicable, the male patient will produce a specimen for semen analysis onsite. • If male is unable to produce specimen onsite please notify the andrology lab in advance to arrange to produce specimen at home and transport to the lab: 484.380.4863. • An IVF nurse will explain the IVF process and answer patient questions. • Carrier (genetic) screening will be offered • Carrier screening provides information on your reproductive risks, which may be used to help minimize the chance of having a child with a particular genetic disease. • 1-2 tubes of blood will be drawn. • If carrier screening is not desired a waiver will need to be signed.

6. A Typical IVF Cycle Takes Up To 6 Weeks: • 3 weeks of birth control pills (if applicable) • Approximately 10-14 days of injectable medications involving up to 8 appointments. • Appointments include blood work to measure hormone levels, and vaginal ultrasounds to count and measure follicles and thickness of uterine lining. • Egg retrieval • A surgical procedure performed under anesthesia • Embryo transfer 3 to 5 days after the retrieval • Hormone level check one week post embryo transfer • Pregnancy test two weeks post embryo transfer

7. IVF CYCLE Progesterone Estradiol Possible Birth Control Pills • Embryo • Transfer • Day 3 • Post Retrieval Lupron or Ganirelix/ Cetrotide Hormone Check 1 week Post Transfer Day 1 Menses Call Monitoring ** Pregnancy Test 2 weeks Post Transfer HCG Ovulation Stimulation Meds 7 days ---------------------------- Day 1 Menses Egg Retrieval Blastocyst Transfer Day 5 or 6 Post Retrieval ** Cycle Start Schedule Blood Draw, Hysteroscopy & Injection Teaching

8. The IVF cycle begins with day one of the menstrual cycle. Please call the IVF Monitoring Team on the first day of full flow: 484.380.4890

9. IVF Monitoring Appointments: • First appointment (cycle day 2 or 3): • Blood work and possible ultrasound • Some patients are started on birth control pills and some on injectable medications. • If your doctor prescribes birth control pills, a hysteroscopy may be scheduled at this time. • Verbal and written instructions for your next steps and next appointment date. Throughout cycle appointments • Blood work for hormone levels • Ultrasound to count and measure follicles, as well as thickness of uterine lining. • Expect call back from IVF Monitoring team nurses with next step, after they have reviewed the cycle with your doctor. • If you plan to create embryos, your partner should have ejaculations every 2-3 days to assure the freshest sperm will be available on retrieval day.

10. Stimulation • This is an ultrasound image of follicles in the process of growing during a stimulation cycle. • Follicles are fluid filled structures ranging in size from 10-20 mm. • Eggs are retrieved from follicles. • Not every follicle contains an egg. • Follicles grow in response to fertility medications and secrete estradiol (E2).

11. While your follicles are growing your uterus is also being prepared to accept the embryos that are to be transferred. • This is an ultrasound image of a uterus. . ,

12. hCG Instructions: hCG is used to assist in the final maturation of eggs. • when follicles have reached adequate size and hormone levels correlate….you are ready for egg retrieval! • Have pre-retrieval instruction sheet ready to fill in the blanks.(Right click on this link to open hyperlink: hCG instructions 2013.doc) • Make sure you have your hCG (Pregnyl, Profasi, Novarel, chorionic gonadotropin) or Ovidrel available. • Prepare the medication a few minutes before the dose is due. • Inject the medication at the EXACT time instructed. • Egg retrieval will occur approximately 36 hours after the injection.

13. Egg Retrieval Day • You will be asked to arrive approximately one hour before the egg retrieval. Please be on time to allow proper preparation. • Please shower in the AM of your retrieval but do not use scented products(shampoo, soap and deodorant are fine). • Brush your teeth but do not swallow any water. • Do NOT have anything to eat or drink, including candy, mints or gum. • Do NOT bring valuables or jewelry with you to the retrieval. Bring only necessary items, which can be stored in a small locker. • Please do NOT wear contact lenses. • Plan to spend up to 2 ½ hours at the Center. You will need a driver to take you home. • Your partner will be expected to produce a sperm specimen upon arrival to the Center, IF you plan to create embryos. A 2-3 day abstinence is recommended. Photo ID is required. • During the 20-30 minute egg retrieval procedure, eggs are retrieved under anesthesia using transvaginalultrasound guidance (to visualize the follicles)** see next slide. A needle attached to the ultrasound probe penetrates the vaginal wall into the ovaries, suction is applied and the follicular fluid is aspirated into a tube. The fluid is checked by an embryologist to isolate the egg. Not every follicle contains an egg. Eggs are “cleaned up” then exposed to sperm in the lab, if embryos are desired. If eggs are to be frozen, they are frozen on retrieval day. • Patients are usually discharged home within an hour after the retrieval, with minimal complaints. • Risks of egg retrieval may include, but are not limited to: abdominal cramping, loss of blood, infection, loss of fertility, injury to pelvic or abdominal organs, nausea/vomiting or adverse reactions to anesthesia medications.

14. Egg Retrieval Room

15. Prep-Recovery Area

17. Egg Retrieval • Eggs are removed from your follicles along with follicular fluid. Eggs are surrounded by cumulus cells when they are first isolated. Veek, L

18. This is a mature oocyte (egg) without the surrounding cumulus cells. The outside wall is the zona (z). The small cell (f) is the polar body, and the large cell (o) is the oocyte itself. Veek, L

19. Sperm • A normal sperm cell contains a head, neck, and tail. • During the semen analysis the count, %motility (% of swimming sperm) and morphology (shape) will be evaluated. Veek, L

20. ICSI (Intra-Cytoplasmic Sperm Injection) • ICSI is a micro-surgical technique where a single sperm is manually injected into each egg. • This is an egg undergoing sperm injection. • ICSI is typically used if sperm count, motility and/or morphology are not within normal range.

21. Embryo Observation • Fertilization of the eggs is observed the morning after your retrieval(day 1) • This is a typical newly fertilized embryo known as a zygote. • Two pronuclei (2PN) are seen in a fertilized egg. Veek, L Main Line Fertility & Reproductive Medicine, LTD. And The Center For Reproductive Medicine, Bryn Mawr Hospital

22. Embryo Observation • The embryos are commonly 2 to 4 cells the day after fertilization check (day 2, or 2 days after retrieval). • This is an example of a 4 cell embryo. Veek, L Main Line Fertility & Reproductive Medicine, LTD. And The Center For Reproductive Medicine, Bryn Mawr Hospital

23. Embryo Observation • The third day of culture (day 3, 3 days after retrieval) the embryos are mostly 6 to 8 cells. • This is an example of an 8 cell embryo. Veek, L

24. Embryo Observation • The fifth day (day 5, 5 days after retrieval) some embryos typically reach blastocyst stage. Not all embryos are capable of reaching the blastocyst stage. • This is an example of a blastocyst. Veek, L

25. Embryos are loaded into the catheter by the embryologist and are inserted through the cervix into the uterus by your physician using ultrasound guidance. Embryo Transfer Wallace/Cook OB?GYN

26. Embryo Freezing • Embryos are frozen if: • There are more good quality embryos produced from your IVF cycle than your physician feels you should have transferred. • Your uterus is not ready for implantation or for an embryo transfer procedure • Your embryos are frozen and stored in a tank filled with liquid nitrogen.

27. Cryo tank

28. Ovarian Hyperstimulation Syndrome (OHSS) Medications used to stimulate ovaries may cause side effects ranging from mild to severe. Please keep in touch with the IVF staff if you develop moderate to severe symptoms.

31. Risks of oocyte (egg) retrieval may include, but are not limited to, the following: • Potential reactions from the drugs and procedures used in the administration of anesthesia. • Risks associated with the passage of the needle through the vagina into the ovaries (including infection, bleeding, inadvertent damage to adjacent structures including, but not limited to, the bowel, bladder, blood vessels, ureter, uterus or ovary(ies), and adhesion formation (internal scarring) following the procedure. Although uncommon, significant bleeding or damage to the bowel may occur, and surgery may be required to repair such damage; this is a very uncommon event. Rarely, infection may become severe enough to require hysterectomy and/or removal of one or both ovaries.