The In vitro Fertilization Unit

Medical Director: Yaacov Mamet, M.D.

Head Nurse: Hedva Stern, R.N.

Laboratory Manager: Diana W. Stein, M.Sc.

"פרו ורבו ומלאו את הארץ" (בראשית א' כח')

"Be fruitful, and multiply, and replenish the earth…" (Genesis 1:28)

An idea, that sounds so simple and natural, is actually very complex and for many couples difficult to achieve.

Infertility is a disease of the reproductive system, in either a male or a female, that inhibits the ability to conceive and deliver a child. Infertility is the inability to conceive after one year of trying with unprotected intercourse for couples in which the female is under 35 and six months of trying for couples in which the female is over 35.

Approximately 15%, or one in six couples, are affected by infertility and there are a number of factors, both male and female, that can cause the condition. In nearly 30% of cases the cause is attributed to the female, in 30% the cause is attributed to the male, in 30% the cause is attributed to both and in 10% of cases the cause is unknown. In addition, it is estimated that a further 10-25% of couples experience secondary infertility, i.e. are unable to conceive a second or subsequent child.

Most couples who enter into IVF treatment do so for the following reasons:

· Mechanical Infertility

· Hormonal Dysfunction

· Endometriosis

· Male Factor

· Immunological Problems

· Unexplained Infertility

· Prenatal Genetic Diagnosis

· Egg Donation

· Surrogacy

What is IVF Treatment?

In vitro fertilization (IVF) is an assisted reproductive technique otherwise known as ART. In short, it is a process in which one or more healthy eggs (ova) are fertilized outside the woman's body. IVF is a major treatment in infertility where other methods of achieving a pregnancy have failed. An IVF treatment cycle, although technically easier and more successful than it was 5, 10, 15 or even 20 years ago is not easy. The physical and emotional demands it puts on a couple, although highly individual, can not be understated. Each stage of the cycle culminates with either passing to the next step or starting over again. For those who manage to complete each step of the process there is a success rate of only approximately 20% in any given cycle.

The treatment cycle is a process which can be broken down into six stages:

· Ovarian stimulation or Ovulation Induction

· Sperm collection and preparation

· Oocyte retrieval

· In vitro Fertilization

· Embryo Transfer or replacement and

· Post-transfer

Ovarian stimulation or Ovulation Induction.

Under normal conditions a woman will spontaneously ovulate a single egg each month. To increase the chances of success in IVF an effort is made, through ovarian stimulation, to recruit more than a single egg. This is achieved by daily injections of fertility drugs such as Pergonal®, Puregon®, Gonal-F®, Menogon®, Menopur®, Decapeptyle®, Orgalutron® to name a few. These medications not only boost egg production but also hormone levels therefore close monitoring of the growth and development is necessary and frequent blood tests for hormone levels (estradiol, progesterone and luetinizing hormone) as well as repeated ultrasound studies are preformed. Based on the information gained from these test, the optimal timing for ovulation is determined. Ovulation is triggered by a single injection of Ovitrell® or Chorigon®. The oocyte retrieval is performed approximately 34-36 hours later.

Sperm collection and preparation.

Prior to the oocyte retrieval the husband is asked for a sperm sample. Sperm samples are obtained according to the Codes of Jewish Law. A special hotel suite within the unit is provided. Following collection of the sample the laboratory staff will examine the sample to assess its suitability. If adequate sperm are present in the sample the laboratory staff will begin to process it, separating the sperm cells from the seminal fluid and other cells, and give the green light to proceed with the oocyte retrieval.

Oocyte retrieval.

Oocyte retrieval is performed approximately 34-36 hours after the final injection of the ovarian stimulation stage. The procedure is performed in the unit under general anesthesia by way of transvaginal ultrasound. A needle, guided by ultrasound imaging, is inserted through the vaginal wall into the ovaries, where the fluid-filled follicles, each hopefully containing an egg, are punctured and aspirated. The follicular fluids are collected into test-tubes and quickly transferred to the laboratory where each is examined under the microscope for the presence of oocytes (eggs). The procedure generally takes less than 15 minutes, and after a few hours of recovery in the unit the woman can return home.

In vitro Fertilization.

Once the eggs, or oocytes, are retrieved they are placed in a dish containing a special liquid (culture medium) designed to mimic the fluid found in the female reproductive tract and placed in a chamber called an incubator which maintains an environment of constant temperature, humidity and gas composition healthy for the eggs while they are outside of the woman's body. Several hours after the eggs are retrieved they are exposed (inseminated) to the husband's sperm either by conventional IVF (c-IVF) techniques or by intra-cytoplasmic sperm injection (ICSI).

In conventional IVF a small amount of the prepared sperm sample is added directly to the dishes containing the eggs (at a ratio of about 100,000:1) in a process referred to as insemination. The dishes containing the inseminated eggs are returned to the incubator and left to interact together in a relatively natural fashion for approximately 18 hours.

In ICSI, the eggs are denuded (a chemical-mechanical process which involves removing the protective layers of cells surrounding the egg leaving an exposed nude egg). Once the eggs have been denuded only mature eggs are selected for ICSI. A high-powered microscope, which magnifies the sperm and eggs 600x their normal size, equipped with sensitive micromanipulators controlled by hydraulic joysticks is used to delicately manipulate the eggs and sperm. One at a time a single sperm is gently inserted (injected) deep into the cytoplasm of each mature egg by way of a very fine glass needle. Following ICSI, the eggs are incubated for approximately 18 hours.

The morning after the egg retrieval, or approximately 18 hours post-insemination/injection the eggs are evaluated for signs of fertilization. Eggs which show signs of normal fertilization, 2 pronuclei (one containing the genetic material from the egg itself and one containing the genetic material from the sperm) are

transferred to growth medium and incubated an additional 24-48 hours. Only normally fertilized eggs which have continued to develop normally over the course of the 24-48 hour growth period are considered for embryo transfer or allowed to continue to develop and growth is assessed over a 5-7 day period in the laboratory in what is termed extended or blastocyst culture.

Embryo Transfer or replacement.

Although factors, such as, age, previous history and embryo quality are considered when determining the number of embryos to replace in general (in compliance with guidelines set by the Ministry of Health) two (2) embryos are usually selected for embryo replacement (transfer) back to the woman's uterus. If more than the transferable number of eggs develop into embryos, all good quality embryos remaining after selection, for fresh embryo transfer, are cryopreserved for thawing and replacement in a later IVF cycle.

The embryo transfer itself is usually a simple and painless procedure which does not require sedation or anesthesia. The procedure involves passing a very fine plastic catheter (tube) through the cervical canal into the uterine cavity. Before removing the embryos from the incubator the physician will perform a "trial transfer" using an empty catheter. If the "trial transfer" is successful a green light is given to the laboratory staff to aspirate the embryos into a catheter for transfer. The catheter containing the embryos are handed off to the physician who gently inserts the catheter through the cervical canal and releases the embryos into the uterine cavity. Once the embryos have been released into the uterine cavity the catheter is gently withdrawn and returned to the laboratory where it is checked by the laboratory staff to assure that the embryos have been expelled. The procedure generally takes less than 5 minutes, and after an hour of rest in the unit the woman can return home.

Post-transfer.

Generally, following embryo transfer the woman can resume her normal activity but should refrain from physical exertion. Complete bed rest is not necessary and does not seem to offer any real benefit to the success of a treatment cycle. Progesterone, a hormone which keeps the uterine lining thickened and suitable for implantation is usually prescribed as a luteal phase supplementation in the form of Endometrin®, Uterogeston® or Crinone®. A pregnancy test is usually performed two weeks after the embryo transfer.

The IVF Unit of Laniado Hospital is under the direct supervision of Rabbi Y. Schwartz. The entire staff of the IVF Unit at Laniado Hospital is devoted to the care of infertile couples and is available to answer any questions you may have before, during and after your treatment cycle. If you would like more information or would like to set up an appointment please feel free to contact us at:

Phone: 09-8609532 or 09-8609590

Fax: 09-8609531

e-mail: ivf@laniado.org.il