Newport Fertility Center      (949) 222-1290       

Advances in IVF Success

Mark T. Kan, M.D., F.A.C.O.G., Reproductive Endocrinology and Infertility 

Overview

For many patients, IVF represents the best chance for achieving pregnancy. Each year, IVF success rates continue to improve with refinement of stimulation protocols, laboratory techniques, and technical procedures. Over 100,000 A.R.T. cycles are performed each year, and national success rates (live birth per retrieval) have increased from 22.3% in 1995 to 32.6% in 2002. Current success rates are even higher, with the most recent national data still being evaluated. The following factors have played an important role in the improvement of IVF success:

 Uterine Evaluation

 Proper evaluation of the uterine cavity is important to screen for polyps or fibroids, which may prevent an embryo from implanting into the endometrium. Originally, the inside of the uterus was evaluated with HSG (X-ray dye test). Subsequently, the HSS or saline sonogram was developed which enabled an office-based evaluation using ultrasound. Today, a 2.7mm flexible fiber-optic hysteroscope can be used in the office to show direct visualization of the uterine cavity with minimal discomfort. Many patients enjoy watching the monitor as the test is performed. This represents the most direct and thorough test because you can actually see the inside of the uterus.

Antral Follicle Count and Ovarian Volume

Recent studies have shown that ovarian response to gonadotropins correlates with the size of the ovaries and the number of small (antral) follicles present. In general, women with more antral follicles will produce more eggs and require less medication during an IVF cycle. These determinations are used in conjunction with ovarian reserve testing (day 3 FSH or clomiphene challenge testing) to determine appropriate dosing of gonadotropins. Appropriate dosing is important because it minimizes cancelled cycles and maximizes the number of high-quality eggs.

Stimulation Protocols

 There are many good stimulation protocols for IVF. Initial IVF cycles were performed simply with gonadotropins. Unfortunately, many patients had to have their cycles cancelled because the eggs would start the ovulation process early. To prevent this, GnRH agonists like leuprolide acetate (Lupron) were given. These medications were and still are very effective for preventing a premature LH surge. Additional protocols were developed to try and give the follicles a “kick start”. These include the “flare” Lupron and the microdose Lupron protocols. More recently, GnRH antagonists were developed obviating the need for agonists altogether. There is no single best protocol. Each protocol has its pros and cons and should be individualized to the patient.

 ICSI

 Intra-cytoplasmic sperm injection (ICSI) represents one of the most important breakthroughs for IVF in the past 20 years. Originally reported by Palermo et al in Lancet (1992), ICSI revolutionized the fertilization process for male factor infertility. Today, in many centers, ICSI is utilized in 50% to 75% of all IVF cases. In many large centers, ICSI fertilization rates are 5% to 10% higher when compared to standard insemination rates. Aside from male factor infertility, ICSI may be used for cryopreserved sperm, low oocyte yield, or previous fertilization failures. Dr. Palermo (whom I had the privilege of working with for several years) still performs the ICSI procedures to this day at the Cornell IVF center in New York.

 Embryo Selection 

Embryo selection remains a crucial component to success. Normal embryos will grow and divide to a certain stage over time. By day 3, embryos are typically between 4 and 8 cells. There have been advances in culture media which enable the continuation of growth through the 5^th day to the blastocyst stage. There is plenty of debate regarding day 3 versus day 5 embryo transfer, and the pendulum continues to swing back and forth. It has been shown that there is a slight increase in risk for monozygotic twinning with blastocyst transfers. This should be weighed against the fact that fewer blastocysts are generally transferred compared to day 3 embryos. A recent meta-analysis of embryos that underwent assisted hatching demonstrated a favorable trend for pregnancies from hatched embryos. Newer hatching techniques have been developed using lasers which markedly reduce the time required to perform the procedure.

 Embryo Transfer

 Embryo transfer has been one of the least evaluated procedures in IVF until recently. Each detail of the transfer is crucial; from the type of catheter to the amount of media to the depth of the placement. Concomitant trans-abdominal and trans-vaginal ultrasound guidance techniques have evolved as important clinical tools for the embryo transfer. These newer techniques require dexterity and technical aptitude. Catheters are now made specifically with materials which can be seen on ultrasound. Studies have shown that the transfer depth from the fundus has a significant impact on pregnancy rates. Uterine manipulation and contractions have been shown to adversely affect outcome.  Newer medications and protocols have been developed to minimize uterine contractility. A new transfer media containing hyaluronan (coined “Embryo Glue”) has been developed to aid in the implantation process.

Donor Egg IVF

 I have always felt that donor egg IVF rates represent the “gold-standard” for IVF success. With egg donation, every aspect of an IVF cycle must be performed precisely for the cycle to be successful. In addition to all of the above IVF factors, recipient endometrial preparation and cycle coordination of the implantation window must be optimized. Newer protocols and improved coordination have increased donor egg pregnancy rates. Because egg donors are relatively healthy patients who respond well to gonadotropins, they represent a very uniform group of comparable patients. Donor egg IVF pregnancy rates are typically the highest of all IVF pregnancy rates. Over the past 2-3 years, donor egg IVF clinical pregnancy rates have approached 75% to 85% per transfer, with 2 or less embryos transferred.

 Conclusion

 Remarkable achievements have been made in the field of infertility since the first IVF baby was born in 1978. Assisted reproductive techniques and advances in related scientific areas have given many couples the ability to achieve pregnancy and start a family. Although it can be a challenging time for many of these couples, there are more options for successful treatment today than there have ever been in the past. 

Dr. Kan | Fertility Treatment | In-Vitro Fertilization | 
Reproductive Surgery | New Patients | About Us | Directions 
Home | FAQs | Testimonials | Location | Contact Us | Home

Articles