Additional Fertility Links

Published: 12/14/2015

• Transvaginal aspiration of eggs
• Additional information on ICSI
• Gonadotropin therapy
• Medications prior to embryo transfer
• Cystic fibrosis testing
• Transfer of multiple embryos
• Risks of multiple gestations

TRANSVAGINAL EGG ASPIRATION

Through transvaginal aspiration Dr. Lipskind recovers oocytes (eggs) for fertilization. Local anesthesia, or light IV sedation is usually given, but in some cases is not necessary. An aspirating needle is attached to an ultrasound-guided vaginal probe in order to locate the follicles on the ovary. The needle is guided through the vagina into the abdominal cavity, then into the follicle(s) on the ovary(s) where the contents are removed. In most cases, the fluid inside the follicle will contain an egg(s). It is possible that a follicle will not contain an egg. Complications from transvaginal aspiration of oocytes are very rare but may include bleeding, infection, or damage to surrounding tissues and organs.

In some cases it may be necessary to recover eggs by laparoscopy, which is done under general anesthesia. A small telescope is introduced through the umbilicus, allowing Dr. Lipskind to visualize the ovary(s) and follicle(s). The egg retrieval is then performed as described above. Complications from laparoscopy are very uncommon but can occur. Some of the risks associated with laparoscopy are bleeding, infection, damage to other internal organs, nerve injury, or other complications. In the unlikely event that an injury occurs, a repair may be done through the laparoscope or by a laparotomy (incision in the abdominal cavity).

All patients undergoing oocyte aspiration will have the opportunity to ask Dr. Lipskind and/or his staff questions, to assure that they fully understand the risks and benefits of the above procedures. It should also be understood that it is not possible to list all unforeseeable complications that can occur from transvaginal aspiration and/or laparoscopy for egg retrieval.

ADDITIONAL INFORMATION ON ICSI

Intracytoplasmic sperm injection (ICSI) is a procedure designed to support the fertilization process. ICSI is performed by the embryologist in the laboratory after egg retrieval. The egg is held under the microscope and a single sperm is injected into the interior of the egg (ICSI). Thereafter, the newly formed zygote, which then becomes a developing embryo, must be cultured in an environment of constant temperature, with humidity control and strict limitations of oxygen and carbon dioxide levels. The culture medium containing salts and nutrients is altered and changed at intervals to promote cellular division.

Not all eggs retrieved will be mature or normal in appearance. The percentage of eggs achieving fertilization depends on many factors. Some eggs, which appear to be mature and normal in appearance, will not become fertilized even when exposed to normal-looking sperm. Not all of those exposed to sperm will go on to division (cleavage). Not all transfers of embryos will result in pregnancy.

The biological mechanisms of ICSI are not completely understood. The selection of spermatozoa for ICSI is based solely on a cursory overview of morphology and may unwittingly result in the transmission of chromosomal abnormalities. Genetic data on children born as a result of ICSI is limited. It has been reported that ICSI performed with sperm from men with congenital bilateral absence of the vas deferens may pass on a cystic fibrosis mutation should pregnancy occur. It is suggested that a couple undergo genetic screening and /or testing to assess their risk factors. In addition, the reproductive ability of the offspring of ICSI is not able to be determined at this time.

All patients having ICSI performed on their eggs will be provided with the above information and will have the opportunity to ask Dr. Lipskind and/or his staff questions regarding this procedure to assure that they fully understand their options and the risks and benefits of doing ICSI. Informed consent to proceed with ICSI will be given by the couple which must agree to hold ACFS — including all staff that participate in the above procedure — harmless from any liability, damages, claims, or costs which may arise from or relate to the procedure mentioned above.

GONADOTROPIN THERAPY

HMG is a combination of two naturally occurring hormones, FSH (follicle stimulating hormone) 75 IUs, and LH (luteinizing hormone) 75 IUs. Follistim, Gonal F, or other pure FSH drugs consist of 75 IUs of FSH. Both these medications are used for the correction of ovulatory dysfunction. Other indications are ovulation, luteal phase defect, as well as repeat pregnancy loss and unexplained infertility. Gonadotropins may also be used to induce the production of more than one follicle (the fluid-filled sac the egg grows in). This response is dosage-dependent, and not guaranteed to result in the production of multiple follicles.

Patients using gonadotropin therapy should understand and consent to the following general steps involved in the use of gonadotropin treatment.

1. The gonadotropins by intramuscular or subcutaneous injection will be administered by Dr.Lipskind, his partner, or chosen staff member, who will be instructed on injection technique and medication preparation.
2. Monitoring the growth and development of a follicle(s) will be done by vaginal ultrasound.
3. Serum estradiol level will be done when follicles reach optimal maturity as determined by ultrasound.
4. Administration of HCG will be timed in order to complete the maturation process of the eggs, and then allow them to be released, (ovulation).
5. Intercourse, IUI (intrauterine insemination), or ART (assisted reproductive technique) will be timed appropriately.

There are potential risks and side effects of gonadotropins, which may include but are not limited to the following:

1. The use of gonadotropins may result in overstimulation of the ovaries, the production of too many follicles (eggs), or hyperstimulation; which may cause pain and fluid retention due to enlargement of one or both ovaries. In its' most severe form hyperstimulation may result in hospitalization for management. This is extremely rare.
2. The use of gonadotropins may result in the formation of ovarian cysts. These are usually detected by ultrasound and may result in the need to "skip" a cycle, as gonadotropins should not be administered in the presence of an ovarian cyst. Sometimes birth control pills are used in the "skip" cycle to quiet the ovaries in an attempt to eliminate the cysts.
3. Multiple gestations may occur from the use of gonadotropins. At ACFS 80-90% of pregnancies following the use of gonadotropins will be single births. The multiple gestation rate is approximately 10-20%, the majority of which are twins, less than 1% of total pregnancies result in triplets and 0.3% quadruplets. Over the age of 35, these statistics begin to decrease, and after 40 multiple birth rate is much less common.
4. If too many mature follicles develop (when doing timed intercourse or IUI) and/or the serum estradiol level is too high, the cycle will be canceled. In some cases, Provera will be given to induce an ovulatory withdrawal bleed, and protection with intercourse will be suggested. However, without HCG ovulation should not occur.
5. Other possible adverse reactions that have been reported with gonadotropin use are allergic sensitivity, rash, swelling or irritation at the injection site, headaches, irritability, restlessness, depression, and fatigue. As with any attempt at pregnancy, ectopic pregnancy may result.
6. Genetic defects or congenital malformations that may result have not been linked to the use of gonadotropins.
7. Ovarian cancer has not been linked to gonadotropin usage.

MEDICATIONS PRIOR TO UTERINE EMBRYO TRANSFER

PRENATAL VITAMINS:

The American College of Obstetricians and Gynecologists recommends taking a minimum of 400 micrograms of folic acid if you are low risk. If you are a high-risk patient (i.e., prior history of spina bifida or other neural tube defects, taking anti-epileptic medications, or have an elevated homocysteine level) you should be on 1000 micrograms (which is in prescription prenatal medications). Newer prenatal vitamins have omega-3 fatty acids, which have been shown to support eye and brain development in the third trimester.

DOSAGE: Prescription for Duet DHA-EC or Prenate DHA or Prenexa

BABY ASPIRIN:

Baby aspirin has been shown to improve blood flow to the uterus and ovaries, and to help reduce the risk of miscarriages. Generally, there are no disadvantages to taking this medication unless otherwise specified by Dr. Lipskind.

DOSAGE: One baby aspirin to start day one of the gonadotropins (hMG and/or FSH) until 12 weeks pregnant.

ANTIBIOTIC:

Antibiotics have been shown to be protective against the small risk of infection during egg retrieval and subsequent tubal or uterine embryo transfer.

DOSAGE: The antibiotic is Zithromax. Take 500 mg starting the night before your retrieval and continue every night through the night after the tubal or uterine transfer. You should not be taking this if you have an allergy to Erythromycin so please let us know if this is the case. Zithromax may cause mild stomach upset. An alternative antibiotic would be Vibramycin.

GLUCOCORTICOID:

This medication is a steroid, like cortisone, and has been shown to possibly protect the embryo(s) from attack by the immune system after transfer. Serious side effects from this medication are rare, especially from low-dose, short-term use. Please see the package insert.

DOSAGE: The steroid is Medrol (Methylprednisolone). Take 32 mg starting the morning before your egg retrieval, (you will take it after your retrieval so bring it with you) and continue every morning through the morning after the tubal or uterine embryo transfer.

CYSTIC FIBROSIS CARRIER SCREENING

Cystic fibrosis (CF) is a genetic disorder developed by having two changed copies of the CF gene. If both partners are carriers of CF any child they have has a 25% chance of inheriting two changed copies of CF, thereby developing CF. Anyone having one changed copy of the CF gene is a carrier but does not have CF. CF is a life-long illness usually diagnosed in the first few years of life, causing problems with digestion and breathing. It does not affect intelligence or appearance. Digestive problems can usually be treated with daily medications. Breathing problems are usually treated with daily respiratory therapy to help clear mucus from the lungs. Lung infections can develop resulting in hospitalization. Infections tend to become worse over time and more difficult to treat. Treatment is costly and may become burdensome financially. Not all people with cystic fibrosis have the same symptoms. Symptoms can be mild in some people and severe in others. The reason for this is not completely understood. It's not always possible to predict the severity of symptoms based on prenatal testing. In general, people with cystic fibrosis have a shortened life span. Some die in childhood while others live into their 40s or even longer. There is no cure for cystic fibrosis, but treatment research is ongoing. Cystic fibrosis carrier testing is provided to see if a couple is at risk for having a child who will have cystic fibrosis. Testing is done on a sample of blood to determine carrier status. The illness cannot be treated before birth. If both parents are carriers, additional testing on the developing baby can be done so you can decide how to proceed and prepare for the future. You can be a carrier of CF even if no one in your family has CF and even if you already have children without CF. The following table shows the chance of being a CF carrier depending on race/ethnicity.

Your chance is higher if there is a carrier or a relative with CF in your family. Screening to determine CF carrier status is voluntary. It may be right for some people and not right for others based on many factors, including your level of risk, family situation, plans, and needs, as well as religious and spiritual beliefs. Current testing is limited, as there are some mutations of the CF gene that cannot be found. Many labs test for only 32 mutations. Here at ACFS, we use a lab that is able to test for 97 mutations. Due to the fact that there are some unknown mutations, it is best to test for as many as possible. However, it is important to know that this still will not guarantee you are not a carrier. The likelihood of you still being a CF carrier is very small if your results are normal. If your test shows you are a carrier, your partner should be tested as well. CF testing only has to be done once as the result is definite and will not change. If CF seems like a serious disorder to you, if the chance of being a carrier seems high to you, if you have a family history or are related to someone with the disorder, if both partners found to be carriers would consider amniocentesis or CVS testing (to show if the baby will develop CF & decide to keep/terminate the pregnancy), if test results are reassuring to you, or if the cost of testing is covered by insurance, you may consider testing. If you feel any of the above does not affect you, you may consider declining testing.

TRANSFER OF MULTIPLE EMBRYOS

A transfer of multiple embryos increases the possibility of multiple births and the associated obstetrical, maternal, and financial risks. While each embryo transferred has a chance of implanting, it is possible that all embryos transferred may implant.

Selection of the number of embryos transferred at ACFS is based on the guidelines created by the American Society of Reproductive Medicine (ASRM) and the Society of Assisted Reproductive Technology (SART), and is dependent on the woman's age, quality of embryos, and the number of cells in each embryo.

Since obstetrical complications, including prematurity, occur at a higher percentage in multiple gestations, higher-order multiples can be reduced via Selective Reduction. This procedure involves the insertion of a needle, guided by ultrasound, through the abdomen and into the gestational sac(s). A toxic solution is injected into the sac(s) reducing the pregnancy. Selective Reduction appears to be an effective and safe procedure with a 3% to 5% chance of complications including pregnancy loss.

RISK OF MULTIPLE GESTATION

If you have elected a prescribed course of treatment, which utilizes fertility drugs, you are at potential known risk for multiple gestations (twins, triplets, quadruplets, etc). These are inherently difficult pregnancies, which may be further complicated by underlying health problems or age (when >35 years). Conditions associated with multiple gestations include premature labor, premature birth, stillbirth (death of one or more of the fetuses), incompetent cervix (opening of the cervix and loss of the pregnancy prior to the estimated date of delivery), diabetes, placenta previa (placenta blocking the exit from the uterus), and thrombophlebitis (blood clots). Cesarean section is commonly required to deliver these babies safely and at a much higher incidence than what is normally seen in singletons.

Any of these problems may require you to be hospitalized, and the care needed may be prolonged (weeks or months). Occasionally babies will be born so prematurely that they cannot survive. In other cases, the problems of prematurity are very severe leaving the child permanently and severely disabled. The total expense of health care for you and your babies may be high. This may be further compounded by the loss of wages from time off work. Dr. Lipskind can neither predict nor prevent a patient from experiencing any of these events once the pregnancy has been established. The only way to minimize risk is to limit the number of embryos entering the uterus. Even then, there is a slight chance of multiple gestations (i.e., identical twins form when the embryo divides into two spontaneously prior to implantation, occurring in 1 out of 250 pregnancies).