Common Reasons for IVF and Treatment Types

In Vitro Fertilization (IVF) is a procedure that has been used for more than 30 years to help tens of thousands of couples have babies. Couples with medical or fertility conditions who have not become pregnant using other fertility treatments typically use IVF.

Some of the common reasons patients undergo IVF include:

  • Blocked tubes
  • Unexplained Infertility
  • PCOS
  • Endometriosis
  • Preimplantation Genetic Diagnosis (PGD), for elimination of genetic diseases
  • Recurrent spontaneous abortions with genetic etiology
  • Male causes such as low sperm count, low motility, or lack of sperm
  • Failed therapies with ovulation induction
  • Advanced female age
  • Donor egg cycles

In general, female patients should be 44 years of age or younger (except in donor cycles), have at least one normal ovary and a normal uterus, and must be in good health to qualify for IVF.

Types of IVF Cycles

We developed and have been using Natural Transfer treatment cycle since 2014, AFCT.

 In the recent past, freezing of embryos created during IVF was unreliable and many embryos did not survive after the thawing process. Therefore, physicians were under pressure to transfer the best embryos immediately after ovarian stimulation to avoid freezing. As a result, the best embryos were transferred into the uterus after it had been exposed to large amount of hormones, which reduced its ability to accept embryos for implantation.

Thanks to the breakthrough in embryo freezing – vitrification – embryos can now be cryopreserved without a significant risk of damaging them in the process.

AFCT has always been at the forefront of new developments in clinical embryology and became one of the first IVF programs in the United States to adopt vitrification for embryos and egg freezing to all their patients.

AFCT uses a proprietary vitrification protocol, which has been perfected by Dr. Dmitri Dozortsev.

Vitrification uses an extremely high cooling speed that prevents formation of ice crystals, which are damaging to the embryo. Unlike automated programmed freezing, vitrification relies heavily on the expertise and skills of the operator; therefore, it takes time to perfect the process.

As a result, all AFCT patients have their best embryos transferred into the uterus during what AFCT calls “Natural Transfer”, where they are welcomed by the uterus, which has completely recovered from the ovarian stimulation and is in a perfect state for implantation.

Since 2014 and the introduction of the Freeze All approach, AFCT has maintained phenomenally high pregnancy rates, which were recently verified by the CDC.

Several studies confirm the theory that we can obtain significantly higher pregnancy rates when we wait and transfer the embryos in a frozen cycle. A major advantage of freezing embryos is that they can be safely stored until a woman’s normal hormonal balance is restored, which make the uterus more receptive to implanting embryo.

“Natural Transfer™” can provide the highest chance of pregnancy with the lowest complications associated with ovarian stimulation. Published data show that infants born after transfer of vitrified embryos in non-stimulated cycle are about 150 grams bigger and the mothers have a lower risk of premature labor.

There are several reasons for improved outcomes with a natural transfer:

∙ With ovarian stimulation and the growth of the oocytes (eggs), estrogen levels increase to 10-20 times higher than normal in a natural cycle. The high estrogen levels have a negative effect on the uterus, which now may be out of sync with the growth of the eggs. High estrogen levels inhibit the effects of progesterone, which is the most essential hormone in the process of implantation and pregnancy.

∙ Women with the diagnosis of Polycystic Ovarian Syndrome (PCOS) naturally have a higher number of eggs compared to other patients. The higher number of eggs will lead to very high levels of estrogen by the end of IVF stimulation.

∙ The risk of ovarian hyperstimulation syndrome increases with high estrogen levels, and this is more common in patients with PCOS. Patients with PCOS experience severe abdominal discomfort, fluid collection in the abdomen, and shortness of breath, which may require hospitalization. When we perform frozen embryo transfer, we can alter the stimulation protocol and almost completely eliminate the risks with this syndrome.

Dr. Michael Allon, Board Certified Reproductive Endocrinologist and a Medical Director of AFCT: “It is difficult to exaggerate the significance of Natural Transfer IVF success. Miraculously, we see that not only does this new approach drastically increases the chances of pregnancy, but it also diminishes the difference in outcomes between older and younger patients.”

At the Advanced Fertility Center of Texas (AFCT) we have a Min Stimulation Cycle for patients with low ovarian reserve. This can help you achieve pregnancy with lower medication use.

In vitro fertilization protocol must be individualized for each patient and the traditional IVF protocol was intended to grow as many follicles (eggs) in order to obtain as many quality embryos for transfer. In the minimal stimulation protocol we can utilize less medications and accumulated more embryos over two cycles, which will in turn increase the chance of conception. We can now freeze embryos with a method called vitrification, which is performed by removing the water from the embryos and then freezing them rapidly. This method results in a greater than 99% survival rate of frozen embryos. Once we accumulate the embryos, we can select the best viable embryos for transfer and optimize our pregnancy rate.

In patients with low ovarian reserve, Antimullarian hormone of (AMH)< 1.0 ng/mL, or less than four antral follicle count (eggs in the ovary), the traditional IVF protocol would result in only one or two eggs and one or zero quality embryos for transfer. We now understand that in these cases, it is better to utilize a protocol that exposes the ovary to a smaller dose of gonadotropins instead of bombarding the ovary with an exaggerated amount of hormonal stimulation. It appears that our previous protocols may also be harmful to the egg by altering the chromosomal alignment through high gonadotropin exposure. In the Min Stimulation protocol we can use less medication and accumulate more embryos over two or more cycles, which will in turn increase the chance of conception.

What medications are used in min stimulation?

We usually use Clomiphene Citrate daily and then start gonadotropin injections (2-3 ampoules daily) on day 6 of stimulation. Vaginal ultrasounds are used to monitor the follicular growth, and the medication regimen continues until the follicles reach mature sizes. The medication that we use is a fraction of that of the typical IVF cycle, which results in a substantial cost reduction.

How long is the Min Stimulation process?

With the Min Stimulation IVF, we attempt to collect about five embryos. From these five embryos we should be able to select at least two good quality embryos, which will hopefully lead to a successful pregnancy. This may require one to two cycles of stimulation.

Using Clomiphene Citrate will have a negative impact on the endometrium, so we prefer to freeze the embryos.

How does the embryo transfer occur?

Once we have accumulated about four or five embryos, we can prepare the patient for the embryo transfer. This will include evaluation of the uterine cavity by a process called a hysteroscopy and an endometrial biopsy. This procedure has been shown to improve embryo implantation by creating a new layer of endometrial cells.

The uterus lining is prepared and thickened by estrogen therapy, which lasts for about 14 days. The estrogen phase is followed by 4-6 days of progesterone. The embryos are then thawed and transferred.

How does the Min Stimulation IVF differ from the natural cycle IVF?

In a natural cycle IVF we don’t typically use any medications to induce the growth of the follicle (egg). This makes the process much more problematic because it is difficult to pinpoint the exact time of follicle maturation and can result in cancellation of the egg retrieval. By using gonadotropins, we have more control over the growth of the follicle. Also, we can stimulate the growth of more than one follicle, which allows us to select the best ones.

During an IVF cycle, the physician and the embryologist have to strike a delicate balance between giving a patient the best chance of pregnancy while limiting the risk of multiple pregnancies.

In an ideal world, we would like to fertilize only a single egg, transfer a single embryo, and have a single baby. A singleton pregnancy is typically the safest and least eventful pregnancy and is best for the full-term development of the child.

However, limiting the number of eggs to be fertilized, which is the typical practice in Italy, results in a very low pregnancy rate of about 8% per cycle. In other words, only 8 couples out of a 100 starting an IVF cycle will have a baby. This is about five times lower than in the United States.

With such a low level of effectiveness, IVF treatment would not be affordable for the majority of couples who need it.

Why does a single embryo transfer results in about 10-15% lower pregnancy rates compared to a double embryo transfer?

The answer is as simple as it is vague: Not every egg is able to develop to term once fertilized. We call this phenomenon a variation in egg quality. The majority of eggs from an average woman are simply not good enough to produce a viable embryo.

Depending on the woman’s age and other factors, the percentage of “good” eggs is between 5% and 30%. But that average has very little practical meaning because there are women with nearly 100% good eggs, and there are those with nearly none.

The only proven way to determine egg quality is to fertilize them (all eggs) and to culture them in vitro for 5-6 days. During such extended in vitro culture, those embryos that are not viable will stop developing, while those that are viable will continue and become a so-called blastocyst by day 5 or 6.

Embryo selection using extended in vitro culture to the blastocyst stage is probably one of the most important factors perfected over the last 15 years. Blastocysts can be graded based on their appearance to further improve the selection process.

The chance of a single excellent quality blastocyst to produce a baby may be a 50% or higher.

There are also factors other than embryo appearance that determine viability. Even if an embryo looks normal, it may still have chromosomal errors preventing pregnancy from taking place. Such chromosomal errors are frequently responsible for pregnancy loss.

In many cases (but not all), testing for chromosomal errors with PGS (CCS) helps to further narrow down the most viable embryo.

Still, even after PGS, the chance of a single embryo becoming a baby is probably not higher than 78% even in patients with the best prognosis.

Therefore, no matter how much testing is done on embryos, our current ways to select them remains imperfect, and the chances of pregnancy are higher when two or three embryos, rather than just one, are transferred.

We have to accept, for now, that for most patients we cannot reduce a chance of a multiple pregnancy without reducing the chance of pregnancy altogether.

Interestingly, the chance of a multiple pregnancy with a single blastocyst transfer is still not zero; about 5% of the blastocysts can split into monozygotic twins. This is a high percentage compared to that of natural conception.

Blastocyst Transfer
Culturing the embryos to the blastocyst stage, or day 5 or 6 after egg retrieval, may be recommended for patients that have at least 8 fertilized oocytes on the first day after retrieval. The decision to culture embryos to day 5 is based on the development of the embryos and the patient’s individual history. Blastocysts have higher implantation and pregnancy rates, and fewer embryos are usually transferred back to the patient than would be transferred on day 3. Culturing embryos to day 5 may not always be beneficial, as some patients may have embryos that do not tolerate in vitro culture well.

At AFCT we practice elective single embryo transfer (e-SET). This means that we don’t have predefined criteria, but rather carefully review the patient’s circumstances in their entirety before recommending e-SET.

A possibility of e-SET will be discussed with the patient when:

  1. A woman only has a single embryo available.
  2. There are several excellent blastocysts available on day 5, and the woman is under 35 years of age.
  3. At least one excellent blastocyst is available on day 5 after testing by PGS, and it survived freezing/thawing without any identifiable damage.
  4. A woman has a history of cervical or uterine abnormalities, which may make a multiple gestation pregnancy particularly risky.

We take the time to get to know each patient individually and will address all your concerns on the road to parenthood in the most compassionate manner.

What is a Frozen Embryo Transfer (FET)?

FET is a cycle in which frozen embryos from a previous fresh IVF cycle are thawed and then transferred back into the woman’s uterus. Overall, 50% of all fresh IVF cycles completed at AFCT result in high-quality blastocyst-stage embryos on day 5 or 6 that are available for freezing. The chance of having embryos available to freeze greatly depends on age. For example, in 2011, 50% of cycles in which the woman was 38 years old or younger had embryos available for freezing, while only 12% of women over the age of 40 had blastocyst-stage embryos available for freezing.

In recent years, the success with FET has increased substantially, making it a viable option to consider before moving to another fresh IVF cycle. Over the past few years, our team has received several questions from patients about FET and how they work.

What are the benefits of Frozen Embryo Transfer?

  • There are now several studies that confirm the theory that we can obtain significantly higher pregnancy rates when we wait and transfer the embryos in a frozen cycle (about 6 weeks from egg retrieval) as compared to transferring the embryos in a fresh cycle. This is particularly important in patients who we anticipate will have a good response to ovarian stimulation (estrogen levels greater than 5000 pg/mL).
  • When we stimulate the growth of the oocytes (eggs), we are increasing the estrogen levels to 10-20 times higher than normal in a natural cycle. Such high estrogen levels appear to have a negative impact on the uterus, which now may not be aligned with the growth of the eggs. High estrogen levels inhibit the effects of progesterone, which is the most essential hormone in the process of implantation and pregnancy.
  • Patients who have polycystic ovarian syndrome (PCOS) naturally have a higher number of eggs compared to other patients prior to egg stimulation. The higher number of eggs leads to high levels of estrogen in the end of IVF stimulation. Therefore, patients with PCOS greatly benefit from frozen embryo transfer.
  • The risk of ovarian hyperstimulation syndrome increases with high estrogen levels, and this is also true in patients with PCOS. In this syndrome, patients experience severe abdominal discomfort, fluid collection in the abdomen, and shortness of breath, which may require hospitalization. When we perform frozen embryo transfer, we can slightly alter the stimulation protocol and almost completely eliminate this syndrome.
  • Some data suggests that the pregnancies resulting from frozen embryo transfer are healthier and the infants are about 150 grams bigger.
  • The process of freezing and thawing the embryos is called vitrification and has been perfected to the point where almost all the embryos that we freeze can now survive the thawing process.
  • The process of frozen embryo transfer involves only the preparation of the uterus so that it can be aligned with the embryos that are frozen. This can be easily accomplished by administering estrogen pills for about 2 weeks. The embryos will be thawed and transferred according to a set calendar provided for our patients.

Frozen embryo transfer leads to higher pregnancy rates.

Frozen embryo transfer is the process by which a woman’s ovaries are stimulated with medications to produce several eggs. This process takes about 10-14 days so that the follicles (eggs) can reach a mature size. The follicles are than retrieved with the aid of a transvaginal ultrasound and within four hours they are united with the partner’s sperm to produce embryos. The embryos are placed in culture for five days produce a blastocyst and are then vitrified (frozen). The process of vitrification has revolutionized embryo storage and has led to an excellent survival of the embryos of greater than 96% once they are taken out for the process of embryo transfer.

There are many advantages of utilizing the process of frozen embryo transfer

  • The exposure of the uterus to high estrogen levels, which can reach 10-20 times that of the normal cycle, will advance the endometrium to create a mismatch with the embryos in a normal cycle and that is now eliminated. We can now allow all the hormones to dissipate outside the body and use minimal preparation of the uterus for the process of embryo transfer.
  • We can eliminate the risk of ovarian hyperstimulation syndrome when the ovaries continue to enlarge and cause severe abdominal discomfort, fluid accumulation in the pelvis, and dehydration, which may require hospitalization. This process is particularly common in women with PCOS
  • Children born from frozen embryo transfer are about 150 gm. bigger than children born in the conventional fresh embryo transfer.
  • Frozen embryo transfer allows us to accumulate embryos over 2 cycles if the patient has poor quality embryos in the first cycle and transfer the best embryos.
  • Several studies confirm that frozen embryo transfer has about 5-15% higher pregnancy rates.

What are the success rates for a Frozen Embryo Transfer?

The success rates of an FET cycle are higher than those of fresh IVF cycle and have the same primary indicator for success: the maternal age at the time of embryo freezing. Many patients wait several years between the initial freeze of their embryos and attempting a subsequent FET cycle. Any patient, regardless of the amount of time between embryo freezing and thawing, can expect nearly the same potential for success as they experienced with a fresh IVF cycle, which the frozen embryos initially came from. Patients can expect the same chances of success because frozen embryos are suspended in time and do not age.

Women 37 years and younger can expect about 65% delivery rate per thaw. This rate declines with increasing maternal age at the time of embryo freezing.

Blastocyst Transfer
Culturing the embryos to the blastocyst stage, or day 5 or 6 after egg retrieval, may be recommended for patients that have at least 8 fertilized oocytes on the first day after retrieval. The decision to culture embryos to day 5 is based on the development of the embryos and the patient’s individual history. Blastocysts have higher implantation and pregnancy rates, and fewer embryos are usually transferred back to the patient than would be transferred on day 3. Culturing embryos to day 5 may not always be beneficial, as some patients may have embryos that do not tolerate in vitro culture well.

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Advanced Fertility Center of Texas
The Advanced Fertility Center of Texas (AFCT) has several fertility treatment centers located throughout Houston metropolitan area. We offer the most comprehensive list of state-of-the-art fertility services.

TEL: 1.713.467.4488
FAX: 1.713.467.9499
info@afctexas.com