Our Assisted Reproductive Services
Lab Monitor Showing ICSI Procedure In Real Time
Assisted reproductive technologies (ART) involve retrieval of one or more eggs to increase the chance of successful conception.
At Monterey Bay IVF, our specialized ART services include:
- In Vitro Fertilization
- Egg Freezing For The Future
- Three Day Embryo Transfer
- Blastocyst Embryo Transfer
- Frozen Embryo Transfer
- Assisted Hatching
- Intracytoplasmic Sperm Injection (ICSI)
- Ultrasound Guided Embryo Transfer
- Transepididymal Sperm Extraction (TESA)
- Preimplantation Genetic Diagnosis (PGD)
- Donor Egg IVF
- Gestational Surrogacy
- Cryopreservation or Embryo Freezing
We form a cohesive team made up of doctor, nurse, embryologist and patient to work together to decide on which treatment is best, both medically and emotionally.
In Vitro Fertilization (IVF)
As of 2012, there have been over 5 million babies born from in vitro fertilization (IVF). The very first IVF baby, Louise Brown, was born in England in 1978 due to the genius and scientific abilities of Dr.s Edwards and Steptoe. Back then the babies that were produced from IVF were known as “test tube babies” since they were conceived outside the mother’s womb. IVF is now a common term without any of the stigma or mystery that was attached to it in the early days. So many couples who would have never been able to have children are now proud parents.
IVF is never the first step in the treatment of infertility. It is the treatment of last resort for cases in which other methods such as fertility drugs, surgery, and artificial insemination haven’t worked. Unlike other forms of assisted reproduction, like artificial insemination, IVF involves combining eggs and sperm outside the body in a special embryology laboratory. Once an embryo has formed in the petri dish, one or more are transferrred into the woman’s uterus, usually 3 to 5 days after the egg retrieval. At our center, we pride ourselves on our success rates with IVF and the fact that we never approach this option unless a thorough evaluation has been done and all the other possibilities have been tried or ruled out.
Please see the IVF Process page for a detailed description of in vitro fertilization.
Intracytoplasmic Sperm Injection or ICSI
ICSI is useful for couples where the male patient has low sperm count or poor sperm morphology, since only one sperm is required to fertilize each egg. It may also be recommended for couples who have had low or no egg yield or poor fertilization success in the past, since there is greater control of fertilization. It is known that with an abnormal semen analysis, there is a higher possibility of a functional problem i.e. that the sperm cannot fertilize the egg. Also, it is recommended in older patients (>37 years old) because the shell of the egg is thicker and sperm have a more difficult time penetrating the shell normally. In some cases, patients will choose to have ICSI because they don’t want to take the risk of fertilization not taking place (fertilization failure), which will essentially end the cycle at that point.
When doing ICSI, an anatomically normal appearing and swimming sperm is identified and aspirated into a glass needle. Each of the retrieved eggs is placed in a dish and held still with gentle suction while a single sperm is carefully inserted into the cell using a needle. This whole procedure is done microscopically in our laboratory by our embryologist, Lisa Nelson. ICSI essentially assists the step whereby the sperm enters the egg. The next day it is possible to determine which eggs have been successfully fertilized.
Three Day Embryo Transfer and Blastocyst Embryo Transfer
The embryo actually can be transferred at any point in its development, but time and research has identified the two optimal embryonic “ages” as day-3 or day-5. These are the two ages that most IVF centers in the world use in their transfer protocols. Our patients are contacted soon after their retrieval to schedule their embryo transfer. At our center, the transfer will take place between three or five days following the egg retrieval. According to their particular treatment goals, Dr. Ramirez will sit down and discuss with the patient the recommended number of embryos to transfer.
There are studies suggesting that pregnancy rates in women with less than three or four nice 8-cell embryos on day 3 will have a higher chance of pregnancy with a day-3 transfer as compared to women with less than three or four nice 8-cell embryos who have a day-5 transfer.
At our center, we have specific criteria to determine whether or not to proceed to Blastocyst. One of these criteria is that there has to be a minimum of 8 good quality embryos (7-8 cell, grade 1) because we know that many embryos will not make it to Blastocyst, and that is not necessarily because the embryos are bad. A clinic that puts only a few embryos at risk to develop to Blastocyst is basically risking the cycle by not having anything to transfer. For that reason, we want to make sure that there are enough embryos to start with so that there will be embryos to transfer. In addition, it is Dr. Ramirez’s personal belief that the uterine cavity is a better culture environment and media than what we have available in the lab. For this reason, most of our transfers are on Day#3.
With a day-5 transfer the embryo has divided further and is known as a Blastocyst. In doing PGD (preimplantation genetic diagnosis), Dr. Ramirez has seen Blastocysts turn out to be chromosomally abnormal embryos whereas an embryo that did not survive to Blastocyst had normal chromosomes (PGD usually is done with Day-3 embryos and takes two days to get the result, so by the time the result comes back, the embryos are Day-5). He has also seen ugly, poor looking embryos (4 cell, Grade 3) lead to pregnancies when transferred at Day-3 that would not have survived to Blastocyst.
Because of the political pressure to do more single embryo transfer cycles, or SET, many clinics are now culturing to Blastocyst stage before doing the transfer. This is because culturing to Blastocyst stage leaves less embryos to choose from and MAY indicate a healthier embryo, but the latter conclusion is not an absolute. There are several advantages to blastocyst transfer, including the ability to choose a “better” embryo and a lower risk of multiples in pregnancy by transferring fewer embryos. A drawback is that some embryos do not survive to the blastocyst stage even in the most optimal lab conditions. When a decision is made for a day-5 transfer, the embryologist will culture all embryos to day 5, select the best one or two for a fresh transfer and freeze the remainder as a day-5 embryo. Patients can then return for a frozen embryo transfer with their day-5 frozen embryos if they do not succeed with their present cycle or if they do, at some later point in time to attempt to have a second or third child by IVF.
Frozen Embryo Transfer or FET
We offer the ability to do frozen embryo transfers (FET) for all our existing patients as well as new patients who have frozen embryos stored at another clinic. A patient may do a frozen embryo transfer (FET) cycle whenever she has frozen embryos and wishes to use them. This may be after already having had a child via IVF and there is a wish to have another a few months or years down the road. It could also be after an unsuccessful stimulated IVF cycle in which there were obtained frozen embryos.
The FET cycle requires very little pre-testing. Another Mock Embryo Transfer (Mock ET, or uterine sounding) will be completed if deemed necessary in order to accurately measure and map the patient’s uterine contours. Most patients will be on a month of oral contraceptives (birth control pills) before their actual frozen cycle. The average patient will have four appointments prior to the transfer and can be monitored by their local physician if they are out of the area. Due to Dr. Ramirez’s expert transfer technique and protocols, our FET’s have excellent success rates, nearly the same as fresh IVF cycles.
Benefits include lower cost, less complex treatment (e.g. no surgical retrieval of eggs), less medication, and generally similar success rates. See our financial page for approximate costs under “Frozen/Thawed Embryo Transfer Cycle”. An FET is included in our Shared Risk Plan.
Ultrasound Guided Embryo Transfer
After a patient’s retrieved eggs are fertilized and monitored in the lab for about 1-3 days, or 4-5 days for blastocyst transfer she will come into our surgery center for her transfer. This is done in our comfortable recovery rooms utilizing a calming mind/body approach. Typically one or two of the best embryos are selected for transfer, and are placed via an ultrasound-guided needle into the uterus.
For the transfer, Dr. Ramirez puts on several layers of sterile gloves and measures the embryo transfer catheter, marking how far the catheter should be inserted. This measurement is based on the MET (mock embryo transfer) that he has done prior to the start of the IVF cycle. Before the ultrasound was used to verify the position of the catheter (ultrasound guided embryo transfer), this measurement was the only way that fertility specialists knew where to put the embryos. Fortunately, someone was smart and astute enough to think to use the ultrasound to help identify the position of the catheter within the uterus, which has immensely helped increase pregnancy rates. Since doing ultrasound guided transfers, I have had many situations where I changed the position of the catheter beyond the original measurement based on the ultrasound visualized position. Dr. Ramirez still marks the position on the catheter just in case he is unable to visualize the catheter by ultrasound, which can happen in heavier patients, patients with retroflexed uteri and patients without sufficient urine in their bladder. This is an example of his dedication to quality and soundness of patient care.
After the patient is prepared for the procedure she is placed into the lithotomy position. Soon thereafter, the doctor removes his first set of gloves and helps position the abdominal ultrasound transducer to find the uterus, and make any adjustments he needs to make to the ultrasound machine. His assistant Elvira Garcia has been trained to do this as well and holds the transducer in the proper position. This frees the doctor up to do the transfer procedure. Because the ultrasound sound waves have to pass through the abdominal tissues of fat and muscle to reach the uterus, there has to be adequate filling of the bladder for the sound waves to pass through and get deep enough to see the uterus. If the bladder is filled properly, the uterus can been seen properly and, more importantly, the endometrial lining so that the doctor can see the catheter pass within. At this point Dr. Ramirez is ready to proceed with the transfer procedure with the assistance of the ultrasound. The ultrasound ultimately helps to see the catheter tip to verify its location and make sure that it is in the proper place. If the catheter is seen as not in the proper place, then the position is adjusted to put it in the correct position.
Assisted Hatching is a procedure in which a small hole is made in the embryo using micromanipulation, making it “easier” for the embryo to hatch. Zona means “shell” and zona hatching is where the blastocyst gets rid of the surrounding zona pellucida in order to implant in the uterus. Assisted hatching is usually reserved for couples that have failed IVF multiple times or for women between 35 and 40 years of age. There have been many studies showing a dramatic increase in success rates after using this technique.
In theory, assisted hatching works on the assumption that some women fail multiple cycles of IVF because their eggs have a “thicker shell”. When our embryologist, Lisa Nelson, creates a minor defect in the zona (shell) with her pipette the result is a greater chance of the embryo “hatching” and increased the chances of implantation in the endometrium. First, a special pipette is used to hold the embryo in place. She then takes a hollow needle that contains an acidic solution and places it next to the zona pellicuda. Some of this acidic solution is released from the needle so that it comes into contact with the zona pellicuda. This acidic solution begins to slowly digest the protective layering, creating a small hole. The embryologist then washes the embryo in a special solution and places it back inside the incubator until embryo transfer can take place.
We know that hatched embryos implant one day earlier another factor that may allow for a successful implantation due to the fact that the endometrim is advanced by the ovarian stimulation.
Preimplantation Genetic Diagnosis (PGD)
Preimplantation Genetic Diagonsis (PGD) allows us to test embryos for genetic disorders before performing the transfer. This is especially helpful for expectant parents whose child is at high risk of inheriting a genetic defect. One cell from each of the fertilized embryos is tested for the DNA mutation responsible for the condition(s). It is currently possible to test for over 100 genetic disorders, including cystic fibrosis, sickle cell anemia, Tay-Sachs disease, Huntington disease, hemophilia, and some types of leukemia. In addition, the proportion of embryos that test genetically normal with PGD appears to be around 45% under age 35, 20% at age 37 and this percentage drops to somewhere between zero and 10% after age 40. There are individual instances where patients, at all ages, may have either no normal embryos or more than the expected percentage for their age.
Please see our section on Genetic Testing/PGD for a more detailed description.
TESA Or Transepididymal Sperm Aspiration/Extraction
With some forms of male factor infertility there is an inability to produce a sufficient amount of sperm for fertilizition. At Monterey Bay IVF, we have a skilled urologist come to our surgery center to perform this procedure which is technically called transepididymal sperm aspiration/extraction (TESA/E) and it involves the direct removal of sperm from the testicles. Under local anesthesia, a small amount of testicular tissue is removed. Afterwards the collected sample is examined and if there are sperm present they can then be used in conjunction with Intracytoplasmic Sperm Injection (ICSI). Fertilization rates with testicular sperm are no different from ejaculated sperm. Male factor ICSI and TESE have all but eliminated the need for vasectomy reversal and have significantly reduced the need for donor sperm.
Egg Freezing For The Future
For several years now, egg freezing has been approved as a procedure to extend fertility in both cancer patients and women who would like to “shatter the biological clock”. There are a few reasons that a woman may choose to freeze her eggs: a medical condition, future family planning, timing, or uncertainty. A woman 37 or younger with a normal ovarian reserve should count on freezing 15 to 20 eggs.
Donor Egg IVF
Please see our section on Donor Egg IVF for a more detailed description of this service.
Please see our section on Gestational Carriers for a more detailed description of this service.
Cryopreservation or Embryo Freezing
Please see our section on Fertility Preservation, for Cancer Patients and Embryo Freezing & Banking For The Future for a more detailed description of this service.