Step 1 - Ovulation Induction Hormone injections are given to stimulate multiple egg production rather than the single egg normally produced by the body each month. This stimulation process usually requires the initial use of Lupron to suppress the ovary, preventing ovulation until the desired time. A protocol individualized to your particular hormone levels and history will be provided to you. Daily injections of gonadotropins are then added to stimulate the development of the eggs. These are usually given subcutaneously (under the skin).  Then the progress of ovulation induction is monitored with ultrasounds and blood estrogen levels over several days.

Step 2 - Egg Retrieval An egg retrieval is performed by placing a special needle into the ovarian follicle and removing the fluid that contains the egg. This is a relatively minor procedure and is performed by visualizing the follicles with a vaginal ultrasound probe. A needle is directed alongside the probe, through the vaginal wall, and into the ovary. To avoid any discomfort, strong, short acting intravenous sedation is provided.

Step 3 - Fertilization and Embryo Culture Once the follicular fluid is removed from the follicle, the microscopic eggs are identified by the embryologist and placed into an incubator. The eggs are fertilized with sperm by “conventional” insemination or by Intracytoplasmic Sperm Injection (ICSI).  This decision is individualized for each case.   For men with CF, the ICSI option is the best choice because the sperm retrieval procedure (such as MESA) DOES NOT supply the needed 50,000 (or more) sperm for a “conventional” insemination. During "conventional" insemination approximately 50,000 sperm are placed with each egg in a culture dish and left together overnight to undergo the fertilization process.  These sperm swim and fertilize on their own, just as they would inside the female.  ICSI is often necessary to be used in men who have had a MESA sperm retrieval because of CBAVD.  Many times, the number of sperm retrieved during a MESA retrieval doesn't provide enough sperm to use "conventional" insemination.  Nor are the sperm retrieved from a male with CBAVD motile enough to swim into an egg themselves.  Therefore, ICSI is necessary to ensure that the eggs become fertilized and that the sperm retrieved are utilized and don't go to waste.  The IVF with ICSI method requires only 1 egg and 1 sperm to create fertilization, whereas the conventional method requires as many as 50,000 sperm and a dozen or more eggs to ensure at least 1 success.   Regardless of the fertilization method, the eggs will be checked the following day to document fertilization and again the next day to evaluate for early cell division. They are now called embryos and are placed in a special culture media to promote growth. If Preimplantation Genetic Diagnosis (PGD) has been scheduled, it is at this point that one or two of the cells are removed through a procedure called Embryo Biopsy and sent to the Center for Preimplantation Genetics for analysis. This analysis will identify which of the embryo(s) are free of genetic abnormalities and recommended for transfer.  This procedure is often used when people have been previously identified as CF carriers and are wanting to have a baby, or by people who are carriers and already have a child with Cystic Fibrosis or for a situation when one partner has CF-just to be certain.    Until recently, embryos were cultured for three days and then transferred to the uterus and/or cryopreserved (frozen).  There is now the ability to grow the embryos for five or six days until they reach the blastocyst stage. For some couples these blastocysts may have a greater chance of implantation, allowing us to transfer fewer embryos and lower the risk of multiple births while increasing the chance of pregnancy. On day two or three after fertilization, the embryos will be evaluated. If there are sufficient numbers of dividing embryos they will be placed in special blastocyst media and grown for two or three additional days.

Step 4 - Embryo Transfer Embryos are transferred on day 3, 5, or 6 after egg retrieval. They are placed through the cervix into the uterine cavity using a small, soft catheter. This procedure usually requires no anesthesia. It is similar to an insemination or the Mock Embryo Transfer which is performed prior to the actual IVF cycle.  Sometimes prior to an embryo transfer, the doctors will perform an Assisted Hatching procedure.

The most commonly used indications for assisted hatching with an in vitro fertilization case are: Age factor - Couples having IVF with the female partner's age over 37 Egg quantity and quality factor - Couples in which the female's day 3 follicle stimulating hormone (FSH) level is elevated Embryo quality factor - Couples having IVF with poor quality embryos (excessive fragmentation or slow rates of cell division) Zona factor - Couples having IVF with embryos that have a thick outer shell (zona pellucida) Previous failures - Couples having IVF that have had one or more previous IVF cycles that failed

EGG ASPIRATION

INSEMINATION

INCUBATION

EMBRYO TRANSFER

EMBRYOS