grow your family through ivf
In Vitro Fertilization (IVF)
In Vitro Fertilization (IVF)
With In Vitro Fertilization (IVF), eggs are fertilized by sperm in a laboratory instead of inside the fallopian tube. IVF is the most advanced and effective fertility treatment available today. While IVF has excellent success rates, it is a more invasive procedure than intrauterine insemination (IUI).
What is In Vitro Fertilization?
In Vitro Fertilization (IVF) is a form of assisted reproductive technology (ART) that many individuals and couples struggling to conceive utilize to successfully build their famlies. The process involves extracting eggs, collecting a sperm sample, and combining the egg and sperm manually. After the egg and sperm have been combined in the laboratory, the embryo or embryos are transferred to the uterus.
Advanced Fertility Care
An IVF Cycle Typically Includes The Following Steps:
Phase 1: Pituitary and Ovarian Suppression
Pituitary and ovarian suppression occur for the month prior to your scheduled retrieval. Oral contraceptive pills or leuprolide acetate (Lupron) shots are used to suppress your natural hormonal surges and “take control” of your stimulation with gonadotropins (injectable fertility medication). By suppressing or “down-regulating” your pituitary gland (which releases hormones) and ovaries, the formation of naturally occurring ovarian cysts may be minimized and the FSH and LH receptors on the ovaries may become more sensitive and require less medication to stimulate them. In certain circumstances, a different treatment protocol called an antagonist protocol may be recommended and this phase of IVF may not be necessary. The antagonist protocols are typically used when there is a timing issue with a certain cycle.
Phase 2: Ovarian Stimulation
During the stimulation phase, patients give themselves daily injections of fertility medications (gonadotropins) for 9 to11 days. These injections stimulate the development of multiple ovarian follicles which contain the eggs. Careful monitoring with ultrasounds and blood hormone levels allows our physicians to make necessary adjustments to your treatment regimen and minimize any complications from the powerful fertility medications. Once the follicles have reached their ideal size, a subcutaneous (under the skin) or intramuscular injection of HCG mimics your own body’s hormonal LH surge which causes the final maturation of the eggs prior to retrieval.
Phase 3: Egg Retrieval
The egg retrieval occurs 35-36 hours after receiving the HCG shot, and is performed in our on-site dedicated procedure room. A board-certified anesthesiologist will provide intravenous sedation to prevent any pain or discomfort during the procedure. Under ultrasound guidance, a very thin needle is passed through the upper portion of the vagina into the ovary and into the individual ovarian follicles. The fluid containing the egg is aspirated and subsequently identified by our embryologist in the adjoining laboratory. In general, the recovery from an egg retrieval procedure is rapid and you will be monitored by one of our registered nurses for 30 to 60 minutes after the procedure prior to being sent home. Since anesthesia is used on the day of retrieval, someone must be available to drive you to and from our facility. Some patients may experience mild cramping on the day of retrieval which usually subsides by the evening of retrieval. In some cases, a sensation of fullness or pressure may last for up to one week following the procedure.
Phase 4: Fertilization
Once the follicular fluid is removed from the follicle, the eggs are identified and isolated by the embryologist and placed into an incubator. The eggs are fertilized with sperm later that day by conventional insemination or by Intracytoplasmic Sperm Injection (ICSI). For conventional insemination, the sperm obtained from the partner or donor is placed into a specialized culture solution with the egg and then placed in a specially regulated incubator. If intracytoplasmic sperm injection (ICSI) is to be performed, this takes the place of conventional insemination. During ICSI, the embryologist uses a microscope to pick up a single sperm and inject it directly into the cytoplasm of the egg using a small glass needle. ICSI allows couples with very low sperm counts or poor quality sperm to achieve fertilization and pregnancy rates equal to traditional IVF. It is also recommended for couples who have not achieved fertilization in prior IVF attempts. Special urological procedures are available to you for cases where it is difficult to obtain sperm or for men with no sperm in the ejaculate.The eggs will then be checked within 18-20 hours later to document fertilization. The embryologist will check the eggs again the next day to evaluate for early cell division. Once a sperm fertilizes an egg, it is considered a zygote which then develops into an embryo. The embryos are then transferred to a different culture media and grown over the next 2-6 days. On day two or three after fertilization, the embryos will be evaluated for blastocyst culture. If there is a sufficient number of dividing embryos they will be placed in special blastocyst media and grown for two or three additional days. Ideally, the embryos will have grown for five or six days until they reach the blastocyst stage. For many couples, these blastocysts have the greatest chance of implantation. This allows us to transfer fewer embryos, in some cases only one, and lower the risk of multiple births while increasing the chance of pregnancy.Any additional procedures (i.e. assisted hatching or Preimplantation Genetic Testing (PGT) ) prior to the transfer of the embryo(s) into the uterus will be determined on an individual basis. Some embryos may also be cryopreserved (frozen) at the end of the culture period.
Phase 5: Embryo Transfer
The embryo transfer is a brief, painless procedure involving the use of ultrasound guidance while the embryo(s) are placed into the endometrial cavity of the uterus, using a small highly specialized plastic catheter. No sedation is necessary for this procedure, although we do recommend and prescribe diazepam (Valium®) to ensure overall relaxation. After transfer, progesterone supplementation via injection or vaginal suppository will be taken for the next 10-12 days and a blood pregnancy test will be performed approximately 2 weeks from the retrieval date.
Phase 6: Pregnancy Test and Early Obstetrical Care
The initial pregnancy test will be performed in our office two weeks after your retrieval date. Blood hCG levels will then be checked every 2-3 days for those who do have an initial positive pregnancy test. An ultrasound will be performed at approximately 5-6 weeks of pregnancy (2-3 weeks after embryo transfer) and repeated one to two more times during the first trimester until a normal healthy heartbeat is confirmed. Once viability is confirmed, you will be referred back to your ObGyn for appropriate obstetrical care.
Advanced Fertility Care
What are the success rates for IVF?
Who Needs IVF?
Tubal Factor (Damage to Fallopian Tubes) / Pelvic Adhesions
There are two options to treat patients with significant tubal damage and/or pelvic adhesive disease. The first option is to surgically repair the tubes and either get pregnant naturally or use Artificial Insemination or IUI to get pregnant. In many cases, however, surgery is not a good option as it may be very difficult to surgically fix the damaged tube(s) or the surgery may cause a high risk of an ectopic pregnancy. In these instances where the surgical option does not pose a high chance for success, the second option is to bypass the tubes completely by using IVF as the treatment plan.
Current scientific data about endometriosis show that mild to moderate forms of endometriosis may be effectively treated with a combination of surgical and medical therapy. For more stages of endometriosis, including the presence of endometriomas, IVF is the optimal first-line treatment and offers the highest pregnancy success rates.
Male Factor Infertility
One of the most significant advances in the treatment of infertility has been the ability for men with severe sperm abnormalities to achieve fertilization of the egg and successful pregnancy. IVF with the addition of ICSI (Intracytoplasmic Sperm Injection) has enabled couples suffering from abnormal sperm, who would not otherwise be able to conceive, to be able to start a family. ICSI is often recommended if there is any suggestion of a sperm issue, if sperm are obtained surgically, or if there has been a prior failure of fertilization.
Diminished Ovarian Function & Age-Related Infertility
Ovarian function decreases with age. In many cases, this reduced function can be overcome through the use of IVF alone, or in conjunction with techniques such as Assisted Hatching and ICSI. For some women, this decrease in ovarian function may start at earlier ages and may require aggressive treatment with IVF sooner.
Anovulation & Polycystic Ovarian Syndrome (PCOS)
The majority of patients with anovulation or PCOS often conceive using less aggressive treatments such as ovulation induction with IUI. For some patients who are “high responders” to gonadotropin therapy, IVF offers an excellent prognosis and reduces some of the risks of higher-order multiples.
Approximately 20% of couples will have no identifiable cause of infertility after completing a comprehensive evaluation. IVF is often successful even if more conservative treatments have failed, especially since some of these couples may have yet unidentifiable causes of infertility or sub-fertility.
Family Balancing (also known as Gender Selection or Sex Selection)
For families that wish to have additional children of a particular gender after already having a previous child, PGT-M allows for selection of embryos to transfer based on gender. While not perfect, embryo biopsy with genetic chromosome determination prior to transfer of embryos can allow families choice in how they expand the family. Read more about PGT-M.
Those looking to use preimplantation genetic screening (PGT-A or PGT-M)
Those wishing to utilizing preimplantation genetic testing will need to undergo IVF as IVF treatment makes it possible to administer genetic testing on embryos. One additional indication for IVF is to provide genetic testing on embryos prior to implantation. Preimplantation Genetic Testing (PGT) is the testing of embryos for genetic diseases and chromosomal disorders. There are three different types of PGT: PGT-A, PGT-M, and PGT-SR. Preimplantation Genetic Testing – Aneuploidy (PGT-A) is the most common and helps identify the embryos that are most likely to implant and result in a successful pregnancy and also reduces the chance of having a child with extra or missing chromosomes which could cause disorders such as Down syndrome During PGT-A, embryos created through IVF are biopsied and screened for all 46 chromosomes. PGT-A also identifies the chromosomal sex of the embryo (XX or XY) and this information is provided for those who wish to have it.
Advanced Fertility Care
Additional Treatment Options for IVF
Intracytoplasmic sperm injection (ICSI) involves injecting one sperm into the middle of an egg. ICSI is performed in our state-of-the-art embryology laboratory. Under the microscope, our embryologist isolates a single sperm and puts it into a specially designed needle. The needle with the single sperm is then carefully inserted past the outer shell of the egg, past the egg membrane and into the inner part of the egg called the cytoplasm.
Not all embryologists are equally skilled at ICSI. At Advanced Fertility Care, our embryologist obtains over an 80% fertilization rate of the eggs after ICSI. This is far above the normal average of 65%. A fertilization rate is different from a pregnancy success rate. A fertilization rate is the percentage of eggs that are injected with a sperm using ICSI that fertilize and begin to grow into an embryo.
Will I Need ICSI With My IVF Cycle?
Not all patients undergoing an IVF treatment need ICSI. ICSI is used to overcome male factor infertility, and it provides an alternative to couples who previously had to turn to donor sperm. ICSI allows couples with very low sperm counts or poor quality sperm to achieve fertilization and pregnancy rates equal to traditional IVF. The use of this specialized insemination technique represents a major advance in reproductive medicine and benefits couples with male factor infertility as well as couples where the female has abnormal egg morphology and previous IVF history of poor fertilization.
We believe that ICSI should only be performed when it is medically indicated, which represents ~40% of our IVF patients. By individualizing our treatment plans to patients’ actual needs, we save our patients significant amounts of money while still providing the top success rates. At Advanced Fertility Care we are currently recommending in vitro fertilization (IVF) with ICSI for:All couples with severe male factor infertility that do not want donor sperm insemination.
All couples with infertility with:
- Sperm concentrations of less than 15-20 million per milliliter
- Sperm motility less than 50%
- Very poor sperm morphology ≤ 4% normal shaped sperm by Kruger Morphology
- All couples having IVF who have had a previous cycle with no fertilization – or a low rate of fertilization (low percentage of mature eggs that are normally fertilized).
- All couples having IVF who have a very low yield of eggs at the egg retrieval – our current cutoff is 5-6 (or less) eggs. In this scenario, ICSI is being used to try to get a higher percentage of eggs fertilized than with conventional insemination of the eggs (just mixing eggs and sperm together).
- All cycles utilizing frozen donor sperm from a sperm cryobank
Similar to embryos, sperm can also be frozen for potential future use. At Advanced Fertility Care we offer sperm cryopreservation services to our patients as well as to those referred to us for fertility preservation. Reasons to freeze sperm may include:
Logistical considerations: If the male partner will not be in town or will be unavailable to provide a specimen at the time of planned IUI or IVF cyclePoor sperm quality and/or quantity: If previous semen analysis samples cause concern as to having enough sperm for future fertility treatment, we often recommend freezing multiple sperm samples for future use with either IUI or more advanced techniques like IVF with ICSI for which relatively few numbers of sperm are needed.
Ejaculatory dysfunction: For some men, the pressure of producing a specimen on a certain day and time may cause performance issues resulting in a situation where the woman is ready for insemination or eggs have been harvested by IVF and the male is unable to produce sperm. This issue occurs more readily in males over the age of 50, however, can happen to anyone. If there is any concern or history of ejaculatory dysfunction, we recommend freezing sperm prior to treatment.
Fertility Preservation: Advanced Fertility Care belongs to the Livestrong Program formerly the Fertile Hope Network which was created to serve patients diagnosed with cancer who wish to preserve their fertility prior to undergoing toxic treatments such as chemotherapy. We also receive self referrals and referrals from oncologists. For these patients, our andrology laboratory will perform the initial analysis and freezing process, however, these specimens will be immediately shipped to a separate long term storage facility.
While we do perform sperm cryopreservation services, Advanced Fertilty Care IS NOT a sperm bank and we do not offer sperm banking services.
Assisted hatching is a laboratory procedure used to improve the probability of an embryo implanting into the uterine wall after transfer into the uterine cavity. Every embryo has a protective layer that surrounds it called the zona pellucida (ZP). Before an embryo can implant into the uterus, it must hatch from the ZP. In some cases, the zona becomes toughened, restricting the embryo from hatching. The assisted hatching procedure involves thinning or making a small hole in the ZP, which helps the embryo exit its protective “shell” and implant into the uterine lining. Numerous studies have shown that assisted hatching improves pregnancy rates and implantation rates.
The Assisted Hatching Treatment Process
- The embryo is held with a specialized holding pipette.
- A hole is made in the ZP using either a laser or acid solution. A very delicate, hollow needle is used to expel an acidic solution against the outer “shell” (zona pellucida) of the embryo.
- A small hole is made in the shell by digesting it with the acidic solution.
- The embryo is then washed and put back in culture in the incubator.
- The embryo transfer procedure is done shortly after the hatching procedure. Embryo transfer places the embryos in the woman’s uterus where they will hopefully implant and develop to result in a live birth.
Who Should Be Treated With Assisted Hatching?
The most commonly used indications for assisted hatching with an in vitro fertilization case are:
- Women over 38 years and using their own eggs
- Women who had recurrent failure of embryo implantation
- Women whose embryos exhibit thick ZP (zona pellucida)
- Women with elevated FSH levels
- Women with poor embryo quality
A minimally invasive outpatient surgical procedure performed using conscious sedation anesthesia in which a long thin camera is inserted through the vagina and cervix and into the uterus in order to correct any abnormalities of the uterine lining or cavity as detected by previous diagnostic testing. Most commonly, removal of endometrial polyps (non-cancerous small growths), fibroids, or extra tissue can be performed easily and quickly using instruments inserted through the camera. This procedure will be performed by an AFC physician on an outpatient basis within our own state-of-the-art ambulatory surgery center (Arizona Advanced Surgery Center) or at nearby Scottsdale Shea Hospital or at a Banner Hospital.
Advanced Sperm Recovery
We offer the following procedures for those who cannot ejaculate or have no sperm in the ejaculate, but can still produce sperm in the testicles. All of these procedures are done under local or general anesthesia and can be very effective in yielding a pregnancy when combined with advanced reproductive techniques such as IVF with ICSI.
> Percutaneous Epididymal Sperm Aspiration (PESA)
> Testicular Sperm Extraction (TESE)
> Micro-epididymal Sperm Extraction (MESE)
> Testicular Biopsy
Situations that may result in the need of these techniques include:
> Previous vasectomy (male sterilization)
> Congenital obstruction of the sperm ducts (vas deferens) which carry the sperm away from the testicles where they are made
> Congenital absence of the vas deferens due to Cystic Fibrosis
> Inadequate development of the sperm such that they cannot leave the testes.
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Arizona Fertility Services
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See What Our Patients have said
“Just a tiny token of appreciation. We are so grateful to have benefitted from the wonderful job each of you do! You took such great care of us, and we are so thankful! We’ll see you again in the future for a sibling 🙂”
“Thank you to Dr Zoneraich, Dr Larsen & everyone at Advanced Fertility care for helping to bring our little miracle into the world! We are so grateful to have this wonderful child in our lives & it would not be possible without your expertise and care. We are so happy and feel incredibly blessed… Thank you!”
“We cannot say enough about AFC. We started our infertility journey at another practice and had a horrible experience. After starting with AFC, everything changed. Dr. Larsen took time to listen and was truly aware of our needs and feelings. We cannot thank him enough. We have a beautiful son and are over the moon.“
“Thank you for all you have done for us, you are an amazing group of people and we couldn’t be happier that we chose you to take us through this process.”
“Thank you so much for making our dreams come true. We feel so lucky for the blessing that you made possible. We couldn’t have picked a better team to work with.”
“There are no words to truly express how much we appreciated your kindness during our time working with you. You are truly in our hearts each time we look at our son. Thank you.”
"My wife and I have been trying for over six years to start a family, starting with trying naturally of course, IUI, IVF, and 3 transfers prior to meeting with Dr.Z and the Advanced Fertility team. We wanted to give it one more shot and were lucky enough to have a family friend offer to be a carrier, as well as try one more time with my wife as well. We felt very comfortable right off the bat. We had worked with 2 other fertility centers in Phoenix and Scottsdale prior. This team made us feel welcome and laid out a game plan and set our expectations and were very clear and realistic. Our wait times were non existent compared to another major facility where we did our first IVF, their avg wait 30-60 mins. We were not sold or told that they guaranteed to fill our house with kids like we heard verbatim at other establishments."
"We wanted to introduce you to our little miracle baby girl. She has blessed us in so many ways already. We want to say thank you to everyone at the office. You were all great during every step. You made IVF seem not so intimidating and then when we found out we were pregnant between treatments you were with us from the beginning until we saw her little heartbeat on ultrasound. A “BIG” thank you to Dr Z. You are great and so personable. You all can expect to see us again in a year or so."
"We cannot say enough about AFC. We started our infertility journey at another practice and had a horrible experience. After starting with AFC, everything changed. Dr. Larsen took time to listen and was truly aware of our needs and feelings. We cannot thank him enough. We have a beautiful son and are over the moon."
"We’ve been on our infertility journey since 2009. Advanced Fertility Care is the 4th fertility Drs office we went to. We LOVE them! I will never go anywhere else. They are the whole package. In our early experiences with other offices, we found the hands off approach frustrating. We saw Drs at consultations but all treatments and ultrasounds were done by nurse practitioners. Decisions were frequently made by nurse practitioners. We thought this was normal care – it’s not! I have never been seen by a nurse practitioner at Advanced Fertility Care."