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High Tech Treatments

IVF-ET (In-Vitro Fertilization and embryo transfer)

In-Vitro Fertilization and embryo transfer is probably the most well-known of the Assisted Reproductive Technologies. Initially known as the “test tube baby” technique, it has helped infertile couples conceive and bear children . IVF-ET was originally developed to treat women with tubal factor infertility. However, it is used today to treat infertility problems due to adhesions, endometriosis, sperm antibodies, moderate male factor infertility and unexplained infertility.

Now Offered with Blastocyst Transfer

In-Vitro Fertilization and embryo transfer (IVF-ET) is probably the most well known of the Assisted Reproductive Technologies. Initially known as “test tube baby” technique, it has helped infertile couples conceive and bear children . IVF-ET was originally developed to treat women with tubal factor infertility. However, it is used today to treat infertility problems due to adhesions, endometriosis, sperm antibodies, moderate male factor, failed GIFT cycles and unexplained infertility.

Description of IVF Process

In order for pregnancy to occur, the egg must be released from the ovary and unite with the sperm. Normally this union, called fertilization, followed by development of an embryo, occurs in the fallopian tube which joins the uterus to the ovary. However, in IVF the egg and sperm are collected from each partner and are united in the laboratory to produce an embryo. This embryo is then transferred back to the uterus for continued growth. The process of IVF involves five major steps: 1. Monitoring the development of follicles in the woman’s ovaries. 2. Aspiration of the follicle’s contents and identification of the eggs. 3. Obtaining a semen specimen from the male partner. 4. Processing the eggs and sperm in the laboratory, enabling fertilization and embryo growth to occur. 5. Transferring the embryo(s) into the uterus. To control the timing of egg release and to increase the number of eggs collected, the woman will receive ovarian stimulating hormones selected for her individual situation. To determine egg development is satisfactory, she will undergo ultrasound scans of the ovaries to see images of the enlarging follicles which contain the eggs. Hormone levels are also checked by taking a series of blood samples. Using the above information the physician determines when to administer an injection to cause final ripening of the eggs and when to schedule the egg retrieval. The egg retrieval is performed using a needle guided by transvaginal ultrasound. During this procedure the follicles in the ovary are visualized by placing an ultrasound probe into the woman’s vagina. A needle is then guided into the follicle through the vaginal wall. Fluid from the grape size follicle, which presumably contains the egg, is then withdrawn. This is called follicular aspiration. During this procedure, which may take less than 30 minutes, the patient is given sedation intravenously. Timing is very important for this procedure because unripe eggs may not develop in the laboratory if the retrieval is too early. If the retrieval is too late the eggs may also not develop or may be lost because of release from the ovary. After retrieval, the patient is allowed to rest a short time before going home. The fluid obtained during the egg retrieval is taken to the laboratory where the eggs are isolated and mixed with properly processed sperm. This mixture is placed in incubators to allow fertilization to take place. The eggs are observed for fertilization 12-16 hours later, and placed in fresh culture medium for continued growth. Once cell division occurs in the fertilized egg it is then referred to as an embryo. Embryos that have developed satisfactorily are placed in the woman’s uterus three to five days after egg retrieval. This procedure requires cleansing of the vagina with a solution and then transferring the embryo(s) into the uterus through a small catheter. This is a short, painless procedure not requiring sedation. The patient must lie down for a period of time after the embryo transfer. Continuous rest for a day after the transfer is recommended.

Risks and Complications with IVF

Complications of a serious nature are quite uncommon in Assisted Reproduction. Multiple pregnancies and ovarian hyper stimulation syndrome are the most common. Reactions to medications and anesthesia, infection, internal bleeding, and injury to internal organs with possible need for surgical correction are all potential complications but happen very infrequently. If pregnancy is established, the multiple pregnancy rate is definitely higher (twins account for approximately 20% of the pregnancies) than natural conception. Fetal reduction is a procedure which is undesirable but sometimes indicated in higher order multiple pregnancies. The risk for this procedure can be decreased through limitation of the number of embryos transferred. The frequency of miscarriages is slightly higher than natural pregnancy but the frequency of congenital abnormalities is comparable. Tubal pregnancies may be slightly higher than the general population but IVF-ET may actually lower the risk quite dramatically in some patients.

Cancellation of a IVF Cycle

Unfortunately not all cycles lead to successful retrievals or a pregnancy. Some of them must be canceled. Some of the reason are: 1. Poor Ovarian Response. The cycle may be canceled if the ovarian response to hormones is poor as indicated by low blood estradiol levels on cycle day-8 of ovarian stimulation or if you have less than 3 preovulatory size follicles on the day of hCG. Most women at risk of poor ovarian response are those in the late 30s or older. 2. High ovarian response. Women who develop many follicles during a stimulation cycle are at risk of suffering the Ovarian Hyper-Stimulation Syndrome (OHSS). High blood estradiol level is an indicator of hyper stimulation. Preventive measures include: decreasing the dosage of gonadotropin or finishing the cycle without transfer of any embryos (as pregnancy will increase the risk) during that cycle. Instead cryopreserve all resultant embryos and transfer them in a latter cycle. The most extreme measure against OHSS is to cancel the cycle. The Center for Reproductive Medicine & Robotic Surgery policy to decrease the likelihood of a multiple pregnancy Maximizing your probability of pregnancy while trying to keep the chance of a multiple pregnancy low is our main objective. However, you must realize that this goal can not be reached in all cases. The number of embryos selected for transfer determines your pregnancy rate and the probability of a multiple pregnancy. It is not advisable to match a predetermined number of embryos for transfer, as some have suggested. Number, quality and developmental stage of the embryos in addition to your age and number of times you have been through IVF&ET cycles are some of the factors to consider in order to select the best number of embryos for transfer. Additional embryos may be frozen and stored.

When Male Infertility is present

Male infertility is a factor in about 30-40% of couples suffering from infertility. At CRMRS we believe that infertility is a “couple problem”. Therefore, we have incorporated the latest andrology diagnostic modalities for evaluation of men in addition to conventional infertility evaluation. We treat moderate to mild cases of male infertility through the conventional IVF alternative. For severe cases of male infertility we offer in-office procedures that a few years ago were confined to expensive operating room settings. Among them are: Percutaneous Epididymal Sperm Aspiration (PESA) or Testicular Sperm Aspiration (TESA) for those that do not produce sperm in the ejaculate. This may be a more viable alternative for those considering vasectomy reversal. The sperm retrieved can be used fresh to fertilize eggs or stored frozen for subsequent cycles. This method allows you to avoid the expense and discomfort of subsequent PESA or TESA procedures. Bear in mind, however, that depending on the quality and number of sperm collected on the day of oocyte collection you may need a second procedure. The spermatozoa collected are utilized to fertilize the oocytes by Intra-Cytoplasmic Sperm Injection (ICSI). These technologies have helped couples have children who a few years ago, were considered hopeless. The pregnancy rates with ICSI are encouraging and similar to those cases where conventional IVF is utilized.

ICSI (intra cytoplasmic sperm injection)

Intra Cytoplasmic Sperm Injection (ICSI) is a procedure by which a single sperm is inserted with the aid of a micro needle into the cytoplasm of a mature oocyte. This procedure is recommended for severe cases of male factor infertility (severe oligospermia or azoospermia where sperm can be extracted from the testes and used for ICSI). Intra Cytoplasmic Sperm Insertion (ICSI) is a procedure by which a single sperm is inserted with the aid of a micro needle into the cytoplasm of a mature oocyte. This procedure is recommended for severe cases of male factor infertility, some cases of unexplained infertility and sperms obtained through TESE/PESA. The ICSI procedure is conducted as a part of a cycle in which the ovaries of the female partner or egg donor are stimulated with hormones to increase the production of oocytes. Mature oocytes are removed in our office using mild sedation and an ultrasound guided needle. The oocytes are separated and their maturity is assessed in the laboratory. The mature oocytes are injected one by one using a glass holding pipette to secure the egg and a very small micro needle through which the sperm is inserted. The egg is subsequently placed in culture medium and fertilization is determined 12-18 hours later. Technically, the ICSI technique is a precise and delicate procedure. It requires top quality equipment, well trained and skilled personnel, and attention to detail. In the hands of experienced personnel more than 70% of the oocytes are fertilized with ICSI. Ten percent or less of the injected oocytes are lost in the process of injection, and the pregnancy rates are as good as with standard IVF. As more research is conducted on this technique, it is projected that the results are going to improve the outcome of infertility therapy in the future especially in severe cases of oligospermia or azoospermia.

Who Needs ICSI

Severe male factor infertility may result from of one or more abnormalities of the several factors evaluated in semen specimens. Among these are: low seminal volume, low motility, low sperm counts or high percentage of abnormal spermatozoa. Other conditions such as failed attempts of fertilization in vitro and immunologic infertility, also warrant the utilization of ICSI. Lack of spermatozoa in the ejaculate due to congenital absence of the vas deferens or blocked vas deferens (vasectomies, infections of the reproductive tract) require PESA/TESA to obtain the sperm which are then used to fertilize the oocytes through ICSI.

The Safety of ICSI

It is reassuring to know that more than 50,000 babies have been born in Europe and the USA after ICSI procedures had been employed. These babies have been followed closely and up to now they have not shown a higher incidence of somatic abnormalities than invitro or naturally conceived babies. However, it has been long suspected that chromosomal abnormalities (Chromosomally Derived Sterility) are implicated in some forms of male infertility. Up to 20% of male infertility can be explained by abnormalities in chromosomes. A review of the literature of somatic chromosome investigations in infertile males has shown that 13.7% of azoospermic males (complete lack of sperm) and 4.6% of oligozoospermic (males with a few sperm) have abnormal chromosomes or karyotype. Therefore, a genetic factor may be affecting gamete formation or function. In normal fertile males the mean frequency of chromosomal abnormalities in spermatozoa is about 10%. Cytogenetic studies in spermatozoa (nonsomatic cell) indicates that advanced age (>40 years) has been associated with structural chromosome abnormalities also in fertile males. The first cytogenetic studies on spermatozoa of infertile males were first published about a decades ago. The results show a highly significant increase (10 fold) in the frequencies of chromosomal abnormalities compared with normal fertile patients. Infertile couples electing Advanced Reproductive Technologies should be counseled on the cause of their infertility and the “possible genetic” risks when ICSI is performed. If the male partner is a carrier of a constitutional chromosome aberration then the couple may be aware that: in cases of an autosomal structural aberrations the success rate of ICSI is lowered, an increased risk of miscarriage exists and, in ongoing pregnancies in the presence of a chromosome aberration, multiple congenital abnormalities and/or mental retardation are possible: in cases of a sex chromosome aneuploidy. e.g.: 47,XXY or 47,XYY) the success rate is variable, but if successful the risk of aneuploidy in the offspring is probably low or unknown. In cases of structural aberrations of a sex chromosome there is a greater risk of transmitting infertility, depending on the position of the breakpoint. In some cases of male infertility there may not be major reason for concern about medical conditions being passed on to your offspring. Such is the case of ICSI performed for vasectomy or Immunologic infertility. In other instances, such as in patients with congenital absence of the vas deferens (CAVD) or nonmotile spermatozoa the patient may require further testing and appropriate genetic counseling because those two different scenarios may be indicative of Cystic Fibrosis or Kartagener’s Syndrome respectively. Unilateral Absence of the vas deferens and Young’s Syndrome are conditions with features similar to CAVD. Whether these patients have an increased risk of having children with these syndromes is not known. Recent research indicates that some seminal traits such as low sperm counts are related to genes located in the Y chromosome. Therefore, chances are that this trait may be passed on to future generations in an unidentified proportion of male offspring.


It takes about 60-70 days for a sperm to mature. Sperm are produced in the testicle, stored and matured in the epididymis, transported to the ejaculatory ducts and after mixing with fluid from the seminal vesicles and the prostate, they are finally ejaculated. When this doesn’t occur naturally, PESA or TESA may be indicated to extract sperms directly from the testis. It takes about 60-70 days for a sperm to mature. Sperm are produced in the testicle, stored and matured in the epididymis, transported to the ejaculatory ducts and after mixing with fluid from the seminal vesicles and the prostate, they are finally ejaculated. When this doesn’t occur naturally, PESA or TESA may be indicated. Percutaneous Epidydimal Sperm Aspiration (PESA) or Testicular Sperm Aspiration (TESA) are simplified minimally invasive in-office procedures that allow the physician to recover sperm cells for fertilization in patients with azoospermia (lack of sperm). Prior to the development of in office sperm aspiration, men suffering from azoospermia had to undergo surgery to collect sperm from the epididymis or testis. The operation required hospitalization, and costs were high. PESA and TESA are rapid and performed as an outpatient procedure, virtually painless, conducted under mild sedation, with immediate recovery. The cost in our facility is approximately 10% of the cost of surgery, including the sperm processing and cryopreservation. It must be noted that for some patients a single procedure may produce enough sperm for several ICSI attempts. PESA and TESA are simpler and less expensive procedures than the older micro surgical approach. They are performed in the convenient environment of our office setting and takes between 20-40 minutes. Local anesthesia is infiltrated into the spermatic canal and around the scrotum. Once the analgesic has produced its effects, a PESA requires a needle to be introduced into the epidydimal area of a testicle and gentle aspiration is applied. The aspirate is observed under the microscope to determine if motile sperm cells are present. In some instances there is no need to aspirate the other side. In TESA, the needle is introduced into the testicle itself. The sperm may be frozen for future ICSI cycles or used fresh. Our protocol for PESA and TESA includes a diagnostic sperm aspiration that is done prior to starting ovarian stimulation to ensure sperm will be available. The sperm obtained from this procedure are frozen to be used as the primary source for fertilization. Sometimes, however, frozen-thawed sperm do not survive well and a second procedure may be done on the day of egg retrieval. But this need arise very rarely.

HOS test

Once the TESA is performed, the sperms have to be separated from the testicular tissue which is similar to looking for a need in a haystack. Usually testicular sperms are non-motile and immature. hence it is virtually impossible to separate between live and dead testicular sperms. Fortunately in our CAP certified lab a novel technique test called HOS test has been developed to identify live sperms in testicular tissue. Please click on the image to learn more:

At The Center for Reproductive Medicine and Robotic Surgery(CRMRS) we provide private, professional and compassionate fertility care. Dr. Jacob and our reproductive team provide a very personalized approach, from diagnostic assessment and early intervention through high-tech procedures like In Vitro Fertilization (IVF), and Intracytoplasmic Sperm Insertion (ICSI), intrauterine insemination (IUI) and Pre-Implantation Genetic Testing – Aneuploidy (PGT-A).

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