There are many different types of medications that can be used for ovarian stimulation including oral medications, oral medications with adjuvants, injectable medications and hybrid protocols consisting of both oral medications and injectable medications. The specific protocol will be tailored to the history of the patient, current diagnoses, previous cycles and side effects of previous medication use.
Clomiphene citrate (Clomid) and Letrozole (Femara) are oral medications used in fertility treatment cycles. In non -ovulating women, these oral medications stimulate egg growth. In ovulating women, they are used to enhance the quality of ovulation, super-ovulate eggs, correct luteal phase defects, and to ensure the proper timing of intrauterine inseminations. The medications are taken for 5 days at the beginning part of the cycle (days 3-7). The response to these medications are often monitored by a pelvic ultrasound, ovulation kits, or cycle day 21 progesterone levels. Your physician will discuss the side effects and risks of these medications with you. Overall the risk of twin pregnancy with oral medication treatment is less than 10%, and the risk of triplet pregnancy is less than 1%.
In certain circumstances adjuvant medications will be added to the oral medication protocol. Common adjuvants include metformin and dexamethasone. Adjuvant medication may improve the success rate of the oral medication protocol.
Protocols for ovarian stimulation may also use self-administered daily injectable medications. These medications stimulate the development of eggs. These medications contain follicle –stimulating hormone (FSH) and luteinizing hormone (LH). The development of eggs will be monitored by pelvic ultrasounds and blood tests. There are risks of over stimulation of egg growth (too many eggs) and under stimulation of egg growth (not enough eggs) which may cancel the cycle.
IUI (Insemination) Program
Intrauterine insemination (IUI) can be a treatment for couples with abnormalities on a semen analysis, unexplained infertility, endometriosis or for utilization of donor sperm (see donor sperm section). Intrauterine inseminations (IUI) can be coupled with medications (pills or injections) that increase the number of egg ovulated in the treatment cycle or can be used in a natural cycle. The medications are used to provide extra ovulation or “superovulation” and are thought to increase the pregnancy rate per cycle in certain circumstances.
Most studies show that, among untreated couples with infertility diagnoses, spontaneous pregnancy rates are about 1–5% per cycle. Intrauterine insemination results in pregnancy rate of 8%–20% per cycle, depending on the couples diagnoses.
IVF or In Vitro Fertilization is a method of assisted reproductive medicine used to increase the probability of pregnancy. There are many different reasons that reproductive medicine physicians recommend IVF. Some of the reasons IVF is preformed include:
- unsuccessful attempts of pregnancy after several cycles of intrauterine inseminations
- blocked or damaged fallopian tubes (tubal factor)
- abnormal sperm parameters (male factor)
- unexplained infertility and immunologic disorders.
IVF is a technique of stimulating the ovaries to produce multiple eggs. The eggs are then removed through a minor surgical procedure called an Egg Retrieval. The eggs are combined with sperm and the resulting embryos are grown in a culture system for a few days. The embryos are then transferred back into the uterus one or two at a time.
An IVF consult is the first step to starting an IVF cycle. An IVF consult is designed to accomplish two goals; 1) to educate you about the details of IVF and 2) to begin planning the details of your IVF cycle. The IVF consult is performed by your Physician and the IVF nursing team. The IVF Consult covers the following:
- Review of the IVF Process
- Review the Risks of IVF
- A physical exam, baseline ultrasound and pap smear if needed for the female patient
- Infectious Disease Testing on both partners (If needed)
- Beginning Birth Control
- Review IVF Checklist and Calendar with the IVF Nursing Team
- Discuss financial responsibility and insurance coverage with our Financial Counselor.
An IVF Consult Should Be performed as soon as you have as you have decided to pursue IVF.
There are 9 Steps to IVF at Billings Clinic Reproductive Medicine Center
- IVF Consult
- IVF Preparation for the Male Partner. The male partner must have infectious disease laboratory testing and a semen analysis in accordance with our centers and FDA’s guidelines. The male partner must also sign and have witnessed consent forms prior to the female patient beginning injections.
- IVF Preparation for the Female Partner. The female partner must have infectious disease laboratory testing, a physical exam, a pap smear and an evaluation of the uterine cavity in accordance with our centers and FDA’s guidelines. The female partner must also sign and have witnessed consent forms prior to beginning injections.
- Injection Teaching/ Calendar Review . The next step is to learn about the medications and how to perform the injections. A session with the IVF nurses is scheduled and a demonstration about injection techniques is performed along, with a review of your IVF calendar.
- Baseline Ultrasound, Medication Start and Monitoring. Before starting medications to stimulate egg growth, we will check your ovaries and uterus with a baseline ultrasound. Once medications have started it typically takes 10-12 days to grow up eggs. Egg growing is monitored by ultrasounds and laboratory tests.
- Egg Retrieval and Sperm Collection. The egg retrieval is a minor surgical procedure done under IV sedation. The male partners sperm is collected on the day of the egg retrieval for fertilization of the eggs.
- Fertilization and Development of the Embryos. Once the eggs are retrieved, they are combined with the partners sperm. The embryos that result from the eggs and sperm being combined then grow in a laboratory culture setting for a few days before the best one or two are transferred back.
- Embryo Transfer. The best one to two embryos are transferred back into the uterus using ultrasound guidance.
- Pregnancy Test. The pregnancy test is typically performed 12 days after the embryo transfer.
An egg donor provides eggs for the IVF fertilization process to create embryos for a recipient couple. The eggs are combined with the male recipient sperm to create embryos. Those embryos are then transferred back to the recipient’s uterus. The Billings Clinic follows the protocols and requirements of the FDA and the American Society of Reproductive Medicine (ASRM) for utilization of donor egg.
Before everything else can happen, a recipient must be matched with an egg donor. There are three ways to find egg donors: 1) Fresh Donor Egg Agencies, 2) Frozen Egg Banks and 3) finding your own donor. Please refer to the recommended list of Fresh Donor Egg Agencies and Frozen Donor Banks from our facility.
If you are using a known donor, the please discuss the following parameters/recommendations with your physician.
Known Egg Donor Prerequisites
- No Tobacco Use
- Between the ages of 21-35
- No fertility problems
- No major medical problems
- No contraindications for birth control pills
- BMI less than 30
- Pass Medical Screening Clearance with Reproductive Medicine Physician
- Legal Counseling Visit/Contract Agreement with a letter from Lawyer stating an agreement has been reached
- Psychosocial Counseling – with a letter from the counselor
Donor sperm may be utilized for Inseminations or In Vitro Fertilization treatments. Donor sperm can be utilized in treatment plans for single women, same sex couples and couples with male infertility.
Billings Clinic works with FDA accredited sperm banks across the country. The Billings Clinic follows FDA and American Society of Reproductive Medicine screening recommendations for utilization of donor sperm. Please consult with your physician and nursing coordinator to discuss the Donor Sperm Protocol and for recommendations for FDA accredited sperm banks.
A gestational carrier cycle is where a woman (carrier) agrees to carry a baby through the pregnancy for another person (recipient). This involves in vitro fertilization to create embryos from the recipient couple’s sperm and eggs and these embryo (s) are then placed into the carrier. Rarely sperm donors and egg donors are involved.
The indications for use of a gestational carrier include the absence of a uterus (congenital or surgical), significant uterine anomaly, absolute medical contraindication to pregnancy, a serious medical condition that can be exacerbated by pregnancy, recurrent pregnancy loss or for third party reproduction. The physical and emotional health of a potential surrogate need to be evaluated before an agreement can be reached.
There are FDA and ASRM (American Society of Reproductive Medicine) guidelines and standards that are followed during a gestational carrier cycle along with legal and psychosocial contracts that have to be adhered to. Gestational carrier cycles account for less than 1-2% of all IVF cycles around the United States.
Preimplantation Genetic Diagnosis (PGD)
Preimplantation Genetic Diagnosis (PGD) is a form of genetic testing of the cells from an embryo before transfer of that embryo to a uterus. The cells are obtained during an embryo biopsy during the in vitro fertilization cycle and sent to a genetics lab for a specific analysis.
PGD is performed primarily to test for a single gene disorders. Single gene disorders involve mutations in the DNA sequence of one particular gene. As a result of these mutations, the protein that the gene encodes is either altered or missing. PGD tests embryos for their carrier status of the single gene disorder. Then only non-affected embryos are placed back inside the uterus reducing the risk of conceiving a child affected by the single gene mutation. PGD can be done for many different single gene disorders.
PGD can also be used to test for translocations. A translocation is a change in a chromosome structure where part of one chromosome is attached to another. PGD for translocation testing reduces the chance of miscarriage and having a child with an unbalanced translocation.
Preimplantation Genetic Screening (PGS)
Preimplantation Genetic Screening (PGS) is a form of genetic testing of the cells from an embryo before transfer of that embryo to a uterus. The cells are obtained during an embryo biopsy during the in vitro fertilization cycle and sent to a genetics lab for a specific analysis.
PGS is performed to increase the chances of transferring embryos that do not have recognizable chromosome abnormalities. PGS is done to test primarily for aneuploidy which is a condition where an embryo has an extra or missing chromosome. Aneuploidy increases with maternal age and it is estimated that 50% or more of human embryos may contain chromosomal abnormalities. PGS can also test for translocations (incorrect chromosome positions) or other structural alterations that may be clinically significant. To perform PGS, embryos are made by in-vitro fertilization, and each embryo is biopsied on day 5 of embryo growth. The cells from the embryo biopsy are then analyzed for chromosome content.
Egg freezing can provide a means of fertility preservation for women undergoing cancer treatment or for women who wish to delay childbearing.
Egg Freezing can be a part of a fertility preservation plan in patients facing chemotherapy or pelvic radiation (see fertility preservation section).
Many women who delay childbearing may face infertility by the time they are ready to become pregnant. These women have an option of banking eggs or embryos at an earlier age. Embryo freezing is an established technique; however, it requires use of sperm, making it applicable only for women who have a participating male partner or are interested in using donor sperm. For women who do not have a participating male partner and are not interested in using donor sperm, Egg Freezing is generally the preferred option.
Success of Egg Freezing has improved dramatically over the past decade, and it is no longer considered experimental by the American Society for Reproductive Medicine (ASRM) or American College of Obstetricians and Gynecologists (ACOG).
Billings Clinic Reproductive Medicine offers advanced reproductive surgery, including microsurgical tubal reanastomosis (tubal reversal), robotic assisted myomectomy (removal of fibroid tumor), diagnostic and operative laparoscopic surgery, and diagnostic and operative hysteroscopic surgery.
Our well trained and experienced surgeons can also provide reconstructive surgery for certain congenital anomalies of genital organ such as uterine septum.
Our fertility preservation program at Billings Clinic is designed to help cancer patients retain their fertility and their ability to build a family in the future. As survival rates of cancer patients increase, a shift towards improving post-cancer quality of life has blossomed, and patients identify that a major component of their quality of life is parenthood. Billings Clinic has partnered with several national organizations to bring fertility preservation options to our patients.
Although each patient and treatment protocol is unique, chemotherapy regimens, radiation treatments and other serious illnesses can impact the reproductive lifespan of men and women. These treatment protocols may directly impact the development and quality of sperm and eggs. Certain radiation treatments may also affect a woman’s uterus. Meeting with a reproductive medicine specialist soon after diagnosis is an important part of developing a fertility preservation plan.
Fertility preservation treatment options for men include sperm banking, gonadal shielding, third party reproduction and testicular sperm extraction. Treatment options for women include embryo banking, egg banking, ovarian tissue freezing and third party reproduction.