In Vitro Fertilization

In vitro fertilization (IVF) is a method of infertility treatment in which an egg and sperm are joined in a laboratory container ("in vitro" means "in glass"). This is in contrast to normal "in vivo" conception, in which fertilization occurs in the fallopian tube of a woman's reproductive tract. Scientist S. L. Schenk began animal IVF research in 1880, but it was not until 1959 that the first animal IVF was clearly documented by another scientist, Michael Chang. In 1978 Patrick Steptoe and Robert Edwards in England produced the first human IVF baby, Louise Brown, who became known as the world's first test-tube baby. The first IVF baby in the United States was born in 1981, largely due to the research work of Howard and Georgeanna Jones. The Joneses varied their technique from that of Steptoe and Edwards, and these newer techniques grew into contemporary IVF. In the United States alone, over thirty-five thousand babies were born through assisted reproductive technologies (ART) techniques in 1999. ART use has increased 54 percent between 1996 and 2000, the only years for which data is available. It is unclear if increase in use is due to actual increases in infertility over this time period, increases in knowledge and availability of services, or due to the aging of the large baby-boom cohort, many of whom delayed childbearing and reached their later and less fertile reproductive years during this time. Even so, ART is used by only 1 percent of all reproductive aged women, and by only 7 percent of all women who seek services for infertility.

Typically a woman's ovary produces one egg per month. Physicians who specialize in IVF use fertility drugs to stimulate a woman's ovaries to produce multiple eggs. Eggs are then retrieved during an office procedure in which a needle is inserted into the ovary through the vagina. The eggs are then mixed with sperm in order to allow fertilization. After a period of growth and observation in the laboratory, a number of fertilized eggs, now known as embryos, are returned to the uterus of the woman who will carry the pregnancy. The embryo transfer is another brief office procedure in which embryos are deposited into a woman's uterus through a small plastic tube that is inserted in the cervix.

IVF was originally developed to treat infertility due to blocked or absent fallopian tubes in women under thirty-five years of age. The use of IVF has expanded considerably over the years, and it is now considered to be a treatment for ovulation dysfunction in women, male infertility, and infertility of unknown etiology. Some IVF facilities offer egg donation programs so women without ovaries or women whose advanced age or menopausal status makes successful conception impossible can achieve pregnancy. Embryos can be frozen and stored indefinitely for later use, for donation to other couples, or for transfer to the uterus of a surrogate mother. Embryos can also be screened for genetic disorders prior to transferring them to a woman's uterus.

The American Society for Reproductive Medicine publishes an annual report detailing success rates for IVF clinics in the United States. Success rates vary depending upon patient age, fresh or frozen embryo use and a variety of other factors. Data from 2002 shows that on average for every egg retrieval procedure a woman undergoes she has a 29.1 percent chance of delivering a live infant. There is currently no evidence of increased rates of birth defects in IVF babies, although recently, investigators have raised the possibility that placenta formation in these pregnancies is abnormal, which can lead to fetal growth problems.

IVF raises a host of medical, ethical, legal, sociological and religious questions and controversies. Medically, the techniques pose some risks to women. Fertility drugs can produce ovarian hyperstimulation syndrome (OHSS), which in rare instances can be life threatening. In addition, most IVF practitioners transfer several embryos into a woman's uterus in order to maximize the chance of successful pregnancy. This in turn carries a risk of twin (approximately 25 percent), triplet, and higher order pregnancies (approximately 5 percent). Multiple pregnancies carry increased risks to pregnant women compared to singleton pregnancies, and carry increased risk of premature delivery and associated newborn problems like cerebral palsy, blindness, and death. All of these consequences of IVF place enormous stress on families and on health care systems.

IVF is sociologically interesting because an IVF baby can have up to five "parents"–a genetic mother, a genetic father, a gestating mother, a rearing mother, and a rearing father. The separation of genetic, gestational, and rearing contributions to childhood raises questions about the meaning of parenthood and the family. Legal battles have arisen over "custody" of frozen embryos and of children born to surrogate mothers. Some religious groups prohibit IVF on the grounds that it separates sex and procreation. The issue of what to do with "leftover" embryos is also a source of intense controversy. When embryos are discarded or used for research purposes, as in the case of stem cell research, IVF becomes entangled in the intractable abortion debate in the United States.

IVF also raises questions related to issues of gender, race, and class. While some feminist scholars argue that IVF provides women with additional choices in life because it permits biological motherhood in otherwise impossible circumstances; others argue that it enforces women's conventional roles as reproducers and creates traffic in women's bodies. Some feminist critics argue that the medicalized discourse of "disease" that surrounds infertility prevents clear perception of the ways in which infertility is a socially constructed diagnosis. The racial dimensions of IVF are not well understood, and may relate, among other things, to the stereotype that excess fertility, not infertility, is the most salient black reproductive issue. Although black women in the United States have infertility rates one and one-half times higher than white women, white women use ART techniques at rates twice as high as those of blacks. IVF is inextricably linked to class, as the costs of IVF are exceedingly high–typically $10,000 per month–and not always covered by insurance, and even more rarely covered by public medical insurance.

See also: Conception and Birth; Multiple Births; Surrogacy.

bibliography

Brinsden, Peter, ed. 1999. A Textbook of In Vitro Fertilization and Assisted Reproduction, 2nd ed. New York: Parthenon Publishing.

Chandra, Anjani, and Elizabeth Stephen. 1998. "Impaired Fecundity in the United States: 1982–1995." Family Planning Perspectives 30, no. 1: 34–42.

Jones, Howard. 1991. "In the Beginning There Was Bob." Human Reproduction 6: 5–7.

Raymond, Janice. 1994. Women as Wombs–Reproductive Technologies and the Battle Over Women's Freedom. New York: Harper Collins.

Roberts, Dorothy. 1997. Killing the Black Body–Race, Reproduction, and the Meaning of Liberty. New York: Vintage Press.

Seoud, M., and H. Jones. 1992. "Indications for In Vitro Fertilization: Changing Trends: The Norfolk Experience." Annals of the Academy of Medicine 21: 459–70.

Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine. 2002. "Assisted Reproductive Technology in the United States: 1998 Results Generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry." Fertility and Sterility 77: 18–31.

Speroff, Leon, Robert Glass, and Nathan Kase, eds. 1999. Clinical Gynecologic Endocrinology and Infertility, 6th ed. Baltimore: Lippincott Williams and Wilkins.

internet resources

American Society for Reproductive Medicine. Available from <www.asrm.org>.

CDC Reproductive Health. 2002. "2000 Assisted Reproductive Technology Success Rates–National Summary and Fertility Clinic Reports." Available from <www.cdc.gov>.

National Center for Health Statistics. "National Survey of Family Growth." Available from <www.cdc.gov/nchs/nsfg.htm>.

Lisa H. Harris

In Vitro Fertilization

Definition

In vitro fertilization (IVF) is a procedure in which eggs (ova) from a woman's ovary are removed. They are fertilized with sperm in a laboratory procedure, and then the fertilized egg (embryo) is returned to the woman's uterus.

Purpose

IVF is one of several assisted reproductive techniques (ART) used to help infertile couples to conceive a child. If after one year of having sexual intercourse without the use of birth control a woman is unable to get pregnant, infertility is suspected. Some of the reasons for infertility are damaged or blocked fallopian tubes, hormonal imbalance, or endometriosis in the woman. In the man, low sperm count or poor quality sperm can cause infertility.

IVF is one of several possible methods to increase the chance for an infertile couple to become pregnant. Its use depends on the reason for infertility. IVF may be an option if there is a blockage in the fallopian tube or endometriosis in the woman or low sperm count or poor quality sperm in the man. There are other possible treatments for these conditions, such as surgery for blocked tubes or endometriosis, which may be tried before IVF.

IVF will not work for a woman who is not capable of ovulating or a man who is not able to produce at least a few healthy sperm.

Precautions

The screening procedures and treatments for infertility can become a long, expensive, and sometimes, disappointing process. Each IVF attempt takes at least an entire menstrual cycle and can cost $5,000-$10,000, which may or may not be covered by health insurance. The anxiety of dealing with infertility can challenge both individuals and their relationship. The added stress and expense of multiple clinic visits, testing, treatments, and surgical procedures can become overwhelming. Couples may want to receive counseling and support throughout the process.

Description

In vitro fertilization is a procedure where the joining of egg and sperm takes place outside of the woman's body. A woman may be given fertility drugs before this procedure so that several eggs mature in the ovaries at the same time. Eggs (ova) are removed from a woman's ovaries using a long, thin needle. The physician gains access to the ovaries using one of two possible procedures. One procedure involves inserting the needle through the vagina (transvaginally). The physician guides the needle to the location of the ovaries with the help of an ultrasound machine. In the other procedure, called laparoscopy, a small thin tube with a viewing lens is inserted through an incision in the navel. This allows the physician to see inside the patient, and locate the ovaries, on a video monitor.

Once the eggs are removed, they are mixed with sperm in a laboratory dish or test tube. (This is where the term test tube baby comes from.) The eggs are monitored for several days. Once there is evidence that fertilization has occurred and the cells begin to divide, they are then returned to the woman's uterus.

In the procedure to remove eggs, enough may be gathered to be frozen and saved (either fertilized or unfertilized) for additional IVF attempts. A 2004 study from the Mayo Clinic found that frozen sperm was as effective as fresh sperm for IVF.

IVF has been used successfully since 1978, when the first child to be conceived by this method was born in England. Over the past 20 years, thousands of couples have used this method of ART or similar procedures to conceive.

Other types of assisted reproductive technologies might be used to achieve pregnancy. A procedure called intracytoplasmic sperm injection (ICSI) uses a manipulation technique that must be performed using a microscope to inject a single sperm into each egg. The fertilized eggs can then be returned to the uterus, as in IVF. In gamete intrafallopian tube transfer (GIFT) the eggs and sperm are mixed in a narrow tube and then deposited in the fallopian tube, where fertilization normally takes place. Another variation on IVF is zygote intrafallopian tube transfer (ZIFT). As in IVF, the fertilization of the eggs occurs in a laboratory dish. And, similar to GIFT, the embryos are placed in the fallopian tube (rather than the uterus as with IVF).

Preparation

Once a woman is determined to be a good candidate for in vitro fertilization, she will generally be given "fertility drugs" to stimulate ovulation and the development of multiple eggs. These drugs may include gonadotropin releasing hormone agonists (GnRHa), Pergonal, Clomid, or human chorionic gonadotropin (hcg). The maturation of the eggs is then monitored with ultrasound tests and frequent blood tests. If enough eggs mature, the physician will perform the procedure to remove them. The woman may be given a sedative prior to the procedure. A local anesthetic agent may also be used to reduce discomfort during the procedure.

Aftercare

After the IVF procedure is performed the woman can resume normal activities. A pregnancy test can be done approximately 12-14 days later to determine if the procedure was successful.

PATRICK CHRISTOPHER STEPTOE (1913–1988)

Patrick Christopher Steptoe was born in Oxfordshire, England, on June 9, 1913. His mother was a social worker and his father was a church organist. Steptoe entered the University of London's St. George Hospital Medical School, earning his physician's license in 1939 and becoming a member of the Royal College of Surgeons. When Steptoe volunteered as a naval surgeon during World War II, he was captured and held as a prisoner until his release in 1943. Following his release, Steptoe studied obstetrics and gynecology and moved to Manchester to start a private practice in 1948. In 1951, Steptoe accepted a position at Oldham General and District Hospital in England.

During his time at Oldham, Steoptoe continued his study of fertility problems. Using a laparoscope, he developed a method to remove eggs from a woman's ovaries. In 1966, Steptoe teamed with physiologist Robert G. Edwards who had successfully fertilized eggs outside of the body. In 1968, the pair had a breakthrough when Edwards successfully fertilized an egg that Steptoe had removed, but their attempts to implant the embryo failed repeatedly. However, Steptoe and Edwards experienced success when a fertilized egg was implanted into the uterus of Leslie Brown. Brown gave birth to a healthy baby girl on July 25, 1978.

Steptoe retired and built a clinic in Cambridge. He and Edwards were named Commanders of the British Empire, and Steptoe was honored with fellowship in the Royal Society. He and his wife had two children. Steptoe died on March 21, 1988.

Risks

The risks associated with in vitro fertilization include the possibility of multiple pregnancy (since several embryos may be implanted) and ectopic pregnancy (an embryo that implants in the fallopian tube or in the abdominal cavity outside the uterus). There is a slight risk of ovarian rupture, bleeding, infections, and complications of anesthesia. If the procedure is successful and pregnancy is achieved, the pregnancy would carry the same risks as any pregnancy achieved without assisted technology.

Normal results

Success rates vary widely between clinics and between physicians performing the procedure and implantation does not guarantee pregnancy. Therefore, the procedure may have to be repeated more than once to achieve pregnancy. However, success rates have improved in recent years, up from 20% in 1995 to 27% in 2001.

Abnormal results

An ectopic or multiple pregnancy may abort spontaneously or may require termination if the health of the mother is at risk. The number of multiple pregnancies has decreased in recent years as technical advances and professional guidelines have led to implanting of fewer embryos per attempt.

Resources

PERIODICALS

"Frozen, Fresh Sperm Both Effective for In Vitro Fertilization." Obesity, Fitness & Wellness Week June 5, 2004: 1059.

"Multiple Births Via In Vitro Fertilization Are Declining." Women's Health Weekly May 6, 2004: 16.

ORGANIZATIONS

American Society for Reproductive Medicine. 1209 Montgomery Highway, Birmingham, AL 35216-2809. (205) 978-5000. 〈[email protected]〉 〈http://www.asrm.com〉.

Center for Fertility and In Vitro Fertilization Loma Linda University. 11370 Anderson St., Loma Linda, CA 92354. (909) 796-4851. 〈http://www.llu.edu/llumc/fertility〉.

Resolve. 1310 Broadway, Somerville, MA 02144-1731. (617) 623-0744. 〈http://www.resolve.org〉.

OTHER

"Infertility." HealthWorld Online Page. 〈http://www.healthy.net〉.

"In vitro Fertilization: A Teacher's Guide from Newton's Apple." PBS Page. 〈http://www.pbs.org/ktca/newtons/11/invitro.html〉.

KEY TERMS

Fallopian tubes— In a woman's reproductive system, a pair of narrow tubes that carry the egg from the ovary to the uterus.

GIFT— Stands for gamete intrafallopian tube transfer. This is a process where eggs are taken from a woman's ovaries, mixed with sperm, and then deposited into the woman's fallopian tube.

ICSI— Stands for intracytoplasmic sperm injection. This process is used to inject a single sperm into each egg before the fertilized eggs are put back into the woman's body. The procedure may be used if the male has a low sperm count.

ZIFT— Stands for zygote intrafallopian tube transfer. In this process of in vitro fertilization, the eggs are fertilized in a laboratory dish and then placed in the woman's fallopian tube.

In Vitro Fertilization

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

In vitro fertilization (IVF) is a procedure in which eggs (ova) from a woman’s ovary are removed, they are fertilized with sperm in a laboratory procedure, and then the fertilized egg (embryo) is returned to the woman’s uterus.

Purpose

IVF is one of several assisted reproductive techniques (ART) used to help infertile couples to conceive a child. If after one year of having sexual intercourse without the use of birth control a woman is unable to get pregnant, infertility is suspected. Some of the reasons for infertility are damaged or blocked fallopian tubes, hormonal imbalance, or endometriosis in the woman. In the man, low sperm count or poor quality sperm can cause infertility.

KEY TERMS

Endometriosis— An inflammation of the endometrium, the mucous lining of the uterus.

Fallopian tubes— In a woman’s reproductive system, a pair of narrow tubes (one for each ovary) that carries eggs from the ovary to the uterus.

Gamete intrafallopian tube transfer (GIFT)— A process where eggs are taken from a woman’s ovaries, mixed with sperm, and then deposited into the woman’s fallopian tube.

Intracytoplasmic sperm injection (ICSI)— A process used to inject a single sperm into each egg before fertilized eggs are put back into a woman’s body; the procedure may be used if the male has a low sperm count.

Zygote intrafallopian tube transfer (ZIFT)— The woman’s eggs are fertilized in a laboratory dish and then placed in her fallopian tube.

IVF is one of several possible methods to increase the chances for an infertile couple to become pregnant. Its use depends on the reason for infertility. IVF may be an option if there is a blockage in the fallopian tube or endometriosis in the woman, or low sperm count or poor quality sperm in the man. There are other possible treatments for these conditions, such as surgery for blocked tubes or endometriosis, which may be attempted before IVF.

IVF will not work for a woman who is incapable of ovulating or with a man who is not able to produce at least a few healthy sperm.

Demographics

IVF has been used successfully since 1978, when the first child to be conceived by this method was born in England. Over the past 30 years, thousands of couples have used this method of ART or similar procedures to conceive.

Description

In vitro fertilization is a procedure in which the joining of egg and sperm takes place outside of a woman’s body. A woman may be given fertility drugs before this procedure so that several eggs mature in the ovaries at the same time. The mature eggs (ova) are removed from the woman’s ovaries using a long, thin needle. The physician has access to the ovaries using one of two possible procedures. One involves inserting the needle

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An obstetrician-gynecologist (OB-GYN) with specialized training in IVF supervises the activities of IVF. This specialist performs most of the procedures involving the woman. Most IVF activities are performed in a professional medical office.

through the vagina (transvaginally); the physician guides the needle to the location in the ovaries with the help of an ultrasound machine. In the other procedure, called laparoscopy , a small thin tube with a viewing lens is inserted through an incision in the navel. This allows the physician to see on a video monitor inside the uterus to locate the ovaries.

Once the eggs are removed, they are mixed with sperm in a laboratory dish or test tube. (This is the origin of the term “test tube baby.”) The eggs are monitored for several days. Once there is evidence that fertilization has occurred and the cells have begun to divide, they are then returned to the woman’s uterus.

In the procedure to remove eggs, a sufficient number may be gathered to be frozen and saved (either fertilized or unfertilized) for additional IVF attempts.

Diagnosis/Preparation

Once a woman is determined to be a good candidate for in vitro fertilization, she will generally be given fertility drugs to stimulate ovulation and the development of multiple eggs. These drugs may include gonadotropin-releasing hormone agonists (GnRHa), Pergonal, Clomid, or human chorionic gonadotropin (hcg). The maturation of the eggs is then monitored with ultrasound tests and frequent blood tests. If enough eggs mature, a physician will perform the procedure to remove them. The woman may be given a sedative prior to the procedure. A local anesthetic agent may also be used to reduce discomfort during the procedure.

The screening procedures and treatments for infertility can become a long, expensive, and, sometimes, disappointing process. Each IVF attempt takes at least an entire menstrual cycle and can cost $5,000–10,000, which may or may not be covered by health insurance. The anxiety of dealing with infertility can challenge both individuals and their relationship. The added stress and expense of multiple clinic visits, testing, treatments, and surgical procedures can become

QUESTIONS TO ASK THE DOCTOR

Candidates for in-vitro fertilization should consider asking the following questions, including:

• What is the physician’s evaluation of IVF and its alternatives for the woman seeking assistance?
• Is the surgeon certified to treat infertility?
• How many procedures has the physician performed?
• What is the physician’s overall success rate?
• What is the success rate for women of the same age as the person seeking assistance?

overwhelming. Couples may want to receive counseling and support through the process.

Aftercare

After the IVF procedure is performed, the woman can resume normal activities. A pregnancy test can be done approximately 12-14 days after the procedure to determine if it was successful.

Risks

The risks associated with in vitro fertilization include the possibility of multiple pregnancy (since several embryos may be implanted) and ectopic pregnancy (an embryo that implants in the fallopian tube or in the abdominal cavity outside the uterus). There is a slight risk of ovarian rupture, bleeding, infections, and complications of anesthesia. If the procedure is successful and pregnancy is achieved, the pregnancy carries the same risks as any pregnancy achieved without assisted technology.

Normal results

Success rates vary widely among clinics and among physicians performing the procedure. A couple has about a 10% chance of becoming pregnant each time the procedure is performed. Therefore, the procedure may have to be repeated more than once to achieve pregnancy.

Abnormal results include ectopic or multiple pregnancy that may abort spontaneously or that may require termination if the health of the mother is at risk.

Morbidity and mortality rates

The most common cause of morbidity is ectopic pregnancy. Pain is associated with most components of the procedure. Mortality as a result of IVF is extremely rare.

Alternatives

Other types of assisted reproductive technologies might be used to achieve pregnancy. A procedure called intracytoplasmic sperm injection (ICSI) utilizes a manipulation technique that must be performed using a microscope to inject a single sperm into each egg. The fertilized eggs can then be returned to the uterus, as in IVF. In gamete intrafallopian tube transfer (GIFT), the eggs and sperm are mixed in a narrow tube, and then deposited in the fallopian tube, where fertilization normally takes place. Another variation on IVF is zygote intrafallopian tube transfer (ZIFT). As in IVF, the fertilization of the eggs occurs in a laboratory dish. And, similar to GIFT, the embryos are placed in the fallopian tube, rather than in the uterus as with IVF.

Resources

BOOKS

Charlesworth, L. The Couple’s Guide to In Vitro Fertilization: Everything You Need to Know to Maximize Your Chances of Success. New York: Da Capo Press, 2004.

Olick, D. M. When Nature’s Not Enough: Personal Journeys through In Vitro Fertilization. Guilford, CT: Lyons Press, 2005.

Sher, G., Davis, V. M., and Stoess, J. In Vitro Fertilization: The A.R.T. of Making Babies. 3rd ed. New York: Facts on File, 1999.

Wisot, A. L., and D. R. Meldrum. Conceptions & Misconceptions: The Informed Consumer’s Guide Through the Maze of In Vitro Fertilization & Assisted Reproduction Techniques. 2nd ed. Vancouver, BC: Hartley and Marks Publishers, 1999.

PERIODICALS

Bourg, C. “Ethical dilemmas in medically assisted procreation: a psychological perspective.” Human Reproduction and Genetic Ethics 13, no. 2 (2007): 22–31.

Burns, L. H. “Psychiatric aspects of infertility and infertility treatments.” Psychiatric Clinics of North America 30, no. 4 (2007): 689–716.

Gleicher, N., A. Weghofer, and D. Barad. “Too old for IVF: are we discriminating against older women?” Journal of Assisted Reproductive Genetics 24, no. 12 (2007): 639–644.

Munne, S., J. Cohen, and J. L. Simpson. “In vitrofertilization with preimplantation genetic screening.” New England Journal of Medicine 357, no. 17 (2007):1769–1770.

Soullier, N., J. Bouver, J. L. Pouly, J. Guilbert, and E. de La Rochebrochard. “Estimating the success of an in vitro fertilization programme using multiple imputation.” Human Reproduction 23, no. 1 (2008): 187–192.

ORGANIZATIONS

American Board of Obstetrics and Gynecology. 2915 Vine Street, Suite 300, Dallas, TX 75204. (214) 871-1619; Fax: (214) 871-1943. E-mail: [email protected]. http://www.abog.org.

American College of Obstetricians and Gynecologists. 409 12th St., SW, P.O. Box 96920, Washington, DC 20090-6920. http://www.acog.org.

American Fertility Association. 305 Madison Avenue Suite 449, New York, NY 10165. (888) 917-3777. http://www.afafamilymatters.com/.

American Society for Reproductive Medicine. 1209 Montgomery Highway, Birmingham, AL 35216-2809. (205) 978-5000. http://www.asrm.com.

International Council on Infertility Information Dissemination, Inc. P.O. Box 6836, Arlington, VA 22206. (703) 379-9178. http://www.inciid.org.

OTHER

American Pregnancy Association. Information about In-vitro Fertilization. 2008 [cited January 3, 2008]. http://www.americanpregnancy.org/infertility/ivf.html.

American Society for Reproductive Medicine. Information about In-vitro Fertilization. 2008 [cited January 3, 2008]. http://www.asrm.org/Patients/topics/ivf.html.

American Society for Reproductive Medicine. Information about In-vitro Fertilization. 2008 [cited January 3, 2008]. http://www.asrm.org/Patients/select.html.

National Library of Medicine. Information about In-vitro Fertilization. 2008 [cited January 3, 2008]. http://www.nlm.nih.gov/medlineplus/ency/article/007279.htm.

L. Fleming Fallon, Jr, MD, DrPH

In vitro fertilization

Definition

In vitro fertilization (IVF) is a procedure in which eggs (ova) from a woman's ovary are removed, they are fertilized with sperm in a laboratory procedure, and then the fertilized egg (embryo) is returned to the woman's uterus.

Purpose

IVF is one of several assisted reproductive techniques (ART) used to help infertile couples to conceive a child. If after one year of having sexual intercourse without the use of birth control a woman is unable to get pregnant, infertility is suspected. Some of the reasons for infertility are damaged or blocked fallopian tubes, hormonal imbalance, or endometriosis in the woman. In the man, low sperm count or poor quality sperm can cause infertility.

IVF is one of several possible methods to increase the chances for an infertile couple to become pregnant. Its use depends on the reason for infertility. IVF may be an option if there is a blockage in the fallopian tube or endometriosis in the woman, or low sperm count or poor quality sperm in the man. There are other possible treatments for these conditions, such as surgery for blocked tubes or endometriosis, which may be attempted before IVF.

IVF will not work for a woman who is incapable of ovulating or with a man who is not able to produce at least a few healthy sperm.

Demographics

IVF has been used successfully since 1978, when the first child to be conceived by this method was born in England. Over the past 20 years, thousands of couples have used this method of ART or similar procedures to conceive.

Description

In vitro fertilization is a procedure in which the joining of egg and sperm takes place outside of a woman's body. A woman may be given fertility drugs before this procedure so that several eggs mature in the ovaries at the same time. The mature eggs (ova) are removed from the woman's ovaries using a long, thin needle. The physician has access to the ovaries using one of two possible procedures. One involves inserting the needle through the vagina (transvaginally); the physician guides the needle to the location in the ovaries with the help of an ultrasound machine. In the other procedure, called laparoscopy , a small thin tube with a viewing lens is inserted through an incision in the navel. This allows the physician to see on a video monitor inside the uterus to locate the ovaries.

Once the eggs are removed, they are mixed with sperm in a laboratory dish or test tube. (This is the origin of the term "test tube baby.") The eggs are monitored for several days. Once there is evidence that fertilization has occurred and the cells have begun to divide, they are then returned to the woman's uterus.

In the procedure to remove eggs, a sufficient number may be gathered to be frozen and saved (either fertilized or unfertilized) for additional IVF attempts.

Diagnosis/Preparation

Once a woman is determined to be a good candidate for in vitro fertilization, she will generally be given fertility drugs to stimulate ovulation and the development of multiple eggs. These drugs may include gonadotropin-releasing hormone agonists (GnRHa), Pergonal, Clomid, or human chorionic gonadotropin (hcg). The maturation of the eggs is then monitored with ultrasound tests and frequent blood tests. If enough eggs mature, a physician will perform the procedure to remove them. The woman may be given a sedative prior to the procedure. A local anesthetic agent may also be used to reduce discomfort during the procedure.

The screening procedures and treatments for infertility can become a long, expensive, and, sometimes, disappointing process. Each IVF attempt takes at least an entire menstrual cycle and can cost $5,000–10,000, which may or may not be covered by health insurance. The anxiety of dealing with infertility can challenge both individuals and their relationship. The added stress and expense of multiple clinic visits, testing, treatments, and surgical procedures can become overwhelming. Couples may want to receive counseling and support through the process.

Aftercare

After the IVF procedure is performed, the woman can resume normal activities. A pregnancy test can be done approximately 12–14 days after the procedure to determine if it was successful.

Risks

The risks associated with in vitro fertilization include the possibility of multiple pregnancy (since several embryos may be implanted) and ectopic pregnancy (an embryo that implants in the fallopian tube or in the abdominal cavity outside the uterus). There is a slight risk of ovarian rupture, bleeding, infections, and complications of anesthesia. If the procedure is successful and pregnancy is achieved, the pregnancy carries the same risks as any pregnancy achieved without assisted technology.

Normal results

Success rates vary widely among clinics and among physicians performing the procedure. A couple has about a 10% chance of becoming pregnant each time the procedure is performed. Therefore, the procedure may have to be repeated more than once to achieve pregnancy.

Abnormal results include ectopic or multiple pregnancy that may abort spontaneously or that may require termination if the health of the mother is at risk.

Morbidity and mortality rates

The most common cause of morbidity is ecotopic pregnancy. Pain is associated with most components of the procedure. Mortality as a result of IVF is extremely rare.

Alternatives

Other types of assisted reproductive technologies might be used to achieve pregnancy. A procedure called intracytoplasmic sperm injection (ICSI) utilizes a manipulation technique that must be performed using a microscope to inject a single sperm into each egg. The fertilized eggs can then be returned to the uterus, as in IVF. In gamete intrafallopian tube transfer (GIFT), the eggs and sperm are mixed in a narrow tube, and then deposited in the fallopian tube, where fertilization normally takes place. Another variation on IVF is zygote intrafallopian tube transfer (ZIFT). As in IVF, the fertilization of the eggs occurs in a laboratory dish. And, similar to GIFT, the embryos are placed in the fallopian tube, rather than in the uterus as with IVF.

Resources

books

Boggs, William M., and Rosella D. Smith. The Journey to Fertility: A Couple's Guide to In Vitro Fertilization. Timonium, MD: Wilrose Books, 2001.

DeJonge, Christopher J. Assisted Reproductive Technologies: Current Accomplishments and New Horizons. Oxford: Cambridge University Press, 2002.

Elder, Kay, and Brian Dale. In Vitro Fertilization, 2nd edition. Oxford: Cambridge University Press, 2000.

Trounson, Alan O., and David K. Gaardner. Handbook of In Vitro Fertilization, 2nd edition. Boca Raton, FL: CRC Press, 1999.

periodicals

Aboulghar, M. A., R. T. Mansour, G. I. Serour, H. G. Al-Inany, and M. M. Aboulghar. "The Outcome of In Vitro Fertilization in Advanced Endometriosis with Previous Surgery: A Case-controlled Study." American Journal of Obstetrics and Gynecology 188, no. 2 (2003): 371–375.

Kolibianakis, E. M., et al. "Outcome for Donors and Recipients in Two Egg-sharing Policies." Fertility and Sterility 79, no. 1 (2003): 69–73.

Puskar, J. M. "Prenatal Adoption: The Vatican's Proposal to the In Vitro Fertilization Disposition Dilemma." New York University Law School Journal of Human Rights 14, no. 3 (1998): 757–793.

Squires, J., A. Carter, and P. Kaplan. "Developmental Monitoring of Children Conceived by Intracytoplasmic Sperm Injection and In Vitro Fertilization." Fertility and Sterility 79, no. 2 (2003): 453–454.

organizations

American Board of Obstetrics and Gynecology. 2915 Vine Street, Suite 300, Dallas, TX 75204. (214) 871-1619; Fax: (214) 871-1943. [email protected]. <http://www.abog.org>.

American College of Obstetricians and Gynecologists. 409 12th St., SW, P.O. Box 96920, Washington, DC 20090-6920. <http://www.acog.org>.

American Infertility Association. 666 Fifth Avenue, Suite 278, New York, NY 10103. (718) 621-5083. E-mail: <info@ americaninfertility.org. <http://www.americaninfertility.org>.

American Society for Reproductive Medicine. 1209 Montgomery Highway, Birmingham, AL 35216-2809. (205) 978-5000. <http://www.asrm.com>.

International Council on Infertility Information Dissemination, Inc. P.O. Box 6836, Arlington, VA 22206. (703) 379-9178. <http://www.inciid.org>.

other

American Society for Reproductive Medicine. [cited March 1, 2003]. <http://www.asrm.org/Patients/FactSheets/invitro.html>.

Columbia University College of Physicians and Surgeons. [cited March 2, 2003]. <http://www.columbia.edu/cu/news/01/09/in_vitro_prayer.html>.

Encyclopedia.Com. [cited March 2, 2003]. <http://www.encyclopedia.com/html/i1/invitro.asp>.

International Council on Infertility Information Dissemination. <http://www.inciid.org/ivf.html>.

L. Fleming Fallon Jr., MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An obstetrician-gynecologist (OB-GYN) with specialized training in IVF supervises the activities of IVF. This specialist performs most of the procedures involving the woman. Most IVF activities are performed in a professional medical office.

In vitro fertilization

In vitro fertilization (IVF) is the term used to describe the combination of egg cells and sperm in a glass petri dish in order to fertilize the eggs. "In vitro" comes from the Latin word meaning "in glass." The procedure is used to treat infertility, a condition in which, for various reasons, a woman cannot become pregnant.

In the procedure, eggs are removed from the woman's uterus, fertilized with sperm, and then returned to the uterus to produce a pregnancy. The first baby conceived by in vitro fertilization, Louise Brown, was born in England in 1978. Since then, more than 3,000 babies conceived in this way have been born.

Early Attempts

Early attempts at IVF were made over a century ago, with a successful rabbit embryo transfer carried out by Walter Heape in England. Gregory Pincus (1903-1967) performed further IVF experiments in the 1930s. An editorial in the New England Journal of Medicine in 1937 suggested IVF as a treatment for infertility in women. Although human IVF experiments were carried out in the 1940s and 1950s by John Rock (1890-) and Landrum Shettles (1909-), knowledge of reproductive physiology was too limited for the IVF procedures to be successful.

It was eventually learned that, after ejaculation (the moment when semen is discharged from the body), sperm undergo changes in their plasma membrane (the thin skin covering every cell). The change that occurs in the sperm's plasma membrane is called capacitation, and it must take place in order to be capable of fertilizing the egg cell. The oocyte (egg) also is not ready for fertilization until just before ovulation occurs.

Armed with this knowledge, researchers successfully fertilized rabbit oocytes in vitro. Min-Chueh Chang (1908-) then went a step further and implanted the IVF-fertilized oocytes into female rabbits. IVF for many other species followed.

The final advance was made by British physicians Robert Edwards and Patrick Steptoe, who began collaborating in 1968. The two doctors developed a method of stimulating ovulation with hormone treatment, then retrieving the nearly mature ova (eggs) and culturing them for the several hours needed for full maturation. Meanwhile, a fresh specimen of male sperm was treated so it underwent capacitation, then it was added to the oocytes in the petri dish, where fertilization took place. The researchers waited until the egg divided into an eight-celled embryo, then transferred it into the woman's uterus where, in successful IVF procedures, it would implant.

Variations on IVF

Several variations on IVF are now practiced. One is called gamete intrafallopian transfer (GIFT), in which eggs and sperm are gathered and prepared just as in IVF. Then they are placed into the woman's fallopian tube for fertilzation to occur, rather than in a petri dish. Another method is called zygote intrafallopian transfer (ZIFT), in which one or more zygotes (fertilized eggs that have not yet started to divide) are transferred to the fallopian tubes.

Current Success

Although the success rate is considered modest—approximately 20 percent result in a full-term pregnancy—IVF is a widely used infertility treatment. Hundreds of medical centers around the world offer the procedure. Since the mid-1980s, cryopreservation (freezing) of eggs (or embryos) has become a common practice. This involves the preserving of additional fertilized eggs to be used later, in case the IVF treatment does not produce a pregnancy.

The resulting legal and moral questions of freezing human embryos was dramatized in a 1984 plane crash. A husband and wife who died in the crash left behind cryopreserved embryos in Australia. The sudden deaths raised many questions. What should be done with cyropreserved embryos? Does anyone have the right to dispose of them? How long can they be stored? Who owns them?