What happens during prenatal visits?

During the first prenatal visit, you can expect your doctor to:
• ask about your health history including diseases, operations, or prior pregnancies
• ask about your family´s health history
• do a complete physical exam, including a pelvic exam and Pap test
• take your blood and urine for lab work
• check your blood pressure, height, and weight
• calculate your due date
• answer your questions
At the first visit, you should ask questions and discuss any issues related to your pregnancy. Find out all you can about how to stay healthy. Later prenatal visits will probably be shorter. Your doctor will check on your health and make sure the baby is growing as expected. Most prenatal visits will include:
• checking your blood pressure
• measuring your weight gain
• measuring your abdomen to check your baby’s growth (once you begin to show)
• checking the baby´s heart rate
While you´re pregnant, you also will have some routine tests. Some tests are suggested for all women, such as blood work to check for anemia, your blood type, hepatitis, HIV, and other factors. Other tests might be offered based on your age, personal or family health history, your ethnic background, or the results of routine tests you have had.

How often should I see my doctor during pregnancy?

Your doctor will give you a schedule of all the doctor´s visits you should have while pregnant. Most experts suggest you see your doctor:
• about once each month for weeks 4 through 28
• twice a month for weeks 28 through 36
• weekly for weeks 36 to birth
If you are older than 35 or your pregnancy is high risk, you´ll probably see your doctor more often.

Is IVF pregnancy different from natural pregnancy?

The chance of multiple pregnancy is increased in IVF when more than one embryo is transferred. The risk of premature delivery in multiple pregnancies is high. Premature babies require prolonged and intensive care and risk lifelong handicaps due to premature birth. Data also suggest that IVF conceptions, even singletons, have a slightly increased risk of premature delivery or low birth weight. Some evidence suggests that first trimester bleeding is more common in women who undergo IVF and is not associated with the same poor prognosis as it is in women who conceive spontaneously. Miscarriage may occur after ART, even after ultrasound identifies a pregnancy in the uterus. In addition, there is still approximately a 5% chance of ectopic pregnancy with ART.

How will a “hydrosalpinx” affect the IVF chances?

We now know that a hydrosalpinx (dilated and blocked fallopian tube) will decrease pregnancy chances. However, if the hydrosalpinx is/are removed, or if the proximal portion of the tube is clipped, then pregnancy chances are restored. This surgery can usually be done laparoscopically.

Will I reach menopause earlier if I do multiple ovarian stimulation cycles?

In a natural ovulation cycle, the ovary selects one egg from a pool of over 100 eggs. Those eggs which are not selected for that month undergo a natural cell death process called atresia. Fertility medications override the body´s selection process, and cause many of these “rescued” eggs to grow (hopefully between 10-20 eggs). These eggs would otherwise undergo atresia. Therefore, you are not “using up eggs faster” by undergoing ovulation induction, but are “rescuing” eggs to use in that cycle, which otherwise would have expired.

Is it unsafe to produce many eggs with IVF stimulation?

Patients with PCOS have a tendency to produce many follicles (egg sacs), when undergoing IVF stimulation. When undergoing stimulation, we try to obtain 10-15 follicles, but not so many that the patient is at high risk of severe hyperstimulation syndrome (OHSS). Hyperstimulation occurs in most patients undergoing IVF, in a mild to moderate form. Severe hyperstimulation occurs in 1-2% of IVF patients. We can manage most symptoms of hyperstimulation by performing office procedures (fluid hydration, pain medications, removing fluid). Very rarely does a patient have to be admitted to the hospital.

What does it mean if I am diagnosed with Diminished Ovarian Reserve?

Diminished or poor ovarian reserve has very significant implications for fertility treatment. It does not, however, say you cannot successfully conceive. The patient´s age is of some importance, as women <38 are more likely to be successful than those who are older. However, patients with poor ovarian reserve have lower pregnancy rates and higher miscarriage rates. If all conventional treatment options have been exhausted, usually the most successful option for pregnancy is to pursue egg donation. Pregnancy rates using a donor egg are very high.

I am concerned that I may have poor egg quality. How can I determine my egg quality?

The most important determining factor of egg quality is AGE. As women age, so do their eggs. The consequences of this aging process are lower pregnancy rates and higher miscarriage rates. Poor response to injectable fertility medications, failure of prior fertility treatment, prior surgery to the ovaries and shortening menstrual cycles can be other signs of egg quality issues.
Blood tests including AMH, FSH and Estradiol can indicate if egg quantity issues are present. Poor quality is often associated with low number of oocytes. We do not have confirmation of an egg quality issue until we do an IVF cycle and see how the eggs behave and embryos develop (abnormal fertilization, poor embryo development).

Should I travel?

Many of our patients have to travel various distances to return home after treatment.
Air travel in commercial aircraft is fine. Drink lots of fluids while flying, since the circulated air can be quite dry, and dehydration should be avoided. Car travel is also fine.

If I live out of town, how long do I have to stay in Bucharest?

At Gynera, we care for many patients who come for treatment from other parts of the country, and throughout the world. All communication with our staff throughout the treatment can be via telephone or E-mail. Many of the required screening blood testing and procedures can be coordinated with your local gynecologist. We may be able to have you start your stimulation treatment locally, if we could collaborate with your gynecologist. None of the procedures requires to stay in our center over night.

Can freezing damage the embryos?

Physical damage may result to individual embryos due to the stress of freezing and thawing. The damage can arise in 2 ways. First, despite our best efforts, it is possible that ice shards will form within the straw, and pierce or kill one or more cells within the embryo. Second, during thawing, water rushes back into the embryo at a faster rate than the protective media leaves. This causes swelling of the cells, and occasionally individual cells will not tolerate this swelling and burst.
Any embryo that survives thawing has the potential to establish a pregnancy. However, the chance for pregnancy will depend on how well the embryo survives. If an embryo survives with all cells intact, it will have a better chance for pregnancy than an embryo that loses half of its cells.

How are embryos thawed?

Thawing the embryos is a reversal of the freezing procedure.
The embryos coming out of the freezer (at –1960C) are warmed to room temperature in seconds. This rapid thaw method minimizes damage to the embryo from ice shards. The embryologist has to remove the protective media from the embryo and replace the water that was removed at the time of freezing. This is done by incubating the embryo in different solutions, until finally all the water has been replaced.
Once the thawing procedure is complete, the embryo is warmed up to body temperature (370C).

How long can embryos be stored?

No one knows what the maximum storage period might be. The longest time a human embryo has been stored is 12-15 years. Usually, fertility clinics offer limited storage periods, of about 5 years.

How are embryos frozen?

Freezing is a stressful process for an embryo, and only embryos that are growing well in the laboratory will tolerate the freezing procedure.
Before an embryo can be frozen, all the water that it contains must be removed. Since water expands in size as it turns to ice, water inside the embryo would burst (kill) the embryo if we simply placed it in the freezer.
The embryo is cooled to room temperature as the water is replaced with protective media.
When most of the water has been removed the embryo is inserted into a small straw, then rapidly cooled (vitrified) and stored frozen at –1960C in liquid nitrogen.

Is it true that having embryos transferred at the blastocyst stage gives higher pregnancy rates?

Embryos that have grown successfully in the laboratory for 5 or 6 days are called blastocysts. They have gone beyond the stages where it was possible to count the number of cells that they contain, and have begun to differentiate into 2 different cell types. A normal blastocyst should have developed by day 5 after egg retrieval. Since the blastocyst now has the first placenta cells, it is ready to hatch from its shell and implant in the uterus.
On average, about 30% of fertilized eggs will develop to the blastocyst stage. This number will be lower in older patients, and higher in young patients. Older patients tend to have fewer eggs and fewer embryos. Blastocyst stage embryo transfer will usually not increase the pregnancy rate if we transfer all the embryos into the uterus.. Younger patients, however, tend to have more eggs and therefore embryos; we could consider keeping them in the laboratory for the extra 2 days, in order to make a better selection of the embryos. This is a way of identifying the embryos with the most potential in the group and giving the highest chance of pregnancy.

What is the meaning of embryo grading?

Quality of embryos is assessed by examining how well the embryos appear to be developing in the culture dish, and is usually scored on a scale. Depending on the scale, perfect embryos are usually graded as “1” or “A”. These embryos have round and symmetrical cells, look perfect in every way and give high pregnancy rates when transferred. Only about 20% of all embryos get this top score. The more common situation is that when the cells of an embryo divide, the resulting cells are not quite even in size or shape. Also, human embryos have a tendency to loose tiny pieces or fragments of their cells during cell division, and the severity of this fragmentation is largely what grades are based on.
The grade does correlate with the viability of an individual embryo and the better the grade, the more chance you have of pregnancy. Also, if you are having embryos frozen, only embryos with good grades will tolerate the freezing procedure.

How can I be sure that the IVF laboratory will not mix up any of my sperm, eggs or embryos with those from another patient?

An error of this type cannot happen in Gynera Fertility Center, because we take special precautions and extra care in following protocols, and double check every step of each procedure. Dishes and test tubes containing sperm, eggs or embryos are labeled with identifying information for each patient to prevent mix-ups. We record patient’s full name and his partner´s full name, date of birth and other identification data.
At egg retrieval or transfer time, the embryologist will ask the patient their full name, and repeat the name back to the patient to verify what they heard. The photograph of the embryos is kept in the medical record.
The same precautions are taken for IUI.
Surplus embryos being frozen after a transfer are catalogued with full names, ID, date of freezing and details of the embryos being frozen. Embryos are usually frozen inside special straws and in addition to careful labeling, color-coding is also used as an added precaution.

Are the procedures painful?

The only procedure that could be considered a minor surgery in the IVF process is the retrieval of the eggs from the ovary. During this procedure a needle attached to a vaginal ultrasound probe is passed through the wall of the vagina and into each ovary.
We can use anesthetic medications that are administered through an intravenous line, are rapid in onset of anesthetic effect, and wear off quickly when the procedure is over. After the procedure the patient wakes up relatively quickly and, at most, may feel some minor cramping in the ovaries.

Are the injections painful?

Most injections are given under the skin (subcutaneous) and are not painful.

Will the hormones cause long-term health risks?

Some old studies suggested a possible association between fertility drugs and the risk of ovarian cancer.
An important fact to keep in mind is that women who suffer from infertility and never conceive have a slightly increased risk of ovarian cancer as compared to the general population (about 1.6 times the rate). As these are the women who use fertility medications, the medications themselves have been implicated in the cancer risk but have never been proven to be a cause of cancer. Most recent studies failed to find an association between fertility medications or IVF treatment and any higher risk of ovarian cancer.

Are IVF babies having an increasing risk of birth defects?

The rate of birth defects in humans in the general population is about 3% of all births for major malformations and 6% if minor defects are included. We now have ample data that children conceived through IVF have no increase in these rates of birth defects. Further follow-up on older children indicates that IVF children have done as well or better than their peers in academic achievement and have no higher rates of behavioral or psychological difficulties. However, when ICSI is used in cases of severe male factor infertility, a genetic cause of male infertility may be passed on to the offspring.

How often is IVF successful?

Success rates vary and depend on many factors. Some things that affect the success rate of IVF include:
• Age of the partners
• Reason for infertility
• Clinic
• Type of ART (Assisted Reproductive Technology)
• If the embryo is fresh or frozen
According to the 2007 CDC report on ART, the average percentage of ART cycles that led to a live birth were:
40% in women younger than 35 years of age
31% in women aged 35–37 years
21% in women aged 38–40 years
12% in women aged 41–42 years
5% in women aged 43–44 years

When is IVF Needed?

In infertile couples where women have blocked or absent fallopian tubes, or where men have low sperm counts, in vitro fertilization (IVF) offers a chance at parenthood to couples who would have had no hope of having a natural child. IVF is also used when other conditions are present, including endometriosis and unexplained infertility in which no medical cause for infertility can be found.

How long should I try to get pregnant before calling a doctor?

Most experts suggest at least one year. Women aged 35 years or older should see their doctors after six months of trying. More and more women are waiting until they are in their 30s and 40s to have children. While many women of this age have no problems getting pregnant, fertility does decline rapidly every year after the age of 30. If a woman keeps having miscarriages, it’s also called infertility. You should talk to the doctor if you have health problems: irregular periods or no menstrual periods, endometriosis, pelvic inflammatory disease, more than one miscarriage.

How is infertility diagnosed?

The doctor will conduct an interview and a physical examination of both partners to determine their general state of health and to evaluate physical disorders that may be causing infertility. If no cause can be determined at this point, more specific tests may be recommended. For women, these include an analysis of hormones and ovulation, x-ray of the fallopian tubes and uterus, or laparoscopy. For men, initial tests focus on semen analysis.

How is infertility treated?

Most infertility cases are treated with conventional therapies, such as drug treatment or surgical repair of reproductive organs. The most commonly prescribed ovulation drugs are clomiphene citrate, FSH, human chorionic gonadotropin(hCG), and human menopausal gonadotropin (hMG). Bromocriptine, cabergoline, GnRH, GnRH analogs, insulin-sensitizing agents, and LH have very specialized applications that are prescribed in specific cases.

How long should I use Clomiphene before I switch to Injectables/IUI?

Most pregnancies resulting from the use of Clomiphene occur within 4-5 months of treatment. Most reproductive specialists will recommend switching to injectable medications after 3-4 Clomiphene cycles, or after a maximum of 6 cycles for patients who are anovulatory. For anovulatory patients, if ovulation does not occur using a maximum dose of 200 mg/day, switching to injectable medications should be considered.

How many times should I try IUI before moving on to IVF?

After 3-4 cycles of injectable medications with IUI, the chance of a successful IUI cycle is reduced significantly. IVF treatment would be the next consideration.

Should one or two inseminations be done per cycle?

There are many published studies that address this. Most fertility experts believe that one well-timed IUI is sufficient.

How important is timing of the IUI?

Any insemination should be carefully timed to occur at or a little before the time of ovulation. Eggs are fertilizable for only about 12-20 hours after ovulation. Therefore, IUIs must be properly timed so that sperm show up for the date while the eggs are still viable.