All About IVF, from a Leading New Jersey Authority


After a thorough physical examination and personal history, your doctor may determine that basic infertility treatments, such as surgery, insemination and/or ovulation induction are not appropriate for you. These infertility therapies may have been unsuccessful, or age considerations may suggest it’s time for alternatives if you want to conceive. In these cases, your treatment plan may include assisted reproductive technology (ART).

ART relies on sophisticated laboratory-based techniques for cases requiring advanced treatments to produce pregnancy. IRMS performs approximately 1,000 ART cycles per year and achieves pregnancy rates amongst the highest in the world. The most common ART procedure is in vitro fertilization (IVF).

Like ovulation induction, in vitro fertilization (IVF) uses medications to suppress a women’s natural menstrual cycle and stimulate her ovaries to produce multiple follicles that will contain many eggs. In what is called a “fresh cycle,” the eggs are retrieved and transferred to the laboratory. They are placed, along with sperm, in a special culture medium that encourages fertilization and growth of high-quality embryos.

Sperm from the male is collected on the day of oocyte retrieval, except in cases where donor or previously frozen sperm is used. In cases of male factor infertility caused by conditions such as azoospermia (lack of sperm), tubal blockage and genetic anomalies, sperm is not available in the seminal fluid and surgical techniques may be required to extract it from the surrounding tissue. In any case, the sperm is washed to remove impurities before it is added to the medium, where fertilization of the eggs can occur in just a few hours.

Following fertilization, the egg becomes a zygote, which includes the nuclei from both the egg and sperm. When it has developed into a 6-to-8-celled embryo, usually on Day 3, it will be transferred back into the uterus. A limited number of high quality embryos are chosen for transfer, while others will be cryopreserved, or frozen, for future use in a “frozen embryo transfer” (FET). During this type of IVF cycle, frozen embryos are thawed and transferred into the uterus, eliminating the need for ovarian stimulation as required in a fresh cycle.

Another variation of IVF, egg donation, where a “donor cycle” is required if the woman is not able to produce her own eggs, or their quality will not support fertilization, implantation and pregnancy. In an egg donation cycle, the eggs are retrieved from an egg donor, a young woman who has undergone ovarian stimulation. They are fertilized with sperm from the husband of the recipient couple or an egg donor, and the resulting embryos are transferred to the recipient female, whose body has been prepared for implantation and pregnancy.

Getting Started

To begin your infertility treatment, you will call us on the first day of menses before your scheduled IVF cycle. On the third day, you will visit our office for a blood test to determine your progesterone level, an indicator of ovarian function. You will receive instructions to begin taking a prenatal vitamin, as well as birth control pills and/or Lupron, designed to “turn off” your body’s natural ovarian stimulation process and synchronize your treatment. Whether you are taking Lupron alone, or overlapping Lupron and the pill, your menstrual period should begin 7-10 days after the start of the Lupron injections. On Day 3 of your period, you will visit us for evaluation and instructions to begin your stimulation medications.


During a natural ovulation cycle, a woman usually produces one egg each month. At various points in your IVF cycle, you will take different prescribed hormones – your medication protocol – designed to either suppress your own reproductive cycle, stimulate your ovaries to produce multiple follicles and eggs, promote the ripening of the mature eggs, or prepare your body for implantation and pregnancy.

Stimulation medications, called gonadotropins, are taken by subcutaneous injection (under the skin) once or twice daily. They replace your natural follicle stimulating hormone (FSH) to trigger a very precise, uniform stimulation. If they are successful, the ovaries will produce multiple follicles and high quality, mature eggs. Because these powerful hormones produce significant changes in your system, their effects are tracked by blood tests and ultrasound. Your hormone levels and follicular development are tracked throughout a stimulation cycle. If required, your medication protocol (the type and dose) may be altered for optimum results. When the follicles are mature, usually between 16 and 20 millimeters in diameter depending on your stimulation medication, you will take an intramuscular injection of HCG to prepare for egg retrieval. A variety of medications are available and your physician will choose the drug or combination of stimulation drugs that are best in each case.

During your stimulation cycle, the male partner will begin antibiotics to protect against bacteria that may be present in semen. He also will be given specific instructions for semen collection, or if appropriate, coordination of microsurgical sperm collection procedures.

For more information about infertility medications, visit the medications page in our web site.

Cycle Monitoring

You will be required to visit IRMS as instructed, in the East Wing of Saint Barnabas Medical Center between 6:30 and 8:00 a.m. Alternatively you may visit our Hoboken office for monitoring Monday-Friday between 7:00am and 9:00am. This allows us to track your progress and adjust your medications if necessary. The frequency of these visits is every one to four days, depending on how you respond to the drugs. Ultrasounds will track the number and size of your follicles, and blood work will indicate estrogen levels, allowing the IVF team to determine when your eggs are mature.

Although IVF alone is highly effective for many couples, others may require additional procedures to assist fertilization, implantation, and sustained pregnancy. Click here to find out more information about Additional laboratory services performed at IRMS.

Egg Retrieval

Oocyte or egg retrieval is the procedure marking the beginning of the second significant phase of an IVF cycle. At this point, the focus of care shifts from inside the body (in vivo) where the patient’s ovaries have been stimulated by fertility medications to produce many eggs, to the laboratory (in vitro) where the eggs are carefully handled in preparation for in vitro fertilization, IVF

Egg retrieval occurs 34.5 to 39 hours after HCG is administered by injection to trigger the final stages of egg maturation and to release the eggs from the wall of the follicle. Once they are floating free in the follicular fluid, they are ready for retrieval. The procedure usually takes less than 20 minutes, with a recovery period of approximately an hour.

While the patient is under mild sedation, a physician uses a transvaginal ultrasound probe to visualize the follicles. The probe also is outfitted with a needle to puncture and aspirate the tiny sacs. The fluid containing the egg is aspirated into multiple tubes that are passed to the embryologist who empties the contents into a petri dish to begin the search for the eggs. Once located, they are removed from the mixture of follicular fluid and blood and placed into a culture medium designed in temperature and chemical composition to resemble the environment inside the body.

The culture dishes containing the eggs are then placed in an incubator, set at body temperature, for several more hours to complete the ripening (maturation) process. The timing of these events correlate to those that occur naturally and the egg retrieval is performed shortly before ovulation would normally occur. After the period of in vitro maturation, the oocytes are placed in drops of culture medium that contain processed sperm. (Sperm are prepared for IVF by isolating motile sperm from other elements of the semen).

If fertilization occurs, it happens during the next few hours. The embryos continue to develop over the course of the next three to five days. On the day of transfer, our embryologists select the healthiest embryos for return to the uterus during the embryo transfer procedure.

In some cases, other laboratory-based techniques are required following egg retrieval. Fertilization may be assisted by intracytoplasmic sperm injection (ICSI), a micromanipulation procedure that involves injecting a sperm directly into the core of an egg. Techniques such as assisted hatching may be used to help in embryo implantation. In some cases, preimplantation genetic diagnosis (PGD) may be performed on developing embryos to identify certain genetic abnormalities and prevent the transfer of affected embryos during an IVF cycle.

Intracytoplasmic Sperm Injection (ICSI)

Intracytoplasmic sperm injection or ICSI, used in conjunction with in vitro fertilization (IVF), has revolutionized the treatment of severe male factor infertility. This procedure involves injection of a single sperm through the outer shell (zona pellucida) and the cell membrane of the egg and into the cytoplasm. ICSI may be required when the male has very low numbers of motile (moving) and/or abnormally shaped sperm, or where there are problems with the sperm penetrating the egg. ICSI also can be effective when there are antisperm antibodies in the semen, (products of the immune system which may otherwise attack and destroy sperm before it can reach the egg), or when previous attempts at fertilization with standard culture systems and fertilization methods were not successful. Finally, ICSI may be used when an infertility cycle relies on a limited number of sperm, including frozen sperm collected prior to cancer treatment, or those obtained from the male’s tissue using microsurgical techniques. Semen analysis and prior history will help us determine whether ICSI is likely to be required as part of your infertility treatment.

The ICSI Procedure

During the ICSI procedure, an embryologist holds the egg in place with a thin pipette (similar to a tiny, glass straw). An injection needle is used to pierce the zona pellucida and inject the sperm. The embryologist then carefully withdraws the needle, leaving the sperm in the cytoplasm of the egg. In less than a minute, the zona closes naturally and the egg retains its normal shape.

ICSI provides substantial benefit in cases of severe male factor infertility; however, there are some risks associated with it. The egg can be damaged during the process and, in some cases, the zona is difficult to pierce. Although there is no data to link ICSI to an increased risk of genetic abnormalities, some evidence suggests that males with semen deficiencies have a higher frequency of chromosomal abnormalities that could be passed on to their male children. As a result, candidates for ICSI are carefully selected and, if necessary, undergo genetic screening and counseling prior to IVF.

If ICSI is successful, it results in fertilization. Even so, the embryo may still face problems related to fertilization in general – it may not divide or it may stop growing at an early stage of development. If it develops normally, it may be selected for transfer to the uterus.

Possible Risks and Side Effects of IVF

You will be fully apprised of all of the possible risks associated with your infertility treatment and IVF cycle as part of the informed consent process, which occurs before your cycle begins. Most patients generally do not have problems with blood sampling and hormone injections; however, some experience local discomfort, redness or bruising at the injection sites. Injections can be painful and the side effects of medications may include breast tenderness, fluid retention, a bloated feeling, moodiness and/or tenderness in the ovaries. In fewer than 1% of all IVF cases, a patient may form ovarian cysts that could rupture, a twisting of the ovaries that may require surgery, or experience ovarian hyperstimulation syndrome (OHSS). The latter, associated with enlarged ovaries and fluid in the abdomen, can lead to dehydration, large amounts of fluid accumulation in the abdominal and lung cavities, blood clotting disorders and kidney damage.

Monitoring during your stimulation cycle is extremely important, as it allows our physicians to closely regulate medications to minimize your discomfort and side effects. However, in a relatively small number of cases, they cannot be avoided. Although very rare, there are potential risks associated with egg retrieval that could require surgery, including infection and injury to blood vessels or other structures. Any possible links between stimulation drugs and ovarian cancer continue to be a subject of extensive researched; however, a positive causal effect has not been established.

Other Considerations

Success Rates and Multiple Births

Our success rates for infertility treatment cycles using IVF and other assisted reproductive technologies are very high compared to other programs due to a combination of quality oocytes and the expertise of our team of highly experienced physicians, nurses, embryologists and other laboratory staff. Our staff and laboratories are licensed and/or certified by the State of New Jersey and our screening measures go well beyond those employed by many other programs.

Although the chances for success at IRMS are high, there is no guarantee you will become pregnant. Whether you become pregnant is affected by factors that differ in every case. You or your spouse may face clinical infertility problems that preclude fertilization or successful embryo transfer. Your cycle may be cancelled because of stimulation problems, you may not produce enough eggs or the eggs may not fertilize and develop into quality embryos. Finally, when the process is successful, you may face the risk of multiple pregnancies. At IRMS, we take steps to avoid multiple gestations by limiting the number of embryos transferred, but you still may have to choose between having more than one child and undergoing multifetal reduction to reduce the number of embryos carried to term.

Psychological Screening and Issue Resolution

The psychological issues associated with IVF are significant and not to be taken lightly. Although we do not require every couple to meet with our on-site psychologist before acceptance into the program, we may recommend that this occur in some cases. Further, it is important that you are aware that psychological support is available throughout the process if it is necessary. You will be made aware of the requirements and implications of the procedure. You also will have the opportunity to discuss practical considerations with your nurse, and personal, moral and ethical issues associated with IVF, with our psychologist.

Cryopreservation and Disposition of Embryos

At the end of your cycle, you may have more embryos than required for transfer and, if the quality is good, they may be considered for cryopreservation. This occurs in approximately 25% of IVF cycles involving women age 39 or younger. As a result of several factors, embryos are rarely frozen when the patient is older. The availability of frozen embryos will allow you to undergo a subsequent transfer without stimulation, a process known as a Frozen Embryo Transfer (FET). However, if they cannot be frozen, they can be donated for research or destroyed.

At the end of your cycle, you may have more embryos than required for transfer and, if the quality is good, they may be considered for cryopreservation. This occurs in approximately 25% of IVF cycles involving women age 39 or younger. As a result of several factors, embryos are rarely frozen when the patient is older. The availability of frozen embryos will allow you to undergo a subsequent transfer without stimulation, a process known as a Frozen Embryo Transfer (FET). However, if they cannot be frozen, they can be donated for research or destroyed.