See IVF Tour for a more detailed explanation of the IVF process.

Step 1 Recipient Screening

The recipient or aspiring parent is required to undergo thorough clinical and psychological evaluations:

• A mid cycle ultrasound, post menstrual hysteroscopy, or hysterosonogram is required, regardless of findings from a hysterosalpingogram. Hysteroscopy is usually performed within one week of cessation of menstruation and may be performed in your doctor's office under local anesthesia. Hysterosonography is also performed within one week of cessation of menstruation and is usually performed in a radiology department of a hospital, or in our clinic.

• The male partner of the couple must provide evidence of sperm function with a semen analysis.

• The male partner will have blood drawn for Infectious disease screening (HIVI, HIV II, VDRL/RPR, Hepatitis B Surface Antigen and Hepatitis C Antibody). The female partner will require blood to be drawn for Prolactin, TSH, Rubella, Varicella, ABO/Rh typing and Infectious disease screening. Genetic screening is also recommended, based on ethnic background.

• According to the American Cancer Society, all women between the ages of 35 and 40 are recommended to obtain a baseline mammogram, if one has not been performed within the last five years. Women between the ages of 40 and 50 should obtain a mammogram every one to two years, and women over the age of 50 are encouraged to have a mammogram performed every year. Pacific Fertility Center (PFC) strongly encourages women to obtain screening mammograms prior to attempting pregnancy, and requires women 40 years of age and older to supply documentation of a normal mammogram.

• If a pap smear (a screening test for cervical pre-cancer and cancer) has not been performed within the last year, PFC strongly recommends you contact your gynecologist and have a pap smear performed.

• A careful uterine measurement will be performed and is critical to the outcome of IVF. This is performed with the use of a thin, flexible embryo transfer catheter which is introduced through the cervix to the apex of the uterine cavity. This measurement is critical with regard to the placement of the embryos within the uterine cavity at the time of embryo transfer. This can be done at the time of the mid cycle ultrasound (prior to any uterine hormonal preparation) or at the time of the baseline ultrasound just prior to starting estrogen.

• If the female partner is 45 years old or older PFC requires a letter of medical clearance from your primary doctor. He/she may recommend appropriate tests such as EKG, chest x-ray, or even exercise tolerance tests.

• The intended parent(s) must also meet with our marriage and family therapist, clinical coordinator (for medical clearance), and financial coordinator. At that point, the intended parent(s) can select a donor.

Step 2 Egg Donor Selection

Patients interested in the third party service of egg donation have two options available to them. They can select a known donor (e.g., a family member, a friend) or work through a third party egg donor program that provides anonymous egg donors. When using an agency, we suggest you contact the Pacific Fertility Center Egg Donor Agency, an in-house agency offering donor services or you can opt to choose an independent agency from which to select a donor. Our egg donor agency is located in the same facility right here in Northern California's San Francisco Bay Area.

Step 3 Egg Donor Screening

Once the donor has been selected, she will undergo additional psychological and medical evaluations by the PFC team. These additional pre-cycle appointments include:

Appointment #1 - A psychological evaluation is performed with a thorough review of the following topics:

• any outside stressors and potential scheduling conflicts;
• past history of psychological counseling/treatment;
• history of substance abuse;
• emotional resolution regarding donation of genetic material;
• personal motivation;
• the donor's commitment to completing the program requirements.

The psychological evaluation is of crucial importance because it ensures the donor is psychologically appropriate to be a donor (i.e., she is mature, responsible and has no underlying psychopathology) and comprehends what she is proposing to undertake.

Appointment #2 – A consultation with a clinical coordinator is made to explain the donor's role in the program and give her medical instructions.

Appointment #3 – A general medical history and gynecological evaluation is performed as well as a medical evaluation and pelvic ultrasound with a doctor.

Appointment #4 –

• The donor will have bloodwork performed, including a blood draw for HIV I, HIV II, VDRL/RPR, Hepatitis B Surface Antigen, Hepatitis C Antibody, Prolactin, TSH, HTVL-1, ABO/Rh typing and CMV IgG and IgM antibodies.
• Genetic testing based on ethnic background is also performed.
• Testing is performed for the detection for Chlamydia and Gonorrhea.

Following the donor's appointments, you can expect a call from your clinical coordinator to confirm possible calendar dates.

Step 4 Synchronization of the Donor and Recipient

After all parties have completed the required PFC screening, the Donor and Recipient will usually be started on low dose oral contraceptive pills (OCP's). After a minimum period of at least 14 – 21 days of the pill, a hormone called "Lupron" or "Synarel" will be prescribed for both parties. They work to down regulate the pituitary gland and, in essence, shut down the ovaries. Lupron is taken as a subcutaneous injection. Synarel is administered as a nasal spray. Once it is determined that both the Donor's and Recipient's pituitary glands are adequately suppressed, stimulation of the ovaries and endometrium may be initiated respectively.

Step 5 Ovarian and Endometrial Stimulation

Both Donor and Recipient continue with Lupron injections or Synarel sprays. The recipient will begin estradiol injections in order to prepare her endometrium or uterine lining for the embryo implantation. The Donor will begin injections of fertility medications in order to stimulate the growth of numerous follicles on her ovaries. This process is known as controlled ovarian hyperstimulation.

Step 6 Monitoring

While the Donor is administering the fertility medications, she is required to be monitored by routine estradiol levels and transvaginal pelvic ultrasounds. This follows the rate of follicular growth and rise in estradiol levels. When the physician determines the time is optimal for the egg retrieval, the Donor will receive a final injection called hCG, which will mature the eggs for retrieval. At the same time, the Recipient is monitored by periodic estradiol levels and ultrasound evaluations for endometrial thickness.

Step 7 Egg Retrieval

The egg retrieval is a transvaginal ultrasound directed needle aspiration. This is a minor surgical procedure and is performed under general anesthesia. A vaginal probe (transducer) is placed in the vagina and a needle is inserted through a needle guide attached to the probe. The ultrasound image allows the physician to accurately guide the needle through the vagina directly into the follicles for aspiration under direct visualization. The process takes about 30 minutes. Following the retrieval, the donor recuperates for 1 – 2 hours and is then discharged to resume light daily activities.

Step 8 Fertilization and Embryo Transfer

Fertilization, the union of the sperm and egg, is a very complex process that occurs in the laboratory hence the term "in-vitro" which translates to "in glass". The eggs retrieved are examined by the embryologist and then placed in a specialized culture medium in preparation for insemination with sperm. A masturbated sperm sample is enhanced by a highly specialized process prior to being placed with the eggs. Either 3 or 5 days following egg retrieval, selected embryo(s) are transferred to the Recipient's uterus. If there are embryos of sufficient quality remaining, they may be frozen for subsequent transfers.

The embryo transfer procedure requires no anesthesia. A catheter is inserted through the cervix into the uterus, and the embryos are gently and carefully placed into the uterine cavity. The Recipient is maintained in a recumbent position for approximately fifteen minutes and then discharged.

Step 9 Post Embryo Transfer Management and Follow-up

The Recipient will need to take daily hormone injections in order to sustain an optimal environment for the embryo implantation. Approximately two weeks after the embryo transfer, two pregnancy tests are performed. If the Beta-hCG titer is rising, this indicates that implantation has taken place. Hormone injections will then be continued until 10 weeks of gestation at which time the placenta will supply all the hormones necessary to sustain the pregnancy. In the interim, ultrasound examination(s) will be performed to definitively diagnose pregnancy between 5 to 6 weeks after the embryo transfer. If the pregnancy test is negative, all hormonal treatments are discontinued and menstruation will usually ensue within two weeks.