All About Assisted Reproductive Technologies (ARTs)

The success and availability of assisted reproductive technologies (ARTs) have brought hope to many couples who previously have been unable to conceive. But procedures such as in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) are not for everyone. For one thing, the daily hormone injections and frequent monitoring with blood tests and ultrasounds can be stressful for a woman. Second, the procedures themselves can be expensive, costing upwards of $10,000 for an IVF cycle. Third, some clinics only accept women into their early 40s or have other program restrictions.

Still, since 1981 -- when the first American baby was conceived successfully through IVF -- many couples have been willing to undergo the stress and take the risks of attempting an ART procedure. How do you know if this option is right for you? Here is some information to help you decide.

IVF is a meticulously-timed procedure that involves removing ripened eggs from a woman's ovaries, fertilizing them with semen, incubating the cells in a laboratory, and placing the embryos into the woman's uterus at precisely the right time. The procedure usually takes about one month from beginning to end.

Generally, a woman starts taking ovulation-inducing drugs, such as Clomid, somewhere between the first and fifth days of her menstrual cycle to stimulate the development of multiple follicles. (Several eggs are stimulated to develop at the same time so that a group of eggs will be available for fertilization.) During this period, a woman will have frequent blood tests to check her estrogen levels, and frequent ultrasounds to monitor the growth, size, and number of developing ovarian follicles.

When the follicles reach maturity, usually after seven to 10 days of medication, she'll receive an injection of hCG, a hormone that triggers egg release. About 34 to 36 hours later, the doctor will use ultrasound-guided aspiration to remove the eggs from the ovaries. The egg-retrieval procedure usually takes about 15 minutes, during which time a local anesthetic is given. At this point, the man is asked to provide a fresh sperm sample. For men with normal semen, about 50,000 to 100,000 of the most motile sperm will be incubated with each of his wife's eggs. (If a man has a very low sperm count, doctors may use a procedure called intracytoplasmic sperm injection, or ICSI, in which a single sperm is directly injected into each egg.)

Next, the sperm and eggs are combined in a petri dish, where the eggs become fertilized. If the fertilized eggs (embryos) are developing normally, the woman will return to the hospital or clinic several days later to have them transferred into her uterus. This procedure takes about 10 minutes and requires no anesthesia. About 14 days later, a pregnancy test will be done and a couple will learn whether the IVF procedure has been successful. If it hasn't, they can choose to try again during another cycle.

IVF is often recommended for women who have irreversibly blocked fallopian tubes, endometriosis, a cervical factor problem, ovulation disorders, or unexplained infertility, or for men with a very low sperm count. The success rate for IVF will vary according to a number of factors, including a woman's age. But in general, 15 to 20 percent of all women who begin an IVF cycle become pregnant and carry a baby to term.

GIFT is a process similar to IVF, in that a woman is given fertility drugs to prevent premature hormone surges, facilitate egg growth, and ultimately trigger release of the mature eggs. But unlike IVF, the eggs and sperm are not fertilized in a laboratory. Instead, after the egg-retrieval process, an embryologist draws up small amounts of sperm for each egg, and then places the unfertilized eggs and sperm into a woman's fallopian tubes through a procedure known as laparoscopy. If the process is successful, the egg is fertilized in the fallopian tube, moves down into the uterus, and implants as in a regular conception cycle.

GIFT is suitable for couples with unexplained infertility, cervical or male factor problems, or mild endometriosis, and it may offer women over 40 (with at least one normal fallopian tube) a better chance of pregnancy than IVF. In some centers, the pregnancy rate through GIFT is 25 to 35 percent.

Another option called ZIFT (zygote intrafallopian transfer) is similar to GIFT, except that the egg and sperm are fertilized in a petri dish before they are transferred into a woman's fallopian tubes, usually by laparoscopy. ZIFT has an advantage over a GIFT procedure in that an embryologist can confirm whether a woman's eggs are able to be fertilized by her husband's sperm. If his sperm are unable to fertilize her eggs, then the couple may decide to accept donor insemination rather than trying to achieve a pregnancy using the husband's sperm.

Deciding to go through an ART procedure is a big step -- physically, emotionally, and financially. What's more, there's always a risk that a cycle can be canceled or fail if:

• A woman doesn't respond well to ovulation-inducing drugs
• Her blood tests show that her estrogen levels are low, and her ultrasound exams indicate that she has few or small ovarian follicles
• At the time of retrieval, there are empty follicles (with no eggs)
• A woman's eggs fail to be fertilized by a man's sperm
• Embryos have failed to implant in a woman's uterus, resulting in a negative pregnancy test

If a couple is unsuccessful in their first attempt, they can decide whether to try again. Statistically, most pregnancies from ART occur in the first four attempts, but for some couples, this is too emotionally and physically draining and/or prohibitively expensive. It can cost anywhere from $10,000 to $15,000 for an IVF cycle, and often part or all of these costs are not covered by insurance.

Before choosing an ART program, you'll need to ask any clinic or practice you're considering a number of questions. Here are some basics to start with.

• What are the credentials and training of the IVF staff? Are one or more physicians board-certified in reproductive endocrinology?
• Are you affiliated with an academic medical center?
• Are you a member of the Society for Assisted Reproductive Technologies (SART)? (SART is a professional group that promotes and advances the standards of assisted reproductive technologies. It has more than 370 members, which represent more than 95 percent of the nation's ART clinics.)
• Have you reported your results to SART and the Centers for Disease Control and Prevention? (The CDC publishes annual ART success-rate reports for fertility clinics around the country.)
• How long have you been performing IVF (GIFT, etc.)?
• How many ovarian stimulation/egg retrieval cycles have you performed in the past 12 months?
• What percentage of IVF patients who have egg retrievals go on to embryo transfer?
• What percentage of those patients become pregnant?
• How many live births have resulted from these pregnancies? How many of these were multiple births?
• What is the miscarriage rate?

• Do you have any limitations on the age or types of infertile couples you accept into your program?
• What fertility tests, if any, will you repeat before starting a cycle?
• Does the clinic have its own lab director? If not, how many labs does the director supervise?
• Are there certain times of year when the clinic doesn't offer ART procedures?
• What are the clinic and lab hours? How much time should I arrange to take off from work so that I'm properly rested to begin -- and complete -- the procedure?
• At what point in the cycle do you start ovulation induction?
• Which drugs do you use to suppress hormones and stimulate ovulation? Would you consider reducing the amount of drugs used?
• Does your clinic culture embryos to the blastocyst stage? (This is the final stage of the embryo's development before it hatches out of its shell and implants in the uterine wall. Only the most viable embryos reach this stage.)
• Does the clinic freeze extra embryos, which can be used for a second ART cycle if necessary?
• Do you offer ICSI (embryos produced from sperm injection) or assisted hatching (a technique used to open a small section of the embryonic wall so that it can properly implant in the uterus)?
• What is the total cost of each cycle? (This will be a range, depending on the drugs used, etc.)
• What insurance do you take? How much does insurance cover? (You'll need to verify this with your insurance company.)
• Can we pay in installments?

• Is there an intake interview? Will we meet with a doctor, nurse, therapist, and/or financial manager before treatment begins? What are the fees for these appointments?
• What types of counseling and support services are available?
• Does the clinic have a "contact system," i.e. patients who've finished their treatments, with whom we can speak?

Sources: RESOLVE: The National Infertility Association; MayoClinic.com; American Society for Reproductive Medicine; The Couple's Guide to Fertility by Gary S. Berger, MD, Marc Goldstein, MD, and Mark Fuerst (Broadway Books); The Fertility Sourcebook by M. Sara Rosenthal (Lowell House); Society for Assisted Reproductive Technologies

All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others