Micromaniplulation and Assisted Fertilization
IVF
Egg Donation
Egg Recipient
COS - Medication Instructions (English)
COS - Medication Instructions (Spanish)


Infertility Treatment
Controlled ovarian stimulation: Controlled Ovarian Stimulation is a treatment where we use fertility drugs in different combinations in order to control the ovaries. Controlled ovarian stimulation is done to ensure ovulation with patients with an ovulation or ovulatory dysfunction or during cycle treatment of assisted reproductive technology in order to rescue more eggs from the ovaries. Increasing the numbers of eggs increases the chance for conception either through insemination cycles or through IVF. Different drugs are used in controlled ovarian stimulation. Some of them come in pill form (like clomiphene citrate) and some of them come in the form of daily injections. A specific regime for each patient is created based on the patient's history and her hormonal status.

In Vitro Fertilization: In IVF, our laboratory virtually becomes the Patient's fallopian tubes. The sperm and egg mature, chemically change (capacitation), join (fertilization), and form life (the embryo) all within a culture that exactly duplicates the fluid in human fallopian tubes. The process starts with hormone stimulation of the female partner to induce egg maturation and release. After laboratory fertilization of the retrieved eggs, the embryo is transferred to the uterus.

The culture fluid is truly the magic elixir in this process, turning laboratory scientists into miracle workers. The indications for IVF Include damaged fallopian tubes, low sperm count, endometriosis, or unexplained infertility.

For IVF Patient Information and Instruction click here

Gamete Intrafallopian Transfer (GIFT): One step beyond IUI and IPI is GIFT, the cycle begins with ovulation enhancement followed by egg harvest, usually by means of laparoscopy. Then the gamete (the female eggs and the male sperm) are placed separately into a catheter and injected directly into the woman's fallopian tubes. Fertilization occurs in the woman's body, not outside (as during in vitro fertilization). GIFT mimics the way a normally fertilized egg would begin Its journey into the uterus for implantation.

GIFT requires that a patient have at least one good fallopian tube. The GIFT technique is a one-step procedure lasting 40 to 60 minutes. The procedure is performed on an outpatient basis at the institute.

Zygote Intrafallopian Transfer (ZIFT): In this treatment, following treatment, following retrieval of eggs in a similar way to in vitro fertilization, the eggs are fertilized in a dish. The next morning, when the eggs have fertilized, they are called zygotes. At this stage, the zygote can be transferred back to the uterus through laparoscopy in the manner as the GIFT procedure. Chances for success rate are equal for GIFT, tubal embryo transfer, and in vitro fertilization.

TSET- (Tubal Stage Embryo Transfer): In this treatment, following retrieval of eggs in the same manner as in vitro fertilization, the eggs are fertilized in a dish and two days later, when they become embryos, the embryos are transferred to the tubes via laparoscopy. The treatment success rate is equal to GIFT, ZIFT, and IVF.

Intra Uterine Insemination (IUI): The usefulness of IUI for infertile couples is well established. IUI involves selection of the best sperm and inseminating it into the top of the uterine cavity so it can progress and meet the egg in the faIIopian tube. Correct timing of insemination, precise control and monitoring of follicular development and ovulation are critical factors in achieving pregnancy.

Intra Peritoneal insemination (IPI): IPI is a valuable addition to assisted reproductive technology. The procedure involves placement of prepared sperm through the vaginal wall into the peritoneal cavity in an area called the cuI-de-sac, which is adjacent to the ovary. Precise timing IPI enables the sperm to meet the egg in the cul-de-sac, and start the fertilization process. The method is particularly beneficial for couples with suboptimal sperm, since sperm motility and function are enhanced and fertilization potential is increased by bringing the sperm closer to the egg in the follicular fluid environment

Egg Donation: Egg recipients may be women who are otherwise healthy but have lost their ovarian function prematurely. Ovarian function may be lost spontaneously, or following surgical removal of the ovaries. At the Diamond Institute, carefully screened egg donors, either known and chosen by the couple or anonymous donors, undergo egg retrieval. The eggs will then be fertilized by the husband’s sperm and the embryo will be transferred to the recipient uterus.

For Egg Donation Patient Information and Instruction click here
For Egg Recipient Patient Information and Instruction click here

Sperm Cryo-Accumulation: While not a new process, until recently, sperm cryo-accumulation for treatment of low sperm count has been relatively unsuccessful because freezing and thawing is damaging even to normal sperm. However, the new method used at the Diamond Institute employs a new technique that is particularly effective.

Cryo-accumulation is a two step process for the selection and preservation of sperm. Initially, high gravity centrifugation, coupled with special sperm selection techniques, is used to obtain concentrated samples. The samples are combined and frozen using a cryo-protectant medium that shields the sperm and increases the energy potential of each individual sperm. The concentrated sample will be used later for timed Insemination. With the use of cryo-accumulation, pregnancies and deliveries have been achieved for couples when the male had severely reduced sperm count (as low as one million sperm per ml).

Sperm Preparation Male Antisperm Antibody: Insemination and IVF/ICSI are both acceptable treatments for male antisperm antibody. In both situations, the sperm has to be prepared and washed in order to reduce the amount of antibody attached to the sperm. Using a three stage preparation, the sperm is first produced in medium that dilutes and attaches to the antibodies. In the second stage, the sperm that carries antibodies on the surface is separated from the ones that are clean of antibodies. In the third stage of preparation, the sperm in then concentrated and prepared for other insemination or in vitro fertilization/ICSI.

Treatment of Immunological Infertility: (content to follow)

AID (Artificial Insemination with Donor): This treatment is known to help male infertility problems since the beginning of the century. Sperm stored in a bank is used for insemination. The indications are for males that have no sperm at all even inside the testicles or any other form of sperm problem when the couple does not wish to do in vitro fertilization/ICSI. As in vitro fertilization/ICSI resolves most sperm problems today, the need for artificial insemination is less. When artificial insemination with donor is done in the proper manner with the right controls and right timing, it gives a high chance for conception, which is usually a higher than normal chance in nature, for a cycle attempt.

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Micromanipulation and Assisted Fertilization

Intracytoplasmatic Sperm Injection (ICSI): ICSI involves selecting one sperm from those coIIected and injecting it through the egg membrane and into the actual cytoplasm of the egg. Prior to ICSI, the prospective mother undergoes short-term hormonal stimulation to maximize the number of good eggs. ICSI is a breakthrough for treating male infertility, resulting in pregnancies for couples otherwise unable to conceive with their own sperm.

Assisted Hatching: The human embryo is surrounded by a shell named zona pellucida until approximately the sixth day after fertilization. In order for the embryo to implant in the uterus lining, it first has to hatch out of the shell. The process of hatching happens when the zona pellucida is opening and the embryo will hatch and then implant.

The placement of a human embryo in the uterus after in vitro fertilization (IVF) does not ensure hatching and implantation. Thickening or hardening of the zona pellucida may prevent hatching of the embryo and, therefore, prevent implantation. The possible reasons for thickening and/or hardening of the zona pellucida include maternal age, elevated FSH, and embryo freezing. Assisted hatching is therefore recommended to women with advanced age and premature implantation failure.

The process of assisted hatching has been developed and used to enhance in vitro fertilization success. This process involves careful thinning of the zona pellucida without any damage to the embryo itself.

We have used the technique successfully with many of our patients. The technique has currently been used around the world for almost 10 years and the results indicate possible benefits with no increase in miscarriage rate or pregnancy complications. Children born following IVF and assisted hatching are normal and have not demonstrated an increase in malformations or other abnormalities.

Epididymal Sperm Aspiration for ICSI: (content to follow)

Testicular Sperm Aspiration for ICSI (TESA): TESA is a novel method applied to retrieve sperm from the testes for- IVF by ICSI. It allows us to isolate a single sperm out of testicular tissue removed by testicular biopsy. This is of utmost importance for patients with extremely low sperm production and absence of sperm in the ejaculate (azoospermia). The technique is also helpful for men with surgical or congenital blockage of the vas deferens.

Microsurgical Epididymal Sperm Aspiration (MESA): (content to follow)

Surgical Procedures

• 1) Microsurgery and Tubal Reconstruction
• 2) Operative Hysteroscopy
• 3) Operative Laparoscopy
• 4) Tubal Cannualation


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IVF Patient Information and Instruction

IVF CYCLE
IVF In vitro fertilization was first successfully performed in 1978 in England. Since that time, this procedure has helped millions of otherwise, infertile couples to become pregnant. WHAT IS IVF? The physicians of the Diamond Institute began performing IVF in 1990. IVF is a method of assisted reproduction whereby a woman's fallopian tubes are entirely bypassed. The eggs are surgically removed from the patient's ovaries, transferred to a Petri dish where they are fertilized with her partner's sperm, and then the embryos are transferred back into the uterus.

WHO ARE CANDIDATES FOR IVF?
IVF is a treatment for couples with various types of infertility. Initially, it was only used when women had blocked, damaged, or absent fallopian tubes. Today, it is also used for endometriosis, male factor, immunologic factors, ovulatory dysfunctions, and unexplained infertility.

BASIC STEPS OF IVF
1) Ovulation Enhancement- Drugs are used to stimulate the ovaries to grow several mature eggs rather than the single egg that normally develops each month. Most often, the drugs are given over a period of 7-10 days.

2) Retrieval of Eggs- Egg retrieval is timed carefully through close monitoring of the growing follicles by vaginal ultrasounds and daily blood work. Minimal intravenous anesthesia is required for the ultrasound-guided vaginal retrieval and the entire process is performed on an out-patient basis at the institute.

3) Fertilization- A process in which the partner's washed sperm and mature eggs are combined in fluid mimicking that of the human fallopian tubes and incubated until embryos of 4-8 cells are formed. For some patients, we may wait for the embryos to reach the blastocyst stage before transfer.

4) Embryo Transfer- The placement of fertilized eggs/embryos into the uterus. Transfer takes approximately 15 minutes, but you will be in bed for two hours following the procedure. No anesthesia is required.

PRE-TESTING FOR AN IVF CYCLE
There are several tests and procedures that must be completed before an IVF cycle can be initiated. Basic testing includes analysis of hormones and immunological factors, vaginal ultrasounds for the evaluation of the uterus and ovaries, hysteroscopy for evaluation of the uterus, and semen analysis. Any other procedures or evaluations may be added as deemed necessary for the individual.

GENERAL INFORMATION AND INSTRUCTIONS IVF TREATMENT CYCLES
The following pages will give you specific details about your treatment cycle. They include a generalized picture of an IVF cycle, however, please remember that these cycles are created for an individual and may vary. To ensure the most effective treatment, it is extremely important that you follow your instructions carefully. We are happy to answer any questions regarding this or any information you have received. Please contact us if you are unsure of any aspect of treatment, especially medication administration.

To begin a treatment cycle please:
Notify one of the IVF Nurse Coordinators on Day 1 of your menses "period". If your menses begin during non-office hours, please wait until the next day to notify us. . Make an appointment for Day 2 or 3 blood tests and ultrasound scan according to your individual protocol. . Write down when you are to take your medications and when you are to return to the office for various procedures after speaking with an IVF Nurse. It is important to take only those medications we prescribe for you. If you take other medications routinely that are prescribed by another physician, please tell us. Also, remember that there are other forms of drugs, such as smoking and alcohol, which we discourage.

BLOOD TESTS AND ULTRASOUNDS
Blood tests and ultrasounds are a vital part of your IVF cycle. Although we recognize the stress and inconvenience of the frequent visits, it is imperative that these appointments be kept. If, because of business, travel, or personal reasons, you will be unable to come to the office for the testing required, please notify us before the start of your cycle.

BLOOD TESTS
1) All blood testing must be done in early AM - weekdays between 7:30 and 9AM and weekends 7:30 and 8:30AM.

2) Blood tests will be required starting on Day 3 and daily thereafter until the day of retrieval.

3) On the day you are to get your hCG injection, you will be required to come back a second time to the office between the hours of 3:30 and 4PM on weekdays and between the hours of 11:30 and Noon PM on weekends for blood tests.

4) We will call you daily between 2 to 4PM to give you medication instructions. If you have not heard from us by 4PM please call the office.

ULTRASOUNDS
Vaginal ultrasounds are done by Day 3 and then on the beginning of Day 8. Additional ultrasounds are done at the discretion of the physician. Ultrasounds will be done when you come in for your blood tests. Vaginal ultrasounds are done with your bladder empty. Semen samples will be needed at least two (2) times:

1) Will be cryo preserved before the cycle begins.

2) Will be needed on the day of retrieval. TREATMENT CYCLE Day 2-10: Based on results of the blood tests and ultrasound scans, the patient receives hormones by pill or injection in order to stimulate the ovaries to develop multiple eggs in follicles. The frequency of testing will be determined by your response to these medications.

Ultrasound Scans:
Scans are on Day 3 and as deemed necessary by the physician thereafter.
Day 10-12: Ovulatory process is triggered by injection of hormones (hCG).
Day 13-15: Egg retrieval Partner provides a semen sample. Eggs and sperm are placed together in a laboratory culture medium.
Day 15-18: Transfer of microscopic four to eight (or sometimes blastocyst) cells to uterus. Pregnancy test is done 11 and 13 days following embryo transfer. (ALL THESE DAYS ARE APPROXIMATE AND MAY VARY FROM TRANSFER TO TRANSFER.)

EGG RETRIEVAL
On night before egg retrieval, do not eat or drink anything after midnight. The morning of your retrieval, you and your partner will need to report to the Institute. A semen specimen will be obtained at that time and you will be prepared for the procedure. You will be allowed to go home within a few hours provided your condition is stable.

You may resume normal activity as soon as you feel up to it with the exception of strenuous physical activity. Post Retrieval Symptoms Following egg retrieval, you may experience the following symptoms: -Vaginal Bleeding similar to a light period (this is from the puncture sites during the procedure). -Mild lower abdominal cramps similar to ovulation.

Please call us if you experience: - Heavy vaginal bleeding -severe abdominal pain or swelling - fever higher than 100 degrees F. - Dizziness or fainting. Please weigh yourself (and record) on the day before, day of, and every day after your egg retrieval until your pregnancy test. Please call us to let us know if you experience a weight gain of one to two pounds in one day.

EMBRYO TRANSFER
Day of Embryo Transfer: The physician will discuss with you and your partner the status of your embryos. Remember that while fertilization is a good indicator, it does not ensure embryo development and those with arrested development would not be transferred. Embryo transfer is usually performed with the woman in a reclining position with legs up (same position as a Pap Smear). You may not eat and/or drink before the procedure unless directed otherwise. You will be given an appointment for your pregnancy test. You should then go home and relax for the rest of the day. Following Embryo Transfer you may resume normal activity; however, sexual intercourse may be resumed two days after transfer. Continue your daily progesterone. If your period begins prior to your test date, you will still need to have a pregnancy test performed since bleeding can occur even with pregnancy.

PREGNANCY TEST
Eleven and thirteen days post embryo transfer, you will have a pregnancy test. Hopefully, it will be positive and you will be instructed about the follow up of your pregnancy. Unfortunately, it may be negative. At that point, we would like to see you and your partner for a post IVF consultation.

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Egg Donation Patient Information and Instruction

EGG DONATION CYCLE
Thank you for your response to our request for egg donors. Egg Donation offers renewed opportunity for successful conception in couples who have been infertile due to inability of the ovary to produce eggs, or absence of the ovary. The technique of Egg Donation involves retrieving eggs from the donor and fertilization of the egg by the sperm in the laboratory and placement of the fertilized egg (embryo) into the uterus of the recipient. The Egg Donation process is as follows:

A. INITIAL CONSULTATION AND SCREENING TESTS
Once you have been accepted into the program, the Egg Donation Nurse Coordinator will review the program with you in detail. You will need to undergo screening tests to determine your eligibility, which consist of a consultation, a physical examination, Pap smear, vaginal cultures, vaginal ultrasound, blood tests, and psychological evaluation. Testing may require three to four visits and will be scheduled according to your menstrual cycle and your daily schedule. All testing is paid for by the recipient. At this time, an estimated time for the start of the actual cycle will be established. We require that you avoid excess alcohol and recreational drugs.

B. INDUCTION OF FOLLICULAR DEVELOPMENT
Multiple follicles (the part in the ovary that contains the egg) are needed in order to increase the number of eggs recovered for fertilization, thereby increasing the number of embryos developed and the chances for conception.

The status of the ovary is evaluated by vaginal ultrasound performed on Day 3 of the menstrual cycle. Blood tests and ultrasounds are done between 7:30 AM and 8:30 AM. We will accommodate your schedule. You will be taking daily injections of fertility drugs - Lupron, Metrodin, and Pergonal - provided by the recipient from Day 3 of the cycle to encourage multifollicular development. These medications are taken in the morning and evening and we shall instruct you or the person of your choice on reconstitution and injection techniques.

Follicular maturation is evaluated by daily ultrasound and blood levels. At a time determined by the physician, human chorionic gonadotropin (hCG) is given to bring the eggs to final maturity. Thirty-five hours after you will undergo the egg retrieval, which is done in the morning in our office.

C. SURGICAL PROCEDURE
Aspiration of follicles for eggs is performed through an ultrasound probe approach. This method requires IV sedation, however, epidural or general anesthesia may be required in special circumstances.

The retrieval consists of aspirating the ovarian follicles and then identifying the eggs under a dissecting microscope. The eggs are then held in an incubator until the time of insemination in the laboratory. On this day, you must have someone drive you home.

D. POST-OPERATIVELY
You will be seen for two visits after the retrieval at the intervals of one week and then at the time of your next menstrual cycle to ensure your optimal health.

E. COMPENSATION
You will be compensated on the day of the egg retrieval. However, some patients have an inadequate response to ovarian stimulation in a particular cycle and it is necessary to cancel that cycle. If your cycle is cancelled before the day of egg retrieval, partial compensation will be provided. Egg donation is a wonderful gift to an infertile couple; however, it requires a big commitment on your part. We ask that you review and consider all aspects of it before you decide to become a donor.

F. DONOR FORMS
the first step is to print the following forms and mail a completed copy to:

Egg Donation Program
Diamond Institute for Infertility
89 Millburn Avenue
Millburn, New Jersey 07041

For Egg Donor Forms click here

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Egg Recipient Patient Information and Instruction


EGG DONATION PROGRAM RECIPIENT INFORMATION
Egg donation, a variation of In-Vitro Fertilization (IVF), offers renewed opportunity for successful conception in couples who have been infertile due to inability of the ovary to produce eggs. The techniques of Egg Donation involve synchronizing donor and recipient menstrual cycles with medication, retrieval of eggs from the donor, fertilization of eggs by sperm in the laboratory, and placement of the embryos (fertilized eggs) into the uterus of the recipient.

INDICATIONS: Candidates for Egg Donations may be married or single and may have one or more of the following conditions: premature ovarian failure, gonadal dysgenesis (malfunction of the reproductive organs/chromosomal abnormalities), removal of ovaries (ies), IVF patients with failed stimulations or poor quality eggs, declining or no ovarian function and, finally, those with genetic disorders.

INITIAL CONSULTATION: Your initial consultation will include a meeting with one of the physicians to review your medical history, and at that time, a physical examination will be performed. It may include a Pap and cultures. At your convenience, an additional consultation with one of the nurse coordinators will be scheduled to review the program in detail, discuss the necessary screening tests, and answer any questions you may have. This consultation will end with an assessment of the financial obligations.

SCREENING TEST FOR RECIPIENTS: A list of necessary tests you will need to have is included on a separate sheet. The Mock Cycle, a preparatory cycle that hormonally mimics a natural menstrual cycle, is done prior to the actual Egg Donation cycle to measure the endometriumwith possible biopsy and, if necessary, a hysteroscopy to evaluate the uterus.

CHOOSING A DONOR: Donors can be either known (family member or friend) or anonymous (through the Diamond Institute's anonymous pool of donors). Anonymous donors are available on a first come, first serve basis but, in our experience, recipients have not had to wait for more than six months for an appropriate match. Anonymous donors are offered first to those recipient couples who have completed all the necessary testing. Donors undergo psychological and physical testing before they are accepted into our program. Anonymous donors are between the ages of 21-34; known donors must be over the age of 21 and, although we have no upper age parameters, the donor must have enough ovarian function to respond adequately to stimulation.

It is our policy not to use any donor more than three times. For those choosing anonymous donors, you will be given a complete description of the physical characteristics and medical history of the donor and her family. Any other pertinent information that you find helpful will be provided, if available, with the donor's consent. As previously noted, donors are offered to the recipient couple at the top of our list. If you are offered a donor with whom you do not feel adequately matched, you may refuse that donor and wait for the next available one. Your name does not go to the bottom of our list. That donor, however, will be offered to the next recipient couple who have completed their testing. If you have any special requests, please make the nurse coordinator aware of them. Included on separate sheets are the complete lists of all the testing done for known and anonymous donors.

TREATMENT CYCLE: In order to begin the Egg Donation process, it is necessary to synchronize the menstrual cycle of both the donor and the recipient. The medication protocol for anonymous donors is usually GnRH agonist (e.g. Lupron) and gonadotropins (e.g. Humagon Perganol, Metrodin, and hCG). These medications are provided by the recipient as well as any other medications deemed necessary by the physician (i.e. antibiotics). Medication protocols for known donors are determined individually, based on the age and previous fertility history of the donor.

RECIPIENT: We will prepare your endometrium hormonally by giving you Estrace and adding progesterone the day after the donor takes hCG. The same protocol of medications that was used for the Mock Cycle will be used for the actual cycle. Vaginal ultrasounds will be done to measure the thickness of the endometrium at least two times at the physician’s discretion. Approximately two or three days before the embryo transfer, the physician will pass the catheter used during the actual embryo transfer procedure through the cervix to establish the best method to use.

DONOR INDICATION OF FOLLICULAR DEVELOPMENT: Multiple follicles (the parts in the ovaries which contain the eggs) are needed in order to increase the number of eggs recovered for fertilization, thereby increasing the number of embryos developed and the chance for conception. The status of the donor's ovaries is evaluated by vaginal ultrasound performed on Day 3 of the menstrual cycle. Blood tests and ultrasounds are done between 7:30AM and 9:30AM. The donor will be taking daily injections of the fertility drugs provided by the recipient from Day 3 of the cycle to encourage multi-follicular development.

INCOMPLETE OR DISCONTINUED CYCLES: It is important to realize that 15-20% of IVF cycles started are not completed and that there are several points in the process when cancellations can occur. The following is a list of indications for possible cancellations: *Inadequate ovulatory response to medications. Cancellation may occur any time, up to and including the day of egg retrieval. Each cycle must be viewed individually because hormonal response can vary from cycle to cycle for each individual. In other words, a poor response one cycle does not necessarily preclude a good response in a subsequent cycle. *No eggs retrieved. This is a rare phenomenon, but it does occur in less than 1% of cases. Again, this is not necessarily predictive of future cycles. *No fertilization. This occurs in approximately 4% of cases and can be a result of poor egg quality, poor sperm quality, immunological factors, or for undetermined reasons. Again, this is cycle specific and my not recur. *Acute illness which may occur may preclude the use of anesthesia.

DONOR/RECIPIENT TREATMENT CYCLES

CYCLE DAY 1-13:
DONOR: Based on results of blood tests and ultrasound scans, the patient receives hormone injections to stimulate the ovaries to develop eggs in follicles. The frequency of testing will be determined by response to these medications.
RECIPIENT: Medications (Estrace) begin on or around Day 1 of the donor's cycle and are increased or decreased accordingly.

ULTRASOUND SCANS:
DONOR: Scan performed on Day 3 and as deemed by the physician thereafter.
RECIPIENTS: Scans performed two or three times during the cycle at the physician's discretion.

DAY 10-12:
DONORS: Ovulatory process is triggered by injection of hormone (hCG).
RECIPIENT: Trial passage of embryo transfer catheter through the cervix. Begin progesterone injections the day after the donor takes hCG.

DAY13-15:
DONOR: Egg retrieval will be performed.
RECIPIENT: Husband/partner provides semen sample. Eggs and sperm are placed together in laboratory culture medium.

DAY 15-16:
RECIPIENT: Transfer of microscopic two to eight cell embryos to uterus. Pregnancy test is done 11 and 13 days following embryo transfer.

BLOOD TESTS AND ULTRASOUNDS
Blood tests and ultrasounds are vital part of your Egg Donation cycle. If, because of business, travel, or personal reason, you will unable to come to the office for testing required, please notify us before the start of your cycle.

Blood Test:
1. All blood testing must be done early in the morning - weekdays between 7:30AM and 9:00AM - weekends between 8:00AM and 9:00AM.
2. Blood tests will be required four to five times to be decided individually.
3. You can call the office for your blood work results and medication instructions between 3:00PM and 4:00PM or we will call you.

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