The Fertility Institute of Hawaii has some of the world’s leading experts on In Vitro Fertilization with over 30 years of experience treating infertile couples. The doctors (Dr. John Frattarelli and Dr. Anatte Karmon) are the most experienced IVF providers in Hawaii having personally overseen more than 35,000 fertility treatment cycles that resulted in more than 15,000 babies born.
Certified as a High-Complexity Clinical Laboratory Director (HCLD), Dr. John Frattarelli, HCLD is one of only a few physicians nationally and the only physician in Hawaii who also is qualified to serve as Laboratory Director for the IVF Laboratory. This allows him to provide unique oversight for all Clinical and Laboratory aspects of the IVF practice. This unique oversight of the entire program contributes to the tremendously high pregnancy rates that the Fertility Institute of Hawaii is able to achieve.
The Fertility Institute of Hawaii has offices on Oahu in Honolulu and on the windward side in Kailua. The providers also see patients in Maui and on the Big Island in Hilo and Kona. The Fertility Institute of Hawaii’s IVF program has consistently had superior pregnancy rates that ranked as one of the best in the world.
IVF is a procedure designed to enhance the likelihood of conception in couples for whom other fertility therapies have been unsuccessful or are not possible. It is a complex process and involves multiple steps resulting in the insemination and fertilization of oocytes (eggs) in our laboratory. The embryos created in this process are then placed into the uterus for potential implantation.
In Vitro Fertilization is commonly referred to as IVF. IVF is the process of fertilization by manually combining an egg and sperm in a laboratory dish. When the IVF procedure is successful, the process is combined with a procedure known as embryo transfer, which is used to physically place the embryo in the uterus.
The IVF process can be broken down into five steps which include the following:
In a normal menstrual cycle, only one egg/oocyte each month develops and matures. The egg matures with a fluid filled structure on the ovary called a “follicle” which can be seen on ultrasound. In an Assisted Reproductive Technology (ART) cycle, ovulation induction medications (typically daily self-administered injections) are used to stimulate the ovaries so that multiple follicles (eggs) will develop.
Depending on your stimulation protocol, you may begin your first medication in the menstrual cycle preceding the IVF cycle. Then, after your next period, the ovulation induction hormones are begun. Exact instructions regarding their use will be given to you at that time by the staff. These medications will be used for approximately 8 to 12 days, depending upon how your ovaries respond. These medications and their use will be explained in detail before each cycle.
When the majority of follicles have reached a mature size (17 to 20 mm), another medication, human chorionic gonadotropin (hCG), will be given by injection. The hCG must be given at the appropriate time of follicle development to prepare the egg for removal from the body.
Beginning around cycle day 3, we will draw blood samples every 1 to 3 days to monitor the hormones levels in your blood. These blood tests will be used to determine if the levels are in the range that we would expect prior to ovulation.
Ultrasound monitoring of the ovaries will also be used to follow follicular growth. The ultrasound machine works by sending out sound wave signals which reflect off different structures in the pelvis and give an image of follicles growing on each ovary. When indicated by your hormone levels, ultrasounds will be performed daily as well.
Because ultrasounds are performed using a vaginal probe, you do not have to fill your bladder for this procedure. There have been no harmful effects to developing oocytes or early pregnancy from ultrasound. Monitoring and daily decisions about your care are made by your provider.
When ultrasound and blood estradiol levels indicate that the follicles are maturing, you will be instructed to give the trigger injection in the evening. Depending on your individualized IVF protocol, your injection may consist of HCG, Lupron, or a combination of both. You will be told the specific day and time to give your injection. The egg retrieval is usually performed 34-37 hours after the trigger injection is given. We ask that the male partner refrain from sexual intercourse from the time of trigger until after the egg recovery, in order to obtain the best sperm sample possible.
The morning after your hCG injection you will receive final instructions for egg recovery and final medications.
The majority of IVF patients have a sonographic egg recovery performed. This procedure uses ultrasound guidance to retrieve oocytes from your ovaries. The physician places the ultrasound probe into the vagina and guides the aspirating needle through the vagina into follicles on each ovary. Fluid is aspirated from the follicles and transferred to the embryologist, who will identify the eggs under the microscope.
Eggs are cultured and fertilized in the Embryology Laboratory.
During or immediately following the egg recovery, the male partner will need to give a sperm sample. A private room is provided for discrete semen collection. Patients who need to use donor sperm will be given instructions on ordering donor sperm at the time of the initial screening appointment.
Once the eggs are retrieved, they will be placed in special fluid media for approximately 6 to 12 hours. The semen specimen will be prepared to isolate the best sperm for insemination, then placed with the eggs and incubated overnight. Intracytoplasmic sperm injection (ICSI) may be performed instead for any sperm abnormalities detected.
The eggs will then be examined for signs of fertilization, and normally fertilized eggs will be placed into a special growth medium. Embryos will be examined on the third day following insemination. Normally developing embryo(s) will be transferred back into your uterus three to six days after egg recovery, depending on the number and quality of the embryos as they develop in our laboratory.
Not all follicles aspirated can be expected to yield an oocyte. Moreover, all kinds of oocytes can be recovered: mature, immature, and post-mature or degenerate. You will be notified about the number of eggs that have fertilized the day after egg retrieval. Detailed information about the developing embryos will be available at the time of embryo transfer, at which point you will have an opportunity to discuss these results with your provider. Some patients require special therapy such as assisted hatching to enhance implantation of the embryos. These therapeutic options will be discussed in detail with you at your appointments.
This is the return of the embryos that have developed in our laboratory into your uterus. You will lie on an examination table as if you were going to have a Pap smear. There will be no anesthetic required. A very fine soft catheter is placed through the cervix into the uterine cavity under ultrasound observation, and the embryos are transferred inside the uterus through the cervix. Your partner or a friend may be with you during the transfer and during the 15 minute rest period.
The practice of transferring multiple embryos to a woman’s uterus increases her chance for a pregnancy, but also raises the odds of having a multiple birth. The rate of multiple births for ART is higher than that of the normal population. Most of these are twin pregnancies; however, if more than two embryos are transferred, the risk of higher order multiple pregnancies (e.g. triplets) becomes a concern. Multiple pregnancies have increased risks for both mother and babies, particularly preterm delivery.
You will speak to your provider about your chances of pregnancy and risk for multiple pregnancy. Together, you can determine the appropriate number of embryos to transfer (usually one to three) depending on your personal medical situation.
Many patients will have embryo cryopreservation with a subsequent frozen-thawed embryo transfer rather than an embryo transfer immediately after the egg retrieval. Your provider will discuss this option with you in detail during your IVF cycle.
Depending on your personal medical situation and the quality and number of embryos, you will have the option of cryopreserving (freezing) the remaining embryos for thawing and replacement at a later time. You can learn more about cryopreservation in the fertility preservation section of our site.
You will need to have a pregnancy test 10-12 days after the embryo transfer. We recommend the pregnancy test and first two obstetric ultrasounds (if applicable) be done with our practice. We are also anxious to know the outcome of your cycle, and are better able to offer medical and emotional support if we are informed right away.
Once pregnancy has been confirmed to be doing well with the ultrasound and bloodwork, we will discharge you to your OB/GYN to continue obstetrical care or, if you do not have one, we can provide names of excellent general obstetrician/gynecologists in your area.
Unfortunately not all ART cycles result in pregnancies, you are encouraged to arrange a follow-up appointment with your provider. The purpose of this visit would be to summarize your cycle, answer questions, and discuss future plans, such as future ART cycles, other infertility options or non-medical family building options.
Unfortunately, neither conception nor a successful outcome of pregnancy is guaranteed by the IVF-ET procedure. There are many reasons why pregnancy may not occur with the IVF-ET procedure. In fact, there are complex and largely unknown factors that limit pregnancy rates following assisted reproductive techniques. Some of the known reasons for failure may include, but are not limited to:
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