Minimal stimulation IVF

The first IVF baby in the world, back in 1978, was conceived during a natural menstrual cycle, without the use of any fertility drugs. The introduction of fertility drugs into the conventional IVF stimulation protocols has resulted in an overall improvement in both the pregnancy and live birth success rates. However, one of the disadvantages of using injectable fertility drugs is that they increase the cost of IVF substantially. Not only the drugs themselves are expensive, but also their use require close patient monitoring that involves more office visits for ultrasounds/blood tests before the actual egg retrieval takes place, as well as more work from the IVF laboratory personnel after retrieval to care for the resultant number of embryos. Therefore, in order to give a chance of pregnancy to infertile couples who simply cannot afford conventional IVF therapy with injectable drugs, minimal stimulation IVF is a more attractive alternative.

The advantages of minimal stimulation IVF include: lower costs, fewer injections and fewer days of monitoring. Even though the cost of minimal stimulation IVF compared to full stimulation IVF is lower, it has been shown that minimal stimulation IVF has decreased overall success rates because there is usually a limited number of available eggs and embryos per retrieval cycle. The minimal stimulation IVF protocol may be beneficial for certain patient populations, such as: high responders who are at increased risk of ovarian hyperstimulation syndrome, patients who are not interested in embryo cryopreservation, patients who want to limit the number of eggs to be fertilized or do not want to discard embryos for ethical or religious reasons and low responders who do not stimulate many follicles during full gonadotropin stimulation.

During minimal stimulation IVF, less expensive medications such as clomiphene citrate or letrozole are used, followed by either a low dose of injectable gonadotropins along with a human chorionic gonadotropin (hCG) trigger shot or just the hCG trigger shot alone. The subsequent basic IVF laboratory techniques of egg retrieval, insemination, embryo culture and embryo transfer in conjunction with progesterone supplementation/pregnancy testing after embryo transfer are identical to those used in conventional IVF cycles.

Fertility Potential Preservation for Cancer patients

Cancer is estimated to affect 100 per 100,000 women in the general population under the age of 50 in the United States. The treatment and survival for cancer has improved dramatically in recent years. Therefore, there is a considerable proportion of cancer survivors in their childbearing years. While it is conventional wisdom that cancer therapy can affect a patient’s fertility potential, less than 25% of oncologists inform their patients about the risks and options for fertility preservation.

Cancer therapy in the form of chemotherapy or radiation therapy, for both malignant and non-malignant diseases, often results in infertility due to premature ovarian failure or arrest of sperm production. Thus, cancer patients, even children, can benefit from the fertility preservation technologies. Such techniques can also be implemented when there is a risk of damaging ovaries or testicles due to surgeries in these organs.

Fertility preservation in cancer patients require individualized therapy, depending on the type of malignancy and chosen therapeutic modality. The optimal treatment also depends on time available before treatment, patient’s age and availability of a sexual partner. In fact, most male cancer patients have long been able to preserve their fertility potential by freezing their sperm prior to therapy.

Fertility options for women have evolved more slowly. In vitro fertilization with embryo transfer is a well-tested procedure that leads to high pregnancy rates (30-40% per frozen embryo cycle). Hormonal stimulation is required for the production of the eggs, which may not be recommended for certain types of cancer. The IVF option would also require that the woman has a partner or be mature enough to pick an anonymous sperm donor. Another consideration is that if the patient does not survive her cancer, the frozen embryos could potentially be left behind, raising ethical issues for their ultimate use.

Oocyte donation

For the patient who cannot freeze eggs or embryos, an egg donor may be a viable alternative. Pregnancy rates with egg donors that can be fertilized with a partner/donor sperm and transferred to the patient’s uterus are very high, as long as the donor has good quality egg and the patient has a healthy uterus.

Ovarian tissue freezing

Many oncologists do not support the use of assisted reproductive technologies because it involves the exposure of a cancer patient to high levels of estrogen, which could be detrimental in women who have estrogen-dependent tumors. For these women, ovarian tissue freezing may be an option. This therapeutic modality does not require hormonal stimulation and may be used in pre-pubertal patients. Many immature eggs may be preserved this way, but extensive laboratory culture and/or surgery to replace the ovarian tissue back in the body is still necessary. Even though “auto-grafting” has resulted in a few pregnancies, this therapy is still in early development.

Although these technologies of fertility preservation are available, it is important to notice that there are no large randomized clinical trials to evaluate these interventions. There are no long-term follow up studies assessing the possible effect that these techniques may have on cancer survivors. To date, the available medical literature has demonstrated that pregnancy after cancer treatment does not trigger cancer recurrence, even in survivors of breast cancer. While chemotherapy can damage growing eggs and sperm, this damage generally disappears within 6 months to 2 years after therapy. Nonetheless, pregnancy after cancer can have some increased risks, such as maternal heart failure after certain types of chemotherapy. These pregnancies must be closely followed by a specialist in maternal fetal medicine.

In addition, birth defects in children born to cancer survivors are not any higher than in the general population (2-3%). No unusual risk for genetic diseases, such as Down syndrome and Turner syndrome, has been identified in the offspring of cancer survivors, neither has the risk of unusual cancers been identified in these children. Patients with inheritable diseases can have treatment with in vitro fertilization and pre-implantation genetic diagnosis to select for unaffected embryos for implantation into the uterus.

Gestational Carriers (Surrogacy)

A gestational carrier is a woman who carries the fertilized egg from another woman to term in her uterus. There are two types of surrogacy: classic and gestational. In a classic surrogacy cycle, the gestational carrier is inseminated with sperm from the child’s father. The gestational carrier’s egg is fertilized inside her body and the resulting baby is carried to term on behalf of the intended mother.

In gestational surrogacy, the baby may be conceived entirely by the intended parents (the biological mother’s egg is fertilized with the biological father’s sperm or by a sperm donor). The resulting embryo is then placed in the gestational carrier’s uterus and carried to term. Gestational surrogates may be relatives, friends or women that have not met the intended parents before. The best gestational carrier candidates are usually highly committed women under age 40 with proven fertility potential and at least one healthy child. Potential surrogates must undergo thorough medical and psychological testing. The involved parties are advised to seek legal counsel before the process. A legal contract must be in place prior to the process in order to delineate the adoption process of the intended parents.

Once a surrogate is selected, she will undergo a “mock cycle”, in which she will use all the fertility hormones administered during a frozen IVF cycle. This cycle allows Dr. Gomez to make sure that there are no problems with the uterine lining. After the cycle is complete, there will be a “mock embryo transfer”, where the cervix angle and the uterine cavity length are measured in preparation for the actual transfer.

The surrogate and the intended mother or egg donor are then given birth control pills to synchronize their menstrual cycles. Leuprolide, estrogen and other medications are then given to prepare the uterine lining in the surrogate. The eggs are retrieved and fertilized with the male partner or donor’s sperm. Then, one or more embryos are transferred to the surrogate. If the implantation of the embryos is successful, the surrogate may carry the pregnancy to term. Any unused embryos may be frozen for future use.

Infertility and IVF Financing Information

The cost of the diagnosis and treatment of IVF could be financially challenging for many patients. This reality holds true because this kind of therapy is not covered by most insurance carriers in the state of Florida. However, our infertility testing and treatment options are affordable. Some programs offer a money back guarantee, flexible financing options and package prices without hidden fees.

For patients with insurance coverage, we accept most commercial insurance carriers (Aetna, Blue Cross/Blue Shield, Cigna, Humana Health Plan and United Healthcare) in our office. If your health plan is not listed, please call our office in order to determine eligibility for covered services. As a courtesy to all our patients, we will file your insurance claims to the corresponding health insurance carrier. However, every patient is the ultimate responsible party for all charges generated by your infertility treatment at Reproductive Medicine Institute.

All patient with insurance coverage are expected to present a current insurance card and photo ID at each appointment. All co-payments, co-insurance, deductibles and past due balances must be paid in full at the time of service. Therefore, all patients should be prepared to pay for all charges at the time of their office visit.

We accept cash, money orders, cashier checks and most credit cards (VISA, MasterCard, Discover, American Express, JCB and Dinners Club) as methods of payment.

If an insurance plan does not pay RMI within 30 days of service, you will receive a bill from our billing department. It is the patient’s responsibility to address any disputes regarding insurance payment or non-payment of their medical treatment directly with their insurance company.

If your health insurance plan has assigned you a primary care physician (PCP), a prior authorization or referral is required at the time of your appointment. Please be prepared to furnish such information when you check in at our office. If for any reason you could not provide this information, you will be asked to either reschedule your appointment or to pay for the visit in full. If you opt to pay the visit in full, you will need to sign a financial waiver taking full responsibility for the payment of your office visit or treatment. Thus, your insurance carrier will not be responsible for payment of such visit. Nonetheless, a receipt of payment will be provided, which you could submit to your insurance company for reimbursement.

If a refund is due to you, it will be released only after the insurance carrier has processed ALL your claims.

For patients in need for IVF financing any infertility treatment, RMI has partnered with many lending companies (Advanced Reproductive Care-ARC, Med Loan Finance) which provide low interest rates loans to qualified patients. Our money back guarantee IVF program is through the Advanced Reproductive Care group. Please feel free to contact any of these programs through phone, fax or on-line.

Egg Donation (Donor Egg in VITRO)

Some couples are unable to achieve a pregnancy for a variety of causes, including but not limited to: advanced reproductive age (>35 yo), poor egg quality, ovarian dysfunction, surgical removal of the ovaries due to chemotherapy or for genetic reasons. For women who have an intact uterus, the use of donor eggs becomes an option to conceive a child.

The egg donation therapy is commonly called “third party reproduction”. Egg donation has been offered in the United States since 1986. This therapeutic modality is nowadays highly regulated by the Federal Drug Administration (FDA). Egg donors must fulfill stringent criteria, put together by the FDA, in order to be considered to become a donor. As egg donation becomes more widely accepted and available, more women are choosing it as an option for infertility treatment.

The egg donation process involves the selection of a donor patient (usually a women younger than 28 years old) by a recipient couple. The egg donor could be known or anonymous. The egg donor will undergo ovulation induction to produce multiple eggs. These eggs are retrieved form the donor and fertilized with the recipient’s male partner sperm. The resulting embryos will then be transferred to the uterus of the recipient’s female partner. It is important to understand the role of each participant (donor, female recipient, male partner) when exploring the option of egg donation.

Egg donation is a successful treatment option for many patients. Often times, the IVF pregnancy success rates using an egg donor are superior to the traditional IVF pregnancy rates. These outcomes reflect the use of healthy eggs donated by young women, overcoming the cause of infertility in a given recipient.

At RMI, we adhere to the rigorous egg donation recruitment and matching standards set by the American Society for Reproductive Medicine (ASRM) and the Federal Drug Administration (FDA). Our egg donation program is dedicated to managing complex donation decisions and to ensuring the confidentiality of both donors and recipients.

Gender Selection – Family Balancing

The desire of conceiving a child of a given gender (sex) has been present in society throughout the history of mankind. Until recently, selecting a baby’s gender was only a dream. Gender selection (sex selection) has become clinically possible and available in many in vitro fertilization programs. In fact, the demand for gender selection services has been steadily increasing. Two medical advances have been the driving forces that have allowed gender selection a possibility: improvement in the techniques of sperm selection (Microsort) and the ability to genetically assess embryos prior to transferring them back into the uterus (Pre-implantation Genetic Diagnosis-PGD).

When gender selection is used to prevent a genetic disease, the process is called “medical gender selection”. Some genetic conditions are designated as “sex-linked diseases”. Some of these sex-linked diseases are inherited via the mother but only the male offspring is affected (muscular dystrophy, hemophilia). In other cases, some conditions are more severely expressed in one gender over the other (Fragile X syndrome, autism in males).

Sometimes, gender selection can be “non-medical” or “elective”. In such cases, a child of a specific gender is desired by a couple without obvious medical indications. The most frequent non-medical indication for such gender selection is the so-called “family balancing”, in which one gender is already represented in a family and the other gender is desired.

To date, there are only two techniques that reliably affect the gender of a given embryo. One technique involves the experimental sperm-sorting technique, called Microsort and the other in vitro fertilization (IVF) with PGD. The gender selection technique of Microsort was developed by the Genetics and IVF Institute in Fairfax, VA. Microsort improves the chances for conceiving a girl in approximately 90% of the cases, while the approximate chance to conceive a male child is approximately 80%. In this method, sperm are sorted to the X-bearing and Y-bearing populations based on their weight. A sorted sample of the desired gender is then used in conjunction with intrauterine cycles (IUI) or IVF cycles. However, the Microsort is currently under FDA review and is not currently available in the United States.

Gender selection done through IVF with PGD consists of creating embryos with a couple’s eggs and sperm. On the third day after fertilization, when embryos reach the six to eight cells stage, the embryologist takes off one cell from each viable embryo. This cell is then analyzed for its chromosomal make up. In fact, the removal of a single cell from an embryo does not negatively impact the embryo’s growth or competency potential. This chromosomal analysis allows Dr. Gomez to determine which embryo is male or female. Subsequently, only the embryos of the desired gender are transferred back to the uterus. PGD gender selection is the most reliable method for gender selection, approaching 100% accuracy.

Gender selection is not available around the world. Couples, in many countries, have no choice but to seek this kind of medical treatment abroad. Thus, a good proportion of RMI’s overall patient population seeking gender selection services comes from overseas. We provide personalized treatment protocols and collaboration with reputable IVF centers in patient’s local areas whenever possible. RMI has also partnered with a few nearby hotels/motels to assist our out of town patients with their lodging needs. Please call our office for more information.

Pre-implantation Genetic Diagnosis (PGD)

Pre-implantation genetic diagnosis (PGD) is a technique that allows the testing of embryos for genetic disorders prior to performing their transfer back into the uterus. These genetic conditions can interfere with embryo development and implantation into the uterus, resulting in pregnancy loss or the birth of a child with physical problems, developmental delay or mental retardation. In addition, the PGD technique is extremely helpful for patients whose child may be at high risk of inheriting a genetic disease.

The indications for PGD include: advanced maternal age, recurrent miscarriages, previous unsuccessful IVF cycles, unexplained infertility, male factor infertility and a familial history of an inherited genetic disorder. Thus, the PGD technology improves the chances of a successful pregnancy and birth of a healthy child for couples with any of the previously mentioned diagnoses.

PGD can only be performed as a part of an IVF cycle. IVF is necessary to have access to the embryos and to determine which embryos are free of disease in the embryology laboratory. After the couple completes an IVF cycle, the embryos undergo a biopsy in which one or two cells from each resultant viable embryo are tested for DNA changes (mutations) responsible for a particular condition. It is currently possible to test for over 100 genetic diseases, including but not limited to Down syndrome, cystic fibrosis, sickle cell anemia, thalassemia, Tay Sachs disease, Huntington’s disease, Duchenne/Becker’s muscular dystrophy, myotonic dystrophy, spinal muscular atrophy, hemophilia and some types of leukemia. At the time of DNA testing, the presence of the sex chromosomes (X and Y) could also be determined, allowing the determination of the gender (sex) of the embryo.

Cryopreservation (Freezing) of embryos

The cryopreservation or freezing of embryos is the process by which remaining, good quality embryos from a given IVF cycle could be stored for future use. Cryopreservation of embryos allows for the possibility of pregnancy either when a fresh cycle is unsuccessful or when couples want additional children after a successful embryo transfer. Cryopreservation also avoids many ethical dilemmas by eliminating the need to dispose of embryos. In addition, the medical literature has reported that there is no increase in birth defects or developmental abnormalities in children born from frozen embryos.

As with the case of cryopreserved sperm, many embryos do not survive the freezing and thawing process. In fact, approximately 30-40% of embryos survive the thawing process. Embryos that do survive the thawing process may function less optimal than do fresh embryos, in the sense that they implant and produce ongoing pregnancies at a lower rate than fresh embryos.

Embryo morphology (appearance of the cells/ percentage of fragmentation) is one of the most important factors determining embryo survival. Embryos that are frozen at the 2 through the 8 cells stage of development have about 5-10% greater survival than embryos with an odd number of cells. For this reason, in order to optimize successful pregnancies in the future, only embryos of good quality are candidates for cryopreservation,

A computer-controlled machine that employs special solutions to protect the embryos from damage allows the cryopreservation process to take place. Nowadays, the process called vitrification is the freezing technique of choice in order to obtain more embryos that are viable. This freezing technique is especially important for embryos that are frozen at the blastocyst stage. Blastocysts are much larger embryos that require special handling in order to avoid damage during the freezing process. Frozen embryos are stored in liquid nitrogen at -196°C (approximately -400°F).

Cryopreserved embryos that successfully survive the thawing process are usually transferred back to the uterus during an artificial menstrual cycle in which the patient takes leuprolide, estrogen and progesterone. Clinical pregnancies have been reported from embryos that have been stored as long as 10 years.

Oocyte Freezing

Harvesting and freezing of mature eggs, which could later be fertilized with a partner/donor sperm at a later time, avoids the issues of a patient having to have a partner or pick a sperm donor immediately and prevents the formation of “orphan embryos”. The first baby from a frozen egg was born in 1986. Since then, there have been more than 1,000 babies born worldwide using this technique.

Freezing eggs is more complicated than freezing sperm or embryos. The egg is a large cell which contains a lot of water in its cytoplasm. The water inside of the egg can form ice crystals which can damage the egg and its chromosomes. In order to avoid this damage, a new technique called vitrification has been implemented lately with very encouraging results.

Because the birth rate from frozen eggs is lower than that of conventional IVF, the American Society for Reproductive Medicine (ASRM) considers this technology experimental. Nonetheless, ASRM considers egg freezing an appropriate option for cancer patients, as long as they are informed about the potential risks from the fertility drugs and egg retrieval, the costs associated with the technique and the lower success rates.

Ovarian tissue freezing

Many oncologists do not support the use of assisted reproductive technologies because it involves the exposure of a cancer patient to high levels of estrogen, which could be detrimental in women who have estrogen-dependent tumors. For these women, ovarian tissue freezing may be an option. This therapeutic modality does not require hormonal stimulation and may be used in pre-pubertal patients. Many immature eggs may be preserved this way, but extensive laboratory culture and/or surgery to replace the ovarian tissue back in the body is still necessary. Even though “auto-grafting” has resulted in a few pregnancies, this therapy is still in early development.

Although these technologies of fertility preservation are available, it is important to notice that there are no large randomized clinical trials to evaluate these interventions. There are no long-term follow up studies assessing the possible effect that these techniques may have on cancer survivors. To date, the available medical literature has demonstrated that pregnancy after cancer treatment does not trigger cancer recurrence, even in survivors of breast cancer. While chemotherapy can damage growing eggs and sperm, this damage generally disappears within 6 months to 2 years after therapy. Nonetheless, pregnancy after cancer can have some increased risks, such as maternal heart failure after certain types of chemotherapy. These pregnancies must be closely followed by a specialist in maternal fetal medicine.

In addition, birth defects in children born to cancer survivors are not any higher than in the general population (2-3%). No unusual risk for genetic diseases, such as Down syndrome and Turner syndrome, has been identified in the offspring of cancer survivors, neither has the risk of unusual cancers been identified in these children. Patients with inheritable diseases can have treatment with in vitro fertilization and pre-implantation genetic diagnosis to select for unaffected embryos for implantation into the uterus.

Blastocyst Culture


Blastocyst Culture

Recent advances in embryo culture and transfer techniques have resulted in improved IVF pregnancy rates and reduced multiple birth rates. Traditionally, embryos are transferred back to the uterus on post-retrieval day 3, so-called “a day-3 transfer”. On this day is not uncommon to transfer three or four embryos. However, it is now possible to extend the growth of the embryos in the laboratory until they become blastocysts. A blastocyst is a stage of embryonic development, which usually occurs on day five after fertilization, when the embryo has 50-200 cells. Blastocysts are more capable of readily implanting into the uterus, once they are transferred. Usually the healthiest, strongest embryos make it to the blastocyst stage.

The extended embryo culture allows the selection of the best possible embryos for transfer. The selection process translates into the transfer of fewer embryos back into the uterus. The transfer of fewer number of embryos result in lowering the risk of high order multiple births while maintaining high pregnancy rates. In fact, nowadays there is a trend to transfer a single embryo in the blastocyst stage in selected patient populations.

Assisted Hatching (AH)

During the initial stages of embryonic development, the embryos are contained in a layer of proteins, know as the zona pellucida. The zona pellucida is designed to protect the embryo until it reaches the blastocyst stage of development. In order for an embryo to successfully implant into the uterine lining, the embryo needs to hatch out of this zona pellucida and attach to the walls of the uterine cavity. However, sometimes the embryos may have a difficult time hatching out of their protective layer. This event can occur if the zona pellucida is too thick or if the embryos do not have enough energy to break through this layer. Thus, the procedure called assisted hatching may be needed to help embryos to establish a pregnancy.

The procedure of assisted hatching is another technique of assisted reproduction done during an IVF cycle. Assisted hatching consists of making a small hole in the shell (zona pellucida) of a developing embryo by means of a chemical or laser instrument. Therefore, the hole will help the embryo to hatch out of this protective layer and implant more readily into the uterus.

The procedure of assisted hatching is recommended for women who have failed to become pregnant in previous IVF cycles, poor embryo development, age of 38 and older or have thickened embryo shells, as in the case of eggs coming from patients with polycystic ovarian disease. Assisted hatching is most often performed on embryos transferred on day three after retrieval. Scientific studies have shown that the assisted hatching process improves both implantation and pregnancy rates in many infertile couples.