Pennsylvania Reproductive Associates (PRA) provides state-of-the-art treatment of infertility through the use of assisted reproductive technologies (ARTs). Participants in our program are cared for by a highly skilled and experienced team of board certified reproductive endocrinologists, reproductive biologists, certified clinical nurse specialists and practitioners, ultrasonographers and infertility counselors.
Pennsylvania Reproductive Associates' (PRA) in vitro fertilization (IVF) Program, initiated in September 1983, was among the first IVF programs in the United States. Ours is a proven program, employing state-of-the-art techniques for sperm penetration, ovarian follicle stimulation, egg retrieval, cryopreservation (embryo freezing), micromanipulation procedures including intracytoplasmic sperm injection (ICSI), preimplantation diagnosis, and assisted hatching. In addition, we have an active anonymous donor egg program as well as an IVF gestational carrier program.
In vitro fertilization (IVF) is the fertilization of an egg by sperm outside the body. Once fertilization has occurred and normal embryo development is confirmed, the embryo(s) are transferred to the uterus. If implantation occurs, the remaining development of the embryo occurs naturally within the mother.
IVF therapy may be appropriate for those who are infertile due to one or more of these problems: absence, blockage or irreparable damage of fallopian tubes, male infertility, endometriosis, unexplained infertility or immunologic infertility.
It is important to have some understanding of the various steps involved in IVF prior to applying to the program. This is a brief outline of the phases involved in IVF. Please note that we offer IVF patient information seminars that are held approximately every 8 to 10 weeks at both our Center City and Plymouth Meeting locations. We strongly recommend that you arrange to attend one of these seminars prior to, or during, your application and preliminary evaluation process. This will give you additional information to make informed decisions while pursuing treatment.
An application is submitted and you will be set up for a clinical interview. You will usually attend an orientation, meet with an IVF nurse, clinical psychologist and a financial counselor. You will also have screening laboratory studies as well as screening procedures done.
All current evidence indicates that success with IVF may be maximized when more than one embryo is replaced. Therefore the purpose of using controlled ovarian hyperstimulation for ovulation induction is to stimulate the production of more than one mature egg from the ovary in order to make multiple embryos.
In order to time ovulation accurately and to maximize the chances of collecting several eggs at the time of the procedure, fertility medications are given. To confirm that the ovulation induction process is proceeding satisfactorily and to predict the time of egg retrieval, the woman will undergo frequent ultrasound and blood examinations for assessment of follicular development and hormonal response. With the use of ovulation induction agents, one or more eggs should undergo maturation. The development of the fluid filled sacs (follicles), which contain the eggs within the ovaries will be measured via ultrasound. Information along with interpretation of hormonal assays and measurement of endometrial thickness will help determine when optimal conditions have been reached. At that point, Human Chorionic Gonadotropin (hCG) is given to induce ovulation and stimulate the final maturation process of the eggs.
In some cases ultrasound and blood tests do not reveal optimal follicular development and/or hormonal response. In cases such as this, we may choose to cancel the cycle and begin a new cycle, often utilizing a different medication protocol. Although it is quite disappointing when a cycle is cancelled, the chances for pregnancy decrease with a less than adequate stimulation phase, and we would like to try to optimize the cycle with adequate stimulation.
Egg retrieval is accomplished primarily by transvaginal ultrasound guided retrieval. Occasionally, egg retrieval may be done transabdominally if the ovaries are not accessible transvaginally.
Ultrasound guided egg retrieval is an outpatient procedure and does not require general anesthesia. Intravenous sedation is given by a Certified Registered Nurse Anesthetist to minimize discomfort. The procedure is performed in the IVF laboratory. A vaginal probe, which is a cylindrical device with an ultrasound transducer on the tip, is introduced into the vagina. This allows for visualization of the ovaries, as well as other pelvic structures. There is a needle guide attached to the vaginal probe that directs the aspirating needle through the posterior vaginal wall into the follicle. Many follicles are aspirated in the ovary with only one puncture. The procedure takes less than one half hour to perform and, in most cases, recovery time is approximately one hour prior to being discharged to home.
In the normal process of fertilization, the early development and implantation of the conceptus (embryo) in the uterus is under the control of the corpus luteum. The corpus luteum produces progesterone and develops in the ovary. Since it is necessary to aspirate this follicle, there is some concern that the normal development of the corpus luteum may be hampered, and thus progesterone production deficient. For this reason we supplement the function of the corpus luteum by the administration of progesterone. Progesterone, either by injection, or vaginal suppositories will be prescribed for you.
Unless there is a pre-existing reason that the patient will be at risk and/or a multiple pregnancy exists in a woman over the age of 35, an IVF patient can expect to see their routine obstetrician for obstetrical care and delivery.
One of the questions often asked is, "What is the risk of an abnormal child?" Under normal circumstances, the birth of an abnormal child occurs in less than 2 percent of the population. A special committee appointed by the Secretary of Health, Education, and Welfare, has considered many aspects of IVF, including the question of whether there is an expectation that there would be an increase number of abnormal children born by the virtue of the assisted reproductive technologies. It is the conclusion of the committee that it is unlikely that this is true. In addition, it has been recently reported for IVF centers around the world and within the United States that there has not been an increased risk of congenital defects, with these procedures, above the expected 2 percent found in the general population.
There may be excess embryos that result from an IVF cycle. Because a replacement of more that three to four embryos in the patients uterus does not increase the chances of establishing pregnancy but only increases the chance of multiple gestation, we recommend that you consider exercising the option of cryopreservation. Freezing of excess embryos allows replacement during an unstimulated cycle and does not entail another ovulation induction phase and egg retrieval. At the current state of technology of cryopreservation, 50 to 70 percent of embryos may survive the freezing and thawing procedures and be available for replacement in the uterus.
Micromanipulation is the ability, using specially designed instruments in conjunction with a microscope, to perform operative procedures on individual cells such as sperm, eggs and embryos. It allows the embryologist to perform "cell surgery" and in the experienced, well-practiced laboratory, these procedures are safe and will assist patients in overcoming many forms of infertility.
Male factor infertility is a broad category which characterizes conditions of low sperm concentration, low sperm motility or viability, low normal morphology, high levels of anti-sperm antibodies, or cases in which ejaculated sperm are not available necessitating collection of sperm from the epididymis or testis. These conditions are now treatable through a procedure called ICSI. In ICSI, the eggs are prepared by treating them with a gentle enzyme solution to disperse the surrounding envelope of cells surrounding each egg which is called the cumulus complex. Once the mature eggs are identified, each is injected with a single sperm cell. From that point onward, the course of development is comparable to normal fertilization. The fertilization, embryo development and implantation rates are comparable to those achieved through IVF as were the course and pregnancy outcomes.
The collection of sperm from the epididymis or testis deserves elaboration. These procedures, called Percutaneous Epididymal Sperm Aspiration (PESA) , or Testicular Sperm Extraction (TESE) are performed by one of the urologic consultants to PRA, such as Doctors Marmar, Hirsch, Hirshberg or Fallick. The collection of sperm is performed, with only few exceptions, at our offices and requires only a local anesthetic. The recuperative period is brief.
Once a local anesthetic has been applied, fluid from the epididymis or tissue from the testis is extracted through a fine needle with gentle suction. The sperm contained within this fluid or tissue can then be harvested by the embryologist and used for ICSI.
The patients who may require PESA or TESE have obstructive or non-obstructive azoospermia, or who have azoospermia or oligospermia following radio- or chemo- therapy, or from failed vasovasostomy (reversal of vasectomy). By overcoming barriers to fertilization by directly placing sperm within the egg, ICSI has revolutionized infertility treatment by allowing men, who were previously considered intractably sterile, to become biological fathers.
A particularly frustrating diagnosis for the couple going through infertility is "unexplained infertility". Its very name indicates that no male or female factor was identified in the medical investigation of the couple. For these couples, it is sometimes useful to use an aggressive approach such as ICSI to maximize the opportunity for fertilization even though no male factor, such as low sperm concentration or motility, was identified. On occasion, it is important for the couple and/or their physician to ascertain that the husband's sperm are capable of fertilizing eggs without injection, and they will direct that some of the eggs receive ICSI while the remainder undergoes insemination. This strategy allows an optimization of fertilization through ICSI as well as an opportunity to learn if fertilization can occur un-assisted.
It is also true that some couples will choose to have all of the eggs injected simply to obtain the maximum number of fertilized eggs in cases where there is some concern or doubt about sperm function. In cases in which a low number of eggs is obtained at retrieval, it is routine to perform ICSI on all of them.
The early embryo (for example, 2 to 16 cells) is enclosed and supported by a protein shell called the zona pellucida. As the embryo develops, it increases in both cell number and in diameter, and the zona pellucida grows thinner. Implantation is the process by which the embryo escapes, or hatches, from the zona pellucida that thins to a point through which the expanding embryo can protrude, and eventually exit. The hatched embryo can then attach to and penetrate or invade the uterine lining (endometrium). This phase is called implantation, and is the initiation of pregnancy.
Some couples may not achieve pregnancy because the embryo cannot hatch from the zona pellucida. This may occur in the embryos of older women, with diminished ovarian reserve or with unexplained infertility.
To optimize the opportunity for implantation by the embryos from women who meet these criteria, assisted hatching can be performed on the embryos prior to their transfer into the uterine cavity. Assisted hatching is the creation of a small opening in the zona pellucida through micromanipulation, permitting the facilitated exit, or hatching, of the embryo through this site.
While assisted hatching is a logical step towards improving the implantation potential of an embryo, there is neither consensus nor experimental evidence that it achieves this goal. Nevertheless, assisted hatching does not pose any risk to the embryo when performed in the experienced laboratory; because it may confer an advantage to the embryo in escaping the zona pellucida, we have consistently offered assisted hatching to our patients.
Some couples are at risk for having a child with a genetically transmitted disease, such as Cystic Fibrosis or Tay-Sachs disease. One or both parents may be a carrier of the gene for the disease, placing the child at risk. There are also instances in which one or both potential parents are carriers of structurally abnormal chromosomes, such as those with translocations, or in which the woman is at higher risk for having eggs with an abnormal chromosome number (posing a risk for a trisomy, such as Down's Syndrome).
Pre-implantation Genetic Diagnosis (PGD) allows the identification of embryos that do and do not carry the disease-causing gene or abnormal genetic material(s). PGD is carried out by ICSI of the eggs, followed by biopsy of the embryo. The biopsy entails the sampling of one or more blastomeres (cells) from the embryo, and the analysis of these cells by the genetics laboratory. The normal and abnormal embryos can be distinguished from each other through the genetic diagnosis of their cells, and only the normal embryos are used for embryo transfer.
Although PGD is an established technique and has been applied for 10 years, the recommendation continues to be made for pre-natal testing, i.e., Chorionic Villus Sampling (CVS) or amniocentesis, to confirm that there are no genetic abnormalities.
Embarking on a program involving the ARTs is a major decision. Many people see it as renewed hope for conception as well as their last resort. While the ARTs have helped many couples overcome their infertility, they are not the answer for everyone. For those who choose the ARTs, the process can be emotionally, physically and financially draining, and carries with it a tremendous amount of anxiety.
We regard emotional support and counseling as an important adjunct to treatment. We want to help patients maximize their coping skills during this stressful time, and for this reason have included a session with our counselor in the initial evaluation. This session offers couples assistance with decision-making and an opportunity to explore their feelings. We also find that support groups are often helpful. For more information regarding these support groups call RESOLVE at 215-849-3920.
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IVF is often the final attempt when more conventional, less aggressive methods of therapy have failed. The results from established programs have made IVF a viable option for many couples.
Reported pregnancy rates from established programs may vary. Not all programs are alike; success rates depend not only on the skills of the practitioners and laboratory personnel, but also on individual patient characteristics. Such variables include the patient's age, diagnosis, endocrine status, stimulation, number of eggs retrieved and fertilized, quality and number of embryos replaced, and adequacy of the luteal phase (second half of the cycle). Reported results may include patients of all ages and indications, or they may be characterized separately by age and indication. It is helpful for you to understand the meaning of reported statistics and how it applies to certain individual circumstances.
Specific success rates are presented in detail at our evening IVF patient seminars, or if desired at the time of your initial consultation. Our rates are reported as required by SART [Society of Assisted Reproductive Technology], separating patients by age and/or presence of male factor. PRA has been a member of SART since its inception in 1986.
On your consultation day, you will usually attend an IVF orientation with other couples given by a nurse. After the orientation, you will meet with several team members. This will include an opportunity to pose any further questions you might have about the program. There may be medical screening of both husband and wife to rule out any infectious diseases that might be present. The IVF screening consists of blood tests for HIV (AIDS antibody), RPR (test for exposure to syphilis), hepatitis B surface antigen and hepatitis C. In addition, the wife will also have chlamydia antibody, rubeola, rubella, Cystic Fibrosis and varicella and cervical cultures.
During your visit, you will see our infertility counselor. This appointment provides an opportunity for you to get more information and education about some of the relevant medical and emotional issues, as well as to discuss matters such as coping with treatment, logistics, and dealing with work, family and friends.
An IVF clinical nurse specialist will meet with you to obtain a past medical history, infertility evaluation, and treatments. She will also review the procedure with focus on the medications and timing of the cycle. Please take this opportunity to raise any individual concerns you have.
Finally, you will meet with our financial coordinator to explore relevant financial issues. You will have the opportunity to discuss your individual insurance plans, and request investigation of any coverage to which you are entitled. It is important that you understand the financial obligation and appropriate timing of payments, so as to avoid any undue stress.
Your care while undergoing IVF treatment will generally be coordinated by the IVF clinical nurse specialist you saw in consultation. As you are going through treatment, you will also be meeting with other clinical nurse specialists who will see you after your daily testing and who will also be involved directly with your care. Please feel free to address any of your concerns with them. If you feel you need more contact with your physician, please feel free to request a consultation with him/her.
We wish to help you understand the expenses involved with the each IVF cycle in order to alleviate stress in this matter, and help you to plan accordingly. It is not possible for us to give you an exact dollar amount per cycle in this brochure, as the treatment cycles are individual. Prior to your orientation day, feel free to contact the financial coordinator for your specific costs.
Because each insurance policy varies, even within the same insurance, it is not possible for our financial coordinator to know whether you are covered for specific treatments. The financial coordinator will contact the insurance company directly to determine the coverage you have. At the time of your meeting, you can discuss specifics of coverage for IVF.
We realize that insurance reimbursement can be an arduous process. In order to facilitate this process, we are happy to submit claims on yourbehalf to your insurance company for reimbursement to you. Our computer system generates a generic form which is accepted by almost all carriers. If your insurance company does not accept our generic form, it is your responsibility to submit the properly signed forms to our office. Please be advised that the costs for a cycle must be satisfied before a patient will be allowed to begin a subsequent cycle.
ARC is a national network of leading physicians specializing in reproductive medicine, surgery and In Vitro Fertilization. Through ARC you may finance any of the ARC Family Building Program products or services for a predetermined package price.
ARC is designed for those patients who are unable to seek treatment due to financial barriers or those who would like to finance treatment. The advantages of this program are:
If you are interested in this program or have questions, you may contact one of our financial counselors or ARC directly at 1-888-990-2727 for information.
The initial interview is designed to familiarize you with the facets of our program so that you can make informed decisions. The interview will also help you clarify your feelings about our program as well as to offer you support and information.
The IVF process can be challenging and we hope it is an opportunity for you to realize your dream. Although we cannot guarantee success, we will do our best to make the experience as rewarding and successful as possible for you.
Maureen P. Kelly, M.D., Medical Director
Frances R. Batzer, M.D.
Benjamin Gocial, M.D.
Jacqueline N. Gutmann, M.D.
Dana Tillotson, R.N.C., B.S.N., Director ART Clinical Services
Kelly Graves, M.S.N., C.N.M.
Susan W. Troncelliti, R.N.C., M.S.N.
Marianne Kearney, R.N.C.
Nicole McHugh, C.R.N.P.
Jeanne Laska Walters, ELD (ABB)
Janice Gilchrist, B.S.
Andrea M. Braverman, Ph.D.
Director of Psychological Services
Mary Jane Przydzial
Lynne Elvidge