We generally talk about ART as occurring in cycles. A cycle of ART begins with the stimulation of the woman’s ovaries to produce eggs (oocytes). Commercially produced gonadotrophin (ovary-stimulating) hormones are used in higher than usual doses to stimulate «super-ovulation,» or more eggs than would normally be produced and brought to maturity in one cycle. The development of these oocytes is monitored by ultrasound until they are ready to be released from the ovary (ovulation). Ultrasound checks are performed at least three or four times in the early part of the cycle, sometimes every day, along with measurements of estrogen and other hormones. Maturation of the oocytes is then brought about by giving a syntheric form of luteinizing hormone, a pituitary hormone related to ovulation. At this point, the eggs are «harvested» using a long needle passed through the upper part of the vagina with ultrasound guidance. This egg retrieval is done under light sedation in a clinic or hospital.
This is the process embarked upon by Barbra, as she turned to ART after a miscarriage, a long history of endometriosis and fibroid tumors, and an early ectopic pregnancy.
Barbra hadn’t realized that her endometriosis would make conception and pregnancy so challenging. She and Cory decided to try ART, but only after a long, hard look at their finances: their insurance didn’t cover any type of infertility treatment, let alone ART. Fortunately, they had both been employed full time at good wages for all of their adult lives, and they’d been thrifty, saving systematically. They decided that they could afford to try ART for three cycles. If they were not pregnant at the end of that time, then they would need to reconsider.
Barbra took some accrued vacation time for her first cycle of treatment and was glad she had done so. Most of the time, because of the hormones, she felt as though she had mega-PMS: she had nausea, tender breasts, and headaches, and was on an emotional roller coaster. She was very grateful that she had support not only from Cory but also from the experienced nurses and counselor at the clinic. «Without them, 1 think I’d have lost my mind,» she said. Cory was good about going with her for the ultrasounds and egg harvesting, but he was as nervous as a cat on ice. Barbra couldn’t see why; after all, he wasn’t having all this stuff done to him! Seeing inside her body on the ultrasounds made Barbra anxious and slightly sick to her stomach, but she felt that any woman would probably want to see them, so she suffered in silence.
Barbra and Cory’s studious calculation of the expense of ART was wise. The average cost per cycle is $12,400 (according to the American Society for Reproductive Medicine). Some states require health insurance companies to cover infertility treatment, including ART, but for the majority of Americans these are out-of-pocket costs. (You would need to check with your own insurance company.) Barbra was fortunate to have paid leave to use while adjusting to the side effects. For working women who need to keep working during ART, it is usually possible to manage the hormonal treatments, ultrasounds, and other procedures while working, although you will need a few days off around the time of egg harvesting.
After the eggs are retrieved, they are fertilized in the laboratory using sperm produced by the woman’s partner. This is done by masturbation if the man has normal function or by one of the techniques described above (TESA, MESA) if there is a blockage. Alternatively, if the man has no sperm at all (a condition known as azoospermia), donor sperm may be used. The resulting zygotes are incubated for 24 hours then inspected to confirm that fertilization has occurred. By 48 hours, the embryo should have divided into four cells; this is the point at which most clinics transfer the embryo into the woman’s uterus. Some clinics wait longer and do the transfer at 5 to 6 days, the blastocyst stage, usually because they plan to do some genetic tests before transferring the embryos. Current practice is to transfer not more than two embryos per cycle, to avoid the possibility that the pregnancy will produce triplets or even greater numbers of babies. Extra embryos may be frozen (cryo-preservation) to be used in subsequent cycles.
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