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      • My IVF Cycle Failed – What Went Wrong? Question #9: What About Egg Retrieval and Its Influence on IVF Outcome?

      Dr. Geoffrey Sher Recommends

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      This is the 9th in a series of answers to common questions about failed IVF. Many women tend to be nervous about undergoing a surgical procedure such as egg retrieval (ER), especially when anesthesia is involved. They feel apprehensive about the associated pain and unknown effects the procedure might bring. But in fact, as surgeries go, ER is really rather minor. Pain is generally minimal and the risk of complications is very low indeed.But, either way, it is undeniable that the ER phase of an IVF cycle does mark a build-up in the emotional, physical and financial commitment associated with the cycle. The financial component escalates at this point largely because of costs associated with the egg retrieval procedure itself, laboratory fees for fertilization, and the impending embryo transfer. Because most women (and their partners) tend to be somewhat apprehensive about the egg retrieval, the couple should have a refresher consultation that involves the doctor who will be performing the procedure and the rest of the IVF team that will be involved, including the anesthesiologist and the nurses who will provide postoperative care. At this consultation, the procedure should be explained and discussed, and the woman should be informed as to what she might expect to feel afterward. It should be explained that while ER is a very minor and low-risk procedure, no surgical procedure is completely devoid of risk, and that complications such as infection, bleeding, and injury to surrounding structures, such as the bowel and bladder – although rare – may occur.A consultation should also take place with the anesthesiologist, who should review the relevant medical history, looking for conditions that could complicate the procedure. In the event that any such factors are detected, the anesthesiologist may call for additional tests in order to ensure that the surgery can proceed safely.Finally, prior to the administration of any medication, the woman and her partner should be asked to decide what they wish to be done with retrieved eggs and the embryos that might result following fertilization. The couple should be reminded that while the more embryos transferred, the higher the pregnancy rate, there is also a progressive increase in the concomitant risk of multiple pregnancies, which is dangerous to the woman and her babies. Thus, a discussion should be held regarding the maximum number of embryos/blastocysts to be transferred, how many eggs should be fertilized, and how many should be frozen and stored.If/when egg or embryo biopsies are planned, this should also be carefully and thoroughly discussed. Finally, following complete disclosure and addressing any/all questions directed at the IVF team leader, both partners are asked to read and sign an informed-consent authorizing the go-ahead!ER is usually performed under conscious sedation with an anesthesiologist or nurse anesthetist in attendance, or under local anesthesia. The local anesthesia involves the use of a “paracervical block” where a local anesthetic is injected on each side of the cervix as well as into the upper part of the vagina surrounding the cervix. The egg retrieval procedure involves trans-vaginal needle aspiration performed under direct guidance by ultrasound. It is usually performed on location at the IVF clinic itself or in an adjacent outpatient surgery center environment.With the woman anesthetized, an ultrasound probe is inserted into the vagina. The probe is the “projector” that transmits the clearly identifiable image of each ovarian follicle to the ultrasound viewing monitor. A special sterile needle is then passed via a sleeve alongside the probe through the top of the woman’s vagina into the ovarian follicles.The IVF doctor can accurately direct the needle into the follicles by visualizing its progress on the ultrasound screen. After the contents of the follicle are aspirated, the follicle is usually reinflated with a physiological solution in an attempt to flush out any egg that might otherwise have adhered to the wall of the follicle. Following the ER, the woman and her partner are informed of the number and quality of eggsthat have been retrieved.The egg retrieval procedure takes about 20 to 30 minutes to complete, and after approximately 30 minutes to one hour of postoperative recovery, the woman can usually leave the clinic under her own power (though most women prefer the physical and emotional support of a partner). The woman can usually return to normal activity within 12-24 hours of being discharged.

      Even though the egg is the largest cell in the body (about the size of a grain of sand), and itself is too small to be clearly seen in the follicular flushings without a microscope, it is usually embedded in the collection of cells known as the “cumulus-granulosa complex” which indeed can often be identified in the follicular fluid with the naked eye.

      A mature and fully “competent” mature egg is one that upon fertilization (embryo) and reaching a receptive uterus is capable of resulting in a normal pregnancy. Such an egg will have a normal size, be of rounded shape, have a well defined but thinnish outer envelopment (zona pellucida) and house a well-defined single polar body (PB-1) below its outer surface. Also, the cytoplasm (ooplasma) should be clear, non-granular, and be free of pools of fluid (vacuoles). This having been said, it is not possible to reliably identify a “competent” egg by visual/microscopic evaluation only.

      As I have often mentioned on this blog and elsewhere, it is predominantly the chromosomal integrity of the egg, rather than the sperm, that will determine embryo competence. Most human eggs start off with 46 chromosomes. Soon after the spontaneous LH surge or an hCG “trigger” shot, it enters into maturational division (meiosis). The purpose of meiosis is to reduce the number of chromosomes from 46 to 23 over a period of 24-32 hours. At best, 40% of eggs will end up with precisely 23 chromosomes (“euploid”). This percentage declines rapidly with advancing age, such that by the mid-forties, less than 10% will be euploid and thus capable of propagating a competent embryo.

      However, the fact is that after meiosis, the greater majority of eggs end up being “aneuploid” (i.e having more or less than 23 chromosomes). In such cases, the resulting embryos will invariably also be aneuploid and thus be “incompetent” (incapable of developing into a normal baby).

      While egg aneuploidy is the main cause of embryo incompetence, it is not the only factor. Sometimes an abnormal sperm can cause embryo aneuploidy. Similarly, epigenetic and metabolic factors can also play a role (albeit a much lesser one).

      Evaluation of the egg includes one or more of the following:

      1. Assessment of its overall appearance: Shape color, size, consistency, the absence of vacuoles, thickness of the zona pellucida.
      • Assessment of the 1st polar body (PB-1): The presence of a single PB-1 indicates that the egg has gone through initial maturational development (meiosis-1), in an attempt to halve its chromosome number (from 46 to 23) so as to prepare for fertilization. The detection of a single PB-1 thus suggests that such an egg is “mature” or “dysmature” (M2). The absence of a PB-1 suggests that the egg is chromosomally “incompetent” (aneuploid) and thus incapable of propagating a competent embryo. Detection of more than one PB (polyploidy) likewise points to aneuploidy and egg “incompetence.”
      • Chromosomal analysis (karyotyping): This involves chromosomal analysis of the 1st polar body. In the past, the standard method used was “fluorescence in-situ hybridization” (FISH). However, karyotyping by this method was highly inaccurate. Proudly, it was largely through research conducted at SIRM (published in several medical journals) that Comparative Genomic Hybridization (CGH) was introduced to fully karyotype the PB-1 of the egg. We have reported widely on the fact that an embryo derived through fertilization of a euploid egg will, in more than 80% of cases, turn out to be “competent” (euploid). Such eggs will develop into a normal baby more than 70% of the time. CGH analysis of the egg has decided advantages when it comes to selectively cryobanking eggs for the purpose of female fertility preservation (FP). However, when it comes to selecting competent embryos for transfer it is preferable to fully karyotype the embryo (rather than the egg). The reason is that such an evaluation takes the contribution of both the egg and the sperm into consideration.

      Immediately following the egg retrieval, the doctor will start a series of medications, including antibiotics to prevent infection, hormonal supplements to promote implantation and sometimes pain killers. The patient will be asked to refrain from sexual intercourse for a period of time, and avoid submerging in water (such as swimming or taking a bath). The patient will also be advised to use a peripad, rather than tampons, for vaginal bleeding and will be advised to be on the lookout for:

      • An elevated body temperature (>37C or 101F)
      • Abdominal pain or swelling
      • Persistent nausea or vomiting that doesn’t subside
      • Heavy vaginal bleeding (soaking of a pad in less than 1hr.)
      • Pain or difficulty in passing urine
      • Lightheadedness or fainting spells

      Shortly (a few days) after ER, the fertilized eggs develop into embryos. The woman and her partner are kept abreast of the embryos’ progress all along the way. They will likely be anxious. However, research suggests that lower levels of anxiety favor embryo implantation success. It thus behooves the couple to try and relax before the day of embryo transfer. They should socialize with friends, take outings, etc., if this will help distract them from the stress of the situation. Whatever it takes to make them feel happy and calm before the final phase of their IVF cycle…the embryo transfer!

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      16 Responses to “My IVF Cycle Failed – What Went Wrong? Question #9: What About Egg Retrieval and Its Influence on IVF Outcome?”

      1. Ariagirl says:
        June 25, 2011 at 12:12 pm

        Dear Dr. Sher,

        I am 39 yrs of age with premature ovarian failure (diagnosed at age 14 after 2 years of natural menstrual cycle). I just went through my first IVF cycle with donor egg (Tranfer on 6/13)–my first beta was yesterday (6/24) and measured 1.2. Since I was present at my clinic, I was told my test was negative via my ER's nurse coordinator,in person. We of course had initial questions, which she said I should address to my ER with whom we are meeting on 6/30. She suggested I cease my meds, even though she is scheduling me for a repeat test on 6/30. I have not heard anything directly from my ER a day later, and feel uncomfortable about this. We are left to question whether I should indeed go off my meds with the upcoming repeat test (even though the possibility of a pregnancy here is basically null). More importantly, after the investment we have made (emotionally, and financially) shouldn't that warrant direct contact from my ER? Furthermore, we have read that any detection of HCG in case of a donor egg, may be a good thing. I would appreciate any insight you could provide, however brief. Thank you!

        Lost in NY

        Reply
      2. Krystyn says:
        June 25, 2011 at 9:17 pm

        Dr. Sher,
        On 6/20 I had one CGH normal morula transferred and I am already pretty sure that it didn't work. Out of 17 eggs retrieved, 13 fertilized and only 5 made it to day 5 and only one of those were normal. I did have a few blasts but they were labeled "complex abnormal." It is pretty scary as I had one perfect hatching blast 5AA but it had 5 different trisomies! I am very upset and confused and I was hoping you would have some suggestions for me as I am worried that I will never be a mom. I am 30 years old and I have been pregnant 4 times in the past 18 months; 2 natural, 1 from an IUI, and 1 from an IVF. The first ended prior to 6 weeks, the second right before nine weeks (no abnormalities found when tissue was tested), the third was right before nine weeks and the last was prior to 6 weeks. With the ones at nine weeks we had a healthy heartbeat with both. My husband and I have both been through testing and everything is coming back normal…even karyotyping. After my fourth loss they did find that I had a septate uterus but I had that resected and it was completely gone at follow up a month later. At that time I was told that my endometrial lining looked great and there was no significant scarring.
        One issue that I do have is a thin lining. I am always around a 7.5 except for my first IVf I was at a 6.5. With this last IVF I used vaginal Viagra 25mg 4xday and my final measurement was 7.8 and 8.4 (as they couldn't get a good angle.) Do you think my lining is the cause of all of my losses and my failed CGH cycle? I guess that I am just looking for some hope. I know that compromised endometrial linings can lead to implantation failure, but would it cause me to miscarry every pregnancy? I guess I would think that I would have more negative cycles than positive ones with a poor lining. I have been able to get pregnant on every other try so at least I know that it is even possible.
        I really appreciate any insight that you may have as I know how much experience and knowledge you have with array-CGH.
        Regards,
        Krystyn

        Reply
      3. Geoffrey Sher, MD says:
        June 27, 2011 at 12:38 pm

        Dear Ariagirl!

        I absolutely agree with you. I have seen cases where even a negative beta's go positive in 2 days. This is especially the case where egg donation is done and where any amount of hCG in the blood could only come from the embryo implanting.

        I would respectfully disagree with the nurse and if it were up tome I would continue meds until the 2nd beta is done (2 days after the 1st.

        Good luck!

        Geoff Sher

        Reply
      4. Geoffrey Sher, MD says:
        June 27, 2011 at 12:46 pm

        Hi Krystyn,

        I truly believe that there is an implantation defect in your case. Indeed, a lining of <8.00mm at the time of hCG (or at the time of PIO initiation)often will result in implantation failure. In fact I do not do an ET unless the lining measures at least 8mm >9.00mm being optimal). Another concern is that there may be an immunologic implantation dysfunction (see elsewhere on this site for more information).

        Perhaps we should talk sometime soon. Call 800-780-7437 for a free medical telephone consultation with me.

        Good luck and G-d bless!

        Reply
      5. Krystyn says:
        June 27, 2011 at 3:33 pm

        Thanks so much for your response Dr. Sher! I have always been afraid that an implantation defect has been my issue. I did try vaginal Viagra with no success. Are there any other medications that you recommend or a protocol that can help with my lining? As I said before, I really don't have a great response to Estrace. I do take Crinone and PIO injections after retrieval but I am not sure if the lining thickens any afterwards, as it has not been measured at the time of transfer.

        In regards to the immunological aspect of implantation, I have been doing IVIG for about 1 year and I am put on Dexamethasone, baby ASA, and Lovenox for each cycle just in case. I have been checked for just about everything; ANA, ATA, APA, and NKa and everything is coming back normal.

        I have a phone consultation with you a week from Thursday. I am sorry that I am asking you all of these questions now but I am trying to ease my mind as I feel that I will never be successful with IVF as failure of this cycle was confirmed today. I guess that I am looking for a glimmer of hope to get me through this next week.

        Thanks again,
        Krystyn

        Reply
      6. Geoffrey Sher, MD says:
        June 27, 2011 at 4:03 pm

        I understand. All I can say is that I need to review all the immune tests done, thoroughly. Have you and your husband been matched for DQa/HLA gene similarities (alloimmune similarities?)

        In my opinion, estrace orally is not ideal.

        Until we talk then….

        Geoff Sher

        Reply
      7. Savita says:
        June 29, 2012 at 3:00 am

        Hi Dr,
        I had my first failed IUI last month. I was on following hormonal injection during my IUI treatment starting from 5th day: Inj IVF-M 150 IU IM for 4 days, Inj IVFM 150 IU IM + Inj Ouvurelix 0.25 mg for 3 days, then Inj IVF-C 10,000 for 1 day and then finally on 13th day, IUI was done. 2 eggs were seen. Unfortunately IUI failed and the possible reason given was due to high LH level (11.08) on day 5. Now I have been asked to reduce LH level using Lupron Depot ijection and redo IUI. I have also been prescribed Folic acid tablets. I suffer from PCO. My husband sperm count is fine. I am wondering whether my doctor is going in right direction? Do you forsee any problems with such injections in future? if not, kindly provide some pointers so that I can speak with my doctor.Thanks.

        Reply
        • Geoffrey Sher says:
          June 29, 2012 at 8:59 am

          Unfortunately, I cannot comment on this protocol without total knowledge of your specifics and access to your medical records.

          Geoff Sher

          Reply
      8. anya says:
        February 1, 2013 at 4:29 pm

        im going to appiontment in clinic i think ill be too nervous for egg retrival and embyro transfer what if im too nervous for it what if im too nervous during the whole pregnancy if i do get pregnant

        Reply
        • Geoffrey Sher says:
          February 1, 2013 at 9:27 pm

          This is indeed a trying and stressful time for you. Hopefully it will soon end with you conceiving. and perhaps you are pregnant you will probably become more satisfied…fulfilled and relaxed…..Lets hope so!

          G-d Bless!

          Geoff Sher

          Reply
      9. saanya21 says:
        February 15, 2013 at 7:24 pm

        doctor.i have some questions
        1.Is the Egg retrieval done through laparascopy?or not?

        2.also if the doctor retrieved 20 eggs and if 15 fertilized then is PGD gonna be done on all of the or some of them?
        thanks alot

        Reply
        • Geoffrey Sher says:
          February 15, 2013 at 7:37 pm

          No the ER is done through transvaginal ultrasound guided needle aspiration. Only those fertilized eggs that reach at least 5 cells by day 3 are subjected to PGD or those that reach blastocyst by day 5-6.

          Geoff Sher

          Reply
      10. Mrs S Ali says:
        March 30, 2013 at 11:38 pm

        Dear Dr sher
        I am having the fifth year of my mairrage and suffering from the problem of infertility. My husbands sperm count is ok. Last year my left ovary was drilled due to being polysestic through leproscopy. But despite that I got no result. Now my consultant is asking for IUI or test tube procedure due to my FSH level of 11.08. Dear doctor whether this level of FSH causes infertility?

        Reply
        • Geoffrey Sher says:
          March 31, 2013 at 8:42 am

          An FSH of above 9.0 could be an indication that your ovarian reserve is diminishing. I would do an AMH as well and if this shows the same, I would go straight to IVF if I were you.

          Good luck!

          Geoff Sher
          800-780-7437

          Reply
      11. Mrs S Ali says:
        April 2, 2013 at 1:41 am

        Dr Sher,
        Let me know you I had the Test of FSH on the second of my periods on recomendation of my consultant. But I have come to know that third day of periods is mostly recomended. Does it matter?

        Reply

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      Karmann and Ryan’s Journey – My Approach to Their Treatment
       Please refer to last week’s blog post, where Karmann tells in her own words her struggles with recurrent miscarriage – nine miscarriages to be exact – and her long journey  of heartbreak, disappointment, and finally – hope.... more
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      Why Did My IVF Fail? Part 2 – Uterine Receptivity and Transfer Technique
      This is the second part of a two-part post on IVF failure. In my January 22nd post, I discussed what I often refer to as the “seed” variable in the “seed/soil” relationship – the embryo. This week’s post will address the “soil” variab... more
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      My IVF Cycle Failed – What Went Wrong? Question #19: Why Do I Keep Having Chemical Pregnancies and Miscarrying?
      This is the 19th in a series of answers to common questions about failed IVF. Early pregnancy loss – whether due to miscarriage or chemical pregnancy – is due to two major factors. In more than 70-80% of cases the cause is attributable to... more
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      My IVF Cycle Failed – What Went Wrong? Question #18: My Fertility Clinic Reports a High Success Rate – How Could I Have 2 Failed Cycles In A Row?
      This is no. 18 in a series of answers to common questions about failed IVF. While it is true that IVF failure can be due to preventable factors, it is as important to understand that optimal medical care does not always equate with an optimal outcome... more
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      My IVF Cycle Failed – What Went Wrong? Question #17: Why Didn’t I Get Pregnant When I Used a Young Egg Donor and Had Good Quality Embryos?
      This is #17 in a series of answers to common questions about failed IVF. For women whose advancing age and/or ovarian resistance make having a baby with their own eggs unfeasible or unlikely, IVF using donated eggs from a young donor (under 35 years)... more
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      My IVF Cycle Failed – What Went Wrong? Question #16: Why did my hCG levels stop rising properly?
      This is the 16th in a series of answers to common questions about failed IVF. Immediately following implantation, the root system (trophoblast) of the embryo begins to release the pregnancyhormone, human chorionic gonadotropin (hCG) into the surround... more
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      My IVF Cycle Failed – What Went Wrong? Question #15: Might My Mental State Have Played a Role?
      This is the 15th in a series of responses to common questions about failed IVF There is little doubt that stress and emotional lability plays a role in the normal physiological/hormonal regulation of the menstrual cycle.After all, Eskimos often stopp... more
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      My IVF Cycle Failed – What Went Wrong? Question #14: Could it Have Been Due to Inadequate Hormonal Support After the Egg Retrieval & Embryo Transfer?
      This is the 14th in a series of answers to common questions about failed IVF. In vitro fertilization establishes an abnormal hormonal environment in the uterus.In some cases (especially older women and those with a diminished ovarian reserve), high o... more
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      My IVF Cycle Failed – What Went Wrong? Question #13: Did the Number of Embryos I Had Transferred Play a Role?
      This is the 13th in a series of answers to common questions about failed IVF. Virtually everyone recognizes that pregnancy with multiples (especially triplets or greater) is associated with a high incidence of premature delivery that has serious cons... more
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      My IVF Cycle Failed – What Went Wrong? Question #12: Might the Timing of Embryo Transfer – Day 2-3 (Cleaved) vs. Day 5-6 (Blastocyst) Play a Role?
      This is the 12th in a series of answers to common questions about failed IVF. (Note: I’ll be hosting a live video chat on Aug. 2 on the topic of Failed IVF where I’ll discuss the issues addressed in this series of posts and take your ques... more
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