There are many causes of infertility. For a successful pregnancy to occur, a healthy egg needs to meet healthy sperm, fertilize, develop and find a good place to grow (a receptive uterus).
Problems at any of these steps can cause difficulties in getting pregnant.
A woman’s body might not release an egg each month due to hormone imbalances, or perhaps the man’s body isn’t producing enough motile sperm. The fallopian tubes can be blocked or non-functional, preventing the egg and sperm from meeting. Or maybe infertility is because of abnormal uterine conditions like polyps, fibroids, or infections.
Not necessarily, and at Spring, there’s no such thing as “most people”. While we work with proven protocols, everyone is an individual and each treatment plan is customized to each patient. In order to determine which treatment options are right for you, we’ll conduct a thorough review of your medical history and assessment of both partners to evaluate what’s happening. Then we’ll form a plan to move forward. To get started, call us today to book a consult.
PGS allows patients the highest chance of success (a live birth) with each embryo transfer.Regardless of age, a chromosomally normal embryo has about a 50% chance of live birth. This allows us greater confidence with each embryo transfer such that most patients transfer only one embryo at a time. Keep in mind that while PGS helps us more easily identify the healthiest embryos to transfer (resulting in a higher live birth rate per transfer), it does not increase the chances overall.
The Pros: Highest implantation and live birth rate per transfer, fewer miscarriages, and you are less likely to experience (and pay for) an unsuccessful embryo transfer.
The Cons: Higher upfront cost in order to perform the procedure on the embryos and genetic analysis on sampled cells. And although this procedure is considered safe and effective, the test is about 90% accurate: 4% of cases will result in a "False Positive" (calling a potentially normal embryo "abnormal"), about 4% in a "False Negative" (embryos are determined to be "normal" but later miscarry and are found to have an abnormal chromosome complement), and approximately 2% of the time we do not get sufficient amplification of DNA for the scientists to make a determination on your embryo.
Lastly, it’s important to understand that with PGS, it’s possible that you will not have any normal embryos to transfer. Although this is very disappointing to experience, it also means that a you did not have to endure a transfer that resulted in a miscarriage, with the associated pain and lost time before a successful transfer.
We take enormous pride in delivering the highest chances of successful IVF, anywhere. Your success will depend greatly on your age at the time your eggs are retrieved. Nationally, women under 35 have nearly 50% success rates, while women over 42 have a 5% chance of success with each attempt using her own eggs. As women age, the number of eggs available declines and the miscarriage risk increases due to ovarian aging, making it harder to conceive. Many women require multiple attempts with IVF. Our job is to help you achieve a live birth in as few attempts as possible.*Although aging is the biggest predictor of success, this is due to the age of the eggs and not the uterus. Success rates with donor eggs are over 50% per attempt and depend on the fertility and age of the egg donor.
There are many causes of infertility. For a successful pregnancy to occur: A healthy egg needs to be meet healthy sperm, fertilize, develop and find a good place to grow (a receptive uterus).
Problems at any of these steps can cause difficulties in getting pregnant:
1. A woman’s body might not release an egg each month due to hormone imbalances.
2. The man’s body might not produce enough sperm for successful fertilization.
3. The fallopian tubes can be blocked or non-functional (for example, as a result of scarring from previous infections or inflammatory conditions like endometriosis). This would prevent the egg and sperm from meeting.
4. It’s also possible that the uterus might not be receptive to implantation due to abnormal conditions like polyps, fibroids or infections.
It’s important to note that not all causes are due to female factors. In fact, 30-40% of infertility cases are due to male factors. We need enough motile, swimming sperm to fertilize an egg. A “normal” ejaculate has over 18 million motile (swimming) sperm. Some men produce fewer or no sperm. Other men produce plenty of sperm but have obstructions in their tubes (the vas deferens), preventing sperm from being released. Just because a semen sample appears normal, doesn’t mean that there are sufficient numbers of sperm inside. We need to check with a microscope.
A woman’s ovarian reserve is directly related to her ager and refers to her potential to produce multiple eggs with ovarian stimulation. Ovarian reserve, or egg supply, begins to gradually decline beginning at the age of 30. The amount of medication required to stimulate her ovaries will increase and the number of follicles and eggs produced from her ovaries declines. These factors lower a woman’s chances of pregnancy with our best treatments. Several tests are used to determine a woman’s fertility potential, including blood tests such as Anti-Mullerian Hormone (AMH), FSH and Estradiol and a pelvic ultrasound to evaluate Antral Follicle Count.
Normal ovulation requires a well-choreographed interplay of numerous hormonal events involving the brain, pituitary gland and ovaries. Stress, medical conditions and other events can throw these off and cause hormone imbalances that affect ovulation. If you are not ovulating every month, we will need to screen for conditions like Polycystic Ovarian Syndrome (PCOS), Hyperprolactinemia, Thyroid Problems, as well as other less common conditions. In order to evaluate your case, we may test for additional hormones.
The long answer is that the optimal number to ensure a single healthy pregnancy varies by age, reproductive history (have you been pregnant before?), and other factors that could make it easier or harder to get pregnant in the future.
The short answer: we recommend having at least 20 mature eggs frozen before your 37th birthday. Why? The largest study to date looking at the average number of mature eggs needed per live birth in patients using IVF suggested that 20 egg were needed, up until age 37. Beyond 37 the number was higher (about 40 eggs per baby at age 40 and 60 eggs by age 42). These numbers correlate very well with the national IVF success rates in the United States, as reported by the CDC.
A mature egg (a.k.a. an “M2 oocyte”) is an egg that has completed the first stage of meiosis (reducing its DNA by half to prepare for fertilization with sperm). Not every egg that is retrieved is mature and therefore not every egg can be used. An egg must be “mature” to fertilize successfully.
Although there are several molecular tests of uterine receptiveness, most current tests not very predictive. The most important tool right now is to make sure the uterus is free of any lesions like polyps or fibroids. This is best done by either a Sonohysterogram, also known as a Saline Infusion Sonogram (SIS) or hysteroscopy. Occasionally, an endometrial biopsy can be performed to rule out chronic infections, or to perform experimental molecular testing.
For men, the evaluation is even simpler. We perform a Semen Analysis to see if there are enough motile (swimming) sperm to reach and fertilize an egg. Low or absent sperm counts can be due to problems producing sperm or in a blockage preventing the sperm from being released. Appearing to ejaculate normally does not mean there are enough quality sperm being emitted.
The basic male evaluation can be addressed with two key questions:
Do you produce a sufficient number of “swimming” sperm to total sperm?
Fertile men typically produce tens of millions of sperm per ejaculate. It’s not enough to produce sperm; the job isn’t done until they reach the egg and fertilize it. Unfortunately, it’s a long journey, and therefore nature provides millions of sperm in the hope that one is able to make it to the egg, attach and fertilize.
Are the sperm able to leave your body?
Just as women have tubes that can be blocked (the fallopian tubes), the same is also true with men. The vas deferens is the tube that carries sperm from the testes to the penis. Sometimes these tubes can be blocked or congenitally absent. With an obstructed vas deferens, a man’s ejaculation may appear normal but lack sperm.
We evaluate sperm with a Semen Analysis, which tests the percent motility, or the number of sperm per ejaculation. We also examine direction and speed, shape, and other factors that can give your doctors insight into your ability to conceive without assistance.
The typical fertility assessment of both partners can be completed within a month (or one menstrual cycle) of an initial consult.
With Spring Fertility, you can know what’s happening in just one day. With our Same Day 360° Comprehensive Evaluation & Action Plan, you and your partner can come in to complete an initial consult, evaluation, and review of treatment options in a single day. Within 4–5 hours, we can provide an understanding of your individual situation and your options, then together make a plan to move forward.
How can we do that? We are one of only a handful of clinics across the country to offer everything onsite, including HSG, AMH testing, and semen analysis. Doing so allows us to shorten your wait for results. We know your time is important, so we’ve designed our workflow around your needs.
The IVF process is a series of steps that we’ll help you understand so you know exactly what to expect. Typically, the first 8-12 days encompass ovarian stimulation leading up to the egg retrieval. The egg retrieval coincides with preparing sperm for fertilization.
Then, depending on your situation, we’ll decide on what’s best for next steps:
Fertilization: Conventional IVF or ICSI?
When to plan your transfer: How long should we care for your embryos before transferring or freezing them? 2-3 or 5-6 days?
Embryo Transfer: Fresh or frozen? If frozen, do we transfer them in the future using a controlled or natural cycle?
Genetic testing: Do we test your embryos before transferring them?
We can help you decide what to do for each step based on your unique case and requirements. Learn more about the IVF and ICSI Process.
A pregnancy requires one healthy embryo to be delicately transferred to a receptive uterus at the optimal time. Unfortunately, most embryos are not able to implant successfully, even under the best circumstances.
Here’s what we know: A healthy embryo (called a “euploid embryo”) has 46 chromosomes. Too many or too few and it’s unlikely to implant or might implant and miscarry.
“Euploid” embryos have approximately 50% chance of implanting and developing into a healthy baby. So on average, we need two euploid embryos to have a successful pregnancy.
Women under 35 have a 2 in 3 chance of having chromosomally normal blastocyst, so would need about 3 blastocyst stage embryos (on average) per live birth. As women age, the chances of having a chromosomally normal blastocyst decline.
At 40, women have a 1 in 3 chance of having a chromosomally normal embryo at the blastocyst stage, so would need about 6 blastocysts for a successful pregnancy. At 42, women have a 1 in 4 chance of having a chromosomally normal blastocyst, so might need about 8 blastocyst stage embryos (on average) per live birth. Women over 42 years have a 1 in 5-6 chance of finding a chromosomally normal embryo. This is why many women over 42 are using donor eggs, unless they froze their own eggs earlier.
For women using donor eggs, the chances of a successful pregnancy depends on the age of the donor. Since most donors are in their 20’s, far fewer embryos will be required per live birth.
Please don’t despair! Although the numbers above may seem discouraging, everyone is an individual and we have patients bet the odds and have successful outcomes with a 2% chance. The above numbers are to give you a sense of overall probability. Please discuss your case with your doctor to get more individualized answers.
You do not need to transfer every embryo. After you transfer your desired and recommended embryo(s) we can cryopreserve any additional embryos with the potential for implanting. These are saved for a future pregnancy or if this attempt isn’t successful. Embryologists have been cryopreserving embryos since the 1980s. Today, embryo survival is better than 98% and many studies have shown the outcomes with frozen embryo transfers to be as good or better than with fresh embryos.
Several recent studies have been published that suggest frozen embryos may have higher pregnancy and live birth rates and may even have better live birth outcomes. Our interpretation: For some patients a frozen embryo transfer is going to be safer and result in a higher pregnancy rate. However, not all patients benefit from this approach so we do not recommend freezing all embryos to every patient. We believe we can identify the patients who will benefit from a “freeze all” approach and frozen embryo transfer during their monitoring. In these cases, we recommend cryopreserving all of your embryos without transferring them in order to increase your chance of a successful and healthy pregnancy.
Reasons we might cryopreserve without transferring an embryo:
Elevated early progesterone. The uterus has a “window of receptivity” when it will allow a good embryo to implant. Before and after that window, even a good embryo won’t be successful. Sometimes, the elevated hormone levels seen with ovarian stimulation can “confuse” the uterus into thinking the embryo will be arriving before it is ready. By the time the embryos arrive, the uterus is not receptive to implantation. So, instead of transferring a good embryo into a uterus that is no longer “receptive,” we’ll wait and use a frozen embryo when the timing is better
New concerns about the uterine lining. Rarely, we detect a new polyp or bleeding that was missed before starting the IVF process.
Ovarian hyperstimulation syndrome. In patients who produce many eggs and embryos, ovaries can become hyperstimulated and need time to ‘cool down’ to allow for successful implantation. This is quite rare, and although it’s disappointing to experience an unplanned delay, it usually means there’s a good chance at a successful pregnancy the next month with a frozen embryo transfer.
*Patient choice. One of the most common reasons is that a patient or couple wants to create embryos to transfer later, either for medical or personal reasons.
Embryo freezing has been performed since the 1980s. Sperm cryopreservation has been successfully performed since the 1970s. We have seen many births from embryos cryopreserved for over 10 years and even some births from sperm cryopreserved for as long as 19 years. Animal studies suggest that cryopreservation is possible for even longer without detectable consequences but beyond 10-15 years, our experience is limited.
One decision we’ll consider together is whether you’ll want to do a natural or controlled (medicated) frozen embryo transfer.
If you’ve decided to get genetic testing or are otherwise using frozen embryos, then we’ll work with you to time your transfer. Compared to a “fresh” IVF cycle with ovarian stimulation, a frozen embryo transfer is much easier. Depending on your preferences for timing and your medical history, we can do a controlled cycle or a natural cycle.
Controlled Cycle: We give you medications to prevent your body from ovulating. We provide all the estrogen and progesterone you need for about 10 weeks.
Advantages: You can schedule the transfer to your convenience and have more control over the process.
Disadvantages: Cost and inconvenience of taking medications for 10 weeks.
Natural Cycle: We allow your body to ovulate on its own. As a result, you produce your own estrogen and progesterone and require minimal additional medication.
Advantages: Lower cost of medication.
*Disadvantages: There is more initial monitoring to make sure we know when you ovulate and as such, it’s more unpredictable. We cannot control the exact date of the embryo transfer, since your body will ultimately determine when we need to transfer the embryo. We are also unable to give supplemental estradiol before you ovulate, so patients with thin lining may do better with a controlled cycle to supplement endometrial growth.
Unfortunately, miscarriages are very common and related to the age of the woman whose eggs are being used. While only 10-15% of pregnancies in your 20’s will end in miscarriage, this risk increases substantially during your mid to late 30’s. For women over 40 years of age over half of pregnancies will end in miscarriage. By age 45, nearly 75% of pregnancies will end in miscarriage.
While IVF alone cannot prevent a miscarriage, it does allow for embryo testing, which can minimize the risk of miscarriage after embryo transfer. After embryo sampling and PGS, the subsequent miscarriage rate is very low (3-8%) if the embryo has been tested and shown to be euploid.
Protocols can vary this is typically a two week process involving:
1. 8-14 days of hormone stimulation, culminating in a final “trigger shot” 36 hours before the egg retrieval
2. Usually 5 monitoring appointments
3. The egg retrieval: a 20 minute procedure under sedation (you are asleep with an anesthesiologist present but you are not intubated or paralyzed). Some patients may additionally benefit from two weeks of hormonal preparation prior to beginning stimulation. The addition of these medications helps follicles grow at the same rate to optimize the number of eggs retrieved.
Our goal is to obtain the greatest numbers of healthy eggs from your ovaries. The eggs begin in a small “antral” follicle in your ovary. Ovarian stimulation gently prompts these follicles to grow or “mature” a cohort of eggs. You will follow this process and can see how we measure your follicles during your monitoring appointments, which are usually 20-30 minute morning visits leading up to your retrieval. Based on the growth of your follicles (assessed by ultrasound), and hormone levels (assessed by blood tests), we adjust your medications and time your final injection, the “trigger shot” which causes the eggs to complete maturation for retrieval.
Some patients report bloating and may feel tired from the hormones. These effects are usually well tolerated and do not require treatment. While the injections can cause minor irritation and discomfort, our patients make it through just fine. We'll provide instructions and tips to make it easier.
During the retrieval, you'll be under anesthesia for 20 minutes. Most patients wake up with minimal discomfort or cramping that does not require additional medication. For the few patients who experience more severe cramping, rarely do they need more than Tylenol.
The idea of giving yourself injections can be intimidating. While many people feel anxious the first or second time, hundreds of thousands of women have safely undergone hormone stimulation and find that they quickly get used to administering their own medications. Some patients have a friend or partner help with the injections. We also work with several nurses who offer home visits to administer nightly injections. Lastly, we can recommend a protocol with fewer shots for those who are still uncomfortable.
The night before, you’ll have a hearty dinner and then abstain from any food or drink after midnight. The morning of your retrieval, you’ll check in about an hour before the procedure. Your nurse will guide you over to the lab where you’ll change into a warm robe and place your belongings in a secure locker. You’ll meet the anesthesiologist and embryologist who will be caring for you and your eggs. Under their watchful eye, you’ll fall asleep under anesthesia, while our specialists aspirate your eggs using a very fine needle. 20 minutes later, you’ll awaken in our recovery area.
If a fresh semen sample is used, your partner will produce the sample while your eggs are being retrieved. Otherwise, we will thaw a frozen sample.
Our care team will be there to look after you and ply you with juice and snacks. Most patients walk out the door about 45 minutes later. Most patients take the rest of the day off to rest.
Learn more about the IVF and ICSI Process.
The transfer itself takes a few minutes and is not painful. The primary discomfort you may experience is from a full bladder we ask you to have so that we can all see best by ultrasound.
We confirm that we’ve got your best embryo(s). You’ll arrive early to change and get ready. There’s no anesthesia required, but we recommend Valium to minimize uterine contractions. You’ll watch us on a closed circuit television as we gently draw your embryo into a thin soft catheter for transfer. You’ll then watch by ultrasound as the embryos are returned to your uterus.
Learn more about the IVF and ICSI Process.
People ask this all the time and unfortunately, you’ll hear varying (conflicting) opinions from different people in and outside of our field. At Spring, we recommend a healthy, balanced diet with proper hydration. Avoiding highly processed foods and anything that doesn’t have nutritional value is always smart. Beyond that, be good to you!
We recommend taking prenatal multivitamins that have a healthy amount of folic acid and Calcium with Vitamin D. Folic acid helps prevent neural tube defects, and is good for spine and brain development. Other supplements to consider are CoQ10 and DHEA, however evidence for these are limited.
Many people find this a good time to pursue their healthiest habits. Alcohol is fine in moderation until 2-3 days before your egg retrieval but should be avoided post-transfer.
Research suggests mild to moderate caffeine intake is not associated with any adverse outcomes. Up to 2 cups of coffee per day are not associated with any worse outcomes. Some studies suggest that 3 or more cups of coffee per day when pregnant may increase the risk of miscarriage.
No. In addition to numerous other health risks, cigarette smoking is a reproductive toxin. It accelerates the loss of eggs and can advance menopause. Less is known about marijuana.
Yes. Exercise is encouraged as part of a healthy lifestyle. At key points, you’ll want to take it easy. Moderate exercise is fine until around day 5 of stimulation, then we recommend low impact activities like biking, hiking, yoga, or walking. After your retrieval, we recommend taking it easy from strenuous activities for about a week. The week before and after your transfer, you’ll also want to rest.
Many of our patients report positive effects of acupuncture and massage on their comfort levels and overall well-being. Even a brief massage can greatly improve relaxation and state of mind, while helping to flush toxins from the body.
If you decide to do acupuncture, most herbal remedies should be fine prior to ovarian stimulation, but we recommend stopping them once we begin. Please do not use any herbs or preparations that contain hormones, blood thinning agents, or blood clotting properties.
Spring Fertility enjoys productive relationships with several acupuncturists and is willing to work with your acupuncturist to provide integrated and holistic care.
Hot tubs are fine through the egg retrieval, but should be avoided after an embryo transfer. Older studies suggested the potential for elevated core body temperature to affect early embryo development.
Travel is fine, as long as you can make it to your monitoring appointments during stimulation and are local and well-rested leading up to your retrieval and transfer. If you need to be out of town for a few days, you can find a fertility center there to do a monitoring appointment or two. When traveling long distances, you can keep refrigerated meds in a cooler pack and the TSA should let you through airport security just fine (though it’s wise to bring a note from your doctor which we can provide).
Trying to conceive can be one of the most stressful times for relationships and individuals. Research has shown that anxiety levels can be similar to patients who have been diagnosed with cancer, heart disease, and HIV.
While acupuncture, yoga, and meditation are helpful for some patients, communicating and supporting your partner is important. There is no “right” way to react to the medicines and process. Respecting each other’s stress and sensitivities is key. Many of our patients can find additional support and strength through support groups or mental health professionals.
Come see us for a fertility consult. Just contact us to book and we’ll send you a questionnaire and medical records release form so we can review your file in advance of our first meeting. Your insurance may require pre-approval in order to cover the cost of the consult.
Not ready for a consult? Come for a free info session. You can meet our team, tour our facility, and get more information about fertility treatments. We’re here for any and all your questions!
This depends on your specific plan. Group plans are more likely to have infertility coverage than individual plans but each case should be verified. Our team can help you check your benefits prior to your first consult and confirm what’s covered through the course of your treatment plan.
Many top employers in the Bay Area offer progressive fertility benefits to support their employees. Contact your HR department to see if yours does.