SART FAQ About IVF

In vitro fertilization (IVF) is a type of assisted reproductive technology (ART) in which embryologists fertilize eggs with sperm to form embryos that can then be transferred to a woman’s uterus.  IVF was first performed in the United States in 1981 and, while it was originally developed to help individuals with blocked or absent fallopian tubes, its use has continued to grow. It is now used to help many individuals and couples build their families for reasons related not only to infertility but also to other medical conditions.   

Third-party reproduction refers to fertility treatment in which there is a third-party involved.  Examples of third-party reproduction include the use of donor egg, donor sperm, donor embryo, or a gestational carrier.

Infertility can be one of the most distressing life crises an individual or couple can face. The long-term inability to conceive a child can evoke significant feelings of loss, and coping with the many medical decisions and the uncertainties that infertility brings can create great emotional upheaval. Many individuals and couples experience anxiety, depression, and feelings of being out of control or isolated. Social support, stress management techniques, and counseling with a qualified fertility counselor can help people experiencing infertility to find effective strategies for dealing with these feelings.  For more information, please see Preparing for IVF: Emotional Considerations.

SART (Society for Assisted Reproductive Technology) is the primary organization of professionals dedicated to the practice of assisted reproductive technology (ART or IVF) in the United States.  It's a non-profit organization that maintains standards for ART so that patients receive the highest possible level of care. SART member clinics, which include the majority of ART clinics in the country, are required to follow evidence-based national guidelines, employ boarded or board-eligible physicians, accurately report outcomes, and advertise truthfully.  SART member clinics work with nationally accredited laboratories to assure the best quality IVF lab environment.

During each menstrual or IVF cycle, a person has a group of follicles (antral follicles) in the ovary that are ready to develop into eggs. In a unmedicated cycle, one grows and eventually ovulates, while the rest die off.  During an IVF cycle, the goal is to grow as many follicles safely as possible for an egg retrieval.  Sometimes smaller follicles are difficult to see at the beginning of the cycle but then grow.  Conversely, there are some follicles that don’t grow.  The follicle count at the start of a cycle is just an approximation- a better estimate of how many eggs will be retrieved is based on how many follicles have grown during the stimulation process. 

During natural embryo implantation, there is a “shell” around the embryo called the zona pellucida (ZP). To implant into the uterus, the ZP breaks down and allows the inner embryo to “hatch” out of the ZP, resulting in the embryo attaching to the uterine lining (endometrium).

In the IVF laboratory, a procedure called assisted hatching (AH), has been used to theoretically aid in embryo implantation. Assisted hatching involves creating a hole in the ZP to potentially increase the ability of the embryo to hatch and implant. Several methods for AH have been used – laser, needle, or chemical, all with the intention of improving the chance of embryo implantation. Assisted hatching has been typically performed prior to embryo transfer, either on day 3, 5, or 6 following insemination of the eggs.  Evidence regarding the benefits and risks of assisted hatching is mixed and can be discussed on a case-by-case basis with your physician.

There are several types of “genetic testing.”  Genetic carrier screening, also called panethnic carrier screening (PECS), may be completed prior to treatment and is a mechanism to test for recessive genetic conditions that the egg or sperm source may pass on to the offspring. Preimplantation genetic testing (PGT) can be performed during an IVF cycle and involves embryo biopsy, removing several cells from an embryo for testing for genetic viability or for a specific genetic disease when indicated.  Decisions regarding genetic testing should be made on a case-by-case basis and can be individualized based on age, medical history, patient preferences, and ovarian reserve.

The most commonly adopted type of PGT is preimplantation genetic testing for aneuploidy, or PGT-A. This test is designed to screen for aneuploidy, or an abnormal number of chromosomes in an embryo. Aneuploidy is strongly associated with miscarriage and therefore PGT-A allows us to prioritize embryos based on their chances of implantation and ongoing pregnancy. It is important to note that PGT-A cannot guarantee an ongoing pregnancy or a healthy livebirth and is still considered a screening test. It is recommended that you discuss PGT-A with your care team to learn if it is appropriate for your care. Some patients may be eligible for other types of PGT, such as PGT-M or PGT-SR, tests that screens for a known inherited genetic condition or structural chromosome difference (balanced translocation). For example, PGT-M might be offered to a couple in which both partners carry sickle cell disease or cystic fibrosis.

Finally, genetic testing may be recommended to you by your care team in order to diagnose certain genetic conditions you may have that may explain certain aspects of your infertility such as recurrent pregnancy loss or male infertility.

If you are uncertain about pursuing any of the different genetic tests available to you, speak with your physician or genetic counselor for their recommendation.

The goal of infertility treatment is the birth of one healthy child at a time. Various treatment options are associated with a risk of multiple gestation (twins, triplets, etc.). Moreover, some patients view twins as desirable and are unaware of the risks they pose to both mother and babies. Patients should understand these risks before starting treatment.

The ability to limit the number of embryos transferred during IVF is effective to limit multiple pregnancies. The Society for Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM) have published guidelines recommending an optimal number of embryos for transfer based on patient age, embryo quality, and other criteria.  If the eggs are from a person less than 38 years old or the embryo has had preimplantation genetic testing, the recommendation is to transfer only one embryo (single embryo transfer or SET).

In the United States, the decision regarding the number of embryos to transfer is made jointly by the physician and the patient.  The ultimate goal is to achieve a high pregnancy rate while reducing the risk of multiples. Recent laboratory improvements (blastocyst transfer and preimplantation genetic testing (PGT) of embryos) have allowed programs to transfer one embryo while maintaining acceptable pregnancy rates.

A principal limitation to human reproduction is the normal loss of healthy eggs as a woman ages. Women are born with all the eggs they will ever have, and over time, most are lost through a natural process called atresia. By the mid-thirties, it may be more difficult to achieve a healthy pregnancy, and the risk of chromosomal abnormalities in the eggs, and subsequent pregnancy, increases. By their early forties, many women face significant infertility due to the depletion of healthy eggs.

You may need to consider using donor eggs if you have significantly diminished egg quality or quantity.  Egg quality and quantity naturally decline with age, especially after 37 and more sharply after 40. Common reasons patients explore egg donation include previous failed IVF cycles, being over the age of 42–45, a diagnosis of primary ovarian insufficiency (POI) or early menopause, or having lost your egg reserve due to cancer treatments or other medical conditions.

In these situations, egg donation offers a path to parenthood. Like sperm donation, it allows individuals or couples to build a family when their own gametes (eggs or sperm) are not viable. Egg donors are typically younger, healthy women who undergo comprehensive screening, including medical, psychological, genetic, and infectious disease testing, to ensure they are appropriate donors. Once selected, the donor’s cycle is coordinated with the recipient’s, allowing fertilization and embryo transfer to occur in the same month or the embryos may be frozen for future use. Alternatively, frozen donor eggs may be obtained from an egg bank.  Egg donation cycles have some of the highest success rates in IVF.

Most eggs will fertilize when they are placed in a culture dish with several thousand normal sperm. This process is called “in vitro fertilization” or “IVF.”  Intracytoplasmic sperm injection (ICSI) is a procedure where a single sperm is selected and injected into the egg to facilitate fertilization.  ICSI is performed when semen parameters are not optimal or as a routine procedure in many laboratories.   On rare occasions, fertilization does not occur even with ICSI, presumably because of a problem inherent to either eggs or sperm.  In these cases, donor sperm and/or donor eggs may be recommended.  Experimental treatments such Artificial Oocyte Activation (AOA) with calcium ionophore or In Vitro Maturation (IVM) whereby immature oocytes are matured in the laboratory prior to exposure to sperm are performed at some laboratories. These techniques should only be pursued in laboratories which have an established record and experience using them.  Your fertility specialist and IVF laboratory personnel will help you determine which approach is most likely to result in egg fertilization.

The purpose of ICSI (intracytoplasmic sperm injection) is to assist the fertilization process and is typically performed when the sperm is very poor quality (low count, motility and/or morphology). The technique involves the injection of a single sperm into one egg. Since 1991 when it was first described, it has revolutionized the treatment of male infertility.  Other reasons to choose ICSI may be: a history of failed fertilization in a prior IVF cycle, the need for some types of genetic testing on embryos, the use of frozen eggs, and surgically removed sperm.

A response to ovarian stimulation with IVF medications depends on a number of different factors. The most important include ovarian reserve, appropriate hormone levels, proper administration of medications, and lifestyle/environmental factors.

In order to respond to ovarian stimulation, a patient must have eggs available to respond; this is sometimes referred to as ovarian reserve. If a patient has diminished ovarian reserve (identified by a high blood levels of follicle stimulation hormone (FSH), low blood levels of anti Müllerian hormone (AMH), or a low antral follicle count on ultrasound), they may not respond adequately to stimulation. For these patients, an alternate stimulation protocol may be tried or an egg donor may be considered.

It is possible that a patient has good ovarian reserve but lacks the appropriate pituitary hormones to stimulate the ovaries. In this case, using a different medication (one which may contain both follicle stimulating hormone (FSH) and luteinizing hormone (LH)) may allow for an optimal response.

Lifestyle factors can also affect a patient's response to stimulation. Optimizing weight and cessation of tobacco or alcohol may help response. Speak to your physician regarding improving your particular response to ovarian stimulation.

If you decide to not continue to store your frozen embryos, you may have several options, depending on your clinic's policies and laws in your region.  Here are the most common options: 

1. Donation of your embryo(s) to another individual or couple.  You can opt to donate them either without knowing who the embryos will be donated to (de-identified embryo donation) or you can donate them to a specific person with whom you will have contact information and mutually agreed communication with.  This is called directed donation.
2. Donation of your embryo(s) to scientific research.
3. Discarding your embryo(s).
4. Donation of your embryos to clinical training.

The difference between a day 3 and a day 5 embryo transfer is the difference in the stage of embryo development that the embryo is at the time of embryo transfer.

A day 3 embryo is an embryo that has been in the laboratory for 3 days after fertilization and is a cleavage cell embryo. It typically has 6- 12 cells.

A day 5 embryo is and embryo that has been in the laboratory for 5-6, and rarely 7, days after fertilization.  It is at the blastocyst development stage.  A blastocyst has hundreds of cells and is a more complex structure consisting of an inner cell mass (the cells that will become the fetus) and a fluid filled cavity.  Per embryo, blastocyst transfers have higher implantation compared to day 3 transfers, especially with good quality embryos.

The answer quite simply, is yes. IVF is an effective treatment for many types of infertility. Success rates vary depending on several factors, and age is the biggest predictor of IVF success. In 2023, the chance of having a baby after just one cycle of IVF was 42.8% for women less than 35 years old. A personalized success rate can be estimated by using the SART Success Predictor Tool:

https://sartcorsonline.com/Predictor/PatientV2Landing

Coverage for infertility treatment depends on where you live and the type of insurance plan you have and if your employer has decided to offer treatment benefits.  Twenty-two states and the District of Columbia currently have laws that require insurers to either cover or offer to cover some form of infertility diagnosis and treatment. However, the laws vary greatly in their scope of what is and is not covered. For more information about the specific laws for each of those states, please call your state's Insurance Commissioner's office or to learn about pending insurance legislation in your state, please contact your State Representatives.

Whether or not you live in a state with an infertility insurance law, you may want to consult with your employer's director of human resources to determine the exact coverage your plan provides. Another good source of assistance is RESOLVE (resolve.org), an infertility patient advocacy and information organization.