Thirty minutes after her egg retrieval, Terra was still groggy from the anesthesia. Knowing she might have just a faint memory of this conversation, I turned to her husband, who had just been allowed to come join her in the recovery room, and reported the good news to him.
"15 eggs"
"That’s better than we expected," he beamed.
An IVF cycle has the variability of a sporting event. Most of the time, the high scoring teams will score well. Most of the time, the low scoring teams will score poorly. Occassionally, upsets and surprises happen, but usually, not.
For Terra, we saw about 11 mature follicles on ultrasound in her last scan prior to the retrieval. With that, it would be no surprise if she got anywhere between 6 to16 eggs. Anything way above or below that would be quite a shock, although things like that HAVE happened. In this case, the outcome was good. It’s obviously good to have results that are better than expected.
As per my routine, as I drive from the surgery center back to my office, I used the time to dictate the operative report via my BlueTooth.
The next morning, I received the fertilization report. First of all, I should tell you that we had made the decision ahead of time to do ICSI with all the eggs. There are two ways to do IVF — the standard way and ICSI (Intracytoplasmic sperm injection). Standard IVF involves layering the sperm over the eggs and letting them do their thing on their own. The advantage to this is that natural selection is allowed to come into play as the strongest individual sperm with the best fertilizing ability are the ones that end up in the egg. With ICSI, the embryologist chooses the best-LOOKING one, based on how well it looks and how well it moves and then injects it into the egg.
I love to do standard IVF as much as possible and I probably do it in up to 25% of my cases. My colleagues, on the other hand, tend to do ICSI on 100% of their cases. The advantage of their strategy is that they don’t have to think about the risk of failed fertilization. If you choose to do standard IVF rather than ICSI, you might come back the next morning and find that all the eggs are sitting in the dish with a lot of sperm swimming around them, but with none successfully fertilized and that would be a horrible feeling. You are then forced to do second-day ICSI, which still has SOME hope, but is much much worse at getting you a pregnancy than if you would have done ICSI on the first day.
Then, why not play it safe and always do ICSI? Because, when you let survival of the fittest come into play, there is the belief that the embryos are "stronger" and result in a higher chance of pregnancy. It also saves the patient money, usually $1000-1500, depending on the lab. There is no evidence that the standard IVF babies are cuter, stronger, or better at math than "ICSI" babies, but whenever I feel it is safe, I will prefer recommending standard IVF over ICSI, because I believe in the principal of natural selection.
For which patients do I recommend ICSI?
- Cases in which the sperm is the suspected problem.
- Cases in which the husband has never proved that he can fertilize, meaning he has never initiated any pregnancies in his life.
- Cases when we use frozen sperm.
- Cases in which we don’t have a lot of eggs.
- Cases in patients who had poor fertilization in the past.
For which patients do I sometimes recommend standard IVF?
- Cases in which the sperm is almost for sure not the problem and the husband has a proven record of fertilization in the past (either naturally or through IVF).
- Cases in which the sperm is PROBABLY not the problem, but the husband has no proven fertility AND we have a lot of eggs to play around with. In these cases, I will consider taking some of the eggs and doing standard IVF and then doing ICSI on the rest, just to be safe.
I will only do this if the patient is well aware of the risk involved. A lot of times we do this mixed strategy and find that the ICSI group fertilizes fine, but the standard IVF embryos all failed to fertilize. In this case, we learned a big lesson about how bad the sperm functions. Fortunately, it’s not TOO costly a lesson as we can then get a pregnancy from the successful ICSI embryos. Other times, we might come back the next day and find equal or even BETTER fertilization in the standard IVF group. In these cases we will take into account this fact when we choose which embryos to transfer. We’ll still pick the better looking ones to transfer, but if it’s a tie, then we lean towards using the non-ICSI ones. In the future, if this couple does IVF again, then we would likely have the confidence to NOT do ICSI.
For Terra and Miles, since Miles had never fertilized any pregnancies before and Terra made a lot of eggs, we could have chosen to do the mixed strategy, but they decided to play it super safe and just do all ICSI. Their results were excellent. 11 embryos out of 11 injected. Recall that they had 15 eggs. Well, 11 of them were mature and normal enough to undergo ICSI and to our pleasant surprise all of them fertilized normally. This is usually not the case, just like hitting 11 out of 11 free throws is not usually the case for a basketball player. But when it does happen, everyone is feeling good (except maybe for the opposing team).
We’re going to let these embryos incubate for two days and reevaluate our next strategy on how many embryos to transfer and when to transfer them.
