During IVF, eggs and sperm from the couple are incubated together in a laboratory to produce an embryo. A health care provider then places the embryo into the woman's uterus, where it may implant and result in a successful pregnancy.

The steps of IVF are:

• Superovulation
• Egg Retrieval
• Fertilization
• Embryo Transfer

IVF, which stands for in vitro fertilization, is an assisted reproductive technology. In vitro, which in Latin translates to "in glass," refers to a procedure that takes place outside of the body. There are many different indications for IVF. For example, a woman may produce normal eggs, but the eggs cannot reach the uterus because the uterine tubes are blocked or otherwise compromised. A man may have a low sperm count, low sperm motility, sperm with an unusually high percentage of morphological abnormalities, or sperm that are incapable of penetrating the zona pellucida of an egg.

A typical IVF procedure begins with egg collection. A normal ovulation cycle produces only one oocyte, but the number can be boosted significantly (to 10-20 oocytes) by administering a short course of gonadotropins. The course begins with follicle-stimulating hormone (FSH) analogs, which support the development of multiple follicles, and ends with a luteinizing hormone (LH) analog that triggers ovulation. Right before the ova would be released from the ovary, they are harvested using ultrasound-guided oocyte retrieval. In this procedure, ultrasound allows a physician to visualize mature follicles. The ova are aspirated (sucked out) using a syringe.

In parallel, sperm are obtained from the male partner or from a sperm bank. The sperm are prepared by washing to remove seminal fluid because seminal fluid contains a peptide, FPP (or, fertilization promoting peptide), that-in high concentrations-prevents capacitation of the sperm. The sperm sample is also concentrated, to increase the sperm count per milliliter.

Next, the eggs and sperm are mixed in a petri dish. The ideal ratio is 75,000 sperm to one egg. If there are severe problems with the sperm-for example, the count is exceedingly low, or the sperm are completely nonmotile, or incapable of binding to or penetrating the zona pellucida-a sperm can be injected into an egg. This is called intracytoplasmic sperm injection (ICSI).

The embryos are then incubated until they either reach the eight-cell stage or the blastocyst stage. In the United States, fertilized eggs are typically cultured to the blastocyst stage because this results in a higher pregnancy rate. Finally, the embryos are transferred to a woman's uterus using a plastic catheter (tube). The figure below illustrates the steps involved in IVF.

IVF

In vitro fertilization involves egg collection from the ovaries, fertilization in a petri dish, and the transfer of embryos into the uterus.

IVF is a relatively new and still evolving technology, and until recently it was necessary to transfer multiple embryos to achieve a good chance of a pregnancy. Today, however, transferred embryos are much more likely to implant successfully, so countries that regulate the IVF industry cap the number of embryos that can be transferred per cycle at two. This reduces the risk of multiple-birth pregnancies.

The rate of success for IVF is correlated with a woman's age. More than 40 percent of women under 35 succeed in giving birth following IVF, but the rate drops to a little over 10 percent in women over 40.

Assisted reproductive technology (ART) is used to treat infertility. It includes fertility treatments that handle both a woman's egg and a man's sperm. It works by removing eggs from a woman's body. The eggs are then mixed with sperm to make embryos. The embryos are then put back in the woman's body. In vitro fertilization (IVF) is the most common and effective type of ART.

ART procedures sometimes use donor eggs, donor sperm, or previously frozen embryos. It may also involve a surrogate or gestational carrier. A surrogate is a woman who becomes pregnant with sperm from the male partner of the couple. A gestational carrier becomes pregnant with an egg from the female partner and the sperm from the male partner.

The most common complication of ART is a multiple pregnancy. It can be prevented or minimized by limiting the number of embryos that are put into the woman's body.

Gametogenesis in females is called oogenesis. The process begins with the ovarian stem cells, or oogonia.

Oogonia are formed during fetal development, and divide via mitosis, much like spermatogonia in the testis. Unlike spermatogonia, however, oogonia form primary oocytes in the fetal ovary prior to birth. These primary oocytes are then arrested in this stage of meiosis I, only to resume it years later, beginning at puberty and continuing until the woman is near menopause (the cessation of a woman’s reproductive functions). The number of primary oocytes present in the ovaries declines from one to two million in an infant, to approximately 400,000 at puberty, to zero by the end of menopause.

The initiation of ovulation—the release of an oocyte from the ovary—marks the transition from puberty into reproductive maturity for women. From then on, throughout a woman’s reproductive years, ovulation occurs approximately once every 28 days. Just prior to ovulation, a surge of luteinizing hormone triggers the resumption of meiosis in a primary oocyte. This initiates the transition from primary to secondary oocyte. However, this cell division does not result in two identical cells. Instead, the cytoplasm is divided unequally, and one daughter cell is much larger than the other. This larger cell, the secondary oocyte, eventually leaves the ovary during ovulation. The smaller cell, called the first polar body, may or may not complete meiosis and produce second polar bodies; in either case, it eventually disintegrates. Therefore, even though oogenesis produces up to four cells, only one survives.

Meiosis of a secondary oocyte is completed only if a sperm succeeds in penetrating its barriers.

These actions may increase your chance of achieving a pregnancy, having a healthy pregnancy, and avoiding complications that could affect your health and the outcome of your pregnancy.

• Start and continue taking 400 mcg of folic acid daily, in the form of a vitamin supplement or enriched foods.
• Stop smoking cigarettes.
• Eliminate alcohol consumption.
• Reduce or eliminate caffeine intake.
• Start or continue an exercise regimen that helps control weight and provides relaxation and stress reduction benefits.
• Control your chronic conditions under medical supervision (e.g., high blood pressure, diabetes, reproductive tract infections, dental disease, anxiety, lupus, arthritis, epilepsy.)
• Develop eating habits that can continue into pregnancy and beyond, consider smaller portions of high quality foods providing sound nutritional value.
• Be sure your immunization records are up-to-date. Vaccines protect you from diseases such as rubella, tetanus, influenza, and whooping cough.
• Take advantage of wellness programs at work or in the community.

You may need to make some changes as you begin infertility treatment.

• Use of medications and treatment (prescription, over-the-counter, herbal or complementary) that could affect fertility treatment outcomes or may cause birth defects.
  • If you choose any form of infertility treatment, including ART, your physician should review these medications because some may interfere with treatment outcomes.
  • You also need to know what drugs and medications are not advisable for use during pregnancy (e.g., cause birth defects, pregnancy complications) or can be used in moderation or with increased supervision.
• Exposure to environmental and workplace hazards. These can include products such as pesticides, solvents, and even prescription medicines that you may handle or touch. This includes clothing or equipment used by a household member in their work or as part of a hobby. If a pregnancy occurs, these exposures could be dangerous during the first trimester.

"The healthiest women, the healthiest couples have the healthiest babies. The healthiest couples are going to have the best chance of successful assisted reproduction…" ~Dr. Callaghan.

Don't forget your emotional health during this time. It is one part of the construct of health and wellness. Some ART clinics and several national organizations can provide peer support programs for you and others involved in your life.

For couples hoping to become parents, difficulty conceiving a baby can be frustrating and unexpected. Many couples who struggle with infertility do end up having children, sometimes with medical help. An important early step is understanding possible causes of infertility.

In general, infertility is defined as not being able to get pregnant (conceive) after one year (or longer) of unprotected sex. Because fertility in women is known to decline steadily with age, some providers evaluate and treat women aged 35 years or older after 6 months of unprotected sex. While these definitions of infertility are used for data collection and monitoring, they are not intended to guide recommendations about the provision of fertility care services. Individuals and couples who are unable to conceive a child should consider making an appointment with a reproductive endocrinologist—a doctor who specializes in managing infertility. Reproductive endocrinologists may also be able to help women with recurrent pregnancy loss, defined as having two or more spontaneous miscarriages.

Pregnancy is the result of a process that has many steps. To get pregnant:

• An egg must be released from one of the ovaries (ovulation).
• Sperm must fertilize the egg.
• The fertilized egg (embryo) must travel from a fallopian tube toward the uterus (womb).
• The embryo must attach to the inside of the uterus (implantation).

Infertility may result from a problem with any or several of these steps.

Couples with the following conditions, signs, or symptoms should not delay seeing their health care provider when they are trying to become pregnant:

For women:

• Irregular menstrual periods or no periods.
• Endometriosis.
• A history of pelvic inflammatory disease
• Known or suspected uterine or tubal disease
• A history of more than one miscarriage
• Genetic or acquired conditions that predispose to diminished ovarian reserve (chemotherapy, radiation)

For men:

• A history of testicular trauma
• Prior hernia surgery
• Prior use of chemotherapy
• A history infertility with another partner
• Sexual dysfunction

Is infertility a common problem?

Yes. In the United States, about 1 in 5 (19%) married women aged 15 to 49 with no prior births in the United States are unable to get pregnant after 1 year of trying. Also, about 1 in 4 (26%) women in this group have difficulty getting pregnant or carrying a pregnancy to term.

Though it is often thought of as a woman’s problem, infertility can affect both men and women.

What causes infertility in men?

Infertility in men can be caused by different factors, including disruption of testicular or ejaculatory function, hormonal, and genetic disorders, and is typically evaluated by a semen analysis. A specialist will study the volume, number, movement, and shape of the sperm in a semen sample to determine if a male factor is involved.

What increases a man’s risk of infertility?

• Couples in which the male partner is 40 or older are more likely to report difficulty conceiving.
• Having overweight or obesity.
• Excessive alcohol or drug use (opioids, marijuana).
• A history of trauma to the testes.
• Exposure to testosterone, radiation, certain medicines, or certain environmental toxins.
• Frequent exposure of the testes to high temperatures.
• Hormonal disorders caused by improper function of the hypothalamus or pituitary glands, which maintain normal testicular function.
• Genetic disorders such as Klinefelter’s syndrome, Y-chromosome microdeletion, myotonic dystrophy, or other, less common genetic disorders.

What causes infertility in women?

Women need functioning ovaries, fallopian tubes, and a uterus to get pregnant. Conditions affecting any one of these organs can contribute to female infertility. Some of these conditions are listed below and can be evaluated with tests.

Disruption of ovarian function and effects of ovarian “age”

A woman’s menstrual cycle is, on average, 28 days. Regular, predictable periods that occur every 21 to 35 days mean that the woman is likely to be ovulating. A woman with irregular periods may not be ovulating. Not ovulating can be caused by the following:

• Polycystic ovary syndrome (PCOS). PCOS is a condition that causes women to not ovulate or to ovulate irregularly. PCOS is the most common cause of female infertility.
• Diminished ovarian reserve (DOR). Women are born with all the eggs they will have in their lifetime, and the egg count naturally decreases over time. DOR is a condition in which there are fewer eggs remaining in the ovaries than normal.

• Functional hypothalamic amenorrhea (FHA). Women with FHA do not get their periods because of excessive exercise, stress, weight loss, or a combination of these factors.
• Improper function of the hypothalamus and pituitary glands. These glands in the brain produce hormones that maintain normal ovarian function.
• Premature ovarian insufficiency (POI). POI, sometimes referred to as premature menopause, occurs when a woman’s ovaries stop producing eggs before she is 40.
• Menopause. Menopause is a natural decline in ovarian function that usually occurs around age 50. By definition, a woman in menopause has not had a period in 1 year.

Fallopian tube obstruction

Risk factors for blocked fallopian tubes can include a history of pelvic infection, ruptured appendix, gonorrhea or chlamydia, endometriosis, or abdominal surgery.

Physical characteristics of the uterus

Depending on a woman’s symptoms, the uterus may be evaluated by transvaginal ultrasound to look for fibroids or other problems, including intrauterine adhesions, endometrial polyps, adenomyosis, and congenital anomalies of the uterus.

What increases a woman’s risk of infertility?

• Age. About 1 in 5 (22%) married couples in which the woman is 30-39 have problems conceiving their first child compared to about 1 in 8 (13%) married couples in which the woman is younger than 30. Fertility declines with age primarily because egg quality declines over time. In addition, older women have fewer eggs left and they are more likely to have health conditions that can cause fertility problems. Aging also increases a woman’s chances of miscarriage and of having a child with a genetic abnormality.
• Smoking.
• Excessive alcohol use.
• Extreme weight gain or loss.
• Excessive physical or emotional stress that results in amenorrhea (not having periods).

How do doctors treat infertility?

Male and female infertility can be treated with medicine, surgery, intrauterine insemination, or assisted reproductive technology (ART).

Doctors recommend specific treatments for infertility based on the factors contributing to infertility, its duration, and the age of the female.

Health care providers evaluate men and women differently to diagnose infertility.

In evaluating a woman's fertility, a health care provider will ask specific questions about her health history. These include:

• Prior pregnancies
• Prior miscarriages
• The regularity of her menstrual period
• The presence of pelvic pain
• Whether she has abnormal vaginal bleeding or discharge
• Whether she has a history of pelvic infection or previous pelvic surgery

Initial screening may also involve a physical exam, including a pelvic exam or pelvic ultrasound, a Pap test, and blood tests to look at overall health. The health care provider may look for signs of milk production in the breasts, which suggests a hormone imbalance, and other physical symptoms of polycystic ovary syndrome and other conditions that affect fertility.

A health care provider may also conduct the following laboratory tests and evaluations:

• A blood test around day 23 of the woman's menstrual cycle can measure the amount of a hormone called progesterone. This test can tell whether ovulation has occurred and whether the ovaries are producing a normal amount of this hormone.
• Tests may also measure levels of other hormones that are important for fertility. The levels of follicle-stimulating hormone (FSH) and anti-Müllerian hormone (AMH) in the blood can help determine the quantity of a woman's remaining egg supply. FSH stimulates egg production and a hormone called estradiol. High FSH levels may mean that a woman has ovarian failure or is in perimenopause or menopause. Low levels of FSH may mean a woman has stopped producing eggs. AMH is produced only in ovarian follicles, so the levels of AMH in the blood indicate the presence of growing follicles.
• Other tests may include those to examine the fallopian tubes and determine whether there is blockage that prevents movement of the egg from the ovaries. These include the following:
  • X-ray hysterosalpingogram (pronounced HISS-tuh-roh-sal-PING-goh-gram). A health care provider injects a radiographic dye into the cervix to fill the uterus. If the fallopian tubes are clear of blockages, the dye will flow out the end of the fallopian tube into the peritoneal cavity. Movement of the dye is monitored by x-ray fluoroscopy.
  • Laparoscopy (pronounced lap-uh-ROS-kuh-pee) is a surgery in which a small viewing instrument, called a laparoscope, is inserted through a small cut in the abdomen to examine the female reproductive organs. If the procedure identifies blockages in the fallopian tubes, the blockages can be surgically treated with instruments attached to the laparoscope.
• A health care provider may examine the inside of the uterus to look for scarring, uterine fibroids, or polyps. The following procedures are used to examine the uterus:
  • Transvaginal ultrasound. An ultrasound looks at the internal organs using sound waves. A wand inserted into the vagina applies sound waves to the body. This provides a health care provider a better view of the female reproductive organs, including the uterus and ovaries.
  • Hysteroscopy (pronounced hiss-tuh-ROS-kuh-pee). A hysteroscope is a long, thin camera that is inserted through the vagina and into the uterus.
  • Saline sonohysterogram (pronounced sah-noh-HISS-tuh-roh-gram). In this procedure, a health care provider injects sterile saline into the cervix to fill the uterus. Once the uterine cavity is full, it is easier to see its inner lining. The pelvic organs are visualized with transvaginal ultrasound. It is also possible to see fluid move into the peritoneal cavity at the same time, which indicates that at least one tube is open.
• Health care providers may test a woman older than age 35 to get a snapshot of the number of remaining follicles or if her follicles mature to the stage of ovulation. This type of testing includes performing a transvaginal ultrasound to look at the ovaries and measuring hormones in the blood on certain days of the menstrual cycle.

Health care providers evaluate men and women differently to diagnose infertility.

The evaluation of a man's fertility includes looking for signs of hormone deficiency, such as increased body fat, decreased muscle mass, and decreased facial and body hair. The evaluation also includes questions about the man's health history, including:

• Past injury to the testicles or penis
• Recent high fevers
• Childhood diseases, such as mumps
• Low sexual desire (libido)

A physical examination of the testes and penis allows for identification of problems, such as:

• Infection, signaled by discharge or prostate swelling
• Hernia
• Malformed tubes that transport sperm
• Hormone deficiency as indicated by small testes or lack of facial and body hair
• Presence of a mass in the testicles
• Varicocele (abnormal veins in the scrotum)

A health care provider may also ask a man to provide a sample of semen to assess the health and quality of his sperm. To give a semen sample, the man is requested to refrain from ejaculation for around 48 hours before the test. He then provides a sample by masturbating into a cup or by having intercourse using a special condom (without contraceptive) that collects semen without affecting the sperm. A man may need to provide a semen sample on more than one occasion, because sperm production can vary over time depending on the man's current health status, activities, and stress level.

Other tests may include:

• Measurement of hormones in the blood, including testosterone and follicle-stimulating hormone, thyroid hormones, and prolactin
• Biopsy of the testicle. A health care provider uses a needle to extract sperm from the testicle.
• Genetic testing. In cases where no or very few sperm are found in the semen, a health care provider may do genetic testing before starting fertility treatments. Testing can identify chromosome abnormalities that may cause the lack of sperm or lead to developmental problems among offspring.

Some common medicines used to treat infertility in women include:

• Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovary syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.
• Human menopausal gonadotropin or hMG (Repronex, Pergonal): This medicine is often used for women who don't ovulate due to problems with their pituitary gland. hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.
• follicle-stimulating hormone or FSH (Gonal-F, Follistim): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.
• Gonadotropin-releasing hormone (Gn-RH) analog: These medicines are often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.
• Metformin (Glucophage): Doctors use this medicine for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.
• Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of prolactin. Prolactin is a hormone that causes milk production.

Many fertility drugs increase a woman's chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born too early (prematurely). Premature babies are at a higher risk of health and developmental problems.

These questions will help you learn more about a fertility clinic, its services, and staff.

1. What procedures do you currently offer that may fit with my/our needs?
2. How much experience do you have with these procedures?
3. What are your current success rates with these procedures?
4. What are your criteria for accepting new patients? (Is there a waiting list? Age limits? Single or married?)
5. What tests are required for my care? Will you accept results performed by others?
6. Do you have or help arrange for gestational carriers (Surrogates)?
7. Do you have or help arrange for obtaining donor eggs, embryos or sperm?
8. Do you offer elective single embryo transfer?
9. What would be an optimal schedule for the ART procedure I (we) would have?
10. If I (we) need storage of eggs/embryos or sperm, what are the costs for storage?
11. What types of counseling and support services are available?

Care and Treatment

1. How many physicians will be involved in my care?
2. Are the physicians providing my care board-certified? Are any specialists in reproductive endocrinology?
3. How will the clinic work with my current health care provider (i.e., OB/GYN, or urologist)?
4. What staff members are available to answer my questions about treatment, services, tests, and medication?

Costs and Financing

1. Do you have cost estimate for the tests and procedures I (we) may need?
2. What are your available payment options?
3. Do you accept insurance and if so, for what tests, medications and procedures?

Affiliations

1. Does the clinic follow American Society for Reproductive Medicine (ASRM) practice guidelines?
2. Is the clinic currently a member of a national organization or medical society?

In this process, also known as ovarian stimulation, ovulation induction, or stimulation of egg maturation, a woman takes medication to stimulate the ovaries to make many mature eggs at one time.

These medications are given by injection for 8 to 14 days. A health care provider closely monitors the development of the eggs using transvaginal ultrasound and blood tests to assess follicle growth and estrogen production by the ovaries. When the eggs are mature—as determined by the size of the ovarian follicles and the level of estrogen—an injection of the hormone hCG initiates the ovulation process. A health care provider takes out (egg retrieval) the eggs 34 to 36 hours after the hCG injection.

This is the process used to remove the eggs from the ovaries so they can be fertilized. The procedure is performed in a physician's office as an outpatient procedure. A mild sedative and painkiller are often used during the procedure, and it normally takes about 30 minutes. The steps for egg retrieval are as follows:

• An ultrasound probe is inserted into the vagina to visualize the ovaries and the follicles, which contain the eggs.
• A needle is inserted through the wall of the vagina to the ovaries. Generally, ultrasound is used to guide the placement of the needle.
• Suction is used to pull the eggs from the ovaries into the needle.

A man provides a semen sample. If the sperm are healthy, they are centrifuged to concentrate them and reduce the volume, placed in a dish with the egg, and left overnight in an incubator. Fertilization usually occurs on its own. However, sometimes sperm are not able to fertilize the egg on their own. When this is the case, a single sperm is injected into an egg using a needle. This process is called intracytoplasmic (pronounced IN-truh-sahy-tuh-PLAZ-mick) sperm injection (ICSI). About 60% of IVF in the Unites States is performed with ICSI. The pregnancy rate is about the same for IVF using natural fertilization or ICSI.

If sperm cannot fertilize the egg without assistance, couples should consider genetic testing. This testing can determine whether the sperm have chromosome problems that might cause development problems in the resulting embryos.

Embryos that develop from IVF are placed into the uterus 1 to 6 days after retrieval.

Couples can opt for donated sperm if a man does not produce sperm, produces very low numbers of sperm, or has a genetic disease. Donated sperm can be used with IUI or with IVF.

This process may be an option when a woman does not produce healthy eggs that can be fertilized. An egg donor undergoes the superovulation and egg retrieval steps of IVF. The donated egg can then be fertilized by sperm from the woman's partner. The resulting embryo is placed into the woman's uterus, which is receptive for implantation because of hormone treatments.

Egg donation may be particularly helpful for women who:

• Have primary ovary insufficiency
• Have had chemotherapy or radiation therapy
• Have had surgical removal of the ovaries
• Were born without ovaries
• Are carriers of known genetic diseases
• Are infertile because of poor egg quality
• Are menopausal

How to collect a family medical history

There are different ways to collect family health information. You can choose one family member to collect all the health information from various relatives or have each relative fill out their own health record. You can also create a checklist that is organized by medical condition.

If a family member does not want to discuss their health issues around other people, ask to pull them aside and have a private conversation. Try to remind them of the importance of having a family health history.

But remember that health can often be an emotionally charged topic. Listen carefully and try to be as respectful and patient as possible.

For adopted children or children of sperm or egg donations, health records may be available from the original adoption or donation agencies. Genetic testing can also help determine certain conditions.

Fertility-preserving options for females include:

• Embryo cryopreservation. This method, also called embryo freezing, is the most common and successful option for preserving a female's fertility. First, a health care provider removes eggs from the ovaries. The eggs are then fertilized with sperm from her partner or a donor in a lab in a process called in vitro fertilization. The resulting embryos are frozen and stored for future use.
• Oocyte (pronounced OH-uh-sahyt) cryopreservation. This option is similar to embryo cryopreservation, except that unfertilized eggs are frozen and stored.

Some of these options, such as sperm, oocyte, and embryo cryopreservation, are available only to males and females who have gone through puberty and have mature sperm and eggs.

This procedure is performed in a physician's office. The procedure is normally painless, but some women may experience cramping.

A health care provider inserts a long, thin tube through the vagina and into the uterus and injects the embryo into the uterus. The embryo should implant into the lining of the uterus 6 to 10 days after retrieval.

Sometimes the embryos are frozen and thawed at a later date for embryo transfer. This is often done when fresh embryos fail to implant or when a woman wants to preserve her eggs in order to become pregnant years later. Women either time implantation with their ovulation cycle or receive estrogen and progesterone medications to prepare their uterine linings for implantation.

During in vitro fertilization (IVF), you can transfer one embryo (single embryo transfer, or SET) or two embryos (double embryo transfer, or DET). If you are a good candidate for single embryo transfer, your chance of having a baby after two single embryo transfers is as good as your chance of having a baby after one double embryo transfer. That’s important to know because twin pregnancies are risky for baby and mother.

The chart below compares the percentage of women who had single babies or twins after single and double embryo transfers among good candidates for single embryo transfer. These women were good candidates for single embryo transfer because they were using IVF for the first time and were (1) younger than 38, transferring fresh embryos created from their own eggs, and freezing at least one embryo or (2) any age and transferring fresh embryos created from donor eggs.

• 1 SET (fresh): transfer of one fresh embryo for the first IVF cycle.
• 1 SET (fresh) + 1 SET (frozen): transfer of one fresh embryo for the first IVF cycle, followed by transfer of one frozen embryo, if the first fresh embryo transfer does not lead to having a baby.
• 1 DET (fresh): transfer of two fresh embryos for the first IVF cycle.

Source: Centers for Disease Control and Prevention, National Assisted Reproductive Technology Surveillance System (NASS), 2010-2012.

For women who are good candidates for single embryo transfer, transferring one fresh embryo followed by one frozen embryo, if a second transfer is needed, offers the best chance of having a baby without increasing the chance for twins.

We know that you are ready to start or add to your family. You may be concerned about your chances of having a baby using in vitro fertilization (IVF) or how much cycles of IVF cost. These concerns are common and may lead you to think about transferring more than one embryo during your IVF procedure. However, transferring more than one embryo increases your chances of having twins or more. Twin pregnancy is risky for baby and mother, whether or not IVF is used. Some of these risks include:

Almost 3 out of 5 twin babies are born preterm, or at less than 37 weeks of pregnancy. Twin babies are nearly 6 times as likely to be born preterm as single babies.

Twin babies are more likely to be stillborn, experience neonatal death, have birth defects of the brain, heart, face, limbs, muscles, or digestive system, and have autism than single babies.

About 1 out of 4 twin babies are admitted to the neonatal intensive care unit (NICU). Twin babies are more than 5 times as likely to be admitted to the NICU as single babies.

About 7 out of 1,000 twin babies have cerebral palsy. Twin babies are more than 4 times as likely to have cerebral palsy as single babies.

Twin babies are more likely to be stillborn, experience neonatal death, have birth defects of the brain, heart, face, limbs, muscles, or digestive system, and have autism than single babies.

Almost 1 out of 10 women carrying twins gets pregnancy-related high blood pressure. Women carrying twins are twice as likely to get pregnancy-related high blood pressure as women carrying single babies.

Almost 1 out of 20 women carrying twins gets gestational diabetes. Women carrying twins are 1.5 times as likely to get gestational diabetes as women carrying single babies.

If a woman is unable to carry a pregnancy to term, she and her partner may choose a surrogate or gestational carrier.

A surrogate is a woman inseminated with sperm from the male partner of the couple. The resulting child will be biologically related to the surrogate and to the male partner. Surrogacy can be used when the female of the couple does not produce healthy eggs that can be fertilized.

A gestational carrier is implanted with an embryo that is not biologically related to her. This alternative can be used when a woman produces healthy eggs but is unable to carry a pregnancy to term. If needed, egg or sperm donation can also be used in this situation.

What is a pregnancy test?

A pregnancy test can tell whether you are pregnant by checking for a particular hormone in your urine or blood. The hormone is called human chorionic gonadotropin (HCG). HCG is made in a woman's placenta after a fertilized egg implants in the uterus. It is normally made only during pregnancy.

A urine pregnancy test can find the HCG hormone about a week after you've missed a period. The test can be done in a health care provider's office or with a home test kit. These tests are basically the same, so many women choose to use a home pregnancy test before calling a provider. When used correctly, home pregnancy tests are 97–99 percent accurate.

A pregnancy blood test is done in a health care provider's office. It can find smaller amounts of HCG, and can confirm or rule out a pregnancy earlier than a urine test. A blood test can detect pregnancy even before you've missed a period. Pregnancy blood tests are about 99 percent accurate. A blood test is often used to confirm the results of a home pregnancy test.

Other names: human chorionic gonadotropin test, HCG test

What is it used for?

A pregnancy test is used to find out whether you are pregnant.

Why do I need a pregnancy test?

You may need this test if you think you are pregnant. Symptoms of pregnancy vary from woman to woman, but the most common sign of early pregnancy is a missed period. Other common signs of pregnancy include:

• Swollen, tender breasts
• Fatigue
• Frequent urination
• Nausea and vomiting (also called morning sickness)
• Bloated feeling in the abdomen

What happens during a pregnancy test?

You can get a home pregnancy test kit at the drug store without a prescription. Most are inexpensive and easy to use.

Many home pregnancy tests include a device called a dipstick. Some also include a collection cup. Your home test may include the following steps or similar steps:

• Do the test on your first urination of the morning. The test may be more accurate at this time, because morning urine usually has more HCG.
• Hold the dipstick in your urine stream for 5 to 10 seconds. For kits that include a collection cup, urinate into the cup, and insert the dipstick into the cup for 5 to 10 seconds.
• After a few minutes, the dipstick will show your results. The time to results and the way the results are shown will vary between test kit brands.
• Your dipstick may have a window or other area that shows a plus or minus sign, a single or double line, or the words "pregnant" or "not pregnant." Your pregnancy test kit will include instructions on how to read your results.

If the results show you are not pregnant, you may want to try again in a few days, as you may have done the test too early. HCG gradually increases during pregnancy.

If your results show you are pregnant, you should make an appointment with your health care provider. Your provider may confirm your results with a physical exam and/or a blood test.

During a blood test, a health care professional will take a blood sample from a vein in your arm, using a small needle. After the needle is inserted, a small amount of blood will be collected into a test tube or vial. You may feel a little sting when the needle goes in or out. This process usually takes less than five minutes.

Will I need to do anything to prepare for the test?

You don't need any special preparations for a pregnancy test in urine or blood.

Are there any risks to the test?

There is no known risk to having a urine test.

There is very little risk to having a blood test. You may have slight pain or bruising at the spot where the needle was put in, but most symptoms go away quickly.

What do the results means?

Your results will show whether you are pregnant. If you are pregnant, it's important to see your health care provider as soon as possible. You may be referred to or may already be receiving care from an obstetrician/gynecologist (OB/GYN) or a midwife. These are providers who specialize in women's health, prenatal care, and pregnancy. Regular health care visits during pregnancy can help ensure you and your baby stay healthy.

Is there anything else I need to know about a pregnancy test?

A urine pregnancy test shows whether HCG is present. HCG indicates pregnancy. A pregnancy blood test also shows the amount of HCG. If your blood tests show a very low amount of HCG, it could mean you have an ectopic pregnancy, a pregnancy that grows outside the uterus. A developing baby can't survive an ectopic pregnancy. Without treatment, the condition can be life-threatening for a woman.