Thursday, March 4, 2010

More Questions Regarding IVF and ICSI: Can I Have Twins, SET, And Other Post Retrieval And Transfer Questions


Hello again, this is S. with some follow-up questions from my earlier email.
Thanks for answering my questions. I have a few more. I know that obviously it depends upon the number of viable eggs removed during egg retrieval for IVF with ICSI but how many of the eggs would they try to fertilize and use at a time? How does it work with the frozen embryos? What are the chances of twins or triplets with this type of procedure? Can I decide if I want twins if I have more than 1 egg that is ready? After the egg is fertilized and put back do I have to be off of my feet for a time? How long does it take for the process to take place?

Sorry I'm just really unclear about all of this. Do I have to go back for ultrasounds afterwards and if so how often do I have follow up appts? Thanks again!


Hello S.,

You're welcome to follow up with additional questions any time. I probably did not address the ICSI (intracytoplasmic sperm injection) question you had in your first email. With ICSI, all mature eggs are injected since not all with fertilize. If they only took a few and did ICSI, which I understand some clinics will do, that could impair the number of embryos you have to work with if they don't fertilize.

These are then allowed to divide over a 3-5 day period. An appropriate number is then chosen to transfer. That number is decided between you and your doctor. With frozen embryo transfers, the embryos are thawed, allowed to expand, and if they survive, are transferred. Usually the number thawed are the number transferred because re-freezing is not necessarily a good thing.

If three embryos are transferred, the risk of twins is about 35% and triplets less than 10%. This risk declines as the number of embryos transferred decreases. Because of the high pregnancy rates these days, many clinics have moved to doing a single embryo transfer, or SET, in order to minimize the risk of twins or more. This is based on new recommendations that have come out from the American Society for Reproductive Medicine and the Society for Advanced Reproductive Technology. There has been strong political pressure for IVF centers to reduce the incidence of a multiple gestation (twins or more). If you want twins, then you have to discuss this with your doctor and see if that is something the doctor feels comfortable with. Depending on your age, either two or three embryos would be transferred to try to achieve twins.

Once the embryos are transferred, you do not have to "rest" for any period of time. I have my patients do light activity for three days after the transfer to allow for implantation to take place, but I do not want them to be at bedrest. From that point it is a natural process and is the same that your body would go through if you were trying on your own.

In terms of your last two questions, these are answers that you should be getting directly from your IVF center. You pay them a lot of money for this procedure and they should be giving you almost royal treatment. If they are not, then you should demand it. The IVF process is a three week process, basically mimicking your natural process. The ovaries are stimulated, which takes 10-12 days, the eggs are retrieved at the mid-cycle and allowed to fertilized, then they are allowed to grow in culture for 3-5 days, then they are transferred back into the uterus. 8-10 days later a pregnancy test is done, which usually coincides with the end of the month if you started at the beginning of the month. (You should check out my website and I have an outline of the IVF process.) In the first 10-12 days, ultrasound and blood tests are done periodically to evaluate how you are responding, how many follicles you have, how big the follicles are and when to trigger for the retrieval. These ultrasounds can be done daily, every other day or farther apart depending on how big the follicles are and how close you are to the trigger day (generally as you get closer, the appointments get closer). The egg retrieval is usually done two days after the trigger (35-36 hours from the trigger injection) then the transfer is done 3-5 days after that.

Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.


  1. Hi Dr. Ramirez.

    Found today's post interesting as I am an IVF/ICSI mom.

    It is amazing to me, since the conception of Louise Brown, the number of babies and the advances in technology that have come about with regard to ART...especially for male-factor infertility.

    I have a friend who just recently went thru IVF/ICSI and was SHOCKED to learn that the REs now GRADE the sperm...WOW!!! They couldn't do that a mere 6 years ago!

    With our protocol, I produced 24 follicles (I think it was like 10 in left ovary and 14 in right) and they retrieved 14 eggs. Nine eggs fertilized and only TWO made it to 5-day transfer. All others stopped dividing or began defragmenting (I think that was the term used). Of those two or "twin" embryos transferred, only 1 stuck...but what a beautiful medical miracle she is!!! Mary Catherine will be 6 in August and starting hard for me to believe.

    As I mentioned previously, we went on to conceive naturally 18-months after Mary's birth and have conceived again (I'm 40!) with our 3rd baby due in August. (I find it fascinating that our 1st and 3rd babies have almost the EXACT same conception and due dates while one was an IVF/ICSI baby and the other a natural conception 5 years later!)

    Interestingly, no twins, even with my "advanced maternal age" with all 3 healthy pregnancies, which I attribute to the male factor part of the equation.

    Thanks again for providing this service to your readers,


  2. Dear Valerie,
    Thank you for your comments, it's good to see you still follow my blog, and thank you for your past comments as well! Hope that your pregnancy progresses well and that your third will be just as joyful as the first two! I'm always gratified to learn how ART affects women in a positive way and that the children resulting from ART are just as healthy and well-adjusted as any other child!

  3. Hello,
    I am hoping that you might be able to clarify some questions for me reguarding fertility for both myself and my husband. We have been trying to fall pregnant for 4 years now. As we live in a remote indiginous community (Bamaga NPA) we are unable to use IVF. At the moment we are been adviced that my husband might be infertile and I may have PCOS. I am doing daily ovulation tests and not getting any results so we are wondering what our next step could be remembering where our location is. Is there anything my husband can do to maybe increase his fertility like diet, excercise. Please, we are getting desperate!
    Waiting for your reply

  4. Hello Mindy,

    Where is NPA? Being away from a reproductive center is certainly going to be a problem, especially with the two issues you mentioned.

    First, the only way to get you to ovulate properly if you have PCOS is to use fertility medications. This is not something that you can just order and take without monitoring by a Physician. Some PCO patients have to use IVF because they do not respond to the simple fertility medications.

    Secondly, the treatment for your husband's problem depends on how bad it is. He needs to have a semen analysis done. There is an over-the-counter male fertility test that is sold in the stores here in the U.S. to check for sperm fertility. It is not a substitute for a formal semen analysis but can give you an idea if that might be a problem. For some subfertile men, using a fertility medication like Clomiphene might help to increase count or using an OTC formulation like Fertility Blend or Proxeed might help to increase motility. But both treatments have limited effect so it depends on the problem. In many cases, ICSI in conjuctionn with IVF is the only option. One treatment option, if the sperm parameters are not too bad, is to do IUI (intrauterine insemination). Again, this will require a Physician trained in the sperm prep and IUI technique.

    Sorry I can't offer more for you. One thing you might want to consider, if you are willing to do IVF, is to plan an IVF trip. The IVF process takes about 2.5 weeks on-site to accomplish. You could take an extended vacation and have this done, which would give you the highest chances of success per cycle. IUI can also be done this way, but it is a lower yield for the cost and time of travel.

  5. Dear Dr. Ramirez,

    I followed an ICSI in October 2011, I had just 5 matures ovules and just one of them has been feconded. Anyway, It doesn't work.
    We will try a new ICSI in March.

    I would like to check with you if my husband is doing the correct procedure. We didn't receive any indication for him. For the transfer in October he didn't renew his spermes from September... I just heard that it is better to renew spermes 2 o 3 days before using them, is it correct?
    From your experience which is the best to do?

    Thanks a lot, M.Cristina.

  6. Hello Jan 23,

    If ICSI is going to be used, then he does not need to ejaculate prior to the IVF cycle. The embryologist will find the best sperm and the appropriate number, of which there should be plenty. Of course, with IVF/ICSI, there is no need to refrain from intercourse prior to the cycle because millions of sperm are not needed.

    Good Luck



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