In Vitro Fertilization and Embryo Transfer

SYLVIA PACE-0 WENS, RNC

In vitro fertilization and embryo transfer now provide an acceptable

therapeutic alternative for some infertile couples. The University of
Texas/Houston Medical School uses a nurse-coordinated, in vitro
fertilization computer program that combines a variety of nursing
interventions. The nurse specialist functions to coordinate clinical
and laboratory steps and to interpret the complex process to the
couple.

In uitro fertilization (IVF) and to reopen the tubes must be

embryo transfer (ET) are the result
of a complex new technology with
growing, but still low, success
rates. Even though the cost ranges
from $3000 to $6000 per treatment
cycle and the probability of suc-
cessful embryo implantation is
only one in ten, in uitro fertiliza-
tion-embryo transfer programs are
sought out by couples experiencing
in f ert i 1i ty .
The rapid developments in and
growing demand for infertility
technology and therapy have
given rise to a new role-the nurse
specialist in reproductive endocri-
nology and infertility. The in uitro
fertilization nurse provides close
coordination between basic sci-
entists, clinicians, and patients, all
of whom must be involved actively
to achieve success. The nurse is a
planner, coordinator, assimilator
of data about the progress of ovu-
lation induction, educator, and
counselor.
The University of Texas/Houston
Medical School uses a nurse-co-
ordinated, in uitro fertilization
computer program that combines
a variety of nursing interventions.
COUPLE SELECTION
Requirements a r e stringent at
the Houston site. To be accepted
by the Houston in uitro fertilization
team
1. The couple must be married.
2. The wife must be under the age
of 42 years at the time of the first
outpatient consultation.
3. The woman must have a normal
uterus with n o pelvic adhesions
obscuring the ovaries and at
least one ovary that is accessi-
ble to the laparoscope for egg
retrieval.
4. Ovulation must be demon-
strated to occur either sponta-
neously o r following the admin-
istration of ovulation-inducing
agents.
5. Both partners must be assessed
for emotional stability, since
undergoing in uitro fertilization
is a stressful experience.
6. The couple must also fit into at
least one of the following cate-
gories:
a. In the woman, both fallopian
tubes are absent o r blocked.
If tubes are blocked, surgery
inadvisable, impossible, or
have been attempted with no
pregnancy resulting within
one year after surgery. Many
pregnancies occur more than
one year after a microsurgi-
cal tubal repair, but a wait of
one year is considered ade-
quate for the Houston pro-
gram.
b. The husband has a low
sperm count (less than 20
million/ml), but has at least
2.5 million/ml.
c. The couple has not known
tubal infertility or is “nor-
mal” infertile (infertility
persisting more than two
years in spite of an appar-
ently normal fertility evalu-
ation).
d. The woman has had pelvic
endometriosis and has not
conceived for at least one
year after conventional med-
ical and surgical treatment.
If endometriomas are pres-
ent, in uitro fertilization is not
attempted.
e. The couple has multiple-fac-
tor infertility nonresponsive

44s November/Decernber 1985 JOCNN (Supplement)

 to available medical and/or
surgical therapy.’
Selection factors vary consider-
ably from institution to institution.
Some programs do not require a
couple to be married; others have
stringent age limitations. Physical
parameters also vary widely. Some
programs, Hillcrest Infertility Cen-
ter, Tulsa, Oklahoma, for example,
will accept 500,000 sperm/ml.
The nurse plays a very important
part in the selection process. Often
the first point of contact with the
couple seeking care, the nurse in-
terprets and explains the rationale
for the program’s criteria. Through
in-depth interviews, the nurse as-
sists in assessing emotional stabil-
ity and helps the couple form re-
alistic expectations of the in uifro
fertilization-embryo transfer pro-
cess.
ORIENTATION AND
EDUCATION PHASE
Throughout the world, more
than 1000 pregnancies have been
established and more than 300 ba-
bies have been born through hu-
man in uifro fertilization-embryo
transfer programs.’ At the Univer-
sity of Texas/Houston, 28 pregnan-
cies have occurred, and 25 babies
have been born as a result, includ-
ing one set of twins and one set of
triplets. These pregnancies are the
result of 211 embryo transfers in
couples.
The couple about to undergo in
uitro fertilization-embryo transfer
must have a realistic understand-
ing of the overall success-failure
rate; both husband and wife must
realize that most couples going
through the process do not achieve
a pregnancy. At the Houston site,
couples are told that they have
reasonable chance of going all the
way through the program to em-
bryo transfer. Although most pro-
grams have a good fertilization and
cleavage rate, only 10 to 20% of
embryos will implant into the uter-
Novernber/Decernber 1985 JOGNN (Supplement)
ine lining and continue to grow.
Because of the low success rate,
couples must use the in uifro fer-
tilization treatment time to prepare
themselves for a possible failure,
and to explore options such as
adoption, surrogate parenthood, or
remaining childless.
Despite preliminary explana-
tions, at first couples have only a
limited comprehension of prog-
nosis and actual details of the in
uifro fertilization treatment cycle.
The couples require constant con-
tact with a primary nurse who co-
ordinates day-to-day events, ex-
plains, teaches, and reassures. The
clinical coordinator must be thor-
oughly familiar with all facets of the
in uitro treatment cycle in order to
instruct and guide the couple
through the treatment p r o t ~ c o l . ~ is abnormal or estradiol levels are
Emotional guidance is as important
as particular information about
physiologic events. The nurse spe-
cialist must be able to listen, ex-
press empathy, encourage ques-
tions, and often must be available
for 24 hours a day during a treat-
ment phase.
FOLLICULAR RECRUITMENT
OR OVULATION
INDUCTION PHASE
The patient is instructed to con-
tact the program coordinator at the
onset of a menstrual period. At this
time, the medical protocol to be
followed for the individual couple
is described in detail. The physi-
cian prescribes fertility drugs
(clomiphene citrate, injectable fol-
licle-stimulating hormone/lutein-
king hormone, or both). These
drugs are usually taken on cycle
days 3 through 7 to produce mul-
tiple ovarian follicles. The hus-
band, another family member, or
close friend may be taught to ad-
minister intramuscular medica-
tions. Daily monitoring of the fol-
licles by ultrasound and serum es-
tradiol levels is expected to begin
on cycle days 8 through 10. Both
ultrasound and estradiol values are
used to show follicular develop-
ment, and this information is co-
ordinated with the clinical pic-
ture, particularly cervical mucus
changes, to determine the amount
of fertility medication that will be
required.
The follicular recruitment phase
can be very difficult for the couple.
Anxiety levels are high, and a great
deal of technical information must
be processed and interpreted. Two
or three appointments per day are
required, and the couple may feel
that the medical team controls
their lives. There is no set time
limit as it may take several days
for a follicle to reach 20 mm di-
ameter, and the process seems to
go on and on. If follicular growth
too low, the cycle must be aborted.
Anger and frustration are common,
and effective communication,
which is often facilitated by the
nurse, is essential to lower anxiety
levels and redirect or define hos-
tility.
When the largest follicle reaches
the optimum diameter of 20 mm,
the couple is prepared for follicular
aspiration by laparoscopy. At this
time, the ultrasonographer may be
able to show the couple a cumulus
in the largest follicle, which is ev-
idence of an egg.
LAPAROSCOPY
When the largest follicle reaches
20 mm in diameter, blood is drawn
for a luteinizing hormone (LH) test.
The patient is then given an injec-
tion of hCG (human chorionic go-
nadotropin), which induces the lu-
teinizing hormone surge that oc-
curs just before ovulation in a nor-
mal cycle. Expulsion of the oocyte
from the follicle, as occurs in a
normal ovulation, would be ex-
pected to take place around 36
hours after the injection, but sur-
gery (laparoscopy) for follicular
aspiration must take place imme-
45s

Figure 1. Mature egg-just aspirated.
diately before expulsion to retrieve
the oocytes with their surrounding
cumulus and fluid.
The nurse coordinator meets the
couple in day surgery to make sure
consent forms have been signed.
The husband is given a private
room where he can collect the
sperm specimen, which is then
taken to the embryo lab. The co-
ordinator answers any questions
the couple may have before the
laparoscopy. The husband may sit
in an area next to the operating
room to watch the television mon-
itor attached to the embryologist’s
microscope. As follicular fluid is
aspirated from each follicle, the
husband can observe the search
for the oocytes (Figure 1). After
follicular aspiration, the wife is
taken to the recovery room for a
brief time. The husband may ac-
company her, and when she wakes
up, tell her the outcome.
If no oocytes are recovered, the
coordinator meets with the couple
to explain any details regarding the
surgery. If oocytes have not been
retrieved and the physician be-
lieves that another attempt to re-
trieve oocytes is advisable, the co-
ordinator may schedule an ap-
46s
pointment for a second attempt in
a subsequent cycle. The couple can
then go home.
When oocytes are recovered, the
couple will receive a fertilization
report from the coordinator the
next morning, confirming the
number of eggs that have fertilized
(Figure 2). If two pronuclei are
seen, the egg is presumed fertil-
ized, and there is an 80% chance
that normal cleavage will occur.
LABORATORY PHASE
Retrieved oocytes are permitted
to mature under totally controlled
conditions and inoculated with
sperm from the husband’s or do-
nor’s ejaculate which has been Figure 2. Fertilized egg (2 pronuclei seen)
mixed with a culture medium made 16 hr after insemination.
from maternal serum and centri-
fuged. One hundred thousand of mg intramuscularly is given im-
the most active sperm can be used mediately after transfer. Although
per oocyte for in uitro fertilization. the transfer is usually a quick, sim-
Embryos are incubated and ple procedure, bed rest in the hos-
watched continually as they de- pital until the next morning is usu-
velop and divide. When the em- ally required. The couple is then
bryos reach the two- to six-cell discharged with vaginal proges-
stage, about 45 hours after insem- terone suppositories, 25 mg bid for
ination, the clinical coordinator is 12 days, to support development
notified that embryo transfer may of the corpus luteum. Ten to 14
take place. In the United States, the
general practice is to transfer all
healthy fertilized embryos, al-
though the advent of cryopreser-
vation facilities in some institu-
tions means that some embryos
may be transferred at a later date.
EMBRYO TRANSFER PHASE
When the embryo is ready for
transfer (Figure 3), the couple is
notified. After being admitted to
the hospital, the woman is placed
in the dorsal lithotomy position
while an embryo transfer team
member loads a catheter with the
embryos. The physician inserts the
small tip of the catheter into the
patient’s uterus through the cer-
vical canal. Usually, discomfort is
minimal, with occasional mild Figure 3. 4-cell embryo shortly before em-
cramping. Progesterone in oil, 25 bryo transfer.
November/December 1985 JOGNN (Supplement)
 days after transfer, a serum preg-
NAME: Pat. # Rx CYCLE #: ETIOLOGY INFERT. nancy test will reveal if one or more
CLOMIPHENEDOSE: DAYS: PERGONALDOSE(AMPS/DAYS): TOT. AMPS: embryos have implanted. The
LMP: ULTRASOUND: DAY: R: L: LGST(rnrn): nurse stays in close communica-
DAY: R: L LGST(mrn): tion with the couple during this dif-
DAY: R: L LGST(rnrn):
ficult time.
DAY: R: L: LGST(rnrn):

DAY 20/16X2 Fol.: #FOL. 10-14rnrn. #FOL.15-19rnrn. #FOL. 20rnrn+:

PREGNANCY
hCG DOSE: hCG DATE: hCG CYCLE DAY TIME:

COMMENTS Although the most modern and

sophisticated technologic inter-
"LAPAROSCOPY vention has been used to achieve
CYCLE DAY: DATE: TIME ASP: #FOL.ASP: #EGGS REC: #MAT #IMM: the in oitro fertilization pregnancy,
intensive intervention ceases when
the positive hCG level is reached.
FOL-l(R/L DIAM) FFVOL: EGG(Y/N) MAT/IMM IN A/N/F#
FOL-P(R/L DIAM) FFVOL EGG(Y/N) MAT/IMM INA/N/F# - The pregnancy is considered nor-
FOL-S(R/L DIAM) FFVOL: EGG(Y/N) MAT/IMM IN A/N/F# mal, and no further manipulation
FOL-4(R/L DIAM) FFVOL: EGG(Y/N) MAT/IMM IN A/N/F# is required. The pregnancy is fol-
FOL-B(R/L DIAM) FFVOL EGG(Y/N) MAT/IMM IN A/N/F# lowed closely for the first two
FOL-6(R/L DIAM) FFVOL EGG(Y/N) MAT/IMM IN A/N/F# weeks to identify multiple gestation
FOL-7(R/L DIAM) FFVOL: EGG(Y/N) MAT/I MM IN A/N/F#
FOL8(R/L DIAM) FFVOL: EGG(Y/N) MAT/IMM IN A/N/F#
by use of ultrasound. At 10-weeks
FOL-9(R/L DIAM) FFVOL: EGG(Y/N) MAT/IMM IN A/N/F# gestation, the couple is referred to
COMMENTS: the obstetrician of their choice,
and no longer considered high risk.
Figure 4. Computer patient record. Part 1.
THE COMPUTER

Programs such as in oitro fertil-

PATIENT PATIENT #: Rx CYCLE: ization-embryo transfer require a
MEDIUM (SPECIFY/H20/GAS PHASE)
concerted team effort of nurses,
SEMEN#l(PREWASH):VOL(ml): CONC(rn1): MOTILITY(O/o): PROG:
physicians, and basic scientists.
Many patient-couples may be in
VOL.WASHED(rn1): POST-CONC(rni1): POST-MOTIL(%): POST-PROG:
different stages of treatment at any
SEMEN#2(PRE-WASH)VOL(rnl): CONC(rni1): MOTIL(O/O): PROG:
given time. An extremely important
vol.washed(rn1): POST-CONC(mi1): POST-MOTIL(%) POST-PROG:
factor in the success of the Uni-
EGG#1 :FOL Mat/lrnrn EgglncHrs SP# SplncHrs Fert Cleav Trans
versity of Texas/Houston in oitro
EGG#2:Fol Mat/lrnrn EgglncHrs SP# SplncHrs Fert Cleav Trans fertilization-embryo transfer pro-
EGG#3:Fol Mat/lrnrn EgglncHrs SP# SplncHrs Fert Cleav Trans gram has been a computer system.
EGG#4:Fol Mat/lrnrn EgglncHrs SP# SplncHrs Fert Cleav Trans The system was initiated a year af-
EGG#B:Fol Mat/lrnrn EgglncHrs SP# SplncHrs Fert Cleav Trans ter the program started and as-
EGG#6:Fol Mat/lrnrn EgglncHrs SP# SplncHrs Fert Cleav Trans
sures competent data manage-
Egg#l :Hrs/l stObs Hrs/TranObs ~ n e n t Each
. ~ treatment cycle gen-
Egg#P:Hrs/l stObs Hrs/TranObs erates a large amount of data from
Egg#3:Hrs/l stObs Hrs/TranObs hormone assays, embryo lab, ul-
Egg#4:Hrs/l stObs Hrs/TranObs trasound, surgery, and clinical ex-
Egg#B:Hrs/l stObs Hrs/TranObs
Egg#6:Hrs/l stObs
ams that must be organized in
Hrs/TranObs
comprehensive patient records
TRANS HRS: CATHETER USED: # ATTEMPTS/BLEED/CRAMP: (Figures 4, 5, and 6). Appropriate
NO. EMBRYOS TRANS: PROGESTERONE(DOSE/DAYS): NEXT MENSES: collection, storage, correlation,
OUTCOME: LAP.Dr.: TRANS DR." GROUP: and data retrieval are critical to the
COMMENTS:
functioning of an in oitro fertiliza-
tion-embryo transfer program for
Figure 5. Computer patient record. Part 2. clinical treatment and research.

November/December 1985 JOG" [Supplement) 47s

 IVF Program under the direction of
NAME: PAT. #: Rx CYCLE #: LMP: Dr. Martin M. Quigley, 1983.
*PA€-hCGHORMONES (LMP IS CYCLE DAY 1)’ Figures 4, 5, and 6 are patient
CYCLE DAY/TIME: LH(mlU/ml): P(ng/ml):
computer records for IVF designed
FSH(mlU/ml): by Dr. Martin Quigley, July 1982,
CYCLE DAYPIME: LH(mlU/ml): P(ng/ml): and updated by Dr. Al Berkowitz,
FSH(mlU/ml): PhD, Director, Radioimmunoassay
CYCLE DAY/TIME: LH(rnlU/ml): P(ng/ml): Laboratory, University of Texas.
FSH(mlU/ml):
CYCLE DAYITIME: LH(rnlU/ml): P(ng/ml)
FSH(mlU/ml):
REFERENCES
CYCLE DAY/TIME: LH(mlU/ml): P(ng/ml)
FSH(mlU/ml):
1. Wolf DP, Beauchamp PJ. Informa-
CYCLE DAY/TIME: LH(mlU/ml): P(ng/ml):
tion for in oitro fertilization and
FSH(mlU/ml):
embryo transfer patients. Univer-
CYCLE DAYPIME: LH(mlU/ml): P(ng/ml):
sity of Texas/Houston IVF-ET Pro-
FSH(mlU/ml): gram. July 1984.
CYCLE DAY/TIME: LH(mlU/ml): P(ng/ml): 2. Olson M, Alexander NJ. In oifro
FSH(mlU/ml): fertilization and embryo transfer.
CYCLE DAY/TIME: LH(mlU/rnl): P(ng/ml): Portland: Oregon Health Sciences
FSH(mlU/ml): University Press, 1984:l-30.
3. Pace-Owens S. The clinical coor-
POST-hCG HORMONES (DAY OF hCG IS DAY 0)’ dinator in an in oifro fertilization
CYCLE DAY/TIME: P(ng/ml): B-hCG(mlU/ml): and embryo transfer program. In:
CYCLE DAYPIME: P(ng/ml): 6-hCG(mlU/ml): Wolf DC, Quigley M M , eds. Human
CYCLE DAY/TIME: P(ng/ml): B-hCG(mlU/ml): in oifro fertilization and embryo
CYCLE DAYPIME: P(ng/ml): B-hCG(mlU/ml): transfer. New York: Plenum Press,
CYCLE DAYPIME: P(ng/ml): B-hCG(mlU/ml): 1984:375-82.
CYCLE DAY/TIME: P(ng/ml): B-hCG(mlU/ml): 4. Quigley MM. Data management in
CYCLE DAY/TIME: P(ng/ml): 6-hCG(mlU/ml): an in oifro fertilization and embryo
CYCLE DAYPIME: P(ng/ml): 6-hCG(mlU/ml): transfer program. In Wolf DP,
CYCLE DAY/TIME: P(ng/ml): 6-hCG(mlU/ml): Quigley MM, eds. Human in oitro
CYCLE DAY/TIME: P(ng/ml): B-hCG(mlU/rnl): fertilization and embryo transfer.
New York: Plenum Press, 1984:383-
401.
Figure 6.Computer patient record. Part 3.

Address for correspondence: Sylvia

CONCLUSION
The successful functioning of an
in uirro fertilization-embryo trans-
fer program requires comprehen-
sive professional knowledge and
personal insight. The coordinator
must be certain that all of the pa-
tients’ anxieties have been ad-
dressed, necessary information
has been given, and questions have
been answered. The in uitro fertil-
ization nurse coordinator must en-
sure the smooth orchestration of
the entire in uipo fertilization/em-
bryo transfer team.
ACKNOWLEDGMENTS
Figures 1,2, and 3 are taken from
slides of the University of Texas
Pace-Owens, RNC, The Woman’s Hos-
pital of Texas, 7600 Fannin Street,
Houston, TX 77054.
Sylvia Pace-Owens is a clinical faculty as-
sociate in Ob-Gyn at the University of Texas
School of Nursing/Houstonand the nurse co-
ordinator of the in vitro fertilization and embryo
transfer program at the Woman’s Hospitalof
Texas in Houston. Ms. Pace-Owens is a
member of NAACOG. ANA, and the American
Fertility Society.

48s November/December 1985 JOG” (Supplement)