Solutions and Treatments
- In Vitro Fertilization (IVF)
The first ivf baby was born in England in 1978. The first born in the US was in Eastern Virginia in 1981. The first ivf baby in the western US was at USC in 1982 and the first born IVF baby in San Diego was produced by Dr. Rakoff, working at Scripps Clinic, in 1983. He was also the first Fertility doctor in San Diego to have IVF twins and to have a SART-FDA /certified IVF lab. Dr.Rakoff's IVF treatments produced the first San Diego IVF babies delivered at UCSD School of Medicine Hospital( Hillcrest), Balboa Naval Hospital (San Diego), And Pomorado Hospital( Near Escondido,Temecula, Rancho Bernardo, and Poway)
As the years progressed, many couples were successfully treated . Recently Scripps Clinic chose not to upgrade and maintain the Embryology Lab originally built by Dr.Rakoff and his team, including world famous research scientists, Dr.Joel Gottesfield, Ph.D.( the Scripps Research Institute) and Frank Chisari, M.D.( Scripps Clinic and Research Foundation).
NOW in the 21st Century- "To provide the best possible success rates,"- Dr. Rakoff offers state of the art IVF care working with the excellent staff & embryologists at SDFC. Success rates continue to improve & new equipment & technology enable Dr. Rakoff to offer optimal IVF services for his patients on a personal & caring basis.
The steps involved with IVF include the following:
1. Ovulation stimulation medications with several hormone blood tests & ultrasound (sonogram) exams.
2. Ova (eggs/oocytes) Retrieval. This is done under anesthesia with sonogram -ultrasound directed needle aspiration of the eggs from the ovaries. This is an out patient-ambulatory, same day surgery procedure.
3. A few hours after the egg retrieval, the eggs are fertilized with sperm. Usually the sperm is collected at home & delivered to the IVF lab at the time of the retrieval. Optimal fertilization will occur when we wait a few hours to place the sperm with the eggs.
4. Usually 2-6 days after fertilization, the embryos (generally 1-2) are placed in the woman's uterus. This commonly is a pain free, easy procedure performed in the exam room.
5. Pregnancy tests are done 2 weeks later.
Our experienced team of doctor, embryologists and nurse educators (Nurse@sdfertility.com) are available by appointment or phone (1-858-794-6363) to review specific details that may be involved in creating your specific IVF Treatment Plan.
- Natural Cycle Plus IVF (Mini Stimulation IVF)
Dr. Rakoff offers a more natural Mini Stimulation in his IVF Program as an alternative to the standard IVF Program. In both techniques IVF, egg retrieval and embryo transfer procedures are the same; however, minimal stimulation IVF requires the use of less fertility medication than their standard counterpart. The minimal stimulation IVF allows us to give patients the flexibility to choose a treatment plan that meets their specific needs. We are pleased to offer this program in San Diego to patients who are seeking a more natural approach to treatment.
Our standard IVF requires the administration of higher dosages of injectable medications to stimulate the growth of multiple eggs. These medications are expensive and may be associated with Ovarian Hyperstimulation syndrome. Frequent monitoring is done to ensure safety. The result is an increased number of embryos available for transfer. Also, in traditional IVF, cryopreservation of surplus embryos for transfer in a subsequent non-stimulated cycle is available. The overall success rate with standard IVF varies, based primarily upon the patient's age, but generally gives the best success rate world wide.
Mini Stimulation IVF,however, involves fewer medications & a cycle typically results in the maturation of only 1-5 follicles. Therefore, we have less shots, medications, expense & swelling of the ovaries. However, it is important to note that with this technique we also have less embryos & a lower success rate. We often have few or no embryos to freeze.
Candidates for Natural Cycle Plus IVF may include any patient who is an appropriate candidate for standard IVF. Patients often select the Mini protocol to more closely mimic nature, to reduce the number of shots & decrease anxiety about extra frozen embryos. In cases where our standard protocol has resulted in limited ovarian response, some patients will also elect this Mini protocol.
Supervised by Jeffrey Rakoff, M.D. this highly successful program features an experienced team of medical & laboratory specialists committed to maintaining the highest standards of excellence & helping every patient achieve a successful pregnancy.
Many women need to consider the procedure of Donor Egg IVF because of various problems, such as ; Ovarian failure, chemotherapy, genetic causes, no eggs due to previous surgery, poor egg quality, surgical loss of ovaries due to trauma, cancer or other medical conditions, or advanced maternal age.
In the egg donation process, eggs are retrieved from a known or anonymous donor's ovaries and fertilized in the laboratory with the sperm from the recipient's partner (or, if needed, a sperm donor). The healthy embryos are returned to the recipient (or,if needed, a gestational surrogate).
A typical egg donor is healthy, between the ages of 21 and 29, single or married (preferably with known & proven fertility). Eggs can be donated by a friend or family member or anonymously.
Egg donors receive approximately $5000 in compensation once they have met all the necessary obligations. Some people choose to ask a friend or relative to donate for no compensation.
- Male Infertility Treatment
Infertility affects men and women equally. In some cases there are combinations of problems between both genders. Delay in conception that can be attributed to the male partner is called "male factor infertility." For the benefit and convenience of our patients, Dr. Rakoff, is closely associated with urologists who are trained in reproductive urology and are the foremost experts in their field.
Causes of male factor infertility include Azoospermia (complete absence of sperm) and oligospermia (few sperm cells produced), low sperm motility and poor sperm morphology. These problems may be caused by diabetes, genetic make up, injury, cancer , general health problems or varicocoele. Sometimes the urologist may not be able to find the cause.
In most cases male factor infertility is treated by artificial insemination (IUI), IVF and intracytoplasmic sperm injection (ICSI). In some cases, the urologist may perform surgery, prescribe medication, or obtain a testicular biopsy (TESE) to retrieve sperm for IVF in men with prior vasectomies or health related causes of azoospermia.
- Intracytoplasmic Sperm Injection (ICSI) Treatment Program
Intracytoplasmic Sperm Injection is a micromanipulation technique. ICSI involves gently placing a single sperm directly into the egg. While possible increases in congenital abnormalities in the offspring with this procedure have been investigated, unexplained or genetic factors in the semen may be the cause.
ICSI has proven to be beneficial in many cases of infertility, where A. sperm counts are low or B. fertilization rates were low in prior IVF attempts.
ICSI is also recommended in some cases of advanced maternal age, unexplained infertility, or prior IVF failures, etc.
ICSI may be performed as part of your IVF program. It is a single sperm injected into the center of each egg by an embryologist. After the egg has been injected with the sperm, we will observe the egg over the next day or so. If fertilization occurs & the embryo matures properly, it will be transferred into your uterus.
Although some centers may not emphasize ICSI, we find that ICSI can be helpful for a variety of cases, e.g. advanced maternal age, thickened zona, prior Fertilization failures, and couples with no diagnosis. ICSI is also recommended in cases in which PGD (preimplantation genetic diagnosis) based on the recommendation of the geneticist.
- Preimplantation Genetic Diagnosis (PGD) Treatment Progra
PGD (pre Implantation Genetic Diagnosis can only be performed with IVF. PGD offers a way to test patient's embryos for genetic disorders before transferring them into the uterus. The procedure is most helpful for patients with a genetic disorder who wish to avoid passing this onto their child. PGD has been used to lower the risk of having an abnormal pregnancy or to explain the causes of recurrent miscarriages and implantation failures.
Some case of PGD are done for sex selection, family balancing or to avoid x-linked genetic disorders. Dr. Rakoff working with some of the nation's leading molecular geneticists and our very experienced embryologists are able to help diagnose and or treat people with many genetic disorders.
The first step in the process is to gently extract a cell from a 3 day old embryo. The genetic material in the cell undergoes DNA analysis. The techniques employed may include Fluorescent In Situ Hybridization (FISH), Polymerase Chain Reaction (PCR) technique , Micro-array or newer technologies depending on the type of genetic abnormality involved.
Dozens of diseases can now be detected such as:
Tay-Sachs diseas
Polycystic kidney disease
Klinefelter syndrome
Huntington's disease
Thalassemia
Balanced translocations
Sickle-cell anemia
Hemophilia A
Cystic Fibrosis
X linked diseases (muscular dystrophy)
Fragile-X Syndrome
Retinitis pigmentosa
Some of the advantages of PGD include fewer abnormal babies and pregnancy terminations. We also hope to avoid the transmission of familial diseases and hopefully achieve greater embryo survival rates.
Some of the newer technologies may allow us to determine if the source of the abnormality is from the sperm or the egg. This can potentially be very helpful in cases of fertility failure or recurrent miscarriage (recurrent pregnancy loss).
Some risk is involved with PGD. Accidental damage may occur in rare cases resulting in failure of the embryo to grow. As the technologies are very complex, in some cases a misdiagnosis or no diagnosis may be made. These limitations must be considered when deciding to proceed with PGD.
All embryos need to escape or "hatch" from it's protein shell before it can implant in the uterus. In AH, a chemical or a laser can be used to dissolve part of the zona to facilitate the hatching process later. Our embryologist will discuss the process with you as they observe the growth of your embryos.
- Embryo Cyropreservation - Fertility Preservation
Dr. Rakoff recommends that strong embryos that are not transferred be cryropreserved (frozen). We recommend freezing only high quality embryos that survive to the blastocyst stage. These embryos will be in liquid nitrogen and can be thawed at a later date. While the pregnancy rates with fresh embryos may be higher, the process for you to prepare for a frozen embryo transfer may be simpler & less expensive. Freezing only embryos that survive to the blastocyst stage maximizes the chances for success in a thaw cycle.
Some people, who may wish to limit the chances of having extra frozen embryos, may choose our “Natural” minimal stimulation IVF protocol. The trade off is the possibility of lower over all success rates when Mini Stimulation is chosen.
- Egg Freezing - Fertility Preservation
In recent years we have developed the technology to allow us to successfully freeze human eggs. Later, at a date of your choosing, the eggs can be thawed/fertilized/and then placed in the uterus, hopefully resulting in a successful term pregnancy.
In order to improve success rates, we will prescribe ovulation stimulation medications as is done in a typical IVF cycle. This produces a large number of mature eggs which can then be retrieved i.e. aspirated from the ovaries at one time.
Human eggs result in one baby for every four eggs retrieved from a 20 year old, but only one baby in 10 to 15 eggs from a 35 year old woman. In a 45 year old woman the odds reduce dramatically to one baby in 100 to 150 eggs. Also as woman age they tend to produce fewer eggs even when given ovulation medications. We cannot guarantee success. Consequently, we encourage women to bank their eggs as young & as often as they are able.
Women may urgently need to bank their eggs if they have been diagnosed with a disease such as cancer or any autoimmune disease that may require chemotherapy or radiation or any other problem requiring the surgical removal of their ovaries.
In other cases women who feel that they are aging, but have no current prospects for starting a family often seek our services to freeze their eggs while they are still young. Thereby, hoping to ensure better fertilization success rates, when the eggs are thawed at a later date. The younger you are when you freeze your eggs, the better the odds for success.
Dr. Rakoff has had many years of experience working with and having offices next to the Hematology Oncology dept. at Scripps Clinic. Consequently he has been a member of the Fertility Cryro-Preservation study groups of the ASRM.
Now in private practice, he has the added advantages of working with the support & experienced egg freezing Embryologists at the San Diego Fertility Center.
As stated above,the fertility potential of an egg decreases as women get older. This has been observed for many years and in many different countries. Newer data developed by geneticists, such as those at the Gene Security Network (GSN) have also shown an increasing percentage of embryo chromosome abnormalities grown from eggs retrieved from women as they get older. Consequently, Dr.Rakoff is available now to help you preserve your fertility with our modern Egg freezing technology.
DR. Rakoff is a founding charter member of the Society of Reproductive Surgeons (SRS) of the American Society of Reproductive Medicine (ASRM). He has performed over 8,000 Infertility surgeries. He is a teacher and expert with Laser Laparoscopy & complex hysteroscopy procedures. Because of minimal discomfort & enhanced convenience, most of our patients go home on the day of surgery.
Dr. Rakoff is the only Fertility specialist working at Scripps Clinic-Green Hospital and the Scripps Clinic ambulatory surgical Centers at Carmel Valley and Rancho Bernardo. Dr. Rakoff can perform can perform your surgical procedure either in the Ambulatory Surgical suite at his office in Del Mar or in the Scripps Clinic hospital or Surgical centers in Carmel Valley or Rancho Bernardo.
Hysteroscopy is utilized to diagnose and treat abnormalities within the uterus. Hysteroscopy can be used to remove uterine fibroids (myomas), polyps, scar tissue, and uterine malformations such as septums or to treat abnormal bleeding and other reproductive conditions. Hysteroscopy is performed with a thin telescope that is inserted through the cervix into the uterus. The operative hysteroscope is designed so that instruments can be placed inside the scope to remove tissue samples for biopsies or to remove fibroids, polyps or tumors.
During the procedure, the uterus is filled with a liquid such as saline or glycine to distend it so that Dr. Rakoff can see inside. The procedure is usually mildly uncomfortable. A woman can usually return to her normal activities in 1-2 days.
Laparoscopy is used to remove pathology and restore normal anatomy. A laparoscope is a thin, fiber-optic telescope attached to a video camera. The laparoscope is inserted through a small incision, generally but not always in the naval. After the incision is made and the laparoscope inserted, the surgeon looks at the pelvis and assesses the anatomy. The surgeon may place additional incisions with additional instruments in order to remove an abnormal cyst, excise/laser endometriosis, remove myomas or treat an abnormal fallopian tube.
The major benefit of laparoscopic surgery is that it on requires a few small incisions, meaning less pain and external scarring and healing is faster than traditional, open surgery. Most women can resume normal activities in 3-7 days.
- IUI (Intrauterine Insemination)
IUI is performed using sperm to overcome mild to moderate Male Factor Infertility. IUI may also be recommended in cases of unexplained infertility, inability to have intercourse, or simply as a last effort to improve pregnancy rates before proceeding with IVF.
Donor sperm may be used for intrauterine insemination (IUI) in cases where the male partner cannot produce viable sperm or carries a potentially serious genetic condition. Screened, cryopreserved sperm from a donor sperm bank is utilized. See IVF, ICSI and PGD sections of this website if you wish to use your own sperm rather than donor sperm
The first step in the IUI process is to prepare the sperm. Fresh sperm must be washed in our lab. This involves the removal of abnormal sperm & other debris in order to produce a concentrated sample of healthy, motile sperm.
Once the sperm sample is ready, a thin catheter is gently placed through the cervix & into the uterine cavity. The sperm is then flushed into the uterus and the catheter is withdrawn. Undergoing IUI does not involve anesthesia & is usually painless or minimally uncomfortable.
1. Clomiphene Citrate (clomid or Serophene) is an oral pill that works by stimulating the body to produce eggs. This medicine is often among the first used for ovulation induction. It may have a few side effects. Generally there is a 7-8% chance for multiple gestation, most of which are twins. Your primary care or Ob-gyn physician may prescribe this medicine for you for 3 cycles. If you fail to conceive with the clomid, we will frequently prescribe gonadotrophins with IUI or IVF.
2. Gonadotrophins are frequently used for ovulation induction during IVF. This is a type of injectable fertility drug that directly stimulates the ovaries. Gonadotrophins such as Bravelle,Follistim and Gonal-F are made from purified FSH and cause the ovaries to develop mature multiple eggs at the same time.
3. Human Menopausal Gonadotropin (Menopur) or hMG contains both follicle stimulating hormone (FSH) and luteinizing hormone (LH). Like the Gonadotrophins listed above, hMG is an injectable fertility medication used in ovulation induction for IUI or IVF.
4. Human Chorionic Gonaotrophin or hCG (Ovidrel) is a hormone that has an effect on the body similar to luteinizing hormone (LH), which initiates the final maturation and release of the eggs from the ovary. HCG is often used to trigger ovulation following the use of the other fertility drugs.
5. Progesterone is an ovarian hormone necessary for the support of the early embryo. Without it, the uterine lining may not adequately thicken and mature. Women who undergo egg retrieval for IVF are generally prescribed progesterone supplements, because some of the cells that normally produce progesterone are removed. We also frequently prescribe progesterone hormone in our IUI cycles or in women with concerns re miscarriage.
- Gestational Surrogate Carrier
A gestational carrier is a woman who volunteers to carry a pregnancy for another woman and is frequently compensated for her time & potential pain and suffering. Unlike traditional surrogacy arrangements, a "gestational" carrier has no genetic connection to the child she carries.
To become a gestational carrier, a woman must have experienced at least one full term live birth & be less than 40 years old. She must be free of physical or mental conditions that could pose a risk to herself or the fetus. These arrangements begin with a thorough screening and matching process, followed by the formation of legal agreements to ensue that the parties are protected.
A woman who has any type of medical condition that prevents her from carrying a pregnancy to term will need IVF Gestational Surrogacy. This includes women who have a missing or malformed uterus, certain immunological disorders, or any disease that makes pregnancy risky, e.g. Cardiac, Rheumatologic and Neurologic diseases or bleeding disorders. In order to use a gestational carrier, however, it is necessary that the infertile woman have a useable supply of eggs for fertilization or an appropriate egg donor available.
To begin the process we must synchronize your menstrual cycle with your surrogates cycle. Both women are given medications to control the progression of their cycles & bring them in "synch", so that the uterus of the carrier is ready to receive the embryos when they are ready to be transferred. The biologic mother or egg donor undergoes ovulation induction & egg retrieval, just as she would for standard IVF. When the embryos are ready, they are transferred into the uterus of the gestational surrogate.
In most cases, the parents stay in contact with the gestational surrogate, providing support throughout the pregnancy. Keep in mind that financial & legal agreements need to be agreed upon initially. |
