Over the past 35 years, In Vitro Fertilization (IVF) treatment has helped thousands of couples worldwide overcome a wide variety of infertility diagnoses enabling them to realize their dreams of becoming parents. IVF helps infertile couples become pregnant by joining the egg and sperm together in an embryology laboratory where embryos are created that can later be transferred back into the woman’s uterus. While most of us have heard about IVF, not many people know exactly how the process works.
IVF can be broken down into six parts from pre-cycle appointments and preparations through the pregnancy test making understanding the process just a little bit easier. Whether you’re just starting to research fertility treatments or are already a patient planning to begin IVF, knowing more about the treatment can reduce your anxiety and make your journey feel less complicated.
Initial IVF Consultation & Preparing the Ovaries for Stimulation
In preparation for an IVF cycle, you will undergo a Mock Embryo Transfer. This procedure is a “practice run” for the embryo transfer and allows the doctor to test the size and placement of the catheter with your particular anatomy before the big day. During the procedure, an ultra-thin catheter is inserted into the uterus while a sonogram guides the process on a monitor. Many patient compare the Mock Embryo Transfer to a pap smear, it is relatively painless and takes only a few minutes.
Following the completion of the pre-cycle testing, you will meet with your physician to review the results and plan their protocol for treatment. The protocol is like a blueprint that is used by you and your medical team. It is important to remember this plan provides tentative dates; frequently, treatment timelines will need to be adjusted based on how you respond to medication; you should anticipate changes and block time as needed in your work and travel schedules.
Many women start an IVF cycle by taking birth control pills for a set number of days, to help:
Decrease the chances of creating cysts that could interfere with the cycle start.
Synchronize the egg follicles so they all start at the same stage, on the date collectively chosen by the doctor and patient.
Allow the physician and patient to control the timing of the cycle.
Ovarian Stimulation and Monitoring
In a normal ovulation cycle, one egg usually matures per month. In an IVF cycle, the goal is to have as many mature eggs as possible, as this will increase your odds of success with treatment. In the stimulation phase of the IVF cycle, injectable medications are used for approximately 8-14 days to stimulate the ovaries and produce eggs.
Stimulation medications are derivatives from the hormones FSH and LH, which are the natural hormones involved in the natural ovulation process. Some protocols use one or the other of these hormones exclusively and many use a combination.
During the ovarian stimulation phase, you will come into the office approximately 7-8 times for morning monitoring appointments. Monitoring appointments consists of:
Transvaginal Ultrasound – Measures the growth of the egg follicles and the thickness of the uterine lining, both of which should be increasing as you take the injectable medications.
Bloodwork – Measures the estrogen level. The levels of estrogen in the blood are another indicator of the growth and maturation of the eggs – rising as the follicles grow.
After each monitoring appointment, you will receive a phone call from your nurse, usually in the afternoon. It is extremely useful to be available to speak with the nurse when she calls to make sure you receive the important instructions and clarify any aspects of your care. During the update your nurse will give you inform you of the progress of your cycle, medication modifications, and when you should return for the next monitoring appointment. This is also an opportunity for you to ask any questions about your cycle, test results and any side effects you may be having.
The Trigger Shot and Egg Retrieval
The stimulation phase ends with a trigger shot. The trigger shot provides final maturation to the developing follicles and sets ovulation in motion. Timing is crucial in this phase because the egg retrieval must be preformed prior to the expected time of ovulation. The doctor decides when you are ready to trigger based on the two key factors that have been monitored during the stimulation phase:
Size of the Follicles – The goal is to have as many follicles as possible be 18mm or larger since these are the most likely to contain mature eggs.
Level of Estrogen (Estradiol) – While there is no specific number the physicians are looking for, your estrogen level should not be too high or too low. The level directly correlates with the number of follicles in the ovaries. The cells inside each follicle produce estrogen so a patient with 8 follicles will generally have a blood estrogen level that is lower than a patient with 16 follicles.
Your partner’s sperm is either collected the day of the retrieval or if he is unavailable, occasionally the case for out-of-state or international patients, previously frozen will be thawed and used.
The day of your egg retrieval you will meet with two different providers, the first is the Shady Grove Fertility physician that will be performing the egg retrieval to verify your protocol and what will happen during the fertilization phase in the embryology laboratory. You will also meet with the anesthetist, who will review your medical history and start the IV that will deliver the anesthesia medication. This is not general anesthesia but a quick-acting sedation that lasts as long as the procedure.
The egg retrieval itself takes only about 20-30 minutes. During the procedure, an ultrasound is used to guide a needle into each ovary and remove the follicular fluid and egg.
Inside the Lab: Embryo Development
After the eggs and sperm are collected, sorted, and prepared, the Embryology Team begins the fertilization process. There are two ways that fertilization can occur:
Conventional Fertilization: Frequently used in cases such as blocked fallopian tubes or unexplained infertility. The embryologist isolates the healthy sperm, which are then exposed to each egg inside the embryology laboratory where fertilization occurs naturally.
Intracytoplasmic Sperm Injection (ICSI): Used in cases when the quantity or quality of sperm is poor and therefore unable to effectively penetrate the egg on its own. The embryologist selects a single healthy sperm and injects it directly into the center of each egg. Since fertilization only requires one healthy sperm, ICSI has become one of the most incredible advances in treating severe male factor infertility.
The decision about which method to use is based on the quality of the sperm. To test sperm, an analysis is completed as part of the initial basic fertility work-up for diagnosis before treatment and then again when the semen sample is provided on the day of the egg retrieval. If the results from this analysis do not meet the parameters required for conventional fertilization, the embryologist will make the decision to switch to ICSI so that the cycle can still produce embryos and increase your chances of success. The clinical team will let you know if an unplanned ICSI procedure is recommended.
Once fertilization occurs, the embryos begin to develop. Every morning for the next five to six days, an embryologist examines the developing embryos and adds notes in your record regarding each individual embryo. Your nurse will follow up daily with your fertilization report updating you on the status of each growing embryo.
The embryo transfer is a simple procedure that takes about five minutes to complete. There’s no anesthesia or recovery time needed. This experience will be similar to the mock embryo transfer performed prior to starting the cycle. When your transfer is scheduled, your nurse will notify you, and provide specific instructions on when to arrive and how to prepare.
The morning of the transfer, the embryologist will make a final assessment of your embryos and provide a recommendation on the number to be transferred. These recommendations are based on overall embryo quality and the age of the embryo, which will ideally be at day 5 or 6. The doctor will use the information provided by the embryologist and other factors related to your case, such as your age and history with previous treatments, to make their recommendation.
Often times, when patients meet a specific criteria, physicians will suggest elective Single Embryo Transfer (eSET). eSET is the transfer of a single embryo, usually a blastocyst-stage embryo, despite having many available. Transferring one high-quality embryo is found to reduce the risk of multiples while maintaining a similar chance of pregnancy. Patient criteria for eSET:
The female partner is age 37 or younger
It is her first cycle of IVF or she has had a previous successful cycle of IVF
She has a good quality blastocyst
Prior to the start of the embryo transfer, the patient reviews her cycle with the physician and the final decision regarding the appropriate number of embryos to transfer is made, along with what to do with any remaining embryos.
Once the number of embryos to transfer is determined inside the laboratory, an embryologist will verify all identifiers, such as your name, identification number, and compare them to the embryo culture dish and corresponding egg datasheet. The transfer catheter is loaded with the appropriate number of embryos. Upon entering the transfer room, the embryologist will state your last name and the number of embryos in the catheter. You will be able to watch the process on a monitor in the exam room and see the embryos as they are selected.
During the transfer, the doctor will insert the catheter and push the embryo into the uterus with a small puff of air. The procedure is guided visually on a monitor with an abdominal sonogram. Once transferred, the doctor will slowly remove the catheter to eliminate or decrease any uterine contractions. Since the embryo is invisible to the naked eye, the embryologist will then check the catheter under a microscope to make sure the embryo was released. You will be asked to lie quietly for five minutes after the transfer. Then, you’ll be given instructions for the following two weeks until it’s time for the pregnancy test.
The Pregnancy Test
The pregnancy test occurs around 18 days after the egg retrieval. Unlike a home pregnancy test, blood is drawn and the hCG level is measured. An hCG level of over 100 is considered to be positive although many ongoing pregnancies start out with a beta hCG level below 100. You’ll be asked to repeat the test in two to three days. The goal is to have the level of hCG roughly double every two days. If it does, another beta may be ordered. If all three betas indicate a healthy pregnancy, then a vaginal ultrasound will be scheduled between the sixth and eight week of the pregnancy. At that time, your doctor will be looking for a heartbeat and a gestational sac to confirm the pregnancy, around the eight week of gestation patients are “graduated” and referred back to their OBGYN for continuing obstetric care.
If the cycle results in a negative pregnancy test, it’s very disappointing. It’s important to remember, you have a treatment plan with options for trying again. Your medical team will start by instructing you to stop your medications and offer you to schedule a consultation with your doctor. At that time, you’ll discuss what happened during the cycle, any changes you might make to your protocol, and ultimately how you want proceed.
While there are several phases to an IVF cycle with many details to consider, it’s an exciting time filled with hope and possibility. Whether you are about to start an IVF cycle or you’re just exploring fertility treatment in general, don’t hesitate to ask all your questions and express your concerns.
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