In-vitro fertilization is a lengthy, emotional process to undertake. Even though many couples who try IVF have already endured other fertility treatments, it is much more involved and complicated. Here are things you can expect during an IVF cycle, from beginning to end.
Before in-vitro fertilization can begin, doctors usually require a series of tests and bloodwork. The tests check for things such as polyps or blocked tubes and the bloodwork checks for STD’s and other issues that may affect the outcome of the cycle. Usually the test results must be less than a year old and can take a few months to complete. After the initial work-up you will have an appointment with the doctor to discuss your protocol. They will explain what medications you are using and at what dosage. IVF involves multiple medications to produce a sufficient amount of follicles for retrieval. There are medications to produce follicles and other hormones such as FSH and LH. There are also medications to prevent your body from ovulating on its own. The medications are almost always in the form of injections. Depending on your specific protocol you may be injecting yourself multiple times a day. Most fertility clinics offer classes as part of their program that explain how to mix and administer medications.
The first step to in-vitro fertilization is actually birth control pills. Birth control pills help to quiet the ovaries in preparation for a month of over-stimulation and allow your body to start with a clean slate. It can also benefit the fertility clinic because they can control when you start your IVF cycle. Sometimes clinics will cycle a group of patients together to make it easier for monitoring.
After 14-30 days of birth control pills is the start of the first injections. Some protocols actually have the patient begin injections while they are still on the pill. Each protocol is different based on how the doctor feels your body will respond. Injections are best given in the stomach area but can also be given in the thigh. The stimulation drugs are sub-cutaneous meaning they are injected into the skin but not the muscle. They are relatively painless but the area can be prepped with ice beforehand to prevent any discomfort.
After 3-5 days of stimulations the doctor will begin monitoring your ovaries via ultrasound. They count and measure the number of follicles in each ovary. They will also take a blood sample to make sure that the estrogen level correlates with the number of follicles in your ovaries. If the estrogen is too low it can indicate that some of the follicles are empty. If the estrogen is high or there are a large number of follicles it can indicate Ovarian Hyperstimulation Syndrome (OHSS). OHSS is a dangerous side effect of fertility medications and can cause the cycle to be cancelled or even require hospitalization in severe cases.
During an IVF cycle stimulation drugs are usually taken for an average of 10 days. During that week your doctor will continue to monitor you via ultrasound and bloodwork until the follicles are a sufficient size. This usually occurs when the largest group of follicles is between 16 and 20mm. Some follicles may be larger and “overripe” when it comes time for retrieval but it is possible for smaller follicles to catch up even after they have been retrieved. When the doctor is ready to retrieve the eggs you will be told to administer an HCG shot. This is usually an intramuscular shot but can also be sub-cutaneous. The HCG shot triggers your body to ovulate. All other stimulation medications are stopped at this point. Approximately 36 hours after the HCG shot the egg will be ready for retrieval.
Egg retrieval is an important day during an IVF cycle. Almost all patients are placed under some form of anesthesia, therefore you will not be able to eat or drink the morning of your retrieval. The anesthesiologist will give you a light sedative but generally does not make you completely unconscious. The egg retrieval process involves the doctor using an ultrasound to guide a needle through the vaginal wall into the ovary. The doctor pokes each follicle with the needle, sucking out the fluid inside and hopefully an egg. The process usually takes about half an hour, depending on how many follicles there are. During this time the male partner will be asked to provide a fresh sample of sperm, or a frozen sample will be thawed. After waking up from the anesthesia the doctors may monitor you for a while before releasing you. After the egg retrieval you may be given the following medications: Tylenol or Percocet for pain (no ibuprofen), stool softener for constipation, anti-nausea pills or an anti-biotic. An escort will be required to drive you home.
The doctors are usually able to identify how many eggs were retrieved immediately after the egg retrieval. Not all follicles will have an egg in them and not all eggs retrieved will be mature. The eggs will be placed in a petri dish to be fertilized. If intracytoplasmic sperm injection (ICSI) is chosen then the sperm will be injected directly into the egg. Otherwise the eggs and sperm are left together to fertilize on their own and the embryologist checks on their status the next morning.
The day after egg retrieval will reveal how many eggs fertilized. The average fertilization rate for non-ICSI eggs is about 60-80%, depending on multiple factors such as age, egg quality, and sperm quality. If very few eggs fertilize then ICSI may be performed on the remaining ones. This is also the time when most patients are instructed to start progesterone medication. Progesterone helps to build the lining of the uterus and aid with implantation. Progesterone can either be prescribed as a vaginal suppository or as an intramuscular injection.
Over the course of 2-5 days the embryos will continue to split and grow. Depending on the clinic and the quality of the embryos, the transfer may occur as soon as 2 days after retrieval, however clinics usually do a 3-day or 5-day transfer. There are pros and cons to each choice and while it is argued that one may be better than the other, there is no actual proof.
When it comes time to transfer the embryos back into the uterus the doctor will discuss with you the state of your remaining embryos. Each embryo may be “graded” depending on how fragmented or symmetrical they are. The embryo will usually be 4 to 8 cells by transfer. The doctor will also discuss how many to put back. If only one or two embryos remain then all embryos may be transferred but age and prior history are also issues to consider when transferring embryos. On the transfer date you will need to arrive at the clinic with a full bladder. This helps to guide the catheter into the uterus more easily. If a bladder is not full enough it may cause the embryo to fall out of the catheter in a less than desirable place, such as near a fallopian tube. Compared to the egg retrieval the embryo transfer is a relatively quick and painless process. After the transfer most doctors require that you lie on the table for 20-30 minutes before getting up and walking around. They will sometimes prescribe bed rest for a day or two and pelvic rest (no sex or exercising) for 2-4 weeks.
After the transfer comes the dreaded “two week wait”. This refers to the waiting period that couples have before they are tested for pregnancy. During this time it would be advisable to relax, try not to lift more than 10 pounds and skip hot baths. While IVF is a long process lasting about 40 days from beginning to end it is one that hopefully ends in a healthy pregnancy.
