In Vitro Fertilization (IVF) is sometimes incorrectly believed to be the only fertility treatment option for patients. In reality, it is not even the most frequently prescribed option. The reason IVF gets more attention is that the success rates are very high and because it allows couple to overcome many different infertility diagnoses that lesser treatments may not.
In Vitro Fertilization is a process that helps infertile couples become pregnant by joining the egg and sperm together in a lab to create embryos that can be transferred back into the woman’s uterus. This treatment has helped thousands of couples worldwide overcome a wide variety of diagnoses and realize their dreams of becoming parents.
While most of us have heard about IVF, not many people know exactly how the process works. Whether you’re just starting to research fertility treatments or are already a patient preparing to begin IVF, knowing more about the treatment can reduce your anxiety and make your journey through the process smoother.
This is the first part of a four-part series on the IVF process that will detail IVF treatment from cycle start to graduation. In this first piece, we will look at the steps from diagnosis and ovarian stimulation to egg retrieval.
Diagnosis
The first step on the path to parenthood is diagnosing all the factors that might be contributing to a couple’s infertility. This is done through a basic infertility workup that includes testing of both the male and female partner. The work-up includes:
- Medical History – During the initial consultation, the doctor will take a detailed medical history that includes medical and lifestyle factors that can affect conception.
- Day 3 Testing- This testing is done around the 3rd day of bleeding in a woman’s menstrual cycle. Blood work is obtained to measure fertility hormone levels that will help determine a sense of your fertility potential, and identify any age related decline. On the same day, a vaginal ultrasound is done to image the uterus and ovaries and assess their health. The ultrasound technician will perform an “antral follicle count”, a count of potential eggs in each ovary, this helps determine the possible number of eggs a woman could produce during a IVF treatment cycle. Both of these tests will help your doctor select the proper dosing and types of medications for your treatment.
- Hysterosalpingogram (HSG)- This is a test that uses X-ray technology to assess the uterine cavity and the fallopian tubes. The test involves a pelvic exam and the placement of a small catheter into the cervix. A safe X-ray dye is then infused into the uterus and fallopian tubes causing the dye to fill the uterus and travel through the fallopian tubes. This test allows the doctor to check for any abnormalities in the cavity of the uterus and to verify that the tubes are open.
- Semen Analysis – Male factor infertility accounts for 40% of all infertility cases making this non-invasive test equally as important as the tests to the female partner. In this simple test a sample of semen from the male partner is analyzed under a microscope to evaluate the fertilization potential of the sperm. The test measures volume, concentration, motility and morphology.
These diagnostic tests will reveal not only if IVF is the right course of treatment, but also how best to tailor IVF to the couple’s needs.
Diagnoses that Require IVF
Once diagnostic testing is complete, the physician will discuss treatment options with the patients. Most times, IVF is not the only option for patients, and many start with simpler treatments like Intrauterine Insemination (IUI). However, IVF would be the first line of treatment for patients with the following conditions:
- Tubal Disease or Tubal Ligation – If a patient has had a tubal ligation (had her “tubes tied”) or the HSG test reveals that there are issues within the fallopian tubes, such as blockages in both tubes, and then IVF would be the best treatment available since it allows for pregnancy to be achieved without the use of the fallopian tubes.
- Severe Male Factor Infertility – If the semen analysis shows that there is not enough healthy sperm to be successful with a regular insemination process, then IVF can help patients overcome male factor infertility. With IVF, advanced methods of fertilization, such as ICSI, can be performed in the lab so that only one healthy sperm is needed for each egg.
Patients with a host of other diagnoses may start with “lower tech” treatments like hormone therapies or IUI and then transition to IVF. Data shows that after 3-4 treatment cycles, success rates begin to decline sharply. By moving to IVF treatment, a couple increases their chances of success dramatically. Some additional diagnoses for which IVF can improve the chances of success are: advanced age, endometriosis, ovulatory disorders and unexplained infertility.
IVF Cycle Outline
An IVF cycle takes about 2 months to complete. The basic outline of a cycle is as follows:
- Pre-Cycle Appointments
- Preparing the Ovaries for Stimulation
- Ovarian Stimulation and Monitoring
- Trigger Shot and Egg Retrieval
- Embryo Development in the Lab
- Embryo Transfer
- Pregnancy Testing and Monitoring
Pre-cycle Testing and Consultation Appointments
In preparation for an IVF cycle, patients will undergo a Mock Embryo Transfer. This procedure is a “practice run” for the embryo transfer that will take place at the end of the cycle. It allows the doctor to test the size and placement of the catheter with the patient’s particular anatomy before there is a live embryo loaded into it. During the procedure, an ultra-thin catheter is inserted into the uterus while a sonogram guides the process on a monitor. It is completely painless and takes only a few minutes.
Following the completion of the pre-cycle testing, each patient will meet with their physician to review the results and their planned treatment protocol. The treatment protocol is like a blueprint that is used by the patients and their medical team throughout the IVF cycle. It identifies the treatment plan from medications to lab procedures, all the way through the transfer and storage of embryos. It is important to understand that this blueprint can only provide tentative dates for stimulation, egg retrieval, and embryo transfer. Frequently, treatment timelines will need to be adjusted based on how each patient responds to their medication. Every patient should anticipate changes and block time as needed in their work and travel schedules.
Preparing the Ovaries for Stimulation
Many women start an IVF cycle by taking birth control pills for a set number of days. Birth control medications decrease the chances of creating cysts that could interfere with the cycle start. They also allow the doctor to control the timing of the cycle.
As a quality control measure, Shady Grove Fertility only allows a certain number of IVF cycles to begin at any given time. The patient may also have scheduling issues that dictate starting on a certain date. The birth control medication will synchronize the egg follicles so they all start at the same stage, on the date collectively chosen by the doctor and patient.
Some women can’t start their cycle with birth control pills because they have a blood clotting disorder or other condition that prevents them from taking oral contraceptives. Also, in cases where women have low ovarian reserve, the doctor may not want to suppress their ovaries with birth control medication. Sometimes, these patients use estrogen patches instead to help the ovaries prepare for stimulation.
Ovarian Stimulation
In a normal ovulation cycle, one egg 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 this phase of the IVF cycle, injectable medications are used for approximately 8-14 days to stimulate the ovaries and produce eggs.
Some women are concerned that using several eggs in a single cycle may prematurely deplete their ovarian reserve and cause an early onset of menopause. Women are born with all of the eggs they will ever have, around 1 million. By the time they reach their first menstrual cycle there are approximately 400,000 eggs remaining. Retrieving several eggs at any given time will not cause women to use all of their remaining eggs or develop an early onset of menopause.
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 some use a combination.
Patients give themselves these medications via subcutaneous injections, which means under the skin, as opposed to intramuscular injections which go into a muscle. These injections for some patients can be the most intimidating aspects of IVF. To help ease the fear of injections patients are encouraged to take advantage of injection classes provided at Shady Grove Fertility.
Injection classes are available and will help patients master the following:
- Understanding which syringes and needles to use with which medications
- How to draw up and mix medications
- How to administer the medications
Patients can also find videos at ShadyGroveFertility.com that demonstrate injections for each type of medication used. Almost all patients find that they get better at the injections as progress through their first cycle. Most women, even those who were very fearful of the injections to start, find the process easier than expected. Watch an Injection Demonstration Video.
Possible Medication Side Effects
Women may experience side effects from the injectable medications, such as headaches, irritability, fatigue, bloating and mood swings. These are similar to symptoms of PMS or menstruation but may be slightly more intense. Some women, however, have no side effects.
Although rare, one possible side effect from the stimulation phase is called ovarian hyperstimulation which occurs in about 1-2% cycles. Ovarian hyperstimulation happens when a woman’s body over-responds to stimulation medications. This can cause fluid to build up in the abdomen and pelvis and possibly lead to blood clots. The good news is that this condition can usually be prevented through close monitoring of the woman’s response to medications. If there are signs that a patient may be moving toward hyperstimulation, her doctor can reduce the amount of medications she is taking to avoid it.
Morning Monitoring
During the ovarian stimulation phase of the IVF cycle, which lasts 8-14 days, patients come into the office approximately 7-8 times for morning monitoring. Monitoring consists of:
- Transvaginal Ultrasound – This ultrasound is used to measure the growth of the egg follicles and the thickness of the uterine lining, both of which should be increasing as the patient takes the injectable medications.
- Bloodwork – Blood is drawn at each appointment to measure a patient’s level of estradiol, or estrogen. This level is another indicator of the growth and maturation of the eggs, and it rises as the follicles grow.
Monitoring appointments are shceduled in the early morning so that patients do not have to miss work. This scheduling also helps us to have time to analyze all the bloodwork so that patients can be called the same day with results and further dosing instructions.
Every time a patient comes in for monitoring, they receive a phone call from their nurse in the afternoon. The nurse tells them their level of estrogen, the dosing of each medication they should take that night and when to come in for the next monitoring appointment. This is an opportunity for patients to ask any questions they may have about their cycle, their test results and any side effects they may be having. Most patients find their nurses to be a great resource while going through treatment.
Cancelling a Cycle
Sometimes a cycle will be cancelled during the stimulation phase. One reason that cancellations occur is if a patient is showing signs of ovarian hyperstimulation. If decreasing the medication dosages will still leave the patient at risk for hyperstimulation, patients will be instructed to stop medications right away, which will remove the risk.
Another reason a cycle could be cancelled is if not enough follicles are growing to justify an egg retrieval. It’s important to remember that each follicle only contains one mature egg, at best. Some follicles will be empty and some will have eggs that are too immature to fertilize. If a patient has less than 3-4 follicles developing, the cycle will be reevaluated and may be cancelled.
A cancelled cycle is disappointing for both patients and physicians. The egg retrieval is the most costly part of the cycle, it’s often best to stop, save the costs associated with the retrieval and try again after changes have been made to the protocol. Patients who have cycles cancelled should remain hopeful. Having a cycle cancelled doesn’t mean they are less likely to have success with IVF on the next try.
The Trigger Shot
The trigger shot is the last step before the egg retrieval. Depending on the protocol, patients will either have an hCG or Lupron trigger. The trigger shot provides final maturation to the developing follicles and sets ovulation in motion. Timing is very important in this phase because the egg retrieval must be preformed prior to the expected time of ovulation. Once the eggs are ovulated they are no longer able to be retrieved. The trigger shot is carefully timed to be 36 hours before a patient’s egg retrieval. It is usually an intramuscular injection that is administered by someone other than the patient. The doctor decides when a patient is ready to trigger based on the two key factors that have been monitored during stimulation:
- 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 Estradiol – The patient’s estrogen level needs to be neither too high nor too low. There is no specific number that physicians deem acceptable. The Estradiol 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.
The patient’s nurse will give specific instructions on the day of the trigger about the shot, the monitoring appointment on the next day and the scheduling of and preparation for the egg retrieval.
Egg Retrieval
The Egg retrieval procedure is done at the ambulatory surgery centers (ASC) at Shady Grove Fertility’s Rockville or Towson locations. The patient’s nurse will provide specific instructions about when to eat and drink, what to wear and bring, and when to arrive.
On the day of the egg retrieval, strict identification security procedures are followed. Patients must have a photo ID with them. They are given a wristband with their name, patient ID number and social security number. They are asked multiple times to read the information aloud and verify that it is correct.
A doctor meets with every patient before the procedure to review her protocol, particularly what will happen during the fertilization phase in the lab.
If patients are using a fresh sperm sample as opposed to a frozen one collected at a previous date a lab technician will come to accept the sperm sample. Some patients may prefer to collect a semen specimen at our surgery center. Collection rooms are also available, if needed. We encourage patient to collect at home, if possible, to help ease anxiety about this part of the procedure.
Prior to the procedure, you will meet with an anesthetist, who will review your medical history and will place an IV. IV fluid will be given prior to the start of the procedure and this IV will be used to deliver the anesthesia medication for sleep during the procedure. This is not general anesthesia but a quick-acting sedation that lasts as long as the procedure.
The egg retrieval itself takes about 20-30 minutes. During the procedure, a needle is guided into each ovary and the fluid in each follicle is removed along with the egg. An ultrasound is used to visualize the process on a monitor.
Recovery takes about 30 minutes and patients are able to walk out on their own, though they need someone to drive them home. Patients should rest and relax for the remainder of the day. Some women experience cramping or mild abdominal pain after the procedure, so everyone is sent home with oral pain medications sufficient for a couple of days. Almost everyone goes back to work or their regular activities the next day. Watch SGFCs “What to Expect the Day of your Egg Retrieval” Video.
Risks
The risks from the egg retrieval are minimal. Patients can expect a small amount of vaginal spotting or bleeding, this is normal. A different concern is internal bleeding that can occur around the ovaries. Using ultrasound guidance during the egg retrieval greatly minimizes this risk to patients. Patients experiencing significant abdominal or shoulder pain after their egg retrieval should contact their nurse to be checked for bleeding. Few patients, approximately 1 in 800 patients will experience this bleeding.
Before a patient leaves, she will be told how many mature eggs were collected. Patients should expect that not every follicle will have an egg and not every egg will be mature. Once they go to the lab, not every egg will be able to fertilize. A good outcome is to have half of the eggs retrieved fertilize and become embryos.
The Hard Part is Over
After the egg retrieval, the active part of the process shifts from the patient to the laboratory. The next part of the IVF series looks inside the IVF laboratory, where many of the hurdles that patients face, such as male factor infertility, are overcome. This is where precision combines with the wonders of science to give couples the best possible chance to fulfill their dreams of parenthood and family.
Read our IVF Treatment Series:
Part One of the IVF Treatment Series- Cycle Start to Egg Retrieval
Part Two of the IVF Treatment Series- In the Embryology Lab
Part Three of the IVF Treatment Series- Final Steps of IVF Treatment
