If you have made the decision to proceed with in vitro fertilization (IVF) to achieve pregnancy, here is your step-by-step guide to prepare for the discussion with your fertility specialist at your IVF consult. Regardless of the reason for choosing IVF, here are 10 common considerations for every IVF cycle. We encourage you to discuss each one with your physician during the consult.
1. Stimulation protocol
Based on your age and testing of your ovarian reserve, your doctor will choose a protocol that will best balance optimizing the number of eggs available for retrieval while being careful to avoid ovarian overstimulation. There are several protocols that are used and other factors to consider such as whether you have endometriosis, polycystic ovarian syndrome (PCOS), or prior IVF cycles with low egg yield. A common question is whether there are supplements that you should be taking prior to starting that may improve the outcome. I encourage women considering IVF treatment to ask their doctor if taking supplements such CoQ10 or Ovasitol may be a good idea for their individual preparation.
2. Monitoring
In general it takes about 9 to 12 days of injections to stimulate the ovaries to produce mature-sized follicles. The dose of medications may be adjusted during this time based on your hormone values and the rate of follicle growth. Your response to the injectable medications to simulate your ovaries is evaluated by bloodwork and ultrasound. The average number of visits for monitoring is about 6 and is more frequent towards the end of the stimulation when the follicles are close to maturity.
3. Trigger
The goal is to have a reasonable cohort of follicles in the mature range before “triggering” the release of the eggs from the wall of the follicle. There are two medications that are used either individually or together to cause the eggs to release at a specific and predetermined time so that your egg retrieval occurs at a predictable timeframe. The choice of the trigger medication depends on how robust your stimulation is, whether a fresh embryo transfer is planned, and whether you have a medical history that may guide the choice. Most patients have their egg retrieval done about 36 hours after the trigger shot.
4. Egg retrieval procedure
You have done a lot of work to get to this point! With daily injections and frequent monitoring visits with bloodwork and ultrasounds, you may start to “feel” your ovaries getting full of mature follicles. We perform the typically quick (15-20 minutes to perform) egg retrieval procedure under anesthesia. The procedure requires a needle aspiration under ultrasound guidance.
5. Fertilization technique
There are two main ways to expose the eggs to the sperm. Conventional IVF involves simply putting the eggs and sperm in the same dish and allow nature to take over. Intracytoplasmic sperm injection (ICSI) is a technique where we select a single sperm to directly inject into a mature egg. We generally recommend ICSI in cases of low sperm concentration and/or motility, a lower percentage of normal sperm shape, use of frozen sperm (like donor sperm), or when we plan for additional genetic testing on the embryo. There are other techniques that are less standard but may be considered in unique scenarios such as PICSI, but talk to your doctor about whether this is right for you.
6. Assessing embryo development
After the sperm fertilizes the egg, it becomes an embryo. The embryology lab will be your embryos’ first babysitters! You should get updates at critical stages such as how many eggs fertilized normally and how many reach a stage suitable for transferring. Remember, not all eggs are mature and not all mature eggs fertilize normally. The percentage of embryos that develop into a stage that can be transferred is variable and often dependent on your age. The quality of the embryos can also vary and the lab will grade them based on their appearance and development overall.
7. Assisted hatching
Your physician will discuss with you if he/she recommends assisted hatching. Assisted hatching is a technique performed by the embryologist to create a “window” in the shell around the embryo called the zona pellucida. It can help the embryos hatch out of the shell to allow it to implant in the uterus. There are usually clear medical indications for assisted hatching so discuss with your fertility specialist his/her recommendation individualized for your unique situation.
8. Number of embryos to transfer
There are national guidelines on the safe number of embryos to transfer, which balance pregnancy success rates and the risk of multiple gestation. There should be a plan on the number of embryos that is right to transfer for you. It is important to remember that the overwhelming majority of pregnancies from IVF are singletons and IVF is the safest option to avoid multiples. If you are worried about twins, there are effective ways to select the best single embryo for transfer (eSET).
9. Preimplantation genetic screening
Your physician will discuss with you if he/she recommends preimplantation genetic screening (PGS). PGS allows you to know whether your embryos are chromosomally normal or have abnormalities such as an extra chromosome 21, which causes Down syndrome. Missing and extra chromosomes account for the majority of genetic abnormalities seen in embryos and can contribute to failed implantation or miscarriage. The likelihood of having these chromosomal abnormalities increase with age. Risk of a chromosomal abnormality may also be increased in some cases of prior recurrent pregnancy loss.
10. Embryo disposition options
If you have extra embryos created during an IVF cycle, most patients choose to freeze or cryopreserve them for the future. If you choose not to freeze them, you may choose to donate them for research or anonymously to help other couples build their families. You should take time to explore your values, family building goals, and preferences before choosing to discard the embryos.
The IVF consult is the best time to ask all the questions you have so you are comfortable that the plan is designed specifically for your needs. There are risks and potential unexpected situations specific to each stage of the IVF process, which you will have a chance to discuss at your consult as well as the process to minimize those risks and available back up plans. Most of your interactions will be with your physician and nurse but there is an entire team that collaborates in your care including the embryology lab, anesthesia team, finance team, pharmacy, and possibly the genetic testing lab if you are electing any preimplantation testing. It is important that everyone is on the same page, knows your preferences, but also has an opportunity to help guide you to make the right decisions for you. From the time you start stimulation medications until you get your pregnancy test results, it can be as quick as a month. For many patients IVF will be quicker than they thought but also easier with the right planning.
Written by: Kara Nguyen, M.D., M.P.H, of Shady Grove Fertility’s Reading, PA and Harrisburg, PA offices.
To schedule your IVF consult appointment with one of our reproductive endocrinologists, please call 1-877-971-7755 or click here to complete this brief online form.
