If you have decided on going through an IVF cycle, are currently discussing the option with your doctor(s), or just curious about what is involved in the process I will discuss the basic steps in the IVF (in vitro fertilzation) procedure.
Every IVF cycle, no matter the complexity, or the patient’s involved can be broken down into a similar series of steps. The particulars can vary a bit if you use a donor (sperm or egg) or utilize additional services like ICSI or PGD with your cycle but the all the same steps will be the same.
- Pre-cycle workup and diagnostic testing. Before the doctors even start prepping you for your cycle they have an extensive checklist of tests that they will put you through. This ‘workup’ will vary depending on the clinic; some clinics are more thorough than others, and age and past conditions can lead to additional tests. The purpose of these tests are two-fold. It is very important that the doctors have a clear understanding of your biology going into the cycle, and that they do as much as they can to optimize your chances of a successful cycle. This phase includes diagnostic work to survey both the uterus and fallopian tubes, ultrasounds and hormonal testing to ascertain how you will respond to the stimulation medications (important in determining the drug protocols that will be recommended), a semen analysis, and possibly some genetic testing. You can gauge the quality of a clinic by how thorough their workup is, although you also do not want to be put through tests just for the sake of it – often very hard to determine from a patient’s perspective.
- Preparing for the cycle It is very important the that woman’s hormones be carefully controlled throughout the entire cycle. Having a late or delayed period could stop a cycle dead in the water, to this end, a clinic will have you regulate your cycle with birth control pills or other hormones. There will be some blood work and ultrasounds to monitor hormone levels and make sure the ovaries are responding appropriately. A problem in this phase, although unlikely, can derail a cycle. If that occurs the clinic will likely just push the cycle back, rather than spend all that time and money at a sub-normal success rate.
- Stimulation phase Once you are all prepped and your hormones are down-regulated the clinic will prescribe you a series of hormonal treatments. The purpose of which is to hyper-stimulate the ovaries to produce more ‘mature’ eggs than normal. The key word here being mature, the stimulation protocols don’t increase the amount of eggs being selected for growth each month, that amount remains the same. This is one of the reasons why age is such a factor in success rates. As a woman ages, their egg supply dwindles, and they have both less and lower quality (chromosomally normal) eggs. The meds instead trick the body into maturing more of these eggs. This is good, because more eggs usually = higher chances of success and/or additional embryos to freeze after the cycle for additional attempts.
The stimulation medications can be quite expensive with a price tag ranging from a couple thousand up to ten thousand depending on the protocol used.
During this time you will be closely monitored by the clinic. This means lots of blood draws, and ultrasounds! The close monitoring is really important as it is vital you receive just the right amount of stimulation, and get “triggered” at the proper time. Triggering refers to a hormone injection (usually human chorionic gonadotropin or hCG) that you will be given at the proper time that tells the eggs to undergo the final stage of maturation before they can be retrieved. Timing is vital here as the eggs may not fertilize correctly if they are triggered too soon, or too late.
- Egg Retrieval After you have been triggered, you are ready for the egg retrieval. The egg retrieval is a surgical procedure where the physician removes your eggs. This is done with a long needle that reaches the ovaries through the vaginal wall. The needle is attached to an ultrasound probe, for guidance, and will be used to flush each of your mature follicles (the place where the eggs develop in the ovaries). The fluid that is taken out is then closely examined by an embryologist to see if it contains an egg. This process is repeated until all the appropriate follicles have been aspirated. This procedure is usually done under full anesthesia and will last between 20-40 minutes, depending on the number of follicles you have.
- Fertilization and monitoring Once the eggs are retrieved they travel back into the IVF or embryology lab. There they will be combined with the male partner, or donor, sperm in order to be fertilized. There are two main methods of fertilization that are used. The first is often just called IVF, or possibly normal, fertilization and is when the sperm is carefully washed and prepared and then a set amount is combined with the eggs in a petri dish, and left overnight for the magic to happen. If the sperm is sub-optimal and/or there is some kind of male factor and/or history of fertilization issues and/or not many eggs retrieved (lots of different reasons) your doctor may recommend that the eggs are fertilized with ICSI or intracytoplasmic sperm injection. During ICSI the embryologist will pick out individual sperm with a tiny pipette and manually inject each egg with a single sperm.
After the eggs have been fertilized they are now referred to as embryos. These embryos are closely monitored under highly controlled conditions in the laboratory. During this time you will receive periodic updates from the doctor or lab staff keeping you in the loop as to how your precious embryos are doing. Depending on how well the embryos are doing, and how many you have, the clinic might decide to continue monitoring them into the blastocyst stage. After a few days in the laboratory it will be time to put the best embryo(s) back into the uterus.
- The embryo transfer After thoroughly discussing the pros and cons of how many embryos to put back into the uterus. The physician will carefully transfer the selected embryo(s) into the uterus with a small catheter. Close attention is placed on putting the embryo in just the right place in the uterus to help facilitate a healthy implantation of the embryo on the uterine wall. The transfer usually occurs on either day 3 or day 5 of embryo development. The benefit of waiting until day 5 is it allows the clinic to obtain more data on the embryos. By watching how they developed for those additional days the clinic will have a better idea on how the embryos will do once they are transferred back. The procedure is usually done without anesthesia, unless specifically requested by the patients. At this stage any extra embryos may be frozen for a frozen embryo transfer (FET cycle) at a latter date
- Pregnancy test After the embryos are transferred there is not much else to do but wait. It takes some time to determine if the procedure was successful in generating a pregnancy and most clinics will have you wait 2 weeks before summoning you back for the fateful blood test. If you are really impatient, home tests can be used. It is possible to test positive as early as 10 days after the transfer, but as they are largely unreliable at this stage it is probably better just to wait the extra days for the blood test.
There you have it. All IVF cycles will have these basic step to it. The who and when can vary a little when using a egg or sperm donor, but everything else is basically the same.