IVF treatment explained step by step
Here’s our 101 guide to help you understand what is required during the IVF treatment process.
In a typical menstrual cycle, one ovary makes one follicle that releases one egg when you ovulate. However, to maximize the chances of success of ART treatment, we try to increase the number of follicles the ovaries are producing in a single cycle. For IVF, this is so your doctor can retrieve the maximum number of eggs from which she can create embryos.
Your stimulation protocol will be tailored by your fertility doctor specifically for you. Almost all protocols involve one or two daily hormone injections, and sometimes will also include another injectable medication to prevent you from ovulating on your own (i.e., before your doctor can retrieve the eggs). The hormones you take are the same as those that tell the ovary to grow a follicle in a natural cycle, just in higher doses. The shots are done with very small, thin needles in the tissue just under the skin. Your doctor will expect you to administer these medications by yourself (or your support team), at specific times each day. This part of the process take on average about 9 to 12 days, but may be a bit longer or shorter depending on your response.
Monitoring your cycle
Throughout the process, your doctor will monitor your progress very closely, watching the growth and behavior of your follicles in order to know how many eggs you are producing and when they will be ready for retrieval.
For a standard IVF cycle, you should expect to visit the fertility clinic at least five or six times during the stimulation process. Initially, you’ll have to go every three days or so; as you get closer to ovulation, this may increase to as often as every day. Daily monitoring involves an ultrasound to measure the size of your follicles and thickness of your uterine lining, and may also include a blood test to measure your estrogen level as well.
Don’t be surprised if your doctor changes your IVF program a few times as your follicles develop based on what she sees in your test results. She’s tweaking your medications to make sure you get the best, safest response possible.
The trigger shot
As the follicles grow, the eggs inside them are developing too. When a follicle gets larger than about 13 mm, its egg is more likely to be mature and therefore capable of being fertilized. Once the largest follicles reach about 17 to 18 mm, they (and you) are ready for egg retrieval. Just one more step: an injection of human chorionic gonadotropic hormone (hCG, brand name Pregnyl or Ovidrel) and/or gonadotropin-releasing hormone agonist (leuprolide acetate, brand name Lupron), either of which trigger ovulation. You can give yourself the injection or schedule an appointment with the nurse.
For this shot, timing is crucial: it has to be taken a specific number of hours before your scheduled egg retrieval (typically 36 hours). Be sure to set an alarm!
Prepping for the egg retrieval is important. Often, you’ll be asked not to eat or drink anything after midnight the night prior and need to arrive about an hour before your appointment to check in and give the nurses time to get you settled. We recommend that you take the rest of the day off after the procedure. Clinics also may require that you have someone to escort you home afterwards.
The actual egg retrieval procedure is surprisingly short after all the hard work you’ve been doing for the past few weeks. Your doctor will use a thin needle with a hollow point to remove the egg from each follicle that has developed, guiding it with an ultrasound probe. The procedure is done through the vaginal wall, which sounds worse than it is–there is usually minimal pain and no need for any stitches or other incisions. All in all, the procedure itself takes only 20 to 30 minutes.
Different clinics use different types of anesthesia for the egg retrieval procedure. If this is something that you’re worried about (or if you have any allergies), be sure to talk with your doctor about it beforehand. Typically, clinics give a moderate anesthesia, meaning that you will be asleep but breathing on your own and, most importantly, won’t feel or remember anything.
As the eggs are retrieved, they are handed over to the waiting embryologist to be counted and prepped for the next step of the process: fertilization.
Fertilization is the process of combining the sperm and the egg. This can be accomplished one of two ways (you should discuss with your doctor which one is appropriate for you).
1. Standard insemination
Basically, the sperm is placed on top of the egg and allowed to make its way into the egg on its own.
2. Intracytoplasmic sperm injection, or ICSI
Here, the sperm is injected directly into the egg using a very thin needle. Traditionally, ICSI is used in cases where the sperm counts are low or the appearance of the sperm is abnormal. However, today many clinics will use ICSI for other reasons, such as poor fertilization in a prior cycle, in cases when fewer eggs are retrieved, or simply because it has become the lab’s standard practice.
Fertilization takes place the same day as the egg retrieval. The next day, the embryologist determines how many of eggs fertilized successfully (on average, this will be about 75 percent of what was retrieved). These are your embryos, and they are immediately transferred to a special environment that mimics the tubal fluids inside the body. There, they continue to mature for up to six days while embryologists monitor their growth and appearance (called “morphology”) daily to ensure that they are developing normally. Embryologists also use the morphology of the embryos to help determine which ones to select for your transfer.
Although emotionally this will probably be a very stressful day, the actual embryo transfer procedure is one of the easiest. It takes just a few minutes and doesn’t require any anesthesia or recovery time.
After reviewing your health and your embryos’ development, your doctor will load the chosen embryos into a thin catheter and gently place them in your uterus, often using an ultrasound to guide them to the correct location. Afterwards, you will have some time to relax and then can go about the rest of your day.
The pregnancy test
Two weeks after the embryo transfer, you’ll take a pregnancy test at your doctor’s office or your local lab. Unlike an at-home urine test, this one measures the hCG level in your blood and is very sensitive. It is typically repeated one to two more times, 48 hours apart, to confirm a diagnosis and make sure that the hCG level is rising appropriately in the case of a positive test result. Your doctor will then schedule a vaginal ultrasound at around six weeks (which is about two weeks after your positive pregnancy test) to make sure that the pregnancy is in the right place and looks healthy. Many clinics repeat the ultrasound in another one to two weeks to check for appropriate growth. After that, you’ve graduated–your work at the fertility clinic is done and your work with your OB/GYN begins.
If the tests are negative, it’s time to start planning for the future. Are you going to try another IVF cycle? Take a break? Is it time to consider other options? Talk to your doctor about next steps, take your time, and make the decision that is best for you.