IVF process explained
If you’re considering in vitro fertilization (IVF), you’ve likely been trying to conceive for quite some time. As a result, you’re probably feeling frustrated, anxious, and sad – infertility can impact all aspects of your life and add stress to your relationships. In some cases, IVF might be your first choice for medical reasons or if you’re in a same-sex relationship.
Whether you’re considering IVF for the first time or you’ve been through it before, there are a few things you need to know. First, IVF can be a significant financial investment, and it can be really hard on your mind and body. Going in blind and trying to navigate the process on your own can add to the stress of the situation. The blood tests, scans, injections, and timings can seem overwhelming at first, and the lingo and acronyms can be confusing.
That’s why we hope this blog post will answer your questions about the entire IVF process from start to finish.
Common causes of infertility in women
IVF Facts: The Basics
Let’s start by defining IVF – in vitro means ‘in the lab” – you’ll also hear this process referred to as ‘lab assisted conception.’ Simply put, the woman or AFAB (assigned female at birth) person takes hormonal medications to stimulate the production of additional eggs.
In a regular cycle, you tend only to release one or two eggs; for conventional IVF to work, you need plenty of eggs. If you don’t want to take injectable medications, you can also consider minimal stimulation IVF (aka mini-IVF). IVF cycles are either ‘long’ or ‘short’ – this depends on your medical needs and specific issues; both are equally effective.
The doctor retrieves your eggs from your ovaries with a transvaginal ultrasound-guided needle during minor surgery. Next, your eggs are placed in a petri dish and mixed with washed sperm cells from your partner or donor.
In some cases, women use donated eggs or donated sperm (if they don’t have a partner who produces healthy sperm). Ideally, the sperm will fertilize at least some of the eggs and go on to become embryos. If a fresh transfer is suitable, the doctors will transfer one or two of the embryos into her uterus, and ideally, an embryo will implant and begin to grow.
If the sperm has mobility, shape, or count issues, doctors may recommend ICSI or intracytoplasmic sperm injection. In this technique, a lab tech injects a single sperm into a single egg.
You may also consider having your embryos tested for genetic abnormalities with PGT-A technology. Doctors often recommend this testing for older women and those who have experienced multiple miscarriages. While it doesn’t increase your chances of success for each cycle of IVF, it can prevent you from implanting an embryo that is certain to fail, thereby saving you time. Preventing wasted time is particularly important for women of advanced maternal age and/or with a low egg reserve.
IVF Success Rates
IVF can be successful, but it’s important to remember that it is a numbers game. Your chances of success increase with every successive IVF cycle. According to an American study of 156,000 women, 29.5% of women under the age of 35 had success on their first cycle. Over the course of six cycles (usually over the period of two years), the same study found that the live birth rate was 65.3%.
However, as you age, IVF success rates decrease. According to NHS data, the success rates per embryo transferred are as follows:
- 29% for women under 35
- 23% for women aged 35 to 37
- 15% for women aged 38 to 39
- 9% for women aged 40 to 42
- 3% for women aged 43 to 44
- 2% for women aged over 44
Some women choose to seek the services of an egg donor (or travel to a country where donor eggs are freely available and affordable), but others baulk at the suggestion. Again, this is a personal choice and should be discussed with your partner (if applicable) and your doctor.
The Costs of IVF
Privately funded IVF is expensive, time-consuming, and stressful. Payment options can be through private insurance that covers fertility treatment, financing through dedicated loan or refund packages.
If in the UK, your GP will be able to advise you if one or more cycles of IVF are covered by the NHS in your borough. If not, you will need to pay for private treatment in the UK or travel abroad for more affordable options.
The key message is that before you move forwards and say yes to treatment with a fertility clinic, it’s important for you to do your research
We want you to fully understand that IVF is an accumulative process and no-one can guarantee that you will be successful on your first round. In fact, on average, it can take 3 rounds of IVF to achieve a live birth. So, this is something to bear in mind if you are having to fund your IVF cycles yourself.
Some examples of costs are:
In the USA, the average cycle cost would be around $12,000 and medication costs would be around $7,000.
In the UK, a single cycle of IVF, without any associated costs, would be between £4,000 to £6,000 depending on the clinic.
The cost of a cycle varies from 4,500 to 7,000 euros in Spain.
Private IVF treatment costs between £4000 – £7000 per cycle in the UK, with additional fees for add-ons like ICSI. These estimates do not include the expensive medications, costing between £500 – £2000 per cycle.
Regulating Your Menstrual Cycle (Down Regulation)
Depending on your medical needs and whether you are doing a long or short protocol, you may need to regulate your menstrual cycle during the month before your IVF treatment. This is referred to as down regulation. Down regulation essentially ‘turns off’ your ovaries to better control your egg maturation and ovulation.
To begin down regulation, your doctor will prescribe birth control pills. This can be confusing – after all, you’re trying to get pregnant, why are you taking the pill? But, in some cases, taking birth control can help regulate your menstrual cycle, improve your chances of success and prevent OHSS. Again, your doctor will make the call depending on your specific medical needs.
Your doctor will likely ask you to track your ovulation using pee sticks or basal body temperature monitoring. You’ll let them know as soon as you detect your ovulation, and then you’ll start taking a GnRH antagonist (like Ganirelix) or a GnRH agonist (like Lupron). These medications are usually injectable but can also be delivered via nasal spray. If you don’t ovulate or menstruate regularly on your own, your doctor might also prescribe progesterone tablets, injections, or suppositories/pessaries.
Remember – you might not need to down regulate for your IVF treatment. Your doctor will assess your medical history and test results to determine if you would benefit from down regulation.
Your Next Period – Cycle Day 1
Day 1 of your cycle officially starts on the day you get your period. Even if you’ve started taking oral or injectable medications, Day 1 is when you menstruate. If you notice flow after 5 or 6 pm, your clinic might consider the following day your Day 1 – always ask for their guidance.
On Day 2, you’ll likely undergo blood tests and a transvaginal ultrasound. Don’t be shy or nervous about having this ultrasound during your period, as the doctor and nurses have seen this before, and it’s completely natural. This blood test and scan are your baselines, and will determine if you are ready to progress to egg stimulation.
Stimulating Your Ovaries and Egg Production
If you’ve been assigned a long protocol with down regulation, now it’s time to move on to ovarian stimulation. For anyone doing a short protocol, this is where the treatment begins.
Depending on your treatment protocol, you’ll be prescribed anywhere between one and four shots per day for a week to ten days. Injections can be really intimidating for some people, but watching some YouTube videos can really help you get over your nerves. The needles are very small, and the shots aren’t usually painful. Your clinic will also be able to show you how to do the injections.
Some of the drugs you might inject include:
- GnRH agonist (Lupron)
- GnRH antagonists
Your doctor will continue to monitor your ovaries throughout your treatment, doing scans and bloodwork every few days. They’ll assess the number and size of the follicles growing in your ovaries. Depending on your progress, your doctor may increase or decrease dosages. Once you have at least one follicle between 16 to 18 mm in size, they may want to start seeing you every day. Finally, they will schedule your egg retrieval.
Here are some of the most common complications that can occur during stimulation:
Your follicles aren’t growing
Of course, sometimes things don’t go to plan, and your follicles might not grow. If this happens, your doctor might increase your meds. However, if they still don’t grow, they’ll likely cancel your cycle. This can be devastating but will allow the doctor to make adjustments for your next round.
You’re at risk of OHSS
If your ovaries respond too much, you may be at risk of ovarian hyperstimulation syndrome (OHSS). While mild OHSS can be treated and managed, a severe case can be extremely serious or even fatal. So, if your doctor suspects severe OHSS, they might cancel your trigger shot.
Since pregnancy worsens OHSS, they might also design to retrieve your eggs, create embryos, and then freeze them. Then, once you recover from your symptoms, you can have a frozen embryo transfer (FET).
Some studies show that FETs are more successful than fresh transfers, as they give your body a chance to recover and relax after stimulation.
You ovulate prematurely
In rare cases, your retrieval cycle might be cancelled if you ovulate before your retrieval procedure. If this occurs, you should refrain from having sex, resulting in a dangerous multiple pregnancy. While this might sound desirable, if you get pregnant with six+ eggs, it can be very hazardous to your health.
The Trigger Shot
Now that you have multiple eggs ready for retrieval, it’s time to stop preventing ovulation and instead trigger it with a ‘trigger shot.’ This is an injection of human chorionic gonadotropin (hCG) that triggers your eggs to mature and prepares them for collection. For example, your trigger shot might be Ovitrelle, Novarel, Pregnyl, or Choragon.
The timing of your trigger shot is essential – you will usually be instructed to take it precisely 36 hours before your retrieval procedure. If you take the shot too early, they won’t have matured enough. On the other hand, if you take it too late, the eggs may be too old, preventing fertilization.
Your doctor will usually monitor you with daily ultrasounds as you get closer to your retrieval date in order to determine your eggs are at the perfect stage. They’ll usually recommend you take your trigger shot when you have at least four follicles between 18 to 20 mm in size and blood tests show that your estradiol levels are more than 2,000 pg/ML.14.
The Egg Retrieval Procedure
Next up is your egg retrieval procedure, which usually takes place around 36 hours after you take your trigger shot. The procedure is usually done under general anaesthetic or a similar sedative, so you don’t feel any pain.
Once you are ‘under,’ your doctor will use a transvaginal ultrasound to see the inside of your ovaries and then guide a needle to the correct place to gently ‘aspirate’ (suck gently) the follicle fluid up into the syringe. Everyone gets a different number of eggs – you’ll usually have some estimate going into the procedure from the images on your ultrasounds. The average is 8 to 15 oocytes.
It’s normal to feel cramping when you wake up from your procedure, and your nurses can give you oral painkillers. However, up to 10% of patients experience ovarian hyperstimulation syndrome (OHSS), so you’ll be told what to look out for so you can monitor your health.
If you are using your partner’s sperm, they’ll be asked to provide a fresh sample at roughly the same time as your retrieval.
As you recover from your procedure, the lab technicians will assess the follicles collected for eggs. Sadly, not every follicle contains an egg. The embryologist will evaluate your eggs, and they’ll determine which can move on to the fertilization stage – if they’re too mature, they will likely be discarded. If they’re too young, the embryologist may be able to stimulate them further.
Next, the embryologist ‘washes’ the sperm to separate the sperm cells from the semen, and they’ll select the ‘best’ sperm, placing around 10,000 of them into a petri dish with an egg. If you’re dealing with male factor infertility, they will likely recommend ICSI (pronounced ick-see). With this procedure, the embryologist injects the egg with healthy-looking sperm. Some newer techniques, such as PICSI (physiological intracytoplasmic sperm injection) and MACS (magnetic-activated cell sorting), can help select the best sperm more reliably than by eye.
These culture dishes are then incubated and monitored for fertilization, which occurs within 24 hours. Your clinic will usually keep you updated about your number of fertilized blastocysts a day or two after your retrieval.
Transferring the Embryos
Between three to five days after your retrieval, your embryologist will assess your embryos for health and often give them a grade based on their cell division. At this stage you can undergo a ‘fresh transfer’ with your highest-graded egg. However, if you are recovering from OHSS or you have elected to have your embryos genetically tested with preimplantation genetic diagnosis (PGD) or preimplantation genetic screening (PGS), they will all be frozen for later transfer.
If you’re planning for a fresh transfer after your egg retrieval, you’ll start taking progesterone supplements, either as an oral pill, vaginal gel, pessary, suppository, or an injection in oil. If you’re doing a frozen transfer, your doctor will advise you when to start taking the progesterone. It helps to thicken your uterine lining and prepare for embryo transfer. You’ll continue to take this progesterone until you have a negative pregnancy test or your sixth to twelfth week of pregnancy (your doctor will advise).
Whether you’re doing a frozen or fresh transfer, you’ll undergo a simple procedure that does not require pain medication. It feels very similar to an IUI treatment. During the procedure, the doctor will pass a thin catheter up through your cervix, and the embryo will be transferred into your uterus. Some people choose to transfer more than one embryo at a time. This depends on your age and the quality of the embryos; most doctors will not transfer more than two embryos.
The number of embryos transferred will depend on the quality of the embryos and discussion with your doctor. Depending on your age, anywhere from one to five embryos may be transferred. Transferring two embryos is the most common option, reducing the high risk of a multiple pregnancy.
After the transfer, you can get up immediately and use the toilet. While previous advice stated that you should lay down and rest, this has been debunked. Just avoid strenuous exercise and heavy lifting.
The 2-Week Wait
For many women, the 2-week wait is the most stressful part of the entire process. It can be extremely nerve-wracking to sit and wait, and it makes many women feel helpful. There are plenty of myths and superstitions around foods and rituals to improve your chances of conception, and some women take comfort in participating.
During this time, remember to eat well and prioritize relaxation. Avoid alcohol and drugs, but don’t stress yourself out by trying to be ‘perfect.’ While it’s easier said than done, resist the urge to endlessly Google for signs of conception. As you already know, the signs of early pregnancy can be identical to PMS, so you’ll just drive yourself mad. Try engaging in your favourite hobbies, taking a holiday, and spending time with friends.
Taking A Pregnancy Test
Most doctors will order a blood test around 9 – 12 days after your transfer. They’ll be monitoring your HCG levels and progesterone levels, and you may need to come in for additional tests to confirm your levels are rising. If your test is positive, congratulations! Your doctor will tell you what to do next, which will likely include continuing your progesterone for at least a few more weeks.
Again, resist the urge to take a home pregnancy test, or at least wait a week after your transfer! Many women start testing immediately, which can be highly stressful.
What happens next?
If your pregnancy test is negative, it can be a crushing blow – it’s normal to feel intense grief and disappointment. Seek the services of a counsellor and find an online or in-person support system. In addition, there are plenty of IVF and infertility groups online.
Your doctor will advise you to stop taking your progesterone, and you should get your period within a few days. They’ll also schedule a follow-up call or appointment to discuss what went wrong and what can be adjusted for next time.
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