The different stages of an IVF cycle

Before you begin the IVF process, take some time to read through the different stages of treatment. We know it’s quite a long read, but taking the time, and understanding the process will help you feel in more control. If there is anything you feel unsure about, either drop us a line or speak to your doctor.

Stage One

Once you get your period, give your clinic a call. They will ask you to come into the clinic two days later for some blood tests and your ‘day 3 test’, or baseline scan.

The baseline scan is a transvaginal ultrasound scan that examines your ovaries and will give your doctor a better idea about the quality and quantity of your eggs.

You may also have a scan called a Hysterosalpingogram that will assess your fallopian tubes for blockages, view the uterine cavity to check for polyps, fibroids and scar tissue. During this procedure, a specialist doctor slowly injects a liquid dye into the uterus via the cervix, which shows any blockages up on x-ray fluoroscopy. The test can also help to diagnose PCOS and assess any other risks.

Once you’ve had all the initial tests, and the decision is made that IVF is the right choice for you, you will have a discussion with your consultant, and be given your treatment plan, or IVF Protocol as we call it.

There are a number of different Protocols but the two most common are ‘Long Protocol’ and ‘Short Protocol’. Your consultant will advise which is the best one for you to take. Every plan is different, yours will be based on your age, medical history, cause of infertility and if relevant, your reaction to previous fertility treatment and IVF cycles.

Your consultant will also advise you on the fertility drugs that you will be taking. This can be quite overwhelming at first but your consultant will take you through it all and decide on which will suit you best.

The IVF process can be quite overwhelming, so we always recommend talking to a fertility counsellor. Most clinics have an in-house counsellor who can help you make informed choices, and help you consider what your treatment options may involve, including the emotional and financial stresses of those choices.

Stage Two

If your doctor has decided that the long protocol is your course of action, then this is the stage when you will begin down regulation.

It involves effectively giving your doctor ‘control of your ovaries’. Don’t worry, you’re still in charge!

This simply means they will use medication to suppress your ovaries, using either birth control pills or medication. This medication stops the pituitary gland in your brain from controlling your ovaries and prepares them for external stimulation.

You will take your drugs as injections or a sniffer spray for anywhere between 1-4 weeks. This course of GnRH medication will stop your ovaries actively developing eggs, meaning you will then be fully ‘down regulated’. Though as with everything, it all depends on the individual, timings may vary slightly for you.

We should also mention, that some people experience side effects with GnRH, that are similar to the menopause, such as headaches, hot flushes, night sweats and mood swings. But your doctor will explain everything as you go along.

At the end of your down regulation, you will have a blood test to check that your oestradiol levels are low. You will also further blood tests and scans to make sure your ovaries have down regulated and the lining of your uterus is the correct thickness (approximately 3mm). If all looks good you’re all set to start treatment!

If you have been put on the short protocol, you will skip this down regulation stage. Instead, on day 3 of your period, you’ll have a scan, and then if all looks good you will begin stimulation.

Stage Three

A few days after your period starts you’ll be given FSH (follicle stimulating hormone) in the form of injections. This medication will stimulate the ovaries with the aim of producing and obtaining several mature eggs for retrieval and fertilization, rather than just the one egg that is typically released each month.

‘Inject myself?!’ we hear you cry! We know this may sound daunting, but you’ll be shown exactly how and when to do it by your fertility nurse.

You may experience some bruising at the site of your daily injections, but you can minimise this by choosing a slightly different site each day. You may also notice a tiny bit of bleeding after you’ve injected but this should clear up quickly. It’s not as bad as it sounds though, just take a deep breath and remember why you’re doing it! You can always ask your friend or partner to do it for you.

You’ll need to continue taking your GnRH medication throughout stimulation treatment unless your doctor tells you not to. If you are initially classed as ‘short protocol’ by your doctor, they will prescribe alternative medication, to prevent natural ovulation called an LH antagonist. And this will be administered when stimulation treatment begins.

It does feel like there is so much to remember, what medication to take, when to take it and how. But just keep that diary planner up to date and you’ll be fine. You can also note down if anything needs to be kept in the fridge.

During this stage, as the eggs start to grow, you may feel a little bloated and uncomfortable. The drugs can also cause emotions and mood swings similar to PMS. More seriously, these stimulation drugs can cause a condition called Ovarian Hyper Stimulation Syndrome, or OHSS, where the ovaries are overstimulated and produce too many eggs.

This can cause a mild bloated feeling but in serious cases can cause pain, vomiting and blood clots. Your regular clinic visits should prevent this from happening – if your medical team see any sign of OHSS developing on your blood test or ultrasound results, they will discuss your options with you.

Stage Four

On day five of stimulation treatment, you’ll be given blood and ultrasound tests. These continue every day or two until egg collection

The aim of these tests is for your GP to check follicle size, oestrogen and progesterone levels as well as the thickness of your uterus lining. When all of these are at just the right level and size you’re ready for the all important Trigger Shot.

This can be a really emotional stage of treatment. You’ll hang on to every word your doctor says and be counting follicles in your sleep!

Here are some common questions answered in more detail:

What is the optimum size of a follicle for egg retrieval?

Ideally 18 to 20 millimetres. The larger the follicle, the nearer the egg is ready for collection. As stimulation progresses through the early stages (the first 5 days) the follicles grow more slowly.

Once they reach about 12 to 14mm, they will grow at a rate of around 2mm per day. The average number of follicles is around ten to twelve, but this number can be higher or lower depending upon your age. And not every follicle will have an egg.

How many mature follicles do I need for egg retrieval?
Three to four (18-20mm) follicles.

How thick should the lining of my uterus be?

No less than 7mm. Progesterone given towards the end of the IVF cycle will help to maintain this.

What should my oestrogen levels be?

Every woman is different, but if your oestrogen baseline level on day two to five is 60-150pmol without stimulation, you’re doing just fine. If your oestrogen levels are too high or too low, your doctor will adjust your treatment accordingly. This can mean stopping stimulation if levels are rising too quickly and deferring the Trigger Shot. Retrieving the eggs but delaying embryo transfer until your levels are back to normal. Or in some cases cancel your cycle if you’re deemed at risk from hyper ovarian stimulation syndrome or OHSS.

Stage Five

This is a very exciting moment within the IVF cycle – the trigger shot!

This is the name given to an injection of hCG (human Chorionic Gonadotrophin). This kick starts a cycle of development that enables the egg to mature and loosen from the follicle wall so it can be collected.

You will be told a specific time by your GP when to inject. Timing is crucial so you’ll need to set an alarm!

The trigger shot is given about 36 hours prior to egg retrieval. All cases vary, and your doctor will tell you exactly when the time is right for you. It is SO important you set an alarm at the given time, otherwise you put your whole cycle at risk.

You will also stop all your GnRH analogue or antagonist medication at the same time.

Stage Six

Around 34–40 hours after your Trigger Shot, and just before ovulation, your eggs are collected

A needle, attached to an ultrasound probe, is inserted through the vagina. Eggs are taken from follicles of each ovary and placed into separate test tubes. You’ll have a mild sedative or anaesthetic for this and the whole thing takes no more than twenty minutes.

The next day you will start taking progesterone. This prepares the lining of the uterus to allow a fertilised egg (embryo) to stick. If a pregnancy does not happen this time, you will have your period. This is always tough, but don’t give up. Your doctor will talk everything through with you.

If an embryo implants successfully into the lining of the uterus, the ovary will produce progesterone for eight weeks on its own. Some patients will need progesterone supplements for up to twelve weeks. After this time progesterone will be produced naturally by the placenta throughout the rest of the pregnancy.

Your partner’s sperm is usually collected on the same day or just before your eggs are collected. Your clinic will let you know what to do and when. This will need to be collected at the clinic. This can often be difficult as there’s so much pressure and not a lot of romance!

You may feel a bit bloated and constipated and all the medication can make you feel nauseous following egg collection. This should ease off after a day. It’s also not unusual to experience some stomach or pelvic pain. When you do, you can ease with a hot water bottle or painkillers. Check with your doctor or pharmacist which painkillers are best for you. If the pain is severe or continuous speak to your doctor as soon as possible. There may also be some light bleeding for a few days following egg collection, so wear panty liners. This should be dark red or brown. If it’s bright red or you are bleeding profusely, you must contact your doctor straight away.

Take things really easy for the first 24 hours after surgery, and no heavy work! Get your partner or close friend to stay with you.

Stage Seven

Your precious eggs will now be placed in special fluid and stored in an incubator. They will then be mixed with your partner’s sperm and left for 16 – 20 hours to fertilise

If the sperm count is low or not great quality, you may be offered ICSI (intracytoplasmic sperm injection). This is where the sperm is injected directly into the egg. This can greatly improve the chances of fertilisation.Over the next few days, the fertilised eggs turn into embryos.

An embryologist then carefully cultivates them for up to 6 days. This will maximise their chances as they progress through this critical stage.Embryos advance through several stages. When they reach the last stage, blastocyst (an embryo with a fluid filled cavity), the best embryos will be chosen for transfer.

Stage Eight

The whole IVF cycle now depends on the delicate embryo transfer. This usually takes place on either day 2, 3, 5 or 6 following egg collection and involves placing an embryo (or embryos) through a tube inserted into your vagina and placed near the middle of the uterus

Your age, the number of eggs collected and your clinic’s guidelines will determine how many embryos are transferred.

Any healthy embryos not used can be frozen for future attempts.

The more embryos placed in your womb does increase your chances of becoming pregnant, but there are also more risks. Such as multiple pregnancy and possible health issues. A single embryo transfer (SET) is usually the best way to go, especially at first. But discuss this with the clinic.

Before the transfer, the cervix is swabbed. This may result in a small amount of clear or bloody fluid shortly afterwards. So don’t worry, it’s all perfectly normal.

There is a small risk of infection for a few days, so avoid hot baths and stick to showers.

Should I stay in bed?

You should take things easy for the rest of the day following transfer. But prolonged bed rest has not been proved to be helpful. You can get back to normal work routine the next day. In nature, the embryo floats freely in the endometrial cavity for a number of days before implantation and it is exactly the same in the IVF. Prolonged bed rest is only recommended If there is an increased risk of Ovarian Hyperstimulation, your clinic will let you know what you need to do.

Why is using progesterone during this period important?

Ovaries do not always create enough progesterone naturally during IVF. Which your body needs to support to the lining of the uterus and to help maintain an early pregnancy. In this case your clinic will advise you take progesterone pessaries, or shots for IVF (once-a-night intramuscular injections).

Stage Nine

The Two Week Wait. This is often considered to be the hardest part. An agonising fourteen days while you patiently wait to see if IVF has been a success, and that you’re finally pregnant

There’s very little to be done, try not to worry. Just take it easy, relax and let your body do its thing. You should avoid sex for two weeks, but no need to worry about moving around too much or lie in bed all day.

We know it’s tough, but avoid the temptation to take a pregnancy test too early! Wait until day 12. The hormones will probably give you a false positive result. Your clinic may also get you to provide a urine sample to check your hormone levels.

You may experience mild cramps and some pelvic discomfort but that’s normal. Any spotting that occurs midway through the two week wait may be caused by the embryo implanting itself into the uterine wall. It’s probably best not to travel abroad so that you can stay in touch with the clinic if you have any concerns.

Stage Ten

12 to 14 days after the IVF embryo transfer you should get a blood pregnancy test, carried out by your doctor. This will give you the most accurate and reliable result

If you test positive, then fantastic, you now begin the next phase of this incredible journey – being pregnant!

If the result is negative, give your clinic a call to book a follow up appointment. Your doctor will discuss the result with you and a new plan of action. Ask to speak to the fertility counsellor too.