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What are the Steps of the IVF Process?

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The IVF cycle entails multiple steps, and each step takes place at a specific time during a 6-week period. The IVF procedure is based on the following steps: (1) preparation for treatment, (2) induction of ovulation, (3) egg retrieval and (4) embryo transfer. If your IVF cycle will involve the use of Preimplantation Genetic Diagnosis (PGD), we will need to document that the necessary screening laboratory studies have been completed by the reference lab. The process starts about the time of ovulation in the month prior to the IVF cycle. Each patient will receive a personal calendar with her individual schedule, and the nurse will carefully review the plan and answer any questions you may have.

Cycle Preceeding ART (Assisted Reproductive Technology) Cycle

  • Initiation of oral contraceptives
  • Initiation of Lupron

Step 1: Initiation of Oral Contraceptives

We may use birth control pills starting on day 3 of your cycle. There are 2 main reasons for taking birth control pills prior to your IVF cycle. First, taking birth control pills prior to a stimulation cycle may help the ovaries respond better to the stimulation medication. Second, taking birth control pills allows flexibility in coordinating your cycle, so that procedures can be planned around your work schedule, trips and when all the necessary professionals are available. Please note that many patients experience “breakthrough bleeding” when taking birth control pills. This is normal. Please continue taking the birth control pills daily regardless of the bleeding. Plan to be on birth control pills a minimum of 2 weeks.

Step 2: Baseline Pelvic Ultrasound

At the time of your expected period, we will perform a blood test to check your estradiol level, and an ultrasound to examine the ovaries.

Step 3: Ovarian Stimulation

ultrasound-150x150If the baseline ultrasound shows no significant cysts, we start ovarian stimulation after menstrual bleeding begins. Ovarian stimulation medications are preparations of naturally occurring hormones, which are used to develop and mature multiple follicles by directly stimulating the ovaries. Gonal-F and Follistim are the brand names for a group of medications known as gonadotropins which contain only FSH (follicle stimulating hormone). Repronex and Menopur are the brand names for another group of medications known as human menopausal gonadotropins containing both FSH and LH (luteinizing hormone). Many protocols use a combination of both medications.

Typically the injections are given daily for 8-12 days, depending on how your body responds to the medications. The average number of eggs retrieved at IVF is between 8 and 15. Please remember that it is the quality of the eggs, not the quantity that is important.

Step 4: Monitoring of Follicle Development and Estradiol Levels

Transvaginal ultrasound examination takes between 5-20 minutes to perform. It provides valuable feedback for monitoring follicular growth and determining when the follicles are mature and ready for retrieval. Ultrasound monitoring is performed in the Frisco, Dallas and Grapevine offices 8-10:30 AM weekdays and as needed in the Frisco office on weekends.

We correlate the estradiol levels in your blood with the ultrasound results frequently during the IVF cycle to ensure that you are taking the proper dosage of medication. We may adjust the dose of medication to improve follicular development. The amount of medication prescribed depends upon the results of the blood tests and ultrasound exams. The lab results are not available until 2 pm, so we must have a number where we can reach you the same day you have your ultrasound monitoring. You will receive a call from our IVF nurse coordinator as well as written instructions through our portal detailing the exact dose of your medications. Our goal is to make this process as easy and seamless as possible, and we have found that patients like to have written documentation of medication dosage. If you have not heard from the IVF nurse coordinator by 4:30 pm, either by phone or email, you should call our office.

Step 5: Final Oocyte Maturation and HCG Administration

Human chorionic gonadotropin (HCG) is a drug that stimulates the final maturation of the eggs. If it is given too early, few, if any, oocytes will be mature. If it is given too late, the eggs within the follicles may be post-mature and will not fertilize. HCG needs to be given 36 hours prior to the egg retrieval; when we schedule your retrieval, we will notify you of the time that HCG is to be given.

Step 6: Transvaginal Oocyte Retrieval

The Transvaginal Oocyte Retrieval is an in-office procedure performed in our state-of-the-art IVF center in Frisco and is performed 36 hours after taking Ovidrel. You should arrive 1 hour prior to your scheduled procedure time. You will be called the evening prior to the procedure by the anesthesiologist. During the call, he will discuss your medical history, complete a preoperative evaluation, and answer any questions you may have.

During the retrieval, the anesthesiologist administers intravenous medications (pain relievers and sedatives) in order to minimize the discomfort that may occur. The egg retrieval is performed via vaginal ultrasound (similar to the ultrasound used for monitoring your follicles during your stimulation). Once you are comfortable and relaxed, a tip of a thin needle is passed through the top of the vagina and into the cul-de-sac (space behind the uterus). The ovaries are located near the bottom of the cul-de-sac allowing the tip of the aspirating needle to enter the ovarian follicles and aspirate the follicular fluid from them.

The egg retrieval takes 5-10 minutes. Sometimes there are ovarian cysts that contain no eggs but appear identical to follicles that do contain eggs. Also, follicles of smaller size may not yield eggs. The number of follicles seen with ultrasound, therefore, may not correspond to the number of eggs retrieved. Ultrasound provides only an approximation of the number of oocytes that one can expect to recover.

Step 7: Insemination of Oocytes

Later, the sperm is prepared and placed with the eggs. In some cases, the embryologist will need to identify normal, motile sperm and inject them individually directly into each egg. This procedure is called Intracytoplasmic Sperm Injection (ICSI). Once the eggs are inseminated or placed with the sperm, they are placed into an incubator overnight.

Semen samples for use in IVF procedures will be required on the day of egg retrieval and should be collected at the andrology lab at Fertility Specialists of Texas. On rare occasions, the laboratory staff may request a second semen sample. The specimen should be obtained by masturbation after 3-5 days of abstinence. More than 5 days of abstinence is NOT recommended. It is important not to use any lotions or lubricants for sperm production as it may harm sperm motility. If you anticipate any collection difficulties, please notify your IVF coordinator prior to the procedure so we may have your husband cryopreserve semen before the day of the actual procedure.

 

Watch. Learn. Know.

A normal 2-PN embryo on Day 1. Normal fertilization is characterized by a pronucleus of the egg and sperm that can be visualized under a microscope.

 

Blastocyst embryos on Day 5. This patient had multiples embryos to freeze on day 5, however, in general, 15-20% of patients have embryos that meet criteria to be cryopreserved on Day 5 in our program.

Step 9: Embryo Transfer

The embryo transfer (ET) is usually performed 3 days or 5 days after the oocyte retrieval. Alternatively, there is increasing evidence to suggest that success rates are improved if the embryo transfer is delayed 1 month to reduce the risk of ovarian stimulation and improve receptivity of the uterus.

Once you, the embryologist and physician, have confirmed the plan for the embryo transfer, the physician will insert a speculum. An abdominal ultrasound will be used to visualize the uterine cavity. The embryologist will load the embryos into a small catheter which is then gently inserted through the cervical opening into the uterus, and the embryos are placed into the uterine cavity along with a very small amount of fluid. The catheter is then carefully removed.

You will be called the day before the embryo transfer and given a specific time. It is very important to have a full bladder before the embryo transfer. The procedure takes 10-15 minutes and is very similar to the uterine measurement taken at your baseline appointment. You will need to arrive at our Frisco facility with a full bladder as the physicians perform all embryo transfers under ultrasound guidance. Please arrive at our Frisco office 30 minutes prior to scheduled transfer time.

Embryo transfers are typically scheduled between Noon and 2 pm on weekdays, and 9 am-Noon on weekends. You will not need anesthesia on this day, so there is no need to abstain from eating or drinking before your ET. Both you and your partner will be able to see the embryos actually go inside the uterus under ultrasound guidance. We ask that you do not apply perfume or scented lotions on the day of your embryo transfer.

Following the ET you will remain lying down for approximately 1 hour, then we advise you to rest at home for at least 24 hours. You must have someone accompany you and drive you home.

Step 10: Progesterone Supplementation

You will take progesterone injections beginning the evening after the oocyte retrieval and continue daily until your serum pregnancy test.  If pregnant, progesterone will be administered for a total of 12 weeks. Ordinarily, the granulosa cells in the follicle will produce progesterone following ovulation, but some of these cells are removed during the oocyte retrieval. Therefore, supplemental progesterone is needed to help maintain the uterine lining for implantation.

Progesterone is a hormone normally produced by the ovarian corpus luteum during the last 2 weeks of the menstrual cycle and during early pregnancy. After the seventh or eighth week of pregnancy, the placenta takes over progesterone production. Natural progesterone is prescribed in many fertility treatments for luteal phase support of implantation and early pregnancy. Natural progesterone is also prescribed to support the luteal phase for patients in virtually every IVF program today. The progesterone prescribed is derived from natural sources and is identical to that produced in the body.

Do NOT discontinue your progesterone until directed by our office.

Step 11: Pregnancy Follow-up

Please call our office after the embryo transfer to schedule your pregnancy test 14 days after the egg retrieval. The pregnancy test is obtained before 10 am and the results will be called to you the same afternoon. Positive tests are repeated in 1 week, and a sonogram will be scheduled. Once we document a heartbeat on the sonogram, we will return your care back to your obstetrician. If your pregnancy test is negative, we ask that you schedule a follow-up visit to review your cycle and discuss options.

 

FAQs

What are possible reasons for cycle cancellation?

  • The follicles are not developing properly.
  • An inadequate blood estrogen level.
  • Excessive estradiol level, indicating an increased risk for ovarian hyperstimulation.
  • Less than 5 maturing follicles seen on ultrasound.
  • If a cycle is canceled, medication may be modified in subsequent cycles in an attempt to improve your response.

What are the side effects of gonadotropins?

  • Multiple Births: While most multiple pregnancies are twins, some are composed of triplets or more. High-order multiple gestation pregnancies are associated with increased risk of pregnancy loss, premature delivery, infant abnormalities, handicaps due to the consequences of a very premature delivery, pregnancy-induced hypertension, hemorrhage and other significant maternal complications.

 

  • Ovarian Hyperstimulation Syndrome (OHSS): OHSS is uncommon, occurring in only 1-5% of cycles and is more frequently seen in women who have been diagnosed with Polycystic Ovarian Syndrome (PCOS). It is characterized by rather sudden ovarian enlargement and abdominal fluid retention. If your monitoring indicates that you may develop hyperstimulation, we will bring this to your attention as soon as possible. Treatments most likely will consist of bed rest and careful monitoring of fluid levels. Hyperstimulation may be aggravated if pregnancy does occur. In such cases, we may either cancel the cycle or proceed with the egg retrieval but then cryopreserve (freeze) all embryos and transfer a month or 2 later.

In severe cases, OHSS can result in kidney damage, blood clots, ovarian twisting and chest and abdominal fluid collections. During these times hospitalization may be required, usually for monitoring purposes, although a surgical procedure may be called for in some instances.

I had my tubes tied (tubal ligation) a few years ago. Should I have a tubal reversal or IVF?

Depending on the method of tubal ligation, you may or may not be able to have a tubal reversal. Factors such as the age of the woman or in couples with male factor infertility become important considerations in determining whether tubal reversal is reasonable. If tubal ligation reversal has been attempted and was unsuccessful, then IVF-ET represents the best option.

Is there a possibility of multiple births from ART?

Yes, any time more than one embryo is transferred, there is a chance for multiple pregnancies. It appears that the rate of twin births is greater than in the normal population (1 in 80). We follow the guidelines established by the American Society of Reproductive Medicine (ASRM) regarding the number of embryo’s to transfer.

 

twin pregnancy scan

 

singleton OB scan

 

Is there an increased risk of birth defects if I become pregnant through ART?

Recent studies suggest there is an increased risk of birth defects among patients who conceive through IVF compared to patients without fertility issues. What is unclear is whether or not patients who have infertility have an inherent increased risk of conceiving babies with birth defects or if the increased risk is due to the ART procedures themselves. Research is ongoing to clarify these issues. When comparing groups of infertile patients who conceive with ART to infertile patients who conceive spontaneously, there appears to only be an increased risk of birth defects for those patients using intracytoplasmic sperm injection (ICSI), and those defects are still quite rare.

Can we have intercourse while taking the hormone medications?

Yes. However, it is recommended that the male abstains from ejaculating for 3-5 days preceding the egg retrieval. This precaution assures that the semen sample on the day of egg retrieval contains the maximum number of motile sperm. You may find that near the time of egg retrieval your ovaries will be markedly enlarged and tender, possibly making intercourse very uncomfortable.

Are activity restrictions recommended during my stimulation?

As your ovaries begin to stimulate, they will become enlarged and tender. Limited activity reduces the risk of ovarian torsion and/or rupturing the follicles on the ovaries. As a general rule, it is advised that you stop any activity that involves bouncing, or jarring the pelvis by the time you are returning for your first ultrasound to monitor your stimulation.

What if I ovulate before the retrieval?

On the day of the egg retrieval, a vaginal ultrasound will confirm that the follicles are still intact. If they are, it can be assumed that ovulation has not occurred, and oocyte retrieval will be attempted. The medications Lupron, Antagon, or Cetrotide also help to assure that ovulation does not occur before egg retrieval has been performed.

How much activity is recommended after Embryo Transfer (ET)?

Strenuous exercises, like running or heavy lifting, etc. should be avoided until a pregnancy test has been performed.

If an embryo transfer takes place, how long should we wait until we have intercourse without risk to the embryo?

Nobody really knows for sure if intercourse aids or impedes implantation. Theoretically, uterine contractions result from intercourse, so to be safe, we advise abstaining from intercourse until after the pregnancy test.

Can I have a glass of wine or alcohol during the cycle up until the pregnancy test?

No alcohol should be consumed after the procedure.

Can I travel more than 4-6 hours in a car after my transfer or fly in a plane?

Yes, but extended travel is not recommended until the day after the transfer.

Immunizations/Injections

The following list of immunizations or injections are OK during a cycle:

  • Flu shot
  • Hepatitis vaccine
  • Chicken Pox immunoglobulin
  • TB test
  • Tetanus shot
  • Allergy shots
  • Novocaine (dental procedures)

Medications

The following list of medications are OK to take before or after embryo transfer:

  • Cold medications (Sudafed, Robitussin)
  • Amoxicillin, Ampicillin, Erythromycin
  • Bactrim – OK before pregnancy test
  • Flagyl – OK before pregnancy test
  • Nasal spray decongestants
  • Tylenol Cold or PM
  • Claritin D
  • Benadryl
  • MOM, Colace, Senekot, Immodium, Pepcid
  • Headache meds: Fioricet, Fiorinal

Do NOT take the following medications:

  • Echinacea
  • St. John’s Wort
  • Gingko Biloba