Words by CNY Fertility 

In Vitro Fertilization (IVF) is a beast and a blessing. A beast in that it is truly a grueling process. A beauty in that it is the single greatest family building technology every created and offers the highest per-cycle success rates of any Assisted Reproductive Technology (ART)  or natural remedy. Since its first successful attempt in 1978, new techniques have continued to evolve and as a result, around 2% of the nearly 4 million births per year in the US are via IVF.

Because of IVF’s importance in the world of fertility treatments it’s a good idea to know as much as possible about the treatment including the cost, how it works to solve infertility, and of course the process when undergoing IVF treatment.

As many of you know from my IVF journey, I’ve been through the IVF process quite a few times. But even for seasoned veterans, each time you go through IVF, your body responds a little differently; you don’t feel the same, but you’re filled with the same incredible hope of bringing home a child. And with my support and guidance on your path to parenthood, you can make IVF your new BFF.

 

But that’s not to say you shouldn’t know about the treatment process itself so let’s dive on in and start learning!

IVF Process Overview

In the simplest terms, IVF removes eggs from the intended parent, fertilizes the eggs outside the body, and places the fertilized egg (now an embryo) into the uterus of the mother (or carrier). 

To better understand the process, we are going to break the IVF treatment into four distinct sections:

  • ovarian stimulation: medications are taken to stimulate the growth of many eggs
  • egg retrieval: a relatively minor surgery to remove the eggs from the ovaries
  • fertilization & development: the eggs are fertilized and developed inside the embryology/IVF lab
  • embryo transfer: the embryos are placed back inside the womb

Now that we have a high level overview, let’s take a closer look at each stage of the IVF process.

Step One:  Ovarian Stimulation

At the start of your cycle (around days 2-4), you’ll have an initial or “baseline” appointment to measure the lining of your uterus, the size of your follicles, and various hormone levels to establish a starting point for each.  You’ll then begin taking injectable medications (namely FSH and LH) to stimulate your ovaries in the hopes of producing a large number of mature eggs. You’ll give yourself these daily injections for approximately 10 days. 

Around the 6th day of FSH injections, you’ll begin taking another medication to prevent early ovulation as we actually don’t want the eggs to be release with IVF.

Every few days during the ovarian stimulation phase of IVF, you’ll need to see your doctor for monitoring appointments to track the thickness of your uterine lining and monitor follicle development as well as draw blood to review levels of several different hormones.  Around day 8-10, when your doctor looks at your egg-containing follicles under ultrasound and determines they’ve reached the appropriate size, the first two medications will be stopped, and a third medication (the trigger) is taken for either one or two days to promote the final maturation of the eggs.

Pro Tip – Treatment Variation:  During the stimulation phase, different medication protocols may be utilized, but an antagonist protocol as described above is the far and away the most common. Mini IVF, short for minimal stimulation IVF, is a common and subtle variation of a standard antagonist protocol in which fewer medications are used to stimulate the ovaries. This generally allows the woman to produce a small number of high-quality eggs while substantially reducing the risk of hyperstimulation and the overall cost of IVF as medications makeup a substantial portion of the total cost.

Step Two:  Egg Retrieval & Sperm Collection

The egg retrieval is scheduled for 35 hours after the first “trigger” shot so that your doctor can collect your eggs.  This is a minor outpatient procedure. Under light anesthesia for your comfort, the mature eggs are removed from your ovaries by a physician (usually a reproductive endocrinologist) using a tiny hollow needle to pierce through the vaginal wall and drain the fluid from the follicles (think a blood draw). This fluid contains the eggs. The retrieval itself only lasts around 5- 15 minutes.

The follicular fluid is immediately brought to the IVF laboratory where an embryologist will isolate and nurture the eggs in an environment similar to the fallopian tubes (where fertilization occurs naturally). How many eggs are ultimately retrieved depends on your age, medical history, fertility diagnosis, medication type and dosage used, and how your body responds to the medications you’re taking.

If a male partner is providing fresh sperm, on the morning of egg retrieval, he will be instructed to ejaculate into a sterile cup. Sperm may also be collected beforehand, frozen, and then thawed. The sperm are washed, concentrated, and suspended in a solution, then transferred to the embryology lab.

Pro Tip – If the man has no sperm:  Sperm can also be provided by a donor or surgically retrieved from the man if there is no sperm present in his ejaculate. 

Step Three:  Fertilization & Embryo Development in the Laboratory

Fertilization:  After retrieval, eggs need 4-6 hours to reach their final stage of maturity.  Once this occurs, the eggs can be fertilized with sperm.  The two fertilization methods used in IVF are:  

Conventional IVF:  Many sperm are combined with the eggs in a Petri dish and stored in an incubator for about 18 hours to allow them to fertilize “naturally” on their own.

 

Intracystoplasmic Sperm Injection: During ICSI, an embryologist injects a single sperm directly into each egg.

Embryo Development:  Once fertilized, the embryos continue to grow in the IVF laboratory for 3-7 days or until they reach a cleavage or blastocyst. At this stage, viable embryos must be transferred into the carrier’s uterus and/or frozen for a future frozen embryo transfer (FET). An embryologist will continue to regularly monitor each embryo for progressive development.

It’s important to understand that during IVF, there is constant attrition in the number of viable options. Here’s a pretty typical IVF scenario: 15 eggs were successfully retrieved, but only ten were fully mature and able to be fertilized. Of those ten that were attempted to be fertilized, only eight successfully fertilized. Out of the eight embryos, only 6 made it to the cleavage stage. Of those six cleavage stage embryos, only 4 made it to the blastocyst stage. This attrition is why producing additional eggs during ovarian stimulation provides most women with a better chance of conceiving.

Pro Tip- Laboratory Alternative:  If the idea of a laboratory being in control of the fertilization and early embryo development process – one that naturally occurs in a woman’s body- is problematic for you, there is another option available in place of IVF. INVOCELL® is an IVF alternative that uses a unique device (about the size of a thumb) that allows egg and sperm to fertilize and develop within a woman’s body.  The process of using INVOCELL® is nearly identical to conventional IVF, only fertilization and early embryo development happen inside the INVOCELL® device (instead of in an embryology lab) Just before embryo transfer, the device is removed, and the embryo is transferred to the carrier’s uterus.

Step Four:  Embryo Transfer

The embryo transfer itself is a quick treatment stage, but one typically prepares for the transfer by taking estrogen and progesterone for a number of days before the actual transfer.

Anesthesia is rarely if ever necessary for the embryo transfer, but your doctor may suggest a muscle relaxer or Valium to help you stay relaxed. Embryo transfer happens on day 3, day 5, or during a future cycle using a frozen embryo.

For best results, any IVF cycle’s goal is to always transfer the highest-quality embryo(s) to provide the best chance of reproductive success. Your doctor will help determine the best timing for your cycle based on your uterine lining, hormone levels, and embryo development.  Embryos that are further developed have a higher probability of being genetically normal and resulting in live births than earlier stage cleavage embryos. And most clinics will only perform genetic testing on blastocyst stage embryos. While genetic testing isn’t recommended for all parents, it may be beneficial in reducing the odds of miscarriage, avoiding known genetic disorders, and even allowing parents to choose the sex of their child.  However, if you have fewer eggs, your doctor may recommend transferring a cleavage stage embryo.

During the transfer, your doctor will use a catheter containing the embryo(s) to go through the vagina and cervix and into the uterus. He or she will do this using ultrasound to guide the process. The embryo is then gently deposited into the uterus. After the transfer the catheter is then visualized under a microscope to ensure the embryo was indeed expelled.

Pro Tip – Treatment Variation:  While embryos are traditionally transferred back into the woman who underwent the ovarian stimulation and egg retrieval, there are a number of instances in which the embryo is transferred to another person. Donor Egg IVF uses eggs from a known or anonymous woman (typically much younger than the intended parent). Reciprocal IVF is a unique option for Lesbian women and trans men that allows for both partners to be biologically involved in the child creation process (one partner provides the egg, which is then transferred to the uterus of the other partner to carry). Similarly, Egg Freezing follows a similar process to IVF only there is a (typically) long pause between the egg retrieval and when the eggs are frozen and transferred.

Supporting Your Pregnancy After IVF:  While the process of IVF technically ends with the embryo transfer, most patients continue to take medications to support embryo development. A pregnancy test is usually done two weeks after the egg retrieval and if pregnant, continue to take the medications and are monitored by their fertility doctor for several weeks before being released to their regular OBGYN for prenatal care.

Wrap Up:  IVF is no walk in the park for anyone.  The hormones, injections, monitoring appointments, and constant worrying about whether everything will work in your favor tests even the strongest relationships.  There are so many details to follow and choices to be made throughout the process. A good fertility doctor is essential, along with helpful nurses and financial counselors, and the right support (whether its friends, family, or others who have been through it before) can give you the extra boost you need as you work toward growing your family using IVF or other fertility treatments.

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