Detailed Explanation of IVF
Ovarian Stimulation - This is the stage where I am at right now...
An IVF treatment cycle begins with the onset of a menstrual period. A week before the beginning of the next period a medication called Lupron is administered. Lupron prevents premature release of eggs from the ovaries. Lupron is a very small daily subcutaneous injection given just under the skin. Any part of the body can be used for these shots and the woman or her partner can administer them. Lupron is given daily for about three to four weeks. Because estrogen levels are low, side effects may include fluid retention, headaches or hot flashes.
About a week after taking Lupron your period will start. From this point on, Lupron will keep you hormonally “frozen” in that normal egg production is put on hold. A few days to a week from the start of your period, hMG injections will be taken along with the Lupron injections. Follistim, Gonal-F, Fertinex, Perganol, Repronex and Humegon are all collectively known as hMG, but you will only be injecting one of these medications. Lupron puts your ovaries on “hold,” – that is, prevents them from releasing the eggs before we are ready to collect them. At the same time, HMG stimulates development and maturation of multiple eggs in the ovaries. The objective of this medication protocol is to produce as many eggs as possible in a given cycle, and “tell” the ovaries to hold them until we are ready to collect them. On average, about 6 to 12 eggs develop.
Before starting HMG injections, an ultrasound will be made of your ovaries to check that no cysts or large follicles exist. Injections in the form of Follistim, Gonal-F or Fertinex are shallow injections whereas Pergonal, Repronex and Humegon are deeper injections. Some side effects may occur with hMG injections, such as abdominal bloating, weight gain due to fluid retention and pelvic or abdominal discomfort or both. These are signs of ovarian hyperstimulation and usually do not require any treatment. It is rare for a woman to be hospitalized for severe symptoms.
You will be taking Lupron and hMG injections every day for about ten days. During these ten days your progress will be monitored with ultrasound and possibly estradiol blood tests. Since the eggs are microscopic, they cannot be seen on ultrasound. However, we can see when the eggs are mature from the size of the ovarian follicles, or the fluid filled sacs within the ovaries that contain the eggs. These monitoring visits are brief and usually done in the morning
Once the eggs are almost mature you will stop taking the Lupron and hMG. You will then take a single injection of hCG hormone. This medication triggers the final stages of egg maturation. The eggs are nonsurgically removed from the ovaries 36 hours after the hCG injection. You should not have intercourse during the time between the hCG injection and egg retrieval.
Egg retrieval is an office procedure during which partners are invited to be present. Using ultrasound as a guide, a thin needle is passed through the top of the vagina and into the ovarian follicles. This nonsurgical procedure is possible because the ovaries are located directly next to the vagina. The needle enters the follicles and removes the follicular fluid which contains the eggs. The fluid is then examined under a microscope to identify the eggs.
Egg retrieval can take anywhere from 15 to 45 minutes. Medications are used to relieve the pain of the needle, but many women cannot feel the eggs and follicular fluid being drawn. Most likely, you will feel a short menstrual-like cramp when the needle is passed through the top of the vagina – once for each ovary. Because of the pain medications you will receive that day, you should not drive. Egg retrieval is a very safe procedure and serious complications are rare.
The number of eggs retrieved will depend upon your age and response to hMG. But on average, 6 to 12 eggs are developed. As soon as the eggs are identified under the microscope, they are placed in petri dishes which contain a culture medium. The prepared culture medium is a composition that so closely resembles your own body’s fallopian tube secretion that the eggs, and subsequently the embryos, will develop in the petri dish just as they would in your body. The dishes are kept in an incubator at a constant temperature of 37ºC, 100% humidity and 5% CO2 concentration.
At the time of egg retrieval, the male partner will collect his sperm into a clean cup. The semen is then washed and processed to remove the seminal fluid to get the highest quality sperm possible. It takes about four to six hours after retrieval for the eggs to finally mature to the point that they are ready for insemination. Traditionally, sperm has been added to each dish containing the eggs and letting nature take its course by fertilizating overnight. However, we are using ICSI even in normal cases to ensure that the best eggs are indeed fertilized. The fertilized eggs, now called embryos, continue to grow in the IVF laboratory. In three to five days, you will return for embryo transfer.
Intracytoplasmic sperm injection (ICSI) is a micromanipulation procedure developed to help couples with male factor infertility or previous low or failed fertilization. ICSI involves using a powerful microscope and an extremely small glass needle to physically inject a single sperm into the center of the woman’s egg. After egg retrieval, the eggs which are most likely to be successful ICSI candidates are chosen. While holding the egg in place, the glass needle containing the single sperm is inserted into the egg and the sperm is injected directly into the cytoplasm, thereby fertilizing the egg.
Dr. Kiltz along with the embryologist will examine the embryos before transfer to determine the likelihood that any given embryo will implant. The quality of the embryos is very important. Several other factors may determine how many embryos will be transferred, such as your age, how many years you have been infertile and previous IVF cycles. Most couples with an average embryo quality usually select between two or three embryos to transfer. Generally, the pregnancy rate increases as more embryos are transferred, but so does the chance for multiple pregnancies. These issues will be discussed prior to your embryo transfer.
The actual transfer is a brief procedure. The embryos are “loaded” into the tip of a catheter along with a very small amount of transfer medium. The catheter is then gently passed through the cervical canal and into the uterus. Usually, you never feel this. The embryos are slowly expelled near the top of the uterus. This transfer only takes a few seconds. No rest period is required after transfer and you can go back to your normal routine right away.
To help your body prepare itself for the embryos, you will be given daily progesterone to supplement your own. This additional progesterone starts the day after egg retrieval and continues for at least two weeks. Progesterone is a hormone which transforms the lining of the uterus to be an ideal receptor for the embryos.
After the embryo transfer, it’s now up to nature. The front and back walls of the uterus gently squeeze the embryos and keeps them in the uterine cavity. Your embryos cannot fall out, so there is no need to restrict physical or sexual activity. Even so, it might be wise to wait a few days before beginning any strenuous activity.
About two weeks after transfer, a blood test will be performed to determine if you are pregnant. This can be done at any lab of your choice. Your results should be available the same day. If the pregnancy test is positive, an ultrasound will be scheduled two weeks later to determine the implantation site and often detects a heartbeat. The heartbeat should be seen by four weeks after a positive pregnancy test. At this time, you will be given instructions regarding progesterone or other medication use.
Once a heartbeat is detected, there is a 90-95% probability that the pregnancy will continue to a live birth. There is only a 5-10% chance of miscarriage. IVF pregnancies are no higher a risk than natural pregnancies. At about 12 weeks into your pregnancy, you can return to your obstetrician for routine prenatal care.
If the pregnancy test comes back negative, you can stop the progesterone. Your period should start in a few days. You can begin another IVF cycle after one spontaneous menstrual cycle. Waiting will give your ovaries time to rest from the previous IVF treatment. There are several factors to consider before deciding on how many IVF cycles you may try before moving on to other treatments. These factors include your response, age, previous IVF cycles and the number of years you have been infertile. Just because you may not become pregnant after one, two or even three tries, does not automatically mean your chances of becoming pregnant are slim.
A Typical IVF Calendar (based on 28-day menstrual cycle)