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What happens with IVF?
After a patient or couple have completed an initial workup and evaluation and IVF is chosen as the treatment by the patients with their doctor then:
- Both partners undergo the final FDA required screening tests and sign consent forms and select the global or the insurance plan for payment of care.
- The woman receives conditioning medications to prepare the ovaries and then to stimulate the development of multiple follicles (egg-containing structures) in the ovaries. The injection phase can continue for about 8-12 days until the eggs are ripe. The entre preparation and stimulation can be up to 6 weeks depending on individual stimulations and kinds of cycles recommended.
- Blood and ultrasound testing is done every 1-3 days during injections to monitor the developing follicles.
- When the follicles have matured, the eggs will be removed using a transvaginal ultrasound procedure under sedation.
- The eggs are then fertilized in the laboratory with the woman's partner's sperm. If the sperm are poor quality or there has been poor or failed fertilization in the past, the IntraCytoplasmic Sperm Injection procedure might be used to assist fertilization.
- The embryos are cultured in the laboratory for 2-5 days.
- On the final day of culture, the embryos are placed in the woman's uterus where they will hopefully implant and grow.
- If there are additional embryos (of good quality) beyond the number transferred, they can be frozen for use in a future cycle. A frozen IVF cycle is substantially easier and less expensive than a new cycle.
What happens in the lab?
On the day the eggs are retrieved:
- The eggs are carefully placed into a previously prepared culture dish to mature until the sperm is added.
- These dishes are placed in a portion of the incubator designated for the specific patient.
- A physician or embryologist will meet with the partner, verify his identity and then show him to the collection room.
- When the sperm specimen is returned to the lab, a mini semen analysis is performed and the sperm is "washed" to remove any dead sperm
- If donor sperm is being used, the specimen number will be verified with the patient having the retrieval and her partner and the sperm will be thawed according to the fertilization protocol.
- Later in the day, the sperm and eggs are combined in the petri dish. Each consecutive day, the embryos are carefully checked for their rate of development.
On the morning of embryo transfer:
- The embryos are again carefully checked for their rate of development and prepared for either transfer into the uterus or freezing for future use, depending on the patient's wishes.
- Prior to the embryo transfer, the physician will discuss with the patient the quality of the embryos, the number to be transferred and the number to be frozen. We strongly recommend single embryo transfer in most cases, but the embryo number is an individualized decision.
- The embryo(s) are carefully loaded into an embryo transfer catheter by the embryologist and handed to the physician.
- The embryos are then placed into the uterus, using the catheter while watch with an abdominal ultrasound to confirm placement in the correct location in the uterus.
- Once the embryos are placed into the uterus the catheter is handed back to the laboratory personnel and the transfer of the embryos is confirmed.
Steps in the IVF Process
IVF (In Vitro Fertilization) is the process of removing eggs from a woman’s body, fertilizing them in a lab dish (‘in vitro’ means ‘in glass’) before transferring the resulting embryos back to the uterus.
Controlled Ovarian Stimulation
In a normal menstrual cycle, hormones stimulate the ovaries release one egg each month. In an IVF cycle, your doctor will prescribe medications that encourage your ovaries to produce several eggs.
Medications can include:
- Leuprolide acetate (Lupron) – a man-made hormone that effectively shuts down the normal menstrual cycle. Lupron works by blocking the release of hormones than control the menstrual cycle. This allows for better control of the ovarian stimulation, and also prevents early release of the eggs.
- GnRH Antagonists (Antagon) – Antagon is used as an alternative to Lupron. This drug inhibits ovulation from occurring prior to egg retrieval and is begun when the follicles reach a certain size.
- Gonadotropins – FSH and LH, are hormones that stimulate follicular development. They are injected daily during the stimulation phase of your cycle. The goal is to produce multiple eggs that can be retrieved and then fertilized via IVF.
The IVF team will closely monitor you during your IVF cycle with blood tests and ultrasounds. When it is determined that you are ready, you will give yourself a final injection of chorionic gonadotropin (hCG) to mimic a natural body process that finalize the development of the eggs and prepares them for retrieval.
- Ultrasound – This provides an image of the number of eggs developing and the rate of development. Ultrasounds will be performed frequently once gonadotropins are started until the day of egg retrieval.
- Blood tests – Estrogen measurements take place at your baseline ultrasound, and frequently throughout the time you are taking gonadotropins. This measurement, combined with the ultrasound results, will inform the doctors’ decisions about your medication dose and timing of your egg retrieval.
The egg retrieval is performed using a needle guided by a trans-vaginal ultrasound. The patient is sedated with IV medication during the procedure. Once the probe is lined up with the follicle, the needle is inserted and gentle suction is applied to remove the fluid containing the egg which goes into a test tube and is transported to the embryologist in the next room. This procedure continues until all eggs have been removed. As the patient recovers from the procedure, lab personnel will identify the eggs and prepare for fertilization.
In Vitro Fertilization (IVF)
After the eggs are retrieved, they are combined with sperm in lab dishes. The dishes are kept in an incubator to control the temperature, humidity, and atmosphere. Fertilization will take place in the next few hours. Three to five days after the eggs are retrieved; the embryo(s) will be ready to be transferred to the uterus.
Sometimes the sperm may have or be suspected of having a problem that might limit fertilization. In these cases we recommend intracytoplasmic sperm injection or ICSI. ICSI is a very important and effective treatment for male factor infertility but we do not perform ICSI on all our patients. We find that many do not need it.
The patient returns to the IVF suite for the embryo transfer. This process involves using a small catheter to gently place the embryo(s) into the uterus during a speculum exam. After the embryo is inserted, the patient remains lying down for about 30 minutes. A blood pregnancy test is done 9-11 days after the transfer to determine if the procedure was successful.
The level of progesterone circulating in the body after ovulation is important for fostering early pregnancy. Since some of the cells that would normally make progesterone are removed during the egg retrieval, the patient uses daily progesterone supplementation starting after the procedure.
Like most medical procedures, in vitro fertilization carries some risks. It is important to understand the risks that may be involved in the process.
The risks of IVF can include:
- Multiple Pregnancy – If you have more than one embryo transferred into your uterus, multiple pregnancy may occur. Twins are the most common type of multiple pregnancy; however higher numbers (triplets or more) are possible. At UVM Medical Center, our goal is to maximize your chance of a pregnancy, while minimizing the chance of multiple gestation. You and your physician will work together to decide on the number of embryos to transfer. We greatly prefer single embryo transfer (SET) unless the ASRM guidelines suggest that the prognosis would be better with two or very rarely more embryos transferred.
- Ovarian Hyperstimulation Syndrome (OHSS) - OHSS is a rare complication that can result from a large number of developing eggs in combination with a very high estrogen level. It occurs less than 2 percent of the time. Close monitoring is the key to prevention of OHSS. Sometimes the doctor recommends cryopreserving or freezing all the embryos and not performing a transfer with the fresh cycle, but delaying to a later frozen embryo transfer. This can often avoid OHSS.
- Complications from Ultrasound-Guided Egg Retrieval - Complications can include bleeding, injury to internal organs, or infection. They are extremely rare and we take every possible precaution to prevent complications from this procedure.
Your doctor will discuss any other personalized risks with you in your intake and evaluation for the IVF program.
Please note we request that patients stop smoking if they are considering IVF treatment. Nicotine interferes with egg and embryo quality and impairs IVF success markedly. Infertility patients in general should do all they can to stop smoking because smoking damages the ovaries and increases the risk of early ovarian failure.
The UVM Medical Center offers smoking cessation classes for those who want to quit smoking.