In Vitro Fertilization Process

In Vitro Fertilization (IVF) is a process in which fertilization occurs in a petri dish.  IVF involves several stages that are carefully timed requiring close monitoring to maximize the success for each patient. The following is an overview but the details will be different for every patient because we individualize treatment based on your specific fertility situation.

Before starting your IVF cycle the following will be done:

1. Blood tests for hormones and overall health. Specific hormone tests for egg quantity may include Anti-Mullerian Hormone (AMH) or cycle day 3 follicle stimulating hormone (FSH) and estradiol, which are helpful in determining success rates and the dose of medication. Other tests include a metabolic panel, complete blood count, Vitamin D level, thyroid testing, and prolactin level. If any of these are not in the normal range, corrective treatment will be prescribed prior to initiation of the cycle.    Blood testing for certain infectious diseases is also required and will be ordered. Genetic carrier screening blood tests are always recommend because if we know to look for a genetic problem in an embryo we can prevent some serious birth defects.
2. Imaging of the ovaries, tubes, and uterus. The antral follicle count (AFC) is performed by pelvic ultrasound and is another important test for egg quantity just like the AMH or FSH/estradiol blood tests (see above). We usually use both the AFC and AMH to determine IVF success rates and medication doses. A pelvic ultrasound also provides information about a) the shape of the uterus, including the presence of any fibroids, b) any sign that tubes may be blocked e.g. if the tube(s) are filled with fluid, and c) if any large ovarian cysts are present.  Either a 3-D saline infusion sonohysterogram (abbreviated as SIS or SHG) or an office hysteroscopy check for abnormalities inside the uterine cavity, such as fibroids or the presence of a septum (fibrous wall).  If any abnormality is found that is felt to be significant enough to compromise the chance of achieving a successful pregnancy, corrective surgery may be recommended prior to starting an IVF cycle.

Starting your IVF cycle with Ovulation Induction and Ultrasound Monitoring

In the month prior to the start of IVF stimulation medications, the patient is often (but not always) placed on birth control pills for about three weeks to help synchronize the eggs.  The success of IVF depends on the ability to collect healthy, mature eggs from the ovaries, in order to allow several eggs to be fertilized by sperm to form embryos that grow into babies.    In order to stimulate the maturation of several eggs, the hormones FSH and luteinizing hormone (LH) are administered as daily subcutaneous injections (in the lower abdomen) for approximately 10 days. These are usually a combination of the injectable medications Gonal-f, Follistim, and/or Menopur.

An additional injection is also necessary to prevent ovulation (the release of eggs from the ovaries) prior to the egg retrieval. The medications used to prevent early ovulation are called Lupron, Cetrotide and Ganirelix.  Adjunctive medications including other hormones or vitamins may also be recommended.

Ultrasound monitoring and blood tests are used to monitor the maturation of the ovarian follicles (and eggs within them) during the first portion of the treatment cycle. Once this monitoring determines that the eggs are ready for retrieval, the above medications are stopped and the patient receives an injection to trigger the final maturation of the eggs. The trigger shot is called HCG (Novarel, Pregnyl, Ovidrel) or Lupron. Ovulation would normally take place about 40 hours after the trigger shot, so the egg retrieval is scheduled for 35 or 36 hours after the trigger injection.

Each patient receives detailed instructions by a nurse coordinator regarding medications they will be receiving, as well as how and when these medications will be administered.

Egg Retrieval

The egg retrieval will take place in our operating room at our Sacramento office, which is connected to our embryology laboratory.

The patient will have medications administered through an IV, such that she will be under light sedation but will not feel any discomfort. The egg retrieval is accomplished using transvaginal ultrasound to guide a special needle through the vaginal wall into each ovarian follicle, such that the egg is drawn out of the follicle through the needle into a test tube. The procedure takes approximately 10 minutes to complete, after which the patient rests in the recovery room for about 30 minutes and is then ready to be driven home. The recovery time from the egg retrieval is usually less than one day.

Fertilization of the Eggs with Sperm

During the egg retrieval procedure, the test tubes containing the eggs are passed through to the embryology lab, where the embryologists will identify the eggs under a microscope and then place them into special IVF culture media. During this same time, the male partner will collect a sperm sample or previously frozen sperm will be thawed in order to fertilize the eggs.

Once eggs and sperm are prepared, they are combined in a carefully controlled environment and then placed into an incubator where fertilization will take place.  Sperm may be placed with the egg in a petri dish, or if sperm parameters (e.g. count, motility or morphology) are low, insemination may be accomplished by injecting a single sperm directly into the egg to maximize the chance for fertilization. This procedure is called intracytoplasmic sperm injection (ICSI).

Approximately 18 hours after insemination of the eggs, they are examined under a microscope to identify those that have fertilized. These early embryos are then replaced into the incubator for further development and examined again usually three and five days later. The best embryo(s) are then selected either for transfer to the uterus, for embryo biopsy (PGD/PGS) and cryopreservation (freezing), or directly for cryopreservation, depending on what has been planned for that cycle. The process of cryopreservation is called vitrification, which is essentially flash freezing.

Embryo Transfer

If embryo transfer is planned for the “fresh cycle” in which the egg retrieval took place, the embryo(s) selected for transfer will be placed into the uterus five days following the egg retrieval and other good quality embryos will be cryopreserved. If all embryos were cryopreserved in the egg retrieval cycle, some will be thawed and replaced into the uterus at a future date.

The placement of the embryo(s) into the uterus takes only a few minutes and involves minimal discomfort.  A speculum is placed into the vagina, then a thin catheter is threaded through the cervix.  A smaller catheter, containing the embryo(s) is passed through the first catheter and into the uterine cavity.  This is done under ultrasound guidance (ultrasound probe is placed on the abdomen) to confirm proper placement of the catheter within the uterus. Once the embryo(s) have been deposited into the uterus, both catheters are withdrawn.  These are taken back to the embryology laboratory where the inner catheter is examined under a microscope to confirm that the embryos were transferred.  Very rarely an embryo is found retained within the catheter and the transfer is repeated.  This does not affect the patient’s chance of conceiving.

In order for an embryo to implant into the uterus, it must hatch out of its shell (zona pellucida).  If an embryo or embryo(s) are going to be transferred on the third day after egg retrieval and the shell is noted to be somewhat thick, assisted hatching  is performed prior to the transfer, to facilitate the embryo’s ability to exit this shell.

Medication Support of the Luteal Phase

In a natural menstrual cycle, the hormone progesterone (named for pro-gestation) is produced by the ovaries after ovulation, to prepare the uterine lining for implantation of an embryo.  Progesterone from the ovaries is also important in supporting an early pregnancy up until the time the placenta has the ability to produce sufficient progesterone.  Estrogen is also important for pregnancy, but less so than progesterone.  Therefore, in order to be sure the patient has sufficient progesterone and estrogen, these hormones are usually administered to about 9 weeks gestation (7 weeks following the egg retrieval). Progesterone is most often taken by intramuscular injections but may also be administered vaginally.  In addition to this, a suppository containing both estrogen and progesterone is also placed into the vagina.

Two blood pregnancy tests, drawn two days apart, confirm the embryo has attached. We perform early ultrasounds around 6 and 8 weeks of pregnancy to confirm the baby is growing well. At 10 weeks of gestation our patients graduate from NCFMC and follow-up with their personal OB/GYN.