In Vitro Fertilization Process: Process

Evaluation and Testing

Prior to any type of in vitro fertilization (IVF) treatment, one of our physicians will meet with you (usually as a couple) and review your history and desires. You may need some further medical tests prior to starting treatment.

A "trial transfer" is done at some point to simulate the transfer process of the embryos and intrauterine catheter. This gives us information about the depth and curvature of the catheter for when we perform the actual embryo transfer. This catheter is very thin but you may experience mild cramping and spotting that day.

When your evaluation is complete, your physician will provide you with a folder of information that discusses the IVF process. If you decide to proceed with the treatment you will need to complete on online course. This course discusses the IVF process and risks.

Following completion of the online course, you will be scheduled for a clinic visit to learn how to self-administer the medications you will be taking as part of the IVF process.

The class teaches you about the process of preparing and injecting the medications. The class will also give you an overview of what will be happening during your treatment cycle. Individual instructions on the actual injection process will be provided. Please review the documents in your information folder and bring this folder with you to the medication class.

For online information about your medications, instructions for mixing and injecting them, and directions for finding and buying the supplies please visit the Medications section.

Monitoring

After the evaluation, we will need to coordinate a date for a baseline ultrasound and pregnancy test. This is usually done on day 24 of your cycle or as close as possible.

The baseline ultrasound is performed just like the monitoring ultrasounds. A vaginal ultrasound probe that is smaller and usually more comfortable than a speculum (used for gynecologic exams) is used for the monitoring.

The lining of the uterus is measured as are any cysts that may appear on your ovaries. These are usually cysts from follicles that formed in previous cycles and are rarely anything to worry about.

On the same day as your baseline ultrasound you will have a pregnancy test. We occasionally do have a positive pregnancy test -- always welcome news!

If the pregnancy test is negative you will begin Lupron 10 units or 0.1 ml. Continue taking Lupron every morning until you are directed otherwise by someone from our clinic. When your next menses occurs you will need to call the clinic during working hours. If you have not had a menses after 14 days on the Lupron you will need to call the clinic.

We will give you a date to begin taking your gonadotropins. On the same day you begin gonadotropins you will also decrease your Lupron dose to 5 units or 0.05 ml.

Visiting the Clinic

At the same time you are instructed to take gonadotropins and decrease the dose of Lupron you will be given a date for your first monitoring visit. The monitoring visit consists of a monitoring ultrasound, a serum estradiol, and a brief discussion of your progress.

Since this clinic is designed for monitoring progress, the discussions will focus on the findings and informing you what to do next. If you have questions about the overall management of your care you may wish to schedule an appointment with the physician in our clinic that enrolled you in IVF.

The number of people in this clinic is variable so you may wish to bring reading materials or other tings to occupy your time. The monitoring phase of the IVF cycle usually requires three to five visits.

Estradiol is released by the follicles. We monitor the rise of the estradiol in your blood while you are taking gonadotropins. There is not a magic number your estradiol "should be". We like to see a rise in the values early in the cycle but do not want the value too high towards the end of the medications.

A high estradiol level (greater than 4,500) can be a concerning indicator for the risk of ovarian hyperstimulation in some patients. The IVF cycle may be delayed or canceled if this becomes too great of a risk.

The ultrasound will look at the endometrial lining as well as growth of the follicles. Preferably, the endometrium will be greater than 5 mm. The target size for the follicles is 18 to 20 mm for the lead or largest follicle and greater than 14 or 15 for the other follicles.

Once the follicles are thought to be mature we will instruct you to stop taking your Lupron and gonadotropins. You will be given written instructions on what to do for the retrieval.

Human chorionic gonadotropin (HCG) will be administered between 9 p.m. and 10 p.m. for weekday retrievals and 5:30 p.m. to 6:30 p.m. for weekend retrievals.

This injection is timed in conjunction with your retrieval so the oocytes will be "released" from the wall of the follicle but not "released" from the ovary into the abdomen. After you have been given instructions to take your HCG you will not take anymore medications including Lupron and gonadotropins. (You will still take Lupron the morning of your HCG injection.)

You will likely be advised to have intercourse on the night of HCG administration and abstain from intercourse until after the retrieval has been completed. There will be no further injections until after the retrieval.

Retrieval and Transfer

On the day of the retrieval we will need to collect a semen specimen. Couples will be given the choice of collecting at home or at the clinic.

To do the collection at home you will need to be able to bring the specimen to the clinic within 30 minutes. Be sure you have the appropriate specimen container and label before you leave the clinic.

The semen should be collected by masturbation without lubricants. Do not attempt to collect any semen that was not deposited directly into the collection container. Double check the lid of the container to make sure it is properly sealed and put the identification label on the container.

You will then put the container inside the plastic bag and subsequently inside the brown paper bag which have been provided for you. Be sure to complete and sign the slip of paper that is included in the bag.

Individuals who wish to collect their specimen at the clinic will be given directions and containers upon arrival at the clinic. A collection room is available for privacy. Materials are available in the collection room to provide the appropriate visual stimulus that males often need.

During the week most specimens will need to be turned in by 8 a.m. When you are given written instructions for the retrieval process, you will also receive instructions regarding specimen collection.

The Retrieval

When you arrive at the clinic you will be checked in and taken to the recovery and observation area. A nurse will put in an intravenous catheter (IV) and administer sedatives when you are ready to go to the operating room. Additional sedatives and pain medication will be given as needed during the procedure.

The retrieval procedure takes approximately 10 to 15 minutes, though you will be out of your recovery room for about 30 minutes. The procedure involves a transvaginal ultrasound with a needle guide that is used to aspirate the fluid from within the follicles under real time visualization.

The oocytes are identified in the follicular fluid by an embryologist. The number of follicles will be known at the completion of the procedure or shortly thereafter.

The recovery takes one to two hours on average. You will be given discharge instructions by the nurse that was present at your retrieval. Because the medications used for the retrieval often cause memory impairment and drowsiness you should plan to have the remainder of the day free of any activities. Most importantly, do not plan to drive as you will not be allowed to drive yourself home.

The next day the monitoring physician will call you with fertilization results. Do not expect to have 100 percent of the oocytes retrieved fertilized. There is no good way to predict how many eggs will actually fertilize. Depending on several factors, including number of fertilized eggs and age, the embryos will be transferred into the uterus on either day two or day three following the retrieval.

Supplemental HCG or progesterone will be administered following the retrieval. If you are instructed to take HCG you will need 5,000 units of HCG total.

Mixing instructions will be given to you along with your discharge instructions prior to leaving on the day of your retrieval. You will need to mix 10,000 units with 2 ml of liquid. This will make a solution that contains 5,000 units in 1 ml. Administer 0.5 ml (2,500 units) the day after retrieval and again in three days (four days after retrieval).

Donor oocyte recipients will be using intramuscular injections of progesterone twice daily to prepare the uterus for implantation and provide support for an early pregnancy. For those taking progesterone, it is usually continued for approximately nine to 10 weeks into the pregnancy until the placenta has completely taken over the hormone production function.

A pregnancy test will be done around 14 days following the embryo transfer. This test should be done even if menstrual bleeding occurs since there is still a good possibility of an ongoing pregnancy.