IVF Using Own Eggs
In vitro fertilization (IVF) is one of the most effective techniques available for improving your chances for a pregnancy. In order to reach this potential, your participation and that of your physician (reproductive endocrinologist), nurses and embryologists require close coordination. Precise timing of medications is critical, and close monitoring with ultrasound is required. This reproductive journey is detailed and involved, but we are here to guide you and help ease as many of the complexities that may occur along the way.
In Vitro Fertilization
With IVF, oocytes (eggs) are retrieved from the ovary and placed in a Petri dish with active, motile sperm. Because fertilization occurs in the Petri dish rather than in the woman’s body, this process has been called “in vitro.” The eggs and sperm are maintained in a special culture media (nutrient fluid) within a controlled environment (incubator). If a fertilized egg is developing properly, it will consist of 6-8 cells at 3 days after egg retrieval. If an embryo is continuing develop appropriately, it will form a blastocyst by 5-6 days after egg retrieval. After embryos have developed in the laboratory for several days, one or more are selected for transfer into your uterus and if additional embryos are developing, they may be frozen to be transferred at a future time.
Guide to IVF at Serum Biomedical Institute
IVF treatment at our center is highly individualized but there are certain commonalities in the procedure.
Pretreatment preparation
- Ovulation induction
Oocyte retrieval
Fertilization of eggs in the laboratory
Embryo transfer
Luteal phase
Pregnancy test and pregnancy follow-up
After the decision is made to proceed with IVF, the doctor will give you a medication calendar outlining the treatment. In many cases, oral contraceptive pills (OCPs) will be prescribed in the cycle, prior to active treatment. The purpose of the OCP is to reduce the chance that an ovarian cyst will be present at the time when we plan to start treatment and to allow flexibility in the timing of the cycle (the number of days on OCP can be varied).
Ultrasound. While you are on the OCP, you will have a Transvaginal ultrasound to assess whether there are any cysts present in the ovaries. In one commonly used protocol, you will begin a medication called Lupron (a GnRH agonist) while you are still taking the OCP. Your individual protocol may vary, and you may be prescribed a medicine other than Lupron (such as a GnRH antagonist called Ganirelix or Cetrotide) to prevent premature release of the eggs.
Uterine screening. If you have not had an evaluation of your uterus within the last year, your doctor may recommend a screening test as a hysteroscopy or a saline infusion sonography to be done while you are taking the OCP. You will be given more information about any procedure that will be recommended. Backup semen sample. In some cases a semen sample is obtained, frozen, and stored as a “back-up” specimen available on the day of egg retrieval.
2. Ovulation induction
Success rates with reproductive technologies (ART) are improved if multiple mature oocytes are available for retrieval. In order to mature a group of eggs, medications are administered by subcutaneous injection on a daily basis. The medications are in a class called gonadotropins injections.
Baseline Ultrasound. Your baseline ultrasound will be performed before starting the gonadotropin. Occasionally you may have an ovarian cyst at this time. If you have a cyst, it often disappears with continued Lupron treatment, or less commonly your attending doctor might recommend aspiration of the cyst. If the baseline ultrasound is normal, you will begin gonadrotropin injections. This medication will promote a group of several follicles (the sacs of fluid which contain the microscopic eggs) to develop together. Ideally about 10-12 follicles develop, but the response is quite variable and you may produce only 2-3 follicles, or as many as 20-30. The dose of medication you will receive is based on a prediction of how your ovaries will respond based on your age, your baseline FSH and estradiol levels, and any previous ovulation induction experience.
Timing of hCG. When ultrasound examination suggest that the eggs are mature (usually when the lead follicle size is about 18 mm in diameter), you will be asked to take an injection of human chorionic gonadotropin (hCG). The timing of the hCG is critical, so you need to take it precisely at the time given to you on the schedule. Once you take hCG, your gonadotropin and GnRH agonist or GnRH antagonist will stop.
3. Oocyte retrieval
Approximately 35 hours after the hCG injection, the egg retrieval will be performed under sedation. Intravenous medications will be given to prevent discomfort during the procedure. You will be asked not to have anything to eat or drink after midnight the night before the egg retrieval. Once you receive the intravenous medication, the vagina will be cleansed with sterile water. A needle will be placed through your vagina and into the ovary, under ultrasound guidance. Most women will not feel this procedure at all due to the effects of the intravenous medications. The follicular fluid (which contains the eggs) from the follicles in your ovaries is collected in test tubes and passed to the embryologists in the IVF laboratory.
The egg retrieval takes approximately 10-30 minutes. After the procedure is completed, you will be transferred to the recovery room to rest for about an hour. Risks from the egg retrieval include pain, infection in the pelvis and ovaries, injury to the bowel, bladder, uterus, ovaries or major blood vessels. Since the procedure is done under ultrasound guidance and the needle can be seen on the ultrasound, the chance of serious problems is extremely small. Many women return to work the next day, while others also rest the day following the retrieval. You may feel some pelvic heaviness or soreness and cramping. Often there is a small amount of spotting. Your bleeding should be less than a normal period.
4. Fertilization of eggs
Once the eggs are retrieved and placed in the incubator, they rest for several hours before the sperm is added, usually in the afternoon of the egg retrieval. Addition of sperm to the culture media is called insemination, and is followed by fertilization, when the sperm enters the egg. Fertilization can also be accomplished by ICSI (intracytoplasmatic sperm injection). ICSI will be recommended if your physician suspects that there will be a significant chance of no fertilization or a low rate of fertilization with conventional insemination of the oocytes in the laboratory. We will call you the day after retrieval to let you know how many eggs have fertilized. The embryo can begin cleaving, or dividing, first into two cells, then into four. Cleavage to four cells generally takes 36-48 hours or more after the egg retrieval. After 3 days, an embryo which is growing properly will have 6-8 cells. An embryo should reach a blastocyst stage at 5-6 days after retrieval.
5. Embryo transfer
Three to five days after the oocyte retrieval you will be scheduled for your embryo transfer. Your physician will recommend which day is most appropriate for you. In general, blastocyst transfer is recommended when there are a large number of embryos of good quality, or for couples desiring only a single embryo to be transferred. Your physician will give you a recommendation regarding the number of embryos to be transferred based on your age, your medical history if you have had IVF performed in the past, and the quality of the embryos.
On the day of the transfer you will come to the clinic with a full bladder. A partially full bladder often will allow the transfer to be completed more easily and will allow a better picture on the abdominal ultrasound. Abdominal ultrasound is used to guide the transfer. To perform the transfer, your physician will place a speculum in the vagina and the cervix will be rinsed with a sterile solution. The embryologist in the laboratory will load the embryos into a small catheter and your physician will ease the tip of the catheter through the cervix into the uterus. You may have a sensation or twinge as the catheter passes through your cervix or you may not feel anything. For this reason, anesthesia is not used for the transfer. There is no pain associated with the procedure. You are allowed to rest up to 30 minutes on the table before getting up.
6. Luteal phase
You will take progesterone by injection and/or vaginal suppository gel because it has been shown that progesterone supplementation increases the chance of success with IVF. Progesterone is the natural hormone that your body produces to support the uterine lining and maintain an early pregnancy. However, you will only receive progesterone, the same natural hormone your ovaries produce, in a dose that is not excessive. After the egg retrieval, you will receive your first dose of progesterone. You will continue this daily for the next two weeks according to a schedule you will receive.
A pregnancy test will be performed approximately two weeks after your egg retrieval. Waiting for your pregnancy test is a difficult time. It is not unusual to have symptoms of pregnancy that come and go due to the hormonal changes with IVF. The only way to know whether or not you are pregnant is by the pregnancy test done two weeks after egg retrieval. Bleeding may occur even if a pregnancy is developing normally. Please continue to take the progesterone that is prescribed until your pregnancy test, even if you think you may not be pregnant. Because the hormones that you are taking may confuse the symptoms that you have come to recognize as signs that you may or may not be pregnant, try not to guess or do home pregnancy tests before the blood test. They may or may not be accurate.
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