OHSU

Steps in IVF

fertility baby

After you have finished all of your screening, an individualized treatment plan will be developed. You will follow your plan until pregnancy is achieved. Since each patient is different, each treatment plan will be different.

Your IVF nurse coordinator will guide you through the process and explain each important step, procedure and medication.

Sample IVF Treatment plan

Below you will find an explanation of steps in a sample treatment plan.  Click on the links below for information:

 

Initiation of Oral Contraceptive Pills

Some patients will receive oral contraceptives at the start of their IVF cycle. The possible benefits include:

  • Shortened use of ovarian suppressive drugs such as GnRH-agonists (e.g. Lupron).
  • Decreased chance of developing ovarian cysts prior to starting gonadotropins.
  • Improved ovarian response during ovarian stimulation resulting in better egg recovery.

It is important to suppress your ovaries before starting stimulation medications. This helps optimize the chances of uniform follicle growth.

 

Baseline Ultrasound

Around the time of your expected period, we will perform a transvaginal ultrasound scan to examine your ovaries. This procedure is used to ensure your ovaries are not producing eggs at the moment (are suppressed). It also measures your serum estradiol level.  In some cases, women may develop cysts.  If we detect a cyst, we may not continue therapy until your cysts resolve on their own (usually in about a week). If your baseline ultrasound is normal, you will begin stimulatory medication.

 

Ovarian Stimulation

If you take ovarian stimulants, you may experience fullness in your ovaries and have some skin reactions. However, side-effects are generally minimal.

We’ll teach you how to use injectable fertility medicines to encourage the growth of multiple follicles. Your specific stimulatory medication depends on your individual protocol (procedure). It may include any or all of the following medications:

  • GnRH-AGONISTS (e.g. Lupron) – The desired effect is to prevent early release of the developing eggs. This medication suppresses the pituitary gland. This, in turn improves the recruitment of multiple follicles (making more “targets” for the sperm to find and reach).
  • GnRH ANTAGONISTS (e.g. Ganirelix, Cetrotide) – This medication is similar to Lupron but works in a different way. It can also improve ovarian response.
  • Gonadotropins (e.g. follistim, Gonal-f, menopur, repronex, bravelle) – This medication helps to stimulate follicle development and egg maturation.

The medicines are injected just underneath the surface of your skin. Our team will teach you and your partner how to safely and easily do injections.

 

Monitoring

Along with your stimulatory injections, we will monitor you in the clinic using ultrasounds and hormone measurements. You may need to visit the clinic frequently for monitoring.  Patients are usually seen every one to three days depending on follicle growth and estradiol level. This frequency allows us to adjust the dose of medication in an effort to improve follicular development. Your IVF nurse coordinator will be in contact with you during this period of time. She determines how frequently you will need to come in.

 

Final Maturation HCG

Oocyte retrieval

Thirty-six hours after taking your HCG injection, you will come into the clinic. Our team will perform an oocyte retrieval procedure, which involves removing eggs from your ovary. During the retrieval, we will use an IV-anesthetic that will not put you to sleep. It will just help you feel comfortable.  This state is called “conscious sedation.” An anesthesiologist will monitor you during your sedation. You will be awake, but have enough anesthesia so that you will feel a little “cloudy” mentally. Physically you will be quite comfortable.  You must not eat or drink anything after midnight the night before this procedure.

Throughout this procedure, we will use an abdominal ultrasound to watch everything that’s happening inside.  If you would like to watch, you can also see the screen.  A very thin needle is inserted into your vagina and into your ovary. The contents from each follicle will be drawn into a test tube. The contents will be immediately delivered to our embryo laboratory and examined to find eggs. The egg retrieval takes approximately 20-30 minutes.

You will be able to return home after a brief recovery from your procedure. Because of the powerful narcotics and effects of the anesthesia, you must have someone else drive you home.  Most patients continue to rest at home for the remainder of the day. Soreness, cramping and mild vaginal bleeding is common on the night of retrieval. We will prescribe pain medication before you leave the clinic. You should feel back to normal by the following day.  After the retrieval, your ovaries actually enlarge and remain enlarged for the next several weeks. Therefore, you should avoid heavy lifting, vigorous exertion or intercourse until your pregnancy test.

 

Fertilization

A semen sample is generally collected on the day of retrieval and processed by the laboratory for the IVF procedure. In some cases, a frozen sample can be used, particularly when a sample from a sperm donor is necessary. Eggs are then inseminated with the sperm sample. On the day after the retrieval, we will call you and let you know the number of eggs that fertilized.

 

Embryo Transfer

This procedure will happen three to six days after the oocyte retrieval. The timeline is based on what the doctor and embryologist determine will be most successful.

A catheter (tube) will be inserted into your uterine cavity to place the embryos chosen for transfer.  In this case, as well, we will use an abdominal ultrasound to watch and guide what is happening inside.  This procedure requires a full bladder. That permits our staff to best see your uterus, and allow for the best possible placement of the embryo(s).

Your doctor and embryologist will work with you to decide on the number of embryos to transfer.  A number of factors will be looked at in making this decision:

  • Quality and number of embryos retrieved.
  • Your age.
  • Previous pregnancies.
  • Whether you have had a previous transfer.

Embryos that are not chosen for transfer and that meet freeze criteria will be frozen and stored for later use, if you choose.

On the day of the transfer, we will give you specific instructions. The information involves bed rest, medications and other important directions to follow until the day of your pregnancy test.

Luteal phase

Progesterone (a hormone naturally made by the ovary) helps to support the uterine lining. It’s important in helping a healthy pregnancy develop. Progesterone supplementation increases the chance of success with IVF.  For this reason, you will take progesterone after your egg retrieval.  You will take it either by injection and/or vaginal suppository. Your package insert will include warnings about progesterone use in early pregnancy. However, progesterone supplementation is used worldwide for IVF and other infertility treatments. It is the same natural hormone your ovaries produce and is used in a dose that is not excessive. Progesterone will be continued at least until your pregnancy test and longer once you are pregnant.

 

Pregnancy

Pregnancy Test

A pregnancy test is performed approximately two weeks after your egg retrieval. Pregnancy symptoms are not a reliable sign of pregnancy success or failure, because symptoms may come and go. Bleeding is also more common following IVF.  If you discover vaginal bleeding after the transfer, it does not mean that the procedure was unsuccessful. We will you ask you to get a blood pregnancy test (hCG level), approximately 12 days after embryo transfer. You’ll take this test even if you’re bleeding,.  When the test is positive, you will return for a follow-up test two to three days later. The test is to confirm that the level of hCG is rising appropriately.

Early Obstetric Ultrasound

After two positive pregnancy tests, an early obstetric (OB) ultrasound will be scheduled. This will be about two to three weeks following the embryo transfer.  This ultrasound is done transvaginally (as opposed to abdominally). We will look for an early fetal heartbeat, a yolk sac and gestational sac.  If the ultrasound shows all of these elements, and is determined to be normal, you will start seeing a care provider. We will recommend that you begin to see an obstetrician or nurse-midwife for the remainder of your pregnancy.

In some cases, a second ultrasound is advised one week later. Progesterone is continued until eight to 10 weeks from your retrieval.

 

References:

  • Lee A, Christenson LK, Patton PE, Burry KA, Stouffer RL: Vascular endothelial growth factor production by human luteinized granulosa cells in vitro.  Hum Reprod 12(12):2756-61;1997.
  • Public Press Release, Oct 28, 1999:  Woman pregnant after selecting healthy embryo.  OHSU Team First in NW to Succeed with Preimplantation Genetic Diagnosis.  HYPERLINK "http://www.eurekalert.org/pub_releases/1999-10/OHSU-Wpas-281099.php"http://www.eurekalert.org/pub_releases/1999-10/OHSU-Wpas-281099.php
  • Patton PE: Fertility breakthrough: Blastocyst transfer.  Bottom Line/Health, May 1999, Boardroom, Inc., Greenwich, CT.
  • Gregory T and Patton PE: Pulmonary complications following ovarian hyperstimulation.  Am J ObstetGynecol 180:1468-71;1999.
  • Gorrill MJ, Kaplan PF, Patton PE, Burry KA: Initial experience with extended culture of cryopreserved embryos.  Am J ObstetGynecol 180:1504-11;1999.
  • Patton PE, Sadler-Fredd K, Burry KA, Gorrill MJ, Johnson A, Larson JM, Wolf DP: The development and integration of an extended embryo culture program.  Fertility Sterility 72:418-22;1999.
  • Gorrill MJ, Johnson LK, Patton PE, Burry KA: Oocyte donor screening: the selection process and cost analysis.  FertilSteril 75:400-4;2001.
  • Gorrill MJ, Sadler-Fredd K, Patton PE, Burry KA:  Multiple gestations in assisted reproductive technology:  can they be avoided with blastocyst transfers?  Am J ObstetGynecol 184:1471-7;2001.
  • Kaplan PF, Austin DJ, Gorrill MJ:  Satellite and Transport In Vitro Fertilization.  In: Contemporary Endocrinology.   Assisted Fertilization and Nuclear Transfer in Mammals.  Don P. Wolf and Mary B. Zelinski-Wooten, eds.  Totowa, NJ: Humana Press, Inc.  2001, Chapter 11, pp. 189-97.
  • Patton PE, Wolf DP:  Unstimulated In-Vitro Fertilization and In-Vitro Oocyte Maturation.  In:  Seifer DB, Collins RL, eds.  Office-Based Infertility Practice.  New York:  Springer-Verlag New York, Inc., 2002:174-83.
  • Gorrill MJ, Burry KA, Patton PE:  Pregnancy outcomes using donor sperm insemination following failed IVF/ICSI cycles in couples with complex infertility disorders.  FertilSteril 2003;80:936-8.
  • Molskness TA, Stouffer RL, Burry KA, Gorrill MJ, Lee DM, Patton PE:  Circulating levels of free and total vascular endothelial growth factor (VEGF-A), plus sVEGF receptor-1 and -2, during ovarian stimulation in primates:  relevance to ovarian hyperstimulation syndrome.  Hum Reprod 2004;19:822-30.
  • Sampson JE, Ouhibi N, Lawce H, Patton PE, Battaglia DE, Burry KA, Olson SB:  The role for preimplantation genetic diagnosis in balanced translocation carriers.  Am J ObstetGynecol 2004;190:1707-13.
  • Stanek M, Borman S, Molskness T, Larson J, Stouffer RL, Patton PE.  Insulin and IGF stimulation of VEGF production in luteinized granulosa cells:  comparison between PCOS and non-PCOS women.  J ClinEndocrinolMetab. 2007;92:2726-33.