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The IVF Process Explained Step-By-Step
The IVF process can be pretty intense, so it's good to know ahead of time what to expect.
Remember that your situation is always going to be unique to you. Consult with your doctor if you need any clarification on your particular treatment.
Step 1: Period Starts and Ovarian Stimulation and Monitoring Begin
The length of this stage can vary, but for a patient with a 28 day menstrual cycle it can last about 14 days.
Once you have undergone a preliminary workup, your physician will plan a treatment protocol. Ovarian stimulation can be a very complex process.
It’s important to note that different clinics may prefer slightly different protocols, drugs and techniques for ovarian stimulation. You need to talk to your physician about which is best for you in your particular circumstances.
The general goal of this phase of treatment is to get multiple follicles to grow and produce mature eggs. In a normal cycle, a woman will only produce and release one egg per month. With ovarian stimulation, the woman can produce as many as 20-30 eggs.
You will being this phase of treatment by starting injections of ovarian stimulating medications. Ovarian stimulating medicine are derivatives of the hormones FSH (follicle stimulating hormone) and LH (luteinizing hormone). Different protocols will require taking one of more of these medications.
During stimulation, the clinic will monitor the development of your follicles, uterine lining, and blood hormone levels.
Typically, patients will go to the clinic every 2-4 days as needed for an ultrasound and blood tests.
Transvaginal Ultrasound – a nurse will use the ultrasound to scan your ovaries and measure your follicles on the left and right sides. Basically, they are looking for a group of follicles to increase in size at the same pace. The nurse will also measure the thickness of the ovarian lining.
Blood tests – The nurse will also draw some blood, which will be tested for estrogen levels. Estrogen levels will rise as follicles grow and the eggs grow and mature.
Adjustments to your medication and schedule
Usually, your clinic will call you with the results of your blood tests at the end of the day. They might change your dose of medication, so it’s important to be available to take this call. This is also your chance to ask any questions you might have about the progress of your cycle or clarify any instructions.
Step 2: Trigger Shot
The trigger shot induces the final maturation of the eggs and sets ovulation in motion. The timing of the trigger shot is CRUCIAL, so pay attention to your clinic’s instructions. The trigger shot is usually prescribed 36 hours BEFORE egg retrieval is scheduled.
When you take the trigger shot will depend on two things:
Follicle size: The follicles should have reached 18-22mm
Estrogen levels (estradiol): this is related to how many follicles you have, but in general it should be at the appropriate level given your number of follicles.
Step 3: Egg Retrieval
During egg retrieval you will be sedated with a fast-acting anesthesia. The physician will use ultrasound to guide a needle into each ovary and aspirate the eggs from the follicles.
The procedure usually takes less than 30 minutes.
Step 4: Fertilization
Once the eggs have been retrieved, they are mixed with either fresh or thawed sperm to fertilize.
If the quantity or quality of the sperm is poor, the clinic may use ICSI (Intracytoplasmic sperm injection) to fertilize the egg. The embryologist will select a single sperm and inject it directly into the center of the egg to fertilize it.
The embryologist will assess fertilization 16-18 hours after insemination or ICSI. Fertilization is noted by the presence of 2 pronuclei. Typically, the clinic will be able to tell you how many eggs fertilized normally, how many eggs fertilized abnormally, and how many did not fertilize.
Step 5: Embryo Development
Once the egg is fertilized, it become an embryo. The cells will divide and the embryos will increase in cell number every day. After 2 days, they should have at least 4 cells. On day 3, embryos typically have 4-8 cells.
On day 4, the embryo should reach the morula stage, about 10-30 cells. It’s possible to have morulas on day 5 if they are either weaker or healthy but slower growing. Embryo arrest at the morula stage is not uncommon. (Hence the argument for transferring blastocysts.)
Blastulation can begin as early as day 4 to day 7. At the blastocyst stage, an embryo has developed 2 different cell types and a fluid cavity. The outer layer of cells become the placenta and the inner cells become the baby.
Step 6: Embryo Transfer
Embryo transfer typically happens 3 or 5 days after fertilization. Generally, if there are lots of very strong and “good looking” embryos, the clinic will let them develop as long as possible, ideally to the blastocyst stage. By doing this, it’s easier to obtain a clearer view of which embryos are “the best” and should be transferred.
Embryos which are not transferred but which are of good quality may be frozen and used for a frozen embryo transfer (FET) at a later date.
During transfer, you will go to the clinic, where a catheter is inserted into the uterus and the embryos are transferred directly into the uterus. You will be awake for this procedure. It’s generally reasonably quick but can take longer if, for example, a woman has an unusually shaped cervix.
Most patients will begin taking progesterone at this time.
Step 7: Two week wait
For many women, the two week wait (TWW) is the hardest part of IVF. The TWW is the period of time between the transfer and your pregnancy test.
It takes about two weeks from the time an embryo implants in the uterine wall to start emitting enough hCG (human chorionic gonadotropin) to be detected in a pregnancy test.
Most patients will continue taking progesterone during the TWW and may also take estrogen.
Step 8: Pregnancy test
The date for a pregnancy test is generally calculated at 18 days after egg retrieval.
There are two different types of pregnancy tests. One is a home pregnancy test (HPT), colloquially known as “pee on a stick” (POAS). The other type of pregnancy test is a blood test at the hospital. A blood hCG number over 100 is a good first beta result. However it’s quite common for many successful pregnancies start out with a beta hCG level below 100. Multiple fetuses (twins or triplets) can drive this number higher, but only ultrasound can confirm the presence of multiples.
Check out the TedEd Video "How IVF Works"