What is the process of IVF?

Most people have at least heard of In Vitro fertilization or IVF with great certainty. After all, this treatment has been in existence for decades, with the first successful human procedure dating back to 1978 and the birth of Louise Brown, the original “test-tube baby.”  Nevertheless, there are still many misconceptions about this process.

The process of IVF involves retrieving eggs from a woman’s ovaries and fertilizing them with a man’s sperm in a laboratory dish. The resulting embryos are then implanted in the woman’s uterus. In Vitro Fertilization, or IVF is a type of Assisted Reproductive Technology (ART) that has been used for over four decades to help women become pregnant.

This fertility treatment involves retrieving eggs from a woman’s ovaries and fertilizing them with sperm in a laboratory. The resulting embryos are then transferred back into the woman’s uterus with the hope that they will implant and she will become pregnant.

From that point onwards, IVF has continued to advance. Today, IVF is the logical first choice for many individuals or couples who dream of being parents to their own genetic/biological child or children, yet have been unable to conceive on their own.

Most people understand that IVF has something to do with uniting the egg and sperm outside of the female body. However, this is only a simple explanation. There is much more to the process and it is important for anyone who is considering IVF to understand its steps from start to finish. 

However, first, it’s essential to understand why you (or someone you love) might be considering IVF as a way to help get their family started. This therapy is undertaken for a number of different reasons, and for many women, it is the best alternative available when spontaneous conception has unfortunately not been successful.

IVF can be used when the woman trying to conceive has blocked fallopian tubes or perhaps lives with endometriosis. An older woman who may not be producing as many eggs as she once did could also be a candidate for IVF. In addition, couples who can’t conceive because the male partner has fertility issues and same-sex female couples who are using donor sperm for conception can benefit from this therapeutic process.

The 5 steps of IVF

Regardless of the reason you or your loved one may have chosen IVF, it’s wise to understand the process before you/they begin. Basically, there are 5 major steps:

Enhancing egg production

The first step is to boost the production of eggs or oocytes. Every woman is born with a finite number of eggs that essentially “run out” at the time of menopause, and normally she will only ovulate one egg per month. However, with the use of drugs that contain a follicle-stimulating hormone, the body can be prompted to recruit more eggs to grow and mature. This part of the process is called “stimulation” or “superovulation.”  Of course, the more eggs a woman has available at ovulation, the greater the chances of her having successfully fertilized eggs later in this process.

The medications used to induce superovulation will be closely monitored, with blood testing and transvaginal ultrasounds being performed in order to assess the ovarian responses and hormone levels.

The drugs taken during this step are chosen in accordance with the patient’s individual medical history. These include injectable gonadotropins, which are hormones that are administered daily for 8 to 10 days, usually starting on day 2 or 3 of the menstrual cycle. Initially, the majority of patients are given a short course of birth control pills to suppress their own hormones and thus “prime” the ovaries for more uniform and enhanced recruitment of eggs.  Most women can administer the shots by themselves, or they may have a partner/other loved one do this for them. These are powerful medications and generally prompt a robust ovarian response. As such, their use requires frequent, precise monitoring of the ovaries so as to prevent side effects of hyperstimulation.

In rare cases, oral medications including Clomid® and Femara® may be utilized when the goal is to recruit a small number of eggs. These medications are taken for five days, beginning on the third or fifth day of the menstrual cycle, and they usually only produce one to three mature eggs per cycle thus they are much less frequently used than the injectable gonadotropins.

Irrespectively, your doctor will determine which treatment protocol is right for you and will explain the benefits and risks of the chosen method based on your individual situation.

Retrieval of the eggs

Once the eggs have been produced, they will need to be removed from the ovaries for fertilization in the laboratory. The patient will receive a hormonal injection approximately 36 hours before the procedure is scheduled to induce the final maturation of the eggs, thus ensuring that the eggs retrieved are optimized.

Next comes the procedure itself, which is known as “Transvaginal Follicular Aspiration”, or “TVA”.  This is a relatively quick, minor surgical procedure – generally carried out in the doctor’s outpatient surgical suite – that allows the eggs to be removed from the patient’s body. Specifically, it is performed by inserting a thin needle through the vagina into each of the ovaries sequentially.  Ultrasound guides the doctor throughout the procedure so that the process is both precise and accurate, and very safe for the patient. The needles are attached to a device which then suctions the eggs one at a time out from the ovaries.

Patients are given anesthesia for this procedure to eliminate any pain or discomfort. The entire process – from the administration of anesthesia until the completion of the egg retrieval – takes only about 15 minutes. In essence, the aspiration of eggs from the ovaries is minimally invasive and the recovery time is short. Afterward, patients may experience some discomfort, akin to menstrual cramps, but that usually goes away within 24 hours.

Sperm collection

The patient’s partner will be asked to provide a sperm sample the morning that the eggs are being retrieved. If donor sperm is being used, this would be discussed and coordinated with the patient or couple beforehand.

Either way, once the sperm is received, it will be put through a high-speed “wash and spin” process that will identify the healthiest sperm. In other words, it will isolate the sperm that have the best chance of successfully fertilizing the retrieved eggs.

Bringing the sperm and egg together

The eggs will be transferred to the embryology laboratory during egg retrieval. There, they are placed and cultured in a fluid environment that is designed to mimic a woman’s fallopian tubes, and then moved to an incubator.

At this point, it is time to unite the best sperm with the best eggs. This stage is known as “insemination.” This is the first step of the IVF process that does not physically involve the would-be mother, her partner, or sperm donor if applicable.  This step is carefully completed by the embryologist.

It generally takes a few hours for the sperm to fertilize the egg. In some instances, specifically, when there is a sperm factor present such as a low count, low motility, or even in cases of prior failed or suboptimal egg fertilization with standard insemination, the doctor will order “intracytoplasmic sperm injection,” or ICSI to be performed.  In such circumstances, the embryologist will select the healthiest appearing individual sperm to inject directly into each egg in order to maximize the chance for successful fertilization.

Eggs will be fertilized about four hours after retrieval and then placed back in the incubator. They are checked regularly until they’ve reached a stage where the doctor determines they can be transferred into the uterus; usually, this is between 3 and 7 days post-fertilization.  At this time, an embryo or embryos may be transferred, or as is the case more frequently today, the embryos will be cryopreserved, or frozen, for subsequent embryo transfer in a future frozen embryo transfer (“FET”) cycle.  In rare circumstances, such as when very few fertilized embryos are available, an earlier transfer may be considered. (See our article on Day 5 embryos and/or blastocysts for more details.)

Embryo transfer

Once the eggs are retrieved, fertilized, and the embryos have thus formed, the patient is ready for the next step in the IVF process, namely the Embryo Transfer.  Generally, this will be undertaken in a subsequent menstrual cycle to allow for recovery and synchronization between the embryo and the patient’s uterine lining, or endometrium.

Initially in this cycle, the patient will be given estrogen and progesterone to prepare the lining of the uterus to receive the embryos.  The embryos are then transferred to the uterus via the use of a thin, flexible catheter. This procedure is performed at the doctor’s office while the patient is awake. In some cases, anesthesia is given to patients who may have difficulty with such procedures.  Prior to the days of Preimplantation Genetic Testing, or Comprehensive Chromosome Screening, which are frequently undertaken by patients today to confirm the normal chromosomal competence of their embryos, multiple embryos may have been returned to the womb in hopes that at least one would implant itself in the uterine lining.  However, this is why multiple pregnancies (twins and triplets) were more common in IVF patients than in those who conceived naturally in the past, thus the current standard of care is to transfer one embryo at a time, especially with the availability of the genetic testing methodologies. 

Yes or no?

What comes next is a very passive, yet oftentimes emotionally charged part of the process.   The patient and her partner now simply wait to see if pregnancy occurs. There is no way to know whether the attempt has been successful until about 10 days after the embryos are transferred. While some patients feel the need to check an at-home pregnancy test that analyzes the urine for signs of pregnancy, all patients are instructed to head to the doctor’s office (or hospital) for a pregnancy Beta HCG blood test, which is far more reliable and accurate.

These one and a half weeks can be extremely stressful, especially for women/couples who have been trying to conceive for some time. Furthermore, there aren’t a lot of clues that signify that the transfer “took,” or successfully implanted in the patient’s uterus. Some women may notice some fatigue, breast tenderness, or even slight spotting. Nevertheless, only a blood test can confirm the success of the IVF cycle, and at this point, patience is an important, yet understandably difficult, part of the process.

We hope this article has taught you more about the IVF procedure and clarified the steps involved in its process. At Advanced Reproductive Medicine, we collectively possess decades of experience in assisting patients with IVF from start to finish. We can also suggest other options and help you determine which therapies can best assist you in achieving your dream of parenthood. For more information or to schedule an appointment, call our office at 732-339-9300.