Your fertility specialist will perform your IVF in either the doctor's office or an outpatient surgery facility. To increase your chances of success, the IVF procedure must be very well organized and perfectly timed. Most IVF programs follow these important steps. Each of these stages is discussed in more detail immediately following the list.
• Ovulation stimulation
• Egg retrieval
Semen collection and preparation
• Embryo monitoring
• Embryo transfer
• Cryopreservation after IVF
You will be given fertility medication to develop multiple eggs and stimulate ovulation. The usual protocol involves three types of medication: a GnRH agonist or antagonist to suppress your natural hormones, a gonadotropin to stimulate follicle and egg development, and hCG to finalize egg development and trigger ovulation. Your doctor will discuss the exact medications and timing with you.
Hormonal blood levels and pelvic ultrasounds are performed every few days to monitor the progress of the developing follicles. The doctor notes the number of developing eggs and records the size of each follicle. Once the follicles have reached their goal size and there are between 10 and 30 developing follicles, the egg retrieval process will be scheduled.
When the follicles are mature, the ultrasound guided egg retrieval procedure is performed. The purpose of this step in the procedure is to remove the eggs from your ovaries. The egg retrieval procedure is performed either in the doctor's office or in an outpatient surgery facility. The average time to perform this procedure is about 20 minutes. For your comfort, you will usually be given an anesthetic for this procedure.
Your doctor will introduce a long ultrasound probe into your vagina. This probe will transmit a clear image of your ovaries on the ultrasound monitor. The doctor will then pass a sterile needle alongside the ultrasound probe through the top of your vagina and into the ovary and gently suction each developing egg.
You'll be asked to recover and rest for about an hour following the egg retrieval. During this time, your doctor's lab employee, the embryologist, will examine the collected eggs and let you know how many high-quality eggs were collected. In most cases, you can return to your normal routine the following day.
Most laboratories need the sperm specimen within a few hours after egg retrieval. The fresh semen is taken to the laboratory, where it is washed and separated from the liquid portion of the semen. The washed sperm are placed into a sterile medium and then concentrated into a small volume.
The sperm are then treated in the laboratory with a variety of techniques to enhance their ability to fertilize an egg. The sperm are treated and incubated in a special medium that alters the membrane covering the sperm, increasing enzymes that will be needed for egg penetration and fertilization. The sperm are also processed in a centrifuge, which allows the laboratory to isolate the highest quality and concentration of sperm. Some labs have the sperm swim through special tubing to isolate only the most vigorous and healthy sperm. Occasionally, labs will add a caffeinelike substance to the sperm to invigorate the sperm and make them more active and mobile. The purpose of all of these sperm preparations is to ensure that the best, highest quality, and greatest concentration of sperm is available to fertilize your eggs.
In the laboratory, your recently collected eggs are placed in a Petri dish and combined with the healthy sperm. The Petri dish contains a nourishing liquid that bathes and nourishes the eggs and sperm, just as it would occur in nature within your own body fluids and reproductive tract. The egg and sperm Petri dish mixture is then placed in an incubator and closely monitored to see which eggs become fertilized.
Fertilization, which is the actual entry of the sperm into the egg, usually occurs within a few hours. A typical goal for most labs would be that each collected mature egg has a better than 70 percent chance of fertilization. The fertilized eggs are left in the incubator to continue to grow and develop into embryos.
The embryos continue to grow and develop in the incubator set at normal body temperature, which is the same temperature of your uterus. The laboratory serves as a temporary womb and ensures that the newly fertilized eggs are nourished and monitored closely. Those that are growing and developing properly will typically consist of four to eight cells within two or three days. This level of development serves as a guide to determine which of the embryos are developing normally and which will be the best candidates for transfer back into your uterus. At this point, the newly formed embryos are prepared for transfer to your uterus.
You should be as comfortable as possible during the embryo transfer. Many doctors offer a relaxing medication or sedative for this stage of IVF. Fortunately, the procedure is not uncomfortable and it only takes a few minutes to perform.
For the procedure itself, you will be placed on the examination table with your feet in stirrups, very much like the position you are in for a Pap test. Sometimes the table is tilted somewhat with your head down. Your doctor will use an ultrasound to guide the placement of the very thin and flexible catheter through your vagina and cervix and into your uterus. The lab assistant will load the embryos into the catheter, and your doctor will carefully inject the embryos into your uterus. Once the catheter is withdrawn, the lab assistant examines the catheter in the laboratory to make sure that all the embryos have been properly transferred.
Although embryo transfer is the shortest step in the IVF procedure, it is a very important and critical element of the entire process.
You'll be asked to stay reclining for between 30 minutes and an hour. During this time, you may experience mild abdominal or pelvic cramping. You may also notice a slight vaginal discharge after the procedure, which is likely due to the supplies and equipment used during the procedure itself.
Once transferred, the developing embryos should begin to implant into your uterine lining within the next couple of days.
Your doctor will give you instructions about what activities you should and should not do after your IVF. Many women prefer to take it easy and rest for the remainder of the day.
Depending on your medical history and your doctor's preferences, you may be started on progesterone hormone supplementation to maintain and stabilize the uterine lining for the next few weeks, just in case you are pregnant. Some IVF programs wait until they can confirm a pregnancy and then begin hormonal therapy to help support and maintain the pregnancy. Still other IVF programs do not prescribe any hormones at all after the transfer. This controversial issue has no clear-cut answer. Ask your doctor which method would work best for you.
The doctor will ask you to make a follow-up appointment after your IVF procedure for pregnancy testing and early ultrasound monitoring. A positive blood test may indicate the possibility of a pregnancy. However, pregnancy will be confirmed by ultrasound, usually three weeks after the embryo transfer.
After your IVF treatment cycle, you could possibly have some leftover embryos. That is, healthy fertilized eggs were not transferred to you because you already received the proper amount. Many couples choose to freeze their leftover embryos, a process called cryopreservation. For more about this technique, see the section specifically on cryopreservation near the end of this chapter.
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