The IVF cycle entails multiple steps, and each step takes place at a specific time during a six-week period.
The IVF procedure is based on the following steps:
1. Preparation for treatment
2. Induction of ovulation
3. Egg retrieval
4. Embryo transfer.
Cycle Preceding ART Cycle
1. Initiation of oral contraceptives
2. Initiation of Agonist Depot
IVF Cycle Steps:-
- Initiation of Oral Contraceptives
- GnRH Analog (Lupron) Administration
- Baseline Pelvic Ultrasound
- Ovarian stimulation (e.g. Follistim, Gonal F, Menopur)
- Monitoring of Follicle Development and Estradiol levels
- Final Oocyte Maturation and HCG administration
- Transvaginal oocyte retrieval
- Insemination of oocytes
- Embryo Transfer
- Progesterone supplementation
- Pregnancy test
Step 1- Initiation of Oral Contraceptives
Birth control pills are prescribed starting on day 5 of your cycle. There are two main reasons for taking birth control pills prior to your IVF cycle. First of all, taking birth control pills prior to a stimulation cycle may help the ovaries respond better to the stimulation medication. Secondly, taking birth control pills allows flexibility in coordinating your cycle. Please note that many patients experience “breakthrough bleeding” when taking birth control pills. This is normal. Please continue taking the birth control pills daily regardless of the bleeding. Plan to be on birth control pills a minimum of two weeks. On day 3 of this cycle, hormonal analysis for FSH & LH are done along with transvaginal ultrasound scan to know the ovarian reserve i.e the number of follicles in each ovary & their sizes. Based on these results the protocol regimen will be decided.
Step 2- GnRH Analog (Lupride) Administration
Lupride prevents the premature release of the eggs from the ovaries before the egg retrieval procedure. The Lupride injection is given on the 18th day in the cycle preceding the actual IVF-ET cycle.
The dosage of lupride will depend on the investigations done on day 3 of the menstrual cycle.
Step 3-Baseline Pelvic Ultrasound
On day 3 of the menstrual cycle, a blood test is done to check the estradiol & LH level, an ultrasound scan to examine the ovaries & the baseline follicles in each ovary and the endometrial study. If your estrogen level is too high or if a cyst is detected, further a day or 2 is given to allow the cyst to resolve spontaneously or if the cyst is too big it is aspirated & ovarian stimulation medications are started.
Step 4-Ovarian Stimulation
If the baseline ultrasound shows no significant cysts, we start ovarian stimulation after menstrual bleeding begins. Ovarian stimulation medications are preparations of naturally occurring hormones, which are used to develop and mature multiple follicles by directly stimulating the ovaries.
Typically the injections are given daily for 8-12 days, depending on how your body responds to the medications. The average number of eggs retrieved at IVF is between 8 and 15. Please remember that it is the quality of the eggs, not the quantity that is important.
Step 5-Monitoring of Follicle Development and Estradiol & LH levels
Transvaginal ultrasound examination takes between 5-20 minutes to perform. It provides valuable feedback for monitoring follicular growth and determining when the follicles are mature and ready for retrieval. We correlate the estradiol levels in your blood with the ultrasound results frequently during the IVF cycle to ensure that you are taking the proper dosage of medication. We may adjust the dose of medication to improve follicular development. The amount of medication prescribed depends upon the results of the blood tests and ultrasound exams. Our goal is to make this process as easy and seamless as possible.
Step 6- Final Oocyte Maturation and HCG administration
Human chorionic gonadotropin (HCG) is a drug that stimulates the final maturation of the eggs. If it is given too early, few, if any, oocytes will be mature. If it is given too late, the eggs within the follicles may be post-mature and will not fertilize. HCG needs to be given 36 hours prior to the egg retrieval, so when we schedule your retrieval with the ARTS lab, we will notify you of the time that HCG is to be given. Since the oocyte maturation is an individual phenomenon apart from being a biological one our IVF team of doctors & embryologists work 365 days 24*7 round the clock not compromising on the time which is the most crucial part of an IVF-ET regimen.
Step 7-Transvaginal oocyte retrieval
The couple is expected to report one hour early to the time of egg retrieval. During the retrieval, the anesthesiologist administers intravenous medications (pain relievers and sedatives) in order to minimize the discomfort that may occur. The egg retrieval is performed via vaginal ultrasound (similar to the ultrasound used for monitoring your follicles during your stimulation). Once you are comfortable and relaxed, a tip of a thin needle is passed through the top of the vagina and into the cul-de-sac (space behind the uterus). The ovaries are located near the bottom of the cul-de-sac allowing the tip of the aspirating needle to enter the ovarian follicles and aspirate the follicular fluid from them.
The egg retrieval takes approximately five to ten minutes. Sometimes there are ovarian cysts that contain no eggs but appear identical to follicles that do contain eggs. Also, follicles of smaller size may not yield eggs. The number of follicles seen with ultrasound, therefore, may not correspond to the number of eggs retrieved. Ultrasound provides only an approximation of the number of oocytes that one can expect to recover.
Step 8-Insemination of Oocytes
Later, the sperm is prepared and placed with the eggs. In some cases, the embryologist will need to identify normal, motile sperm and inject them individually directly into each egg. This procedure is called Intracytoplasmic Sperm Injection (ICSI). Once the eggs are inseminated or placed with the sperm, they are placed into an incubator overnight. Semen samples for use in IVF procedures will be required on the day of egg retrieval and should be collected at the andrology lab at DRIFF. On rare occasions, the laboratory staff may request a second semen sample. The specimen should be obtained by masturbation after 3-5 days of abstinence. More than 5 days of abstinence is NOT recommended. It is important not to use any lotions or lubricants for sperm production as it may harm sperm motility. If you anticipate any collection difficulties, please notify your IVF coordinator prior to the procedure so we may have your husband cryopreserve semen before the day of the actual procedure. A normal 2-PN embryo on Day 1 Normal fertilization is characterized by a pronucleus of the egg and sperm that can be visualized under a microscope.
Step 9-Embryo Transfer
The embryo transfer (ET) is usually performed two, three days or five days after the oocyte retrieval. It is very important to have a full bladder before the embryo transfer. The procedure takes approximately 10-15 minutes and is very similar to the uterine measurement taken at your baseline appointment. You will not need anesthesia on this day, so there is no need to abstain from eating or drinking before your ET.
Once you, the embryologist and physician, have confirmed the plan for the embryo transfer, the physician will insert a speculum. An abdominal ultrasound will be used to visualize the uterine cavity. The embryologist will load the embryos into a small catheter which is then gently inserted through the cervical opening into the uterus, and the embryos are placed into the uterine cavity along with a very small amount of fluid. The catheter is then carefully removed.
Following the Embryo Transfer you will remain to lie down for approximately one hour, then we would like for you to rest at home for at least 24 hours. You must have someone accompany you and drive you home.
Step 10-Progesterone Supplementation
You will take progesterone injections beginning the evening after the oocyte retrieval and continue daily until your serum pregnancy test. If pregnant, progesterone will be administered for a total of 10 weeks. Ordinarily, the granulosa cells in the follicle will produce progesterone following ovulation, but some of these cells are removed during the oocyte retrieval. Therefore, supplemental progesterone is needed to help maintain the uterine lining for implantation.
Progesterone is a hormone normally produced by the ovarian corpus luteum during the last two weeks of the menstrual cycle and during early pregnancy. After the seventh or eighth week of pregnancy, the placenta takes over progesterone production. Natural progesterone is prescribed in many fertility treatments for luteal phase support of implantation and early pregnancy. Natural progesterone is also prescribed to support the luteal phase for patients in virtually every IVF program today. The progesterone prescribed is derived from natural sources and is identical to that produced in the body. Occasionally estradiol may also be supplemented from day 7 of the egg pick-up if it is deficient.
Do NOT discontinue your Progesterone or estradiol until directed by us.
Step 11-Pregnancy Follow-up
After the embryo transfer pregnancy test is done 12 to14 days after the embryo transfer. The pregnancy test is obtained before 10:00 a.m. and the results will be called to you the same afternoon. Positive tests are repeated in one week, and a sonogram will be scheduled after 30 days from the day of embryo transfer. Once we document a heartbeat on the sonogram, the pregnancy is confirmed. If your pregnancy test is negative, we ask that you schedule a follow-up visit to review your cycle and discuss options.