The IVF Cycle:  A Complete Guide

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Evaluation and Preparation Phase

You will begin the road to IVF by consulting with one of the doctors at the Wisconsin Fertility Institute. At that visit, the doctor will review all treatment options available to you, as well as their likelihood of success and approximate cost. The doctor may also suggest additional tests to further refine the likelihood of success with each option. If you should then opt for IVF you will meet with a member of the nursing staff who will review which tests are required prior to beginning the IVF treatment. Once these tests are completed and we have the results, you will again meet with your doctor and a nurse, review the test results and, if all are normal, proceed to treatment. If one or more tests is abnormal this will be discussed with you and treatment plans reconsidered.

Cycle of Treatment

There are a number of different approaches to drug administration for an IVF treatment cycle, and each has been found to be the best approach in some patients. However, no approach works in everyone, and occasionally a poor response to medication may necessitate a discontinuation of treatment, with resumption later using a different drug combination. In this center, three approaches are used primarily, although small variations may sometimes occur for individual patients:

  1. Agonist suppression:  With this approach, women begin a drug called Lupron after a couple of weeks on oral contraceptives. The drug is administered daily by subcutaneous injection. When a period begins, the woman comes to the clinic for a "baseline" visit. This visit consists of four steps:

(a) an ultrasound to show that nothing has begun to grow on the ovaries
(b) a blood estrogen level to confirm that nothing was missed on ultrasound
(c) a fake embryo transfer with an empty catheter to insure that the embryo transfer can be done at the appropriate time with a minimal amount of trauma to the cervix and uterus and
(d) a check to make sure consent has been obtained.

If the ovaries are quiet, the estrogen level is low, the uterus is easily entered and consent forms are signed, we are ready to begin stimulation of the ovaries. To this end, the Lupron is continued (albeit at half the dose) and a drug called Follistim is added each day. This too is a subcutaneous injection, and will cause the eggs in your ovary to grow. Every two to five days we will bring you back into the office, recheck your ultrasound and estrogen tests, and adjust the Follistim dosage for a few days. Eventually, if all goes well, many eggs will grow on both ovaries. When they are large enough (usually after 9-14 days of Follistim) we stop the Lupron and Follistim and administer a single injection of a drug called Ovidrel. This subcutaneous drug is given 35 hours prior to the harvesting of your eggs, and is responsible for their final maturation and readiness to be mixed with sperm. The agonist suppression protocol is the most commonly used drug regimen for IVF, and has been repeatedly shown to produce the highest pregnancy rates in most patients.

  1. Microdose flair:  In patients with a previous poor response to Agonist Suppression, who are age 40 or over, or who have a day 3 FSH value over 10, the first line approach to stimulating the ovaries is Microdose Flair. The idea behind this treatment protocol is to use the body's own FSH in combination with Follistim to stimulate the ovaries to grow eggs. The day after your period begins you have a baseline visit, and if all is acceptable you administer a low dose of Lupron subcutaneously. After 2 days of Lupron only, Follistim is added at the maximum dose. This is continued, with periodic ultrasound examinations and blood estrogen tests, until a reasonable number of eggs have grown and matured (usually 9-14 days). The drugs are then discontinued and Ovidrel is administered.
     
  2. Antagonist :  For women who show a poor response to the above approaches, or for those women expected to have a huge and highly dangerous response, no Lupron is administered. Instead, after the menstrual period starts a baseline visit is conducted and if all is adequate Follistim is begun on a daily basis. Periodic ultrasound examinations and blood estrogen levels are performed. When the largest ovarian follicle (egg surrounded by fluid) measures 14 mm, daily injections of Antagon are administered subcutaneously each day until a large number of eggs are fully grown and mature. The drugs are then discontinued and Ovidrel is administered.

Egg Retrieval

Thirty five hours after the administration of Ovidrel you will undergo a procedure called egg retrieval. You will be instructed not to eat or drink anything after midnight the night before the egg retrieval, due to the anesthesia given. You should also have someone with you at the retrieval as you should will not be allowed to drive immediately afterwards. On the day of the retrieval, a fresh semen sample will be obtained for use in the fertilization process. In certain situations, a sample can be obtained earlier and cryopreserved or frozen. The specimen would then be then thawed for use on the day of retrieval.

The egg retrieval procedure is done at our office under light anesthesia (intravenous sedation). A needle guided by ultrasound is passed through the top of the vagina and into the follicles in the ovary. It takes about 30 minutes to retrieve the eggs, and then 60-90 minutes to rest in our recovery room.

The fluid we remove from the follicles is given immediately to our embryologists who use their microscopes to find the otherwise invisible eggs. The eggs are usually inseminated a few hours after retrieval with sperm from your husband, partner, or an anonymous sperm donor. This is done by our embryologists who are also responsible for culturing the fertilized eggs (now called embryos) until the time of transfer to your uterus.

You will also begin daily administration of two drugs at this time: Estrace (a pill taken twice daily) and progesterone (an intramuscular injection taken each day). These drugs help prepare the lining of the uterus for the embryos to implant and grow, and will be continued until either pregnancy does not occur or 11 weeks of pregnancy is reached.

Embryo Transfer

Prior to the transfer, you will be instructed to eat or drink lightly. The transfer itself is a very simple procedure and is nearly always completely painless. It is very much like a routine pelvic exam and involves the passage of a very small plastic catheter through the cervix. A tiny drop (20-30 microliters) of culture media with the microscopic embryos suspended within are deposited in the upper reaches of the uterus.

Embryos are usually transferred either three or five days after the egg retrieval. Five days is preferred, but occasionally day three is chosen due to issues with embryo number or growth. For more information, see the discussion "Choosing Your Day of Transfer".

Embryos that are not transferred can be frozen in liquid nitrogen provided they are of good quality. Once frozen, they can remain potentially viable for many years, perhaps even indefinitely. From reported studies on the matter, babies born from a frozen embryo transfer are just as healthy as babies conceived naturally and have the exact same chance of having birth defects.

Post-Transfer

After the transfer, an anxious wait begins until the pregnancy test, which is called a quantitative Beta hCG. We routinely get pregnancy tests 17 days after egg retrieval.

If the pregnancy test is positive, you will be instructed to continue the Estrace and progesterone. An ultrasound will be scheduled approximately two (2) weeks after the positive test results to confirm a clinical pregnancy and determine the number of babies present.

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