IVF Step By Step
STEP ONE: STIMULATING EGG DEVELOPMENT
At the start of a woman’s normal menstrual cycle, a part of the brain called the hypothalamus releases a hormone that stimulates the pituitary gland to produce a hormone called follicle stimulating hormone (FSH). This hormone acts on the ovary to prepare an egg for ovulation. The egg develops in a fluid-filled bubble on the surface of the ovary called a follicle and when this is mature, another pituitary hormone called luteinising hormone (LH) induces ovulation or rupture of the follicle and release of the egg.
In an IVF cycle, artificial versions of FSH and LH are used by the doctor to stimulate the ovary to produce multiple follicles instead of just one and to control the timing of follicle maturation and ovulation. This process is called controlled ovarian hyper-stimulation (COHS). Medications are also used to switch off or ‘down-regulate’ the patient’s own hormone signals and prevent them from interfering with this process.
The fertility medications are administered in various ways: down-regulation drugs may be in the form of a daily nasal spray or injections and FSH is commonly a daily injection. The IVF nurses will teach you to administer the medications yourself and will explain exactly what you need to take and when according to your doctors instructions.
Soon after FSH treatment has started, ultrasound scans are required to carefully monitor the response of your ovary and the growth of the follicles. Blood tests may also be used to monitor oestrogen levels (a hormone produced by the follicle). The growth of the follicles is assessed by observing their increase in size however the eggs inside the follicles are too small to see.
The ultrasound technique that is used in this monitoring is quick and involves the gentle placement of a probe into the vagina. Results of these scans will allow the doctor to make the necessary medication adjustments in order to achieve optimum follicle development. Occasionally treatment may have to be cancelled during this process if the ovary does not respond or is thought to be over-responding.
STEP TWO: EGG RETRIEVAL
When a proportion of the follicles seen on the ultrasound scan have reached a diameter of 17mm, another hormone called human Chorionic Gonadotrophin (hCG) is administered. This hormone starts the final maturation and release of the eggs and mimics the LH surge that induces ovulation in the normal menstrual cycle. You will often hear this injection referred to as the ‘trigger’ injection. 36 hours after the trigger injection and before they are naturally released from the follicles, the eggs are collected by the clinician in a theatre procedure called egg retrieval or egg pick up (EPU).
The hCG trigger is often given late in the evening with EPU scheduled in the morning about 36 hours later. So, as an example, if hCG is administered at 11.00pm on April 14th, the EPU would take place at 11am on April 16th.
Your Nurse Coordinator will give you specific instructions as to when to cease the other medications you have been administering to stimulate the ovaries, and also the exact date and time to administer the hCG injection.
As egg retrieval is a theatre procedure, you will also be given the date and time for clinic or hospital admission as well as the time to cease eating and drinking (normally 6 hours before the egg retrieval).
Patients are normally asked to arrive at Life Fertility Clinic an hour and a half prior to the scheduled EPU. They will have a brief consult with a scientist and nurse coordinator before the woman is taken to theatre. Immediately before EPU, the woman will also talk to the anaesthetist. For some patients a local aneasthetic can be used for egg retrieval, but more commonly sedation will be used to induce sleep for about 30 minutes.
After the procedure you will remain in recovery for 1-2 hours until you feel well enough to go home accompanied by your partner or a responsible adult. You will not be able to drive after your anaesthetic.
The EPU procedure uses the same vaginal ultrasound probe that was used for follicle monitoring. An aspiration needle is attached to the probe and is passed through the wall of the vagina and into the follicles on the ovary. The follicle fluid and eggs are aspirated into a test tube and the fluids are passed to a scientist who will identify and isolate the eggs. The eggs are rinsed to remove any traces of blood and are then moved into small culture dishes containing a special fluid called culture medium. The eggs are cultured in this medium in the IVF laboratory until insemination with sperm 3-5 hours later.
STEP THREE: SPERM COLLECTION
On the day of egg collection, where appropriate, the male partner will be asked to produce a semen sample, around the time of the EPU. The semen sample may be collected at home as long as this is no further than 1 hour travelling time from Life Fertility Clinic; otherwise there is a designated private room for this purpose at the clinic. Specific instructions will be given with regard to semen collection including an appointment time to produce or drop off a sample at the clinic. Two to seven days abstinence from ejaculation is recommended prior to producing this sample.
It may be difficult for some men to produce a sperm sample on request under these conditions, or they may not be available on the day of egg collection due to unexpected work commitments. In these circumstances provision can be made for a semen sample to be frozen prior to the day of egg collection.
Some men do not produce sperm in their ejaculate even though sperm is being produced in the testis. For these patients a procedure called Percutaneous Epididymal Sperm Aspiration (PESA) or Testicular Sperm Aspiration (TESA) may be used to surgically retrieve sperm. Both of these procedures can be done through Life Fertility Clinic and will be arranged in advance by your clinician and Nurse Coordinator.
The use of donor sperm is another facility that Life Fertility Clinic can provide. This should be discussed with the IVF doctor and nurse coordinator prior to starting IVF treatment as there are several prerequisites to the use of donor sperm.
STEP FOUR: IN VITRO FERTILISATION AND EMBRYO CULTURE
Once the semen sample has been received by the laboratory (or a sample of frozen sperm has been thawed), various techniques are used to separate normal motile sperm from the seminal fluid. The resulting sperm preparation is used to inseminate the eggs. For standard IVF insemination, a large number of normal motile sperm must be present in the sperm preparation to optimise the chance that fertilisation will occur. If a suitable number of sperm are available, the sperm preparation is added to the eggs in the culture dish and they are cultured together overnight. If the number of sperm in the sperm preparation is too low for standard IVF however, or if they are of suboptimal quality in some way, a micromanipulation procedure called intra-cytoplasmic sperm injection (ICSI) can be used, whereby a single sperm is injected into each egg.
Irrespective of the method of insemination used, the morning after insemination (day 1), the eggs are examined under a microscope for evidence of fertilisation. If an egg has fertilised, the male and female genetic material are visible as two spherical bodies in the egg called pronuclei. A scientist will contact you on that day to inform you of your fertilisation results. Complete failure of fertilisation occurs in about 5% of patients who have eggs collected. This may be due to unpredicted problems with the eggs or sperm but sometimes may be completely unexplained.
In a normally fertilised egg, the pronuclei eventually fuse and the resulting embryo then begins to divide. For the first couple of days following fertilisation, development involves simple cell division so that by day 3, most embryos are somewhere between 5 and 8 cells. From day 3 onwards, the cell number continues to increase and the cells begin to rearrange themselves, start to differentiate into different cell types and by day 5 some embryos will reach a stage of development called the blastocyst.
A scientist checks the embryos every day that they are in culture; assesses and records their progress and quality; and changes the culture medium as appropriate. The scientist can also provide the couple with an update on the embryo development at any stage and will inform the patient if they have any particular concerns.
STEP FIVE: EMBRYO TRANSFER
At Life Fertility Clinic it is common practice for embryo transfer to take place on day 5 after fertilisation when the embryos are at the blastocyst stage. Embryo transfer can however take place on any day from day 2 to day 5 and the IVF clinician will decide which day is most appropriate for each couple.
‘Embryo Transfer’ is accomplished by depositing the embryo(s) into the uterus by means of a thin plastic tube called a transfer catheter that is passed through the woman’s cervix.
The clinician inserts a speculum into the vagina (as for a pap smear) and locates the cervix (the opening at the neck of the uterus). The scientist uses a syringe to pick up the embryo(s) into the tip of the catheter. The clinician then carefully passes the catheter through the cervix into the uterine cavity and the embryo(s) are deposited in the uterus. The process lasts only a few minutes and does not normally require an anaesthetic but patients will be asked to have a full bladder for the procedure as most clinicians like to visualize the embryo transfer using an abdominal ultrasound scan. After the embryo transfer the Nurse Coordinator will explain the procedure following transfer, such as medications to commence to support the uterine lining and the timing of your pregnancy test.
Couples who have more embryos than they can use may have any ‘extra’ good quality embryos cryopreserved for their future use. However, to do so, the couple must have signed the appropriate consent forms.
Embryos may be frozen for a period of up to five years, with an option to renew consent for a further five years.
STEP SIX: FOLLOW-UP
A pregnancy test will be arranged 10-12 days after the embryo transfer. It is important to note that bleeding prior to the pregnancy test date may not be a period, so you must continue on all medication until advised to cease.
If the test is positive a repeat blood test will be ordered. If you are on medication to support the endometrial lining you are to continue until advised to cease. An ultrasound examination will be arranged within the next two to three weeks. Once an ultrasound confirms the presence of a healthy fetus, the IVF doctor will discuss your plans for pregnancy care. For those who live at a distance from Brisbane, telephone follow-ups may be arranged.
If the pregnancy test is negative, patients will be advised by the nurse co-ordinator which medications to stop and when. The menstrual cycle may take 1Ð2 weeks to start and may be slightly heavier than normal. Progesterone may delay a period, even if the patient is not pregnant. You are advised to make an appointment with your doctor to discuss the results of your previous IVF cycle and plan future treatment. Our highly trained IVF Nurse Coordinators and reproductive counsellors are available to you and your partner at this time if you wish to discuss any issues arising as a result of a negative pregnancy test.
For more information or queries regarding any of the services offered at Life Fertility Clinic, please contact us.