IVF 101

This is borrowed from another bloggers page "God's Faithfullness Through Infertility", but I thought it was a very good overview, so I borrowed some of it! This is my second fresh IVF cycle, so I am already familiar with the process and I know what to expect (for the most part anyway)!

This post is meant to serve one main purpose: to help family and friends who never been through in-vitro fertilization (IVF) to better understand the process. It is complicated, and if you have questions, please don’t hesitate to ask!

There are five main phases of the IVF process. The process is completed during the same amount of time it takes to complete a normal one-month menstrual cycle.

1. Ovarian Stimulation
1. Egg Retrieval
2. Fertilization
3. Embryo Culture
4. Embryo Transfer

Ovarian Stimulation
During ovarian stimulation the ovaries are stimulated using powerful fertility drugs with the goal of having as many eggs as possible mature. Having as many eggs as possible mature is necessary because some may not fertilize at all while others will fail to develop normally after they are fertilized.

The ovarian stimulation drug I will be taking is called Follistim. Many ladies undergoing IVF procedures have to take multiple stimulation drugs, but I stimulate very well on just the one, so there is no reason to add another!

During ovarian stimulation my ovaries will be closely monitored by frequent ultrasounds, and my estrogen and progesterone levels will closely monitored by frequent blood work. When any of the follicles get close to measuring on the “mature” range (usually above 14 mm) I will start taking another medication called Ganerillex. Ganerillex with keep my body from ovulating on it’s own, prior to the egg retrieval (which would be VERY bad and would cancel the IVF cycle!). On average I take the Ganerillex for about 3-4 days prior to the egg retrieval.

There is a condition called Ovarian Hyperstimulation Syndrome (OHSS) which can occur during ovarian stimulation. I am at a higher risk for developing this condition because I am young, lean and have developed the condition before (in July with my Follistim IUI cycle – I had to be hospitalized – YIKES!). The ultrasounds will also allow my doctor to watch for OHSS developing during ovarian stimulation.

The stimulation drugs have all kinds of lovely side effects (pages in fact). However, I’ll just have to take what comes, knowing the side effects will only be temporary. Again, we will be praying against negative side effects!

Egg Retrieval
As the eggs mature I will have one last injection: an hCG injection. I had this injection during all three IUI cycles to induce ovulation. The purpose of an hCG injection during IVF is to mature the eggs even further before they are retrieved (instead of ovulated).

The egg retrieval procedure is performed in the surgical unit on the 9th floor of Methodist Hospital here in Omaha. The procedure takes approximately 15 - 20 minutes.

Eggs are retrieved by a transvaginal ultrasound-guided aspiration procedure. Basically, during the procedure an ultrasound probe is inserted into the vagina to identify mature follicles. Then, a fine needle is guided through the vaginal wall and into the follicle where the egg is aspirated (retrieved) through the needle.

Ouch?!?! Don’t worry. I will be fully sedated throughout the whole procedure although I have to admit, I would love to witness the whole thing. It does tend to be pretty painful for a couple of days afterwards too, but I should be medicated appropriately and it shouldn’t be too big of a deal=).

There are many variables that influence the number of eggs that will be retrieved from any one woman.

Fertilization
Shortly after egg retrieval, eggs are placed with motile sperm in a petri-dish (hence the name, in-vitro fertilization). And then, well, it’s quite simple. The number of eggs that successfully fertilize is completely up to God, since He is the creator of life.

Depending on the quality and quantity of the sperm sample a procedure called intracytoplasmic sperm injection (ICSI) may be performed. During ICSI, a single sperm is injected directly into the egg, however, fertilization is still not a guarantee because, once again, fertilization is God’s business. God is the creator of life! Our RE automatically does ICSI on IVF cycles, so we know ICSI will be used this cycle as well.

The day after the egg retrieval I will receive a report on how many eggs fertilized successfully. Fertilization is documented by the presence of two nuclei. One nucleus is from the sperm and one is from the egg.

Embryo Culture: A Three to Five Day Process

Day 1: After fertilization, the nuclei from the egg and sperm fuse and the cellular division process of the newly created embryo begins.

Day 2: The embryos are carefully monitored for growth and proper cell division. The embryos are growing from a two-cell embryo to a four-cell embryo.

Day 3: The embryos are in the six to eight-cell stage now. Depending on the number of embryos, day three may be the transfer day (will explain what “transfer” is below.) If three or more eight-cell embryos are present, a 5-day transfer is very possible. Five-day transfers allows for better embryo selection since some of the embryos will not progress beyond the eight-cell stage. The decision on whether to do a 3-day or 5-day transfer is largely dependent on the number of embryos present and their quality. The first IVF cycle we did we transferred 2 – 3 day embryos and did not achieve pregnancy. On our following frozen IVF cycle we transferred 2 – 5 day embryos and did achieve pregnancy, so I suspect for this fresh cycle we will be doing a 5 day transfer.

Day 4: Eight-cell embryos that continue to grow and develop will now be at the morula stage (15-32 cell embryo).

Day 5: The embryos who make it to day five, form a cavity called the blastocoel (which is why the embryo can now be called a blastocyst).

Everyone going through IVF prays for embryos that are strong enough to make it to a 5-day transfer.

In summary, there are three critical development points that must occur if a 5-day transfer is to take place:
Fertilization
Four to eight-cell embryo stage
Morula to Blastocyst Stage

Embryos are “graded” using a numeric grading system with a Grade 1 embryo being the best and a Grade 4 embryo being the worst. It is important to know that the grade an embryo receives is no indication whatsoever about whether it will become a healthy or unhealthy baby. The grade is meant to only give doctors and their patients a means by which to measure the viability of any one embryo. In other words, a Grade 1 embryo has a much higher chance of actually implanting into the uterus and becoming a viable pregnancy whereas a Grade 4 embryo’s chance of becoming a viable pregnancy is not impossible, but very unlikely.

Obviously, we will be praying for many Grade 1 embryos that can make it to a 5-day transfer!

Embryo Transfer
During the embryo transfer, the doctor inserts a catheter through the cervix into the uterus and transfers one or more embryos. The embryo(s) is/are strategically transferred to the particular place an embryo would naturally implant in the uterus. If the embryo continues to develop in the uterus, it will hatch from the egg’s outer layer and implant into the uterine lining approximately six to ten days after the egg retrieval.

Depending on a woman’s age and the viability (grade) of her embryos, the American Society for Reproductive Medicine recommends transferring one to three embryos.

Cryopreservation – What to do with any “left over” embryos

Any remaining embryos following the embryo transfer can be frozen for future use.
This is perhaps the most controversial aspect of the in-vitro fertilization process. I believe the only unethical aspect of the cryopreservation process is discarding left-over embryos because “we are done having children”. I also believe that the moment sperm and egg unite, new life is formed.

If there are any “extras” and the first cycle of IVF fails, we will not have to go through any of the first four steps described in this post. A certain number of frozen embryos will be “unfrozen” and then transferred into my uterus at a third of the cost that this first, fresh IVF cycle.