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Typically, we begin IVF cycles at the beginning of the woman’s menstrual period. While details may vary based on the individualized needs of the patient, the following may serve as a general guideline.
Ovarian Stimulation and Egg Retrieval
Baseline test
On day 2 or day 3 following onset of menses, a baseline ultrasound examination and blood test is done in our office.
Ovarian suppression – 2 to 4 weeks
Birth control pills are taken for 2 to 3 weeks to prevent ovulation and synchronize the egg follicles in anticipation of hormonal stimulation. Ganirelix (a GnRH antagonist) once your follicles reach 14 mm in size. Your doctor will discuss each protocol with you in order to choose the most appropriate.
Ovarian stimulation – 8 to 12 days
Ovarian stimulation with daily injectable fertility medications typically commences 4 to 5 days after stopping birth control pills. The medications are usually self-administered by injecting under the skin (subcutaneous) using a short needle.
Cycle monitoring – Day 4
Cycle monitoring consisting of ultrasound and blood tests typically begins on day four of ovarian stimulation. Monitoring visits to the clinic continue every one to two days until egg retrieval takes place. An ultrasound and blood test for estradiol are performed at each visit.
Trigger Injection – Between day 8 and 12
Final egg maturation is triggered with an injection of human chorionic gonadotropin (hCG). This injection is usually given in the evening approximately 36 hours prior to the egg retrieval.
Egg retrieval – 36 hours following hCG injection
The eggs are then retrieved in a 20- minute procedure conducted by passing a needle through the vagina into the ovary under anesthesia. The entire appointment will take approximately three hours.
Fertilization and Embryo Culture
Sperm collection – Day of egg retrieval
Sperm are obtained from the male partner on the day of retrieval. In order to optimize sperm quality, it is recommended that the male partner abstain from ejaculation for two to five days prior to providing the sperm specimen.
Fertilization – Day of egg retrieval
Semen is washed and processed, and the most robust sperm selected for fertilization. In general, one sperm is injected into each mature egg to achieve fertilization, a procedure called intracytoplasmic sperm injection (ICSI).
Embryo Culture – 5 to 6 days
Embryos are incubated in the IVF laboratory for 5-6 days until they reach the blastocyst stage. Culturing embryos in the laboratory allows selection of the most viable embryos. Blastocysts are assigned a single numerical (1-4) and two letter (A-D) grades. The numerical grade denotes the expansion of the embryo; the first letter – the grade of the cells that become the fetus; and the second letter – the grade of the cells that become the placenta. The letter grades are the most important as they represent the cells that will hatch from the eggshell and lead to a pregnancy. In general embryos graded BC and above are considered viable and frozen for future transfer.
Preimplantation Genetic Technologies (PGT) – 5-6 days after retrieval
If indicated, PGT is done when the embryo reaches the blastocyst—generally 5-6 days after fertilization occurs. PGT-A is used to determine whether the correct number of chromosomes are present embryo, and to select gender. The embryo biopsy procedure is performed by sampling 5 to 6 cells from the compartment of embryo that becomes the placenta. Results are usually available within two weeks.
Embryo Transfer and Progesterone Support
Assisted hatching – Day of embryo transfer
If indicated, assisted hatching is conducted in order to facilitate embryo hatching and implantation. This is accomplished by making a small hole in the outer shell of the egg.
Embryo Transfer
Research indicates lower pregnancy rates with fresh embryo transfer. For this reason, embryos are typically frozen and transferred at a later date. The embryo transfer procedure is performed by placing a soft guide containing the embryo(s) through the cervix under ultrasound guidance. The procedure is usually done under Valium to help relax the pelvic muscles. Patients are asked to arrive thirty minutes prior to embryo transfer and must remain in bed for fifteen minutes following the transfer. Patients cannot drive after taking Valium and need to arrange an alternative form of transportation.
Progesterone support – Day of transfer
Progesterone support typically begins 6 days before the embryo transfer and continues until 12 weeks of gestation if a pregnancy ensues or after a second negative blood pregnancy test. Vaginal suppositories are equivalent to intramuscular shots of progesterone injections.
Pregnancy testing – 7-10 days after transfer
A pregnancy test can be performed seven days after embryo transfer.