In Vitro Fertilization (IVF)
After months and possibly years of living with infertility, couples who no longer want to defer their dreams may decide to embark upon an IVF cycle. IVF often follows other, more conservative treatments.
Where do I begin?
At your initial visit, we take a detailed history, assess hormonal profiles, do a semen analysis, and examine the uterine cavity and fallopian tubes to diagnose your condition and create for a treatment protocol tailored specifically for you. During your follow-up visit, the physician and care team will outline a medication protocol and, together, we will work the plan.
How does IVF work?
IVF increases the probability of creating a pregnancy during a menstrual cycle by harnessing the body’s own reproductive potential. At birth, a woman has all of the eggs (oocytes) that she will ever use. Starting with her first period, her ovaries prepare approximately 400 oocyte candidates to be the single egg that is chosen monthly. If the egg is fertilized, it may result in a baby. The remaining candidate oocytes are lost.
This selection of the premier oocyte is driven by a hormone called FSH (follicle stimulating hormone) made within the pituitary gland of the brain. It is the food that signals that premier follicle to grow. Minimal concentrations are present so that there is only enough stimulation for one follicle, while the remaining follicles simply dissolve away. When the body is supplemented with FSH as an injectable medication, a few more of the 400 oocytes present can compete for the stimulatory source. In these instances, the better oocytes are spared from destruction and can be cultivated in the hope that they will generate a fertilizable oocyte and the potential for a good embryo and resultant baby.
Which protocol will optimize my chances?
In IVF, there are three major medication protocols that are used to boost your reproductive potential by stimulating your ovaries to make more eggs.
Ironically, most of these protocols begin with birth control pills. Birth control pills help stabilize your hormonal profile, minimize miscarriage rate and provide some control as to when the stimulation aspect of the cycle may start so that scheduling can be adjusted accordingly. These different stimulation cycles may be used in any order and are customized to the patient’s needs.
Leuprolide acetate (agonist cycle) is one of the most common cycles employed. While still taking the birth control pill, you will begin to inject a small daily dose of leuprolide under the skin through a very small needle. The pill will be discontinued and you will be on leuprolide alone from 5 days up to 10 days. The leuprolide temporarily will induce the brain to no longer respond to the increasing estradiol levels (the natural ovulatory signal) made from the developing follicles and will allow us to dictate the final maturation process for the eggs and the time of ovulation. You may or may not have a short menstrual cycle; however, having your period will not dictate when the stimulatory medications begin. As you continue to take the leuprolide blocking-injection daily, the stimulatory medication will begin and may take between 8-12 days. The stimulatory medication for all of our cycles is FSH and is comparable to the hormone that your body naturally makes but at a higher concentration. Often, but not always, a complementary stimulatory medication may be added.
A second type of cycle, microflare, involves leuprolide given in smaller doses twice daily in conjunction with stimulatory medications. The third cycle type is an antagonist cycle. Both the microflare and antagonist cycles most often require a birth control pre-treatment. When you are ready to proceed, our care team will give specific directions as to when to discontinue the birth control pill and an appointment to return to the center for ultrasound monitoring and blood work. Similarly, you may have a period at the time of this appointment. You will then begin your stimulation protocols, which are anticipated to last between 8 and 12 days.
Finally the cycle begins…now what?
After you have met with the patient care teams, have a diagnosis and treatment protocol, you and your partner will need to sign the necessary consent forms for the treatment protocol. These forms MUST be completed prior to beginning medications, and if applicable, submitted to your insurance company. The insurance company’s review time can be variable – days to weeks. Upon insurance approval, your care team will notify you when your medications are ordered and when you are to begin the stimulation cycle.
While you are in an active treatment cycle, we will ask you to have multiple visits to one of our centers for careful ultrasound monitoring and blood work. We use ultrasound and blood work as surrogate markers to follow and anticipate egg maturity. Depending on your progress, we may make medication adjustments. Our monitoring is in the early morning. When in a treatment cycle, you always will receive a phone call, voice mail, or email between noon and 5 p.m. with your directions for that day and instructions for the next step. We understand the stress that both infertility and treatments bring and strive to make the process as easy as possible.
Once the oocytes are deemed to be mature, you will be asked to take the ovulatory trigger shot. It is generally an intramuscular injection that must be taken in a timely manner. Our care team will give you explicit directions about the timing of this medication.
Approximately 36 hours after the trigger shot, you will be given an appointment for the retrieval, which occurs in our Reading, MA, office. The retrieval can be both exciting and nerve-racking for patients waiting to hear how many eggs are obtained. For the retrieval, you will receive intravenous (IV) sedation so that our physicans can perform the 10-minute procedure of oocyte aspiration under ultrasound guidance. Once awake, you will be transported to our recovery room for close monitoring. Most patients are discharged from our facility within two hours of the procedure. We ask that you return home to relax and recuperate. You will be given instructions to begin oral medication, injectable medications, or vaginal preparations to prime the endometrium for the embryos.
The IVF Laboratory
Within a minute of the procedure, the eggs are transported to the lab where then they are examined under the microscope. That day, the egg and sperm meet. The potential embryos are examined the next day, and fertilization parameters are assessed. We will contact you to discuss how the eggs and embryos have fared and set the day for transfer. You will continue to take the hormones prescribed as well as your prenatal vitamins.
The Embryo Transfer Day
On the day designated for embryo transfer, you will return to the Reading, MA, center, where your doctor will discuss the progress of your embryos and prepare for transfer. With a full bladder, and under ultrasound guidance, the candidate embryo(s) will be guided into the endometrial cavity and placed in a position to maximize pregnancy and reduce the risk of abnormal placement. We ask that you minimize your activities for the next couple of days.
The Next Two Weeks
Some patients report that the final two weeks of the cycle are the most challenging. During this time, you continue to take medications that promote implantation. We will schedule a date to return to one of our centers for a pregnancy test. These days may seem to take forever to pass. At this juncture, there is little that can influence the fate of the embryos. You have done your best and it is all that we can ask.
We know the day of the pregnancy test is anxiety provoking, so we work to get these results to you quickly. A welcomed pregnancy is followed carefully with serial blood tests, measuring the increasing levels of pregnancy hormone. Once we anticipate that we will be able to visualize the pregnancy by ultrasound, we will do so. Medications regimens will change, and we will transition you to assuming care with your obstetrician. Your pregnancy course should not vary from any women conceiving without ART.
The day of the pregnancy test is not always filled with happiness. The disappointment of a negative test can be paralyzing, if only temporarily. When you are ready, we invite you to make an appointment to meet with your physician to discuss the cycle and what has been learned from the experience with regard to embryos and optimizing the cycle. A negative pregnancy test does not necessarily mean that pregnancy cannot occur; it simply means that it has not happened yet.