In Vitro Fertilization (IVF)
Where do I begin?
The decision to embark upon an IVF cycle is often the result of many months and years of living with infertility, often attempting other, more conservative treatment modalities. Most couples never believed that they would be at this juncture; but are resolved to no longer deferring their dreams.
Optimization of outcome begins with your initial visit with one of our physicians. A detailed history, assessment of hormonal profiles, semen analysis and uterine cavity and fallopian tube assessment allow us to provide for a treatment protocol tailored to the individual. During your follow up visit, the physician and care team will outline a medication protocol and together we will work toward its implementation.
How does it work?
IVF in particular is not smoke and mirrors. These advanced technologies increase the probability of creating a pregnancy during a menstrual cycle through 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 and hopefully it will be fertilized and result in a baby. The remaining candidate oocytes are lost.
This selection of the premier oocyte is driven by a hormone made within the pituitary gland of the brain; the hormone is called FSH (follicle stimulating hormone). It is the food that signals that premier follicle to grow. Minimal concentrations are present such 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. IVF cycles function successfully upon this premise.
Which protocol will optimize my chances?
It has been a long road, not one that ever would have been anticipated; but finally you have arrived. You have endured the testing, the ultrasounds and uterine evaluation. Now you have a diagnosis. Your physician will recommend a treatment protocol that is believed to be best suited to your situation. If your treatment includes IVF, there are three major medication protocols that are used to harness your reproductive potential by stimulating your ovaries to make more eggs.
Ironically, most of these protocols begin with birth control pills. These medications allow us to provide your body with a stable hormonal profile, working toward minimizing miscarriage rate and affording you some control in 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 tailored to the patient’s perceived needs.
Leuprolide acetate (agonist cycle) is one of the most common cycles employed. You will begin to inject a small dose of leuprolide under the skin through a very small needle (the kind used for insulin by people who have diabetes) while still taking the birth control pill. The leuprolide will be continued daily and the pill will be discontinued. 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 and 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; it is simply a higher concentration affording a response from multiple, competent follicles. 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 pretreatment. 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 bloodwork. 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.
Now you have met with the care teams, have a diagnosis and treatment protocol; you are almost there. At this time, you and your partner will need to sign the necessary consent forms for the treatment protocol. It is essentially, that these forms are completed prior to beginning medications and if applicable, submission of your case to your insurance company. Those patients submitting for insurance approval may find that the insurance company’s review time can be variable – days to weeks. Upon insurance approval, you will be notified by your care team that your medications are ordered and when you may begin the stimulation cycle and move forward in a timely manner.
Finally the cycle begins…now what?
Now that you are cleared and ready to go the process begins. While you are in an active treatment cycle, we will ask you to have multiple visits to any one of our centers for carefull ultrasound monitoring and bloodwork. We use ultrasound and blood work as surrogate markers to follow and anticipate egg maturity. You can anticipate between 3-5 early morning appointments so that we may monitor your progress and make necessary medication adjustments. Our monitoring is in the early morning. When in a treatment cycle, you always will receive a phone call or voice mail between noon and 5:00 pm with your directions for that day and instructions for the next step. We understand the stressors that both infertility and treatments bring and strive to minimize the inconveniences the process may cause you.
Once the oocytes are deemed to be mature, you will be asked to take the ovulatory trigger shot. It is an intramuscular injection and it is important that it is taken in a timely manner. As they have guided you through the cycle thus far, our care team will give you explicit directions with regard to 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 is both exciting and nerve racking for most patients as they await to hear of how many eggs are obtained. For the retrieval you will receive intravenous (IV) sedation. While sedated, our physicans will 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 or our 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 and injectable medications 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 shall meet. The potential embryos are examined the next day and fertilization parameters are assessed. On this day, you will find out how the eggs, and embryos have faired and the day for transfer. You will continue to take the hormones prescribed as well as your prenatal vitamins.
The Embryo Transfer Day
At last you have a tangible demonstration of your efforts, an embryo. On the day designated for embryo transfer, you will need to return to the Reading, MA center where you will discuss with the physician 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 those medications that promote implantation. Already you have been given a date to return to one of our centers for a pregnancy test. These days 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 and we hope to have 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.
