IVF - In Vitro Fertilization
You will find below a general overview of what an IVF process entails. The 10 Step IVF Process provides more detail of how an IVF cycle gets started when you are a SRM patient. These details are meant as a general guideline only and serve as a reference only.
The actual timeline will depend on many factors, including your physician's recommendation whether any more evaluation is needed or surgery needs to be done, how long testing takes to get completed, where you are in your menstrual cycle at the time of your initial consultation and how many IVF cycles are going at the same time as your desired timeline.
SRM is the largest practice in the Pacific Northwest. Nevertheless, to maintain the highest quality care and ultimately success, SRM does not like to run too many IVF cycles at the same time. We do run IVF cycles continuously for your convenience and do not batch IVF cycles. Being the largest practice, our threshold for IVF cycles is very high so it very rare that an IVF cycle is delayed. The fastest timeframe is 2 months from the decision to proceed to knowing outcome of that cycle. We, of course, suggest to take as much time as you need to prepare.
SRM upholds to the principle that every patient is important from the first visit to every embryo in our laboratory. The education of the patient is of utmost importance. You have a primary nurse to field any questions via email or phone, visits with your physician culminating in a discussion of treatment plan and expectations, injection teaching class and finally the IVF seminar we encourage all our IVF patients to attend.
For any questions, please contact your primary nurse at 206-301-5000 or their direct line.
Our laboratory received accreditation for the College of American Pathologists. What does this mean?
The IVF cycle includes five basic phases:
- Development of ovarian follicles, i.e., the ripening of oocytes (eggs)
- Ultrasound guided, transvaginal aspiration of the oocytes.
- Fertilization and development of the fertilized eggs (embryos)
- Transfer of one or more embryos back into the uterus
- Follow-up Blood Tests and Obstetrical Appointment
Ovarian Follicle Development
In a normal menstrual cycle, just one egg/oocyte each month develops and matures. The egg matures with a fluid filled structure on the ovary called a "follicle" which can be seen on ultrasound. In an ART cycle, ovulation induction medications (typically daily self-administered injections) are used to stimulate the ovaries so that multiple follicles (eggs) will develop.
Depending on your stimulation protocol, you may begin your first medication in the menstrual cycle preceding the IVF cycle. Then, after your next period, the ovulation induction hormones are begun. Exact instructions regarding their use will be given to you at that time by the SRM nursing staff. These medications will be used for approximately 8 to 12 days, depending upon how your ovaries respond. These medications and their use will be explained in detail before each cycle.
When the majority of follicles have reached a mature size, another medication, human chorionic gonadotropin (hCG), will be given by injection. The hCG must be given at the appropriate time of follicle development to prepare the egg for removal from the body.
Monitoring of Ovarian Follicular Development
Beginning around cycle day 3, we will draw blood samples every 1 to 3 days to monitor the level of estradiol (a form of estrogen) in your blood. These blood tests will be used to determine if estradiol levels are in the range that we would expect prior to ovulation.
Ultrasound monitoring of the ovaries will also be used to follow follicular growth. The ultrasound machine works by sending out sound wave signals which reflect off different structures in the pelvis and give an image of follicles growing on each ovary. When indicated by your hormone levels, ultrasounds will be performed daily as well.
Because ultrasounds are performed using a vaginal probe, you do not have to fill your bladder for this procedure. There have been no harmful effects to developing oocytes or early pregnancy from ultrasound. Monitoring and daily decisions about your care are made by an SRM physician.
Doctors are on-call one week at a time so we can provide the seven day a week coverage. You will probably will see at least two physicians during your cycle. You may or may not see your primary SRM physician. The SRM physician on-call will abide by the treatment plan dictated by your primary physician unless there are extenuating medical circumstances that necessitate a change in your treatment plan. Any concern or questions regarding your individual treatment plan is best discussed with your primary SRM physician or nurse.
Day of hCG Injection
When ultrasound and blood estradiol levels indicate that the follicles are maturing, you will be instructed to give the hCG injection in the evening. You will be told the specific day and time to give your hCG injection. The egg retrieval is usually performed 35-36 hours after the hCG injection is given. We ask that the male partner refrain from sexual intercourse from the time of hCG until after the egg recovery, in order to obtain the best sperm sample possible.
The morning after your hCG injection you will receive final instructions for egg recovery and final medications.
Sonographic Egg Recovery (SER)
The majority of IVF patients have a sonographic egg recovery performed. This procedure uses ultrasound guidance to retrieve oocytes from your ovaries. The physician places the ultrasound probe into the vagina and guides the aspirating needle through the vagina into follicles on each ovary. Fluid is aspirated from the follicles and transferred to the embryologist, who will identify the eggs under the microscope.
Eggs are cultured and fertilized in our Embryology Laboratory. SER is performed in the special procedure room in our Seattle practice site with intravenous anesthesia. An intravenous catheter is placed in your arm through which to give medication as it is needed before and during the procedure.
Sperm (Semen) Collection
During or immediately following the egg recovery, the male partner will need to give a sperm sample. A private room is provided for discrete semen collection. Patients who need to use donor sperm will be given instructions on ordering donor sperm at the time of the initial screening appointment.
Culture and Fertilization of the Oocyte(s)
Once the eggs are retrieved, they will be placed in special fluid media for approximately 6 to 12 hours. The semen specimen will be prepared to isolate the best sperm for insemination, then placed with the eggs and incubated overnight. Intracytoplasmic sperm injection (ICSI) may be performed instead for any sperm abnormalities detected. (For information about the ICSI procedure, please see separate information sheet).
The eggs will then be examined for signs of fertilization, and normally fertilized eggs will be placed into a special growth medium. Embryos will be examined on the third day following insemination. Normally developing embryo(s) will be transferred back into your uterus three to six days after egg recovery, depending on the number and quality of the embryos as they develop in our laboratory.
Not all follicles aspirated can be expected to yield an oocyte. Moreover, all kinds of oocytes can be recovered: mature, immature, and post-mature or degenerate. You will be notified about the number of eggs that have fertilized the day after egg retrieval. Detailed information about the developing embryos will be available at the time of embryo transfer, at which point you will have an opportunity to discuss these results with the SRM physician. Some patients require special therapy such as assisted hatching to enhance implantation of the embryos. These therapeutic options will be discussed in detail with you at your appointments.
This the return of the embryos that have developed in our laboratory into your uterus. You will lie on an examination table as if you were going to have a Pap smear. There will be no anesthetic required. A very fine soft catheter is placed through the cervix into the uterine cavity under ultrasound observation, and the embryos are transferred inside the uterus through the cervix. Your partner or a friend may be with you during the transfer and during the 15 minute rest period.
The practice of transferring multiple embryos to a woman's uterus increases her chance for a pregnancy, but also raises the odds of having a multiple birth. The rate of multiple births for ART is higher than that of the normal population. Most of these are twin pregnancies; however, if more than two embryos are transferred, the risk of higher order multiple pregnancies (e.g. triplets) becomes a concern. Multiple pregnancies have increased risks for both mother and babies, particularly preterm delivery.
Please talk with your doctor about your chances of pregnancy and risk for multiple pregnancy. Together, you can determine the appropriate number of embryos to transfer (usually one to three) depending on your personal medical situation.
Depending on your personal medical situation and the quality and number of embryos, you will have the option of cryopreserving (freezing) the remaining embryos for thawing and replacement at a later time.
Cryopreservation is used to minimize the risk of multiple gestations (twins, triplets, etc.) which increases dramatically if more than two or three embryos are returned to the uterus. Depending on the quality and number of embryos available, a SRM physician will discuss with you the appropriate number of embryos to transfer in your particular situation.
Follow-up Blood Tests and Obstetrical Appointment
You will need to have a pregnancy test 10-12 days after the embryo transfer. We recommend the pregnancy test and first obstetric ultrasound ( if applicable ) be done with our practice. We are also anxious to know the outcome of your cycle, and are better able to offer medical and emotional support if we are informed right away.
Once pregnancy has been confirmed to be doing well with the ultrasound and blood work, we will send you back to your referring physician for continue obstetrical care or, if you do not have one, we can provide names of excellent general obstetrician/gynecologists in your area.
Unfortunately not all ART cycles result in pregnancies, you are encouraged to arrange a follow-up appointment with your original and primary physician. This appointment may be done by phone or face-to-face. The purpose of this visit would be to summarize your cycle, answer questions, and discuss future plans, such as future ART cycles, other infertility options or non-medical family building options.
If you elect to pursue another cycle without a visit, feel free to call your SRM nurse and your chart will be reviewed by your original physician for further recommendations.