Medical Contribution by Jason Bromer, M.D.

If you’re considering fertility treatment, it’s understandable that you would be naturally curious about in vitro fertilization (IVF) since it’s the most widely discussed form of fertility treatment. For many, IVF treatment can offer the highest chances of success, with a nearly 50 percent live birth rate for women under the age of 35.

While IVF treatment is a more advanced form of treatment, with this step by step beginner’s guide to IVF treatment, it is our goal to provide readers with a glimpse of what to expect with IVF treatment and address many of the common questions patients have about treatment in a comprehensive, understandable way. Think of this as “The Beginner’s Guide to IVF.”

What involved in the basic infertility work-up?

“The first step on the path to parenthood is identifying all the factors that might be contributing to a couple’s infertility,” explains Dr. Jason Bromer. This is done through a basic infertility work-up that includes testing of both the male and female partner.  The work-up includes:

  • Initial consultation: Your physician will take a detailed medical history that includes medical and lifestyle factors that may affect conception.
  • Day 3 testing: This consists of simple bloodwork to determine a women’s hormone levels and a pelvic ultrasound to count the potential eggs in each ovary. These tests will help your doctor select the proper dosing and types of medication for your treatment.
  • Anti-Müllerian hormone (AMH) testing: AMH is the most accurate predictor of a woman’s egg supply. Determined through a blood test, a higher AMH level would indicate a large amount of antral follicles and a strong ovarian reserve where as a lower value would lead your physician to believe there has been a decrease in the ovarian reserve.
  • Hysterosalpingogram (HSG): An x-ray dye test used to assess the uterine cavity and the Fallopian tubes. This allows the doctor to check for abnormalities in the cavity of the uterus and to verify your Fallopian tubes are open.
  • Semen analysis: Because male factor counts for 40 to 50 percent of all infertility cases, it’s critical to have a semen analysis as part of the basic infertility work-up. In this non-invasive test, we will analyze a sample of semen from the male partner under a microscope to evaluate the number and quality of the sperm. The test measures volume, concentration, motility (movement), and morphology (shape).

What diagnoses require IVF treatment?

Once diagnostic testing is complete, your physician will review your treatment options. Many patients are surprised to learn that IVF is not their only treatment option. However, IVF would be the first line of treatment for patients with the following conditions:

  • Tubal disease or tubal ligation: If a patient has a tubal ligation, IVF treatment would be the best treatment option since it bypasses the Fallopian tubes to achieve pregnancy.
  • Severe male factor infertility: If the semen analysis shows there are not enough healthy sperm to be successful with more basic treatment, such as intrauterine insemination (IUI), then IVF treatment can help patients overcome male factor infertility. With IVF treatment, an advanced method of fertilization known as intracytoplasmic sperm injection (ICSI) (pronounced “ick-see”) can be performed in the lab. With ICSI, only one healthy sperm is needed for each egg.

“Patients with other diagnoses may start with basic, ‘low-tech’ treatments like hormone therapies or IUI and then transition to IVF, if needed. However, with most of the more basic treatment options, data shows that after three to four treatment cycles, success rates begin to decline sharply,” says Dr. Bromer. By moving to IVF treatment, a couple increases their chances of success dramatically. Some additional diagnoses for which IVF treatment can improve the chances of success include: advanced age, endometriosis, ovulatory disorder, and unexplained infertility.

What’s involved in the IVF treatment process?

Step One: Stimulation

In a normal ovulation cycle, one egg matures each month. The goal of an IVF cycle is to have many mature eggs available, as this will increase the chances of success with treatment. In the stimulation phase of the IVF cycle, injectable medications are used  for approximately 8 to 14 days to stimulate the ovaries to produce eggs.

The injectable stimulation medications are derivatives from follicle-stimulating hormones (FSH) and luteinizing hormone (LH), which are both produced naturally within the body throughout the natural cycle.

During the ovarian stimulation phase, patients come into the office approximately 5-7 times for monitoring appointments. Monitoring allows physicians to track the progress of the cycle and adjust medication dosages as needed. Monitoring appointments typically last 15 to 20 minutes, early in the morning to avoid as much disruption to your daily schedule as possible, and consist of a transvaginal ultrasound and bloodwork.

  • The transvaginal ultrasound measures the growth of the egg containing follicles and the thickness of the uterine lining, both of which should be increasing throughout the stimulation phase.
  • Bloodwork is drawn at each appointment to measure the levels of estradiol, or estrogren. This level is another indicator of the growth and maturation of your eggs, and it rises as the follicles grow.

The last step of the stimulation phase before the egg retrieval involves the trigger shot. Depending on the protocol, you will either have a human chorionic gonadotropin (hCG) or Lupron trigger shot. The trigger shot provides final maturation to the developing follicles and sets ovulation in motion.

Timing is very important in this phase because we must perform the egg retrieval prior to the expected time of ovulation. Your designated nurse will give specific instructions on the day of the trigger about the shot, the monitoring appointment on the next day if needed, and the scheduling and preparation for the egg retrieval.

Step Two: Egg Retrieval and Fertilization

The egg retrieval procedure is done at one of Shady Grove Fertility’s fully accredited ambulatory surgery centers (ASC) in Rockville, MD, Towson, MD, or Chesterbrook, PA. Your physician will meet with you before the procedure to review the protocol and what will happen during the fertilization in the lab.

If patients are using a fresh sperm sample, a lab technician will come to collect the sperm sample. (Note: the preference from the lab is to have most patients produce a sample at home and carry it here in a sterile container, vs. producing a sample here.  Allowances are made of course, for those folks living far away (>2 hrs). If you are using a frozen sperm sample collected at a previous date, the technician will verify those details with you.

Prior to the procedure, you will meet with an anesthetist, who will review your medical history and place the IV. The IV fluids will be given prior to the start of the procedure and will deliver the anesthesia medication to induce sleep during the procedure.

The egg retrieval itself takes about 20 to 30 minutes. During the procedure, the physician will guide a needle into each ovary to remove the fluid along with the egg from each follicle. He/she will use an ultrasound to visualize the process on a monitor. Recovery takes about 30 minutes and you will be able to walk out on your own, though you will need someone to drive you home.

Step Three: Inside the IVF Lab

After the retrieval, the eggs and sperm are sorted and prepared. There are two ways that fertilization can take place: conventional insemination and ICSI. The decision about which method to use is based on the quality of the sperm.

What’s the difference between conventional insemination and ICSI?

With conventional insemination, the embryologist takes the prepared sperm sample and isolates the healthiest sperm. That sperm is incubated with the mature eggs in a Petri dish and fertilization. is visualized the next day.  (Fertilization is not ‘automatic.’)

During ICSI, an embryologist injects a single, healthy sperm into the cytoplasm, or center, of each egg. Since fertilization only requires one healthy sperm, ICSI has become one of the most incredible advances in fertility treatment because it allows for fertilization even in cases of severe male factor infertility.

Typically, ICSI is planned in advance, but sometimes it is unanticipated. The embryologist may see that semen parameters for conventional insemination are not being met, in which case, the embryologist will make the decision to switch to ICSI so that the cycle can still produce embryos and increase the chances of success for the patient. Your clinical team will let you know if an unanticipated ICSI procedure is recommended.

When does embryo development begin?

Embryo development begins when the fertilized eggs are placed in an incubator. Our embryologists examine each developing embryo very closely throughout the development process. The embryologist will makes notes about each embryo in your electronic record. At the SGF lab in Chesterbrook, PA, embryos are sometimes placed into an EmbryoScope. The Embryoscope allows for regular monitoring of embryo development without removing embryos from the incubator. The goal is to see the slow and steady development, with a two to four-cell embryo visible on the second day and an four to eight-cell embryo visible on the third day. After the eight-cell stage, cell lines begin to blur and the embryo enters what is called the blastocyst stage most often on day 5 (with day 1 being the day after your egg retrieval).

Preimplantation Genetic Screening (PGS): Your physician will discuss with you if he/she recommends PGS. PGS allows you to know whether your embryos are chromosomally normal or have abnormalities such as an extra chromosome 21, which causes Down syndrome. Missing and extra chromosomes account for the majority of genetic abnormalities seen in embryos and can contribute to failed implantation or miscarriage. The likelihood of having these chromosomal abnormalities increase with age. Risk of a chromosomal abnormality may also be increased in some cases of prior recurrent pregnancy loss.

Step Four: Preparing for the Transfer

Choosing the highest quality embryos to implant is the main goal of the embryologist since these are the ones most likely to result in pregnancy and ultimately a healthy baby. Embryologists  evaluate embryos by appearance and by how they have progressed through the stages of development during the few days spent in the laboratory.

A physician will transfer the embryo(s) into your uterus on day 5 when they have reached the blastocyst stage or are considered to be high-quality.

While embryos are in the laboratory, your nurse will call you regularly with a status report on each embryo. You can be rest assured the embryologists in the laboratory are using all of their skills and experience to choose the embryo that gives patients the best chances of success at transfer.

What happens during an embryo transfer?

The embryo transfer is a simple procedure that takes about 5 minutes to complete. There is no anesthesia or recovery time needed. When your transfer is scheduled, your nurse will notify you and provide you with specific instructions on when to arrive and how to prepare. You will need to have a full bladder for the procedure and will be asked to drink a specific amount of fluid 30 to 40 minutes ahead of time.

You will review your cycle with the physician to determine the appropriate number of embryos to be transferred. The transfer catheter is loaded with the appropriate number of embryos, and upon entering your room, the embryologist will verify your identification,and the number of embryos in the catheter. The doctor will insert the catheter into your uterus and release the embryo(s) through with a small puff of air. The procedure is guided visually on a monitor with an abdominal sonogram.
Once transferred, the doctor will slowly remove the catheter to eliminate or decrease any uterine contractions. Since the embryo is invisible to the naked eye, the embryologist will then check the catheter under a microscope to make sure the embryo was released. You will be asked to lie quietly for 5 minutes after the procedure. Then, you will be given instructions for the following 2 weeks until it’s time for the pregnancy test.

Step Five: The Pregnancy Test

Two weeks after the transfer, we will perform a blood pregnancy test to determine the results of the cycle. The blood pregnancy test is frequently called a “beta” because the test measures a beta chain portion of the hCG hormone emitted by the developing embryo and is officially named a “beta hCG” blood test.

As tempting as it is, we advise patients not to use home pregnancy tests before they have their beta test. Home pregnancy tests can render false results for patients, either negative or positive. A false positive can result because hCG that is usually given to “trigger” ovulation may remain in the blood; a home pregnancy test cannot determine the difference between the two. A false negative might occur because a low level of hCG may be undetectable in a urine test despite a pregnancy starting.

Affording IVF Treatment

Shady Grove Fertility works with over 30+ insurance providers and an average of 90 percent of patients will have coverage for their initial consultation. When insurance is not an option, Shady Grove Fertility offers several exclusive programs such as our Shared Risk 100% Refund Program and a variety of discount programs such as our Shared Help and Multi-Cycle Discount Programs. Click here to learn more about SGF’s unique financial programs.

 Editors Note: This post was originally published in March 2016 and has been updated for accuracy and comprehensiveness as of February 2019.

For more information about IVF treatment or to schedule an appointment with one of our physicians, please speak with one of our New Patient Liaisons at 1-877-971-7755 or click