In this three-part blog series, we discuss the process of IVF.
There are alternative approaches to IVF which involve less medication and are not discussed in this article.
Part 1 of this series discusses the first part of the cycle from deciding your treatment plan to the point of egg retrieval.
Part 2 of the series covers the in-vitro fertilisation process, embryo transfer and what happens after the embryo transfer.
Part 3 focuses on the side effects of the drugs, potential complications of IVF and how to know whether you could be eligible for NHS funding.
This blog follows on from our previous blog ‘What exactly is IVF?’ which discussed facts about the success rates and the impact of having IVF treatment.
So let's get started!
The image above, summarises the various stages of the IVF process, also known as the IVF cycle and the range of time it takes to complete this process. The timeframe can vary from person to person depending on the protocol chosen and the findings during the monitoring process.
Preparation for the IVF cycle:
IVF Treatment Plan -Protocol Selection
Leading up to any treatment you will have had investigations including blood tests and a transvaginal ultrasound scan (where the ultrasound probe is inserted into your vagina instead of placed on your belly). During the ultrasound scan, the antral follicle count will be taken and this will be viewed together with your other results including your AMH to determine your ovarian reserve.
You may also require other investigations or treatment before you start IVF. The ovarian reserve assessment and other investigations are discussed in our blogs female fertility tests and male fertility tests.
This article only focuses on the IVF treatment itself.
Your fertility specialist will put together your IVF treatment plan also called the protocol. The main types of protocols are discussed below in the section ‘IVF protocols for ovarian stimulation’. Your specialist should also give you an estimation of the success rate for your treatment.
The doses of drugs and timings of the various phases of the IVF cycle, vary from person to person, as does the response to treatment. Your protocol may be different to others who are having IVF. You may be required to take additional drugs, you may need to have additional procedures. Also be aware that a cycle can be cancelled at any point if the response is not satisfactory.
For now, we’ll discuss some of the practical issues you need to know.
The doctor will prescribe the drugs and the clinic will either arrange for them to be delivered to you, or you will need to collect them. If you are self-funding, you will have to pay for the drugs in advance of receipt; either directly to the dispensing company or to your clinic.
The drugs can be available in various forms and will include one or more of the following:
Vials for Injections
Pre-loaded syringes ready for injection
Oral tablets (taken by mouth)
Some drugs need to be stored in your fridge, so when they arrive you will need to do this straight away.
The equipment you will need to administer the injections should also be provided. This includes:
Syringes & needles
A storage bag
A special sharps bin to dispose of the ‘Clinical waste’, i.e. needles and syringes*
You may also need to buy additional supplies e.g. alcohol swabs, cotton wool, tape or plasters.
*For safety reasons, clinical waste should not be disposed of in your household waste. Clinical waste should only be disposed of in special bins and are incinerated. If clinical waste is disposed of in household waste, it could cause injury to the workers who clear your household waste and are not expecting to be exposed to needles.
Blood borne viruses such as hepatitis and HIV can be transmitted from needle injuries. Once you have finished your cycle, close the sharps bin, ensure it’s fully sealed and take it to your clinic for proper disposal by incineration.
The fertility nurse at your fertility clinic will show you how to use the equipment and administer any injections. Some women administer the injections themselves and some get their partners to do it. It can be a nice way for your partner to become more involved in the process, and help them to feel like they
The First Phase of the IVF Cycle
Menstrual Cycle Suppression and Ovarian Stimulation
During your natural menstrual cycle the FSH hormone (follicle-stimulating hormone), which is one type of gonadotropin hormone, is produced by your pituitary gland and acts on the ovary to stimulate the growth and development of a single follicle (which contains a single egg).
During the first half of your menstrual cycle both FSH levels increase, first to stimulate the growth of a follicle and then LH (luteinising hormone) levels increase to stimulate growth of the endometrial womb lining. As the follicles grow they produce oestrogen. A final surge in LH levels occurs just before ovulation.
The first phase of IVF involves downregulation of the system, described above, to suppress your natural menstrual cycle, then controlled ovarian stimulation aims to encourage several follicles to develop. This is done with gonadotropin drugs given by injection or nasal spray.. The intention is that a good number of eggs will be collected at a specific time for the IVF fertilisation process later on.
The gonadotropin drugs used contain FSH and LH in different quantities. e.g. Menopur (FSH and LH) or Gonal-F (FSH only). They are taken by subcutaneous injection (injection under your skin), most commonly in your abdomen. You will take the gonadotropins, for around 10-14 days.
As the follicles grow, a gonadotropin-releasing hormone agonist (GnRH agonist) is then given to prevent ovulation of those eggs. Buserelin is most commonly used for this purpose and is given by subcutaneous injection or nasal spray.
During this time you will be monitored by the doctor with blood tests to check that your oestrogen levels are rising. You will also undergo ultrasound scans to check that the follicles are growing and to measure their size.
The fertility specialist will be looking to ensure that you are responding to your medication. They will want to prevent the follicles from getting too large and risking ovulation (ejection of the eggs from inside the follicles). Once the eggs have ovulated they cannot be used for IVF.
The fertility specialist will want the follicle size to be around 12-19mm in diameter on the day of the trigger injection (next phase).
As the follicles grow you may start to feel more bloated and full. It’s important to stay hydrated and not to overexert yourself. In the next blog, I’ll discuss the risks and potential complications of IVF.
IVF Protocols for ovarian stimulation
There are several types of protocols used in IVF treatment to stimulate the ovaries. The most common protocols used are the long protocol and the short protocol. The protocol is decided by your fertility team before you start treatment.
The decision is based on your likelihood of responding to the gonadotropin drugs which is influenced by factors including your age, ovarian reserve, oestradiol levels, your response in previous cycles, e.g poor response or poor embryo quality or whether you have a condition such as polycystic ovary syndrome (PCOS) where ovaries can be prone to over stimulation.
There isn’t a set criteria for deciding which protocol to use, and the selection process varies between doctors and clinics. Overall, the doctor wants to stimulate your ovaries to get a sufficient number of mature and good quality eggs, whilst avoiding over stimulating the ovaries which can cause other complications such as ovarian hyperstimulation syndrome (OHSS), which will be discussed in the next blog.
A long protocol consists of two separate phases. The down-regulation to temporarily suppress your ovaries, and then the monitored ovarian stimulation.
The drugs you take for the down-regulation are GnRH agonists e.g. Buserelin started on or around day 21 of your cycle, depending on the length of your cycle. You will be asked to call the clinic on day 1 of your period so your clinic can tell you which day you should start taking it.
The downregulation phase may take 2-3 weeks or up to 6 weeks. Towards the end of this phase you will have a bleed. Your