Updated: Nov 19, 2021
In this three-part blog series, we discuss the process and timeline 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.
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 IVF timeline 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 the IVF timeline 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 clinic will arrange blood tests and an ultrasound scan. The scan is used to check that the ovaries are suppressed, that no cysts or large follicles are seen and that the endometrium (the lining of the uterus), is thin.
If you have an ovarian cyst, you may require a minor procedure under sedation, to remove (or aspirate) the fluid from the cyst to reduce the size.
If the ovaries are not fully suppressed you will continue the down-regulation medications until another ultrasound scan confirms that you are ready for the next phase.
During the second phase, the ovarian stimulation, you will take the FSH injections. As mentioned previously, this is usually over a period of 10-14 days. You will have bloods and an ultrasound usually at the beginning of the second week, and again every 1-3 days. The frequency of monitoring will vary depending on your protocol and the methods used by your clinic. After you’ve had your blood tests and scan, the clinic will ring you in the afternoon or early evening to tell you whether you need to change your dose of injection, and when you should return for repeat monitoring.
You will then move to the trigger injection (see below).
A short protocol is most commonly used if you’ve had a poor response to ovarian stimulation in the past, or it is anticipated that you may not respond to a long protocol. This type of protocol is also used if there is a risk of excessive response to stimulation.
You may be prescribed a pretreatment with the combined oral contraceptive pill or oestrogen tablet/patch during the second half of your menstrual cycle, also called the luteal phase, before starting your IVF cycle.
If you’ve had a previous cycle where one follicle has grown ahead of the others, meaning that only one follicle could be retrieved, it’s most likely that the cycle was cancelled. Or if you went ahead with egg retrieval, you did not get a sufficient amount of eggs or embryos.
Giving the pretreatment can result in a more coordinated number of follicles developing at the same time, which would give an overall greater number of follicles that could be stimulated during the ovarian stimulation phase, and subsequently more eggs that could potentially be retrieved.
Pretreatment, also called oestrogen priming, may be given for a few weeks or months. Oestrogen priming is not always used in the short protocol. It’s most commonly used if you have premature ovarian failure (also called early menopause) or low ovarian reserve.
After the oestrogen priming described in the previous paragraph, you will take FSH and LH injections for around 10-14 days to stimulate a number of follicles to grow. A GnRH antagonist injection, e.g. cetrorelix (Cetrotide), will be added on or around day 5-6 to stop the ovary from releasing the eggs before they are ready.
If you did not have oestrogen priming, you will have your bloods and ultrasound scan on day 1 or day 2 of your menstrual cycle. Then you will be advised when to start the FSH and LH drugs. This will usually be on day 1 or 2 of your menstrual cycle which is much earlier than in the long protocol. Then soon after, the GnRH antagonist will be started.
Similar to the long protocol, you will be monitored with bloods and ultrasound scans. you will be called by the clinic with further instructions on which drugs and the doses to take and when to return for repeat monitoring.
You will then be given your trigger injection.
Although the follicles are being stimulated to grow by the gonadotropin drugs, the eggs inside are not yet mature enough to be ready for fertilisation..
When a sufficient number of follicles are of the right size then an injection is given to complete the maturation process. The drugs most commonly used are HCG (e.g. Gonassi or Ovitrelle) or LH. You will have to take the injection at a specific time to ensure there is enough time for maturation but prevent losing the eggs by ovulation.
At the end of this process, your egg collection procedure will take place. The time between the trigger injection and your egg collection is around 36 hours. Some women who have had unsuccessful cycles in the past may need an extra 1-2 hours to allow the eggs to mature.
HFEA Consent Forms
Before or during the ovarian stimulation process you will be provided with, and asked to sign, a number of consent forms. These are required by law under the Human Fertilisation and Embryology Act 1990.
By signing these forms you confirm that you are happy to proceed with the IVF treatment, that you give or deny permission for your clinic to share your sensitive identifiable information with your GP, and other healthcare professionals etc, whether you consent to the storage of any embryos for future use, the law regarding storage periods and what will happen to your embryos should you not use them, e.g. training or research purposes or potentially donate to another couple.
You will also need to consider what would happen in the event that you or your partner pass away, e.g. do you consent to your spouse using the embryos in the event that you pass away and vice versa, who would be registered as the legal parent(s).
You will also sign the ‘welfare of the child’ form which is used to identify any issues which require support and assistance to ensure safety and protection for any child born as a result of undertaking fertility treatment.
You and your partner will be provided with separate consent forms and you will be required to sign independently. The forms must be read and signed and handed back to your clinic before you proceed with the egg retrieval, i.e before the IVF or any HFEA regulated assisted reproductive treatment, e.g. ICSI, IUI, Egg or sperm freezing.
There are also consent forms available to withdraw your consent should you wish to do so in the future.
The Second Phase of the IVF Cycle
The egg retrieval process occurs around 36 hours after the trigger injection has been administered. The egg retrieval is usually done in the morning. In the UK, patients have this procedure under sedation and therefore will arrive at the clinic having fasted (nothing to eat or drink for seven hours).
The nurse will do the admin, give you an ID bracelet, take your blood pressure, temperature, weight and pulse to prepare you for the procedure. You’ll meet the anaesthetist who will ask some questions. You'll briefly discuss the procedure and sign a consent form for the actual procedure with your fertility doctor and then go to the theatre for sedation.
The anaesthetist will put a drip in your arm or hand and then inject the sedative. You will then be taken for the egg retrieval procedure.
During the procedure, your legs will be raised and placed in stirrups. The doctor will use an ultrasound scan probe with a needle attached to it. The needle is placed into each ovary to suck out or aspirate the fluid inside the follicles, which contains the eggs into a test tube. The fluid is then poured into a petri dish.
If your partner is providing a fresh sperm sample, it will need to be produced whilst you are having the egg retrieval. He will already have been given instructions to abstain from masturbation and sexual intercourse for a period of time usually 2-5 days.
During your egg retrieval, he will be given a sample pot and a private room with a TV, DVD player and magazines. Your partner can also bring his own materials to help with arousal.
If you are using a frozen sperm sample this is the time it will be thawed. The embryologists then prepare the sperm sample for fertilisation.
After the procedure, you’ll be given antibiotics and painkiller suppositories into your rectum and then woken up from sedation. You will be given fluids and usually biscuits (which feels like a bit of a treat). Your doctor will tell you whether any eggs were collected and if so how many were collected. You can usually go home once you’ve passed urine and are mobile.
You won’t be able to drive for 24 hours, but can return to work or usual activities the next day if you are feeling well enough.
In part 2 we will cover the second part of the IVF cycle. The blog will be released in two weeks or you can subscribe to be notified of when it’s released. If you subscriebe you will also receive our monthly newsletter.
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