In this blog we will cover:
The complications and risks of IVF treatment.
Deciding on how many embryos to transfer.
How to know whether you could be eligible for NHS funding.
Some information on how to manage the two week wait period; the period from after the embryo transfer to the day you are due to take the pregnancy test.
If you haven’t done so already, make sure that you read the first two parts of this series. Just to recap;
Part 1 of this series discussed the first part of the cycle from deciding your treatment plan to the point of egg retrieval….and
Part 2 of the series covers the in-vitro fertilisation process, embryo transfer and what happens after the embryo transfer.
So let’s continue.
IVF: Potential Complications
Generally, IVF is safe and the risk of serious complications is low. As with almost all procedures, there are some risks associated with IVF treatment.
Risks of IVF include:
Multiple pregnancy
IVF can lead to increased chance of a multiple pregnancy e.g. twins or triplets. This risk is greater when more than one embryo is transferred into the womb. Multiple pregnancies are higher risk pregnancies than pregnancies with a single baby.
The mother is at greater risk of having conditions such as diabetes, high blood pressure, preeclampsia during pregnancy, or the need to have surgery by Caesarean section, with the potential risks of surgery such as serious bleeding.
There are also risks for the babies such as premature birth before the lungs have fully developed, or even the loss of one or more babies.
The BFS recommends single embryo transfer to reduce the chance of having a multiple pregnancy, and to improve overall safety of the IVF process. This is discussed later in this blog.
Due to the increase in multiple births from IVF treatment, the HFEA set a goal to reduce the national multiple birth rate. In 2008 the multiple birth rate was 24% i.e. just under 1 in 4 couples who had fertility treatment gave birth to more than one baby at a single time. In 2017 it was down to 10% i.e. it had reduced to 1 in 10 couples, and in 2019 it was 6%, approximately 1 in 20 couples.
Side Effects from the medications used
The range of side effects experienced from the medications used during IVF will vary with each person. Some people won’t experience any side effects at all. Other side effects can include tiredness, headaches, hot flushes, nausea, vaginal discharge, bloating and ovarian hyperstimulation syndrome (OHSS) which is discussed below.
You should be informed of potential side effects of the drugs you have been prescribed from your fertility doctor or fertility nurse and pharmacist. If you develop any symptoms related to allergy, inform your clinic or your GP immediately.
Ovarian Hyperstimulation Syndrome (OHSS)
OHSS occurs if your ovaries respond excessively to the stimulation medication. The ovaries continue to grow and become painful. OHSS can be mild, moderate or severe.
Your abdomen can become distended and painful. The distension may be mild or marked. You may even start to feel nauseous or vomit. Fluid from your blood vessels may leak into your abdomen, around your heart and lungs, and in severe cases you may develop shortness of breath.
If you are experiencing distension, abdominal pain, vomiting, urinary symptoms, chest pain or any difficulty in breathing, seek medical advice as soon as possible from your fertility doctor, GP or urgent care service e.g. NHS 111 or A&E.
Mild OHSS treatment can usually be treated from home. You will be advised to drink fluids, take painkillers and be monitored. If your OHSS is severe you will be admitted to hospital for observation and be given intravenous fluids, ie. blood thinning drugs and painkillers. If there is a lot of fluid in the lungs, abdomen or around the heart, this will be drained.
Risk of infection during egg retrieval
The risk of infection during egg retrieval is usually mitigated by giving you some antibiotic cover during the procedure, and ensuring that you have been screened for chlamydia before the procedure.
Problems during the cycle
The cycle can be cancelled before egg retrieval if you are not responding to the medications. There is a risk that no eggs are retrieved at egg retrieval, that no eggs fertilise after egg retrieval, or that no viable embryos are produced. If the ovaries are overstimulated it can lead to ovarian hyperstimulation syndrome as discussed above. It can be extremely disappointing and frustrating to have to cancel a cycle. Additionally, you may have already incurred the costs related to the cycle such as medication used, ultrasound monitoring and costs associated with egg retrieval. If problems occur during the cycle or if you have a familed IVF cycle, a follow up appointment will be arranged with your fertility doctor to discuss the issues and help decide the next steps.
Ectopic Pregnancy
IVF can lead to a slightly increased chance of ectopic pregnancy. Ectopic pregnancy occurs when a pregnancy forms outside of the womb. They most commonly occur in the fallopian tube but can occur anywhere in the pelvis.
A tubal ectopic pregnancy can burst through the fallopian tube and cause severe bleeding and even death. The embryo has to grow to a certain size before this happens, so you will have completed the two week wait and had a positive pregnancy test.
Ectopic pregnancies usually present with pain, and sometimes vaginal bleeding, but not always. Therefore if you experience any pain in the abdomen or pelvic area, with or without shoulder tip pain, and with or without vaginal bleeding or spotting, you must seek medical advice as soon as possible from your fertility doctor, GP or urgent care service e.g. NHS 111 or A&E.
Depending on the location, size and stage of the ectopic pregnancy, treatment may involve observation, medication or surgery. If you have one ectopic pregnancy you may have an increased chance of having another ectopic pregnancy in a future pregnancy. Therefore if you have a positive pregnancy test in the future, you will be monitored with blood tests and scans from an early stage to keep you safe.
Having IVF Does Not Guarantee That You Will Become Pregnant or Have a Healthy Baby
Whilst the success rates for IVF have improved over the years, there is a risk that having IVF won't result in getting pregnant or having a baby.
The success rates of IVF in the UK show that across all patients who received IVF, the birth rate per embryo transferred was over 1 baby born for every 5 embryos (20%) on average for the first three cycles. To explain further the figures demonstrated that in 2018:
For every 100 embryos transferred into patients during their first cycle, just over 26 babies were born.
For every 100 embryos transferred into patients during their second cycle, just over 24 babies were born.
For every 100 embryos transferred into patients during their third cycle, 21 babies were born.
The rates steadily decreased with each new cycle as the patient's age increases and from the fourth cycle onward there were fewer than 1 baby born for every 5 embryos transferred (i.e. less than 20%).
The live birth rates per embryo transferred were lower in older age groups.
Using donor eggs can more than double the chances of success in patients aged 35 or more.
How Many Embryos Are Transferred During IVF
The British Fertility Society strongly recommends single embryo transfer but if you are over 35 or have had repeated failed IVF cycles, your doctor may recommend that two embryos are transferred. If you are aged 40 or more and are using embryos fertilised from your own eggs, you can have a maximum of 3 embryos transferred.
Embryo Grading and Quality
The embryo grading system was developed, reviewed and refined to improve the selection process of embryos and blastocysts to allow the best single embryo or blastocyst from your selection to be transferred.
So how does the grading system work? In the UK the system is approved by the Association of Reproductive and Clinical Scientists (ARCS) and the National External Quality Assessment Service (NEQAS). There is a grading system for embryos and for blastocysts, and each is based on various characteristics.
In embryos grading is determined by the size and number of cells, and the percentage of fragments and defects in embryos. The grading score is from 1 to 4, with 4 being the highest quality embryos due to a smaller percentage of fragmentation and good sized blastomeres, and 1 being poorer quality embryos.
In blastocysts, the grading is a combination of letters and numbers. The number correlates with the stage of the blastocyst so that an early blastocyst is 1, and a hatched blastocyst in 6.The letter correlates with how developed the trophoectoderm and inner cell masses are, with A being most developed and D being least developed. So the grading could be 4AB or 3BC. Grade 5 and Grade 6 are hatched blastocysts with 6 having progressed further in the hatching process.
Early blastocysts are not suitable for freezing as they are unlikely to survive the process required to freeze and thaw and still be effective.
Important point!
It’s important to be aware that these systems are designed to help select the best embryos for transfer from those embryos or blastocysts available. They are not designed to predict the success of treatment, or likelihood of implantation or pregnancy. If an embryo or blastocyst is of poorer quality it can still be implanted and become a healthy baby. It’s possible to become pregnant and have a healthy baby from a single ‘poor quality’ embryo transferred on day 2.
What Day Is Embryo Transfer?
As described in part 2 of this series, the embryology team at your fertility clinic will nurture your eggs and sperm and mix them together to allow fertilisation to occur, or perform ICSI. Once the eggs have fertilised they will be incubated and allowed to divide and develop into embryos over a period of 2-6 days. Embryos may be transferred back into the womb on day 2, day 3 or day 5. Day 5 embryos are known as blastocysts.
Any embryos or blastocysts that aren’t transferred back into the womb may be frozen and stored for future use, with the right consents in place, and if they are suitable for freezing.
Embryos are formed of blastomeres, which are cells that are created from dividing. During embryo culture, fragments or defects in the embryo can be seen. The fragments can be related to maternal age related factors, chromosomal abnormalities, quality of the egg or sperm, and other factors.
Around day 5 an embryo becomes an early blastocyst. The blastocyst is formed of an outer layer of cells called trophoectoderm, which, after implantation, will form the placenta and an inner cell mass which will become the foetus. The blastocyst is surrounded by a shell called the zona pellucida, which needs to become thin and then break, so the blastocyst can implant into the lining of the womb. The breaking of this shell is called hatching.
The Two Week Wait
After the embryo transfer, all of the procedures are over. It’s now time for the embryo or blastocyst to start implanting into the womb lining, and continue to develop into the baby you long for. The team at the fertility clinic will have given you a date to perform your pregnancy test. It’s approximately two weeks after the date of your embryo transfer.
It’s a time that can be filled with a combination of hope and anxiety, because you don’t know what’s happening inside. Over the next 1-2 weeks you may feel various symptoms or may not feel symptoms at all. Disappointingly, there is no set of symptoms that classically confirm that things are moving in the direction you hope for.
For tips on how to cope during this 2 week waiting period with regards to mindset and keeping good health I highly recommend watching this webinar from Fertility Network UK. The presenters answer numerous questions from the audience and provide some insightful tips along the way.
Eligibility for NHS Funding
This particular section is relevant for UK readers only, so if you do not live in the UK, please skip to the next section which briefly discusses other methods of funding including self-funding.
If you live in the UK, you may be eligible for funding from the NHS to help cover part, or all of your assisted reproductive technology (ART) fertility treatment which includes IVF and IUI. Unfortunately this does not apply to everyone in the UK. In some area’s funding may not be provided or you may not be eligible for funding.
Everyone in the UK is entitled to investigation to try determine the underlying cause of infertility. This usually starts at your GP and then continues at an NHS fertility clinic. You may be required to see a specialist gynaecologist, endocrinologist or urologist. NICE recommends clinical assessment and investigation of any woman of reproductive age with the following conditions:
Has not conceived after 1 year of unprotected vaginal sexual intercourse.
Is using artificial insemination to conceive if they have not conceived after 6 cycles of treatment
Women who are 36 years or over, or who have a known clinical cause of infertility or a history of factors that could increase the chances of infertility e.g. endometriosis, PCOS should be referred to a specialist investigation earlier than the time frames provided above.
Your CCG may have their own guidelines for when your GP can refer you to see a specialist, but your GP can still arrange a number of investigations in the meantime.
ART is only performed by fertility clinics licenced by the HFEA, and this is funded separately from fertility investigations and seeing a gynaecologist or urologist. If your fertility clinic is recommending ART, they will have to complete an application on your behalf to your Clinical Commissioning Group (CCG) to request NHS funding to go ahead. If you are not eligible for funding, you will have to consider whether you can self-fund your treatment.
So how do you find out whether you can receive funding?
You can speak to your GP as a first start. As mentioned above, your fertility clinic will know. You may be able to enter a term such as ‘IVF’ or ‘fertility’ in the search bar on your local CCG website or another CCG that you are considering moving to.
If that doesn’t work, you can enter the phrases above into google search to locate it.
The information is written on a specific policy so you can try one of the following phrases:
Fertility treatment access policy in ‘x’
IVF Treatment policy in ‘x’
Access to infertility treatment in ‘x’
Replace the ‘x’ with the CCG you want to find out about.
The policy will state whether same sex couples or single people will also have access to NHS funding treatment and will include any exclusions that apply to all patients.
Be sure to check the date of the policy. If in doubt you can contact the CCG to check that you have the current version.
Insurance Funding For IVF
If you do not live in the UK, and you have health insurance, check with your insurance provider to see whether they cover fertility investigations, medications and ART treatments. In some states in the US, it is mandatory for insurers to cover some infertility services.
In the UK, health insurance providers do not cover any investigations, medications or treatments related to fertility issues, but they usually cover any investigations and treatments for conditions that could cause infertility e.g. endometriosis, PCOS. They may cover surgery for symptom control, but if the surgery is solely related to preserving your fertility or improving your chances of conceiving, then they may not cover the cost.
If you are experiencing depression or anxiety, your insurance may also cover the cost of therapy sessions.
If you experience a miscarriage, your insurance company may cover the cost of any treatment related to this, so make sure to contact them and find out.
Self-Funding IVF Treatment
ART and any additional support services can be self-funded, so many couples who are not eligible for NHS or insurance funded services, will have to self fund if they are able to do so.
Getting support
Experiencing failed IVF treatments, an ectopic pregnancy, OHSS or baby loss can be deeply distressing. Please ensure you follow up with your GP who will check your overall health and can refer you for counselling support.
If you are about to start IVF, or are at the early stages of your fertility journey, I hope you’ve found this series and our blogs informative.
If you are reading for interest, I hope you are more aware of what IVF entails, and that it can be a challenging process to go through. You can also read our article on other fertility treatments which may be performed before IVF.
Please share these articles with anyone who you think will benefit from them.
Thank you for reading and wishing you all the best❤️
Additional Information Resources
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