Stimulation & Monitoring
IVF stimulation involves using various subcutaneous injection medications such as Follistim or Gonal F and Menopur. Oral medications such as Letrozole or Clomid may be added as well. The average number of days of stimulation depends on age and egg supply but usually ranges from 9-16 days. During stimulation, there may be 6 - 8 (or more) office visits. Most visits are every other day, but may be daily towards the end of stimulation. These careful evaluations of labs and ultrasounds are necessary in order to monitor the sizes & number of egg sacs or follicles developing and checking Estrogen and Progesterone levels. The testing is done in the morning so we can review the results later the same afternoon. After reviewing all patient results, my orders are then given to my nursing team and they place your instructions in your patient portal (or call if necessary). The fertility medication dosages are then adjusted accordingly, in order to individualize and optimize the hormone stimulation.
When several of the largest follicles reach a certain size (21+ mm), another hormone injection, called the ‘trigger shot’ (hCG or Lupron) is given to help the egg ‘break away’ from the follicle wall so it is floating in the fluid. The trigger shot also helps ‘mature’ the eggs (within the follicle). To become ‘mature’, the egg must reduce the number of its chromosomes by half. Usually 75% or more of the eggs we retrieve are mature. We cannot use immature eggs since they have too many chromosomes. The type of trigger shot used—hCG vs. Lupron, depends on the type of protocol used, the woman’s age and her Estrogen hormone levels and risk for OHSS. Lupron trigger eliminates any risk for OHSS, but we will then recommend freezing all embryos since the uterine lining may not be as receptive.
The egg retrieval is usually 36 to 37 hours after the trigger shot. The egg retrieval is transvaginal with ultrasound guidance under anesthesia (conscious sedation) and takes approximately 10 - 15 minutes. There is a needle guide attached to the US probe, which is placed vaginally, so that a hollow needle will be placed through the thin vaginal wall and into each ovary. We will drain every follicle that is > 10mm trying to recover eggs. The fluid from each follicle is given to the embryologist (sitting next to us) and they will use a microscope to find the eggs.
Managing expectations: When you are doing your office monitoring ultrasounds, you may often be told how many follicles are being measured or identified on US. Occasionally some patient are arriving for their IVF retrieval expecting more eggs than they have good-sized follicles and this sets up patients for disappointment. Keep in mind that we will always empty every follicle that is over 10 mm, but generally only those follicles that are over 15-25 mm at FCI have a >80% chance to even produce an egg. Smaller follicles 10-14 mm usually do not give us an egg, and if they do, the egg is most often immature. In addition, many of the follicles in women over 40 or those with DOR, are empty since the eggs may have degenerated over time. The US evaluation can only tell us about follicles, not eggs. We expect 75% or more of the eggs we get from all the follicles to be mature. Remember we can’t use immature eggs.
The retrieval with anesthesia will not be painful and most women will have mild to moderate pain afterwards, easily controlled with oral pain medications. A few minutes after the retrieval, we will know the total # of eggs we retrieved, so you will be given that information before you leave 30 minutes later. The egg maturity will not be determined for another 2 hrs, until the embryologist begins trying to fertilize the mature and normal looking eggs.
The embryologist attempts to fertilize only mature and normal appearing eggs with the sperm in the IVF embryology lab. For most couples, even when there are no male sperm factor problems, ICSI (Intracytoplasmic Sperm Injection) is utilized to pick out the best morphologic looking sperm to place inside the egg. This improves fertilization rates, as well as better embryo development. The morning after your retrieval, you will be notified about how many of your eggs were mature and normal and how many fertilized properly to become embryos on day 1. The embryologists place all fertilized eggs (embryos) in your own incubator and carefully monitor the development of the embryos for several days. We prefer to transfer and/or freeze (vitrify) embryos on day 5 of their development. (Day 6 is good for freezing as well). The embryologists can gain far more information about an embryo’s quality the longer it is monitored. For example, many embryos, if not genetically normal, may often grow very slowly or poorly from d1 to d5. An embryo on day 3 averages only 7-8 cells. By day 5, an embryo will average approximately 150 cells and have 2 cellular compartments. Embryo Grading: The 1st compartment of cells, called the inner cell mass, will become the fetus or baby. The 2nd group of cells will become the future placenta. Each of the two compartments is given a ‘grade’ (A B C or D), based on the number and quality of the cells. Only embryos that are graded AA, AB, BA, BB or BC can be transferred, or biopsied (if doing PGT--Preimplantation Genetic Testing), or frozen (vitrified).
The vast majority of embryo transfers will be done without anesthesia. Valium is often used to relax the uterine muscle and the patient. On occasion, if we anticipate a more challenging transfer, sedation can be used. When the embryologist removes the embryo(s) from the incubator, they will show you the embryos on the video screen magnified 100-1000x and then we will begin using the vaginal speculum in order to wash off the cervix with some sterile fluid. You will feel pressure but generally not pain. For those of you who have undergone intrauterine inseminations (IUIs) it should be very similar. We do the embryo transfer under ultrasound (US) guidance so that we can be very exact in the embryo placement location, generally 1 to 2 cm from the top of the uterine cavity. After cleansing the cervix with solution, an empty transfer catheter is placed through the cervix into position inside the uterine cavity. Next, we will wait a few moments for the embryologist to bring the catheter containing the embryo(s) from the lab a few feet away so we can minimize the time that the embryos are exposed. We will then feed the catheter with the embryo(s) through the empty catheter that is already in place so you will not feel anything once the empty catheter has been placed in position. On the ultrasound (US) screen you will be able to watch the bubble of air and fluid the embryo is contained in placed gently into the uterine cavity. After placement of the embryo(s), we wait until the embryologist checks the catheter under the microscope to make sure that the embryo(s) got out properly. Then you can get up and go straight to the bathroom if you desire. Several recent studies have confirmed that immediate bed rest after the ET is unnecessary.
When you get home, you do not need bed rest... just be a 'coach potato'. The first 24 hours after an embryo is transferred are most likely the most critical since within this timeframe an embryo has to 'attach' to the uterine wall before it can fully implant, which may take several days. Therefore, for the first 1-2 days, stay home and chill out. Do not do normal vigorous activities, such as heavy lifting, bending or exercise. You want embryos to remain in the uterine cavity and not be pushed into a Fallopian tube resulting in an ectopic or tubal pregnancy. Common sense goes a long way. Good mental health is very important during the 10-12 days waiting for the pregnancy test. You do not want to second-guess yourself regarding doing certain activities. It is not your fault if an embryo does not implant but you do not want to give yourself any possible reasons for feeling guilty or second-guessing your activity level if it does not work.