IVF (in vitro fertilisation) treatment

Step 1: Pituitary suppression

In a natural menstrual cycle, hormones from the pituitary gland, luteinising hormone (LH) and follicle stimulating hormone (FSH), cause the growth of an egg within the fluid-filled space (follicle) in the ovary. Although several follicles start to grow each month, in a natural cycle, only one will mature enough to release its egg. The release of the egg (ovulation) is triggered by a sudden surge of LH at mid-cycle, which is two weeks before menstruation.

In contrast, during an IVF cycle, several eggs should mature simultaneously. To prevent a premature LH surge from triggering the early release of these eggs, a gonadotropin-releasing hormone (GnRH) agonist is used to temporarily turn off your own LH and FSH secretion. These medications are used at various stages of the IVF cycle.

*If you are undergoing what is called an antagonist cycle, there is usually no need for pituitary suppression. Your fertility specialist will select the right cycle type based on your needs.

Step 2: Ovulation stimulation and monitoring

The ovulation stimulation phase involves daily FSH injections (Gonal F or Puregon) between nine to 14 days. This stimulates the growth of several follicles instead of just one or two.

The ovaries’ response is monitored by ultrasound and, occasionally, blood tests. The dose and combination of medications are adjusted to suit your individual response, so do not be surprised if you are on a slightly different protocol or FSH dose to other women. Every cycle is unique and is closely monitored in this way. Most women learn to give their own injections to reduce the number of visits to the clinic.

Step 3:Trigger injection

Once the ultrasounds indicate a reasonable size and number of follicles, the stimulation phase ends and the FSH injections and GnRH agonist are stopped. An injection of hCG (called the trigger injection) is then given, causing final maturation and loosening of the egg from the wall of the follicle. The egg retrieval occurs the second morning after this final injection (34 to 36 hours later).

Step 4: Egg retrieval and semen collection

The egg retrieval is performed by an ultrasound-guided needle puncture through the top of the vagina.

The egg retrieval process takes 20 to 30 minutes and involves these steps:

• You are given light sedation
• The ultrasound-guided needle is passed through your vaginal wall and into each follicle on your ovary
• The fluid in the follicle is aspirated into a test tube
• This is then examined under a microscope to look for eggs
• You rest in the recovery area for about an hour

Some cramping and discomfort after egg retrieval are standard, as is some vaginal spotting or bleeding. If this continues, a heat pack, hot water bottle or analgesic may be helpful at home.

After egg retrieval, you will be issued medication/s (usually just progesterone) that will support the development of the endometrium (lining of the uterus) in preparation for embryo transfer.

Semen collection
Your partner (if applicable) will be asked to produce his semen sample on the day of your procedure. A room is available for this at our clinic. Understandably, some men have concerns about this part of the process. It may be possible to produce the sample at home and take it to the clinic – this can be discussed with our staff at the start of your cycle. If you have any concerns about collecting the sample, please discuss them with us before starting your cycle, as it may be possible to freeze one of your partner’s semen samples as a backup.

Step 5: Fertilisation (insemination) and embryo development

The sperm sample is prepared by being washed and concentrated, and all the dead sperm and debris is removed and then added to the eggs a few hours after retrieval. The eggs are examined the next day for signs of fertilisation. We expect about 60% to 70% of the eggs to fertilise if the sperm sample looks and prepares normally.

It is important to note that not every follicle will contain an egg, and not every egg will fertilise. Not every egg that fertilises will go on to form a good-quality embryo.

The fertilised eggs are then kept in the incubator for approximately 48 hours. If the sperm quality is low (sperm count or motility), your specialist may suggest Intracytoplasmic Sperm Injection (ICSI) as part of your treatment plan.

ICSI is a specialised form of insemination that is used for the treatment of male infertility. It involves the injection of a single sperm directly into a single mature egg.

Step 6: Embryo transfer

Two to five days following egg retrieval, the fertilised eggs (embryos) are transferred to the uterus using a fine plastic tube (transfer catheter). The exact number transferred depends on the woman’s individual circumstances, age and embryo quality. This procedure takes only a few minutes and is usually not uncomfortable.

The embryo transfer steps are:

• Embryo/s chosen for transfer is/are loaded into a catheter, which is passed through the cervix, into the uterus and gently released
• The catheter is then slowly removed and checked under the microscope to ensure that no embryos remain
• Some couples/individuals will have extra embryos that are suitable for freezing (vitrification)

The best-quality embryos (those most likely to result in pregnancy) are usually transferred in the treatment cycle. To be selected for freezing, embryos must show minimal or no sign of fragmentation (cell breakdown) and no sign of abnormal development.

Step 7: The Luteal phase (aka Two Week Wait)

The luteal phase is the two weeks between embryo transfer and the pregnancy test. You will be encouraged to limit your activity for 24 hours after the transfer. Your movement can be increased gradually over the next few days to non-strenuous, non-aerobic pursuits. Many women return to work the following day if their job is not strenuous.

The progesterone medication you start taking after egg retrieval can sometimes cause cramping, nausea, bloating and tiredness. An analgesic may be taken to relieve any discomfort. If you are concerned about any symptoms, speak to a fertility coordinator.

Vaginal spotting or bleeding may occur before you are due for your pregnancy test. This does not always mean that your treatment was unsuccessful. You should continue using any medications until a full period begins and/or the blood test results are known. Progesterone itself may delay your period, and this, likewise, does not necessarily mean that you are pregnant.

Step 8: Pregnancy test

Your pregnancy blood test will be carried out about 14 days after embryo transfer. It is important to look after yourself in that time, which is often emotionally charged with expectation and anxiety. We understand this can be difficult and encourage you to call us for support if you are finding it especially hard to deal with the stress of waiting.