The stages of IVF treatment

 

A typical IVF or ICSI treatment cycle takes between 6 to 8 weeks, from when you first start taking medication to the pregnancy test. However, it may take less or more time, depending on your response to the drugs, which cannot always be predicted correctly. We will give you a treatment schedule which gives your key expected dates, but please remember that there may need to be changes at short notice because we cannot always predict how your ovaries will respond to stimulation.

Fertility treatments in the UK are regulated by the Human Fertilisation & Embryology Authority (HFEA).


The key stages of treatment are as follows:


1

Controlling your natural cycle – This is not required in patients receiving the GnRH Antagonist

The aim of this stage is to temporarily ‘switch off’ your ovaries, allowing the next stage to proceed without the risk of your ovaries spontaneously releasing the developing eggs before they are ready to be collected. This is achieved using drugs called ‘GnRH agonist’. Treatment cycles of this type are also often referred to as ‘Long Protocol’ or ‘down-regulation’cycles. You may hear these words from time to time – please do not hesitate to ask us to clarify if you find the terms confusing!

Most commonly, we use an injection of Buserelin for this purpose. We teach you to administer this injection to yourself. Please store the drug, like all your medication, according to the manufacturer’s instructions. The Buserelin should be continued until you have the HCG trigger injection. It is important not to miss any doses. If you do forget to take a dose, please take it as soon as you remember and continue using it as before.

Side effects are common during this stage, and may include hot flushes, headaches, lack of concentration and emotional ups and downs. You are likely to get vaginal bleeding during this treatment – this is expected and ‘normal’.

To check if this stage of treatment has been successful, we perform an ultrasound scan and test your blood oestrogen levels after you have been on the Buserelin for 14 days. If the drug has worked, we expect to see only a thin womb lining, and a low level of oestrogen. If this has not happened, we wil ask you to continue the medication and repeat your tests in a week or two.

Controlling your natural cycle

If you are receiving the GnRH Antagonist, you do not need this stage of treatment. In this case, we use a different type of medication to prevent the premature release of your eggs. This drug (the GnRH Antagonist) is started 4 or 5 days AFTER you have started injecting yourself with FSH to stimulate the ovaries. We commonly use a drug called Cetrorelix and we will teach you how to inject it. Once again, this should be continued until you have the HCG trigger injection. It is important not to miss any doses. If you do forget to take a dose, please take it as soon as you remember and continue using it as before.

2

Stimulating the ovaries

The aim during this stage is to encourage your ovaries to develop a number of eggs that can then be used for your treatment. We use injections of a drug called FSH (which stands for ‘Follicle Stimulating Hormone’) and you will be taught how to do these injections. You will be given a date to start these injections. If you are on the Long Protocol, the start date is after you have had a scan and blood test to confirm that the GnRH agonist has worked. If you are on the GnRH Antagonist regime, the start date will fall sometime between day 1 and day 4 of your period (Day 1 is the first full day of bleeding). Please do not start the injections until we have advised exactly when they should be started. It is important not to miss any doses. If you do forget to take a dose, please take it as soon as you remember and continue using it as before.

Based on your screening test results, we will advise you of the dose of FSH: to give you a good chance of success we need a good number of eggs, but at the same time we wish to avoid too many eggs developing as it increases the chance of developing Ovarian Hyperstimulation Syndrome. For this reason, we monitor you closely during treatment, and may advise a change in dose depending on how your ovaries respond to the FSH. Monitoring involves internal ultrasound scans and blood test for oestrogen. It may begin on day 6 or day 8 of stimulation – once again, we will advise you of the appropriate day for you.

During this stage of treatment, the FSH injections cause your ovaries to increase in size and produce higher levels of hormones. As a result you may feel some abdominal swelling and mild discomfort, as well as increased vaginal discharge, breast enlargement and mood swings. If you get pelvic or abdominal pain, please let us know.

An important concern at this stage is the risk of developing Ovarian Hyperstimulation Syndrome (OHSS). Although OHSS does not usually occur until after egg collection, your response to stimulation is an important factor that may tell us whether you are likely to develop OHSS. We take all reasonable precautions to reduce your risk of developing this condition. Sometimes, if it appears that there is a substantial risk of OHSS, we might recommend one of the following measures:

  • We may advise that we cancel the treatment cycle. This means stopping the FSH, but continuing the Buserelin or Cetrotide for 7 to 10 days following which you have a period. Following this, we may recommend a further attempt using a reduced dose of FSH.
  • We may advise ‘Coasting’. This means that the FSH is stopped, but the Buserelin or Cetrotide is continued, along with monitoring. In many cases, this allows the ovaries to ‘settle’ and we can then proceed with the trigger injection.
  • We may advise that you have the trigger injection and egg collection, but any mebryos that are created are frozen. Not having an embryo transfer means that you forgo the chance of conceiving in that cycle of treatment, but it prevents a particularly severe type of OHSS that is associated with pregnancy. If you do not have an embryo transfer, a period usually results in 14 days or so. The frozen embryo(s) can be replaced in the future after a gap of 1 or 2 menstrual cycles.

For more information about OHSS, the symptoms to look out for and what to do if you think you may be developing OHSS, please click here .

3

The Trigger Injection

This injection is administered after a sufficient number of follicles have reached a point where it is likely that they contain mature eggs that can be used for your treatment. We will advise you of the date and exact time of this injection. It is vital that you inject the trigger at the time advised. If, for some reason, you are unable to do so, please let us know as soon as you can of this. The reason why this is so important is because the egg collection procedure has to be precisely timed to 34 to 36 hours after the trigger injection. If for some reason you do not inject the trigger at the correct time, we need to know so that we do not simply proceed with attempting to collect your eggs at the planned time.

We use two types of injection for trigger – Pregnyl and Buserelin – and we will advise you which one is appropriate for you.

Do not take any more Buserelin/FSH/Cetrotide injections following the trigger injection; it is intended that you have a treatment drug free day following the trigger injection.

If a fresh sample is being produced for egg collection then abstinence of between 2-5 days and attendance on the day of egg collection, is required. If a frozen or donor sample is being used, this will be thawed on egg collection day once the eggs have been collected. We advise you to abstain from sexual intercourse after the trigger injection until after your embryo transfer.

4

Egg Collection

IVF Stages Egg collection

This is a procedure carried out under sedation, monitored by an anaesthetist. During this, we pass a needle through the vagina into the ovaries and suck out the fluid in your follicles. This fluid is passed through into our laboratory, where the embryologist examines it under the microscope to see if it contains an egg.

On the day of your egg collection, you will be admitted to the unit in the morning. Please arrive at the time advised by our staff.
Please bring with you:

  • Comfortable underwear (no thongs)
  • Panty liner / Pad
  • Loose clothing for afterwards
  • Please ensure that all makeup, nail varnish, strong perfume / aftershave / deodorants and body piercings have been removed

You will be shown into a private bay, where you will need to change into a theatre gown. You will then walk into a theatre where the egg collection is carried out. Once all of your admission observations and checklists have been completed by the nurse, doctor, embryologist and anaesthetist, the male partner (if appropriate) will then be shown to the sample producing room to produce a semen sample.


It is very important that you follow the instructions below:


  • You must not eat or drink milky drinks for at least 6 hours before egg collection. You can only drink clear fluids up to two hours before your egg collection time. After this you should have nothing further by mouth - this includes chewing gum or sweets.
  • If you are taking any prescribed medicines or tablets they should be taken at the usual times and you should bring them with you to the unit.
  • You must not drink alcohol or smoke on the day of your appointment or the night before as it combines with the intravenous drugs and enhances the sedative effect.
  • You must be accompanied by a responsible adult who must remain in the department throughout your appointment, escort you home afterwards and arrange for you to be looked after for the following 24 hours.
  • Your responsible adult should take you home after treatment by private transport or taxi rather than public transport.
  • You must not drive any vehicle, operate any machinery or use a bicycle or operate any domestic appliance for 24 hours following sedation, as your judgement may be impaired and your insurance affected.
  • You must not drink any alcohol, return to work, make any important decisions or sign any legal document for 24 hours after sedation.
  • You must not wear tight-sleeved clothing or high-heeled shoes on the day of your appointment.

Please feel free at any time to ask the doctor or nurse any questions you may have about your treatment.


What are the risks of egg collection?


The egg collection procedure is generally safe and complications are uncommon. However, as with any surgical procedure, there is a small risk that things may go wrong, such as bleeding from internal vessels, a small puncture to the bowel, bladder or uterus or cyst.

You may experience light vaginal bleeding (‘spotting’) and some pain afterwards, this is common and it is OK to take Paracetamol or codeine for this. Do not take products containing Aspirin or Ibuprofen. If the bleeding is heavy or the pain is severe, please let us know.

In a very small number of cases, especially in women with a previous history of pelvic infection or large endometriotic cysts in the ovaries, a pelvic infection may develop after egg collection. This requires a course of antibiotics and, in a very small number of cases, may be severe enough to need surgical treatment.


Please contact the unit if you experience any of the following:


  • Heavy bleeding
  • Raised temperature or feeling unwell
  • Difficulties with breathing
  • Pain in your tummy not relieved by Paracetamol or Codeine
  • Excessive swelling of your tummy with a feeling of being bloated
  • Any problems passing urine, particularly if you notice that it is more concentrated than usual and you are not needing to pass urine very often
  • Any diarrhoea

What happens after the eggs have been collected?


You will be taken to a recovery area on your trolley. You will be monitored by the nursing staff until you are fit enough to go home. You will be seen by an embryologist before you go home to answer any questions you might have.


When is the semen sample needed?


The semen sample is required on the same day as the egg collection.

For those using a fresh sample – The semen sample production is scheduled for the same time as the egg collection.

For those using a frozen sample from a partner or a donor – the sample is thawed on the day of egg collection.

In some circumstances a second semen sample may be required so it is important that where possible the male partner who has produced the fresh sample, remains within the unit until the embryologist has checked the sample and given the all-clear.


What will happen after I go home?


You may have some abdominal discomfort. You can take 2 Paracetamol tablets every 4-6 hours but be careful not to take any more than 8 tablets in 24 hours. Please do not take medications containing Aspirin or Ibuprofen. If the pain is severe and persistent or you are vomiting please contact us. A little brown spotting or discharge is not uncommon and will usually settle after approximately 48 hours. You may find that eating little and often is easier to tolerate in the first 24-48 hours.

We do not advise you to undertake strenuous exercise in the days following egg collection until the outcome of the pregnancy test is known as the ovaries are often large and can cause discomfort.

5

Embryo transfer

The embryo transfer is scheduled for 2, 3 or 5 days after the eggs have been collected. Our laboratory will advise you about the appropriate date and time for you. This depends on the number of eggs that fertilize and the apparent quality of the embryos that have developed. The laboratory will also advise you regarding the number of embryos to be transferred. We follow professional guidelines aimed at giving you a good chance of success while reducing the risks of multiple pregnancy. This is because multiple pregnancies (twins, triplets or higher) carry greater risks to the health of babies and mothers as compared to singleton pregnancies. More information is available at the oneatatime website

On the day of embryo transfer, please eat and drink normally and arrive at the time arranged. Please do not wear perfume, aftershave or strong deodorant as strong smells can be detrimental to your embryos. A partially full bladder is beneficial for the embryo transfer procedure, so we recommend you drink around 500ml of fluid an hour before your appointment.

Prior to the transfer, we confirm your identity. The embryo transfer procedure involves passing a soft catheter containing the embryo into the womb, where it is released. The procedure is performed under ultrasound guidance, is usually completely painless and usually only takes a few minutes.


Medication following embryo transfer


We provide tablets of a hormone, progesterone, which supports the lining of the womb and helps the womb receive the embryo. These tablets should be inserted into the vagina twice daily from the day of egg collection to the day of your pregnancy test. If the test is positive, we ask you to continue the tablets until 12 weeks of pregnancy. The tablets can also be used rectally (in the back passage) and you may prefer to do that if you have a troublesome vaginal discharge or bleeding.

6

Pregnancy test

Manchester IVF Pregnancy

Please do a urine pregnancy test at home in the morning 16 days after your egg collection, and please let us know the result. Please continue the progesterone pessaries until the result of the test is known. We advise doing the test on the first urine you pass on waking up.

We appreciate how stressful this process can be, and we do provide a full counselling service. 

Infertility Network UK are an excellent organisation who provide support for those who find it hard to conceive. 

Professional bodies who also provide useful information are:

Association of Clinical Embryologists (ACE)
British Fertility Society (BFS)