What happens during IVF

IVF involves the following steps:

Suppressing your natural cycle

Boosting your egg supply

Monitoring your progress and maturing your eggs

Collecting the eggs

Fertilising the eggs (IVF or ICSI)

Transferring the embryos

There are two different treatment protocols; the long protocol and the antagonist protocol. We decide which protocol is best for you based on your ovarian reserve tests.

Most women will follow the long agonist protocol. Women with a very high ovarian reserve who have a higher than average risk of developing OHSS will follow the antagonist protocol. This is because the antagonist protocol can reduce their chance of developing OHSS.

We will explain your protocol and our reasons for choosing it before you start the medication.

Long protocol

The long protocol treatment cycle will take approximately eight weeks from starting the first drug until pregnancy test, although this may vary depending on your response to the medications.

Antagonist protocol

The antagonist treatment cycle can take approximately 5 weeks from initial scan until pregnancy test although this can vary depending on your response to the medications.

Step 1 – Suppressing your natural cycle (long protocol only)

Buserelin Acetate (Suprecur) injections will temporarily ‘switch off’ your natural cycle to allow us to control the timing of your treatment cycle.

This is perfectly safe to do and there is no evidence to suggest it affects your future fertility.

We will give you a programme before you commence your treatment cycle that informs you when to start your injections.

Step 2 – Boosting your egg supply

Medication is used to encourage the ovaries to produce more eggs than usual.

Follicle Stimulating Hormone (FSH) injections stimulate the ovaries to produce eggs. Stimulation injections are administered daily under the skin (subcutaneous). 

Follicles are tiny fluid filled sacs that grow on the ovary and contain the eggs.  In your normal monthly cycle, only one egg is produced. 

To increase the chances of pregnancy with IVF treatment, we need several eggs. The average number of eggs retrieved is eight.

When do I start taking the Menopur or Rekovelle injections?

The expected date for you to start the injections is given on your treatment programme. The date will be confirmed once we are sure that the Buserelin has been effective.

This date is not set in stone, and it is normal for your cycle not to go exactly according to your programme.

Menopur

Menopur is a form of Follicle Stimulating Hormone (FSH) used to stimulate the ovaries to produce eggs.

It can be used both in the long protocol and the antagonist protocol. It should be kept in a cool, dry place and away from direct heat or sunlight.

We will ensure you know how to do the Menopur injections when you are ready to commence them. You will be instructed when to start and stop taking the Menopur injections.

Rekovelle

Rekovelle injections are only used as part of the antagonist cycle. It is in the form of an injectable pen and must be kept in the fridge.

Rekovelle is a form of Follicle Stimulating Hormone (FSH) and the dose is decided based on your weight and AMH levels. This allows us to find a balance between stimulating the ovaries as best we can whilst preventing over stimulation of the ovaries.

It is fine to have sexual intercourse during treatment however you must use barrier contraception, such as condoms, between starting the FSH injections and the embryo transfer.

Cetrotide injections (antagonist protocol only)

Cetrotide (cetrorelix acetate) is only used as part of the antagonist cycle and must be kept in the fridge. It is used to suppress ovulation when the follicles have started to develop.

You will be advised when to start the Cetrotide injections.

We will instruct you on when to start and stop this medication.

Step 3 – Monitoring your progress and maturing your eggs

We watch the number of eggs growing in your ovaries by doing a series of internal scans. The first scan is usually a week after you start the injections. Your treatment programme will tell you when to attend for a scan however we will confirm and book the scan in with you.

The egg is microscopic in size and cannot be seen, but it grows in a small cyst or follicle, which shows on the scan as a black shadow.  The follicle gets bigger as the egg grows. We will count the number of follicles developing in the ovaries, and measure them. 

If you are on the antagonist protocol, you will start another injection called Cetrotide.  When the follicles reach about 16mm in size, we would expect the egg inside to be ready to respond for the next stage of treatment, the trigger injection.

Sometimes the ovaries respond inadequately to the drugs and produce very few, if any, follicles.  A decision will be made as to whether the treatment cycle is to be continued, in spite of the very poor chance of success or cancelled. 

If the latter option is chosen you will be offered a consultation to see a doctor during which other treatment options (if there are any) will be discussed. Occasionally a blood test will be needed to confirm the scan results.

Maturing the eggs

You will be asked to take an injection to mature the eggs, this is sometimes referred to a trigger. It is carefully timed to your egg collection and is usually given in the evening. 

You will be told when exactly to take the injection after you have the last scan before egg collection. On this day take your usual Menopur injection in the morning and continue taking your Buserelin injections at your usual times until you have the hCG. 

There are two types of trigger injection. One is for patients on the agonist protocol (ovitrelle) and one is for people on the antagonist protocol (buserelin). The decision making process regarding this is explained later in this document, in the OHSS section. We will teach you how to do your prescribed trigger injection.

If you are using a partner’s sperm to create embryos then your partner should ejaculate on the day you have your trigger injection and not again until he produces the sample for egg collection.

Can we have sex?

It is fine to have sex during treatment however you must use barrier contraception, such as condoms, between starting FSH and embryo transfer.

Step 4 – Collecting the eggs and sperm

Egg collection

The eggs are collected by using a transvaginal ultrasound scan, just like the ones you have had during the last step. A thin needle is passed along the ultrasound scan machine into the ovaries, via the vagina, to remove the eggs.

The procedure is done under sedation to ensure you are comfortable throughout. You will be offered the option of a pre medication, called Lorazepam.

This is two tablets, one for the night before and one for the morning of procedure to help with nerves if you feel you will be nervous. This is perfectly safe with treatment.

When a decision is made to proceed to egg retrieval you will be given an admission form and instructions regarding your medicines. Please read this carefully because it will tell you when and where to come and what to bring with you.

If you are a single person seeking treatment you might want a friend or relative to accompany you on the day of egg retrieval. If you are attending alone you must arrange for someone to collect you from the recovery area after the egg retrieval and escort you home. You must have someone to stay with you overnight.

What happens when I am admitted?

On admission to the recovery ward, one of our fertility nurses will perform some vital observations including your temperature and blood pressure. 

You will need to change into a theatre gown. The nurse sedationist and operator will see you to discuss the procedure and answer any of your questions. A small needle will be used to introduce a plastic tube into a vein in your hand or arm. This is called a cannula and is how the medication will be administered to you during the procedure.

Partners or friends/relatives are welcome to stay in the unit but we will ask them to sit in the waiting room or leave the clinic once you go into theatre for the procedure. They can join you again when the egg retrieval is finished and you have recovered from the sedation. This is usually 60-90 minutes from the start of the egg retrieval.  

What medication will I be given?

The nurse sedationist will give you two drugs through the cannula in your arm. The first drug is a pain killer (Fentanyl) and the second is a sedative (Midazolam) to make you feel calm and relaxed. You will not be asleep during the procedure but a common side effect of the sedation is that you may not remember the procedure. Some women may need further pain relief such as Entenox gas or IV Paracetemol. We will discuss this with you if needed.

You can also choose to have a pre medication (Lorazepam) the night before and the morning of the procedure if you are feeling anxious.

If you have any worries or concerns or would just like to talk to the nurse sedationists, you can contact them via the unit phone number. We have the facility to play your MP3 or IPOD if you would like to listen to some music during the egg collection.

How are the eggs collected?

Your legs will be put in special supports and you will then have an internal examination and scan.  A very fine needle is inserted through your vagina and into the ovary.  This is uncomfortable for just a few moments.  We can then drain the fluid from each follicle.  The fluid is passed to the embryologist in the next room who will identify and count the eggs and place them in an incubator compartment that is clearly labelled with your name.  The procedure is repeated on the other ovary.  The whole procedure lasts for about 10 minutes depending on how many follicles you have grown. We expect to obtain eggs from approximately 70% of follicles. Occasionally the egg recovery rate may be much lower than this as it is not guaranteed that each follicle contains an egg. On rare occasions no eggs are found in either ovary.

What happens after the eggs have been collected?

You will be taken back to your bed in the recovery area on a trolley. You will feel drowsy following the procedure therefore we encourage you to sleep for the first hour. It takes at least 2 hours for the initial effects of the drugs to wear off so you must stay on our recovery area for that time.

The sedation drugs may leave you with a dry mouth, you may feel drowsy and you may have the inability to perform complex tasks. As it takes 24 hours for the sedation drugs to wear off completely you should rest at home for this period of time. You must have someone with you at all times until the following morning.

You should not drink alcohol, use electrical equipment or machinery or drive for 24 hours.

You should also not sign any legal documents during this time.

If you live more than 40 minutes away from access to emergency care we advise you to stay locally.

Once you are awake and feeling well enough to go home the embryologist will visit you to advise how many eggs were retrieved. They will discuss the results of the semen analysis and confirm if they need to do IVF or ICSI to inseminate the eggs.

What will happen after I go home?

It is normal to have some abdominal discomfort. You can take two Paracetamol tablets every 4 hours but be careful not to take any more than 8 tablets in 24 hours.

If the pain is severe and persistent or you are vomiting please telephone the centre.  Brown vaginal spotting or discharge is not uncommon and will usually settle after approximately 48 hours.

We advise you to have a light meal that evening as you may feel quite bloated. Remember to start your Cyclogest pessaries before bed and use one every morning and night from the following day. The pessaries should be inserted vaginally or rectally, just with your finger, morning and evening until the pregnancy test.  

We advise that you have a day or two off work, resting at home following the egg retrieval.

Sperm preparation (if using partner’s sperm)

A semen sample will be needed and this will be at about the same time as your partner’s egg collection.

Men should not ejaculate for 2-5 days before producing this sample. The fertility nurse will instruct your partner when to produce your sample on the day of egg retrieval.

On rare occasions a second semen sample may be needed so men should stay locally to allow time for the embryologist to check the sample. If men wish to leave the unit please leave a mobile number with the nurse or receptionist for us to contact you should the need arise.

Surgical sperm retrieval

Occasionally, some men produce no sperm at all in their ejaculate e.g. men who have had a vasectomy.  We now have a technique whereby in selected cases sperm can be aspirated directly from the testicle or surrounding tubes using a small needle (PESA) or retrieved from a testicular biopsy. This is usually done using a local anaesthetic.

More complicated sperm retrieval procedures are done under general anaesthetic. The sperm would be injected into the egg by the ICSI method to achieve fertilisation. If you need a sperm retrieval operation, it will be discussed with you fully at the clinic.

After Egg Collection

Cyclogest pessaries

Start using your Cyclogest pessaries tonight. They can be inserted vaginally or rectally.  You may find it helpful to use a panty liner. From tomorrow morning use one pessary every morning and night until your pregnancy test.

Going back to work

We advise you to have 1-2 days off work after your egg collection.  You will be given a letter for your GP, which informs him/her of your treatment.

Step 5 – Fertilising the eggs and embryo development

IVF or ICSI?

We want to give you the best possible chance that the eggs will be fertilised.  At the same time we do not want to carry out any unnecessary interventions. 

There are two ways to fertilise the egg.  If the sperm count is normal, we put about 100,000 sperm with each egg.  This is IVF.  If the sperm count is of poorer quality, we put just one sperm directly into the egg. This is ICSI (intracytoplasmic sperm injection). 

ICSI is much more complicated, can sometimes damage the egg and costs more than IVF.  For these reasons, we prefer to do IVF where possible.

Is there a difference between the fertilisation rate for IVF and ICSI?

Following both IVF and ICSI we expect to have successful fertilisation in about 7 out of 10 eggs (70%).  In a small proportion of both IVF and ICSI, there is unexpectedly no fertilisation.  If this occurs with IVF, we may recommend ICSI in any future treatment.

Is there a difference in the pregnancy rate and safety of IVF and ICSI?

There is no evidence that the pregnancy rates differ whether the eggs were fertilised by IVF or ICSI. 

If you have an extremely poor sperm count, there is theoretically a very small risk that your infertility could be passed on to a male child. If appropriate, we will discuss this in more detail with you in the clinic.

How do we decide if you need IVF or ICSI?

The embryologist will advise you about whether you need IVF or ICSI.  Initially we base this advice on the sperm test before treatment and your previous medical history. 

The final decision cannot be made until we have analysed the sperm sample given on the day of egg collection. The advice also depends on the number of eggs collected. 

Sometimes the advice is very clear.  A normal sperm sample indicates IVF and a poorer quality sample indicates ICSI. 

Analysing sperm samples is complicated and sometimes difficult to interpret. Furthermore, there is considerable daily variation in sperm counts. In the clinic we will recommend either IVF or ICSI based on the evidence at that time. 

We will let you know on the day of egg collection if our advice changes so that you can make a final decision.

What happens to the egg and sperm?

After insemination, the eggs and sperm will be left in an incubator overnight.

How do we prevent laboratory identification errors?

A rigorous system is in place to cross check your eggs, sperm and embryos against your name(s). You are assigned a separate compartment in the incubator that is labelled with your name(s).

Each laboratory dish (containing eggs, sperm or embryos) that is used in your treatment is labelled with your name(s). This identification system is tracked by RFID tags that link your eggs, sperm and embryos and record all actions taken.

Failed fertilisation

Failure of fertilisation is unusual.  Occasionally, this happens even when both sperm and eggs appear normal.  If this happens, we will make you an appointment to see you for individual advice and to discuss further treatment options.  You should discontinue using the pessaries.

Embryo development

A fertilised egg is called an embryo. You will be called by a nurse or embryologist the day after egg collection to inform you how many eggs have fertilised to make embryos. An appointment for embryo transfer on day 5 will also be made during this call.

An embryologist will update you on your embryo development three days after egg collection.

Stages of embryo development

Day 1

Pronuclear embryo The first day after fertilisation, two “pronuclei” are visible.

Day 3

Cleavage stage embryo the embryo has started to divide and several individual cells are visible.

Day 4 to 5

Compacted embryo “morula” The individual cells have started to “compact” into a structure known as a “Morula”.

Day 5 to 6

Blastocyst the compacted embryo has expanded to form a blastocyst which contains a fluid filled cavity.

Step 6 – Embryo transfer

All patients will have their embryos cultured to day 5 before embryo transfer. By waiting until day 5 we are confident we can increase pregnancy rates and reduce multiple pregnancies.

How many embryos do we recommend are transferred?

The number of embryos we recommend to transfer will be based on your age, cycle history and the quality of the embryos on day 5. This is to maximize your chance of success as well as to reduce the risk of twins.

If you have embryos on day 5 that have not yet reached the blastocyst stage but have developed to a compacted stage embryo (morula), you may have 1 or 2 embryos transferred as you wish.

Embryos that have not developed beyond the cleavage stage on day 5 do not have the potential to implant.

What do I/we do before coming in for embryo transfer?

Have your breakfast/lunch as usual then come to the Centre at the time arranged.  Please do not wear perfume, aftershave or strong deodorants as strong smells can be detrimental to your embryos.

What happens when I am admitted?

There may be a little time between your arrival at the Centre and being called for your transfer.  Take this time to relax.  When called for transfer the embryologist will tell you about your embryos.  We will confirm with you again the number of embryos you wish to have transferred. 

What happens when the embryos are transferred?

Before your procedure, we will ask you and your partner (if applicable) to cover your clothes with a theatre gown and remove your outside shoes and put on theatre shoes/slippers. 

In the transfer room we will confirm your name and check it against your embryo with the embryologist.  We will be able to show you your embryo for transfer on the monitor screen if you wish. 

The procedure usually only takes a few minutes and is usually quick and painless. You may go home straight afterwards as resting or lying down does not improve the success rate.  You may also empty your bladder.

Mostly the procedure is straightforward. However, sometimes it may take longer to pass the catheter into the womb.  After the embryo transfer procedure the catheter is checked to confirm that the embryos have gone.  Occasionally one or more may have stuck inside the catheter and the procedure has to be repeated.

After the embryo transfer

We advise you to lead as normal a life as possible after the transfer without doing anything too strenuous. There is no need to abstain from sexual activity after the embryo transfer. 

There is nothing more you can do at this stage to help the embryos to implant. Please don’t hesitate to telephone the Centre if you have any problems.  Remember that we are here to support you throughout your treatment.

Embryo freezing

If there are spare embryos suitable to freeze, we will discuss this with you when you attend for the embryo transfer.

We understand that there are different ways to think about your embryos whilst they are in the embryology laboratory and at this very stressful time in your treatment it may be very difficult to decide whether or not to freeze embryos. 

The embryologist will discuss the quality and the suitability of your embryos for freezing with you at the time of the embryo transfer.  We hope that the information below will help you with this choice.

How does the embryologist decide which embryos are of good quality?

There is no absolute test that tells us whether or not an individual embryo can make a baby. The embryologist will look at the embryos and assess how quickly each embryo is dividing and whether all the cells are dividing evenly.  We always transfer the best quality embryos to give the best chance of a pregnancy. 

How do we decide whether to offer you embryo freezing?

This decision is based on our experience of how embryos survive freezing.

Freezing and thawing is stressful to the cells of an embryo. For some embryos all of the cells remain intact while in others all of the cells break up and are no longer viable. Only the best quality embryos are suitable for freezing.  Poor quality embryos very rarely survive this thawing process.  Thus we only recommend freezing good quality embryos.

How many people have embryos frozen?

In the UK, no more than 1 in 4 couples will have embryos frozen.  This is because not many couples have good quality embryos remaining after embryo transfer.  The most likely outcome for you therefore is that you will not have embryos to freeze.

What is the chance that a frozen embryo will make a baby?

We have analysed our results by looking at all the embryos that are frozen.  If your embryos survive thawing and are transferred, there is about a 30% chance of pregnancy.

There is no evidence that any babies resulting from thawed embryos have an increased risk of harm or abnormality.

Do we have to pay for freezing?

If you are NHS patients, the cost of freezing is often included in your treatment if freezing is recommended. If you decide to freeze against our recommendations you may have to pay. The NHS usually funds storage of embryos for one year.

Ongoing costs

If you have a successful pregnancy you would then need to pay for embryos to be thawed for further treatment.  There is an annual fee for ongoing storage.

The costs of freezing and storage are available in our private patient information.

So should we have embryos frozen?

The decision is yours and will usually depend on how you view your embryos.  We hope that the information above has helped you make this decision. The embryologist will talk to you about the quality of your embryos on the day of embryo transfer and you will need to make a decision then. 

If you want to talk to anyone about this before then please let us know.

What do we do if we want embryos frozen?

If you decide that you want embryos frozen, you must both attend on the day of embryo transfer. You will need to sign the appropriate consent forms and the freezing will be done immediately after the embryo transfer.

What happens to the embryos is they are not frozen?

Embryos that are not suitable for freezing are put into a solution that stops them growing then they are discarded.

Your embryos will not be given to another patient/couple.

Embryos may be donated to research or training but only with your written consent.

What do we have to decide later about the frozen embryos?

If you have embryos frozen, we will contact you each year to ask for your decision about ongoing freezing.  If you wish to have the embryos transferred, we will see you both in the clinic to discuss this.  38% of couples decide not to use their frozen embryos.

This can be a difficult decision and we would be happy to talk to you about this at any time.