STEP 1 – Period
Make an appointment with your doctor on day one or day two of your period. If you do not get periods or have irregular periods, your doctor will be able to induce them with contraceptives or other medications.
STEP 2 – Suppression of hormones to prevent ovulation
About 3 weeks after your period starts you will have a blood test and will begin down regulation—the process of suppressing a woman’s natural hormones before administrating fertility medications.
A course of GnRH analogue drugs will be prescribed for the next 12-28 days, which will allow for the suppression of gonadoptropin hormones to prevent premature ovulation.
This process will temporarily stop your ovaries from releasing eggs, meaning they go into the dormant stage. This is done to prepare your ovaries for external stimulation from drugs.
When your next period arrives, you will need to see your doctor on day 2 to day 5 for a baseline scan. This ultrasound scan is an important part of the IVF program as it will allow the doctor to see if the lining of the womb is thin enough (around 3mm) and the ovaries have adequate number and size of follicles.
The scan will also let the doctor to check for any existing pathology, such as cysts or fibroids, and based on it the next stage of your treatment will be decided.
SIDE EFFECTS: Some women experience headaches, night sweats, hot flushes, and mood swings with the drugs administered.
Please note: The treatment time is variable and drug administration is customized based on your individual response to the drugs.
This is the IVF ANTAGONIST PROTOCOL, which is followed in about 30 percent of all cases.
For the rest 70 percent of cases, hormone suppression is not required and you should be able to go directly to STEP 3. That process is known as the IVF AGONIST PROTOCOL.
STEP 3 – Ovarian stimulation
You will be given injections of FSH (follicle stimulating hormone) drugs to stimulate the ovaries to make multiple follicles and eggs, for about 5-12 days.
You will continue the GnRH analogue drugs throughout the stimulation duration, unless your doctor has advised otherwise.
Sometimes, the GnRH analogue drugs are not administered because the woman doesn’t need them. In those cases, an LH antagonist may be used to prevent natural ovulation. It will be administered after stimulation has started.
After 5 days of stimulation injections, the follicular development is monitored using ultrasound imaging and hormone assessment tests.
The doctor will check for:
- Follicle size – the ideal size of the fluid-filled sacs in which the eggs grow is 18 to 20 millimetres. There are usually 10-12 follicles, but the number may vary from person to person. You need atleast 3-4 mature follicles for egg collection.
- Oestrogen levels – this helps build the thickness of your uterine lining. You need oestrogen level of 60-150 on day 2-4 (without stimulation).
- Progesterone levels – this helps maintain the thickness of the uterine lining and make it super-receptive. Progesterone prepares your endometrium to receive your embryos well.
- Lining of your uterus – in anticipation of an embryo implantation, the lining of the uterus beings to thicken. It needs to be atleast 7mm for a healthy transfer. If it’s over 8mm, that’s even better.
SIDE EFFECTS: Bloating, uneasiness, and discomfort may be experienced as the eggs mature.
STEP 4 – Trigger Shot
If the doctor determines the follicles have reached adequate size, a trigger shot injection of hCG (human Chorionic Gonadotrophin) is given—this gets the eggs to mature and loosen from the follicle wall so they can be collected.
This is the time the other drugs will be stopped.
Egg retrieval is typically scheduled 34-40 hours after HCG injection.
STEP 5 – Egg Retrieval & Sperm Collection
You eggs will be collected via a small surgery, which is done under ultrasound guidance. The doctor will collect the eggs from the ovarian follicles using a hollow needle attached to the ultrasound probe.
You will be sedated during egg retrieval and will not feel any pain.
However, as your regain consciousness, you should expect to feel a little sore in the lower abdominal region. Many women experience cramps and little bleeding from the vagina.
The embryologist will scan the follicular fluids to collect as many eggs as available. The eggs are then placed in a special media and kept in an incubator until insemination.
After egg collection is complete, you will be given injections or gel medication to help prepare the lining of your womb for embryo transfer.
Your partner’s semen will be collected on the same day. It is important to wash the hands and collect the sample in the sterile sample cup under hygienic conditions.
The semen sample will be washed to separate the normal, motile sperm from the poorer-quality sperm.
If the sperm count is low or if you’ve had a surgical sperm collection, the semen sample will be spun to concentrate the sperm together for best results.
If you have a frozen sperm sample, it will be thawed and prepared in the same way.
STEP 6 – Insemination/Fertilization
Your eggs will be mixed with the sperm and kept in the laboratory for 16-20 hours for fertilization.
If sperm parameters are normal, about 50,000 to 100,000 motile sperm are transferred to the dish containing the eggs.
In case the sperm quantity or quality is not good, ICSI will be used to inseminate each egg separately. This procedure is usually available with most IVF clinics, and is charged a little extra for. You will be informed beforehand if IVF with ICSI is required in your case.
STEP 7 – Embryo culture
The eggs that are successfully fertilized—called zygotes—are then kept in a special medium that supports their growth.
2-3 days later they will be assessed for signs of growth.
The doctor can decide to transfer embryos to your womb after three days of culture or wait for them to grow to the blastocyst stage until day five.
The blastocyst transfer has several advantages such as higher chance of success, lesser chance of multiple pregnancies as the embryos at this stage have a higher chance of attaching to the uterus, fewer of them are transferred.
Blastocyst culture is preferred in cases where the number of embryos and their development is good. It may cost slightly more to keep the embryos in the media for two extra days.
STEP 8 – Embryo transfer
Embryos may be transferred on day 2, day 3, day 5, or day 6 after egg retrieval, depending upon their growth. This is a very important step in your IVF procedure.
The placement of the embryos is done carefully near the middle of the endometrial cavity.
The doctor will pick the best embryos from the batch, and load them into a soft thin plastic tube called the catheter, which will be inserted through your vagina, passed through the cervix to place them into the uterus.
This step does not require anesthesia. It is a simple process just like a pap smear.
The embryos are then left there to grow and implant to the uterine wall.
One or two embryos may be transferred, if you are under the age of 40. If you are over 40, three embryos may be implanted for better chances of success.
Many clinics recommend single embryo transfer (SET) for younger women to avoid the risk of multiple pregnancies.
STEP 9 – After embryo transfer
Mild cramps, dizziness, tingling, abdominal pain, cramps or lumbar pain may be experienced after an embryo transfer and are considered quite normal.
Many times, this is due to all the hormone injections and stimulation you’ve been getting in preparation.
Spotting after embryo transfer is normal and may continue for 2-3 days. It is generally due to the tube passing through the cervix.
How long does it take for embryo to attach to the uterine wall after embryo transfer?
Just as in natural pregnancies, IVF embryo floats in the uterine cavity for 1-5 days after a blastocyst transfer before attaching to the uterine wall. If you didn’t have a day-5 blastocyst transfer, it can implant any time between 6-10 days.
Now regarding the dos and don’ts after embryo transfer:
Bathing: Hot baths and sitting in the tub for long are to be avoided. Take quick warm showers and relax outside the bathroom. No bubble baths.
Sex: Avoid for two weeks.
Activity: You will be advised to rest for the rest of the day, and take it easy the following few days. You can resume regular work and activities the very next day after embryo transfer if you are not overly uncomfortable.
Foods: If there were any magical foods that would help the implantation of embryo, we’d have some solid evidence. Unfortunately, pineapple, green tea, raspberry, bananas, tofu, etc. don’t help. What helps is a balanced diet that includes good carbohydrates, proteins and fibre.
Also take the prescribed multivitamins and folic acid.
Does embryo glue work?
Embryo does not need anything additional to attach to the uterine wall. The embryo glue is not actually glue but just some liquids that are similar to your uterine secretions.
The effectiveness of embryo glue and its contribution in IVF success hasn’t been conclusively proven in large, randomized medical trials.
It is advisable to spend money on the doctor and IVF clinic that feels right, instead of buying some random medical solutions that has no convincing evidence of efficacy.
STEP 10 – Waiting for the results
Let me warn you–this seems the easiest but when you get there, it will probably be the hardest part of your entire IVF cycle.
The anxiety, the uncertainty, and the charged emotions make it harder, but you must learn to relax as much as you can and not think too much about what will happen. Do NOT take premature pregnancy tests (before day 12 of implantation). Try to read, watch light television, or do something that you enjoy without stressing too much.