IVF Breakdown: Understanding the Steps and What to Expect

IVF (In Vitro Fertilization) is a versatile technique for fertilizing the oocytes with sperm. It has several fertilization techniques starting from conventional fertilization that is designed for making fertilization as natural as possible and eliminating the micromanipulations by placing oocytes and sperm in a Petri Dish and waiting for the oocytes to be penetrated by sperm cells; and ending with advanced techniques such as ICSI, IMSI, or PICSI, involving manual fertilization of each oocyte with a single motile spermatozoon.  

IVF involves several steps — Fertility Screening, Controlled Ovarian Stimulation, Egg Retrieval, Sperm Collection or Sperm Retrieval, sperm preparation, fertilization, Embryo Cultivation, embryo selection, and Embryo Transfer. After the Embryo Transfer, there are two more steps: a pregnancy test and an ultrasound scan for pregnancy confirmation. Let’s get to know more about each step IVF Treatment has and what to expect. 

Step 1 – Consultation 

Each patient is unique that is why an IVF Program is always tailored for each case. And for making the Treatment cycle as effective as possible, each IVF cycle starts with consulting on the issue and Fertility Assessment. The first step involves a fertility consult with a Fertility Specialist. During the consultation, your family, personal, andrological, and gynecological history including any Fertility Tests and Screenings you have done before will be reviewed. It is also possible to have a Fertility Screening during the first consultation (general exam, fertility scan, and some other tests) or you may schedule/reschedule it to the other date.

Step 2 – Female Fertility Assessment

• You will undergo a screening before the IVF cycle. Usually, it includes:
• General exam, including blood pressure, height, and weight measurements. 
• Breast exam, pelvic exam, and Pap smear.
• Fertility scan (an ultrasound scan to confirm that there are no abnormalities or malformations that may interfere with Treatment, such as uterine abnormalities/malformations (semi–mobile uterus, immobile uterus, septate uterus, bicornuate uterus, didelphys uterus); endometrial abnormalities/malformations (endometrial cysts, endometrial polyps); tubal abnormalities like hydrosalpinx or swollen tubes indicating the tubal disease; ovarian abnormalities/malformations (Polycystic Ovaries (PCO), ovarian cysts, immobility of the ovaries and/or their displacement). 
• Collecting samples for subsequent analysis (cytology) to rule out any infection that may flare up during or after Egg Retrieval. 

Ovarian Reserve Assessment:

• Antral Follicle Count test (ultrasound scan performed before any IVF cycle to confirm the number of Antral Follicles including the dominant follicle(s) (mean size 9.0 +/–3.0 mm), and non–dominant follicles in one of the ovaries or in both ovaries. This test is usually done on day 3–6 of menses. Having 6 to 12 Antral Follicles are considered normal to start the IVF cycle.
• Blood Tests for measuring the levels of the hormones (AMH, FSH, LH, and E2) to evaluate the Ovarian Reserve & Functioning. 
• Genetic Test of Ovarian Reserve (ovarian function test is performed in patients with low ovarian reserve for identifying the genetic cause of diminished ovarian reserve and for achieving a better ovarian response during ovarian stimulation. It can be also done for choosing the medication that is suited to your genetic makeup).
• Premature Ovarian Failure Panel (Blueprint Genetics test enabling identification of the genes causing Premature Ovarian Failure (POF) and ovarian dysfunction using Next–Generation Sequencing technique or Deletion/Duplication Analysis). 

Other tests: 

• Blood Group and Rh factor.
• Complete Blood Count/Hemoglobin (CBC/Hb).
• Coagulation tests.
• Prolactin (measures the level of the hormone prolactin produced by the pituitary gland. High levels of prolactin can indicate infertility).
• TSH (Thyroid–Stimulating Hormone) Test.
• Screening for Sexually Transmitted Infections (STIs) and other viral & infectious diseases (HIV, Syphilis serology, Hepatitis B (HbsAg), Hepatitis C (HCV), Cytomegalovirus, Herpes Virus, etc).

Chromosomal & Genetic tests will be performed if necessary: 

• Chromosome Analysis (Karyotyping) 
• Fragile X Syndrome Testing 
• Testing for Thalassemia
• Carrier Screening for Spinal Muscular Atrophy (SMA)
• Comprehensive Chromosome Screening (CCS) for detecting more than 600 autosomal recessive diseases
• Genetic Compatibility Test (GCT) for screening of more than 2300 genes linked to more than 3000 hereditary diseases

Male Fertility Assessment

Andrological and urological assessments for men usually include: 

• Semen Analysis (Spermiogram) and sperm function tests to evaluate Sperm Count, Sperm Motility, and Sperm Morphology.
• Sperm DNA fragmentation analysis using the tunel assay to assess the quality of the DNA package as the transmission of the full DNA molecule from the sperm cell to the oocyte is essential for successful fertilization and embryo development (and vice versa, if sperm cells contain fragmented DNA, it may be the cause for total fertilization failure, embryonic arrest, and implantation failure).
• FISH–based sperm aneuploidy screening (a diagnostic technique for detecting various types of genetic damage in sperm using Fluorescence In Situ Hybridization (FISH) as a marker of chromosomes 13, 18, 21, X and Y which are mainly involved in recurrent Miscarriage and fetal malformations).
• Screening for Sexually Transmitted Infections (STIs) and other viral & infectious diseases (HIV, RPR (a test for syphilis), hepatitis B surface antigen, and hepatitis C antibody).
• Male Fertility Genetic Test (may be recommended for patients with Azoospermia (semen without sperm), Severe Oligozoospermia (extremely low number of sperm), Asthenozoospermia (poor sperm movement), Oligoteratozoospermia (reduced sperm count and low sperm motility), and Oligoasthenoteratozoospermia (a condition includes Oligozoospermia, Asthenozoospermia, and Teratozoospermia (abnormal sperm shape)).
• The other tests including ultrasound scans necessary for starting an IVF cycle.

Step 3 – Post–Screening Consultation

As soon as the Fertility Assessment will be completed, and your Fertility Specialist will get the results, there will be one more follow–up consultation to discuss the IVF program which will be the most effective in your case, and you will get the Blueprint of the Controlled Ovarian Stimulation Protocol including the prescribed injectable hormones (gonadotrophins) and medication. If you did a Genetic Test for Ovarian Reserve, your Fertility Specialist will prescribe the medication which suits your genetic makeup. 

Step 4 – Controlled Ovarian Stimulation 

Controlled Ovarian Stimulation involves using medication and injecting hormones (Follicle–Stimulating Hormone (FSH) — a gonadotropin, a kind of hormone that plays an important role in fertility), leading to multiple follicle development, and stimulating your ovaries producing more oocytes. Injectable hormones will be paired with medication that prevents spontaneous ovulation. Standardly, stimulation lasts 8–10 or 8–12 days but may be shorter or longer, depending on each case.

For starting the cycle, your gynecologist will recommend the required dose of medication based on the ultrasound scans and blood tests that have been performed (estradiol and progesterone levels). And during the Controlled Ovarian Stimulation cycle, the dosage and medication may be changed according to the ovarian response to medication.  

Usually, the injectable hormone is administrated subcutaneously using a pre–filled pen device or the device that should be filled using the cartridge containing the drug before it is injected.

Single or Duo–Stimulation Protocol 

The Double Ovarian Stimulation or DuoStimulation Protocol is recommended for patients with low ovarian reserve. It involves 2 stimulation cycles and 2 Oocyte Retrievals performed during a single menstrual cycle (approximately 24–28 days). The first Ovarian Stimulation is done in the follicular phase and followed by Egg Retrieval and the second stimulation is done in the luteal phase with one more Egg Retrieval. Duo–Stimulation makes it possible to retrieve more oocytes compared to standard stimulation.

Step 5 – Ovarian Stimulation Monitoring and Testing

The response of your ovaries to medication and hormones will be monitored during office visits via ultrasound scans and blood tests. Your gynecologist may suggest higher or lower doses of injectable hormones and/or medication or may prescribe the different drugs depending on ovarian response. Once the checkups indicate that the ovaries are ready, the Oocyte Retrieval is scheduled.

Step 6 – Trigger Shot: Single Trigger vs Dual Trigger 

Whereas Luteinizing Hormone (LH) and Follicle–Stimulating Hormone (FSH) work on both growing and maturing the oocytes, a trigger shot of hCG (human Chorionic Gonadotropin) helps the ovaries release those mature oocytes as a part of ovulation.

When the ultrasound scan confirms that you have several follicles in one of the ovaries or in both ovaries of about 16–18 mm in diameter, you will be administrated the Trigger Shot (hCG) to induce ovulation. It is given to know the exact timing in which the follicles in your ovaries will rupture and release the oocytes they contain. Ovulation generally happens about 24 to 36 or 36 to 40 hours after administering a trigger shot.  

Depending on the type of Ovarian Stimulation Protocol used, a single trigger or dual trigger will be used. The Single trigger Protocol involves the administration of hCG (human Chorionic Gonadotropin) to induce final oocyte maturation. Dual trigger or double trigger Protocol involves using of FSH combined with GnRH antagonist, and it is used in patients with high response, normal response, poor response, or oocyte immaturity.  

Step 7 – Egg Retrieval

Oocyte Collection is scheduled about 24 to 36 or 36 to 40 hours after hCG (human Chorionic Gonadotropin) injection. It is done by transvaginal ultrasound–guided single–/double–lumen needle aspiration under local anesthesia. Follicular aspiration is painless as it is done under anesthesia taking 15–30 minutes to complete. 

Step 8 – Sperm Collection and Capacitation

According to the standard Protocols of IVF, semen was collected on the day of Oocyte Retrieval. To improve fertilization potential, the semen is activated at the same time as Egg Retrieval is performed. Usually, a density gradient or swim–up technique is used for sperm capacitation. But in some cases, the combination of both techniques (density gradient and swim–up) is used. 

Step 9 – Fertilization

Once the quality of each retrieved egg has been verified, they are fertilized using the partner’s or the donor’s sperm. In IVF, conventional fertilization should take place. For ICSI cycles — the Intracytoplasmic Sperm Injection technique is used. The fertilization technique can be changed right before fertilization if there would be indications for using the more advanced one. 

The result of fertilization (Day 1 embryo) is checked about 18 to 24 hours after fertilization. If fertilization has been successful, the viable Day 1 embryo called a Zygote consisting of two cells is visualized. 

Step 10 – Cultivation 

Fertilization is followed by culturing the embryos in multicomponent nutritious embryonic media that provides everything needed for growth. Embryo Cultivation lasts between 2 and 7 days and during this time the development of preimplantation embryos is monitored by the Embryologists using time–lapse imaging that allows visualizing cellular events and embryonic morphology. 

The development of preimplantation embryos is periodically assessed as not all embryos have enough potency to reach the blastocyst stage. And it should be noted that not all embryos may be top–quality ones, not all can be transferred, not all can be vitrified for future FET cycle, and sometimes embryonic arrest happens. 

Step 11 – Embryo Selection

Routinely, selection of the embryos for Embryo Transfer (ET) takes place between day 2 and day 5; in some cases between day 2 and day 7 of cultivation using one of several embryo quality scoring systems. Usually, the quality criteria of preimplantation embryo are based on cleavage rate, regularity of blastomeres, and a low degree of fragmentation.

Step 12 – Embryo Transfer

Embryo Transfer is a painless procedure usually scheduled on Day 2, Day 3, Day 4, or Day 5 after an Egg Retrieval for cycles without Preimplantation Genetic Testing (PGT). Sometimes, it is scheduled on Day 6 or Day 7. 

In most cases, once the blastocyst stage has been reached, an Embryo Transfer sometimes called the Blastocyst Transfer takes place. Embryo Transfer entails placing the embryo in the mother’s uterus. 

Step 13 – Embryo Vitrification 

Embryos that have not been transferred and meet the Vitrification criteria can be cryopreserved and stored for future cycles. After Vitrification, they are deposited in the cryogenic tanks in the clinic’s lab. 

Depositing the vitrified embryos for future FET cycle(s) eliminates the necessity to start an IVF cycle from Ovarian Stimulation and undergoing Egg Retrieval. It also eliminates the fertilization stage. Vitrified Embryo Transfer will involve the endometrial preparation Protocol, Embryo Devitrification, Preimplantation Genetic Screening with embryo profiling (if necessary), and Embryo Transfer. 

Step 14 – Pregnancy test

The pregnancy test is done on day 13 or day 14 after the Oocyte Collection to lower the risk of getting a false positive or false negative result. It is performed on urine or blood sample, or sometimes both tests are done; and is called a beta–hCG. Human Chorionic Gonadotrophin (hCG) is the embryonic hormone produced by the embryo. 

High levels of beta–hCG detected especially in the blood sample is an early sign of embryo implantation indicating that pregnancy is in progress. Low levels of beta–hCG can be a marker of undesirable results (pregnancy is not achieved, the Miscarriage is going to happen or already has happened).  

Step 15 – Ultrasound scan

If you have a positive beta–hCG pregnancy test, the final step in IVF is scheduling an early ultrasound scan. The first pregnancy scan after IVF Treatment is done between weeks 5 and 7 of pregnancy (between 3 and 5 weeks after the Embryo Transfer). It confirms if the pregnancy is progressing or not; if it is an intrauterine or ectopic pregnancy, and if it is a singleton or multiple pregnancy. 

An early ultrasound scan detects the embryonic heartbeat. If the heartbeat is heard, and it is normal, you will have Congrats from the medical team as the pregnancy has been achieved. 

After this final step in your IVF journey, you will have one more consultation with your Fertility Specialist. Some Fertility Clinics also offer pregnancy care (prenatal care) programs, and some have Guaranteed Pregnancy programs that cover birth. If your clinic has such programs, you may continue your journey there. If nope, the next step would be searching for a maternity hospital and starting the antenatal care program there.