A step into the unknown

So, what is IVF? Most people have a vague idea that it is something to do with helping couples with fertility issues but they do not know the details. Certainly, before my wife and I started treatment we did not know what it involved.

This lack of knowledge created uncertainty and the uncertainty gave rise to fear.

I’m sure we are not alone in feeling this way so before we get into the Plan itself it may be helpful to provide a short overview to help you take back some control. It will also help provide some context for the steps that follow.

A typical cycle

What exactly does the treatment process involve? There are variations on the theme but typically there are several stages:

1. ovary stimulation
2. egg collection
3. sperm collection
4. fertilisation
5. embryo transfer
6. post-transfer follow-up

Let’s have a look at each of them.

Ovary stimulation

The first phase of treatment involves taking medicines to stimulate your body to produce eggs. To do this doctors usually use one of two medicine plans: the “long protocol” or the “short protocol”.

The main difference between the two is the point when you start taking medicines. The long protocol takes place over two periods whereas the short protocol works over one period.

As the name suggests the “short protocol” is quicker and is used where there is a risk of Ovarian Hyperstimulation Syndrome (a potentially dangerous condition where the ovaries overreact to the stimulation drugs).

Where possible, the IVF process seeks to work in harmony with your normal monthly cycle and aims to enhance your ability to produce eggs. This being the case the long protocol starts on day 21 of your first period and the short protocol begins on day 1 (remember, the short protocol takes place over just one period).

In a natural cycle your ovaries grow fluid-filled pouches that each contain a single, immature egg (or “oocyte” to give it the medical name). These pouches are called “follicles”. Without additional drug stimulation only one follicle each month will become mature enough to release its egg. In a natural cycle this happens when the body produces a surge of a hormone called “luteinising hormone” (LH).

With IVF the aim is to encourage multiple follicles to become mature enough to release eggs so a medication is given from day 21 of the first period (long protocol) or day 1 (short protocol) for around 14 days to temporarily switch off LH. This is called “down-regulation”.

The medication is given as either a daily injection or a nasal spray. Without it the body’s natural production of LH would kick in when only one follicle had matured and cause the release to happen too early.

We want to wait until several eggs are mature before triggering the release.

Having switched off LH, in a long protocol another medicine (called, appropriately, “follicle stimulating hormone”) is given from day 3-5 of the second period for 10-12 days to help stimulate the development of multiple follicles.

In the short protocol the same medicine is given from day 1 in parallel with the down-regulation medicine, again for 10-12 days.

This drug is usually given as a daily injection under the skin (called “sub-cutaneous” by the doctors) using a special injection pen that makes it easy for patients to do themselves.

From this point the long and short protocols follow the same path.

During the stimulation stage the doctors will monitor progress using ultrasound scans and blood tests. They are looking for multiple follicles to reach a certain size before giving a final injection about 36 hours prior to egg collection.

This injection contains something called “human chorionic gonadotropin” which finishes the maturation process and loosens eggs from the follicles ready for collection.

Egg collection

The day of egg collection can be both exciting and daunting. Following the ultrasounds you should have a general idea of the number of eggs available for collection but it is not until they have been retrieved that you will know the exact number.

The collection procedure is done under sedation. The doctor uses an ultrasound scanner to help guide a microscopic needle through the vagina to the ovaries. The needle is then used to drain each follicle and collect the contents. Hopefully, this will include an egg. The contents are then examined under a microscope and the eggs are separated.

The procedure usually takes less than 30 minutes.

Sperm collection

At the same time as the eggs are collected your partner will produce a sperm sample. Depending on the circumstances an operation may be required but, generally, the sample is produced “manually” using “traditional” methods!

Fertilisation

Ok, by this stage you will hopefully have a number of eggs and a sperm sample. The sperm sample is treated, concentrated and then combined with the eggs (this is where the phrase “test tube baby” comes from). The mixture is then left overnight during which time the sperm will hopefully have fertilised some of the eggs.

If there have been or may be issues with fertilisation your doctor may recommend using a technique called ICSI (“intracytoplasmic sperm injection”).

ICSI involves the embryologist injecting a single sperm into an egg rather than just mixing the two together.

Fertilised eggs are called embryos and any that are obtained are kept in laboratory conditions for up to 6 days to enable them to develop into something called “blastocysts”. Blastocysts are simply 5-6 day old embryos. Transferring embryos at this stage has been shown to produce better results than transferring 3 day old embryos which used to be the standard practice.

Embryo transfer

At this stage of the process my wife and I froze our embryos for future use so we could get on with the small matter of beating leukaemia. In the typical IVF process once blastocysts have developed they are ready to be transferred.

The thickness of your womb lining now becomes the focus. Whereas up to this point all the attention has been on the number and size of the follicles on your ovaries the thickness of the lining becomes key. It is in the lining that an embryo will hopefully implant and develop into a pregnancy.

If you have had issues with the thickness of your womb lining in the past your doctor may recommend that you take estrogen (usually in the form of patches or injections) and progesterone (as a suppository) to help increase the thickness. If this is the case you will take the drugs for several days prior to the transfer.

The procedure to transfer the embryos is less invasive than the egg collection. It is similar to have a cervical smear test. One or more embryos are delicately inserted into the womb using a fine plastic tube. The procedure takes a few minutes and should be painless.

If you are lucky enough to have produced a number of good quality embryos the remainder can be frozen for future use.

Post-transfer follow-up

This is known as the “two week wait” and, I’ll be honest, it can be quite a tense time. On leaving the fertility clinic you will be given a pregnancy test kit to be used 10-14 days after the embryo transfer. This is crunch time where you will find out whether the treatment has worked or not. You will likely experience a whirlwind of emotions.

If the pregnancy test is positive you will then be asked to have an ultrasound scan in the following weeks to check for a heartbeat and to ensure that your baby is developing properly. Assuming all is ok at this point your care will be transferred to the antenatal team at your local hospital and you will be treated the same as other pregnant women.

Right, let’s get into the steps that you can take to increase your chances of having a family.