Preparing for Treatment
Once any diagnostic investigations are complete and you have decided to opt for a stimulated cycle, your clinic will probably organise a nurses meeting so that consents and paperwork can be completed, along with the opportunity to see the clinic where egg collection will take place. Your clinic should also make sure that the correct medications are given to you, and that mandatory blood screens have been done. These are Hepatitis B core Antibody, Hepatitis B surface antigen, Hepatitis C and human immunodeficiency virus (HIV1&2).
Preparing for egg collection involves stimulating your ovaries to produce as many good quality eggs as possible, instead of a single egg as is the case in a natural cycle. This involves taking hormones similar to those naturally produced during the first part of the menstrual cycle, typically follicle stimulating hormone (FSH). The fertility injections are primarily FSH but also sometimes contain other gonadotrophins. We generally refer to them as gonadotrophins, and they work by stimulating the ovaries to produce several follicles each containing an egg. In a natural cycle there will be a number of follicles that are receptive and these will start to grow every month, but only one normally reaches maturity. By giving a higher dose of gonadotrophin than is naturally produced, it is possible to maintain the development of some of those follicles that wouldn’t usually grow to maturity. IVF treatment does not use up your supply of eggs any quicker, and the time of menopause any is not affected.
Stimulating Your Ovaries
There are a number of gonadotrophin products available and they are all administered by sub-cutaneous injection. To administer, you ‘pinch an inch’ around the tummy area and inject with a very small hypodermic syringe. You will usually start this on day 2 (the day after your period starts) and continue until around day 12, it is better to have the injection at around the same time every day. A good time is typically a quiet reliable time in the late evening.
Your clinic will keep in close contact with you throughout the stimulation as they monitor the development of your ovarian follicles using ultrasound scans and blood tests. Ultrasound shows how many follicles are growing in the ovaries. It isn’t possible to see the eggs themselves on the ultrasound; however, when a follicle reaches around 18mm it will probably contain a mature egg. The level of oestrogen in the blood also provides an important indicator of follicle growth and development.
Once you start taking the fertility drugs you will attend the clinic every few days for ultrasound scans to ensure you have an optimum number and size of developing follicles. These scans and blood tests in conjunction with hormone level results allow the dose of drugs to be adjusted and optimise the timing of egg collection.
Egg Collection
The eggs are recovered using ultrasound guidance and the patient mildly sedated. A fine needle is passed through the vaginal wall and the ultrasound probe passed through it and directly into the ovarian follicles so the eggs can be gently aspirated out. Typically, the egg collection lasts fifteen to twenty minutes. It is usually possible to collect eggs from between 80-100% of the larger follicles. The eggs are inspected in the laboratory for a preliminary idea of their maturity and quality.
You may feel a bit sore after egg collection, slight abdominal cramping is normal. Paracetamol or Co-codamol can be taken if required to ease any discomfort. If you find this is not sufficient then you should contact your doctor for advice. It is not recommended to take aspirin, Nurofen (ibuprofen) or Feminax-Ultra (naxopren) unless specified by the doctor. It is perfectly normal to expect some light red or dark brown bleeding for a few days, which come from the puncture sites in the vaginal wall, if heavy bleeding is experienced please contact your clinic.
On the morning of egg collection your partner will need to provide a fresh semen (sperm) sample so the eggs can be immediately fertilised after collection. In the case of IVF the sperm and eggs are incubated together in a special media under very controlled conditions where fertilisation can occur. In the case of ICSI a single sperm is injected into each egg. A fertilisation check will be made the morning after egg collection and the resulting embryos grown under strictly controlled conditions in the lab. Alternatively, your eggs may be frozen at this point.
Embryo Transfer
Embryos are carefully cultured before being transferred back into the uterus three to five days after the day of egg collection; a five day old embryo is called a blastocyst. The decision of whether to opt for blastocyst as opposed to day 3 transfer is one which depends on several factors including the embryo quality, number of embryos and clinical history etc; your doctor and embryologist will advise you in this regard. The embryo transfer itself is usually a completely painless procedure. One or sometimes two embryos are transferred to your womb.
Typical Timeline
Day 1: Contact the clinic on the first day of your period (which we call day 1) to organise a scan for the following day.
Day 2: At the scan count the number of follicles are counted and a baseline blood sample for measurement of oestrogen (E2) and usually luteinising hormone (LH) is usually taken. On the evening of day 2 you begin the gonadotrophin stimulation.
Day 6: Ultrasound scan and blood test. If your oestrogen levels are starting to rise, this is an indication that follicles are starting to grow. Most patients begin to take the blocker injection on this day. This taken at the same time as the gonadotrophins in essentially the same way, but the purpose is to prevent the natural LH surge, which might otherwise cause premature release of the developing eggs.
Day 8: Ultrasound scan and blood test. You continue to take the gonadotrophin and blocker. The dose of gonadotrophin is under continual review as blood test and scan results are considered.
Day 10: Ultrasound scan and blood test. Continue to take the gonadotrophin and blocker. A preliminary decision about when to trigger ovulation is considered.
Day 12: This is the typical day for the trigger injection. You will be given a time to take the trigger injection. Your egg collection will normally be arranged for around 37 hours after the trigger injection and so you will also be given a specific time for the egg collection. Typically the trigger will be in the evening and the egg collection in the morning two days later. The trigger itself consists of human chorionic gonadotrophin (hCG) and induces the final stages of follicular maturation and ovulation. The trigger is also the hormone that is detected by pregnancy tests so it is not advisable to do a pregnancy test within two weeks of taking the trigger. On the day of the trigger you take the gonadotrophin and blocker for the last time, though in some cases this advice may vary according to the precise situation.
Day 13: On the day before egg collection you shouldn’t eat after midnight and shouldn’t drink after 2 am.
Day 14: Egg collection takes place around 37 hours after the trigger injection. The egg collection procedure requires only light sedation, not as strong as a general anaesthetic, however you will probably not be aware of the procedure taking place. You can expect to be at the clinic for about 4 hours and need someone to take you home afterwards.
Day 15: A fertilisation check is made the next morning and the resulting embryos are carefully cultured.
After egg collection your progesterone level will be supplemented by vaginal pessaries (usually Cyclogest) every night until at least your pregnancy test 2 weeks after transfer. Progesterone helps to maintain the lining of the uterus (endometrium) in a receptive state for implantation of the embryo.
The clinic will keep you informed on the progress of your embryos, which will develop for 2-5 days in the laboratory under very strictly controlled conditions, prior to transfer.
Day 17 – 19: Transferring the embryos back into the uterus is a simple procedure, similar to a cervical smear test. You can go about your daily activities after this procedure. Any extra suitable, good quality embryos are usually frozen at this time if that is your wish.
Day 26: Pregnancy testing should be commenced approximately two weeks after the embryo transfer, but you must wait at least 2 weeks after the trigger.
Summary
IVF is a very specialised area of medicine, and it requires an extremely skilled team of nurses, scientists and clinicians working closely together. All this can seem very daunting to the uninitiated and the purpose here is just to give a flavour and overview of the process. Of course every cycle is individual and unique, like every person. The timeline above represents a typical IVF, ICSI or egg freezing short protocol cycle, but exact timings are subject to change for any given clinical situation. There are also other protocols which may differ significantly from the one presented here and so this outline should be regarded as a guide to the most likely sequence of events.
Science Director Concept Fertility Clinic www.conceptfertility.com
