I get a lot of questions about IVF. And, we’re a holistic clinic, so I am not the holistic expert! But, I really love Dr. Kiltz at CNY Fertility so I had him answer some frequently asked questions about IVF.
While there are many ways to treat infertility naturopathically, including lots of what we do here at Holistic Fertility Center, like laser therapy, focusing on egg quality and uterine quality, and taking beneficial herbs, there are times when IVF becomes necessary. So, what’s involved in the IVF process? Good question. Here’s what you need to know:
In Vitro Fertilization (IVF) has four main steps: Ovarian Stimulation, Egg Retrieval, Fertilization & Development, and Embryo Transfer. Each stage is carefully timed based on the woman’s response to medications and to optimize her readiness to carry the embryo. IVF is the most effective fertility treatment available with the best per cycle success rates of any Assisted Reproductive Technology (ART). IVF was first successfully performed in 1978, and new techniques have continued to improve its success rates.
In very basic terms, IVF removes eggs from a mother or donor, fertilizes them with partner or donor sperm, and places the fertilized egg (now called an embryo) back into the uterus of the mother or carrier where it continues to develop until birth.
Let’s take a closer look at each what’s involved during each stage of IVF.
First Step: Ovarian Stimulation
At the start of an IVF cycle, a woman will have a “baseline” appointment to measure her uterine lining, follicle size, and hormone levels to establish a starting or “baseline” level for each. Around days 2-4 of a woman’s natural cycle (if she has regular cycles), she will begin to take injectable medications to stimulate her ovaries to produce additional mature eggs. These daily injections are taken for approximately 7-10 days. While most women naturally release only one mature egg each month, with the help of Follicle Stimulating Hormones (FSH) injections, ovarian stimulation allows a woman to produce several mature eggs during that cycle. Additional eggs up the odds of having a baby from that IVF cycle. Around the 6th day of FSH injections, a woman also begins to take another medication to prevent early ovulation.
Every few days during this entire process, the woman must see her doctor for monitoring appointments to track the thickness of her uterine lining and monitor follicle development as well as various hormone levels. Once the egg-containing follicles reach the appropriate size as seen on ultrasound (usually around day 8), the first two medications are stopped, and a third medication (the trigger) is introduced for either one or two days to promote the final maturation of the eggs.
During the stimulation phase, various protocols may be used. Mini IVF is one such protocol that uses minimal stimulation. By using fewer medications to stimulate the ovaries, a woman is usually able to produce a small number of high-quality eggs while substantially reducing the risk of hyperstimulation, and it’s a bit gentler on the body.
Second Step: Egg Retrieval & Sperm Collection
35 hours after the first “trigger” shot, eggs are collected during an egg retrieval. This is a minor outpatient procedure. While under light anesthesia, developed eggs from the woman’s ovaries are retrieved by a physician using a tiny hollow needle with suction capabilities to pierce through the vaginal wall and drain the fluid from the follicles. This fluid contains the developed eggs. The actual retrieval itself lasts less than 15 minutes.
The follicular fluid that contains the eggs is brought to an IVF laboratory where an embryologist will locate, isolate, and nurture the eggs in an environment similar to the fallopian tubes where fertilization naturally occurs. The number of eggs retrieved depends on the female’s age, medical history, fertility diagnosis, medication type and dosage being taken, and natural response to medications.
If a male partner is providing the sperm, it is usually collected in a sterile cup the morning of the egg retrieval. It can also be collected beforehand, frozen, and then thawed the morning of retrieval. The sperm is washed, concentrated, and suspended in a solution, then transferred to the embryology lab. Sperm may also be provided by a donor or surgically retrieved from the man if there is no sperm present in his ejaculate.
Third Step: Fertilization & Embryo Development in the Laboratory
Fertilization: After egg retrieval, it takes approximately 4-6 hours for the eggs to reach their final stage of maturity. Once this happens, the eggs are ready to be fertilized with sperm. There are generally two fertilization methods used in IVF:
Conventional IVF: In conventional IVF, a large number of sperm are combined in a Petri dish with the eggs. They are left together in an incubator for about 18 hours giving them time to fertilize “naturally” on their own.
ICSI: Under a microscope, Intracytoplasmic Sperm Injection or ICSI injects a single sperm directly into each egg using an extremely small needle. ICSI was developed to help couples with male factor infertility, but fertility centers use ICSI as their primary method of fertilization.
Once fertilized, the eggs, now embryos, continue to grow in the IVF laboratory.
For those who have struggled with the idea of the laboratory being in control of fertilization that naturally happens in a woman’s body, there is another option available to them. INVOCELL® is a unique device that allows egg and sperm to fertilize in a small container (about the size of a thumb) within a woman’s body. The treatment process using INVOCELL® is very similar to conventional IVF, only fertilization and subsequent early embryo development happens inside the INVOCELL® device which is then placed inside the woman’s vagina for a brief few day incubation period instead of in an embryology lab before being removed from the device and transferred to her uterus.
Embryo Development: Embryos are grown in nourishing media for 3-7 days or until the embryo reaches a cleavage or blastocyst stage. At this point, the embryo must be transferred into the carrier’s uterus or frozen for a future frozen embryo transfer (FET). An embryologist regularly examines each developing embryo to monitor its progressive development.
Cleavage Stage: An embryo usually reaches the cleavage stage of development usually around day 3. They are called cleavage embryos because the cells in the embryo are dividing (or cleaving), but the embryo itself does not grow in size. A healthy day 3 embryo will typically contain between 6 and 10 cells.
Blastocyst Stage: An embryo reaches the blastocyst stage of development around day 5, though it may take up to 7 days. A blastocyst embryo has developed into a single-layered sphere of cells (the trophectoderm, which will differentiate into the placenta) encircling a fluid-filled cavity with a dense mass of cells (endoderm, which will develop into the fetus/baby) grouped together. Blastocysts contains anywhere from 60 to 120 cells.
Further developed embryos have a higher probability of being genetically normal and result in live births than earlier stage cleavage embryos.
Fourth Step: Embryo Transfer
The Process: The embryo transfer itself is a rather quick stage of the treatment. Anesthesia is very rarely necessary, but a muscle relaxer or Valium is commonly used.
During the transfer, a catheter containing the embryo(s) is passed through the vagina and cervix and into the uterus using an ultrasound to guide the process. The embryo is then gently deposited into the uterus.
Key Questions: The goal of any IVF cycle is always to transfer the highest-quality embryo(s) in order to provide the best chance of reproductive success. When this happens and how many embryos are actually transferred are two important questions you must discuss with your fertility provider. Answers to these questions will not always be the same for every patient or every cycle for that same patient.
Cleavage vs. Blastocysts: All things being equal, blastocyst embryos have higher odds of resulting in a live birth than cleavage stage embryos. Why? Because some embryos naturally fail to thrive at all stages of development. The longer you let them develop in a lab, the more confident you can be that the embryo you are transferring is of higher quality.
While it is true that blastocyst embryos have higher odds of implanting and resulting in a live birth than cleavage stage embryos, there are certainly reasons to transfer day 3 cleavage stage embryos. As good as embryology labs have become, most fertility experts will agree that the best place for an embryo to thrive is in a mother’s womb.
In the IVF lab during embryo development, there is a constant drop off or funnel effect to the number of viable eggs. For instance, 15 eggs may be retrieved, but only 10 of them are fully mature and able to be fertilized. Of those 10 that are attempted to be fertilized, only 8 are actually fertilized. Of those 8, only 6 make it to the cleavage stage. Of those 6, only 4 make it to the blastocyst stage. In this example, 2 embryos were lost from cleavage to blastocyst stage. Could those embryos have resulted in a healthy baby if they had been transferred as a cleavage stage embryo? Maybe. Maybe not. It’s difficult to know for sure.
Some patients are simply incapable of making it to day 5 embryos in a lab. Despite multiple cycles attempting to make blastocyst embryos, their embryos repeatedly fail to thrive between days three and five. The potential solution? During a subsequent cycle, embryos are transferred on day three resulting in a live birth.
To balance this risk, many clinics have set standards for when they will transfer cleavage embryos and when they will attempt to take embryos to the blastocyst stage. Other clinics choose to only do one or the other, and it’s the same for every patient.
It is important to remember that most clinics will only perform genetic testing on blastocyst stage embryos. While genetic testing isn’t recommended for all parents, it may be beneficial in reducing the odds of miscarriage, avoiding known genetic disorders, and even allowing parents to choose the sex of their child. For some parents, selecting the gender of their child is desirable. By testing blastocyst embryos, the lab can determine which are XX or XY, and transfer the gender of choice during a frozen embryo transfer.
Fresh vs. Frozen: While fresh embryo transfers were the preferred method for many years, vitrification (freezing) methods have improved considerably making frozen embryo transfer an equally if not more attractive option. The negative consequence of ovarian stimulation is that medications used to optimize egg development has a tendency to cause a hormone imbalance that can interfere with endometrial receptiveness. When doctors believe successful implantation unlikely, they may recommend freezing all embryos and switching to a frozen embryo transfer (FET) to give the carrier’s body time to recover and become better prepared for implantation.
A frozen embryo transfer is a cycle in which frozen embryos from a previous IVF or donor egg cycle are thawed and then transferred into a woman’s uterus. A frozen transfer allows a woman’s body to recover from her stimulation cycle, optimize progesterone/estrogen levels, and make sure the endometrial lining is ideal for implantation.
One Embryo vs. Two: A single embryo transfer is the intentional practice of transferring only one embryo into a woman’s uterus. It has quickly become the gold standard practice of many reproductive endocrinologists. It offers a reduced chance of multiples and is less risky for the mother and fetus while simultaneously achieving the same cumulative success rates (success rates that include all FETs from the one IVF stimulation). This does not mean that multiple embryos are never transferred. It simply means that the decision for each patient is treated individually. ASRM recommends a single embryo transfer in all patients under 38 years of age.
For Lesbian or Trans men couples looking to both be biologically involved in the process of creating their child, reciprocal IVF is an ideal option. This allows one partner to provide the egg, which is then transferred to the uterus of the other partner to carry.
Pregnancy Support After IVF: While the IVF process concludes with embryo transfer, most patients continue to be supported by medications and are monitored by their fertility doctor for a number of weeks before being transferred to their regular OBGYN for pregnancy care.
Paying for IVF: For many couples without insurance coverage, paying for IVF and all of its related expenses is a major consideration. The cost of IVF isn’t cheap, but fortunately, in addition to treatment, some fertility clinics also offer loans and other financing programs that allow parents to make monthly payments and can help make fertility treatment affordable to many. There are even many national IVF grants that offer free or discounted IVF if you qualify.
Final Thoughts: IVF is no walk in the park by any stretch, but it works to solve many key fertility issues. Between the medications, appointments, and worrying about whether everything will work in your favor, treatment takes a tremendous physical, emotional, and financial toll on both partners. And there are an overwhelming number of details and choices to be made throughout the process. But the desire to have a child usually trumps all of these other variables. A good fertility doctor, helpful nurses and financial counselors, and supportive friends and family can make a world of difference as you work toward growing your family using IVF or other fertility treatments.
We are here to support you if Holistic Fertility Treatment is right for you. But, if it’s not the right fit and IVF is better, we are always happy to refer you. Our colleagues at CNY Fertility are great! If you need a consult from us, you can apply for a $1 Fertility Insight session here to get started.