In Vitro Fertilization (IVF)

A typical IVF cycle involves the following steps spread out over a 4-6 week period.

1. Women take fertility medication, given by injection, to stimulate their ovaries to develop multiple mature eggs. The most common medications are gonadotropins, including Bravelle, Repronex, Follistim, Gonal F, and Menopur.
2. Eggs are retrieved from the ovaries using an ultrasound-guided procedure that is performed under light anesthesia on an outpatient basis. A needle is placed through the vagina into the ovary to remove mature eggs.
3. The eggs are inseminated.  The eggs are either mixed with sperm in a Petri dish, allowing fertilization to occur, or the sperm can be injected directly into the eggs using intracytoplasmic sperm injection (ICSI). After fertilization, it takes approximately 16-20 hours to determine if fertilization has occurred.
4. The embryos are cultured. It takes approximately 24-72 hours to determine if the embryo is growing. The embryos will continue to be cultured and grown in the embryology lab for 3 -6 days depending on what stage they will be transferred.
5. One or more embryo(s) is transferred into the uterus. Embryo transfer is done at the infertility clinic and is easy and painless, requiring no anesthesia. A long thin catheter is inserted through the vagina, past the cervix, and into the uterus, where the embryo(s), along with a small amount of fluid, is placed. It is possible to transfer Day 3 embryos, Day 5 embryos (blastocysts), and sometimes Day 6 embryos when necessary because of genetic testing on the embryos. Your infertility clinic will advise you which is the best option for you. The day or the day before the transfer, your reproductive endocrinologist or embryologist will discuss the quality and grade of your embryos and a decision will be made on how many embryos to transfer. If your embryos are of good quality, you will be encouraged to consider transferring one embryo (elective single embryo transfer). This is the overwhelmingly strong trend in IVF and is considered best practice. We strongly encourage you to listen to this interview on a Creating a Family radio show on Single Embryo Transfer to help you decide.
6. The uterine lining is supported by hormones to permit and sustain a pregnancy. Often a blood test is run about 5 days post transfer to check hormone levels and a pregnancy test will be taken 9-12 days after the transfer to determine if it was successful. Your reproductive endocrinologist may recommend further hormones to support the uterine lining and pregnancy.

Success rates for IVF depend heavily on the age of the woman. In the United States, the live birth rate for each IVF cycle where the woman uses her own egg is approximate:

• 30-35% for women under age 35
• 25% for women ages 35-37
• 15-20% for women ages 38-40
• 6-10% for women ages over 40

Before you choose an infertility doctor or clinic, you should look up their IVF success rate. Both the Center for Disease Control and the Society for Assisted Reproductive Technology (SART) have a database of infertility clinic success statistics. The problem with the statistics, as wonderful as they are, is wading through the sea of numbers to figure out which ones are meaningful to you.

Success rates show the number of IVF procedures performed by a clinic in a year and the resulting number of pregnancies or live births. (Note that these statistics are only for IVF, and do not cover IUI success rates.) You can learn a lot about a clinic by comparing their statistics to the national averages for IVF success, pregnancy rates, numbers of embryos transferred, and twin rates. The most important statistic is the percentage of embryo transfers resulting in live births. This statistic shows the number of babies that resulted from each IVF cycle as opposed to the number of conceptions that resulted from each IVF cycle.

Like all statistics, however, you must be careful when interpreting them. IVF statistics can drive treatment decisions that arguably may not be in the individual patients best interest, or they may not be a good representative of what is really happening. Most clinics’ success rates are close to the national average, and often there is a perfectly good explanation for an unusually high or low statistic. One reproductive endocrinologist gave the example of a clinic with an unusually high IVF cycle cancellation rate. Turns out, most of the patients in this practice had the same insurance that covered three in vitro fertilization cycles. According to this company’s policy, “a cycle” only counted against the lifetime max of three cycles after eggs had been retrieved. This fertility clinic was willing to skew their statistics and work with patients by canceling cycles before egg retrieval when not enough eggs were produced.

Another example of statistics possibly influencing fertility treatment practice is when some clinics refuse to accept patients with low probability of success or only accepting woman over 40 if they agree to go straight to donor egg. A case could be made that this is just good medicine since older women have low odds of success, but many women will accept the risk and cost of failure to try at least one round of IVF with their own eggs just to know that they tried.

We strongly recommend listening to this Creating a Family show with leading infertility doctors: How to Interpret IVF Success Statistics.

• Multiple births. The primary risk of IVF is multiple births, which are at greater risk of miscarriage and premature birth. The risk of twins, triplets and more is controllable by limiting the number of embryos transferred.
• Premature birth and low birth weight. Multiple births, even twins, are at high risk of preterm labor and low birth weight, but some evidence suggests that singleton births following IVF are at a slightly increased risk of prematurity and low birth weight.
• Ovarian Hyperstimulation Syndrome. Use of the common injectable fertility drugs used in IVF, such as human chorionic gonadotropin (HCG), can cause ovarian hyperstimulation syndrome. Symptoms include abdominal pain from swollen ovaries, a distended abdomen, nausea, vomiting, and diarrhea. It is possible for ovarian hyperstimulation syndrome to be more severe, and any symptoms, even mild, should be reported immediately to your doctor.
• Egg retrieval complications. While rare, some women have problems with the anesthesia used during egg retrieval. It is also possible, although not common, for the needle inserted through the vagina to retrieve the eggs to cause infection, bleeding, or damage to surrounding tissues or organs.