Typical IVF Cycle
IVF requires timing. This timing is often unique to the individual cycle. This example is just to provide you an idea of what a typical IVF cycle may entail. Frequently, oral contraceptives are used for 3-6 weeks prior to beginning Lupron therapy. Lupron therapy typically starts 2 weeks prior to your first gonadotropin (Gonal-f) injection.
| Day | Primary Event | Tests | Medications |
|---|---|---|---|
| 1 | Menses | Leuprolide Acetate (past two weeks) |
|
| 2 | Menses | FSH, LH, E2, US | Gonal-f or Follimon |
| 3 | Menses | Gonal-f or Follimon | |
| 4 | Menses | Gonal-f or Follimon | |
| 5 | Menses | Gonal-f or Follimon | |
| 6 | Maturing follicles | E2, US, LH | Gonal-f or Follimon |
| 7 | Maturing follicles | Gonal-f or Follimon | |
| 8 | Maturing follicles | E2, US, LH | Gonal-f or Follimon |
| 9 | Maturing follicles | Gonal-f or Follimon | |
| 10 | Maturing follicles | E2, US, LH | Gonal-f or Follimon |
| 11 | Maturing follicles | E2, US, LH | Gonal-f or Follimon |
| 12 | Maturing follicles | E2, US, LH | Gonal-f or Follimon |
| 13 | Mature follicles | E2, US, LH | hCG (LG IVF-C) |
| 14 | Retrieval | Fertilization | Progesterone |
| 15 | Freeze Embryos | Progesterone | |
| 16 | Transfer Embryos | Rest | Progesterone |
| 17 | Rest | Progesterone | |
| 18 | Rest | Progesterone | |
| 30 | Pregnancy Test | Progesterone |
Ovulation Induction and Monitoring 
In-Vitro Fertilization, like natural fertilization and pregnancy, represents a combination of perfectly timed events. IVF uses the fertility medications listed above to mimic the body's natural hormones and to develop multiple eggs which will increase your chances for pregnancy.
Prior to beginning the administration of any fertility drug, a screening ultrasound scan will be performed to ascertain that there are no ovarian cysts which could interfere with proper stimulation. Most ovarian stimulations begin on cycle day 2 or 21 with daily subcutaneous injections of leuprolide acetate. When your estrogen level is adequately suppressed, FSH (Gonadotrophins) injections begin. The dose given is based on your weight and also your individual response during a previous cycle. Leuprolide acetate provides more control over the stimulated cycle by preventing a premature release of luteinizing hormone (LH) that may cause premature release of the eggs from the ovary. It also allows for synchronized follicle development producing more mature follicles of the same size. Gonadotrophins stimulate development of the fluid filled sacs on the ovary called follicles in which the eggs develop. The daily injections will continue until the follicles are a proper size and the blood estrogen levels (E2) reach an optimal level. hCG will then be used to mimic the body's LH surge to bring about final maturation of the egg.
Careful monitoring of estrogen levels and follicle size optimizes ovarian stimulation and provides for increased safety. Blood estrogen levels are performed every 1-3 days from cycle day 2 until the administration of hCG.
Vaginal ultrasound (US) scans are scheduled throughout the stimulation to monitor development of the follicles. It is not necessary to drink water to fill a bladder before the scans. We will ask you to empty your bladder prior to the ultrasound.
As stimulation progresses, the ovaries may become enlarged and tender. It is advised that strenuous activity be avoided after stimulation begins.
Induction of adequate follicle maturation is a difficult hurdle during IVF. It is estimated that up to 25% of initiated cycles will be canceled prior to retrieval because of:
- Inadequate follicle development or hormonal levels.
- Premature LH surges
Cancellation of a stimulation brings with it much disappointment, both for the couple and the IVF team. However, pregnancy rates depend on all factors being optimal. It is preferable therefore to begin a new stimulation in a later cycle so eggs which are retrieved are the best quality possible.
Egg Retrieval 
As with any outpatient procedure, you will meet with your anesthesiologist prior to your egg retrieval. If you have a complicated history or feel the need to talk with the anesthesiologist prior to retrieval day, a phone conference can be arranged.
The egg retrieval is scheduled at approximately 36-38 hours after the hCG is administered.
Transvaginal egg retrievals are performed by ultrasound-guided aspiration. The ultrasound probe is inserted through the vagina. The images of the reproductive organs are translated onto a monitor screen. When a mature follicle is identified, the physician guides a needle through the vaginal wall and into the follicle. The egg is then removed through the needle by a suction device. Although the vagina has a reduced number of pain nerves, this procedure can be associated with some discomfort or intermittent sharp pains. Most patients require light sedation. On rare occasion, general anesthesia may be required. An experienced anesthesiologist or nurse anesthetist will be available to provide either sedation or anesthesia as required or requested.
Patients will go home the same day as retrieval, regardless of whether retrieval is done under sedation or general anesthesia.
During the retrieval, the embryologist will immediately scan follicular fluid for the eggs. Gas composition, temperature and humidity of the environment are specifically controlled. Once identified, the eggs are evaluated for maturity and placed in culture medium.
Following the egg retrieval, the husband is asked to provide a semen specimen for the insemination of the eggs. The time of the semen collection will vary according to the maturity of the oocytes and the requirement for special treatment of the sperm. The mature eggs are inseminated with the sperm 2-6 hours after retrieval.
Sixteen to twenty hours after the insemination, the oocytes are examined for signs of fertilization. Twenty-four hours later, they are examined for cell division and an embryo transfer is scheduled approximately 72 hours after retrieval if cell division has begun. Fertilization does not always occur, and sometimes embryo development halts shortly after fertilization. The 3 day wait from oocyte retrieval to embryo transfer is inevitably stressful. You will be kept informed during this period about the progress of your eggs.
Human egg before fertilization. |
Fertilized egg, approximately one day after
retrieval, showing 2 pronuclei. |
Embryo consisting of 8 cells, approximately
3 days after retrieval. |
Blastocysts, approximately 5 days after retrieval. |
Embryo Biopsy (Day 3) / PGD 
On Day 3, these embryos will be at the 6-8 cell stage. At this point, it would be considered safe to remove one of the cells (blastomeres) for Preimplantation Genetic Diagnosis (PGD). A hole is made in the outer covering of the embryo (zona pellucida) using an acid solution. Thereafter, one of the blastomeres is aspirated through the hole into a biopsy pipette. The blastomere is placed on a slide and is ready for PGD. The embryos are placed back into the special culture media to allow them to develop futher.
Embryo Transfer 
When embryos have developed satisfactorily, they are then transferred into the wife's uterus. Typically, up to four embryos are transferred, however, the final decision will be made the morning of transfer by the physician after consultation with the couple. Medication to promote relaxation will be prescribed to be taken just prior to transfer. A speculum is placed in the vagina and the cervix is cleansed. The embryologist then loads the embryos into a thin catheter which is then given to the physician who places the embryos into the uterus. You will be kept at bed rest for two hours following the transfer. Decreased activity will then be advised for the next 48 hours. If the embryos are sufficient quality, extra embryos in excess of four can be cropreserved. A pregnancy test will be done 12 to 14 days after embryo transfer. After embryo transfer you will receive a "report card" reviewing your cycle, egg retrieval, development and transfer.
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