In Vitro Fertilization (IVF) is the most effective fertility treatment in that it results in the fastest time to pregnancy of any fertility treatment or natural process. It is, however, quite a complex treatment that can lead to a great deal of confusion as to what one can expect throughout the IVF process. In fact, the IVF process consists of hundreds of detailed steps that must be followed by both the patient, doctor, nurses, embryologists, laboratory technicians, and more. While it truly is a complex process that must be followed closely in order for IVF to work, it can be greatly simplified and organized into four main steps.
The timeline or exact day for each event during the IVF treatment process is highly variable from patient to patient and cycle to cycle but in general looks something similar to the calendar below. In general, if one thing shifts, everything following that event shifts in a similar manner. For example, if the follicles are developing as rapidly as “expected,” the trigger shot (Lupron in the example below) would be delayed, which would then push back the egg retrieval, embryo transfer, and pregnancy test in a similar fashion.
Now that we have a high-level overview of the in vitro fertilization process – let’s take a deep dive into each of the four major steps.
Step 1 of the IVF Process: Ovarian Stimulation
Ovarian stimulation is the phase of the In Vitro Fertilization process in which medications (FSH and sometimes LH) are taken so that the woman produces many mature eggs – as opposed to the one or two eggs a woman normally produces. Although there are variations of the IVF treatment like natural IVF, which does not use medications, and Mini IVF, which use different or lower doses of medications with the intention of producing only a few mature eggs, most experts agree that a good simulation is critical to the in vitro fertilization process.
Why exactly is ovarian stimulation so important?
The utility of ovarian stimulation is simple. An egg can not be retrieved from every follicle. Not every egg that is retrieved is mature. Not every mature egg is successfully fertilized. Not every embryo (a successfully fertilized egg) develops properly in the lab. Not every embryo that properly develops and can be transferred results in a pregnancy. Not every pregnancy results in a live birth. Because of this, starting with a high number of eggs leads to higher odds of a live birth. Ovarian stimulation helps ensure that.
As you might expect, numerous studies , show that the odds of a live birth rise drastically as the number of eggs retrieved goes up.
As you can see, the odds of success rises quite a bit until the number of eggs retrieved is somewhere around 15-20. At this point, more eggs don’t necessarily raise the odds of a live birth substantially, though it may actually increase the odds of serious complications. The medication given to stimulate egg growth can cause complications like ovarian hyperstimulation (which could result in hospitalization if it is severe enough) if given too much FSH. While moderate to severe Ovarian Hyperstimulation Syndrome (OHSS) is possible in any IVF treatment and happens in approximately 1-5%, it is more common in young women (or those with high AMHs) and women with PCOS.
Fortunately, through close monitoring, appropriate dosing, and the proper choice of trigger medications, serious hyperstimulation can be largely avoided. In fact, simply following an antagonist protocol rather than an agonist protocol reduces the odds of hyperstimulation form 12 to 2.7% percent . And using a Lupron/GnRH trigger rather than an hCG trigger reduces the odds seemingly virtually .
Because of this, it’s important to work closely with your fertility doctor and nursing staff to develop an appropriate protocol to optimize the odds of success while mitigating risk.
Ovarian Stimulation Timeline:
Ovarian stimulation typically starts on day 2-4 of a woman’s natural menstrual cycle and usually lasts for 10-12 days.
Most often, a patient will be instructed to call the clinic on day one of their menstrual cycle to inform the clinic that their cycle has begun, and they would like to start a treatment cycle. They will then be scheduled to come into the office on cycle day 2-4 for a “baseline” office visit to establish “baseline” measures of follicular size, uterine lining, and hormone levels and to receive instructions on starting the treatment cycle.
It’s important to note that days of an IVF cycle can be confusing as some may refer to day one as the first day of the menstrual cycle where others refer to day one as the first day of FSH injections (and thus day one of treatment would be day 2-4 of the menstrual cycle). For purposes of this article, we will always use day 1 to mean the first day of IVF stimulation medications.
During the ovarian stimulation phase of the IVF process, FSH is taken for approximately 8-12 days. An antagonist medication that prevents ovulation is usually started in addition to FSH around day 5 or 6 (but the true day it is started is determined by the size of the follicles (usually 13mm) and/or your Estrogen levels). A trigger medication is then taken for one or two days, typically around day 10-14 to assist in the final maturation of the eggs.
Here is an example of a day by day look at ovarian stimulation:
The Egg Retrieval: Step 2 of the IVF Process
The egg retrieval will be 35 hours after the trigger shot. You will be given a specific time to arrive at the office at which the retrieval is taking place. The egg retrieval is an ambulatory procedure that requires a sterile environment and mild anesthesia. For that reason, you will need to have arrangements made for someone to drive you home or to your hotel. Often this is a partner, friend, or loved one, but can certainly be a Medicab service if alone. Your partner or loved one will not be allowed in the room.
Preparing for The Egg Retrieval
You will likely be instructed to follow a number of precautions and instructions when preparing for the egg retrieval. For example:
The night and morning before the retrieval
When you arrive
When your name is called
When its time for your procedure
When the procedure is over
The Embryology Lab: Step 3 of the IVF Process
While the patients themself are not involved in the lab part of the In Vitro Fertilization process, their eggs, embryos, and sperm are. And if doing a fresh embryo transfer, they will be preparing their body for transfer while their embabies are in the lab. If doing a freeze all cycle with a frozen embryo transfer, the intended parents will likely be resting and recovering while the embryologists take good care of the developing embryos.
That said, the ongoing of the embryology lab can be broken down into two main parts:
Generally speaking, there are two types of fertilization used in In Vitro Fertilization:
After fertilization, the embryos (fertilized eggs) are placed inside an incubator, which serves as a sort of “artificial fallopian tube” (early development normally takes place in the fallopian tube) during early embryonic development. Maintaining a proper environment that mimics the Fallopian tube/uterus is absolutely critical to embryo development.
Embryos develop inside the embryo incubators for up to 7 days – until they reach a cleavage or blastocyst stage of embryonic development.
The Embryo Transfer: Step 4 of the IVF Process
The embryo transfer is a simple procedure that takes only a few minutes and is relatively pain-free, like an intrauterine insemination, pap smear, or speculum exam at the ob-gyn. No anesthesia or recovery time is needed.
There are many different types of embryo transfers – but from a patient’s perspective, there are really only two types that have a significantly different process: a fresh embryo transfer and a frozen embryo transfer.
The Process of Preparing for a Fresh IVF Embryo Transfer
Fresh embryos can be transferred 2 through day 7 after the egg retrieval, but are usually transferred as a cleavage stage embryo on day 3 or as a blastocyst (blast) stage embryo on day 5. As you can see in the example below, the embryo transfer takes place on day 17, 5 days after the egg retrieval and thus would most likely be a blastocyst stage transfer.
The Days Leading Up to the In Vitro Fertilization Transfer
As you can see in the calendar above, two medications (estrogen & progesterone) are usually started the day after the egg retrieval and continued every day until the pregnancy test (and further if pregnant). After the egg retrieval, most women are able to resume their daily activities, however, it is important to avoid any strenuous exercise and give your body time to heal, rest, and prepare for implantation.
The Day of the In Vitro Fertilization Transfer
The IVF Embryo Transfer Process
Upon arrival to your embryo transfer room, you will meet with a member of our nursing team who will be with you for your transfer. You will also meet with the physician. During the transfer, the embryos are “loaded,” into the tip of a catheter along with a very small amount of transfer medium. The physician, along with a member of the embryology team and a nurse will confirm the patient’s identity to ensure the embryos are properly matched.
The catheter is then gently passed through the cervical canal and into the uterus using an abdominal ultrasound to provide visual guidance during the transfer. The embryos are slowly expelled near the top of the uterus. After carefully removing the catheter, an embryologist will double-check that the embryos indeed left the catheter using a microscope.
The embryo transfer does not require anesthesia but we will provide a Valium 5mg by mouth on arrival if desired.
After the Embryo Transfer
You will rest on the transfer bed for approximately 15 minutes.
During this time we will review post-transfer instructions including scheduling the pregnancy tests or instructing when to make those appointments with a local provider if coming from out of the area. This date will be calculated depending on the “age,” of the embryo, but is generally two weeks after the egg retrieval.
After this rest period, you will have your acupuncture treatment or be discharged to home.
We do recommend that you rest for the remainder of that day, getting up to use the bathroom and for meals only.
The Process of Preparing for a Frozen IVF Embryo Transfer
Unlike a fresh transfer, the process of a frozen transfer cycle is solely dedicated to preparing the body for transfer. That is, no stimulation medications, no egg retrieval.
The process for a FET cycle starts the same way as any fertility treatment cycle: call the clinic on day one of your menstrual cycle. If you don’t have any or they are infrequent, you will likely be instructed to call the office whenever you are ready. Once that happens, the process is quite different (at least until around day 13 of medications – the day after retrieval of a fresh transfer cycle)
The Process of Preparing the Uterine Lining for Transfer
You will come into the office on day 2-4 of your menstrual cycle for the baseline appointment and cycle instructions (this is “Day 1” of the treatment in the calendar above). That same day you will begin estrogen medications and be told to schedule a monitoring appointment for around 7-10 days later. If all goes accordingly (the uterine lining is developing just as it should) you will be instructed to add progesterone to your daily medication list starting a day or two after that monitoring appointment. Of course, it is very possible that you need to come in for another monitoring appointment to check the lining again before receiving instructions as to when you will start progesterone.
If the frozen embryo is a blastocyst, the transfer will be scheduled on the 6th day of progesterone. If the frozen embryo is at its cleavage stage, the embryo transfer will be scheduled for the 4th day of progesterone.
The FET IVF Embryo Transfer Process
The process the day of a frozen embryo transfer is the same as a fresh embryo transfer. Please see the above.
The “Two Week Wait” and Post Transfer Care
While the IVF treatment technically ends with the embryo transfer, you will likely continue medications to help support implantation and pregnancy.
Below is a general schedule of what that might look like:
Things to keep in mind during the two-week wait:
Things you may or may not feel during the two-week wait
If the pregnancy test is positive
If the pregnancy test is positive, we will repeat the pregnancy test in 2-3 days to evaluate your rising levels. An ultrasound will be scheduled approximately one week later to determine the implantation site and a growing gestational sac. The heartbeat should be seen by 6 weeks gestation.
Once a heartbeat is detected, there is a 90-95% probability that the pregnancy will continue to a live birth. IVF pregnancies are no higher a risk than natural pregnancies. At about 12 weeks into your pregnancy, you can return to your obstetrician for routine prenatal care.
If the pregnancy test comes back negative
If the pregnancy test is negative
we will instruct you on what medications to stop and what medications you may continue. Your period should start in a few days. You can begin another IVF cycle as soon as you like.
Your Cycle Report
Within two weeks of your retrieval, in your patient portal, there will be a summary from our embryology team with the details of your most recent IVF cycle. It will outline the number of eggs retrieved and their disposition. Not all embryos will continue on to be transferred or cryopreserved (frozen). There will be a column indicating how many embryos were transferred, how many embryos were cryopreserved, and how many embryos were discarded. Embryos are discarded when their development has arrested.
The IVF Process Summary
If you made it this far, congratulations! You’re either an expert and know everything about the IVF process, or you’re a little bit overwhelmed by too much knowledge. So let’s wrap things up with a nice little recap of what the IVF process looks like one more time. IVF, is an incredibly complex medical treatment that has many ifs and variables and many, many steps. But, if you want to put your mind at ease tonight and rest easy just think of the IVF process as a main four steps encountered in this article:
Most importantly, it’s important to remember that each and every person is unique and will have differences (either small or fairly substantial) throughout the IVF process. The good thing is that you’ll have a fertility doctor, a team of amazing nurses, and a host of other supporting staff guiding you every step of the way,
And, if you’re new here and still looking for experts to lead you on your path to parenthood, we are here and happy to help. If you’re ready, feel free to schedule a consultation
What is considered day 1 of period IVF?
Your day 1 call to the clinic is how you start your IVF cycle. Day 1 is the first day of your cycle that you wake up with your period. If your period starts in the afternoon then the next day is day 1.
Do you have to start IVF on cycle day 1?
IVF – What to expect with an IVF Cycle As part of your fertility plan, you might start medication or injections before the first day of the cycle, however the IVF 'cycle' begins on the first day of your period.
What is considered day 1 after FET?
After an Embryo Transfer Day 1: The blastocyst begins to hatch out of its shell. Day 2: The blastocyst continues to hatch out of its shell and begins to attach itself to the uterus. Day 3: The blastocyst attaches deeper into the uterine lining, beginning implantation. Day 4: Implantation continues.
How do you count days in IVF?
In cases where the date of conception is known precisely, such as with in vitro fertilization, the EDD is calculated by adding 266 days to the date of conception. Ultrasound uses the size of the fetus to determine the gestational age (the time elapsed since the the first day of the last menstrual period).