IVF Overview

Stimulating Egg Production

After completing the comprehensive screening, you will be placed on an oral contraceptive pill or daily Lupron shots or a combination of the two. This allows us to suppress your natural cycle and gives us control over when you are to start your injectable medication called gonadotropins. Gonadotropins work to stimulate the ovary to make numerous follicles, (which each contain an egg) during a single cycle. Typically, you will administer these shots for 8 to 11 days depending on your own response. Once enough follicles reach the mature range, which is approximately 14-19 mm, you will be instructed to take an intramuscular shot of hCG that night. Approximately 36 hours later, you will be scheduled for your egg retrieval.

Egg Retrieval

You will be instructed not to eat or drink anything from midnight on the day prior, and arrive at our Troy office one hour prior to the procedure. You will be asleep for the procedure and will be recovering over the next two to three hours. Your partner will be asked to produce an ejaculate at the time of your retrieval with his last ejaculation being approximately 48-72 hours earlier. Remember that no children are allowed in the recovery area and that you will need someone to drive you home and stay with you for at least the next 24 hours. You will know the total number of eggs retrieved prior to leaving and will be called the following day with the number of eggs fertilized. In preparation for the embryo transfer, you will be asked to take a low dose steroid, antibiotics and some form of progesterone supplementation.

Embryo Transfer

You will be asked to return either on the third or fifth day following your retrieval for your embryo transfer. The decision is based on both the number and the quality of embryos obtained. Basically, if you have many high quality embryos to choose from on day 3, then a day 5 transfer would most likely be scheduled. You will return several times for blood work, including a pregnancy test approximately two weeks after retrieval. An ultrasound is done approximately four weeks after retrieval and will be repeated several times throughout the first trimester, after which you will be returned to your ob/gyn for the remainder of your obstetrical care.

IVF Medications

There are a number of different types of medications that may be used to increase the number of eggs which develop to maturity in women undergoing in vitro fertilization (IVF). The specific medications, the dose of those medications, the times at which they are administered, and the duration of the treatment vary markedly from patient to patient and are based on their individual needs.

Lupron (GnRH agonist): An agonist that inhibits your pituitary's production of FSH and LH. This medication is taken as an injection just beneath the skin. This allows some of the other medications to provide a very even and balanced stimulation to the developing follicles. Lupron will allow patients to produce greater numbers of higher quality eggs during a given treatment cycle. Additionally, it prevents a spontaneous midcycle hormonal surge which may result in cycle cancellation.

Ganerelix, Cetrotide (GnRH antagonist): An antagonist acts to inhibit your pituitary's production of FSH and LH in an immediate fashion unlike Lupron which may take days to weeks to accomplish. This medication is taken as an daily injection just beneath the skin. This medication is given for only a few days prior to the HCG injection and is designed to prevent a spontaneous midcycle hormonal surge which may result in cycle cancellation.

Gonal F, Follistim Pen ( recombinant gonadotropins): These are synthetic recombinant DNA preparations of follicle stimulating hormone (FSH) which are taken as subcutaneous injections. The FSH provides the critical stimulation to the follicles containing the eggs that are developing during the stimulation phase of the cycle.

Bravelle, Menopur (urinary gonadotropins): A highly purfiied preparation of follicle stimulating hormone (FSH) and lutenizing hormone (LH) which is taken as a subcutaneous injection. It is similar to Gonal F and Follistim  but it also contains some LH. This may allow some (but not all) patients to respond somewhat faster and produce somewhat higher estrogen levels.

Pregnyl, Profasi, Novarel (urinary hCG): A highly purified preparation of human chorionic gonadotropin which is taken as an intramuscular injection. This medication is used as a substitute for the midcycle hormonal surge which induces the final maturational changes in the eggs and prepares them for retrieval. NOTE: After receiving this medication you will have a positive pregnancy test for the following 10-12 days (whether you are pregnant or not). Do not be misled by the results of a home pregnancy test!

Ovidrel (recombinant HCG): This is synthetic recombinant human chorionic gonadotropin which is taken as an subcutaneously. This medication is used as a substitute for the midcycle hormonal LH surge which induces the final maturational changes in the eggs and prepares them for retrieval. NOTE: After receiving this medication you will have a positive pregnancy test for the following 10-12 days (whether you are pregnant or not). Do not be misled by the results of a home pregnancy test!

Doxycycline: A tetracycline derivative given to the male partner during the wife's stimulation cycle. This antibiotic is given orally and is used to reduce the low levels of bacteria that may be found in the semen (even in men without symptoms or any other evidence of infection) and which may compromise the performance of the sperm during an IVF cycle. It is also given to the female partner to reduce the risk of infection following aspiration of the follicles at the time of egg retrieval

Medrol: A steroid which is sometimes given to transiently suppresses immune function during the interval following retrieval and transfer up to the time of implantation.

Progesterone:  Natural progesterone normally taken as a daily intramuscular injection beginning 2 days following egg retrieval and continues until the placenta is making adequate amounts of progesterone. (Progesterone injections will be discontinued following your serum pregnancy test if it is negative). Depending on the protocol, progesterone can also be given in the form a vaginal gel (Crinone) or suppositories or pills (Prometrium) given vaginally.

Typical IVF Cycle

Pre-Cycle Day 1 Call with date of onset of menses. This will allow the nursing staff to finalize your schedule.

Pre-Cycle Day 3 Come to the office for baseline hormonal evaluation (bloodwork). You will be instructed to either return on day 21 for bloodwork OR begin birth control pills and instructed on Lupron start date.

Pre-Cycle Day 21 Come in to the office in the early morning to have blood drawn for an estradiol and progesterone level to confirm ovulation. You will be contacted by one of the nurses later that afternoon to confirm that you are ready to start your Lupron. Once you begin your Lupron, you will continue to take a single injection each day until you receive your hCG shot or until told to discontinue the medication by a member of the IVF team. The dose of the medication may be altered (typically reduced when stimulation begins).

Cycle Day 1 Approximately 8 to 14 days after starting your Lupron (it varies from patient to patient and even cycle to cycle), you will have a menstrual cycle. This will be counted as cycle day 1 for the remainder of the stimulation portion of your IVF cycle. Please contact the IVF team and let them know when you begin your cycle so they can tell you exactly when to come in and begin your stimulation (typically cycle day 2 to 4).

Cycle Day 3 Come in to the office in the early morning (between 6:00-7:45 A.M.) for an ultrasound scan and to have your bloodwork done. This will confirm that your hormone levels are low and that your ovaries are ready to be stimulated. The ultrasound confirms that the ovaries have appropriately small follicles which are ready to be stimulated and that the endometrium (lining of the uterus) has shed appropriately and is ready to begin a new development cycle. You will be contacted that afternoon to confirm that you are ready to begin your gonadotropins (Gonal F, Follistim, Fertinex and/or Repronex). The dosing of the medications will also be reviewed at that time. The male partner should begin the Doxycyline at this time. You will be told when to return to the office for your next visit.

Cycle Day 5-? You will be told when to return for blood tests and ultrasounds, typically once every 1-3 days in order to monitor the development of the follicles. Each time you come in, your nurse will contact you in the afternoon with your instructions. If you do not get a call by 7PM, you must have the nurse on call paged for instructions.
	Day of hCG Once your follicles have reached an optimal state of maturity, you will be directed to take your hCG (Pregnyl, Profasi) injection. Unlike the other medications you have taken up to this point, the timing of this injection is very specific (plus or minus 15 minutes). You will stop all other injections at this time (Lupron, Follistim, Gonal F, Fertinex, Repronex).
Day after HCG This will be the final morning for ultrasound and bloodwork monitoring. The IVF team will also make sure that you know when you are to arrive at the office for retrieval and will answer any additional questions. You may not eat or drink after midnight on this day in preparation for retrieval.

Retrieval Day Approximately 36 hours after your hCG injection, you will undergo aspiration of your follicles to obtain the eggs. This is done under ultrasound guidance using a specially designed needle. You will need to arrive at our office 1 hour prior to retrieval. During that time, you will be admitted by the nurse into the recovery room. You will also meet with the anesthesiologist who will start an I.V. Your husband will be instructed when to produce his specimen. Generally, this is after the retrieval has been completed and you have been checked back into the recovery room. Following retrieval, you will remain in the recovery room for approximately 1 hour. You will be instructed to begin the Doxycycline and Medrol today. The Progesterone injections begin the day after retrieval. Your husband can stop his Doxycycline at this time. You must have someone to drive you home after the procedure. Please do not bring your children with you today.

Post Retrieval Day 1 Sometime after 3:00 P.M. on the day following retrieval, you will be contacted by the embryologist regarding your fertilization results. Continue taking your medications unless otherwise directed. Begin your Progesterone injection tonight.

Transfer Day 3-6 days after retrieval your embryos will be replaced into the uterus. Embryo transfers are done in the early afternoon and under ultrasound guidance. You will be instructed to drink 4- 6 glasses of water prior to the transfer, as your bladder must be full to be able to visualize the uterine cavity. Following the transfer, you will be asked to remain in the recovery room for 20 minutes before going home.

Post Retrieval Day 7 Return to the office in the early morning for bloodwork. This bloodwork does not tell us whether or not you are pregnant.

Post Retrieval Day 14 Return to the office in the early morning for a serum pregnancy test. (Testing may be done a day earlier or a day later). If you are pregnant, you will be instructed when to return to the office for additional monitoring (bloodwork and ultrasound scans). If you are not pregnant, you should stop all your medications and wait for a menses. This will occur within a few days.