All About IVF (In Vitro Fertilization)

Science and technology truly amazed us all when the first in vitro fertilization (IVF) baby was born in 1978.  Since then, IVF has gained significant traction as an excellent option to help women achieve pregnancy. However, those who pursue IVF often still feel as if there is a negative stigma associated with it, when truth be told, there were more than 72,000 babies born out of more than 260,000 IVF cycles in the U.S. in 2017 alone!

Statistics also show that 10-20% of women will experience infertility, and a large portion of those women turn to fertility specialists for help.  These numbers demonstrate that seeking infertility treatment should not be something that women hide or lack knowledge in.  We hope, by continuing to share information around IVF, that over time, it will be viewed as a routine medical procedure that no longer has any underlying negativity or embarrassment associated with it.

What is IVF?

Simply stated, IVF is taking the sperm and egg outside of the body and growing an embryo in the lab. But the story is more complex than this, and in order to truly understand IVF, it is helpful to understand what happens in the body naturally.

For pregnancy to occur naturally, the chances are much lower than most would imagine.  There are several actions that must align perfectly to result in conception. For example, the egg must release and be of good quality. The sperm must than find the egg and successfully fertilize it. The embryo must then travel down the fallopian tube and continue to grow and divide.  Even after all of this, the embryo must reach the uterine cavity and implant. Because so much must occur perfectly to result in pregnancy, the chance of achieving pregnancy even in a healthy, young woman is only about 20-25% per cycle.

In vitro fertilization (IVF) helps to remove the difficulty of natural conception and works to increase the chance of a positive outcome at nearly every step of the reproductive process described above.  For example, we remove mature eggs from the woman and actually see the eggs to examine quality; the sperm is manually exposed to the eggs so that we can observe which ones fertilize; we are able to watch the embryos grow and divide; and we are able to pick the best quality embryo(s) to transfer into a woman’s uterus for the highest chance of success. In general, these steps encompass the miracle of IVF for those who have difficulty achieving pregnancy on their own.

How IVF Works

The full process of in vitro fertilization involves several important steps that must occur throughout a woman’s entire cycle, leading up to embryo transfer, that will ensure the best outcome. Throughout these steps, the woman must undergo diligent monitoring and be fully committed to her regimen of medications:

1. Ovary stimulation. During IVF, the goal is to stimulate a woman’s ovaries to mature a larger number of eggs than what would occur naturally. It’s important to note that this does not deplete the ovarian reserve or take eggs from the future; instead it is capturing the cohort present for that month.  Gonadotropin medications FSH (follicle-stimulating hormone) and LH (luteinizing hormone) are used to assist with stimulation, and the egg (oocyte) development is closely monitored with blood work and ultrasounds – usually for a period of 8-12 days.
2. Ovulation suppression. While your clinical team works to aid in stimulating the ovaries, it is also important to ensure the eggs don’t release too soon. Therefore, an additional ovulation suppression medication is used to prevent this. These medications are known as either a GnRH antagonist (cetrotide, antagon, ganirelix) or a GnRH agonist (leuprolide).
3. Ovulation preparation. When the follicles demonstrate adequate growth, the trigger shot(s) are given hCG (human chorionic gonadotropin) or leuprolide to assist in the final maturation and preparation for ovulation.
4. Egg (oocyte) retrieval. Prior to ovulation, the oocytes are retrieved transvaginally with an ultrasound guided needle that aspirates the fluid and egg from each follicle. The egg retrieval procedure routinely takes about 10-15 minutes and is done under IV sedation so that the patient will not remember or feel a thing.
5. Insemination. The eggs are then mixed with the sperm either through conventional insemination or with ICSI (intracytoplasmic sperm injection) where a single sperm is injected into an egg (routinely used in the setting of a male factor).
6. Embryo Growth. The embryos are grown in culture dishes and carefully monitored until either transferred (day 3 or day 5 depending on age of a women, number and quality) or biopsied at the blastocyst stage for preimplantation genetic testing (PGT). PGT- A (aneuploidy) for general chromosomal screening, PGT-M (monogenic) for single gene disorders, and PGT-SR (structural rearrangements) for chromosomal translocations or inversions can all be reasons to consider preimplantation genetic testing.  It is an in-depth discussion with the patient/couple and their physician regarding benefits, risks, and cost.
7. Embryo Transfer. The number of embryos transferred depends on age of the woman, the stage and grade of the embryo(s), and whether testing was done. The transfer typically takes place either 3 or 5 days later – or possibly a few weeks if the uterus requires preparation to be receptive (in this case, the embryos may be frozen due to genetic testing or other reasons). The embryo transfer occurs under abdominal ultrasound guidance with a thin flexible catheter placing the embryo in the uterine cavity. This is not a painful procedure.

This whole process takes anywhere from two weeks to two months, depending if testing and freezing of the embryos is performed.

Who Needs IVF?

Couples who struggle with infertility due to blocked tubes, male (sperm) factor, diminished ovarian reserve, or the dreaded diagnosis of “unexplained infertility” may be candidates for IVF. IVF is also recommended if a couple does not achieve pregnancy with intrauterine insemination. In each case, IVF helps overcome challenges at hand and provides more eggs the opportunity to fertilize, therefore increasing the chance for an embryo to implant.

Others who benefit from the technology of IVF are same-sex couples (including women interested in reciprocal IVF, and men using donor eggs and gestational carriers), single women looking to conceive, older women with poorly functioning ovaries (sometimes requiring donor eggs), as well as men and women who have unfortunately been diagnosed with cancer and have cryopreserved eggs or sperm before treatment.

How Many Embryos Should Be Transferred?

We often hear from couples that they want to transfer multiple embryos to aim for a “one and done” process that results in a multiple pregnancy. While we love for couples to have as many children as they desire, our team believes in, first and foremost, ensuring a safe and healthy pregnancy.

Evidence shows with patients across all age groups that single embryo transfer is increasing to ensure safer pregnancies. In particular, data reveals that 87% of 2017 U.S. IVF pregnancies resulted in singleton births, while only 12% were twin births, and 0.004% were triplet births. Thankfully, more and more fertility practices are focused on achieving a healthy, happy pregnancy and mother, which subsequently leads to a healthy, happy baby. As multiples occur, however, the risks increase. While there are always unique circumstances, it is for this reason, depending on age, that we typically recommend one embryo per transfer.

Overcoming the Stigma

No one ever grows up hoping to need in vitro fertilization to conceive.  It is a path that can cause significant anxiety, stress, and confusion. However, the technology of IVF can help so many couples (and individuals) achieve their goal of becoming parents when they may have otherwise had no alternative treatment options.

If you are considering IVF, gaining knowledge and finding a supportive clinical team to partner with you on your reproductive journey will be invaluable. If you know someone currently challenged with infertility, we encourage you to be the support person for those struggling or to share your own infertility story to remove the stigma. The more we talk, and the more we educate one another, the more we can normalize a treatment that has, and will continue to, aid the growth of loving families.