What exactly does IVF mean?

I was thinking today that maybe there is some who wonder what in the world is this IVF thing. To help I thought I'd put some technical explanations below ... 

Definition: In vitro fertilization (IVF) is a process by which egg cells are fertilized by sperm outside the body. IVF is the major treatment in infertility when other methods of assisted reproductive technology have failed. The process involves hormonally controlling the ovulatory process, removing ova (eggs) from the woman's ovaries and letting sperm fertilize them in a fluid medium. The fertilized egg (zygote) is then transferred to the patient's uterus with the intent to establish a successful pregnancy.

How the process works:

 Most IVF cycles start out with mensus, followed by starting on birth control pills. For me I did bc for 14 days. Two days after stopping bc was my baseline visit to the fertility clinic. During that visit I did blood work, ultrasound and practice embryo transfer. Then, medication is started to stimulate the ovaries to allow many eggs to grow and mature. Usually that is done by the patient (me) giving themselves daily injections of a medication. There is several different one's, for me I am using Follistem as it is the one approved by my insurance.The process of going through this time is called stimming.

Stimulatory: In an IVF cycle, stimulatory medications cause the ovaries to grow all of the eggs that will eventually be retrieved. They are a combination of FSH, or Follicle Stimulating Hormone and LH, or Leutenizing Hormone, the hormones that the body makes naturally during the menstrual cycle. During IVF however, they are given in much higher, precise doses as determined by the doctor, typically for 10 to 12 days.

While stimming every 3 days I return to the clinic for monitoring. During each ultrasound, they will measure the uterine lining and the ovarian follicles. The uterine lining should thicken during the cycle in anticipation of pregnancy. Each ovary will be checked to see the size and progression of the ovarian follicles. (Follicles are little sacs on the ovary which contain an egg). In response to stimulation by FSH, the follicles begin to grow. Once they reach a particular size, the eggs inside are considered mature and ready to be retrieved.

Also at each visit blood tests are done to measure different hormonal levels. Estradiol, a form of estrogen, will be measured to determine if the rate of increase is appropriate. It should rise by roughly 50% each day. If it is rising too quickly, or too slowly the medication dosages will need to be adjusted to produce that rise.

Soon I should be adding a second daily shot to my regime called Ganirelix it is a suppressive drug.

Suppressive: These medications helps prevent the body from doing what it is meant to and ovulating once the the egg follicles begin to progress. If ovulation should occur, the cycle would be lost, as there is no way to retrieve the eggs once that happens

Once the doctor feels I have reached the criteria to proceed to retrieval (About 15 to 20 mm diameter is generally consider a "mature" follicle ready to go). I will be taking a trigger shot of either Ovidrel or Lupron which is an injection of HCG or Human Chorionic Gonadotropin to finalize growth and maturation of the eggs. This shot has to be taken at the precious time the Dr. tells me too...I was told that could even mean in the middle of the night in order to time retrieval just right.

Trigger: A crucial step in the IVF process, this injection is carefully timed so that retrieval will occur at the optimal time just before ovulation occurs. 

Egg Retrieval Process:

Day of retrieval we will arrive at the clinic at a specified time all depending on when the trigger was taken. I'll be put to sleep with light sedation but breathing on my own. I won't feel any pain thankfully, and probably won't remember much about the process. A needle is then passed through the top of the vagina under ultrasound guidance to get to the ovary and follicles. The fluid in the follicles is aspirated through the needle and the eggs detach from the follicle wall and are sucked out of the ovary. Each tube is immediately handed to the lab technician who looks for eggs, the eggs are then rinsed in culture media, and placed in small drops in plastic culture dishes. The dishes with the eggs are then kept in specialized IVF incubators under carefully controlled environmental conditions.. By the time I leave they will be able to give me a count of the number of eggs retrieved. The nurse said it could be as little as 8 or as many as 40 all depends on how I responded to the medication. Afterwards we will get to go home and I'll need to take it easy for awhile.

During my retrieval my husband gets to do his part by giving his sperm sample. That will be taken to the lab washed and prepared to be inserted into the eggs. We will be doing ICSI as the Dr. said with my age and history it is our best chance for successful fertilization.

(ICSI Info) 

ICSI: involves the use of specialized micro-manipulation tools and equipment and inverted microscopes that enable embryologists to select and pick up individual sperm in a specially designed ICSI needle. The needle is carefully advanced through the outer shell of the egg and the egg membrane - and the sperm is injected into the inner part (cytoplasm) of the egg. This usually results in normal fertilization in about 90% of eggs injected with sperm.

Starting that day I will begin on estrogen pills 3xday, progesterone suppositories and baby aspirin 81mg.
  

Hormone Supplementation: After the retrieval, you will take supplements of estrogen and progesterone to prepare the endometrial lining for implantation of an embryo. 

Day 1 of our wait begins the day after retrieval.

Each afternoon the fertility clinic lab will be calling us. First day to tell us how many fertilized then an update each day till transfer on their progress. Depending on how they are progressing they will advise us if a day 3 or day 5 transfer is for us. From what I understand if we have only a few good looking fertilized eggs they may suggest a day 3 if we have more they like to then wait to day 5 to see which one's keep developing into a blastocyst which may give us a higher success rate of implantation.

What is nice about our clinic is if we do a day 3 transfer they are the only clinic in our state that does laser assisted hatching included in the IVF price.

Assisted hatching: was developed from the observation that embryos which had a thin zona pellucida  (shell) had a higher rate of implantation during IVF. It was postulated that creating a minor defect in the zona might result in a greater chance of the embryo "hatching," or shedding its shell, allowing for a better chance of implantation in the endometrium. See video below.

Interesting video below showing the embryonic development from Day 1 to 5

Day of Transfer:

The embryo transfer procedure is the last one of the IVF process. It is a critically important procedure. The entire IVF cycle depends on delicate placement of the embryos at the proper location near the middle of the endometrial cavity - with minimal trauma and manipulation.

I'll have to arrive at the clinic with a moderately full bladder to allow good ultrasound visualization of the catheter which helps with smooth and proper transfer of the embryos to the best location, and it also unfolds the (anteverted, "tipped up") uterus to a more accommodating angle,making the process smoother and less traumatic for the uterine lining and the embryos.

The process of transfer is pretty simple. My husband will get to be with me and will get the important job of confirming the names on the petri dishes before transfer. I think the hardest part of the day will be deciding how many embryo's to transfer, that all depends on how many make it and what grade they are at. Ideally we'd like to do no more than two if possible. One happy healthy baby is all we are trying to achieve, no octomom for me lol.

After getting comfy with some Valium a embryo transfer catheter is loaded with the embryos and the Dr. passes it through my cervical opening up to the middle of the uterine cavity. Abdominal ultrasound is used simultaneously to watch the catheter tip advance to the proper location. 

When the catheter tip reaches the ideal location, the embryos are then "transferred" (squirted out of the catheter) to the lining of the uterine cavity. After the embryos are transferred, the catheter is slowly withdrawn and checked under a microscope for any retained embryos. If an embryo is retained in the catheter (uncommon) the transfer procedure is repeated immediately and the catheter is checked again. They will then empty by bladder and I will rest laying down for at least 30min before going home. I'll want to rest and take it easy the rest of the day. Restrict any heavy lifting, straining, overdoing for next 2 weeks. They said some walking was good as we want to encourage blood flow to the uterus just nothing strenuous. 

(Transfer)

Any remaining embryo's if we transfer on day 3 will continue to grow to day 5 and be frozen or will be frozen right away if we do a day 5 transfer. That gives us options for the future if by chance this time does not work we can do a ET without going through all the rest or save them if we want another child or donate them someday to another family trying to conceive if we decide our family is done.

After Transfer:

The two week wait begins. I will continue to take estrogen, progesterone and baby aspirin.

When does the embryo implant following IVF transfer?

A healthy human embryo will hatch from its shell on day 5-7 after fertilization and implant within hours after hatching out. So actual invasion of the embryo with attachment to the uterine wall occurs about 2-5 days after a day 3 transfer and within 1-3 days after a day 5 transfer.

This will be the longest and probably most stressful two weeks of my life. At the end we return to do blood work to see if the IVF resulted in a BFP or BFN. If embryo implantation has occurred, HCG hormone will be detectable.

I think that pretty much explains it all. It seemed so complicated when we first started but as time has flown by it's so far gone well and smooth to this point.

For you created my inmost being; you knit me together in my mother’s womb. I praise you because I am fearfully and wonderfully made; your works are wonderful, I know that full well. 
Psalm 139:13-14