niaw: a crash course in ivf

have you heard, it’s national infertility awareness week! and in honor of it, i have been doing a bunch of posts this week for all of my fertile friends and family to help inform them about infertility and the issues in our community.

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so, as i mentioned before, there are quite a few different options for assisted reproductive technologies that a couple may be presented with depending on their diagnosis. our first doctor decided that our best course of action would be to jump straight to in vitro fertilization (ivf). this was both scary – since that’s the end of the line, last resort before you have to involve someone else. (well someone else’s egg, sperm, or uterus. there were lots of people involved in making pignut) – and a relief – since we knew that, being the end of the line, this was our best shot without having to move onto third-party reproduction.

before i get into the logisitics of a fresh ivf cycle, i want to clear up a commonly held misconception: even ivf isn’t a guarantee of pregnancy. SART maintains a database of cycles nationwide. you can see the success rates for fresh, non-donor ivf cycles below (click to link to full report).

sart nationwide summary for 2011 (most recent data available)
sart nationwide summary for 2011 (most recent data available)

even in the under 35 range, which has the most success, only 43% of patients who undergo embryo retrieval end up with a live birth nine months later. 43%. with the most advanced science available.

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so what is ivf? well funny you should ask. especially since i wrote up this purdy blog post all about it. (bear in mind though, all this is dependent on your diagnosis and protocol. there is no one-size-fits-all ivf formula).

depending on the protocol you are following depends on when during your cycle the show gets on the road. but i think it’s general practice to have you come in for cycle day 3 bloodwork, to check progesterone and estrogen levels and make sure everything is good to go. the first time around, i also had a sonoghystogram and a uterine biopsy.

injectibles suck
injectibles suck

and then at some point, you take meds to suppress your ovaries and quiet everything down so you can make sure you don’t ovulate on your own and can start off on the right food. i took birth control pills and lupron, an injectable medication, for this part.

once everything looks good and quiet comes the ovarian stimulation portion. most women, during most cycles, have numerous follicles that develop until one follicle takes the lead and develops fully. this follicle produces the egg to be released. but with ivf, you don’t want just one egg. that’s a hell of a lot of work for just one egg. so that’s where the follicle-stimulating meds come in. again, more shots – yay! this phase can take 10 days to two weeks. and while you’re stimming, you get a fun, early morning date every other day with your doc. not only are there more needles (blood draws to check hormone levels), but you also get up close and personal with the transvaginal (internal) ultrasound so that your doctor can check on the number and size of the follicles, as well as the growth of your uterine lining. carrying around all those extra eggs has the added benefit of making you super bloated to. you know, in case this wasn’t enough fun yet.

one of the downsides with medicated cycles is that, although your doctor has tons of experience and women with different diagnoses might react the same, they are kind of one big crap shoot. the first time we tried it, my ovaries were oversurpressed initially, and took a while to respond to the stims. because I didn’t respond right away, they upped my dosage. in the end, my estrogen levels were too high, and this is what the doctor blamed for the poor egg quality. the second time around we were better able to tailor the med dosages and, as a result, got better eggs.

when the time comes and you have a belly full of beautiful eggs, your doctor will give you the exact time to inject your trigger shot. this ensures that all of the mature follicles are ready to release their eggs at the same time and that the doc can be there to collect them all.

crying/laughing fit post ER
crying/laughing fit post ER

36 hours after the trigger shot is time for the egg retrieval. this part is actual surgery, under general anesthesia. using a transvaginal ultrasound and a needle, the doctor punctures each mature follicle and remove the egg and the fluid surrounding it. both times, we had 18 eggs retrieved.

because this is actual surgery, there are actual risks. there is also the very real risk of ovarian hyperstimulation. ohss can range from mild to severe, in about 1% of ivf cases. although very, very rare, deaths have been reported. after our first cycle, I had a very mild case of ohss that only required me to monitor my weight and change my diet for a few days. the second time around, we were able to change the type of trigger shot to prevent it.

the eggs and the sperm sample are then passed off to the embryologist. in traditional ivf, they are given a cozy little petri dish to get to know each other better. in some cases, when there is a sperm motility issue, icsi (intracytoplasmic sperm injection) can be performed, where the embryologist selects a single sperm to inject directly into an egg.

and then you wait. every clinic (and cycle) is different with what they prefer, but both my clinics wanted to aim for a 5 day transfer. on the morning of the third day after retrieval the eggs are checked. those that managed to fertilize are embryos now! even with this level of micromanagement though, not every egg will fertilize. and those that fertilize might not last long. you run into a quantity-vs-quality issue at this point. if there are enough embryos still going strong at three days, you can wait for a day five transfer. if there aren’t many left though, you’ll want to transfer them back asap. obviously, the best environment for an embryo to grow is in a uterus, but you don’t want to waste transferring back low quality embryos that don’t have as good a chance at making it.

20120418-182905.jpgso after three or five days, is the embryo transfer. please note that this says transfer, not implantation. depending again on your clinic, diagnosis, and what you prefer, one to three embryos will be transferred back into your uterus (i will talk more about this in the access to treatment post later in the week). it seems like the standard is to transfer two, although more and more clinics and couples sound like they are leaning towards elective single embryo transfer. despite what you see in tabloids, no one with any brain cells or ethics dumps a whole bunch of embryos back in there though. the embryos are inserted into the uterus through a catheter – you see a little flash on the ultrasound screen when it happens. the embryologist checks the catheter to make sure it’s empty, and then (after a little rest) you get to put your pants back on.

if there are any viable embryos not transferred, you can have the option (if they look good enough) to freeze them for a later cycle. a frozen embryo transfer allows your to bypass the first half of all this junk and skip (with some different meds and all that) right to the transfer portion of the show.

and go home. and wait some more. if you’re lucky, one of those embryos will manage to implant, and grow, and two weeks after your retrieval, you’ll take a beta (blood pregnancy) test. a beta level of more than 5 means you’re knocked up. but you need to check that number a couple of times, 48 hours apart, to make sure that the number is doubling, which indicates a viable pregnancy. in the US, just under half of fresh ivf cycle result in a live birth. half.

during all this waiting, you’re still taking meds. because your follicles didn’t release an egg on their own, they never made the progesterone that your body needs to sustain a pregnancy. so you’ll get to take that, either in a shot or a vaginal suppository. plus some estrogen too to make things nice and homey for that little embryo.

if you’re one of the lucky half of ivf patients, you’ll go in for monitoring – bloodwork and more transvaginal ultrasounds – for a few more weeks. and then, around 8-10 weeks along, you’ll “graduate” and go to an ob or midwife just like a normal pregnant chick.

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so that’s the basic, science-y stuff. the emotional component is much more complex, and you can read all about it in the archives.

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