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In Vitro Fertilization Phases

Jessica Evert, MD, edited by Benjamin McDonald, MD Updated: Jun 28th 2016

Suppression Phase:

male and female symbolsOnce the introductions have been made and the source of sperm/eggs is decided, the actual steps of IVF will begin. IVF occurs over two menstrual cycles. The first step involves suppressing both your ovulation as well as the communication between the pituitary gland (a gland in the brain that makes hormones) and the ovaries. Suppression takes place on the first day of your period, and is accomplished by taking oral contraceptive pills that will prevent you from ovulating for one month. This reduces the risk of cysts and primes the ovaries for the following month when they will be stimulated. Suppression of the pituitary gland is facilitated by use of injected medication called GnRH agonists (gonadotropin releasing hormone), the most common of which is called Lupron. Two weeks after starting the oral contraceptive pills, you will start injecting Lupron (usually into the arm, buttocks, or stomach) under the skin with a small needle (similar to that used for insulin). These shots are self-administered once a day for three to four weeks. If you are squeamish, you may have to find a trustworthy and gentle individual to help you with shots. By suppressing GnRH, the resulting levels of estrogen in your body will be low. As a result, the ovaries are put in a holding pattern so they will not mature eggs until the doctor is ready to harvest them. The potential side effects of low estrogen include fluid retention, headaches, and hot flashes.

Stimulation Phase:

The next step to IVF is stimulating the ovaries to produce multiple eggs. This is desirable so that many eggs can be harvested and then implanted, increasing the likelihood of pregnancy. First, the doctor will do an ultrasound to make sure there are no cysts, large follicles, or abnormal masses in your ovaries. About a week after starting the suppression medications, your period will start. A few days to a week after this, a second medication, hMG (usually one of the following medications: Gonal-F, Fertinex, Perganol, Repronex, Humegon, Follistim), or a similar stimulation drug will begin. These drugs act through various pathways to make the ovaries mature eggs. Some act at the level of the pituitary, while others act directly on the ovaries. The selected medication will stimulate the ovaries to mature multiple eggs (without such medications ovaries only mature one egg per month). Depending on which medication is used, these injections may be shallow (called sub-cutaneous), or deep (called intramuscular). Meanwhile, Lupron is continued so that these eggs are not released from the ovaries, but remain there to be removed by the doctor. Usually, about 6-12 eggs mature, although 50 or more may be produced in exceptional circumstances.

During the stimulation phase, it is not abnormal for you to feel bloated, to gain weight, or have abdominal pain. These side-effects are usually tolerable; however, if pain is severe, accompanied by fever, or other worrisome symptoms, you should speak to your doctor. The Lupron/stimulation medication combination is continued for 5-10 days. Ultrasound and blood tests may be used to evaluate how well these medications are working. Doctors will be able to see how many eggs are maturing by looking for the number of follicles, the fluid filled sacs around the eggs. The stimulation phase is completed with one injection of hCG (human chorionic gonadotropin), which completes the maturation of eggs. They are then ready to be harvested. You should avoid sexual intercourse during the stimulation phase until after the retrieval of the eggs.

The Retrieval Phase:

The ovaries are located next to the uterus, just above the vagina. Getting the eggs out does not require an incision or a surgery. Rather, the eggs are removed with a needle that is inserted through the vaginal wall. An ultrasound machine is used to help the doctor guide the needle into the correct position. During this procedure local anesthesia (numbing medicine to the area), or conscious sedation (a sleep-like state where you don't remember what occurred or feel any discomfort) will be used. If you are awake it may be uncomfortable when the needle is inserted, however, the pain is not usually severe. You should feel free to discuss anesthesia (pain control) options with your doctor. Relaxation medications are often given if conscious sedation is not used. It is not uncommon to feel tired or emotional (crying is normal) after awaking from conscious sedation. The entire retrieval procedure can take 15 to 45 minutes. Often, partners are encouraged to be present to provide support and to feel included in the process. You should arrange transportation to and from the retrieval because pain medications can make you drowsy. A small amount of vaginal bleeding after the procedure is not uncommon. However, you should call you doctor if you experience any large amount of bleeding, severe pain, or fever.

 

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