PART TWO
DIAGNOSTICS, PROTOCOLS, AND EGG RETRIEVAL
This is part two of my IVF 101 Series, where I will describe the basics about the diagnostics, medication protocols, and the egg extraction process. In short, IVF consists of a woman taking drugs to assist in producing eggs, those eggs are extracted, fertilized, and put back into uterus where hopefully it will implant and become a viable pregnancy. Click here to reach Part I of the series, What the Heck is IVF?
DIAGNOSTICS
(Physical Exams and Blood Tests)
Before any doctor can begin to treat a patient, they need to know what is wrong. When contacting a fertility doctor for the first time, you should expect that they will have a consultation session with you, and may have an informational session they want you to attend.
Many of the tests have to be done within certain days of starting your menstrual cycle, so you may find there’s a bit of waiting before you can get started.
A woman is born with a set number of eggs in her body. Each month when a woman ovulates, she just develops and grows one of those preexisting eggs that was already in there, and another number of eggs die off each month naturally. Birth control methods help you not develop eggs, but it doesn’t stop the eggs from dying each month – just because you don’t ovulate doesn’t mean they are saved for later.
So the doctor needs to find out just how many and what kind of eggs might be in there.
Among the blood tests they will run, the doctor will test hormone levels (like estrogen and progesterone), and test your AMH and FSH levels. The AMH levels help indicate to the doctor what a woman’s egg reserve may be, and your FSH levels will help indicate whether the eggs will be of good quality. Some women have lots of eggs but poor quality eggs, other women have very few eggs but good quality (like me), and so on. Learning more about your egg quality and egg reserve will help a doctor determine what kind of drugs they will use as part of the IVF process. For example, I usually took more aggressive hormones and drugs to help me produce more eggs because my quantity was so small.
The doctor will also need to check out your uterus and ovaries to make sure there are no other underlying physical conditions like endometriosis (growth of excessive endometrial issue), uterine abnormalities, of blockages of the fallopian tubes that lead from the ovaries to your uterus. They may do vaginal ultrasounds (where they insert a wand internally to look around), a hysteroscopy where the doctor inserts a tiny camera vaginally to take a look in the uterus, and a hysteropingogram. For a hysteropingogram, a certain liquid is flushed up into your uterus vaginally and an external ultrasound is done at the same time. This kind of works like an x-ray, allowing the doctor so better see the size and shape of your uterus, and whether your fallopian tubes are open and functioning.
If the doctor finds certain issues in the physical diagnostics and blood work above, the doctor may be able to treat another the underlying condition and you may not need IVF at all. If your doctor does recommend IVF, after the blood work and other physical testing is complete, your doctor will figure out what drug protocol will work best for you.
This isn’t all on the women though. Men will also go through some rounds of blood work and sperm sample analysis to see if they have any underlying conditions that need to be addressed. One common issue for men is the motility of their sperm (how well they swim to get to the egg), so sometimes the doctors will help the sperm access the egg easier.
This testing process can be disheartening if you find out news that isn’t what you were hoping for, but just try to keep reminding yourself that every bit of new information (good or bad) is helpful and needed for the doctor to determine the best treatment for you. That being said, messy, ugly crying is always allowed, and it’s OK to be upset. Just remember that all these feelings are normal, and focus on the next steps. Beginning treatment.
Protocols
(Medication and Making those Eggs)
In the first phase of IVF, you will take drugs and hormones to help your body produce the best quality and number of eggs that you are able to produce. The goal is to help you produce the highest number of eggs safely possible for your body, to help maximize your chance of getting viable embryos to transfer later on.
You may take some pills, but most of the medication and/or hormones you will take will be by a subcutaneous injection (a shot) in the stomach or in your thigh. You will receive a medication Protocol from your doctor that will tell you what medications to take each day and at what time. Your Protocol will have set amounts of medication for the first few days, but as they monitor your progress, medication, dosages and timing can all change, so you need to be flexible and know that things will change. After your periodic exams and blood work, your nurse or doctor will call you will the most up to date instructions and any revisions to your Protocol.
First you take medication to help you develop eggs for you egg extraction procedure, which are typically known as follicle stimulating hormones. Common examples of this kind of medication are Menopur, Follistim, Bravelle, and Gonal F, along with many others
As your eggs begin to develop, small pockets of fluid around each egg start to develop, which are called follicles. A few days after you start your start your medication, you will go in for a vaginal ultrasound where they will look at your ovaries and count the number of developing follicles that they can see. Based on the results and your blood work, the doctor will tell you whether you stay on the same amount of medication, or whether they may chance the medication or dosage to help you produce more or less eggs. You will continue to go back into the doctor every other day or so for more ultrasounds to monitor the follicle growth
As the eggs mature and develop, the follicle around each egg grows bigger and bigger. The biggest one is referred to as the leading follicle. Once that leading follicle reaches a certain size (typically over 15mm), the ovulation process can begin to occur. Once ovulation occurs, the other eggs will stop developing and only one follicle will continue to mature. In normal life, that works perfectly well because you only need one egg to get pregnant; however, with IVF, you want to grow as many eggs as you can, so you want them all to keep growing.
To stop the ovulation process from occurring, when the leading follicle is generally somewhere between 15-18 mm in size, your doctor will start you on medication to stop your body from ovulating known an antagonist, such Centrotide or Ganireliex. These antagonist medications will stop ovulation from occurring, which will give the smaller follicles time to develop further.
Your doctor will make a call when he or she thinks you will have the most number of follicles in the mature range, and you will be instructed to stop your antagonist medication (the one that makes you not ovulate) and take a medication commonly referred to as your “trigger shot” approximately 36 hours before your scheduled egg extraction procedure. This trigger shot will start the ovulation process, which may include medications such as Pregnyl, Ovidrel or Novarel.
As your follicles increase in size, you should to be mindful of not doing a lot of bending, twisting or other strenuous activity leading up to your egg extraction. The large follicles can cause the ovaries to become quite large, and you want to avoid the ovary getting twisted or folding over itself because of its large size. Talk to your doctor if you have any concerns, and they will tell you what physical restrictions they recommend during this process.
Egg Retrieval
(OK, here’s the exciting part, its game day!)
You will check into your facility and get taken back to the pre-op and procedure rooms. This is minor surgery, so you will dress in a hospital gown, put your hair in a net, and the nurses will prep you for the procedure. They will start an IV, and the doctor and/or anesthesiologist may come talk with you before the procedure to answer any questions you may have.
Timing is key here. Remember that trigger shot? They need to get you in around your scheduled procedure time so they are extracting the eggs as your body is ovulating.
You will go back to the procedure room with your IVF, and they will administer the sedation. The first time I was super scared about going under, but after a few rounds of treatment I don’t mind it at all and I actually find it to be pretty relaxing.
During your nap, this is what is going on.
The doctor will use that ultrasound wand to locate all those follicles again. This time, that wand will have a tiny needle at the end of it. The doctor will enter with the wand vaginally and then use the needle at the end of the wand to pierce each follicle to extract the egg. The doctor will pierce each follicle to remove all of the eggs during the process. After the follicles are drained, the embryologist at the center will examine the contents and hopefully find a beautiful egg in each one, though not all follicles will contain viable eggs (hopefully not the case, but it can happen).
While your eggs are being extracted, the man will be ushered back to a private room by himself to collect a sperm sample that will ultimately be mixed with the eggs to create fertilized embryos. If there is an issue with the man’s sperm or there is no man in the picture, a sperm donor can also be used, but those samples are typically collected ahead of time and frozen until needed for the process.
If you have lots of follicles you may be a bit more sore than someone who only has four or five (less pokes), but personally I’ve never had more than some light cramping. They will monitor you for a bit as you start to wake up, and the doctor or embryologist will let you know how many eggs were successfully extracted.
This post is the second of my four-part series, IVF 101. Part I of this series explains very basically, What the Heck is IVF. Part III of this series will talk about Fertilization, Embryo Transfer and the Pregnancy Test.
In Part IV, my final post of this series, I will answer your questions, so I’m counting on you guys to ask them. No question is stupid. No question is too personal. Anything I can answer to help you in your journey makes me happy.
Please submit your questions on the Contact page, or email me at Kristy@proseccoandpalmtrees.com.
You can read about my personal journey with infertility in a Q&A session I did for Infertility Out Loud last year, and throughout the Infertility Section of Prosecco & Palmtrees.