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IVF Cycle Overview

This overview summarizes some of the steps an IVF patient undergoes while undergoing an IVF cycle in our program at PFCLA.

After the initial visit with the physician and after all of the testing is completed, the patient is instructed to call with her period to start the IVF cycle. This initial phase can take up to 2-4 weeks to complete.Once the patient calls on the first day of her period, she is typically instructed to start taking birth control pills (BCP), one pill a day, and wait for instructions.

In about 7-10 days, the patient will receive a packet by mail or email, that contains all the information that she needs. At the same time, the Clinical Coordinator would have contacted her to arrange for the delivery of the medications that the patient will use. We can either send a prescription for all the medications or have an associated pharmacy ship all the medications with the syringes and needles.

Once the Calendar packet is with the patient, our office will contact her to make the necessary appointments. These usually include 3 initial appointments:

Calendar review and injection instruction appointment with a nurse. This can be done by telephone if the patient is not local.

A baseline ultrasound or Estradiol test prior to the start of the fertility hormones. Again can be done locally if the patient is not within reasonable driving distance from our office.

Another ultrasound examination with the doctor 6-7 day after the start of fertility hormone. The ultrasound appointments usually take 15-30 minutes. It is during this examination that the doctor determines the number and size of follicles present. Typically, another 1-2 ultrasound examinations will be required before the eggs are ready for harvesting. It takes usually 5-6 weeks after the start of BCPs for the patient to be ready for egg retrieval (ER).
The ER is performed under anesthesia and takes about 10-20 minutes.

The patient is then discharged home an hour later. The day of the ER, the partner has to produce a semen sample. The sperm is washed and prepped and used to fertilize all the eggs on the same day, usually within 4-5 hours after retrieval. The number of eggs produced depends on many factors, including the patient age and her ovarian reserve. In general, women < 35, produce between 10-20 eggs. The younger the woman, the more eggs are produced. Women in their late 30s or early 40s, typically produced < 10 eggs. It is also important to understand that usually, the higher the number of eggs produced, the better the chances of pregnancy.

Fertilization of the eggs is performed on the day of egg retrieval by two methods, depending on many factors including the sperm and egg quality.
The first method, which is much simpler and less complicated, involves incubating the eggs with concentrated sperm in a Petri dish in an incubator. The second more high tech and complicated method is the ICSI or intracytoplasmic sperm injection method, whereby each egg is injected with a single healthy looking sperm to increase the rate of fertilization. ICSI is sometimes the only mean to achieve fertilization, especially in severe male factor cases.
The morning after the ER, the embryologist checks the status of the eggs to determine the fertilization status. Not every egg gets fertilize.
Typically we expect 60-80% fertilization rate. After this brief evaluation, the embryo are placed back into the incubator and left undisturbed until the embryo transfer, which usually takes place 3 to 5 days after the ER.
The day before the embryo transfer (ET); our office will contact the patient to schedule a time for the ET the next morning.
The morning of ET, the embryologist would evaluate the embryos and grade them. The doctor will then meet with the patient and review the status of the embryos with the patient and together decide which embryo to transfer. The number of embryo to be transferred depends on many factors, namely:
  1. Age of the patient producing the eggs
  2. The quality of the embryos at the hand
  3. Previous history of failed IVF cycles
  4. The desire of the patient for multiple births

The grading of embryos varies from one clinic to the next. In our program, we use two criteria to grade embryos:

  1. The number of cells
  2. The percentage of fragmentation

An embryo is formed when sperm and egg unite.

Over the next few days, the embryo which started from 2 cells, will divide into multiple cells. On the 3rd day after ER, a competent embryo would have divided to more than 6 cells. We also evaluate each cell’s fragmentation, which in simple term is analogous with the cracking of a mirror. If more than 20% of the surface of an embryo is involved with fragmentation, then the embryo is graded as GIII. A totally clear and unfragmented embryo would be grade as GI or excellent. Good or GII embryos would have 0-20% fragmentation.

Therefore, when we evaluate an embryo, we would label it by its cell number and then it grading. For instance, an excellent embryo would be 8cell GI, a good embryo would be a 7 or 8 cell GII and a poor quality embryo would be any embryo that is less than 5 cells or with GIII grading.