The IVF Process - Step-by-step
You can read information from IVF clinics on the stages of IVF, although these tend to be the technical steps. They don’t always mention the various appointments, tests and forms that confuse those going through it. So here, in plain language, is what the IVF process is really like for anyone experiencing it first hand.
(Note the obligatory disclaimer: The below is from my personal knowledge and experience of IVF. The exact advice and processes from your IVF clinic may differ.)
1. Preliminary tests and scans
Baseline pelvic scan - An initial transvaginal scan with the dildo wand to see what your ovaries do when they think no one is watching. My scan was between cycle days 2 and 6. The nurse reassured me ‘not to worry’ if I was still bleeding, as that is ‘normal'. But I did worry, as it feels a long way from normal. The scan checks whether everything is OK or anything needs dealing with before the IVF begins, for example the number of follicles, any cysts, fibroids or other surprises, undoubtedly negative ones. The surprise is never a tiny 3 month old foetus happily bouncing off the walls, always a gigantic 3 month old cyst, ready to burst.
Sperm analysis test – The sperm is checked for the usual parameters (volume, morphology, motility etc.) to understand whether an issue with fertilisation is likely and therefore whether ICSI may be required (ICSI is when they select a sperm and insert it into the egg).
Blood test - to check AMH levels - (a test to indicate ovarian reserve). This was the first time my AMH levels had been checked, which was a shocker considering my Infertility Horror Show has been running unceasingly for three years.
The test results from these preliminary tests lets the IVF consultant predict how you, or more specifically your ovaries, will react to the drugs and therefore what protocol/regime to put you on.
2. Complete a forest of preparatory paperwork
Forms upon forms upon forms need completing. They ask basic personal details, your status as a couple, your basic health history.
It turns out not to be an urban myth, they do indeed ask if you’re a paedophile (which makes me question what else is true and whether the snake did eat its owner and the girl did dry the cat in a microwave).
3. The Initial Appointment
Do not anticipate a life-changing appointment (it isn’t) because you think IVF begins today (it doesn’t) and the wait is over (it’s not). You meet with the fertility nurses at the clinic, have your identity checked more thoroughly than at passport control and sign forms. Lots more forms. For everything.
Then comes your appointment with the consultant, who explains the IVF process in detail, how they think you’ll respond to the drugs and therefore which protocol (fancy way of saying drugs plan/schedule/regime) you’ll be on. They also cover when the IVF is likely to start and any other tests you may need beforehand.
Top tip - take notes. I didn’t, for fear that the consultant would judge me to be too keen or geeky. Later in the IVF process they see your vagina, so no need to bother with any pretence. Emotions run high and it is common to forget every word said in the initial appointment. I left clutching an unintelligible drawing from the consultant about how my reproductive organs work (or didn’t in my case) and pondered its meaning, which was tropical seas clear in the appointment, but murky fish pond on exit. I couldn’t even work out which way up the paper went. Please take notes.
A note on the different IVF drugs - Down regulation versus stimulation
Down regulation phase - Suppressing your natural cycle – depending on your drugs protocol (which is a fancy way of saying the plan/schedule/regime of drugs that the IVF clinic put you on for IVF), you may take drugs to cancel out your natural cycle. These are sometimes called ‘down regulation’ or ‘down regs’. They wind down your hormones, ready for the next phase of drugs, and you usually take them the cycle before the cycle in which your eggs are collected.
Stimulation phase - Encouraging your ovaries to produce multiple eggs – this phase is often known as ‘stimulation’ and the drugs as ‘stims’. The drugs encourage your body to produce a crop of eggs while simultaneously preventing their release before egg collection.
What is the difference between long protocol and short protocol?
Long protocol means that you will down regulate before your stimulation phase. This means that you will be on IVF drugs for longer, as it includes the cycle before you start your IVF proper. Your protocol will depend on the results of all the tests and information gathered by your IVF clinic, but long protocol can often (but not always) be used for those who are unlikely to overreact to the stimulation drugs, e.g. low ovarian reserve.
Short protocol means that you only do the stimulation phase (skipping down regulation in the cycle before). It is fewer injections and you take drugs for a shorter period of time. Again, your IVF clinic will advise on the best drugs regime for you, but it is sometimes used for those with PCOS or have ovaries that may be overstimulated by the drugs.
4. Implications Appointment /Drugs Appointment
The most confusingly named appointment in the IVF calendar. For me, the implications of IVF were the potential for my boss to lose patience with me spending more time in the clinic than the office, becoming a monster whilst on the hormones, my heart breaking at a negative result. This appointment is not the nurse handing you tissues as you sob your way through IVF implications. Let’s call it the drugs appointment.
Details of your drugs schedule - This appointment is with a fertility nurse, who sets out the details of your drugs regime - when you will start, how many injections a day, what dose you will be on, when your scans will take place, an estimated date for egg collection. I was handed a printed timetable, finally something concrete on which to pin my hopes, dreams and neurosis.
Being shown how to inject the drugs - The nurse will also show you how to mix the drugs, grab your fat and inject. You may be asked to do a dry run on yourself, right then and there, inserting an empty needle into your tummy to check you can do it at home. I made a morale boosting joke about not having much fat around my middle, only to have multiple areas pointed out by my husband (thanks, love).
Possibly a repeat blood test - The infertility vampires are at it again, with a blood draw to repeat the tests undertaken by the hospital on referral for IVF (HIV, hepatitis B, hepatitis C and Syphilis) as the Human Fertilisation and Embryology Authority, who regulate IVF, require these tests to be undertaken within 3 months of starting IVF.
5. Baseline scan and drugs collection
If you are following a short protocol, the start of your cycle (i.e. your period) is when you call the clinic to start IVF. It begins with (another) baseline scan and collecting your drugs. Despite IVF drugs not being volatile (me on the drugs is a different matter) I drove home with more caution than a nuclear authority transporting an atomic bomb. I then engaged in the compulsory practise of spreading them out on the kitchen table, taking a photo and sharing it with my husband along with an unoriginal joke about being a drug lord.
Top tip - don’t empty your fridge of all perishable goods to make way for its new calling in life as a drug storage facility. Many of the IVF drugs (like all of mine) are stored at room temperature and you’ll spend the rest of the day going food shopping to restock the fridge, when all you’ll really want to do is sit down, get overwhelmed and have a weep.
6. Injections, injections, injections
The famous ‘druggie phase’ is what most people think of when they hear ‘IVF’. It seems daunting but, depending on your views on needles, it isn’t as bad as you’d think and it can be liberating to have something constructive to do.
The drugs (injections, I’m afraid) come in separate vials of liquids and powders like a chemistry set which you have to mix at home. The clinic gave me a demonstration on how to do this and then provided me with a detailed handout on how to do this. And yet, when it came to how to do this, I relied on YouTube. The number of days that you will have injections varies. For me, I had 2 injections a day (1 in the morning, 1 in the evening) for 10 days, which is short by IVF standards. You will be given a sharps bin, a thick yellow plastic box with a skull and crossbones on the side, in which to ditch your used needles.
The IVF clinic are just a call away if you need support due to your own stupidity, in my case accidentally injecting a bit of blood and air alongside my drugs and on another occasion squirting the entire contents of the vial on the floor of a public toilet.
7. Progress Scans
The progress scans are more transvaginal scans to see how your ovaries are responding to the IVF drugs, how many follicles are growing and what size they are. Your drugs regime or your schedule for egg collection may be changed depending on the results. In the worst case scenario, this is the most likely stage at which your IVF cycle could be cancelled due to your body’s response to the IVF drugs.
This is when everyone talks about bloating. You may be tempted to pose in front of the mirror to see if your belly looks big. You’ll try a different angle. And another. You’ll stick out your belly, decide that is cheating, then panic that the lack of bloating means that it isn’t working. Please don’t panic. I was petite, I had zero bloating and yet the drugs were working fine with a bunch of follicles sprouting away in there. You just can’t tell.
8. The Trigger Shot
The last and most important injection. If IVF drugs were a firework display, this would be the finale with the skies exploding to Beethoven’s Ode to Joy. The trigger injection contains human chorionic gonadotropin (hCG), the hormone produced during pregnancy. It ripens the eggs ready for collection and is also the reason that you can get false positive pregnancy test if you take the test too soon after embryo transfer (as the trigger shot of pregnancy hormone can still be lingering in your system).
The trigger shot will be taken at an exact time, determined by your clinic, usually 36 hours before your egg collection. How exact does the timing need to be - to the minute? I mixed the injection early, then sat staring at it, worried that it would curdle. I asked my husband to watch me like an umpire, to check that I don’t do anything stupic. He stared at me, whilst I stared at the needle, and we both waited for our exact time slot.
9. Egg and sperm collection
Egg collection is a 30 minute operation under general anesthetic or sedation. The eggs are collected by ‘performing vaginal scanning and needle aspiration of the eggs’, which in layperson terms means the IVF consultant sticks a long needle in your nether regions and sucks the eggs through your vagina wall, guided by ultrasound. As awful as it sounds, the procedure shouldn’t hurt, with the exception of potential mild cramping post operation.
On the same day your partner will be asked to collect a fresh sperm sample. You may be tempted to feel sorry for him, as having a compulsory orgasm under clinical conditions must be tricky. If that temptation arises, just remember the weeks of injections and impending operation in which they poke a needle through your vag, and natural order will be restored.
After the procedure, you will be visited by the embryologist, who tells you how many eggs were collected. You will switch over to new drugs (progesterone) and you need to have a wee. I didn’t realise that I had to successfully urinate before they could release me from the clinic and instead concluded, on the 10th time of being asked, that the nurse had a fetish.
10. Progesterone
You want me to stick it where? Oh IVF, you flirt! Face head-on (or more appropriately, bottom first) your fear of suppositories. Unless you are French, in which case where else would a medication go?
Progesterone is essential for preparing the womb lining to allow for an embryo to implant. Because your hormones are artificially controlled during IVF and your body isn’t following its usual monthly process, you won’t naturally produce progesterone during IVF. Instead, it comes in the form of a white, waxy tear shaped pessary, the size of half your little finger. The dose will depend on your clinic, but I was advised to take one pessary in the morning and one in the evening (2 a day) until either a negative pregnancy test result or until 12 weeks of pregnancy, when the placenta takes over.
Top tip: if you are allowed/advised to put the progesterone pessary up your vagina rather than your bottom (this chat goes against all my English sensibilities) then it will create an the unstoppable waxy mess in the gusset of your undies. Unless you wish to replace all your underwear, pantyliners are essential.
11. The Embryologist updates
The embryologists provide updates at regular intervals on the fertilisation rates of your eggs and progress of your embryos. You will be told how many eggs were collected shortly after your operation. There will be an egg meets sperm situation overnight and then the following day you will be told how many fertilised. Over the next few days you will have regular calls from the embryologists with updates on the progress of the embryos, which will inform when embryo transfer will take place (usually between 3-5 days after egg collection).
The calls will make your heart gallop, and despite purposefully staying in for most of the day, they will invariably occur during the 15 minutes you are out in public.
12. Embryo Transfer
A short time after egg collection, usually between 3-5 days, you return to the clinic for embryo transfer. It’s another undignified procedure (think 100 watt bulb being shone on an area that only really appreciates romantic mood lighting). The process is similar to a SMEAR test, but rather than taking a swab, a thin plastic tube is inserted into the uterus and an embryo is transferred through it. It takes around 10 minutes, it shouldn’t be painful and doesn’t require sedation or anaesthetic.
In our clinic we entered a small medical room with a bed, wall mounted TV screen and 1970s style serving hatch, behind which stood a smiling embryologist. Also present was the IVF consultant, who would do the transfer, and a fertility nurse, for moral support.
Off came my pants, again, and up pops an image on the screen of my beautiful bundle of cells, ready to be transferred. I got teary, then had a civilized mini domestic with my husband about whether to take a photo (does it jinx it?). The room fell silent as a plastic straw containing all our hopes and dreams passed through the serving hatch and all thoughts in the room turned to my vagina. And just relax.
13. Two Week Wait
An IVF two week wait (the period of time between the embryo being transferred and taking the pregnancy test to find out whether it was successful) is like a normal two week wait on steroids. It lasts approximately 2 years and during that time you osolate between feeling that you are pregnant, are not pregnant, will never be pregnant, it doesn’t matter if you’re ever pregnant, that your life depends on you being pregnant. You ditch the Gregorian calendar in favour of naming days by their lesser known IVF titles (e.g. 6 days post 5 day transfer) and attempt to complete Google by reading every article, research paper, blog post, on IVF success rates.
14. Pregnancy Test
The IVF clinic will tell you exactly when to take a pregnancy test. For me it was 11 days post 5 day transfer. It is one seriously important wee which marks the making or breaking of dreams.
Marvel at how professional the clinic pee test is in comparison to your Amazon cheapies. You may be tempted to test before ‘official test day’. Some people test early and throughout the two week wait, but this can give you false positive results (left over hCG in your system from the trigger shot) or false negative results (because you test too early). Once you have the result, you call the clinic for next steps.
Whatever the result, it is highly emotional. Remember that you are strong and you can cope, no matter what.
15. Viability scan
The callously named Fetal Viability Scan takes place 2-4 weeks after a positive pregnancy test (when you are technically 6-8 weeks pregnant) and checks the progress of the pregnancy. It is looking at whether there is an embryo, in the right place, of approximately the right size. It is another transvaginal scan, so be prepared to part with your pants.
The sonographer is likely to show you the screen and to the untrained eye, the embryo may look like a grainy greyscale photo of a fried egg. The scan will also see whether the embryo has a heartbeat. At this stage in development the heartbeat won’t be heard, but instead appears as a small grey flicker in the middle of the fried egg.
If all is OK then you graduate from the IVF clinic and get released back into mainstream NHS pregnancy care, with just your progesterone butt bullets as a daily reminder of your IVF story.