There are many reasons why individuals and couples decide to embark on in vitro fertilisation (IVF) and you will have made this decision based on your own specific fertility needs in consultation with your specialist. An IVF cycle involves stimulating the eggs within a woman’s ovaries (follicles), removing the eggs and combining them with sperm in our embryology laboratory for fertilisation. The fertilized egg, or embryo, is then placed back into the womb (uterus) in the hope of achieving a pregnancy.
THE FEMALE REPRODUCTIVE CYCLE
The female reproductive system is primarily internal and comprises of the vagina, uterus, fallopian tubes and ovaries. Eggs (‘oocytes’) develop in the ovaries in a structure called a follicle. Unlike men, women only produce eggs once in a lifetime, so a woman is born with all the eggs she will ever have and the number of eggs reduces with age. Each month, hormones signal the ovaries to develop the follicles – each containing an immature egg. Approximately two weeks after the start of a menstrual period, a hormonal surge will trigger ovulation when the largest follicle (the dominant follicle) will release the mature egg (ovulation) into the fallopian tube. Usually, the dominant follicle grows with a whole group of other follicles. These other follicles normally do not ovulate, but help to produce the hormones that create the correct environment for pregnancy. The egg is then fertilized by sperm and the the fertilized egg travels along the fallopian tube where it may be fertilised by sperm. Early in the menstrual cycle, the uterine lining thickens in anticipation of receiving an embryo during the first half of the menstrual cycle.
If fertilisation occurs, the developing embryo continues to travel down the fallopian tube to the uterus, where it implants in the receptive part of the uterine wall (endometrium). If fertilisation does not occur, falling hormone levels over the following two weeks cause the endometrium to shed and a menstrual period begins.
THE IVF CYCLE
Before you start a cycle, you need to have met with our nurse for an education session. This session is designed to give you an overview of your IVF cycle, the medications and procedures – but remember, your specialist and nurse will guide you through the process step by step.
You should never leave any of your appointments at Eve Health without knowing what your next step is.
If you require donor gametes (i.e. sperm or eggs) you should also have met with the QFG donor specialist team and counsellor.
YOUR INDIVIDUALIZED IVF PLAN
At Eve Health, we do not run automated, protocolized, group cycles, but individualized treatment plans. Your specialist and fertility nurse will create a specific treatment plan tailored to your needs. This plan will detail when to start and stop your medications, when to be seen for blood tests or scans and the approximate date for our egg collection and embryo transfer.
At Eve Health, egg collection and embryo transfer will always be performed at the most appropriate time to guarantee success. As such, please be aware that the dates provided are approximate and may change throughout your cycle depending on your individual response.
Everybody is different and your care is individualized to reflect this. Your treatment plan will most likely be similar to either the Antagonist or the Long Down-Regulation protocols described below, but there are many variations of these based on your specific needs. Always check with your nurse if you are unsure about medications, blood tests or scan dates.
OTHER TYPES OF IVF CYCLES
At times, you may require a variation to the above. These include Natural (no drugs), Minimal Stimulation (using tablets or only one or two injections) or Flare (a variation of the down-regulation) cycles. These are not usually used as a first-time option. Should your specialist have recommended either of these, full instructions for these cycles will be provided.
CANCELLED OR FREEZE-ALL CYCLES
Occasionally, despite our efforts to achieve the best response for you, cycles may not go as planned. Unfortunately, we know from scientific studies that there is a thirty percent variation in cycles, even if the medications remain identical. You may either under-respond to the stimulation with no to very few follicles or you may over-respond with excessive numbers of follicles. A cancelled cycle doesn’t mean you will never respond, it just means that we may need to adjust the dose, drug or type of protocol to ensure a better response next time. There will be very little financial implication to you when your cycle is cancelled.
THE EGG COLLECTION
Your egg collection is performed under a general anaesthetic in our day surgery at Spring Hill Specialist Day Hospital. The Hospital is located at:
Spring Hill Specialist Day Hospital
33 North St
Spring Hill QLD 4000
Phone: (07) 3307 3243
You must have no food or drink (including water) for at least 6 hours prior to your scheduled theatre time. Please take your completed admission booklet with you. Your admission time will be on your final instructions given to you by your specialist or nurse – it is usually 60 minutes prior to the scheduled theatre time.
The semen sample
If your partner is providing a fresh semen sample (you are not using donor or frozen sperm, or your partner is not having a surgical sperm retrieval), he should present to day theatres at your admission time. He will then receive instructions. The Day Surgery has specific, private collection rooms for the production of the sample.
Alternatively, he may wish to produce the sample at home. A specific sterile specimen container is available from Eve Health. The specimen should be produced at home by masturbation: bring it with you at your scheduled admission time. The specimen should be produced just before leaving for the day hospital and kept at body temperature (e.g. kept on your body) during transit. Your partner should have had at least two days of abstinence (no ejaculation) prior to the egg collection and preferably has had an ejaculation in the week prior to the egg pick up.
If your partner is having a surgical sperm retrieval (TESA/MESA) he will need to complete a separate admission form and will also need to fast for 6 hours prior to surgery. He will also not be able to drive home, so you will need to arrange for a responsible adult to collect both of you following your procedures.
The egg collection
The egg collection is a low-risk procedure that takes approximately 10 minutes. Egg collections are performed through the vagina and you will not have any abdominal wounds. This is usually performed under a general anaesthetic, but you may be performed under a local anaesthetic in some circumstance. After you have been sedated, the procedure is similar to the vaginal ultrasound scans you have had during your cycle. A very fine needle is used to puncture the follicles and drain the fluid which hopefully contains an egg. Every follicle will be drained to ensure the maximum number of eggs.
Under general anaesthetic, your specialist will use a very fine needle to drain each follicle for an egg.
An embryologist will also attend the procedure. Embryologists have specialized training to handle the eggs and their fertilization and then care for the embryos through to embryo transfer and/or freezing.
AFTER THE EGG COLLECTION
After your egg collection, you will wake up in recovery. Your specialist will often have written the number of eggs collected on your hand, because patients sometimes forget the conversation with their specialist immediately after the procedure because of the anesthetic. Once you are alert and the nursing staff at the day surgery are happy with your recovery, you will be able to get dressed and have something to eat and drink until you are ready to be discharged. A responsible person must be able to take you home as you will not be able to drive or catch public transport (including taxis) on your own.
It is normal to experience mild cramping similar to period pain, some discomfort in your shoulders or abdomen and a small amount of vaginal blood loss for a couple of days. Contact us if you have increasing pain, heavy bleeding, fevers, are unwell or concerned.
Fertilisation of the eggs: IVF or ICSI
There are 2 types of egg fertilisation: IVF and ICSI.
IVF allows the sperm and egg to interact on their own (as happens with natural conception). The sperm all try to penetrate the egg until one successfully achieves fertilization.
If there is male-factor infertility, such as the sperm sample is low in concentration or motility or has a high number of abnormal shape, your specialist and/or the scientist will suggest ICSI as the preferred method for fertilisation. Here the scientist (embryologist) selects an individual sperm from the sample provided and to directly inject into each egg. ICSI may also be used when patients have undergone IVF in the past and had a poor fertilisation outcome.
The result of fertilisation is not known until 24 hours after egg collection. We would hope for up to 4 out of 5 eggs to fertlitise, but this can be very variable.
You need to contact our rooms at 10 am the day after the egg pick up for the results and we will also confirm the timing of the embryo transfer. This can happen anywhere between two to five days after the egg collection. It will depend on the number of embryos created and their quality.
Starting progesterone after egg collection
If you are having an embryo transfer you should commence progesterone supplements on the day after the egg pick up. Progesterone is important to maintain and stabilise the lining of the uterus. Progesterone is given as a vaginal pessary, cream or tablet once to three times a day (depending on the preparation) and needs to continue until your pregnancy test. Progesterone is usually stopped when you have a positive pregnancy test, but in some circumstance, you may need to continue progesterone for a few more weeks. Do not stop your progesterone until advised by your specialist or nurse and please let us know if you are close to running out.
Monitoring your embryos
We will monitor your embryos after egg collection. Please feel free to contact our office to discuss the progress of each of your embryos. Your embryos are graded daily, and the grading of your embryos will likely change on a daily basis. We will always advise you how your embryos are progressing and may change your transfer date accordingly. This will always occur in your best interest in achieving a pregnancy.
YOUR EMBRYO TRANSFER
The embryo transfer is performed in our day surgery as your embryos are kept in the adjoining laboratory. Given there is no anesthetic required, you can eat and drink prior to your appointment. We ask that you have a big drink of water on arrival to day surgery so that your bladder is fairly full (this assists with an easier pass of the catheter into the uterus).
Embryo transfers are very similar to a Pap smear and should only take a few. As no anesthetic is required you can return to work, drive or continue with your usual routine post procedure.
The specialist and scientist will select the best embryo for transfer to give you the highest chance of achieving a pregnancy. In Australia, usually one embryo at a time is transferred to minimize the risk of multiple pregnancy which comes with additional complications and risks. More than one embryo will only be transferred under special circumstances, including poor embryo quality, advanced maternal age and failed implantation attempts.
FREEZING SURPLUS EMBRYOS
From the initial fertilisation of the embryos until they reach a blastocyst embryo (i.e. day 5 or 6 after egg collection) your specialist may freeze any suitable embryos for future treatment cycles. Not all embryos are suitable for freezing and not all patients will have additional embryos to freeze. We will discuss with you any embryos you have had frozen and their quality.
THE PREGNANCY TEST
Your pregnancy test will be scheduled for 2 weeks after the egg collection by a blood test. If you did not receive a request form at the time of the embryo transfer, please attend our office on the morning of the scheduled test. Please be aware that if you present for a blood test over the weekend or late in the afternoon you may not get your result until the following business day.
It is very important that even if you start your period before your pregnancy test that you still come in to have a blood test. There are times that despite bleeding, implantation has occurred and you may have pregnancy hormone (hCG) detected in your blood test result. Please contact the Eve Health nursing team should you start bleeding before your scheduled test and they can advise the appropriate course of action.
If you have a positive result you will be required to have another blood test, usually a week later to ensure your hCG has risen appropriately. At that time, we will also arrange an early pregnancy scan appointment with your specialist (about 5 weeks after your egg pick up).
If your test is negative, we will ask you to stop all medications and discuss your next steps. We always recommend that you make an appointment with your specialist at this point. If we were able to freeze any embryos for you, you may decide to proceed with a Frozen Embryo Transfer cycle.
FROZEN EMBRYO TRANSFER
In the month following a fresh IVF cycle, hormone levels and ovaries can be still affected from the stimulation and so we often recommend that you have a month off to recover both physically and emotionally. However, if you would like to progress immediately into a frozen cycle this may be possible depending on your individual circumstance. The frozen embryo transfer is exactly the same as the transfer procedure in a fresh cycle. Your embryo will be thawed the evening before or on the day of the transfer. The best quality embryo is selected each time to give you the best chance of a pregnancy.
Natural FET cycle
If possible, your embryo may be transferred in a ‘natural cycle’ without using any medications. You need to contact the office on the first day of your period and we track your ovulation by performing a scan and blood test around day 12. You will then be monitored with additional blood tests in the following days until we see that ovulation has occurred. At that point the embryo transfer will be booked at the precise time to match stage of your embryo.
Hormone Replacement FET cycle
If you do not have regular cycles, your hormones are not appropriate or if there are other reasons for not doing a natural cycle, oral medications or injections may be used to prepare the uterus for implantation. We do this by giving you an oestrogen-based tablet to mimic the oestrogen produced by a growing follicle which then thickens the endometrial lining. You will be scanned on approximately day 12 of your cycle to check that this lining is thick enough to be receptive. Progesterone supplements then need to be commenced prior to the embryo transfer, which will be scheduled in line with the grade and stage of your embryos. With this type of cycle, you must continue your medications until at least the time of your ultrasound scan, so it is important that you do not run out of any medications.
Going through IVF can stressful. Please do not hesitate to talk through any concerns you may have with your specialist or Eve Health nurse at any time.
Qualified and specialised counsellors are always available to access in relation to your treatment. If at any stage throughout your treatment you would like to talk to a counsellor for support, you can arrange an appointment through our partners, the Queensland Fertility Group, on 07 30361000.