I jumped a little ahead of myself last time with The Box on Your Doorstep post, but it was appropriate for a few of my gal pals at the time. The majority of the e-mails and messages I receive, though, are along the lines of “I think were going to have to do IVF…,” “We’re having trouble getting pregnant. What’s IVF like?” or “My doctor said IVF is our best route…” But what does that actually mean? I think I’ve touched in previous posts primarily on the emotional facets of IVF and less on the physical. So, I thought it was time, to take a step back and explain, at least from my experience, what IVF entails.
I can’t proceed without reiterating that everyone’s experience with IVF differs from protocol to outcomes. Yet, I’m sure we’d all agree on one thing: Regardless of whether you had no symptoms at all or you suffered from the list of them, the physical pain you endure is incomparable to the emotional suffering. I’d be able to do an IVF cycle every single month for the rest of my life if I had to, if it weren’t for the associated roller coaster of high’s and low’s. With that said, there is some solace in knowing what to expect and having someone to confide in who has been there before.
When IVF is your best route, or as in our case, your only route, the acronyms start flying at you: IVF, ICSI, HSG, HCG, FSH, ER, DPT, TWW, and my personal favorite, PUPO. It’s all so much information to process and I feel as though, once you’re at the point, time finally seems to fly until the dreaded wait of course. I, obviously, am not a doctor or nurse of any kind and was fortunate to have only undergone one IVF cycle. Therefore, while I’d like to consider myself fairly knowledgable in this area, there is so much I continue to learn by being part of this community. The following is a generic timeline for an IVF cycle that includes my specific protocol.
Ovarian Suppression This is the initial step once the month of a cycle has been determined. Different clinics prefer different protocols, but typically the way in which ovarian suppression is achieved depends on your ovarian reserve, or the number of eggs you still have. This is determined by Day Three blood work (day three of your period) which evaluates your baseline levels of Follicle Stimulating Hormone (FSH) and estradiol (E2). There are several means of addressing this based on your baseline results.
Three years ago when I was undergoing IVF, I began by taking birth control pills (BCP) for the month before. However this is less of a common practice now, unless they’re accompanied with an overlapping use of a GnRH agonist (most commonly, Lupron). Regardless the purpose is to better regulate your hormone levels, while also minimizing the potential for cysts to develop. To be completely honest, this is the phase of IVF I’m least familiar with.
Ovarian Stimulation In infertility lingo, when we say we are beginning stims, this is the start of using hormones(s) which stimulate the ovaries to produce multiple follicles. Each follicle is fluid-filled and houses an egg. Ovarian Stimulation begins around day 3 of your menstrual cycle and can range for 8 to 12 days, depending on how you’re responding to the medications. Common side effects include drowsiness, headaches, fever/chills, joint aches, injection site reactions. Typically, monitoring begins around the fourth day of stims and occurs every other day, until you get closer to the point of trigger. The purpose of these frequent visits, which include internal ultrasounds and blood work, is to determine how your body is reacting to the hormones. Estrogen levels are assessed through the blood work and the follicle quantity and size are recorded. It is anticipated that at 12-14 millimeters, the follicles will begin to grow at a rate of 2 millimeters per day. The larger the follicle, the closer it is to maturation. Depending on your results, the medication protocol may be increased or decreased. In many cases an Antagon is added to suppress premature ovulation. This is usually administered during the latter half of the stimulation phase. Once the follicles reach between 16-20 millimeters they are ready for the next step, retrieval.
I began taking Estradiol by mouth (0.5 mg once in am/once in pm) and two hormone injections daily around day 3 of my menstrual cycle (February 8, 2014). My protocol included 150 units of Follistim (FSH) and 75 IU of Menopur (HMG) injections which I had my husband give me around 6 pm every evening. He had already been injecting himself for almost two years, so I was lucky enough to have a skilled injector. For this reason, I’m sure, I found the injections to be completely tolerable with only slight burning and minimal bleeding here and there. My husband would squeeze the injection site (my lower abdomen, below my belly button) and inject on alternating sides. I never needed to ice the area and had very little bruising. We did add Ganirelix to the mix, but I can’t recall when and for how long. I do know that I had Ganirelix leftover.
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I continued on these meds for 10 days before triggering. Between 7 and 9 follicles were monitored and measured. The greatest advice given by the nurses was quality over quantity. I had read so many stories online of women with 20-30 follicles and wondered why my quantity was significantly less. I’d go on to find out that many of these women hyper ovulated, which from what I’ve heard can be very painful. Over-stmulation occurs when estradiol levels soar too high, too quickly. Typically if a women suffers from Ovarian Hyper Stimulation Syndrome (OHSS), the transfer may be postponed to allow the ovaries and lining of the uterus time to get back to normal.
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HCG Trigger Triggering refers a shot of human chorionic gonadotropin (HCG) which stimulates the eggs’ release. Precise timing of triggering is imperative for successful egg retrieval, which occurs within 36 hours of the injection. This time is crucial as it allows the eggs to go through the final maturation process; without this they’d be incapable to fertilize.
I took the trigger shot, Ovidrel, on February 18, 2014 at 10 pm in the evening. Like the others, I didn’t experience any side effects. At this point, the only way I could describe how I felt was as if I was carrying a fanny pack of golf balls.
Egg Retrieval For this procedure, you are given intravenous anesthesia because it is considered minimally invasive. A needle is inserted into each ovary and using an ultrasound to guide them, the doctor is able to aspirate the fluid and egg from the follicle. It is a fairly quick (20-45 minute) and painless procedure.
My egg retrieval was late morning on February 20, 2014, two days post-trigger. It was my first time going under and I can only describe it as the best 15-20 minutes of sleep I’ve ever had. Within no time, I remember waking up and being pushed to the recovery area. I spent less than a half hour waiting for the anesthesia to wear off and the doctor came in to give us the number of eggs retrieved. While the nurse had been monitoring between 7 and 9 follicles, 11 eggs were retrieved in total. We were advised that we would receive a fertilization report the following day via e-mail.
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We also got the green light to begin those oh-so-lovely progesterone shots. My husband injected me in the bum, alternating sides every time. They were, by far, the most painful of all the shots, but of course you’ve probably heard by now how I had him stick me with the 18 gauge needle, so that may have traumatized me!
On a serious note, of all the days within my IVF cycle, this was the most stressful. However, much of that was due to our circumstances. My husband’s surgery was the morning of my egg retrieval, so you must remember I was going to have the eggs retrieved without knowing for certain if there’d be sperm to use or if the eggs would have to be frozen. Again, it wasn’t the physicality of the procedure, it was the emotional duress that made that day the most difficult. Fortunately, they spun the sample extracted during my husband’s surgery and were able to find viable sperm to perform ICSI (Intracytoplasmic Sperm Injection).
Egg Fertilization The embryologist prepares to fertilize the eggs within hours of the retrieval. Traditionally, a sperm sample is placed around each egg to allow for natural selection. With ICSI, a single sperm is injected into each egg. Fertilization rates with ICSI have been found to be slightly higher. The following day, the embryologist will notify you with an embryology report that discusses how many eggs were mature enough to fertilize and out of those how many actually did. The embryos remain incubated until day 3 or 5 depending on when the transfer will occur.
In our case, 6 out of the 11 eggs were mature enough for fertilization. Out of those 6, using ICSI, 4 fertilized. We received these results on a Friday, the day after retrieval, and were elated to have even gotten to that point. The report indicated that we would hear from them again within 1-2 days.
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The next day, Saturday, I received a phone call while working with my husband. The nurse relayed that all 4 embryos were still progressing; however it appeared that only 3 would be quality enough to transfer. I had prepared myself for the more common day-5 transfer (at which point the embryos are considered blastocysts), so when she went on to say that we would be transferring the following day, day-3, I was discouraged to say the least. The decision was made based on the number and quality of the embryos at that point and I was told that they’d best survive in the most natural setting. Unfortunately, this did not put me at ease and I’d consider this the second most difficult day of our cycle.
Embryo Transfer This procedure involves placing a flexible catheter into your cervix to inject the embryos. The number of embryos is decided prior to or the day of transfer and depends on various factors (e.g. patient’s age, number of previous cycles, quality of the embryos, etc.). Post-transfer, recovery usually takes about thirty minutes before going home. Every clinic’s recommendations vary, as you’ll read. However, research suggests that strict bed-rest is counterproductive, but heavy exercise and intercourse should be avoided.
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Meeting with our doctor beforehand and making a final decision on the number of embryos to transfer was the most difficult part of the transfer. Our circumstances are not common; nor is the recommendation of transferring three embryos. However, based on the embryo quality and our openness to twins, the doctor assured us that transferring all three would not result in triplets.
We both dressed for the procedure and entered the surgical room on February 23, 2014 (three days post retrieval). Within a few minutes, the embryologist knocked on the door and presented a catheter containing our three embabies. She confirmed our last name and the number of embryos before passing it over to the doctor. Within minutes, the catheter was inserted and we saw as our three embryos were transferred into the cervix. It was one of the single-most surreal and magical moments of my life.
Recovery was again less than thirty minutes and I went home to let my embabies stick. Pineapple core, warm socks, laughter and all for the days that followed. I took full advantage of having meals made for me and laundry folded, but I did make sure to move around and engage in some activity. I took an extra third day off, as I felt a cold coming on and since I worked with kids at the time, I did not want it to worsen. Other than that, and a tug around my belly button here and there, I did not have any symptoms. Given that early pregnancy symptoms and the onset of your period mimic one another, it’s often hard to differentiate. Please refer to my TWW Survival Guide for enduring the longest 9-14 days (depending on transfer day and clinic) of your life. Naturally, I continued Progesterone injections and went in for blood work once during this time.
Beta Day If implantation occurs, it starts to release the pregnancy hormone, HCG into your bloodstream. It’s imperative for the most accurate results to wait at least 9 days after a day-3 transfer and 7 days post day-5 transfer to ensure that the HCG trigger is out of your system. Initial beta numbers can range from single to triple digits depending on length of time since transfer and when implantation occurred. Regardless, the level should double every 48 hours for a singleton pregnancy and even faster for multiples.
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For us, Beta Day was March 10, 2014 and as it turns out was one of the most cherished days of our lives. We both went for the blood test together; however I received the call that it was in fact positive with a beta of 816, fourteen days post day-3 transfer. The second beta, a few days later was over 16,000.
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With such high numbers, we were able to finally breathe. However, we were far from out of the clear. Unfortunately, especially with IVF, it becomes hard for you to accept positive news and you remain guarded because you’ve encountered so much disappointment. It wasn’t until we actually saw a heartbeat at 6 weeks and then got past the 9-10 week safety zone, that we truly acknowledge that we were an IVF first timer success.
As I re-read this post, it is certainly the most dry of my entries to date. My hope, though, is that it brings some clarity to those who are approaching an IVF cycle or think that IVF might be in their future. There are many common things about our IVF cycle and many unique parts too. The fact that we were an IVF success the first time around places us in the minority. Not a day goes by, where I don’t thank my lucky stars, that after at least 84 injections, over a dozen blood drawings, and more suppositories than I’d like to remember (and that’s just for our IVF cycle and doesn’t include my husband’s shots!), we finally had a child of our own.