January 2016 - IVF #1, Process

Before we jump into all the thoughts and stresses of IVF #1, let's talk some process, if you're interested. IVF stands for In Vitro Fertilization.  This is one of the best and best high-level descriptions of the process that I have come across.

Here's my summary of the process.  Feel free to skip it if the steps / science is not your thing.  Long story short there are quite a few steps and many of them include injections...

Each month, in a normal, natural cycle:
A woman's ovary (this often alternates left to right) will produce 1 mature follicle, which, when the time and hormones are right, will release 1 mature egg, which hopefully meets up with a special sperm,  This zygote will travel down the fallopian tube to the uterus, a journey that takes about 5 days.  If the embryo (now a blastocyst of over 100 cells) seems healthy, the uterus will allow it to implant.  To produce a follicle and a healthy egg, a woman's body must produce a cocktail of hormones in varying proportion to result in a single healthy egg released at the right time.

In an IVF cycle:
The goal is to produce as many follicles with healthy eggs as possible, and keep them inside the ovaries until the RE goes in and can extract them.  Growing more follicles and eggs requires additional hormones beyond that of a natural cycle.  For my first cycle, which is pretty typical, I started out on birth control.  Yes, that sounds odd, but what it does is calms the whole system down to a baseline level of hormones, hopefully with minimal ovary action to start.

From there, a common protocol is the following: Stop the birth control and start hormone injections.  The injections run for ~6 days before an extra "antagonist" shot is added in to prevent premature ovulation.  Usually after about 10-12 total days of shots with visits to the RE's office every other day for ultrasounds to measure and count follicles as well as bloodwork to check hormone levels..  Once the follicles are all the right size and hormone levels are right, a "trigger" shot is administered at a very specific time, and exactly 36 hours later, retrieval happens.  Retrieval is yet another procedure under anesthesia (going under is becoming a routine!).

For me during my first IVF cycle, this portion of the process included the following:

1. My shots started with a combination of Gonal-F (follicle stimulating hormone - FSH) and Menopur (FSH + luteinizing hormone - LH).  
2. After ~6 days of this combination (300 units of each, nightly in 1 shot), I have to add in a second shot called Cetrotide, which is used to keep the LH level in check.  If the LH gets too high, the ovaries can release the eggs, and for this process, we want them to stay put for retrieval.  
3. I would continue with the 2 shots per night until the follicles are the right size to indicate that the eggs are mature enough for extraction (usually >20mm / 2 cm each).

At retrieval, the RE typically gets an average of 15-20 eggs from a <35 year old.  A smaller number (~70%) typically fertilize to become embryos (more about this later), then an even smaller number (~50%) make it all the way to growth day 5/6, when they become blastocysts (which already >100 cells) and can be sampled for genetic testing, and cryogenically frozen for storage.  

The samples (1-2 cells in size) are then frozen and sent off to a special genetics lab that does a full 23 chromosome pair analysis called PGS/PGD (Preimplantation Genetic Screening/Diagnosis).  This is optional, comes at additional expense, and takes about 2 weeks to get results back.  At this point it is clear which embryos are normal, and which aren't (like our previous Nuggets).  PGD ultimately helps ensure that only normal embryos will be transferred back into the uterus, increasing the chances for a successful implantation and pregnancy and greatly reducing the chances of miscarriage. 

Overall, every step of IVF is intensely scientific.  And while taking the injections at the right time is a big responsibility, the whole process is being overseen and supervised by the RE.  He/She is the one checking hormone levels, making adjustments to medicine dosage, and ultimately the one to make the call when it's time to retrieve the eggs.  The lab is then responsible for the fertilization and culturing of the embryos.  All of it is outside our control, yet is the most control to be had over this fertility process that a human can have.  It all takes place over the course of 3-4 weeks, after which, if we have enough blastocysts, we prepare for transfer and hope for the best.

More on fertilization:

At the time of retrieval, while I'm under anesthesia, Michael gives a sample.  The lab then washes the sperm and chooses the most perfect, shiny and strong looking ones from the millions in the sample for a process called ICSI, where they will actually inject a single sperm into each egg.  This increases fertilization success rate from about 60% to 80%, and hopefully results in more blastocysts in the end!  Fascinating!

ICSI in progress.