One of the biggest decisions facing couples going through fertility challenges is whether or not to try In Vitro Fertilization (IVF). Every day in my practice, I talk with women (and their partners) about the positives and negatives of this procedure, and whether or not the time has come to give it a try.
A huge misconception about IVF is that it’s a cure for infertility. When couples go into the process with this idea, the disappointment they feel if it doesn’t work can be devastating. In the United States, the cost is almost entirely out of pocket for most people. Topping out around 15 K for one cycle, the added financial strain only compounds anxieties.
Many couples enter the treadmill of Assisted Reproductive Technology (ART) without fully understanding how the various procedures actually work, what they entail, or how likely they are to succeed. I believe firmly that knowledge is power, and that the more you know, the better you’ll be at making decisions about your fertility. So, here’s the scoop!
Why choose IVF?
If you’ve been down the road of diagnosis and you and your RE (Reproductive Endocrinologist) decides that IVF is your best shot at achieving pregnancy, you may quickly find yourself in a two-week whirlwind of injections, ultrasounds, blood tests and procedures. Some reasons for choosing IVF include:
• Increasing the number of follicles available in a given cycle to maximize the chances of achieving pregnancy
• Assisting with the fertilization of mature eggs through procedures such as ICSI (intra-cytoplasmic sperm injection, where a single sperm is injected into an egg) and assisted hatching (helping an egg “hatch” so it can implant more easily).
• Allowing for genetic testing of embryos to eliminate any which are not chromosomally normal (PGD or PGS).
• Circumventing blocked fallopian tubes
• Overcoming poor sperm count (male factor infertility)
Who Performs IVF?
IVF should always be performed by a board certified Reproductive Endocrinologist/Infertility specialist - at a reputable clinic with a highly regarded lab. Take the time to find out which office has the best reputation in your area, and be willing to spend a little extra for the best clinic you can find. The cost of having to undergo multiple cycles due to physician mistakes is not worth the money saved. That’s still not to say it will definitely work the first time you try, but you want to hedge your bets wherever possible.
What are my chances of IVF Success?
It’s important to remember that IVF is merely a strategy for maximizing your fertility wherever it is in that moment.
IVF is not a cure for infertility, especially when it’s due to advanced maternal, age or severely compromised sperm. That’s because the main reason why IVF (or natural conception, for that matter) doesn’t work is chromosomally abnormal embryos.
We all know that the risk of Down’s syndrome increases as we age. This increase happens because the older we get, that harder it is for our eggs to divide properly (once they are fertilized). When mistakes happen in the dividing process, some genes end up with 3 chromosomes on them when they should only have 2 (some end up with only 1, which is just as big a problem).
None of this means that IVF won’t help, or even significantly increase your chances of achieving a healthy pregnancy, but it’s not magic.
When taken at face value, IVF success rates can seem pretty dismal. However, remembering that a totally healthy couple in their prime reproductive years has roughly a 1-in-5, or 20% chance at pregnancy in a given cycle can lend a little bit of perspective to projected IVF outcomes.
Here are the success rates for live birth outcomes for IVF in the United States, according to the American Pregnancy Association:
• 30 to 35% for women under age 35
• 25% for women ages 35 to 37
• 15 to 20% for women ages 38 to 40
• 6 to 10% for women ages over 40
What Happens During IVF?
Day 2 tests
On day 2 of your menstrual period, you’ll go into your fertility office to have your blood drawn to test Estradiol (E2)/FSH levels. You’ll also undergo a trans-vaginal ultrasound to count and measure the number of antral follicles (the eggs that are candidates for responding to the medications).
In an optimal cycle, all of the potential follicles should be about the same size. If one follicle is already bigger than the rest (a lead follicle), then the cycle should be delayed until the next month or synchronized with medications like birth control pills or estrogen. An early lead follicle will absorb a disproportionate amount of medication and result in a less than ideal outcome. The key is not to let impatience get the best of you here! It’s best to wait until the conditions are right!
Once the lab results are in (later the same day) and the follicles are confirmed synchronized, IVF medications are self-administered via injection, usually starting that very evening. It is critical to follow instructions to a T, and to call the office if you have any questions or concerns. Getting off track here could sabotage the cycle.
There are lots of different IVF protocols, and this post is just a general explanation of how IVF works, so don’t be thrown off if your doctor has you doing stuff that’s outside of what I’m describing here.
After a few days of injections, you’ll return to the clinic to check for progress via ultrasound and blood work. It’ is expected that E2 levels continue to rise with each passing day, as the developing follicles are continuing to secrete more and more estrogen as they grow. Cycles that become significantly de-synchronized may be cancelled at any time, though some doctors will push through and allow the larger follicles to become over-mature in an effort to save the smaller majority. The RE’s I work with most often find this practice to be problematic and do not endorse it, as it is often the larger “lead” follicles that are the most likely to be healthy. Once again, patience is a virtue and it’s better to wait it out for an ideal cycle.
The process of self-administering medications typically lasts about 10-12 days, with frequent visits to the doctor for monitoring and blood work. Once the RE determines that the follicles are at the peak of their maturity (measured by a plateauing E2 level and appropriately sized follicles), then an HCG trigger shot is administered to prepare the body for ovulation, roughly 36 hours before retrieval.
HCG is recognized by your body in the same way as LH, the hormone that “surges” around mid-cycle, to tell an egg that it’s time to ovulate. These “trigger” shots allow your doctor to time exactly when your follicles will be ready to go, and your retrieval will be scheduled accordingly. For example, an HCG shot given on Thursday evening will prime your ovaries for egg retrieval on Saturday morning. Be sure to give yourself the HCG shot at the EXACT hour you are instructed to do so.
Follicle aspiration (retrieval) is a minor surgical procedure, which is performed by an RE in order to remove all of the developed follicles from a woman’s ovaries for fertilization in the lab. The procedure is performed in a sterile operating room under heavy sedation (you’ll be asleep!), by inserting a long needle through the wall of the vagina and into the ovaries, one side at a time. The RE skillfully aspirates the follicles and surrounding fluid out of the ovaries via ultrasound guidance, and they are immediately assessed for maturity.
Once the procedure is over, the follicles are taken to the lab where they are stripped of their outer membrane to reveal the single celled ova, and then fertilized with your partner's sperm (a sample would have been given that morning, or a previously frozen sample might be used).
Ova are fertilized one of two ways; naturally or via ICSI.
• Natural fertilization is the process whereby sperm and egg are place together in a petri dish and left to fertilize on their own. This allows for “natural selection” to occur, if you will.
• ICSI is the process whereby a single sperm is corralled into a pipette and skillfully injected into the ova’s cytoplasm. This procedure is typically performed when a man’s sperm parameters are poor in order to increase the odds of having a healthy sperm meet the egg.
The day following retrieval and fertilization (considered “Day 1” in IVF terms), the follicles are assessed. Normally fertilized ova will have 2 nuclei at this point, and are referred to as 2PN’s (2 pro-nuclei). If a “freeze all” cycle was planned, embryos are often frozen at this stage, as this gives them the highest survival rate when thawed. If a fresh cycle is occurring, then the 2 PN’s are left to continue growing for 2-4 more days, and then transferred into the mom-to-be.
Embryo transfer usually occurs on either day 3 (cleavage stage) or day 5 (blastocyst stage). The choice between these two days is related to how many embryos there are to choose from, how old the mother-to-be is, or clinic preference.
Many clinics routinely do day 3 transfers, while others feel that day 5 offers better results. The difference in development between a day 3 embryo and a day 5 blastocyst is considerable. Typically, there is an attrition rate of roughly 50% or more during these two days. What this means is that embryos that are not chromosomally normal (or are otherwise compromised) won’t make it through the complex cell dividing that must take place to go from the 4-8 cell embryo stage to the hundred+ cell blastocyst stage. Hence, it is presumed that embryos that survive to the blastocyst stage have a greater chance of being chromosomally normal than their day three counterparts.
For this reason, significantly fewer blastocysts are transferred on day 5 than embryos on day 3. The decision of how many to transfer is between a couple and her doctor, and should take into account her age, past cycles, and guidelines put forth by the ASRM (American Society of Reproductive Medicine).
Here are the ASRM recommendations by age for number of embryos to transfer, based on a desired outcome of a singleton pregnancy:
• Under 35: 1 embryo for favorable prognosis/blastocyst transfer; 1 to 2 embryos for favorable prognosis/cleavage-stage transfer; 2 embryos for all others
• 35 to 37 years: 2 embryos for all patients (except 3 embryos for women with less favorable prognoses who receive cleavage-stage embryos)
• 38 to 40 years: 2 embryos for favorable prognosis/blastocyst transfer; 4 embryos for less favorable prognosis/cleavage-stage transfer, and 3 embryos for all others
• 41 to 42 years: 3 embryos for those receiving blastocysts and 5 embryos for those receiving cleavage-stage embryos
The procedure for transferring embryos is quite simple, especially when compared to the complexities of the rest of the IVF cycle. Mom-to-be is placed on an exam table, in the same position she would be in for a gynecology exam. A speculum is inserted and her cervix is cleaned off with the same media that are currently housing her embryos. Next, a catheter is inserted into the cervix, and threaded to about 1 cm from the top (fundus) of her uterus. Next, a thin, flexible catheter containing the embryos for transfer is inserted through the already placed catheter and threaded to the top of the uterus as well. At this point, the embryos are pushed gently into the cervix, at the optimal spot for healthy implantation to occur.
In order to guide the catheter to its ideal location, ultrasound is used. Usually, a woman is asked to drink plenty of water prior to transfer so that her bladder will help to flatten out the uterus, making it easier for the doctor to find the ideal location. Most women find that the full bladder sensation is the most uncomfortable aspect of embryo transfer.
Following transfer, a woman is usually left to rest for 15-60 minutes and then released to go home for a day or so of modified bed rest.
One of the greatest fears that couples have following embryo transfer is that their newly placed critters will somehow fall out when she stands up. This definitely isn’t the case! First, the uterus is not on a vertical plane, and secondly, the inside of the uterus is cavernous, with lots of ridges that can catch an embryo where it lands. One of the clinics that I frequently work with actually allows patients get up to relieve themselves immediately following transfer, without any compromise to their pregnancy rates. So, worry not. If it’s a healthy embryo, standing up won’t ruin your chances!
Two-Week Wait & Pregnancy Tests
Finally, the two-week wait begins. During this time, blood work may be done to make sure that the patient's body has enough estrogen and progesterone to ensure pregnancy can be sustained. Around 14 days following retrieval, blood work is done to check for HCG in the blood stream (the HCG from the trigger shot is all worn off now, so you won’t get a false positive!). Detectable HCG confirms pregnancy. A level above 25mIU/ml is considered positive, below 5mIU/ml is considered negative. More important than a high starting number is that the numbers steadily double approximately every other day. Blood work is generally done every few days to ensure a healthy rise in HCG levels until 6-7 weeks gestation, when an ultrasound is performed to check for a fetal heartbeat. (source)
Patients will generally stick with their fertility specialist through about the 8- week mark, at which point they are “graduated” to their OB/GYN of choice. In the case of high-risk factors or multiples, your RE might suggest that you to see a high-risk perinatologist.
What You Can Do to Improve Your Odds…
When pregnancy doesn’t come easy, stress, fear and anxiety can take center stage, this is totally normal! The longer your fertility journey, the greater the stress, as costs rise and your desired outcome begins to feel less than certain.
While there is no magic bullet for overcoming fertility challenges, there are a few things you can do to hedge your bets, and keep your sanity.
My ebook, Feed Your Fertility (co-written by Emily Bartlett, LAc) is dedicated to providing meaningful solutions for maximizing your fertility. Here are a few of the thing we cover:
• Nutrition: A Real food approach is best. Making sure you get enough healthy fats, pasture raised animal products and organic produce will optimize your overall health, a prerequisite for baby making.
• Mind/ Body Practices: Meditation, prayer, mindfulness, yoga…. These are some of the things you can do to help manage your stress load, a vital component of keeping your body primed for pregnancy.
• Acupuncture: Several studies have shown an increase in pregnancy rates when acupuncture is used in the weeks leading up to, before and after embryo transfer. (source) (source). Beyond these studies, acupuncture does great things for your nervous system and is a key component to managing stress and anxiety. Acupuncture is also extremely effective in preparing the body for pregnancy, even if you aren’t pursuing western fertility treatments.
• Chinese Medicine: Beyond acupuncture, Chinese Medicine encompasses herbal medicine, nutrition and a healthy lifestyle. Make sure to always do your homework here and work with a qualified, licensed practitioner to utilize the incredible benefits this approach has to offer!
• Give it some time: When your biological clock is ticking, it’s hard to imagine slowing down the fertility train. Giving your body a few months of healthy eating, mind-body practices and Chinese Medicine can actually improve your chances of a successful IVF outcome, modulate your stress and potentially minimize the amount of treatment you’ll need.
A few more words…
The decision to pursue IVF can be painstaking and scary. Before you proceed, make sure that you understand your odds for success, and maximize it with healthy living, good nutrition and complementary medicine.
I wish you a smooth and blessed road to the family you so desire!
This post was adapted from my upcoming ebook, Feed Your Fertility: Nourishing Your Mind, Body and Spirit with Chinese Medicine and Healthy Living. The