InVito Fertilisation (IVF) is simply the uniting of egg and sperm in vitro (in the lab). Subsequently the embryos are transferred into the uterus through the cervix and pregnancy is allowed to begin. The process is done inconjunction with ovluation Induction through drugs, monitoring of hormone levels and follicle scans with ultrasound.

The following is an approximate timetable of events:

How is IVF Done?
The steps of IVF are as follows:

• Ovulation Induction
• Retrieval
• Collecting and preparing the sperm
• Insemination of eggs and embryos culture
• Transferring embryos to the uterus
  

What is Egg Retrieval?
Egg retrieval is the process whereby a woman's eggs are removed from her ovaries. These eggs are later mixed with a man's sperm in order to facilitate fertilization. In order for egg retrieval to occur, a woman must first have follicle production stimulated by particular hormones. Once a number of follicles (potential eggs) are produced, fetility specialists can then remove these eggs from the ovaries in order to attempt fertilization. If fertilization is successful, the embryos will be placed back in to the woman's uterus.

What are Egg Follicles?
Egg follicles are fluid-filled sacs that are located inside both of a woman’s ovaries. A woman is born with millions of these eggs follicles, each of which contains an immature egg at its center. Each month, thanks to certain hormones, multiple follicles will begin to develop. The one follicle that is the strongest will attract most of the follicle - stimulating hormone (FSH), a hormone secreted by the pituitary gland, causing it to break open and release an egg while the remain follicles die off. This is ovulation.

Stimulating Follicular Development
In order for IVF to be most effective, more than just one mature egg needs to be retrieved. Your reproductive endocrinologist will attempt to remove all viable follicles that are present in your ovaries, so that multiple eggs can be fertilized. This means that a woman needs to have her follicles stimulated artificially.

There are special medications that you will be required to take in order to help stimulate the development of your follicles. These medications may be given orally or via subcutaneous injections for approximately ten days or so.

Monitoring Follicular Development
Timing is extremely important when it comes to the IVF retrieval process. If your follicles develop too much, then the egg inside will become too mature for efficient fertilization. This can seriously affect the IVF process. For this reason, your ovaries will be monitored in order to keep an eye on your follicular development. This is typically done through ultrasound. When your follicles reach just the right maturity, egg retrieval can begin.

Retrieving the Eggs
The egg retrieval process is a relatively simple one. It typically takes place at your local fertility clinic or in a hospital affiliated with your clinic. Follicles from both your left and right ovary will be removed in a process known as follicular aspiration. Follicular aspiration involves inserting a hollow needle through the top of the vagina and into the ovaries. This needle is then used to suction out any follicles that may be present in the ovaries.

In order to guide the needle into the appropriate area of the ovary, you will be given a transvaginal ultrasound. This will allow your health care provider to insert the needle into your ovary at just the right place. This will be performed under anesthesic, so you shouldn’t feel any pain.

Once the needle is in the proper position, your health care provider will use it to aspirate any follicles inside of the ovary. These follicles will be immediately examined under a microscope to ensure the presence of a viable egg. The follicles will then be placed in an incubator.

Depending upon your age and the effect of your fertility medications, you may have between 5 and 20 eggs removed during the egg retrieval process. The entire process typically takes between 15 and 30 minutes.

How Will You Feel After the Egg Retrieval?
After the egg retrieval process you may feel a little tender in your abdomen. You will also feel fatigued as a result of the anesthetic. After two hours of monitoring at your clinic, you will be allowed to go home. You may notice some light vaginal spotting that is red or brown in color. This is normal, though, and nothing to worry about. You will also receive some antibiotics from your health care provide that will help to prevent any infection.

After the Egg Retrieval: The Next Step
After the egg retrieval, all viable eggs will be mixed with a sperm sample provided by your partner. These eggs will then be cultured overnight until they can be checked for fertilization. If fertilization occurs, the next stage of IVF treatment can begin:Embryo Transfer.

What is Embryo Culture?
Embryo culture is the term used to describe the process immediately follow egg retreival. It is during the culture process that your eggs and your partner’s sperm will be combined in order to produce a fertilized egg (known as an zygote). Once a zygote has been formed, the culture process will continue in order to encourage the growth of the zygote into an embryo. Lasting from 2 to 5 days, the embryo culture process is vital to the success of any IVF procedure. Without accurate and controlled embryo culture, IVF transfer may not be successful.

The First Step: Fertilization
Immediately following your IVF retrieval, any aspirated follicular fluid will be transported to your fertility clinic’s laboratory. Here, your follicular fluid will be examined under a microscope, in order to identify all eggs that are present. Each egg and it’s surrounding cells will then be washed in a special medium, in order to remove any toxins and impurities. These eggs will then be transferred, in separate dishes, to a special incubator containing carbon dioxide. The eggs will remain in this incubator until fertilization is ready to take place. This usually happens between two and six hours after egg retrieval, depending upon the maturity of the eggs.

When the eggs are matured, they will each be combined with some of your partner’s sperm. His sperm will have been washed and divided up into specific amounts. Typically, no more than 100,000 sperm per milliliter are used during the fertilization procedure. The sperm and egg will be combined in a dish that contains special culture medium. This culture medium, made up of protein, salt, and antibiotics, is designed to help the embryo during the first days of division. The dish is then placed back inside of the incubator.

Monitoring the Embryos
Your developing embryos will be monitored carefully by an embryologist, a person who specializes in embryo development for IVF and other fertility treatments. After 18 hours of development, your embryologist will make the first check on your embryos. By this stage, your embryos will still be single cells. However, they will contain two clear bubbles (known as pronuclei) inside. These pronuclei are evidence that the embryo contains genetic material from both you and your male partner. Embryos without pronuclei are discarded.

Your embryos will then be left to develop for another 24 hours. At this point, embryos will be monitored for cell division. Most embryos have developed into two or four-cell embryos at this point. Some laboratories will allow embryos to continue culturing, while other labs will proceed with embryo transfer at this point. Depending upon your particular health needs, you may or may not choose to have a transfer done at this point.

Numeric grading systems for multicell embryos usually have 4 levels:

Grade 1: even cell division, no fragmentation
Grade 2: even cell division, small fragmentation
Grade 3: uneven cell division, moderate fragmentation
Grade 4: uneven cell division, excessive fragmentation

Blastocysts are graded differently with a number and two letters.

The number refers to the degree of expansion of the blastocyst (1 is the least expanded, 6 is the most expanded). The first letter (A,B, or C) refers to the quality of the inner cell mass (the part of the blastocyst that is going to be the baby) and the second letter (A, B, or C) refers to the quality of the trophectoderm (the part of the blastocyst that is going to be the placenta).

Multicell embryos that recieve grade 1 or 2 often develop to the blastocyst stage, those receiving grade 3 or 4 rarely develop to the blastocyst stage. Sometimes the laboratory uses the reversed scale where a grade 4 embryo is equivalent to a grade 1 embryo on the above scale. Check with your lab.

It is unusual to be allowed to go into the IVF laboratory to view your embryos in person since the lab is a sterile room like an operating room. Special clothes, hats, gloves, shoe covers etc., are required. These are not usually supplied to the patients, just lab personnel. You can, however, ask for a picture of your embryos as many labs document the embryo development with photographs or video images. Ask the Lab Director what the policy is. When you see the picture, ask for an interpretation, embryo stage, grades etc.

How Long Should an Embryo Be Cultured?
Embryos can be cultured for a various lengths of time, depending upon the reproductive history of you and your partner. Embryos can be cultured for:

• Two Days: Embryos that are cultured for two days are generally transferred at the two or four-cell stage. This type of transfer is beneficial for couples who have a low number of embryos available for transfer, or who have embryos that are developing poorly.
• Three Days: Embryos that are cultured for three days are usually transferred at the six to eight cell stage. Many laboratories prefer to culture embryos until this stage because it allows for increased monitoring. Embryos cultured for three days can be checked by the embryologist for gene activation and cleavage, which improves the likelihood of transferring a viable embryo.
• Five Days: Embryos that are cultured for five days are transferred at the blastocyst stage. Blastocysts consist of 12 to 16 cells and are well on their way to be ready for implantation into the uterus. Many labs opt to transfer at the blastocyst stage, particularly if you have had repeated miscarriages or IVF failures.

Environment and Embryo Culture
The environments in which your embryos are cultured are of the utmost importance when it comes to completing the culture stage successfully. Some essential components in IVF culture environments include:

• Culture Medium: All developing embryos are cultured is a special medium, designed to help them develop and grow. There are generally two types of culture mediums used by laboratories: one is for initial embryo development (up to 3 days) and the second if for later development (up to blastocyst stage).
• Temperature: Embryos need to be cultured at a specific temperature to ensure survival. The temperature inside of the embryonic incubators is maintained at 37 degrees Celsius. This is the same temperature that is found inside of your fallopian tubes.

Emotions and Embryo Culture
The embryo culture stage is often one of the most frustrating parts of IVF treatment. It is during this stage that you and your partner will find out how many embryos were successfully fertilized and how many are available for transfer. In order to stay sane during this stage or treatment it is important to take time out for yourself. Try not to focus on the development of your embryos, but instead relax, watch television, or meditate. Information will come soon enough.

What is Blastocyst Transfer?

Blastocyst transfer is a type of embryo transfer procedure used during IVF. This type of transfer was first performed 30 years ago and is now being used in an increasing number of fertility clinics. During this type of transfer, a blastocyst embryo is placed inside of your uterus where it will hopefully implant and develop into a fetus. It is now becoming a popular alternative to Day 3 embryo transfer.

What is a Blastocyst?
A blastocyst is formed when an embryo reaches the five to seven-day development stage. At this point in development, the embryo has between 60 and 100 cells distributed in two areas: an outer embryo lining (which will later form the placenta), and an inner mass (which will later become the fetus). During a natural cycle, the embryo develops into the blastocyst stage as it is leaving the fallopian tubes and entering the uterus. An embryo needs to have entered into the blastocyst stage once it arrives in the uterus to ensure proper implantation.

How Many Embryos are Transferred?
Should you decide on a blastocyst transfer, it is likely that only one or two of your embryos will be transferred into your uterus. Fewer embryos are required for this type of transfer because blastocyst embryos are more likely to implant and develop than Day 3 embryos. Typically, between two and four embryos need to be transferred during a day 3 transfer procedure.

Why is Blastocyst Transfer Becoming So Popular?

Blastocyst transfer is becoming extremely popular amongst reproductive endocrinologists and infertile couples. A blastocyst transter is associated with a number of advantages over the typical Day 3 transfer procedure.

A Natural Option
Blastocyst transfer is considered a more "natural" type of transfer than the Day 3 transfer procedure. This is because the blastocyst embryo is implanted into the uterus at almost the same time that it would have entered the uterus should the pregnancy have been a natural one. Alternatively, during Day 3 transfers, embryos are placed inside the uterus at a time when they should normally still be in the fallopian tubes. It is believed that by waiting to transfer a blastocyst embryo, a woman may be more likely to achieve a successful pregnancy.

Higher Success Rates
Blastocyst embryo transfers have also been associated with better IVF success rates. By allowing embryos to culture for a longer period of time, embryologists are better able to choose healthy embryos to transfer into your uterus.

Not all embryos are strong enough to reach the blastocyst stage of development; in fact, approximately 50% of all embryos die soon after the third day of development. By holding transfer off until the blastocyst stage, your embryologist will be better able to ensure that your embryos are healthy and capable of further development. Blastocyst transfer is associated with almost a 50% success rate, compared to the usual 35%.

Fewer Embryos Required
Many couples opt for blastocyst transfer because fewer embryos need to be transferred. This helps to significantly decrease the chances that you should develop a multiple pregnancy. Twin, triplet, and higher-order pregnancies can be very dangerous for both the babies and the mother. If you experience a multiple pregnancy you are at increased risk for miscarriage, stillbirth and having low birth weight babies. Many couples opt to avoid these dangers by undergoing the blastocyst transfer procedure.

Should You Get a Blastocyst Transfer?

Before you and your partner decide on a blastocyst transfer, it is important to consider whether or not you are suited for the procedure. Blastocyst transfer does have its disadvantages and may not be appropriate for all couples.

Who Gets a Blastocyst Transfer?
Some couples are more suited to blastocyst transfer than others. You may be a good candidate for this type of transfer if:

• you have not had success with previous Day 3 transfers.
• you have a relatively small number of embryos available for transfer.
• you need to avoid having a multiple pregnancy for health reasons.

Disadvantages of Blastocyst Transfer
Blastocyst transfer does have a few disadvantages associated with it:

• Difficulty: Blastocyst culture is very difficult to do and requires a fully-equipped laboratory and intensive management. In order to survive the culture process, embryos need to be kept at specific temperatures and exposed to just the right culture medium. Some fertility clinics have not yet perfected this culture process and, as a result, have lower success rates.
• Loss of Embryos: If you choose to have a blastocyst transfer, expect to lose quite a few of your embryos. On average, up to 50% of embryos die before the blastocyst stage, but some couples lose more than half of their embryos.
• Freezing Difficulties: Many couples opt to pursue cryopreservation of any leftover embryos so that they can use them for fertility procedures in the future. Unfortunately, blastocysts do not survive the freezing process as well as Day 3 embryos do, so this may not be a option for you.

What is Embryo Transfer?
Embryo transfer is one of the most important parts of the IVF process. It is during this final stage of the IVF procedure that your embryos will be transferred into your uterus, in the hopes that you will become pregnant. Embryo transfer is completed after your eggs have been fertilized by your partner’s sperm and they have been through the embryo culture process.

It is vital that the embryo transfer procedure be performed by a skilled reproductive endocrinologist; if mistakes are made during the embryo transfer process, it can affect your chances of pregnancy.

When is Embryo Transfer Performed?
Embryo transfer is usually performed once your embryos have been cultured to the right stage. Typically, there are two types of embryo transfers:

• Day 3 Embryo Transfer is performed 72 hours after egg retrieval. Your eggs will be mixed with your partner’s sperm and then allowed to develop for three days. At this point in time, your embryos will be transferred into your uterus where, hopefully, they will implant.
• Blastocyst Transfer occurs when your embryos have reached the blastocyst stage. This occurs after five days of culturing. Some fertility specialists prefer doing blastocyst transfers because it is easier to choose a healthy embryo for transfer at this stage.

How Many Embryos are Transferred?
Generally, between two and four embryos are transferred during each IVF cycle. The exact number of embryos that you have transferred will depend upon a number of factors, including:

• the number of embryos that were formed after egg retreival
• the health of your embryos
• your age
• your risk level for multiple pregnancy

The greater the number of embryos that are transferred into your uterus, the higher your risk of having a multiple pregnancy. When multiple pregnancies form, this can seriously affect the health of both you and your baby, so every effort to minimize multiple pregnancies must be taken by fertility clinics. In some countries, such as the UK, there is a limit of two embryos that can be transferred per IVF cycle.

How Is Embryo Transfer Performed?
Your embryo transfer will likely be performed at your local fertility clinic. It is a completely painless procedure, so you will not have to receive any type of anesthetic during the transfer.

You and your partner will be asked to come in a few hours prior to the transfer procedure. At this time you will be asked to drink a lot of fluids in order to increase the size of your bladder. This is needed in order to help your reproductive endocrinologist see your uterus more clearly during the ultrasound portion of the embryo transfer. Your embryologist will also discuss with you which embryos are the healthiest to have transferred into your uterus and how many embryos should be transferred. You and your partner will be able to see pictures of your embryos before the procedure begins.

Once your embryos have been selected, they will be immersed in a fluid and stored in a special catheter. You will be asked to lie down on an examination table and a speculum will be inserted into your vagina. This allows your physician to access your cervix. Your cervix will be cleaned of any cervical mucus, which could interfere with the placement of the embryos. A flexible, rubber catheter will then be inserted into your cervix and up into your uterus. The catheter containing your embryos will then be placed inside of this rubber catheter.

Your physician will perform an abdominaultrasound in order to determine the best place inside of your uterus to deposit your embryos. This is usually in the space at the very top of your uterus. Once this location has been found, the embryos will be pushed out of the catheter and into your uterine lining.

After the Embryo Transfer
After the transfer procedure has taken place, you will be asked to lie down for two hours. You may experience some cramping, however you shouldn’t experience any other side effects. After two hours, you and your partner can go home. It is usually recommended that you take it easy for a couple of days after the transfer. After 48 hours though, you can resume your normal activities – these will not affect implantation in anyway.

Remaining Embryos
Typically, most couples have leftover embryos remaining from the IVF process. You and your partner will need to decide what you would like to do with your embryos.

Impact On Daily Life

The degree to which IVF treatment may change your life depends on a wide range of factors and no two couples will have identical experiences. Just the process of going through the treatment can be life-changing for some people, never mind the results. Most couples agree that the IVF process is stressful, but the extent to which this stress affects you will depend on your own personality; your health and fitness; any side effects you may experience from fertility drugs; how many cycles of IVF you take; the length of those cycles and, of course, your relationship and interaction with your partner. Of course, once the treatment has been completed, it has the potential to change your life by making you a mother! On the other hand, sometimes it can take more than one cycle of IVF to achieve a lasting pregnancy and the disappointment caused by failed attempts may be immense.

you've made the decision to try IVF. You'll soon find out just what a big commitment you've made. IVF will make significant demands on your time, energy and emotions. If you are lucky, a cycle of treatment will take around four weeks to complete, although some cycles have been known to continue for as long as seven weeks. During this time, you'll be making trips to back and forth to the clinic, taking pills, receiving injections, and being monitored for possible problems as well as signs that the treatment is working. At the egg retrieval and fertilization stages, you should expect to spend around half a day at the clinic. You will have to return two or three days later to have the fertilized embryos transferred to your uterus. Then you have to play the waiting game - waiting to see if the embryos will implant successfully, or if you'll be pregnant with twins or even triplets!

So Why Put Yourself Through It?

Ask any couple who have had a child through IVF - it changes lives, and that's why people do it. Just think how many children there are in the world today that might never have been born if it wasn't for IVF. Think how much love and joy these children have brought into the lives of their parents and siblings. IVF doesn't work for everyone, that's true, but many couples feel it's worth the effort and the risk of disappointment. If you are considering IVF and want to know more about your own chances of success, you should speak to a fertility specialist.

When IVF Fails

Unfortunately, sometimes IVF doesn't work. Some couples go through several, long cycles of treatment before they achieve a lasting pregnancy and sadder still; some couples never manage to have a baby through IVF. When so much energy (and money) has been invested, this can failure can be crushing. Talking to a professional will help you to overcome your fear or, if necessary, work through your disappointment.

Although a great many couples believe the potential results of IVF compensate for physical discomfort or risk involved, it can't be denied that IVF is often a stressful process. When so much time, money and emotion has been invested in a treatment, the one thing you don't need is extra stress worrying about symptoms and side effects. While IVF is mentally draining process for both men and women, it is the woman who ultimately assumes all the physical risks. She may be left wondering, "Is what I'm experiencing normal?" "Am I supposed to have these cramps?" "Why am I getting these headaches?" Meanwhile her partner looks on helplessly for any sign that something is wrong. This is why it helps to know what side effects of IVF to expect. This will help you determine what's normal and what could be a symptom of a more serious problem..

"Menopausal" Side Effects

IVF treatment involves frequent blood tests and almost daily injections or nasal sprays of hormonal drugs. The first stage of the treatment aims to suppress your own natural menstrual cycle, so that your doc can induce ovulation at a later stage, when he is ready to harvest the eggs from your ovaries. Basically, the initial treatment puts you into an artificial and temporary state of menopause, as odd as that may seem, given that you are trying to get pregnant. It therefore comes as no surprise that some women, but not all, experience menopausal symptoms during this part of the treatment cycle.

These symptoms may include hot flushes, headaches, and mood swings. Usually the reaction (if any) to these drugs is mild - however, if you experience any severe symptoms, such as very nasty headaches, disturbances of your vision or severe pain, seek medical advice. You may also find that the repeated injections leave bruises on your skin. Enquire at your fertility clinic if you think you need "re-training" in how to administer the injections.

Stimulation Side Effects

The next stage of the treatment involves using more drugs to stimulate the ovaries into producing and releasing more eggs than they normal would. The eggs will later be removed from the ovaries and fertilized in a laboratory. The drugs used for ovarian stimulation can have a number of side effects, including some abdominal pain, bloating, etc.

OHSS

Ovarian Hyper Stimulation Syndrome (OHSS) is what happens when ovarian stimulation syndrome goes too far. Mild cases of OHSS usually don't require treatment but severe cases can be dangerous, even deadly. That's why you must report OHSS symptoms, even if they are mild, to your fertility doctor.

These symptoms include: stomach swelling and pain (due to cysts on the ovaries and fluid filling the abdomen), nausea, vomiting, rapid weight gain, shortness of breath and decreased urination (even when drinking plenty of fluids).

Retrieval Side Effects

Eggs are retrieved from your ovaries using a long, hollow needle, inserted through the top of your vagina. Anesthetic is used so you won't feel any pain. Some women experience cramping for a few hours after undergoing this process. Your fertility doctor will let you know what to expect. If you have severe cramps or any bleeding, seek medical advice.

Transfer Side Effects

After the eggs have been fertilized and transferred as embryos into your uterus, you may again experience a little cramping. If you have bleeding, speak to your doctor.

Ectopic Pregnancy

Ectopic pregnancy can occur after embryo transfer. This is when an embryo implants and grows outside the uterus, for example, in the fallopian tube. Ectopic pregnancy is a potentially life-threatening condition for both mother and baby - therefore symptoms must not be ignored.

These symptoms include: vaginal bleeding, pain on one side of the stomach or abdomen, severe nausea and vomiting, fainting and dizziness. If you have these symptoms, go to the emergency room.

Consult Your Doctor

Remember, if you have any concerns about IVF side effects, don't hesitate to speak to your fertility doctor right away - his professional opinion takes precedence over anything written here.