IVF by the Numbers
52.5%
Pregnancy Rate per IVF Transfer
Miscarriage Rate
18.5%
Live Birth per Transfer
43.3%
Multiples Rate
16.1%
This is where we put our footnote and reference information describing what people are looking at and how we got those numbers
See how Progyny stacks up against the national average
Progyny Members
National Averages
60.7%
Pregnancy Rate Per IVF Transfer
10.2%
3.6%
IVF Multiples Rate
54.5%
Progyny Outcomes vs. the National Average
Learn how IVF works in our In Vitro Fertilization Infographic
In Vitro Fertilization is a technique in which egg and sperm are combined in a laboratory in order to create embryos. An embryo is selected and transferred into a woman where, with some luck, implantation occurs.
There are a lot of moving parts to an IVF cycle, but the general concepts are fairly straightforward.
In Vitro Fertilization Overview
IVF, or in vitro fertilization, is one of the most common fertility treatments, but it can be an intimidating process. We created this multimedia guide to provide the information you need to better understand the IVF process. With Progyny, you have support every step of the way and we believe you should have the information you need to feel empowered about your care. That's why we have included information from physicians, clinic support staff, Progyny's care team, and those who have been through treatment so you have a more comprehensive understanding of the road ahead.
Implantation, BETA, & Results
8
The Embryo Transfer
7
Embryo Selection & Genetic Testing
6
Fertilization & Embryo Development
5
Egg Retrieval
4
Stimulating and Monitoring
3
Preparing for IVF
2
Fertility Basics & Diagnostics
1
CHAPTERS
Next Chapter
In Vitro Fertilization
This information has been reviewed for accuracy by Dr. Alan Copperman - Medical Director of Progyny and RMA of New York. Please remember, while this guide was designed to help you with information about IVF, it does not provide information that is specific to you and is not a substitute for medical care. If you have any questions you should reach out to your physician or, if you’re a Progyny member, your Progyny Patient Care Advocate.
Fertility 101 & Diagnostics
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The initial consultation can take anywhere from 30 to 90 minutes. It can be helpful to bring a few things with you to the appointment.
What to Bring to the Initial Consultation
The initial consultation is an important first step to treatment. The initial consultation can help guide the physician and patient to create a personalized treatment plan. IVF may be the recommended course of treatment based on the results of the initial consultation.
Initial Consultation
– Kayleigh, Progyny Member
Find your people... I found this community of women and couples who were going through what I was going through.
Intro to Human Reproduction
IVF is an enhancement of the body’s natural reproductive system. Understanding some of the basics of human reproduction can help to demystify the IVF process.
Fertility 101 and Diagnostics
Follicular Phase
An average menstrual cycle lasts 28 days but can range from 21–35 days. The follicular phase can be longer or shorter for different women.
The follicular phase starts on the first day of menses and ends at the time of ovulation, which occurs around day 14 in a 28-day cycle. During the follicular phase, the pituitary gland produces two hormones: follicle stimulating hormone (FSH), and luteinizing hormone (LH). FSH works to recruit follicles (or the sacs that hold the eggs) in the ovaries and will ultimately result in the recruitment of a dominant follicle that will be released during ovulation. The dominant follicle produces estrogen, which helps to build the lining of the endometrium, changes the quality of the cervical mucus to be thin and slippery, and triggers the production of the luteinizing hormone (LH). Following a surge of LH, the dominant follicle will rupture, and ovulation will occur, meaning the egg is released and picked up by the fallopian tube.
Luteal Phase
An average menstrual cycle lasts 28 days but can range from 21–35 days. The luteal phase is typically around 14 days long, regardless of the length of the menstrual cycle.
The luteal phase lasts from ovulation until menstruation. The follicle that bursts to release the egg becomes a gland called the corpus luteum and begins to secrete progesterone to stabilize the uterine lining and prepare it for implantation. Although the egg is viable for 12–24 hours following ovulation, to optimize fertilization, sperm should be there to greet the egg. After 12–24 hours the egg will degenerate if it is not fertilized. Sperm, however, can live inside the female reproductive tract for up to five days.
Fertilization
Once the egg is ovulated, it is picked up by the fallopian tube and transported towards the uterus. If intercourse occurred at the optimal time, sperm should be waiting in the fallopian tubes and be ready to fertilize the egg. If the sperm penetrates the egg, fertilization occurs. The fertilized egg, or zygote, continues to travel down to the uterus for implantation.
Implantation occurs 7–10 days after ovulation when the zygote attaches itself to the uterine wall. Once attached to the uterine wall, the embryo and developing placenta will begin to produce human chorionic gonadotropin (hCG), a hormone that stimulates the corpus luteum to continue making progesterone. Home pregnancy tests are designed to measure hCG, and three to four weeks after the last period the hCG levels should rise high enough to be detected.
During implantation, some women may experience a small amount of bleeding or spotting, which is known as implantation bleeding, or implantation spotting. This normally occurs a week to a few days before a woman’s period would start. Around one-third of women experience some kind of implantation bleeding, which looks like a discharge with pinkish or brownish blood. This type of bleeding is not harmful and does not require medical attention.
Copies of medical records A partner or a friend Questions for your physician Insurance information Medical and Sexual History
If you’re a Progyny member, the initial consultation is a great time to make sure the physician and the practice understands that you have the Progyny benefit. Progyny provides members with comprehensive coverage for their treatments, which will help you and your doctor create the best treatment plan for your unique situation. If you have any questions, you can always reach out to your dedicated PCA.
Lab Work (from drawn blood)
Anti-Mullerian Hormone (AMH): Provides the physician with an understanding of one's ovarian function and egg reserve (which refers to the number of quality eggs in the ovary). Estradiol: To measure ovarian function and to evaluate egg quality. FSH (Follicle-Stimulating Hormone): FSH helps control the menstrual cycle and the growth of follicles, which contain eggs, in the ovaries. Checking FSH helps to evaluate ovarian function and egg quality. LH (Luteinizing Hormone): LH is linked to ovarian hormone production and egg maturation. If performed midway through the menstrual cycle, this level may assist in determining that ovulation is occuring. Pre-Conception Carrier Screening: Idenitifies genes for certain genetic disorders, and allows patients to better understand the chances their child will have a genetic disorder. Progesterone: Progesterone is a hormone produced by the ovaries during ovulation, it prepares the endometrial lining for fertilized eggs. Prolactin: Prolactin is a hormone produced by the pituitary gland that causes milk production and can assist in the evaluation of infertility. Thyroid Stimulating Hormone (TSH): TSH levels determine if the thyroid gland is working the way it should.
Transvaginal Ultrasound and Semen Analysis
Transvaginal Ultrasound: Assess the cervix, uterus, fallopian tubes, and ovaries to look for abnormalities that could make conception more difficult.
Semen Analysis: Approximately 40–50% of all infertility cases are due to male factor infertility. The semen analysis establishes the number, motility, and mobility of the sperm.
Dr. Sheeva Talebian (CCRM NY), Dr. Celeste Brabec (RRC), and Dr. Michael Homer (RSC) break down what you can expect from the initial consultation.
To fully understand the IVF process it helps to first understand how human reproduction works in the body. Featuring: Dr. David Ryley (Boston IVF), Dr. Rashmi Kudesia (CCRM Houston), Dr. J. Michael Putnam (Fertility Center of Dallas), and Dr. Mary Hinckley (Reproductive Science Center)
Excerpt from the podcast
Listen Now
One of the first things to understand is the menstrual cycle. A menstrual cycle is defined from the first day of menstrual bleeding of one menstrual period to the first day of menstrual bleeding of the next. For an ovulatory woman, a menstrual cycle consists of two distinct phases, the follicular phase and the luteal phase, which are separated by an event called ovulation.
1m 08s
There are tests that can be performed for both men and women during a fertility evaluation.
Episode 67: Bariatric Surgery and IVF to Build a Family
Listen to more episodes of This is Infertility
One of the most common questions people ask when they find out they have Polycystic Ovary Syndrome (PCOS) is, “Does this mean I can’t get pregnant?” PCOS is a hormonal imbalance that often presents itself with several symptoms, and yes one of those symptoms may be infertility. But, while PCOS itself isn’t curable, it is possible for women with PCOS to get pregnant. In today’s episode, we’ll hear from Sarah Rivera, who was diagnosed after experiencing two life–threatening ectopic pregnancies. Because of her experience, she decided that IVF was the safest way to proceed, and because she had coverage for fertility treatments provided by her employer, she was able to pursue parenthood at her own pace.
Conception and Pregnancy
Implantation
The Menstrual Cycle
Play Audio
CHAPTER
Stories from the Path to Parenthood...
Hear more about how Kayleigh navigated her journey:
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IVF Overview
Dr. David Ryley (Boston IVF), Dr. Rashmi Kudesia (CCRM Houston), Dr. J. Michael Putnam (Fertility Center of Dallas, Dr. Angie Beltsos (Vios Fertility Institute), Dr. Celeste Brabec (RRC of Greater Kansas City and Dr. Mary Hinckley (Reproductive Science Center) explain the modern IVF process.
IVF simply enhances the bodies natural cycle to help overcome obstacles and significantly increase the chance of success. There are a lot of moving parts to an IVF cycle, but the general concepts are fairly straight forward.
In Vitro Fertilization is a technique whereby fertility medications are introduced to stimulate the ovaries to mature multiple eggs, those eggs are retrieved from the body, and then egg and sperm are combined in a laboratory in order to create embryos. An embryo is selected and transferred into a woman where implantation may occur.
What is In Vitro Fertilization (IVF)
learn more...
Infographic
Testing Performed at the Initial Consultation
The Female Fertility Evaluation
Click here to see the infographic
Infographics
The Male Fertility Evaluation
Once the decision has been made to proceed with IVF, the first thing most clinics will do is to educate about the risks and benefits of the IVF process.
Understanding the Process and Risks
The Care Team
– Angela, Progyny Member
Doctors are humans too. They're far more educated in a world that we know nothing about. And I do trust them. But I also believe it is in your right as someone who is getting treatment to question them.
The IVF Process
Progyny Patient Care Advocate
Each Progyny member has a dedicated Patient Care Advocate, or PCA. PCAs are fertility experts that provide fertility guidance and education throughout a member's journey. PCAs can help find the right doctor and clinic, book appointments, explain how coverage will work with the treatment plan, and help smooth out any obstacles that pop up along the way. In addition to helping understand Progyny coverage and treatment options, PCA's are a shoulder to lean on as members navigate through their fertility journey. If you are a Progyny member, you have unlimited access to your PCA, regardless if you pursue treatment. Call 888.597.5065 to be directed to your PCA.
The Physician
Fertility specialists are doctors who are board-certified in Reproductive Endocrinology and Infertility (REI). The physician’s role is to lead the charge by using their expertise and experience to recommend diagnostic tests and treatment options, and to make sure that a patient is aware of any risks associated with their treatment. Physicians help determine personalized treatment plans and will schedule important events like when to trigger ovulation, and when it’s appropriate to transfer an embryo. Your doctor is the expert, so don't hesitate to ask questions each step of the way.
The IVF Nurse
The IVF nurse (or team of nurses) will provide support every step of the way. From educating patients on how to administer medications at home to working with patients at the morning monitoring visits, nurses are often the members of the care team that patients spend the most time with. Nurses are an invaluable resource throughout your treatment process.
Sometimes this function is also performed by a practice administrator. IVF can be complex and expensive, and most clinics will arrange a meeting for patients with a financial coordinator. For Progyny members, this is typically a very short conversation, as Progyny makes the financial side of IVF straightforward and manageable. It’s important the billing specialist understands that you have Progyny coverage, and that you've connected with your PCA prior to and during treatment. If necessary, you can connect the financial coordinator with your Patient Care Advocate on a call at the office.
Many clinics offer in-person classes with a nurse, and others offer online courses in advance of treatment.
Amanda Garcia, Practice Administer (CCRM NY) explains her role and how the different types of coverage can impact the process.
Dr. David Ryley (Boston IVF), Dr. Rashmi Kudesia (CCRM Houston), Dr. J. Michael Putnam (Fertility Center of Dallas, Dr. Celeste Brabec (RRC of Greater Kansas City), Dr. Peter Klatsky (Spring Fertility) and Dr. Mary Hinckley (Reproductive Science Center) explain the modern IVF process.
IVF is a technique whereby fertility medications are introduced to stimulate the ovaries to mature multiple eggs, those eggs are retrieved from the body, and then egg and sperm are combined in a laboratory in order to create embryos. An embryo is selected and transferred into a woman where implantation may occur.
The Financial Coordinator
Listen to Angela's experience working with her doctor:
Stim and Monitoring
The start of treatment, like many aspects of an IVF cycle, can be different for different patients. The right time and method depends on the patient, the physician's recommendations, and maybe even simple logistics. There are a few different ways to start an IVF cycle.
First Day of Menstrual Cycle: If there’s a regular menstrual cycle, the physician may recommend to start treatment on day two or three of the menstrual cycle. In these cases, patients are directed to call the clinic on the day the period starts to receive detailed adjustments to their medication protocol. Birth Control/Regulated Cycle: Taking birth control feels counter-intuitive when trying to conceive, but birth control can be used to regulate ovulation, in which case birth control could be used for approximately two to four weeks before the start of treatment. Birth control can also be used for “super responders,” those who tend to over-produce follicles/eggs. This is common for patients with a history of polycystic ovarian syndrome (PCOS). Finally, birth control can be used for patients who are traveling to a clinic out of town, or for those who need to work around preexisting travel arrangements. Estrogen Patch/Pills: In order to regulate FSH, the doctor may use an estrogen patch or pill, and start the cycle after the start of the next menstruation cycle.
Determining the Start of Treatment
IVF can be costly and medical billing can be complicated. If you have fertility coverage know that coverage can vary and it is important to understand your coverage and financial responsibility.
Most clinics schedule a conversation with a billing specialist or financial advisor for their patients before treatment begins. This is often called a financial consultation. Here patients gain an understanding of how the treatment protocol and medications can translate into bills along the way. If you’re a Progyny member, your PCA will coordinate with the clinic’s billing specialist.
Financial Responsibility
The IVF treatment protocol can change throughout the IVF cycle. The dosage of medications will be based on the results of the morning monitoring visits. We'll dive deep into the different medication types in the next chapter.
If you have Progyny Rx, medication coverage is rolled into the overall Progyny coverage. Our full catalogue of Progyny Rx Medication Administration videos are available at progyny.com/progynyrxvideos Fertility medication coverage through Progyny Rx includes next day medication delivery, pharmacy clinicians available seven days-a-week, seamless coordination with your PCA, and an UnPack It Call, a one-on-one call with a clinical expert who can help answer any questions about your medications.
Medications and Progyny Rx
IVF Infographic space
IVF Nurse Coordinator, Jamie Walsh (CCRM New York) discusses the importance of IVF orientation, and the role the IVF Nurse plays in this important step.
It is important to feel empowered in your treatment decision making. The doctor is the expert, and available to answer all of your questions. Your voice matters. When making the decision to go through with IVF, patients are also making the decision to commit to a care team. If you are beginning your fertility treatment journey, it's important to choose a clinic that is the best fit for you and your unique situation.
The Patient
Dr. Brian Levine (CCRM NY) breaks down some of the risks and side effects associated with the IVF process.
The suppression check, sometimes called the baseline morning monitoring appointment, is the final step before the stimulation process.
The suppression check entails both blood work and an intravaginal ultrasound. The doctor is checking a few things with these tests: Estradiol Level: Estradiol is a type of estrogen and is secreted by the ovarian follicles as they grow and develop each month. High levels of estrodiol can potentially indicate a problem with ovarian reserve. Uterine Lining: It's best to start an IVF cycle while the uterine lining is thin as it will thicken throughout the process. Visualize the Ovaries: If any of the follicles in the ovaries are too large, or "dominant," smaller follicles may not mature. When this happens the doctor may recommend postponing treatment until the follicle resolves itself, or they may recommend that a birth control pill be used to supporess the ovaries.
The Suppression Check
– Kelly, Progyny Member
Learn more about Kelly's relationship with her PCA
I pretty much email her, I would say on a weekly basis when I'm in treatment... and she always responds with very emotionally thoughtful messages.
Dr. Brian Levine (CCRM NY), lays out the different ways an IVF treatment cycle can begin.
If you’re a Progyny member, the weeks leading up to treatment are a great time to speak with your Progyny PCA and your clinic care team about your Progyny coverage. Doing so now, before you start treatment, will help eliminate any surprises.
Dr. David Ryley (Boston IVF), Dr. Rashmi Kudesia (CCRM Houston), Dr. J. Michael Putnam (Fertility Center of Dallas, Dr. Celeste Brabec (RRC of Greater Kansas City), Dr. Peter Klatsky (Spring Fertility), and Dr. Mary Hinckley (Reproductive Science Center) explain the modern IVF process.
This process requires multiple steps and visits to the fertility clinic. Fortunately, there's a dedicated team to make the process as seamless as possible. In this section we'll introduce some important members of the care team that are involved in the IVF process. This section includes excerpts from our IVF Journey video - you can find the full video by clicking here.
In this excerpt from our "The IVF Journey" video, Progyny's Lissa Kline introduces some key roles played by care team members at a fertility clinic. Click here to watch the entire video.
IVF is a process that requires multiple steps, and multiple visits to the fertility clinic, but IVF also requires a dedicated care team to make the process as seamless and successful as possible. In this section we'll introduce some important members of the care team that most patients interact with. This section includes excerpts from our "IVF Journey" video - you can find the full video by clicking here.
In this excerpt from our "The IVF Journey" video, Progyny's Lissa Kline introduces some key roles played by care team members at a fertility clinic.
How to Choose a Fertility Clinic
Click here to read the article
Article
The physician will determine a specific date and time to administer the trigger shot. The timing of the trigger shot is crucial, so it’s extremely important to have any medication needed ready and to administer this shot at the exact time that the doctor prescribed. The trigger shot helps to fully mature the eggs and prepare them for retrieval. The egg retrieval is scheduled for approximately 36 hours after the trigger shot. If the trigger is administered earlier than instructed, ovulation may occur prior to the egg retrieval. If the trigger is administered late the eggs may not be ready in time for the egg retrieval. Both of these scenarios could result in a cycle.
The Trigger Shot
When patients are administering injections at home, they'll also visit the office for morning monitoring appointments to evaluate how the body is reacting to the medications.
Morning Monitoring Visits
Stimulating the Ovaries
Stimulating the Ovaries and Morning Monitoring
While the trigger shot is often prescribed as a subcutaneous injection, like the other medications you’ve been taking throughout your cycle, it can sometimes be prescribed as an intramuscular injection.
Dr. George Patounakis (RMA of FL) discusses what doctors and staff are looking for during patient's IVF morning monitoring appointments.
The process to stimulate the ovaries is where the injectable medications come into play. The injectable medications associated with IVF are FSH (Follicle Stimulating Hormone) and hMG (Human menopausal gonadotropin, a combination of FSH and LH).
Morning monitoring occurs two–four times a week at the clinic. In these visits blood is drawn for lab work and an intravaginal ultrasound is performed.
The Egg Retrieval
Listen to how Kelly dealt with the more uncomfortable injections.
The menopur ... is uncomfortable which I had read about from other people. It wasn't as bad as I had built it up to be in my head.
Antagonist: While FSH and hMG are working on the ovaries to support follicular growth, antagonists - medications to prevent premature ovulation - may be introduced. The physician will prescribe antagonists as needed. This medication is also a daily injection.
Human Chorionic Gonadotropin (hCG): hCG is given as the IVF “trigger” shot. hCG helps mature the eggs in preperation for retrieval approximately 36 hours later. The timing of this injection is critical, so it's important to be prepared in advance. The trigger may be given subcutaneously or intramuscularly depending on the protocol.
These injectable medications can feel overwhelming so we have created medication administration videos where a licensed nurse walks through exactly how to administer each medication. If you have any questions about your medication, storage, and administration, you should speak directly with your pharmacy or doctor.
Like the other medications, side effects of antagonists include nausea, headache, and pain at the injection site.
Fertility Medications
FSH & hMG: The brands can be different, but generally the medications to stimulate the ovaries are Follicle Stimulating Hormone (FSH) and Human Menopausal Gonadotropin (hMG). Both of these are subcutaneous injections injected daily. The dose is personalized, so it's important to follow the physicians guidance closely.
These medications help stimulate the follicles containing eggs in the ovaries to grow. Both FSH and hMG come with some potential side effects, including mood swings, headaches, nausea, mild abdominal pain, bloating, breast tenderness, pain at the injection site, and in rare cases OHSS (ovarian hyperstimulation syndrome).
Menopur
Gonal-F Follistim Bravelle (less common)
Follicle Stimulating Hormone (FSH)
Human Menopausal Gonadotropin (hMG)
Cetrotide Ganirelix
Antagonist
Novarel Ovidrel Pregnyl
Human Chorionic Gonadotropin (hCG)
The hormones evaluated during IVF cycles generally include estrogen, progesterone, and LH. During the IVF cycle, estrogen levels should increase, and progesterone levels would ideally remain low. LH may or may not be checked (dependent on medication protocol). If any of these levels are not where the doctor expected them, they may adjust the medications, and in rare cases, cancel the cycle.
Lab Work
An intravaginal ultrasound will be completed at each monitoring appointment. This allows the physician to visually see and monitor the ovaries. They are checking the status of follicle growth in response to stimulation medication. On average, a follicle is expected to increase in size by approximately 1–2mm a day. Some patients respond more strongly to the medications than expected, so a physician may switch to a lower dosage to avoid complications like Ovarian Hyperstimulation Syndrome (OHSS). On the other hand, some patients might not be responding as well as hoped so a physician may elect to increase the dosage to try to jumpstart the stimulation for retrieval. After the monitoring appointment the nurse coordinator will contact the patient, usually via telephone, with instructions regarding medication dosing and when to return for the next monitoring appointment.
Intravaginal Ultrasound
Listen to Angela share how her IVF medication protocol was adjusted over time.
They were giving me lower dosage of things, and the amount of time I was going to stim was less.
While your physician can't determine exactly how many eggs will be retrieved, they can start to get a general sense of how the retrieval might go. If you‘re a Progyny member, your Progyny PCA can help you to better understand the results from monitoring and what to expect moving forward.
– Lindsey, Progyny Member
Listen to Chrissy and Lindsey share how they ensured they wouldn't miss the timing on the trigger shot.
I remember I set like 10 alarms. I set my alarm for every 15 minutes leading up and they told us that we could do it between 11 and 11:30pm... so, we did the shot right on time.
Words of Experience...
OHSS is an exaggerated response to excess hormones. This causes the ovaries to swell and become painful. It's important to speak with your doctor if you think you might be experiencing OHSS.
Leuprolide acetate or “Lupron” may be used alongside or instead of hCG to trigger the final maturation of the eggs and the follicle. Side effects of hCG include bloating, nausea, abdominal pain, and bruising or pain at the injection site.
Intramuscular means "into the muscle", and these injections utilize longer needles and are typically injected into the buttocks.
Subcutaneous means "under the skin," and these injections utilize longer needles and are typically injected into the abdomen or thigh.
– Catherine, Progyny Member
Listen to Catherine share how her body reacted to her fertility medications.
I feel like I took to it really well. I don't think I had any terrible emotional reactions.
Medication for IVF
There are many medications involved in fertility treatment. Let's review the different types and their purposes.
Intramuscular means "into the muscle," and these injections typically lead to faster absorption of the body. Common sites for intramuscular injections include the deltoid muscle of the upper arm and the gluteal muscle of the buttock.
After ten-twelve days it is time to trigger ovulation in advance of the egg retrieval.
It is recommended to arrive an hour early to the egg retrieval to allow plenty of time to complete any necessary paperwork or discuss anything with the clinic.
The Egg Retrieval Process
In some instances fresh sperm will need to be produced the day of the egg retrieval, but the choice to use fresh or frozen sperm may be more about convenience than effectiveness.
Fresh vs Frozen Sperm
The Importance of Timing
All of the injections and early morning monitoring visits have been building to one of the most anticipated events of any IVF cycle - the egg retrieval.
Arrive one hour early Prepare for traffic Have a ride home
The egg retrieval process is minimally invasive so the recovery period is typically very quick. Patients may feel some soreness equivalent to cramping, and drowsiness from the anesthesia, but most patients can return to work the following day. It is recommended that patients refrain from returning to work the day of the retrieval just in case they are still experiencing some drowsiness.
Frozen sperm has been used effectively for years, and in 2004 a Mayo Clinic study showed definitively that couples using in vitro fertilization have the same likelihood of successful pregnancy whether the sperm used is frozen or fresh. The benefits of a frozen sample is that the male won’t need to produce a sample on the day of the retrieval.
Dr. Spencer Richlin (RMA of CT) provides an overview of the egg retrieval.
The timing of the egg retrieval is tied to the timing of the trigger shot. Patients must arrive on time, as if the egg retrieval starts late, the cycle could be canceled. It's also important to bring a partner, friend, or loved one to the retrieval as patients cannot drive home or take a cab after being under anestetic.
A fresh semen sample can be provided the day of the egg retrieval, or a frozen semen sample can be thawed as needed. If donor sperm will be used, the lab will have the vial ready for thawing and processing.
Lab and Fertilization
The number of eggs retrieved will vary patient to patient, and the next steps in the process will depend on the results of the egg retrieval.
The results of an egg retrieval can be as low as zero mature eggs retrieved to as high as over 20 mature eggs retrieved, but each patient should have a rough sense of what to expect based on the results of their most recent morning monitoring visits.
Understanding the Egg Retrieval Results
Fresh vs Frozen Sperm: A 2004 Mayo clinic study revealed that frozen sperm retains the same success rates no matter how long it's been frozen - even after 20 years!
Is 15 the Best Number for Egg Retrieval?
Sometimes the results will include two kinds of eggs: mature eggs and immature eggs. Mature eggs will be ready for fertilization later that day and will be prepared and paired with sperm. Immature eggs can continue to mature after retrieval, which is called in vitro maturation.
Immature eggs aren’t a lost cause as eggs continue to mature naturally after retrieval, which is called in vitro maturation.
So, why does this happen? We know that age can affect the health of an egg and the likelihood for a subsequent embryo to develop normally. In general, the age of a women has an impact on the number of eggs and embryos that would be expected to survive the process. There are many factors that come into play and it is important to discuss the results of the egg retrieval with your doctor.
Dr. Gerard Letterie (Seattle Reproductive Medicine) talks about egg retrieval results, and how many a person needs to be comfortable with the results.
After the retrieval is complete, patients are transitioned to a recovery area until they are cleared to leave with a partner or friend who can drive home. At some clinics, the early results of the retrieval are provided onsite, while at others, the results will come via telephone later that day.
Hear Kelly share how she coped with feelings of grief and sadness through her jounrney.
I hope that you have people in your life that are comfortable with feelings of grief and sadness, so they can sit with you in your feelings and not try to fix things.
Fertilization can be as simple as joining sperm and an egg in a dish, or as precise as placing a single sperm inside a single egg.
Insemination vs ICSI
The joining of egg and sperm may seem straightforward enough, but there are some choices to make when it comes to fertilization.
Fertilization: The Basics
The IVF Laboratory
After the egg retrieval, a new phase in the IVF cycle begins, one that will introduce a new member to the care team: the embryologist.
Fertilization and Embryo Development
The Embryologist
Embriologists are responsible for the safe handling of tissue (sperm, eggs, embryos), preparing both sperm and eggs, fertilizing eggs by joining them with sperm, and providing the best environment for the embryos to develop. Embryologists also perform the embryo biopsy needed in order to test the embryo’s chromosome’s for viability - a test called preimplantation genetic testing for aneuploidy (PGT-A), which can greatly improve success rates. PGT-A will be discussed in detail in Chapter 7: Embryo Selection and Genetic Testing.
In the body eggs and sperm most often meet in the fallopian tubes, but with IVF everything happens in the lab. In general, there are two ways an embryologist can fertilize an egg.
Dr. Sharon Jaffe (CRM), breaks down natural insemination and intracytoplasmic sperm injection (ICSI)
At this point in the cycle, patient and physician will have considerably more information than before the egg retrieval. There will now be a clear indication of how the patient's body reacted to the treatment protocol, and how many eggs will be sent to the IVF lab. The patient has done most of the work up to this point, but this is where the IVF lab steps in.
Fertilization is the joining of mature eggs with sperm. A number of eggs will fertilize into zygotes (a bundle of eight to ten cells) on day three, and an even smaller number will mature to day five or six, at which stage they are called blastocysts. Those blastocysts will be evaluated both at day three and day five or six to see if they are developing at the expected rate, and a determination will be made about how many viable (meaning, potentially leading to a live birth) embryos are available for testing, storage and transfer.
Embryo Selection & PGT-A
For patients who’ve experienced failed IVF cycles, and others with unique diagnosis, assisted hatching may help with implantation.
In order for an embryo to implant in the uterus, it has to hatch through its outer layer, a layer called the zona pellucida. Some embryos may have a harder zona pellucida than normal or may lack the ability to complete the hatching process due to a lack of energy. In these cases, the embryologist can help the embryos along through a technique called assisted hatching.
Assisted Hatching
Conventional Insemination
Conventional insemination is the process whereby sperm are placed into a dish with an egg. This closely resembles the natural process that would occur inside the body, and - prior to ICSI - this was the standard fertilization option.
Intracytoplasmic Sperm Injection (ICSI)
ICSI was originally created to fertilize eggs where the sperm may have had difficulty entering the egg alone, usually due to poor sperm motility or if a low number of sperm available. ICSI is the technique in which an individual sperm cell is introduced into an egg cell manually using a tiny needle. The embryologist selects the best-looking sperm from the sample, and injects it inside the egg. One of the advantages of ICSI is that the embryologist can ensure that a sperm did enter each egg. In cases of male factor infertility (the sperm count, motility, or morphology is low), the sperm may not to be able to enter the egg without assistance, and ICSI can be required to acheive fertilization. If genetic testing is planned, many embryology laboratories prefer ICSI to improve the accuracy of the genetic testing results.
Beyond male factor concerns ICSI has been utilized for many patients as physicians work to improve their patient's success rates.
For Progyny members, ICSI is included in the Smart Cycle coverage.
Zona Pellucida: The thick transparent membrane surrounding the ovum before implantation.
On the third or fifth day of growth in the laboratory, and before the transfer, a small hole is made in the zona pellucida of the embryo with a special laser microscope. This opening allows the cells of the embryo to escape from the shell and implant at a somewhat earlier time of development, when the uterine lining may be more favorable. Assisted Hatching might be recommended for women over 38 with mild elevations in their day three FSH, those having repeated ART failures, and those with embryos that have abnormal appearing zona. For Progyny members, Assisted Hatching is included in the Smart Cycle Coverage.
– Philip, Progyny Member
Philip found it important to reach out to the right friends and family for support, listen to his experience here.
Having people around you that you feel comfortable with who are not going to give you the standard responses to a loss. You want someone just to be there, and listen to you.
Twins can cause serious health risks to the mom and babies.
The Risks of Multiples
A main goal of controlled ovarian stimulation is to retrieve a high number of eggs that will hopefully yield a high number of embryos. It's good to have more than one ebryo available since not all embryos will lead to a live birth.
Embryo Selection
You have embryos, and then all you're doing is trying to attach, essentially, more knowledge around it... is it normal, or is it abnormal?
Day 3 vs Day 5/6
Just like not all eggs will fertilize, not all fertilized eggs with successfully develop to a viable embryo.
Embryo Selection and Genetic Testing
Blastocyst
A blastocyst is an embryo which has been left to develop until day five or six after fertilization and presents a complex cellular structure formed by approximately two hundred cells. The more day five or six blastocyst the better because those embryos can be genetically tested and stand the best chance for a successful transfer. In the past, fertility doctors would routinely transfer embryos at day three, when each embryo is a bundle of about eight to twelve cells in total. Now the consensus is an embryo that is healthy enough to survive day five or six is more likely to result in a live birth, so waiting until day five or six to transfer or freeze the embryos has become standard.
The most common complications for intended mothers include elevated risk of preeclampsia, gestational diabetes, miscarriage of one or more of the babies. Babies can experience a much higher risk of prematurity, low birthweight, potentially experience development issues later in life, and will likely spend time in the neonatal intensive care unit (NICU). Fortunately there is a way to identify if an embryo is healthy, and then transfer only one embryo at a time - preimplantation genetic testing for aneuploidy, or PGT-A.
The embryo grading will tell you how well an embryo has developed compared to the expected average, but it isn’t an accurate indication of chromosomal abnormality.
After fertilization, the embryologist is hard at work making sure that the embryos have the ideal micro-environment to develop. Embryos are stored in incubators, which are designed to mimic the environment in the uterus by providing a constant body temperature and a specific mixture of carbon dioxide, oxygen, and nitrogen. Of the eggs that fertilize, some will develop into what is called a blastocyst.
Let's breakdown chromosomes and how this impacts additional decisions in the treatment process.
Listen to Angela share why she made the decision to test her embryos with PGT-A.
Embryo Transfer
Preimplantation genetic testing for aneuploidy, often called PGT-A, and formerly called PGS and CCS, is a game changing technology that has helped increase IVF success rates.
Preimplantation Genetic Testing for Aneuploidy (PGT-A)
PGT-A with an elective single embryo transfer can lead to greater success.
Genetic Testing and Success Rates
If an embryo carries both the maternal and paternal variant or mutation, the baby will carry the disease, so this test can identify embryos destined to carry the disease so that they can be ruled out for transfer.
Some patients may be healthy but carry a rearrangement of DNA called a translocation. These patients can produce some healthy eggs or sperm, but in many cases, will produce gametes that yield embryos with an abnormal chromosomal content. These embryos are likely to not implant or to miscarry. If the patient is at risk of passing on a translocation, their doctor may recommend PGT-SR (structural rearrangement).
Additional Preimplantation Genetic Testing
Modern fertility clinics, largely due to the emergence of genetic testing of embryos, and the risks associated with multiples, have phased out the practice of transferring multiple embryos in favor of elective single embryo transfer.
Catherine shares why PGT-A was so important to her IVF experience
I was in my mid-30s, maybe it was something wrong with the eggs - that it was genetic. And the best way to figure that out would be to do another cycle and test the embryos.
PGT-A removes the guesswork from embryo selection, and allows the doctor to transfer a single embryo with a greater likelihood of success.
It’s important to understand that PGT-A can improve success rates, but it doesn’t do so by changing, or “correcting” aneuploid embryos. PGT-A can increase success rates by ruling out embryos that won’t lead to a live birth, in favor of embryos with a high likelihood to result in a live birth.
Transferring a PGT-A tested euploid embryo can significantly increase success rates per transfer, and because it allows the physician to perform a single embryo transfer, reduces the likelihood of multiple gestations drastically. For older patients, transferring a PGT-A tested euploid embryo brings success rates as high as they would be for a non-tested embryo at a much younger age, making it a great tool for women of advanced maternal age to safely increase their success per transfer.
Increased Implantation Rates When transferring PGT-A tested aneuploid embryos, the implantation rate far exceeds the implantation rate for untested embryos. Reduced Rates of Pregnancy Loss PGT-A with single embryo transfer doesn’t only increase success rates and reduce rates of multiples, but it also helps to reduce instances of miscarriage. Miscarriage is perhaps more common that most people realize. Accoridng to some studies, up to 1 in 4 pregnancies result in a miscarriage. The overwhelming majority of miscarriages are due to chromosomal abnormality of the embryo. By removing aneuploid embryos from the equation the rates of miscarriage plummet well below the national average. Significantly reducing the likelihood of miscarriage is important for anyone, but it’s especially crucial for those who have experienced recurrent pregnancy loss. Reduced Time to Pregnancy PGT-A allows patients to select a healthy embryo for their first transfer, giving each transfer the best possible chance of success, and therefore reducing the number of transfers needed, and the time associated with multiple transfers. Reduced Pre-term Labor Due to complications associated with multiple gestation pregnancy the chances of experiencing a pre-term birth are increased dramatically when multiple embryos are transferred. Transferring one euploid embryo will decrease the chances of experiencing a pre-term labor.
Dr. Candice Perfetto (Center for Reproductive Medicine) lays out the risks of multiples, and why single embryo transfer is a safer option.
In order to test embryos using PGT-A, an embryo needs to be biopsied, meaning a few cells from the part of the embryo that will become the placenta are removed for testing. Keep in mind that the cells that will become the actual baby are not involved in this process and remain intact within the embryo. The embryos are then frozen (vitrified) so that the physician can await test results before making a decision on which embryo to transfer. The biopsied cells are shipped to a laboratory where the chromosomes of each cell can be categorized and counted. The results of this test usually come back in about a week, and the physician will inform how many euploid embryos are available.
Dr. Lora Shahine (Pacific NW Fertility) breaks down embryos selection utilizing preimplantation genetic testing for aneuploidy (PGT-A).
A healthy embryo contains 46 chromosomes, 23 of which are contributed by the sperm, and 23 by the egg. When an embryo has 46 chromosomes it’s called a euploid embryo, which means that it has the correct number of chromosomes needed to develop into a healthy baby. Euploid embryos are not guaranteed to implant and result in a live birth, but they have the potential to. The success rates in IVF when transferring a euploid embryo can be as high as 70%, depending on the circumstances. Unfortunately, not all embryos have 46 chromosomes. Sometimes embryos develop with an extra chromosome, or one too few chromosomes, or even a mixture of extra and missing chromosomes all within the same cells. In these instances, the embryo is called an aneuploid embryo, often referred to as an abnormal embryo. Anyone, at any age, can produce aneuploid embryos, and there are many factors that can affect an embryo’s chromosome count. One of the main factors is the age of the female at the time the eggs were retrieved. Every person is different, but in general the younger the eggs are that are being fertilized, the lower the rate of aneuploidy of the embryos, and the older the eggs, the higher the rate of aneuploidy. Aneuplod embryos lead to poor outcomes: • Fail to develop to a day 5/6 blastocyst, or... • Fail to implant in the uterus, or... • Will implant but then miscarry, or... • In some rare instances will result in a live birth with a serious genetic disorder like Down Syndrome and Edward Syndrome. In short, euploid embryos potentially can lead to a healthy live baby, and aneuploid embryos can’t. Unfortunately, it’s impossible for an embryologist to detect which embryos are euploid and which are aneuploid just by looking at them. In fact, two embryos on day 6 after fertilization could have developed to have the exact same grading but one of them could be aneuploid and the other euploid.
In the past, because it was impossible to know which embryos were aneuploid and which were euploid, doctors would frequently transfer two or more embryos at a time to increase the likelihood of transferring a euploid embryo. Physicians would use this technique especially in older patients, because it was more likely that the embryos were aneuploid. But, as you might expect, transferring multiple embryos dramatically increases the likelihood of a multiple gestation (twins, triplets, more).
Dr. Ravi Gada (Dallas-Fort Worth Fertility Associates) explains how PGT-A can increase IVF transfer success.
As recommended by the American College of ObGyn and ASRM, couples should be counseled regarding carrier status.
Current expanded carrier screening panels test for hundreds of recessive disorders. If partners test positive for a variant in the same gene, they will be offered the opportunity to speak to a genetic counselor about their options, which includes a test that can only be performed as part of an IVF cycle called preimplantation genetic testing for monogenic disorders (PGT-M).
Dr. Carter Owen (CCRM North Virginia) explains preimplantation genetic testing for monogenic diseases and who might be a candidate.
A healthy embryo contains 46 chromosomes, 23 of which are contributed by the sperm, and 23 by the egg. When an embryo has 46 chromosomes it’s called a euploid embryo, which means that it has the correct number of chromosomes needed to develop into a healthy baby. Euploid embryos are not guaranteed to implant and result in a live birth, but they have the potential to. The success rates in IVF when transferring a euploid embryo can be as high as 70%, depending on the circumstances. Unfortunately, not all embryos have 46 chromosomes. Sometimes embryos develop with an extra chromosome, or one too few chromosomes, or even a mixture of extra and missing chromosomes all within the same cells. In these instances, the embryo is called an aneuploid embryo, often referred to as an abnormal embryo. Aneuplod embryos lead to poor outcomes: • Fail to develop to a day 5/6 blastocyst, or... • Fail to implant in the uterus, or... • Will implant but then miscarry, or... • In some rare instances will result in a live birth with a serious genetic disorder like Down Syndrome and Edward Syndrome. In short, euploid embryos potentially can lead to a healthy live baby, and aneuploid embryos can’t. Unfortunately, it’s impossible for an embryologist to detect which embryos are euploid and which are aneuploid just by looking at them. In fact, two embryos on day 6 after fertilization could have developed to have the exact same grading but one of them could be aneuploid and the other euploid.
The embryo transfer is a very quick procedure that is often compared to a pap smear.
The Embryo Transfer Procedure
This is nuts, this is crazy, she is carrying my embryo in a syringe across the room right now! How this ever happens naturally is just a miracle to me.
Transfer Strategies
If there are healthy embryos available, it's time to move forward with an embryo transfer.
A fresh embryo transfer means transferring an embryo that was recently developed, and a frozen embryo transfer means transferring an embryo that had been frozen previously. A fresh embryo transfer will happen approximately 5–6 days after the egg retrieval, where one embryo is transferred, and the remaining are frozen for potential future transfer. Alternatively, patients can choose to freeze the entire cohort approximately 5–6 days after the egg retrieval to preserve them for a transfer planned at a later date. There are several reasons why doctors might suggest a frozen embryo transfer.
Waiting for results of preimplantation genetic testing
The test results from PGT-A can take some time, so it's common practice for the embryos to be frozen pending these results.
Natural and Supplemented Natural Cycle
A natural cycle is a frozen embryo transfer timed with a woman's natural ovulation cycle. The natural ovulation cycle prepares the body for potential embryo implantation, so a natural cycle could result in appropriate conditions in the uterus for implantation. A natural cycle can also be supplemented with an hCG trigger shot which can ensure that ovulation occurs. A supplemented cycle will also likely utilize progesterone for luteal phase support after the transfer.
In order to help thicken the endometrium the doctor may recommend an artificial (or synthetic) cycle. This usually includes taking estrogen and progesterone to mimic the body’s cycle and increase endometrial receptivity. Some artificial cycles include gonadotropin-releasing hormone (GnRH) as well.
Dr. Julie Lamb (Pacific NW Fertility) discusses transfer preparation strategies.
The embryo transfer is a procedure whereby the embryo is placed into the uterus for implantation. There are a few things to consider in order to adequately prepare for the transfer.
Once a patient arrives at the clinic they will change into a hospital gown and enter a surgical room. Like the egg retrieval, patients will go through a series of verifications to ensure that the correct embryo is being transferred. Depending on the clinic, and the personal preferences of the patient, the doctor may prescribe valium for the transfer procedure.
Natural vs Artificial Cycle
Artificial Cycle
Fresh vs Frozen Transfer
Listen to Philip his experience the day of his wife's embryo transfer.
Implantation, and Results
Mock Transfer & Mock Cycle
In a mock transfer the doctor is making sure they can access the uterus, that they have the correct catheter, and that there’s not going to be any issue when the embryo is loaded and ready for transfer. These days it's a bit rare for a doctor to perform a mock transfer. A mock cycle is another rare procedure that includes undergoing all of the blood work, ultrasounds, and medication (usually estrogen and progesterone) that are part of a typical transfer cycle. Then, at the time that a transfer would have occurred, the physician instead takes a biopsy of the endometrial lining, which is analyzed to see if it would have been the correct timing to transfer an embryo.
Prior to the implementation of modern technology like PGT-A it was a common practice to transfer two embryos, but that is no longer considered best practice. The modern standard of care is to transfer a single embryo.
How Many Embryos to Transfer
The stimulation process is an effective way to maximize follicle count, and ultimately the number of eggs available at retrieval, but it does put stress on the body, and can create a less-than-optimal environment to receive an embryo. For this reason, many physicians prefer a frozen cycle so that the body can return to normal, and the uterine lining can be adequately prepared for implantation.
Allowing the body to rest from the egg retrieval process
Similarly, some doctors will recommend a frozen transfer for women who are susceptible to OHSS. OHSS is Ovarian Hyper Stimulation Syndrome, and it can develop as a result of a patient’s reaction to IVF medications. For women with PCOS, or women who are high responders to the stimulation medications, it may be recommended, and in some cases required, to let the body return to baseline before the transfer.
Reducing the risks of OHSS
Many patients need to travel for treatment, and that can make a fresh transfer difficult. Others need to time the transfer for after a trip, event, or work obligation. A frozen transfer strategy allows patients to make these important decisions.
Logistics & Schedule
The decision to transfer one embryo, which is called an elective single embryo transfer, or eSET, is a decision about reducing harmful risks. When multiple embryos are transferred the rate of twins or triplets increases dramatically.
The risks associated with twins and triplets are significant, as laid out in a previous chapter. When combined with PGT-A it’s possible to identify a single healthy embryo for transfer, which increases success rate per transfer regardless of age, while significantly reducing the chances of multiples.
The embryo is brought into the operating room by the embryologist and the doctor will prepare the patient for the ultrasound guided transfer. In some cases patients may be able to watch the process on a screen.
A speculum is placed in the vagina to visualize the cervix. Then, using a catheter inserted through the cervix and into the uterus, the embryo is placed into the endometrial cavity.
Patients usually don't experience any pain following the procedure, but may feel some discomfort or cramping. The embryo cannot fall out, so there is no cause for concerns about moving freely as normal.
Dr. Lorna Marshall (Pacific NW Fertility) explains what a mock transfer and a mock cycle are, and when they might be utilized.
– Cass, Progyny Member
Cass shares why single embryo transfer was the safest option for her.
I have advanced maternal age... the idea of having twins pretty much ensured that I would have some complications as I'm considered high risk.
Dr. Peter Klatsky (Spring Fertility) talks about the advantages of frozen embryo transfer.
Dr. Peter Klatsky (Spring Fertility) discusses the advantages to a frozen embryo transfer.
Dr. Kristi Maas (RCC) talks about the signifant risks that are associated with a multiple pregnancy.
Dr. Kristi Maas (RCC) talks about the health risks associated with multiple pregnancy.
After weeks of stimulation medications, morning monitoring, an egg retrieval, and an embryo transfer it’s finally time for the results.
hCG Test, Monitoring, and Results
While it’s sometimes referred to as “The Two Week Wait” the period between the embryo transfer and the blood pregnancy test is usually approximately eight to ten days.
The Waiting Period
This cycle was different than the previous ones. The doctor monitored my hormone levels almost every day... I felt like it was much more tailored to how my body responded to medication.
Implantation and Results
Embryos implant in the endometrium, the mucous membrane lining the uterus, which thickens during the menstrual cycle in preparation for possible implantation of the embryo. When implantation occurs, the early placental cells produce human chorionic gonadotropin (hCG). Within a week, hCG can be detected through a blood test. Doctors typically don’t recommend patients do a home pregnancy test after fertility treatment since these tests only detect hCG presence, not the exact levels of the hormone. In addition, for those who’ve utilized a fresh transfer it’s still possible that there is hCG in the system from the trigger shot which could result in a false positive test. The levels of hCG are important because they will increase rapidly in a positive pregnancy. The hCG blood test is usually conducted about eight to ten days after the transfer. If the first blood test returns positive, it will be repeated the following days to confirm the pregnancy is progressing.
After the wait it’s finally time for the Beta hCG blood test. This blood test will measure hCG levels. hCG is humanchorionic gonadotropin or “the pregnancy hormone.”
Cass talks about how her treatment protocol was adjusted for subsequent IVF cycles.
Back to Index
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In the next 48 hours, there is a second blood test to ensure hCG levels are roughly doubling, indicating the pregnancy is progressing normally. Patients return to the fertility clinic for monitoring for the next 6-8 weeks before "graduating" to their OBGYN for care throughout the remainder of the pregnancy.
Patients will also likely be put on a few different medications to help make sure the body has everything it needs to support the pregnancy. Typically, these include estrogen and progesterone, hormones that support healthy fetal growth and prevent early pregnancy loss.
An important thing to understand is that IVF pregnancies are comparable to natural pregnancies; they are not considered high risk pregnancies. That being said, around twenty weeks, the American Institute of Ultrasound in Medicine suggests pregnancies be monitored with a special ultrasound as a preventative measure to evaluate for the presence of cardiac side effects. Other than that, medically speaking, patients should experience pregnancy as if they conceived naturally.
If there are any viable embryos remaining in storage they can be kept for future family building, donated to either science or to another person or couple in need, or they can be terminated.
Of course, sometimes the result is negative. After a negative result from an IVF treatment, some patients feel that they need to take a break to physically and emotionally recover after a stressful time, while others feel that they want to do another transfer, or perhaps start another cycle, as quickly as possible. This is a personal choice that should be made with guidance of your physician. But it's important to remember that you do still have options available to you. For Progyny members, your Progyny PCA is still available to you for support throughout every step of your journey.
Lindsey shares how she spent her time during the waiting period after the embryo transfer.
I sort of wish that I walked a little bit more, to clear my mind. Get out a little bit more. I was just so worried.
Index
Two-Week Wait Coping Methods
Two-Week Wait Partner Checklist