In Vitro Fertilization (IVF): What to Expect

Where to Start With the IVF Process

Starting the in vitro fertilization (IVF) process can be an exciting and nerve-wracking experience. Most people pursue IVF only after other fertility treatments have failed. You may have been trying to conceive for months. or, more likely, for years. But this is not always the case. Sometimes, doctors recommend starting with IVF treatment. 

For example, IVF may be the first option if a person's fallopian tubes are blocked or if you will be using a gestational carrier and/or an egg donor. IVF also may be used in severe cases of male infertility or when previously cryopreserved eggs are being used. Still, even in these cases, IVF may come after trying to get pregnant and several fertility tests.

The more you understand about what's coming next, the more in control you'll feel. While every clinic's protocol, and every person's treatment needs, will be slightly different, this step-by-step breakdown takes you through the IVF process and helps you learn where to start with IVF.

IVF step by step
 Illustration by Emily Roberts, Verywell

IVF Process Basics

In vitro means “in the lab” and fertilization refers to conception. Usually, IVF involves taking eggs (retrieved via a transvaginal ultrasound-guided needle) and placing them in a petri dish with specially washed sperm cells (retrieved via masturbation). The entire cycle from start to finish can take four to six weeks.

These eggs are retrieved after the ovaries have been stimulated. For conventional IVF, you need lots of eggs. Injectable fertility drugs stimulate the ovaries to mature a dozen or more eggs for retrieval. There also is minimal stimulation IVF (aka mini IVF), where oral fertility drugs or very low dose injectable drugs help mature just a few eggs.

If all goes well, some of the retrieved eggs will be fertilized by the sperm cells and become embryos. One or two of those healthy embryos will be transferred to your uterus.  

IVF Success Rates

IVF is pretty successful. According to a study of approximately 156,000 women, the average live-birth rate for the first cycle was 29.5%. This is comparable to  the success rates for a natural cycle in couples with healthy fertility.

The best odds for success may come from repeated treatment cycles. This same study found that after six IVF cycles, the cumulative live-birth rate was 65.3%. These six cycles usually took place over 2 years.

Age does play an important role in your success, as does the reason for your infertility. Using an egg donor will also affect your success.

Be sure to discuss your personal odds for success with your healthcare provider before starting treatment.

While your provider can’t tell you for certain whether treatment will work for you, they should have an idea of your odds in relation to the average and in relation to other patients like yourself.

IVF Costs

IVF is expensive. It’s also frequently not covered by insurance, putting the treatment out of reach for many people who need it. Studies have found that only one in four couples who need IVF to conceive can actually get the treatment they need.

The average cost of IVF often quoted is between $12,000 and 15,000 per cycle. Some say this estimate is really below the reality, and the out-of-pocket average costs are higher.

One study found that the average couple paid $19,234 for their initial IVF cycle, with an additional $6,955 for each additional cycle. Why such a difference between the first and subsequent? Partially because some of those second and third cycles are frozen embryo transfers.

This is all for conventional, no-frills IVF. If you need any additional technologies—like ICSI, PGT, assisted hatching, an egg donor, or a gestational carrier—costs will be higher (sometimes much higher).

There are ways to pay less or get financial assistance for IVF treatment. Look into all your options before making a decision on whether or not you can afford treatment.

Safety and Risks of IVF

IVF is generally safe, but as with any medical procedure, there are risks. Your provider should explain all the possible side effects and risks of each procedure before you begin.

Ovarian Hyperstimulation Syndrome

For instance, ovarian hyperstimulation syndrome (OHSS) occurs in 10% of people whose ovaries are stimulated for IVF treatment. For most people, symptoms are mild, and they recover easily. For a small percentage, OHSS can be more serious and may require hospitalization. Less than 1% of people going through egg retrieval will experience blood clots or kidney failure due to OHSS.

Cramping, Discomfort, or Infection

Egg retrieval may cause cramping and discomfort during or after the procedure. Rare complications include accidental puncture of the bladder, bowel, or blood vessels; pelvic infection; or bleeding from the ovary or pelvic vessels.

If pelvic infection does occur, you'll be treated with intravenous antibiotics. In rare cases of severe infection, the uterus, ovaries or fallopian tubes may need to be surgically removed.

The embryo transfer also may cause mild cramping during the procedure. Rarely, people will experience cramping, bleeding, or spotting after the transfer. In very rare cases, infection can occur. Infection is typically treated with antibiotics.

Multiples

There is a risk of multiples, which includes twins, triplets, or more. Multiple pregnancies can be risky for both the babies and the parent. It's important to discuss with your healthcare provider how many embryos to transfer, as transferring more than necessary will increase your risk of conceiving twins or more. When embryos have been tested with PGT, typically only a single embryo is transferred.

Birth Defects

Some research has found that IVF may raise the risk of some very rare birth defects, but the risk is still relatively low. Research has also found that the use of ICSI with IVF, in certain cases of male infertility, may increase the risk of infertility and some sexual birth defects for male children. This risk, however, is very low (less than 1%).

IVF Step 1: Before Treatment

The cycle before your IVF treatment is scheduled, you may be put on birth control pills. This may seem backward, but using birth control pills before a treatment cycle may improve your odds of success. Also, it may decrease the risk of ovarian hyperstimulation syndrome and ovarian cysts.

Not every healthcare provider uses birth control pills the cycle before. Another possibility is that your provider will ask you to track ovulation the cycle before. Most likely, they will recommend using an ovulation predictor kit. However, they may also suggest basal body temperature charting, especially if you have experience charting your cycles.

Then, you will need to let your healthcare provider know as soon as you detect ovulation. Sometime after ovulation, the fertility clinic may then have you start taking a GnRH antagonist (like Ganirelix) or a GnRH agonist (like Lupron). These are injectable drugs, but some are available as a nasal spray or implant.

These medications allow your provider to have complete control over ovulation once your treatment cycle begins. If you don't get your cycles on your own, your provider may take yet another approach. In this case, they may prescribe progesterone in the form of Provera. This would bring on your period.

In this case, your healthcare provider will probably ask that you start taking the GnRH agonist or antagonist about 6 days or more after your first Provera pill. Again, though, this may vary. Always follow your provider's instructions.

IVF Step 2: Treatment Cycle Begins

The first official day of your treatment cycle is the day you get your period. On the second day of your period, your healthcare provider will likely order bloodwork and a transvaginal ultrasound.

These first-day tests are referred to as your baseline bloodwork and your baseline ultrasound. In your bloodwork, your healthcare provider will be looking at your estrogen levels, specifically your E2 or estradiol. This is to make sure your ovaries are “sleeping." That's the intended effect of the Lupron shots or GnRH antagonist.

The ultrasound is to check the size of your ovaries. Your provider will also look for ovarian cysts. If there are cysts, they will decide how to deal with them. Sometimes your provider will just delay treatment for a week. Most cysts resolve on their own with time. In other cases, your provider may aspirate the cyst (suck out the fluid) with a needle.

Usually, these tests will be fine. If everything looks OK, treatment moves on.

IVF Step 3: Ovarian Stimulation and Monitoring

Ovarian stimulation with fertility drugs is the next step. Depending on your treatment protocol, this may mean anywhere from one to four shots every day for about a week to 10 days. Your clinic should teach you how to give yourself the injections before treatment begins.

During ovarian stimulation, your doctor will monitor the growth and development of the follicles. At first, this may include bloodwork and ultrasounds every few days. Your provider will be monitoring your estradiol levels. During the ultrasounds, they will monitor the oocyte growth. (Oocytes are the eggs in your ovaries.)

Monitoring the cycle is very important. This is how your provider will decide how to adjust your medications. You may need to increase or decrease dosages. Once your largest follicle is 16 to 18 mm in size, your clinic will probably want to see you daily.

IVF Step 4: Final Oocyte Maturation

The next step in your IVF treatment is triggering the oocytes to go through the last stage of maturation. The eggs must complete their growth and development before they can be retrieved.

This last growth is triggered with human chorionic gonadotropin (hCG). Brand names for this include Ovidrel, Novarel, and Pregnyl. Timing this shot is vital. If it's given too early, the eggs will not have matured enough. If given too late, the eggs may be “too old” and won't fertilize properly.

Daily ultrasounds help time this trigger shot just right. Usually, the hCG injection is given when four or more follicles have grown to be 18 to 20 mm in size and estradiol levels are greater than 2,000 pg/ML.

This shot is typically a one-time injection. Your healthcare provider will likely give you an exact hour to do this shot. Be sure to follow these instructions!

IVM vs. IVF

During conventional IVF, eggs must complete their development and growth before being retrieved. IVM treatment is slightly different. IVM stands for in vitro maturation. It is similar to IVF but significantly differs at this point in the process.

During IVM, the eggs are retrieved before they go through all stages of maturity. You will not have a "trigger shot" during IVM. The eggs retrieved will be matured in the lab environment. Once the eggs are matured, the rest of the steps follow the IVF process.

If the Follicles Don't Grow

We've assumed to this point that the ovarian stimulation drugs have worked properly. But that isn't always how it goes. Sometimes the follicles don't grow. If this happens, your healthcare provider may increase the medications, but if your ovaries still don't respond, the cycle will likely be canceled.

This doesn't mean another cycle won't work. You may just need different medications. However, if this occurs repeatedly, your provider may suggest using an egg or embryo donor. You may want to get a second opinion before moving forward at this point.

If You're at Risk for OHSS

Another possible problem is your ovaries respond too well. If your healthcare provider thinks you're at risk of developing severe ovarian hyperstimulation syndrome (OHSS), your trigger shot will be canceled and the cycle will be stopped at this point.

Another possibility is your provider will retrieve the eggs, fertilize them, but delay the embryo transfer. This is because pregnancy can worsen and extend recovery from OHSS. Once your body recovers, you can try a frozen embryo transfer.

During your next cycle, your provider may suggest lower doses of medications, try different medications before your cycle starts, or even suggest IVM instead of IVF.

If You Ovulate Prematurely

While not common, a cycle may also be canceled if ovulation occurs before retrieval can take place. Once the eggs ovulate on their own, they can't be retrieved. Your healthcare provider will likely tell you to refrain from sexual intercourse.

It's important you follow these instructions! It's possible you've ovulated up to a dozen eggs, maybe even more. There is danger to both you and the children if you got pregnant naturally with even half of those eggs.

Cancellation happens in 10% to 20% of IVF treatment cycles. The chance of cancellation rises with age. Those older than age 35 are more likely to experience treatment cancellation.

IVF Step 5: Egg Retrieval

About 34 to 36 hours after you receive the trigger shot, the egg retrieval will take place. It's normal to be nervous about the procedure, but most people go through it without much trouble or pain.

Before the retrieval, an anesthesiologist will give you some medication intravenously to help you feel relaxed and pain-free. Usually, a light sedative is used. This isn't the same as general anesthesia, which is used during surgery. Side effects and complications are less common.

Once the medications take effect, your doctor will use a transvaginal ultrasound to guide a needle through the back wall of your vagina, up to your ovaries. They will then use the needle to aspirate the follicle, or gently suck the fluid and oocyte from the follicle into the needle. There is one oocyte per follicle. These oocytes will be transferred to the embryology lab for fertilization.

The number of oocytes retrieved varies, but can usually be estimated before retrieval via ultrasound. The average number of oocytes is 8 to 15, with more than 95% of patients having at least one oocyte retrieved.

After the retrieval procedure, you'll stay in a recovery area for a few hours to make sure all is well. Light spotting is common, as well as lower abdominal cramping, but most people feel better in a day or so after the procedure. You'll also be told to watch for signs of ovarian hyperstimulation syndrome.

IVF Step 6: Egg Fertilization

While you're recovering from the retrieval, the follicles that were aspirated will be searched for oocytes, or eggs. Not every follicle will contain an oocyte.

Once the oocytes are found, they'll be evaluated by the embryologist. If the eggs are overly mature, fertilization may not be successful. If they are not mature enough, the embryology lab may be able to stimulate them to maturity in the lab.

Fertilization of the oocytes must happen within 12 to 24 hours. Your partner will likely provide a semen sample the same morning you have the retrieval. The stress of the day can make it difficult for some, and so just in case, your partner may provide a semen sample for backup earlier in the cycle, which can be frozen until the day of the retrieval.

Once the semen sample is ready, it will be put through a special washing process, which separates the sperm from the seminal fluid. The embryologist will choose the best-looking sperm, placing about 10,000 sperm in each culture dish with an oocyte. The culture dishes are kept in a special incubator, and after 12 to 24 hours, they are inspected for signs of fertilization.

With the exception of severe male infertility, 70% of the oocytes will become fertilized. In the case of severe male infertility, ICSI, or intracytoplasmic sperm injection, may be used to fertilize the eggs, instead of simply placing them in a culture dish. With ICSI, the embryologist will choose a healthy-looking sperm and inseminate the oocyte with the sperm using a needle.

IVF Step 7: Embryo Transfer

About three to five days after the retrieval, an embryologist will identify the healthiest looking embryos. This is typically done visually (with a microscope), but in some cases, genetic screening is performed. This is known as preimplantation genetic diagnosis (PGD) or preimplantation genetic screening (PGS).

Sometimes, with PGD/PGS, the embryos are cryopreserved and transfer is delayed until the next cycle. Otherwise, a "fresh" transfer takes place. The procedure for embryo transfer is just like intrauterine insemination (IUI) treatment. You won't need anesthesia.

During the embryo transfer, a thin tube, or catheter, will be passed through your cervix. You may experience very light cramping but nothing more than that. The doctor will transfer the embryos through the catheter, along with a small amount of fluid.

The number of embryos transferred will depend on the quality of the embryos and discussion with your healthcare provider. Depending on your age, anywhere from one to five embryos may be transferred.

After the transfer, you will remain lying down for a couple hours and then go home. If there are high-quality embryos left, you may be able to freeze them. This is called embryo cryopreservation. They can be used later if this cycle isn't successful in a frozen embryo transfer, or they can be donated.

Currently, many providers suggest transferring just one embryo and freezing the rest. This is known as elective single embryo transfer (eSET), and it can reduce your risk of a multiple pregnancy. When you get pregnant with just one healthy baby, you reduce your risks for pregnancy complications. Speak to your provider to find out if elective single embryo transfer is best for you.

IVF Step 8: The Two-Week Wait

On or after the day of your retrieval, and before the embryo transfer, you'll start giving yourself progesterone supplements. Usually, the progesterone during IVF treatment is given as a self-injection. Sometimes, though, a progesterone supplement is a pill, vaginal gel, or vaginal suppository.

Besides the progesterone, there really isn't much going on for the next two weeks. In some ways, the two weeks after the transfer may be more difficult emotionally than the two weeks of treatment. During the previous steps, you will have visited your provider perhaps every other day. Now, after transfer, there will be a sudden lull in activity.

All you can do is wait the two weeks and see if pregnancy takes place. It can help to keep busy with your life during this wait time and avoid sitting and thinking about whether or not treatment will be successful. 

IVF Step 9: Pregnancy Test and Follow-Up

About 9 to 12 days after the embryo transfer, a pregnancy test is ordered. This is usually a blood test and also will include a test to check the level of progesterone. The test may be repeated every few days.

If the test is positive, you may need to keep taking progesterone for another several weeks. Your provider will also follow up with occasional bloodwork and ultrasounds to monitor the pregnancy.

Possible IVF Pregnancy Risks

Your healthcare provider will also monitor whether or not the treatment led to a multiple pregnancy. IVF has a higher risk of conceiving multiples, and a multiple pregnancy carries risks for both the parent and the babies, including premature labor and delivery, maternal hemorrhage, C-section delivery, pregnancy induced high blood pressure, and gestational diabetes.

People who conceive with IVF are more likely to experience spotting in early pregnancy, though it's more likely for their spotting to resolve without harm to the pregnancy.

The risk of miscarriage is about the same for people who conceive naturally, with the risk going up with age. For those in their 20s, the rate of miscarriage is as low as 15%, while for people over 40, the rate of miscarriage may be over 50%.

There is a 2% to 4% risk of ectopic pregnancy with IVF conception. If you developed OHSS from the fertility drugs, and you get pregnant, recovery may take longer. 

When IVF Treatment Fails

If the pregnancy test is still negative 12 to 14 days post-transfer, your healthcare provider will ask you to stop taking the progesterone. Then, you'll wait for your period to start.

It will be up to you, your partner, and your provider to determine next steps. If this was your first cycle, another cycle may be recommended. Remember that your best chances for success are after doing several cycles.

Having a treatment cycle fail is never easy. It's heartbreaking. It's important, however, to keep in mind that having one cycle fail doesn't mean you won't be successful if you try again. There are many steps you can take after a treatment cycle fail.

Frequently Asked Questions

  • What causes failed IVF?

    Even though IVF has relatively high success rates, there are times that it fails. Sometimes IVF fails due to chromosomal abnormalities. Age also can play a factor in the success rate of IVF. Other times, a failure just can't be explained.

  • What should you do before starting IVF?

    If you are considering IVF, there are lifestyle changes you can make that will improve your chances of success. These include eating a balanced diet, exercising on a consistent basis, getting plenty of water, and practicing good sleep hygiene.

    You also want to be sure you are reducing your stress levels and taking care of yourself. Going through IVF can be a challenging experience and you want to ensure you are in the best shape you can be.

  • What should you avoid with IVF?

    When it comes to IVF, it is important to make the lifestyle changes that your healthcare provider recommends. For instance, many providers recommend avoiding alcohol, caffeine, and smoking. They also may suggest certain dietary changes like limiting red meat, dairy products, refined sugars, and processed foods. Before you make any drastic changes to eating patterns, you should discuss your goals with your provider. They can let you know what is the best meal plan for you.

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