The IVF Process: One Step at a Time
It's Medical Monday, and as promised, one of our fertility nurses has written her version of step by step instructions on an IVF (in vitro fertilization) cycle. I say her version, because Kirsten's sense of humor and the emphasis that she places on certain words and phrases is all her own. Another nurse or doctor may have explained the process in a slightly different way, with each style having it's own merit. Kirsten's voice comes through on this wonderful piece and makes for lively and yes, almost fun, reading. After seven years here at RMACT, I undestand the IVF process better than I have before. Enjoy~ Lisa Rosenthal
Understanding an IVF Cycle
At Reproductive Medicine Associates of Connecticut (RMACT) we recognize how stressful it is for you, our patient, to undergo an IVF cycle. Unfortunately we can’t take the stress away completely. We can help you tackle this task with a clear head, a sound plan, and the comfort of knowing that you have a supportive team rooting for you every step of the way (that’s us!).
In this post I’m going to do my best to give you an overview of what to expect in a typical IVF cycle … think of it as a “zoomed out” picture. (Rest assured, your doctor, nurse, and navigator will help you “zoom in” on your specifics once you get started.)
Our first step is to gather information about you. We want to know how strong and well-functioning your ovaries and reproductive organs are and confirm that you are healthy and fit for pregnancy. We do this with a series of blood tests and ultrasounds. Depending on where you are in your menstrual cycle, it can take 4-6 weeks to complete this step.
Sometimes even this first step can get confusing - but don’t worry! While you are with us, you will be assigned a patient navigator who will assist you every step of the way. She will be your “go to” person. She will help you schedule appointments, and direct your questions when you don’t know who to direct them to. Navigators help you and navigators help us. We love them and you probably will too.
Once we have all of the necessary info, your doctor will decide if IVF is right for you, and if it is, she/he will customize a protocol. This is a fine tuned, carefully thought out “recipe” (medications and ultrasounds) that is very specific to YOU. You will follow this “recipe” for several weeks and we will carefully monitor you along the way.
Goals of IVF Treatment
Our first goal of treatment is to make sure that your naturally occurring hormones don’t interfere with the IVF medications that we are going to use to stimulate you to produce follicles (sacs containing eggs). We do this by starting everyone on birth control pills (in certain cases you may use medications called Aygestin or Lupron instead). Your nurse will ask you to contact them with your next menstrual cycle and she will instruct you on how to start pills or other medications.
While you are on birth control pills our finance team is hard at work. They have the tricky task of getting insurance companies to approve treatments and medications. They work very closely with you so that you understand what you will have to pay along the way, with no unexpected surprises. Once your finance coordinator is confident that both you and your insurance company are on board, they will give us the “green light” to order your mediations. Medications for IVF are ordered thru specialty pharmacies (you can’t just pick them up at your local CVS or Walgreens). If your insurance company is paying for your meds, they will tell us which pharmacy to use.
In the meantime, your assigned nurse will help you schedule an IVF teach class. This is a 2 hour class where a nurse will explain what medications you are taking, why you are taking them, and how to take them. For many of our patients, this is when the moving parts of the cycle start to “click,” and they feel that they have a clearer understanding of what to expect.
Once you have attended class and gotten your medications, we will instruct you to stop your birth control pills. (Our aim is to have you on pills for 1-2 weeks. Occasionally it can be longer.) A day or two after stopping birth control pills we will ask that you come in for a blood test and ultrasound. We are ensuring that everything is “quiet”. (In fact, you may hear us call this visit a “suppression” or “baseline” check.) We want to make sure that the lining of your uterus is thin, that your hormone levels are appropriately low, and that there aren’t any sneaky follicles or cysts growing on your ovaries. If all looks good we will instruct you to start your injections. If something is going on that we were not hoping for, then you will be instructed to stay on birth control pills or be give a new plan. This potentially could delay you by a week or two.
Most women need injections for 10-12 days. The exact amount of time varies from woman to woman, so don’t be alarmed if you need a little less or a little more time. It’s not a race … and please keep in mind – we don’t compare you to other women, so you shouldn’t either. Your ovaries will tell us how long they need.
During the time that you are giving yourself shots, we will instruct you to come for blood tests and scans regularly … typically every other day. As the follicles on your ovaries grow, we count and measure each one of them.
Count and measure, count and measure, count and measure, until TA DA! Your ovaries have their final say and you are ready for surgery (the retrieval) to collect the eggs.
On retrieval day you should expect to be in our Norwalk office for 2 to 3 hours. You will have anesthesia thru an IV that will make you sleep comfortably. The procedure typically takes 15 minutes and then we will monitor you for about an hour. Before you go home we will be able to tell you how many eggs were collected. At this point we won’t know much about them. We will tell you to go home, take a nap, and to start binge watching Downton Abbey (or the series of your choice). You may still feel crampy, bloated, or tired. Usually Tylenol is sufficient for your discomfort.
The day after you retrieval a nurse will call to check in with you, and tell you how many of your eggs fertilized. Two days later a doctor will call with an update, and two days after that you will either come in for your transfer (replacing an embryo or two back into your uterus) or get a call to let you know how many of your embryos were frozen for future use. If you have a transfer, we will schedule your pregnancy test 9 days later. If you freeze your embryos instead, we will ask that you call us when your period starts (usually two weeks later) so that we can schedule an FET (frozen embryo transfer).
For some women, the 9 days between the embryo transfer and the pregnancy test can be the most challenging part of the process. Many of you report that it feels strange to not be coming in to the office regularly (don’t worry – we’ll still call to check in on you). Some of you will be tempted to pee on a stick at home. Please don’t. Here’s why: The medications from your cycle may still be in your system. And, therefore you could have a positive test even if you aren’t pregnant. On the day of your pregnancy test we will ask that you come in first thing in the morning for a blood test. Approximately 4-5 hours later we will give you a call with your news. Regardless of the results, we will go over your next steps. We will tell you what meds you should continue, what you should stop, and what to expect over the next few days. If your result is positive, we will instruct you to repeat the levels 2 days later, and from there we will start booking your ultrasounds.
Occasionally the pregnancy test comes back positive, but your levels are lower than we expect. In these situations, we tread very carefully. You will be instructed to come back 2 days later for a repeat test to see if your numbers are rising appropriately. We are optimistic that they will, but very cautious. Unfortunately, most of these pregnancies will not continue normally.
Fertility Treatment Can Be Intense But Also Empowering
Fertility treatment isn’t a perfect science. And, sometimes we have to give you disappointing news along the way; your ovaries may not respond to medications the way that we had hoped, the number of eggs that we get in the operating room may be less than we expected, or your fertilized eggs may not grow to normal blastocysts. If this happens, we realize you may feel sad, disheartened, frustrated, or maybe even angry. Fortunately, this news rarely sneaks up on us and we will be communicating any concerns along the way. We also have a great team of wellness providers who are available to help you if you feel overwhelmed or need help making decisions and moving forward.
So, yes, IVF treatment can be intense, but it can also be empowering. Many women feel excited about being proactive and moving forward. We know that a lot of responsibility falls on our patients. We know that you will be rearranging your schedule like a Personal Admin, mixing medications like a Chemist, and administering injections like a Nurse. We will give you the tools and you will conquer it with confidence. We are your ultimate fans, and we will root you on as you tackle this journey. Good luck!
"I'm sorry, but your pregnancy test is negative".
You would think after working in reproductive endocrinology (infertility treatment) for 13 years that I would be comfortable saying these words, but I assure that I never am.
Someone asked me once, "What is the hardest call that you have to make?" My initial response was the dread I feel calling any of our patients who has had an IVF (In vitro fertilitization) cycle that has not been successful. I have gotten to know the couple pretty well and I know they put a huge amount of time and effort into this cycle. Recently, though, I have changed my mind.
I have asked my patients about what is the hardest news for them to receive. After informally polling about 20 people, I was surprised at the consensus: it was a negative pregnancy test after their first fertility treatment cycle. Why, I wondered, would this be the most, difficult? I know the statistics, that people have approximately a 15% plus chance per IUI cycle or 30-50% plus chance using IVF. Why, then, would there be such an emphasis on the first IUI or IVF cycle knowing that even if the test is negative, there is an excellent chance with subsequent cycles?
Because, according to the patients I spoke with, it is not a matter of probabilities or statistics. Instead it is the culmination of what already feels like a long journey. By the time they have come in to Reproductive Medicine Associates of Connecticut (RMACT) for a new patient visit, most couples have already been trying for some time. Maybe they were hoping they would get pregnant on their own, or that they really didn't need help or maybe their spouse was reluctant to get help. Maybe they were at another doctor's office and didn't have good luck, or a good experience there. The new patient visit in of itself may seem like an accomplishment because both partners agreed to and came in for an evaluation. There, they either gets diagnosed with a problem and/or are started on a treatment cycle. It is a huge relief that there is finally a plan in place. I can only imagine, then, the magnitude of the disappointment hearing that the cycle didn't work, given the emotional investment that was made even before the cycle began.
What I have learned from this is that our nurses and our patients have to be equal partners in creating a positive experience from a negative result. We, as your providers, are beginning to realize the emphasis placed on the first cycle and are committed to being more sensitive to your feelings. Even though we know, practically speaking, that the odds are that a future cycle is going to work, hopefully sooner rather than later, we will not dismiss the first failed cycle as a minor disappointment. On an fertility journey, there is no such a thing as a minor disappointment.
For our part, we want you to know that having to tell you that you are not pregnant is never easy or commonplace. If we ever relay results quickly or seem flippant, rest assured that it is out of our discomfort and sadness that your cycle didn't work. Please forgive us for a seemingly inappropriate response to your pain. Also, please know that what keeps us going and gets us through relaying bad news is the knowledge that we are hopeful that good news is yet to come.
Monica Moore is a nurse practitioner and one of the nurse managers at Reproductive Medicine Associates of Connecitcut (RMACT). Prior to joining RMACT , Monica was the donor nurse coordinator at the Atlanta Center for Reproductive Medicine. Monica's first job in reproductive endocrinology was at Cornell Center for Reproductive Medicine and Infertility over 10 years ago.
Monica's research interests include: improving the efficiency of donor oocyte programs, advancing education for nurse managers, and developing patient teaching techniques. Monica enjoys any opportunity for teaching nurses or other staff members. Monica has published abstracts, online articles and a book chapter. She chaired the ASRM Nursing course in 2007 and was a recipient of the IVP Care's Professional Patient Education Grant in 2004. She is one of the founding members of the Advanced Nursing Network, a committee of the nursing practice group (NPG), whose purpose is to establish a national network of nurses in managerial or midlevel positions.
Monica received her undergraduate and graduate degrees from the University of Pennsylvania, where she was a member of Sigma Theta Tau, the nursing honor society.