The IVF Procedure: From Consultation to Embryo Transfer

IVF can be a complicated process for intended parents going through it for the first time. To help you gain peace of mind about the procedure, we've outlined what you can expect during the process. Your doctor and dedicated care coordination team will be happy to answer any questions you may have at any point along your journey.

The initial consultation with your dedicated physician

Your initial IVF cycle appointment will lay out the testing requirements before the start of your program. Here's what you’ll learn during this session:

1. Your dedicated coordinator will instruct you to call our clinic at the start of your menstrual cycle to begin the IVF Cycle. Your doctor may, or may not, prescribe daily birth birth control pills to control your cycle.
   Note: This initial phase usually takes up to two to four weeks to complete.
2. You’ll also receive a packet containing all relevant information required for your fertility medications.
3. After financial clearance, your care coordinator will also contact you to arrange the delivery of your medications.
   Note: You can either receive a prescription for the drugs or have an associated pharmacy ship them (including the syringes and needles).

Your next three appointments of the IVF cycle 

Once you've received the medications, your care coordinator will contact you to make the next necessary appointments. These appointments for the IVF cycle include:

• An in-person or phone appointment with your nurse to discuss injection appointments and calendar timeline.
• A baseline ultrasound or estradiol test before the start of your fertility hormone treatment, which can be done locally if you're not within reasonable driving distance from our office.
• Another ultrasound examination with your doctor, six to seven days after starting your fertility hormone medication, which takes between 15 - 30 minutes.
  Note: During this examination, your doctor determines the number and size of follicles present. Depending on your situation, your doctor may suggest you to take a further one to two ultrasound examinations before the eggs are ready for harvesting. 

The egg retrieval procedure

When your or your partner's leading follicles reach 18 - 20 mm (average diameter) in size and estradiol hormone (E2) level increases, your eggs are ready for harvest.

Your doctor will advise you or your partner to self-administer the human chorionic gonadotropin (hCG) injections (described in the IVF Monitoring page) in the evenings (between seven and 11 PM).

36 hours after the hCG injection course, your doctor will schedule the egg retrieval procedure. For example, if you self-administer the injections on a Monday at 9:00 PM, the egg retrieval procedure will occur on Wednesday at 9:00 AM. Here's a comprehensive overview of the egg retrieval process: 

What you and your partner can expect on the day

You and your partner will arrive at PFCLA at least 30 minutes before the egg retrieval procedure's scheduled time. The evening before the egg retrieval, no food or beverages should be consumed after midnight.

The egg retrieval experience 

Here's what you can expect during and after the egg retrieval procedure for the IVF cycle program:

1. The egg retrieval is performed under general anesthesia, without intubation (a tube inserted into the mouth and airway) and takes about 10 to 30 minutes. However, rest assured that you'll feel no discomfort.
   Note: The length of the procedure is dependent on the number of follicles present.
2. You’ll wake up 10 to 15 minutes after the procedure and be monitored by your dedicated nurse at the recovery area where you’ll stay for about an hour or more.
   Note: Depending on how you feel, your nurses can provide you with pain medications as needed.
3. In most cases, you’ll be discharged an hour after the procedure, or when your anesthesiologist discharges you. Your dedicated nurse then checks up on you to ensure everything is okay and provides you with further instructions on what to do once you arrive home.
   Note: Expect to feel some levels of discomfort for at least a few hours following the egg retrieval. You can take tylenol (acetaminophen) at home as needed every four hours. You may feel nauseous in some cases, which usually dissipates within a few hours.

What to expect after your procedure

• You can expect slight pain and cramping in the days following your egg retrieval procedure.

• Most intended parents will notice a slight increase in their weight days after egg retrieval, usually resulting from water retention and other factors. However, if you gain more than five pounds, call your doctor immediately.
• You should start your period about 10 to 12 days after the egg retrieval.

A deep dive into the egg retrieval procedure

Your doctor will perform the procedure under ultrasound guidance, similar to the vaginal ultrasound examination (follicular monitoring).

Learn more about the egg retrieval procedure ➜

Your doctor will guide a needle attached to an ultrasound probe through the guide. Each follicle is then punctured, and the fluid (along with the egg floating in it) is aspirated. Once the liquid is sent to the laboratory, the embryologist searches for, isolates and treats the eggs for freezing or fertilization. 

The sperm collection experience

Here’s what you can expect during this part of the IVF procedure:

1. While your partner or egg donor is undergoing the egg retrieval procedure, you'll need to provide your doctor or nurses with a semen sample.
   Note: If you opt-in for an intracytoplasmic sperm injection (ICSI), your embryologists will ask for another semen sample if the first sample lacks an adequate number of viable sperm.
2. Your physicians wash the semen sample and prepare it for insemination three to four hours later. 

If your doctor has prescribed a testicular biopsy (TESE or TESA) procedure:

1. Your nurses will take you to an adjacent operating room, where the urologist will perform the needle biopsy under local anesthesia. This procedure usually lasts for 15 to 30 minutes.
2. Your urologist will send you home with an ice pack placed over your testicles to prevent swelling.
   Note: The risks of retrieval involve bleeding, infection, and possible damage to adjacent organs.

Learn more about Testicular Biopsy ➜

Fertilizing the eggs

Once the eggs are harvested and cleaned in the laboratory, your embryologist will fertilize them with the fresh or frozen sperm of the intended sperm source. 

The two methods of egg fertilization

There are two methods your doctor can use to fertilize the egg. The process used on the day of your retrieval will depend on your doctor's recommendation. Here are the two methods of egg fertilization available at PFCLA:

1. Most commonly, your doctor will recommend the use of the ICSI methodology. Intracytoplasmic Sperm Injection is when the embryologist carefully fertilizes each egg by injecting a single, healthy sperm to increase the rate of fertilization.
2. In some instances, your doctor may recommend the eggs be fertilized by incubation with the collected sperm overnight in a petri dish. This is a simpler method, but is somewhat dependent on the health and quantity of sperm, as well as the health of the retrieved / thawed eggs. 
   Note: ICSI is sometimes the only means to achieve fertilization, especially in severe male infertility factor cases.

Roughly 16 hours after insemination, your embryologist will examine the fertilized eggs. A fertilized egg is called an embryo, which goes through stages of development until it’s ready for transfer to the uterus. 

The images below represent the different stages of an embryo's growth from actual photographs taken under a microscope of a 2-cell embryo to its final Blastocyst stage. 

While in the incubator, embryos will grow and divide into a stage where they are sturdy enough to undergo an embryo transfer. 

The day of the frozen embryo transfer (FET) procedure

The frozen embryo transfer procedure is the last major step of your IVF journey. On the day of your transfer, your doctor will carefully place the embryo into the uterus, where it will grow into your baby. 

In most cases your embryos will have been frozen (the ‘F’ in FET). This means you can schedule transfer day flexibly - sometimes even years after an embryo’s creation. If you are doing a fresh transfer, the ET procedure may happen three to five days after the egg retrieval. Here's what you can expect before, during and after the procedure: 

1. Before going through with the FET procedure, your doctor may prescribe you with progesterone injections and or suppositories the day of hCG injections. These injections help prepare the uterine lining for implantation. 
2. A day or more before the procedure, our clinic will contact you and provide a specific arrival time for you and your partner.
3. On the morning of your FET, your embryologist will evaluate the quality of embryos available and grade them. About 15 minutes before the transfer, your doctor will meet you to discuss the number and quality of the embryos available and decide on the number of embryos to transfer.
   Note: You will have the option to freeze remaining embryo(s), if this is something you’d like to do.
4. Once decided, the embryologist separates the embryos and then transfers them into a catheter.
5. Where needed, your team of nurses will provide you with a sedative to help relax. The ET procedure is similar to an artificial insemination procedure and typically anesthesia is unnecessary.
6. In most cases, your doctor will use an ultrasound to guide the transfer. The embryologist will then deliver the catheter to your doctor, who then introduces it through the cervical canal and into the uterine cavity to release the embryos. The embryologist will then check the catheter to make sure none of the embryos are left. 
7. The whole procedure takes approximately five to ten minutes, and you’ll remain in a supine position for about an hour until the physicians are happy to send you home. Although the FET process is short, this step is challenging to perform, and having a great doctor can make a big difference.
   Note: Your physician may recommend a one to two-day rest period following the transfer. 
8. A blood pregnancy test is done 10 days after the embryo transfer. You will need to do another test two to four days after—depending on the hCG hormone level found in the blood count.
9. An obstetrical ultrasound may be scheduled two weeks later to check on the pregnancy's health. During this examination, your physicians can determine the number of fetuses (i.e., singleton, twins or triplets).
   Note: Our clinic will support you or your partner until the 10th week of gestation; after that, you'll be discharged to your obstetrician.

The success of IVF is dependent on the quality of the uterine lining, amongst other factors. Thickness and texture are essential parameters our physicians check for, with an ideal thickness and triple-layered endometrial lining shown in the image on the right.

Learn more about the egg retrieval procedure ➜

How our doctors and embryologists grade your embryos

Over the next few days, the embryo—which starts from two cells—will divide into multiple cells. On the third day after ER, a competent embryo would have split into more than six cells. The grading of embryos varies from one clinic to the next. In our program, your doctor will use two criteria to grade embryos:

• The number of cells
• The percentage of fragmentation

Our doctors evaluate each cell's fragmentation, similar to cracks that appear in a broken mirror. Here's a breakdown of how we grade embryos: 

• An embryo has a GIII (poor) grade if more than 20% of an embryo's surface is involved with fragmentation and has a label of 8cell GIII.
• An embryo has a GII (good) grade if between 0 - 20% fragmentation appears on its surface and has a label of 8cell GII.
• An embryo has a GI (excellent) grade if it's a clean and unfragmented embryo and has a label of 8cell GI.

Additional IVF procedures at PFCLA

There are a number of procedures available to you while you are undergoing IVF. Read below for further information regarding additional procedures that can be used during the IVF.

Microsurgical epidydimal sperm aspiration (MESA/PESA) 

In some male infertility cases, the male cannot produce any sperm because of a blockage in the ducts transporting the sperm (vas deferens) or a vasectomy (for contraception). In these cases, sperm is retrieved directly from a storage pouch in the testicles called the epididymis. This procedure is called microsurgical epidydimal sperm aspiration (MESA) or percutaneous epidydimal sperm aspiration (PESA). 

Intracytoplasmic sperm injection (ICSI)

ICSI is when one motile sperm is selected and injected into an egg under a special microscope. This increases the odds of fertilization, particularly if there are issues with sperm count and/or quality.

Learn more about ICSI ➜

Note: The ICSI is necessary to use sperm recovered through MESA or PESA.

Assisted hatching (AH)

AH is a procedure commonly performed under the microscope using a special laser or a specially prepared acid mixture. During this technique, a physician creates a small hole in the embryo's shell (zona). Academics and doctors regard this procedure as an aid to implantation, especially in eggs from women above 37. 

Learn more about AH ➜

Preimplantation genetic screening (PGD/PGS/PGT-A)

PGD and PGS are genetic tests which can tell you genetic traits about your embryos and their viability as candidates for transfer (FET). A physician performs a PGD by removing a blastomere (cell) from an embryo three days after the retrieval (usually at the 8-cell embryo stage) for a panel of genetic tests (in the case of PGS), or for specific genetic tests (in the case of PGD). 

The removed cells are shipped to a specialized genetic testing facility where their traits are analyzed. PGD is particularly useful for detecting certain diseases that have strong inheritance patterns to prevent offspring from being affected. Physicians may also use PGD for cases of recurrent pregnancy loss, advanced maternal age and sex selection.

Learn more about preimplantation genetic screening ➜