There are many many reasons why someone might decide to try in vitro fertilization (IVF). If you've been trying to conceive unsuccessfully for a certain period of time with an opposite sex partner, have received a diagnosis of infertility, have a genetic disorder, are pursuing single parenthood, are using a surrogate or egg/sperm/embryo donor, and/or are LGBTQ+, the fertility treatment IVF may be recommended to help you grow your family.

While you may have heard of IVF before, you may not know what it entails. Below, we'll talk about the IVF process, the IVF timeline, and the IVF “funnel.”

6 Second Snapshot

• During in vitro fertilization, eggs and sperm are retrieved, combined in a laboratory to create an embryo or embryos, then implanted in the uterus.

• During the ovarian stimulation part of the process, fertility medications are prescribed to induce the ovaries to generate as many mature eggs as possible.

• Your reproductive endocrinologist will tailor your IVF treatment plan to you to maximize your chance of success.

• It is very common to need more than one cycle of IVF treatment. In fact, most patients have greater success during successive cycles.

What Is IVF?

IVF is an assisted reproductive technology (ART) that replicates the fertilization process through a series of procedures and medications. While there are many reasons why you might decide to pursue IVF, the overall process is the same for everyone.

Very simply, during IVF, the ovaries are stimulated with medications to produce multiple follicles containing eggs, which are then removed from the body in a process called egg retrieval. The egg(s) is then combined with sperm in a laboratory to create an embryo or embryos. These embryos are graded for quality to determine which embryos have the greatest chance of leading to a successful live birth. The embryos are then transferred into the uterus, usually one at a time, starting with the embryos with the best grade. An IVF “cycle” (also known as a “round” of IVF) is complete when all the embryos created from a single egg retrieval have been transferred to the uterus.

A Step-By-Step Breakdown of the IVF Process

IVF is not a quick process. One full cycle of IVF takes at least three to four weeks. Additionally, it may be right for you to take breaks in between steps, for example, between egg retrieval and embryo transfer. You may also decide to freeze your eggs, sperm, or embryos for a later date. So while a full IVF cycle can take just three weeks, many people wait weeks, months, or even years between certain steps.

The steps below assume that you are the one undergoing ovarian stimulation and embryo transfer. However, if you are using a surrogate, using a donor egg/sperm/embryo, or are using your own sperm, you may be involved in only a part of the IVF process.

Step 0: Baseline Tests - >1 month before ovarian stimulation

• Several days after your period, you will have baseline blood work and a transvaginal ultrasound conducted. The baseline blood work includes testing for the Anti-Mullerian Hormone (AMH) and Follicle Stimulating Hormone (FSH). These, combined with the ultrasound to check your Antral Follicle Count, will give your reproductive endocrinologist (RE) a sense of your ovarian reserve (the remaining supply of eggs in your ovaries) and alert them to any hormonal imbalances.

• Your RE will decide on the medication protocol that they believe will give you the best chance of success. Then they will order fertility medications for you. While most people start medications after their period, you may start birth control the month ahead of your IVF cycle to help your ovaries respond to the fertility medications. If your RE decides that the Lupron down regulation protocol is the right one for you, you will start doing Lupron injections one week before your period begins.

• Don’t worry, you don’t have to figure out how to administer your medications! Your clinic will teach you how to self-administer your medications and tell you which ones to take each day.

Step 1: Ovarian Stimulation and Cycle Monitoring - 8 to 14 days

• A day or two after your menstrual cycle begins, you will go to the fertility clinic for blood work and an ultrasound to establish a baseline for your hormones and to make sure your ovaries are ready for the IVF process to begin.

• Your RE or nurse will tell you which day to begin self-administering medications to stimulate your ovaries to produce multiple follicles.

• Every day at the same time, you will self-administer medications in the form of shots, pills, and/or patches. Every few days, you will go to the fertility clinic for blood work and an ultrasound. This allows your RE to check on how you are responding to the medication and adjust your medications accordingly.

• After about a week, your RE will start you on medication to prevent ovulation (if you are not already taking Lupron). At this point, you will likely go to the fertility clinic almost every day for monitoring.

Step 2: Trigger Shot - 1.5 days

• When two or three of your follicles reach a certain size – about 15-18 mm in diameter – you will take a trigger shot 34-36 hours before your scheduled egg retrieval. It’s very important to take your trigger shot at the right time! The trigger shot medication prompts your eggs to mature and be ready for retrieval.

Step 3: Egg Retrieval - 1 day

• Your medical team will tell you when to arrive at the clinic to prepare for egg retrieval and give you instructions on how to prepare for the procedure.

• You will be put under light IV sedation as the RE guides a thin needle through your vaginal wall with ultrasound guidance. The RE will use the needle to withdraw the fluid from each follicle, including each egg!

• It’s very important to rest after your egg retrieval. Your ovaries are much larger than normal and need time to shrink back to their usual size. You may even experience cramping. You should also watch out for signs of ovarian hyperstimulation syndrome (OHSS). Symptoms may include bloating, rapid weight gain, nausea, pain, and dark urine. While rare, OHSS can be serious and require hospitalization. Alert your care team if you suspect you are experiencing OHSS.

Step 4: Embryo Culture - 3 to 7 days

• An embryologist will assess the retrieved eggs to see which ones are mature, meaning that they have shed half their chromosomes (meiosis) and are ready to combine with the sperm.

• The embryologist can use fresh or frozen sperm to fertilize the eggs. The sperm will either be injected directly into the eggs or simply put in a petri dish with the eggs.

• The fertilized eggs will be placed in an incubator for ~5 days until the resulting embryos have reached what is called the “blastocyst” stage. At the blastocyst stage, it’s possible for the embryologist to grade the embryos to determine which ones have the best chance of implanting and growing into a healthy baby. This is also the stage at which you may decide to conduct pre-implantation genetic testing (PGT) on the embryos if you are worried about genetic disorders or chromosomal abnormalities.

• The embryologist will either freeze the embryos until you’re ready for embryo transfer and/or prepare one or two for a fresh transfer to the uterus.

Step 5: Embryo Transfer - 1 day

• If you have decided to do a fresh transfer after egg retrieval, you will begin progesterone supplementation (through progesterone shots or suppositories) the day after egg retrieval. If you decide to freeze your embryos and perform an embryo transfer at a later date, you will begin progesterone supplementation 2-5 days before you are ready for embryo transfer.

• One or two embryos will be loaded into a catheter, guided through your cervix, and carefully placed in the uterus.

• Following the embryo transfer, you will continue taking progesterone supplements until you’re ready for a pregnancy test.

Step 6: Pregnancy Testing - 11 to 14 days

• The hCG blood test to confirm pregnancy is usually conducted between 11-14 days after embryo transfer.

There are a lot of steps involved in IVF! However, your fertility care team is there to explain the process and support you throughout your fertility journey. Don’t hesitate to ask questions throughout the process. It’s also important to lean on your support system and allow them to care for you.

The IVF “Funnel”

We know that the IVF process is full of hope, but also has its fair share of uncertainty. To sustain that hope, it’s important to have realistic expectations for your chances of success.

At each step of the IVF process, some eggs or embryos are usually lost. For example, you could start out with 12 follicles during ovarian stimulation, but only 10 might be mature when retrieved. You could have 6 embryos reach the blastocyst stage, and only 2 might be chromosomally normal. This attrition is sometimes referred to as the IVF “funnel.” While the IVF funnel is completely normal and expected, it can be discouraging if you aren’t prepared for it. It may help to talk to your RE about your particular chances of success before beginning your IVF cycle.

Below is a chart that shows the average IVF success rates by age for five different stages during a single IVF cycle. The stages here include the average number of follicles before retrieval, number of eggs retrieved, number of eggs that fertilize, number of embryos that have reached the blastocyst stage of development, and cumulative live birth rate for non-canceled cycles (an IVF cycle is complete when all the embryos from a single egg retrieval have been transferred to the uterus). However, age is not the only factor to consider. Your chance of success is also dependent on your ovarian reserve and other individual factors. Talking with your RE about your particular chance of success can help set expectations for your experience.

What If My IVF Cycle Isn’t Successful?

The truth is that IVF often doesn’t work the first time. There are many reasons why your cycle may be canceled before you get to embryo transfer, such as a risk of OHSS or poor fertilization. If you have viable embryos from your first egg retrieval, you may undergo several embryo transfers. If those embryos do not implant, you may need to undergo a second egg retrieval.

This does not mean that you have failed! In fact, the second cycle of IVF often goes better than the first. In some ways, the first cycle can be thought of as a trial run; how your body responds to the medications during the first round of IVF gives your RE valuable information to further tailor your protocol during a second or third round of IVF, improving your chances of success. Encouragingly, we have evidence that even if you undergo the exact same IVF medication protocol, you are likely to have a better result in each successive cycle.

IVF can be challenging physically, emotionally, and financially. It can also take a lot of time and effort. Gathering your support network ahead of time, ensuring that you have the financial resources for each step, and having a way to keep all the medications, appointments, and test results organized will prepare you to begin.

Alife is currently developing a mobile app to help you stay organized, informed, and empowered throughout your IVF journey. To join the waitlist for the app, click here!