What to Expect When You're ... IVFing

In my last entry, I talked about the emotional transition of letting go of IUIs and gearing up to IVF. So today I'd like to give you a little "What to Expect" -- the IVF version.

There are countless sites that will give you specifics about the technicalities of IVFs and the various protocols that your RE will consider before you start a cycle. What I'd like to do is to give you the broad strokes of things that will take place and the things you need to prepare yourself for as you embark on the IVF marathon -- so pardon the cut-and-dry tone of this entry. 

When you decide to go through with an IVF, first call the IVF coordinator at your clinic and reserve your spot for the upcoming cycle. It would suck to get yourself emotionally ready for a cycle, only to find out that they can't squeeze you in for another 2 months. Clinics like to cycle people in groups and every few months (usually 3), they close down their embryology lab for clean ups. So you need to make sure that your period falls during the weeks/months when the lab is open. 

Next, if this is your first IVF, you'll to sign up for injections class. The classes are usually held by one of the nurses and will walk you through the various protocols and the respective injections. Some will be pre-filled syringes (e.g. Lupron), while other will have to mixed (e.g. Menopur). You should attend this class with your partner. Some women prefer to have their partner do the shots for them. I did the large portion of the sub-Q shots myself, but DH would do the progesterone shots (it's hard to aim for your own butt, but I have done it myself on more occasions than I care to remember). Should you need a refresher on how to mix and/or inject yourself with a specific stim, check out this site. It contains a video for every stim medication you will be using; from how to prep the injection site, to mixing, to injecting. 

On Day 3 of your period, you will go in for blood work to check your hormone levels and make sure that your RE doesn't need to do any last minute tweaks -- most importantly, your E2 should be less than 20. An ultrasound will be performed to make sure that your ovaries are quiet and that there are no cysts. Suppressing your reproductive system allows for your RE to control the stimulation of your ovaries in order to obtain as many eggs as possible. From this day forward, you will be going in for monitoring at least every other day (as you get closer to trigger, it will be every day). 

If all looks good, you will begin taking your gonadotropins, which are your ovary stimulating drugs. The duration that it will take for your follicles to be fully mature will vary on your protocol and how your body responds. My stim period was usually around 10 days. During this time, your RE will monitor your progress via blood work (general rule is for your E2 to reach 150-300 IUs for every mature follicle) and ultrasounds. It's a very fine balance that your RE is trying to achieve before deciding when you're ready for trigger -- a large portion of your follicles have to be mature (18-23mm), but not so much so that you might prematurely ovulate. Also, if the blood work detect a slight LH surge (signal that you're starting to ovulate), your RE will should be able to suppress it. This is why it's so important to attend daily monitoring. There is very little room for error. Sometimes your RE will let go of one or two mature follicles in order to give a larger group of them to catch up. One last component to determining your trigger date is the state of your uterine lining. By the time of trigger and/or transfer, your lining should be triple striped and around 8mm (think fluffy cushion = good place to grow for the next 9 months). I will talk more about uterine linings another time (mine never cooperated).

The stimulation period can be physically uncomfortable. As your follicles mature you will feel bloated and have some tenderness in your lower abdomen. That's because you are growing so many follicles. Everyone responds differently, but rule of thumb is to have around 10-12 mature eggs. But more or less is fine too. At the end of the day, it's about the quality of your eggs and not the quantity of them. For instance, women with PCOS tend to produce more eggs, but they also tend to be lower quality. It is essential that your RE monitor you in order to avoid ovarian hyperstimulation (OHSS), which, if left untreated can cause fluid collection in the abdomen, kidney failure and twisting of an ovary. So keep a close watch on your discomfort level and bring it up to your doctor. During the stim period, avoid working out and doing any strenuous activities. Also, avoid eating soy based products (milk, ice cream, etc.) -- soy mimics estrogen, hence may lead to inaccurate readings of your blood work. Reduce your caffeine intake -- it's hard letting go of that 4th cup of coffee, but you can do. Try to keep the stress levels in your life to a minimum and focus on your health and your growing follicles. You're getting so close!

Approximately 34-36 hours before your egg retrieval (ER), you will be asked to take your Hcg shot in order to release your eggs from the follicles. You MUST take the shot at the exact time you're given by your clinic (not an hour before or after). As I've said before, there's no room for error and timing is everything. If you've been doing most of your stims yourself, well tonight's the night for your DH to show that he was paying attention in class. The Hcg shot is a larger needle that has to be given on our tush. 

The morning of your ER will be like any surgery day -- no eating or drinking prior to surgery. Your partner will have to come with you. He will provide a semen sample (remember no ejaculation for at least 48hrs but no more than 4 days). You will meet with your doctor and the anesthesiologist. You'll be placed on a surgical bed: 10, 9, 8 ... Before you know, you'll wake up in the recovery room with your partner waiting for you. A nurse will check on you regularly and when you're ready you'll have to make a trip to the bathroom. There will be some blood in your urine (don't panic!), but if you can urinate, then you're ready to go home and wait for the emrbyology repot. Plan to take a couple of days off work. This is the time to be pampered by your partner -- eat light foods, drink lots of electrolites (Gatorade), and rest.

As you prepare your body for your embryos to come home and hopefully implant, you will start taking progesterone shots. Most are sesame or peanut oil based. These were the most painful part of the cycle for me as the oil is thicker and the needle quite large. Simultaneously, some REs will also have you take estrogen patches. These are pretty easy to apply. Both of these hormones are meant to prep and sustain the (hopeful) pregnancy.

On the 3rd day after your ER, you'll get a call that will let you know how your embryos are doing -- how many there are, how they look (embryologists grade each embryo and ultimately select the ones to be transferred), and most importantly, whether you'll be doing the embryo transfer that day or on Day5 (blastocyst stage). Again, your partner should come with you. When it's time to go in for ET, drink lots of fluid (no peeing right before the transfer!) and ask for some valium. It's important to remain relaxed during the transfer. Some studies have shown that a difficult transfer can hamper success. Your RE will discuss how many embryos he/she recommends be transferred. A good clinic doesn't need to transfer more than 3. In fact, these days, IF clinics aim to transfer 1 or 2. I know you have a lot riding on this cycle, but resist the urge to transfer more than that -- unless you've been living under a rock, you must have heard of Octomom. After the transfer, you can continue to lay down at the clinic for another 30 minutes. You'll probably receive a picture of the embryos that were transferred. Then, take the rest of the day off to soak in the bliss with having your embryos home.

Twelve to 10 days after ET, you'll go in for your beta results (pregnancy results). A nurse will call you with the outcome (unless you already cheated and took an HPT). I hope that it will be fantastic news for all of you. For the next few weeks, they will keep a close eye on your Hcg levels and your progesterone. You'll have your first ultrasound around 6.5 weeks and you'll officially "graduate" onto the the real world around 8 weeks.

My most important advice is to expect the unexpected. Not a single one of my cycles was text book. There was always something that led me to question if the cycle could possibly work under the circumstances. And my worst cycle on paper (fewer embryos, thin lining, etc.) was the one that gave me my beautiful son. So it's not an urban legend, it really does take 1 embryo (perfect or not) to make it happen. Now tie up those running shoes and remember, slow and steady wins the race. I'll be there along the way cheering for you.