IVF

• Phase 1: Pituitary Suppression

  Medications called GnRH agonists (Lupron) and GnRH antagonists (Orgalutran or Cetrotide) are used to inhibit the production of the ovulatory hormone luteinizing hormone (LH) from the pituitary gland in the brain. This helps to prevent premature ovulation due to an “LH surge.” If a premature ovulation occurs, the eggs can potentially be lost from the ovary before the egg retrieval procedure is performed. An LH surge can also affect the receptivity of the uterine lining, causing it to move out of phase in relation to the embryo’s developmental stage, which would ultimately prevent the embryo from implanting in the uterus.

• Phase 2: Ovarian Stimulation and Monitoring

  Ovarian stimulation involves the production of multiple ovarian follicles, which are fluid-filled sacs that contain the eggs. In a normal menstrual cycle, the ovaries typically produce a single mature egg. In IVF, we aim to grow many mature eggs in a single ovulation cycle to optimize a patient’s chances of pregnancy. An ideal egg number ranges between 8-20 eggs, but it varies widely depending on the patient’s ovarian reserve.

  Follicle-stimulating hormone (FSH) and LH are administered by self-injection to stimulate the ovaries into growing several eggs. These injectable medications are required for about 8-14 days. During this time, follicular development is monitored using a series of transvaginal ultrasounds and measuring estradiol (E2) levels. Once there are at least 2-3 follicles measuring at least 17mm in diameter, a “trigger shot” of human chorionic gonadotropin (hCG) or triptorelin is given. This shot is administered by subcutaneous injection 36 hours prior to egg retrieval.

  The purpose of the trigger shot is to re-initiate development within the eggs (clinically referred to as maturation) and loosen the eggs from the follicle wall to facilitate extraction during the egg retrieval procedure. HCG also serves to stimulate progesterone production from the ovary, providing luteal phase support for the implanting embryo and subsequent pregnancy.

• Phase 3: Egg Retrieval and Sperm Collection

  Egg retrieval is an ultrasound-guided needle aspiration procedure to drain the follicular fluid from the ovary. Most egg retrieval procedures are performed under conscious intravenous sedation using an opioid and benzodiazepine (fentanyl and midazolam). The follicular fluid is then examined under a microscope by the embryology staff. Once eggs are located, they are cultured in an incubator until the time of insemination – approximately 4 hours later.

  For IVF, sperm collection is a simple process where the male partner provides a semen sample through masturbation in a private room at the clinic. The sample is immediately analyzed in the lab to assess sperm count, motility, and morphology. It's crucial to abstain from sexual activity for a few days before the appointment to ensure a viable sample. The collected sperm is then used for fertilization in the IVF procedure.

• Phase 4: Fertilization and Embryo Culture

  Eggs deemed suitable for fertilization are selected to undergo the process of fertilization, which starts the afternoon of egg retrieval. The embryology staff processes the semen specimen provided by the male partner or donor and either performs standard IVF insemination by adding approximately 50,000 sperm to eggs in a culture dish or directly injects the mature eggs with a single sperm through the process of intracytoplasmic sperm injection (ICSI).

  The eggs are examined the next morning for evidence of fertilization, at which time they are termed zygotes (i.e., single-cell embryos). The developing embryos are then cultured for 5 days prior to embryo transfer and monitored regularly to follow their growth and appearance.

  Various methods are used to assess the “quality” of the embryos. At PCRM we use a combination of visual grading under a microscope, time-lapse imaging (Embryoscope™), and preimplantation genetic testing (PGT). On the 5th day of development, the embryo is over 200 cells in size. Known as the blastocyst stage, this is the best stage of development to select embryos that are most likely to lead to pregnancy; it’s also the stage which cells can be removed for PGT.

• Phase 5: Embryo Transfer

  Embryo transfer occurs 5 days after egg retrieval. The timing of embryo transfer is determined by the number of embryos and their quality. The number of embryos transferred is based on several patient-specific considerations including the age of the female partner, quality of embryos, past fertility history, and very importantly, the implantation rate (probability of each embryo developing in the uterus) of the particular clinic.

  The patient is requested to have a full bladder so that transfer may be visualized using ultrasound guidance and also help straighten the uterus. The embryos are loaded into a soft, flexible catheter attached to a syringe and passed through the cervix into the uterus. Gentle pressure is then applied to the catheter syringe and the embryos are released into the uterus.

  Another option is frozen embryo transfer [FET], in which embryos are cryopreserved during the blastocyst stage until they are ready to be used at a later time. FET is often utilized by IVF patients who have several viable embryos and wish to save them for a later cycle or patients who are undergoing PGT. FET is also sometimes recommended so that the recipient’s uterus can be prepared for implantation.

• Phase 6: Luteal Phase Support

  The IVF process requires the supplementation of progesterone to support the uterine lining at the time of implantation and early pregnancy. Following the pituitary gland suppression that is required for treatments like IVF, the natural production of progesterone can be inadequate and result in a luteal support deficiency and pregnancy loss. As mentioned previously, hCG stimulates progesterone production from the ovaries, and combined with a long half-life of 48 hours in the circulation, provides for an excellent form of luteal phase support. Progesterone supplementation is most commonly given as either vaginal suppositories or intramuscular injections.

Frequently Asked Questions About IVF

• What is the role of fertility medications in IVF?

  Fertility medications in IVF play a vital role in stimulating the ovaries to produce multiple eggs. These medications regulate the menstrual cycle and enhance egg development. Higher egg numbers increase the chances of successful fertilization. Once the eggs are mature, another medication triggers their release. This controlled ovarian stimulation allows IVF clinics to retrieve multiple mature eggs, optimizing the chances of successful fertilization, embryo development, and ultimately, a successful pregnancy.

• What are the potential risks and complications associated with IVF?

  IVF is generally a safe procedure, but there are some potential risks and complications that patients should be aware of. One of the main complication concerns is ovarian hyperstimulation syndrome (OHSS), a condition that occurs as an overactive response to the fertility medications used to induce ovulation. Patients can also experience other side effects from the medication, such as mood swings and bloating. Another risk of IVF is ectopic pregnancy, which is when the embryo implants outside of the uterus. Ectopic pregnancies are not viable and can be life-threatening. These potential complications highlight the importance of informed discussions with your fertility specialist before undergoing IVF.

• How long does an IVF cycle typically take?

  An IVF cycle typically takes about four to six weeks from the start of medications to the embryo transfer. This duration includes ovarian stimulation, egg retrieval, fertilization in the laboratory, embryo culture, and embryo transfer. However, the exact timeline can vary based on individual circumstances and the specific IVF protocol used by the fertility clinic.

• How soon after IVF can I take a pregnancy test?

  After embryo transfer, patients return to the fertility clinic about two weeks later to take a pregnancy test. However, it’s generally recommended that you not use over-the-counter pregnancy tests during this time, as the results can be misleading.

• Are there any lifestyle changes I should make before undergoing IVF?

  Before undergoing IVF, you can improve your chances of having a successful cycle by incorporating a few basic healthy habits into your lifestyle. This includes eating a nutrient-rich diet, getting moderate exercise on a regular basis, taking prenatal vitamins, avoiding tobacco and alcohol, reducing caffeine intake, getting plenty of sleep, and reducing stress as much as possible.

• What is ICSI?

  Intracytoplasmic Sperm Injection (ICSI) is performed as a part of an IVF cycle wherein a single sperm is inserted directly into the egg for fertilization. The ICSI procedure does not appear to damage the egg and optimizes fertilization rates in cases where a male factor exists. ICSI was a major advance in the treatment of male infertility, allowing virtually all men to father children, with the first case performed in 1990.

• What is the difference between IVF and ICSI?

  ICSI (intracytoplasmic sperm injection) and “standard” IVF are two different ways of fertilizing the egg. Standard IVF refers to placing the egg in a dish with approximately 50, 000 – 100, 000 sperm and allowing natural fertilization to occur. In order to be a candidate for standard IVF, the sperm quality must be normal. When the sperm is not optimal, an embryologist can select a single sperm for each egg and inject the sperm directly into the egg with a tiny needle – this is called ICSI.

• How is ICSI performed?

  ICSI is performed on the day of egg (oocyte) retrieval. A sperm sample is provided by the partner, and approximately 4-6 hours after the egg retrieval, individual sperm from this sample are injected into each of the mature eggs (fig 5). Fertilization rates with ICSI are typically about 70-80% of mature (competent) eggs. Of note, standard IVF insemination of eggs should yield the same fertilization rates, but is reserved for cases when the sperm is considered normal and there is no history of poor fertilization with IVF in the past.

• Who needs to do ICSI rather than standard IVF?

  A male factor component to infertility is present in up to half of all infertile couples, making it one of the most common causes of infertility. In the past, the only option for many male-factor couples was intrauterine insemination (IUI) using donated sperm. Another common reason to use ICSI is for patients planning on undergoing preimplantation genetic testing (PGT).

• How can IVF and ICSI help men with azoospermia?

  Many times the sperm needed for ICSI are retrieved from the ejaculate; however, men with no sperm can often still produce sperm for ICSI. The sperm can be retrieved directly from the testicles using testicular sperm extraction (TESE) or from the epididymis using percutaneous epididymal sperm aspiration (PESA). Fertilization rates using ICSI are typically high, and pregnancy success rates are higher compared to standard IVF culture when a sperm factor is the cause of infertility.

  PCRM pioneered a surgical procedure in Canada called microsurgical testicular sperm extraction (microTESE), for men with a complete absence of sperm (azoospermia). This is possible because of our unique ability to provide reproductive surgery under general anesthesia (as a level 1 surgical centre). In these cases, only small numbers of sperm are available from the testicular surgery, such that freezing cannot effectively be performed for future treatments. This fresh sperm is then used to fertilize fresh eggs that have been collected from an IVF cycle which has been synchronized with the microTESE procedure.

• Is there a cost difference between standard IVF and ICSI?

  Yes. The cost of ICSI is additional to the cost of standard IVF. Please see the price breakdown in our Fees section.

• Can I choose to do ICSI on the day of egg retrieval?

  Under some circumstances, the sperm assessment on the day of retrieval will mandate us to switch to ICSI instead of IVF.