IVF, In-Vitro Fertilization, costs loads of money and takes it’s toll on our bodies. With all this at stake it’s important to be your own advocate!! When I started IVF I was going in blindly- following what the nurses and doctors said without really understanding what was going on – on the backend.
You need to be your own advocate! Yes, your Reproductive Endocrinologist sees patients everyday and knows what works for the majority- but you know your body and your history! Here are the things you should know before going into IVF, the order is more chronological then by importance.
First, IVF Protocol
Antagonist vs. Micro Flare – I have PCOS (obviously) and was first put on the Antagonist protocol for 8 days which resulted in very few and very poor embryos. My second time around they put me on the Micro Flare protocol for 9 days which resulted in double the follicles and triple the amount of mature eggs!! I went into IVF with no idea what the different protocols are. Please, please, please research the different protocols and ask your doctor about the pros and cons of each one. I knew PCOS would cause egg immaturity and looking back I should have pushed for that extra day in my protocol- that 9th day seemed to make quite the difference for me.
Second, IVF Stim Medication
The protocol above dictates which Stim medications you get, but not how much of each medication. With PCOS you will most likely be on a low dose medicated cycle- due to the increased risk of OHSS (Ovarian Hyper Stimulation Syndrome). Some patients are put on high doses of these stims, make sure you find out why your doctor wants you on low or high dosages.
For me my first protocol was as followed:
First IVF Cycle
Cycle Day 3 start daily Stims (going 8 days):
– 225 Follistim
– 1 Menopur
I then had a Ganirelix injection and then 2 trigger shots- a Lupron and an HCG trigger.
Second IVF Cycle
Cycle day 3 start daily Stims (going 9 days):
– 225 Follistim
– 1 Menopur
– 25 Leuprolide
Trigger – one HCG.
Buying IVF Meds
Please shop around! IVF meds are expensive! With my first cycle I had insurance coverage and used Freedom Fertility (East Coast pharmacy), whom my RE’s office uses. They ship overnight and I’ve found them easy to work with. But if you live on the West Coast it is cheaper for cash payers to use a West Coast pharmacy.
For IVF #2 I had no insurance coverage! So the office sent my prescriptions to MDR USA – Encino (West Coast pharmacy). They actually list their prices on the website so you can compare with other pharmacies, plus they sometimes have coupons they’ll apply to your purchase. They were cheaper then the other pharmacies by about a thousand dollars! They also shipped my injectibles overnight.
Third, Estradiol (E2) Number
You know that almost daily bloodwork you get, it measures your Estradiol levels. The significance here is that the Estradiol levels directly correlate to your follicles. I never monitored my E2 levels during my first IVF, but during my second- I requested the exact number after every blood draw.
My First IVF Estradiol level at trigger: 868
My Second Estradiol level at trigger: 6, 689
WHOA! See that difference- my second IVF had 3x the amount of mature eggs! Now that 6,689 number is a little high, ideally they say the range should be 1,000-4,000. I did have a mild case of OHSS after retrieval.
Fourth, Follicle Size
First off, you want all the follicles to be about the same size. This is hard with PCOS, we just have a bunch of immature follicles that are stubborn and have no interest in growing. If the doctor keeps pushing for the little ones to grow- he might over stim the bigger, better ones.
During my first IVF I had a lead follicle at 21mm before trigger. Well, they wanted the other follicles to catch up, even though I continually told them I had PCOS and to give up hope on those others. They ended up adding an extra HCG trigger shot, which I agreed to- not knowing any better.
And guess what… that lead 21mm follicle- was too stimulated – got to big- turned into a dud. And those immature follicles… nothing- no drugs will get those follies to grow. Mind you I went to a great doctor- the best in my area. But he has seen thousands of patients and assumed my body would do this or that.
Ideal mature follicle size at trigger should be 15-20mm in size (at least that’s what I’ve read/heard). This second cycle I was very firm and told my doctor to NOT try to grow the little ones, but to focus solely on the larger ones. He was in sync and that was his plan as well. He told me that the first cycle was a learning experience and that my follicles didn’t react like typical ones. NO kidding- welcome to my life with PCOS- nothing is typical.
Fifth, IVF Embryo Retrieval
You will take your trigger shot(s) 36 hours before egg retrieval- this forces the egg to break free within the follicle.
Then it’s d-day, time to get those eggs out! Here’s what happens: you get anesthesia and fall asleep, they go in and puncture the follicle then suck the egg out, you wake up ten minutes later, recover a bit, and then get wheeled to your car to go home. Seriously it was like boom, boom, boom. I was coherent and walking about 20 minutes after the procedure.
Egg Retrieval Aftermath
You should have lots of Gatorade or Pedialyte at home. These drinks help minimize OHSS symptoms. Your empty follicles will fill with liquid once the egg is removed. This happens after the egg retrieval anywhere from immediately to days later. The Gatorade and Pedialyte will help absorb the excess liquid- salty foods will also help.Protein is also key! Eat protein, ditch the sugar and carbs for the week following. Plan to relax, the rest of the day and perhaps a few days after if possible. I was drinking Gatorade every 5 minutes everyday for 10 days to my OHSS. If I didn’t I will bloat up and feel like it was hard to breathe. This eventually subsided at day 11 after retrieval.
They will fertilize your eggs about four hours after the retrieval. By the next day you should get a call (or you should call) and ask for your ‘Fertility Report’, this will tell you how many of your eggs fertilized successfully. Out of my 21 eggs retrieved, 12 fertilized. You should keep a daily log of your embryo development- this will help if you need to do IVF again. If they don’t call you, you call them!
My recovery after egg retrieval #2 was much harder than the first- due to more follicles. I drank Gatorade, sipped soup, and ate salty foods for ten days post retrieval. I sat in a semi upright position for the remaining of my retrieval day and the day after. I also made sure to monitor my weight and potty breaks- weight also dictates OHSS- I gained 3 pounds in one day.
Intracytoplasmic sperm injection, originally this was only used for patients whose husbands didn’t have good sperm quality. Now, at least at my practice, this is the standard for all patients. Why? Well it appears that sometimes the egg has a hard shell (or something like that) and the sperm may have issues reaching it. So when they do ICSI the fertilization rate increases. The issue I have with ICSI is that the embryologist chooses the sperm and injects it into the egg. So my egg can’t find it’s perfect match by itself. I mean what if the embryologist chooses the wrong sperm. I don’t know- lots of what ifs. But ICSI increases fertilization rates, and many success stories I hear involve ICSI. If you have or had issues with fertilization then this is definitely something you want to bring up with your doctor!
Finally, Fresh vs. Frozen IVF Transfer
The big debate: Fresh Transfer vs. Frozen transfer (FET) and then further debate 2-day transfer, 3-day transfer, or 5-day transfer.
Regarding PCOS specifically- Our follies seem to need some extra coddling, a little more time to mature. So with this mindset it makes sense to do a 2-day or 3-day transfer to give those follies some extra TLC by our uterus as opposed to the IVF culture dish.
On the other hand, waiting till Day 5/6 for the embryo to hit blastocyst stage is a big deal- this signals that the embryo is probably good quality and will make a viable pregnancy- probably. The problem here is that some embyos don’t make it to day 5, and that might be due to the culture environment. So do you risk losing all your embryos just to wait for blastocyst stage? This happened to me- and it sucked!
For my second IVF I was gung-ho on doing a fresh 3-day transfer. I demanded it. My RE would show me the statistics about Frozen embryo transfers and how high their success rates were- but I didn’t budge. I did an FET last IVF cycle that failed, not to mention that my other embryos all arrested Day 3-4. My FET had failed, it was time for a different approach. It makes sense to me to do a fresh early transfer with PCOS, my follies need help, they’re sensitive little fellows.
Well, come embryo retrieval day and my Estradiol was in the six thousands which put me closer to risking OHSS. The doctor told me how if I did the transfer that the number would keep rising and I could be dealing with severe OHSS and a pregnancy. I went home and researched some more- hours and hours of reading papers, studies, blogs, forums, etc. As much as I wanted a fresh transfer, I knew that I shouldn’t put my health at risk.
So for IVF Cycle #2 I did a freeze all— BUT– this time I froze some on Day 3, and allowed the rest to try and hit blastocyst stage. This time around I had 12 fertilize (with ICSI) as opposed to 4 fertilize during round one.
Frozen Embryo Transfer (FET)
As discussed in my original PCOS IVF Post if you’re doing a Frozen transfer they will more then likely put you on birth control pills between retrieval and transfer, sometimes: prednisolone, low dose aspirin, and prescription folic acid.
Prednisolone – is a steroid, it lowers inflammation and apparently helps with implantation. Studies look positive. My clinic tells us to take these in low dose for the thirty days before transfer. Other clinics have you take them for a week. It’s worth discussing with your RE.
Low Dose Aspirin- this helps thin the blood which apparently also helps with implantation and fighting off certain conditions that negatively affect implantation. Again I take this for the entire month before transfer.
Birth Control Pill- is prescribed after retrieval to help with inflammation, hormone balance, and to help the body absorb the follicle cysts.
Your doctor may also want you to have an Endometrial Scratch (which I also discuss in my PCOS post, link above). This scratch consists of the doctor scratching the lining of your uterus- yikes! The thought is that it causes your uterus to enter a healing mode and get active. Then when they do the FET the uterus may recognize the embryo easier and have a higher chance of implantation. I did this and thought the pain was very bearable- just a burning sensation and light cramps the rest of the day. But my doctor said that’s because I’ve already had a child so my uterus is flexible. Whereas women with no children find the pain much worse. You should definitely discuss this with your doctor! I’ve read a lot of success stories from women with implantation issues and this did the trick!
Frozen Embryos – Straw
Yes, straw. When they freeze your embryos they typically freeze them together in a straw. Here’s the problem- say you freeze three in the same straw but only want to transfer one of those. Well they have to thaw all three and then re-freeze two. This can result in the loss of the other embryos.
Depending on how many embryos you have you might want to freeze only two together, or if you only a small number of embryos you may wish to freeze each separately. My clinic gives each embryo their own straw, but this is not the case at other clinics.
Speak to your doctor about this and then make sure they relay your wishes to the embryologist.
I think that’s the majority of the must know! I’ll add more as they come 🙂
Am I leaving anything out here? Comment below!