IVF and fertility treatment, explained

When should we see a fertility specialist?

After twelve months of trying without a pregnancy if you are under 35, and after six months if you are 35 or over. Come sooner, without waiting out the twelve months, if your periods are irregular or absent, if you have endometriosis or have had a pelvic infection, if either of you has had cancer treatment, or if there has been surgery to the testicles. Waiting is the most common thing couples tell me they regret.

The six and twelve month marks are not arbitrary. They are the points at which it becomes more likely that something identifiable is going on, rather than ordinary variation.

Coming in early does not commit you to treatment. A first consultation and a set of tests may well end with the answer that nothing is wrong and to keep trying, which is a useful thing to be told with certainty rather than to hope quietly.

Both partners at the first appointment if you can manage it.

What happens at a first fertility consultation?

Mostly talking. How long you have been trying, what your cycles do, previous pregnancies, operations, illnesses and medication, and the same set of questions for your partner. Then an examination, and usually an ultrasound scan of the ovaries and womb on the same day. You leave with a written list of tests for both of you and a date to come back and go through the results together.

Bring anything you already have. Previous scan reports, blood results, a semen analysis from another clinic, notes from a gynaecologist you saw two years ago. Repeating a test that has already been done wastes a cycle.

If your periods are irregular, a note of the last few start dates is more useful than trying to remember them in the room.

What tests do we need before starting IVF?

For the woman: blood tests for hormones taken at set points in the cycle, a check that the fallopian tubes are open, and an ultrasound of the ovaries and womb. For the man: a semen analysis, which measures how many sperm there are, how well they move and what shape they are. Both sets are arranged at the same time. The pace is set by the cycle, because some blood tests only mean anything on particular days.

The semen analysis is the fastest of these. It is a sample and a laboratory, and results come back within days.

The usual first set. Which of these you need depends on your history, and Dr Bheena Vyjhallaja will say which apply to you.

What is IVF, in plain terms?

IVF means fertilisation outside the body. Eggs are collected from the ovaries, put together with sperm in a laboratory, and the fertilised egg is grown for a few days before one embryo is placed back into the womb. That is the whole idea. The medication that comes before it exists to ripen several eggs at once, instead of the single egg a body usually releases in a month.

The name is literal. In vitro means in glass. The part that happens outside the body is the meeting of egg and sperm and the first few days of growth. Everything before and after that happens in the usual place.

What is ICSI and when is it used?

ICSI is IVF with one extra step. Rather than leaving eggs and sperm together in a dish to meet on their own, the embryologist injects a single sperm directly into each egg. It is used when the semen analysis shows low numbers, poor movement or unusual shape, when sperm have been collected surgically, or when a previous IVF attempt produced no fertilisation at all. The decision comes from the tests rather than from preference.

ICSI stands for intracytoplasmic sperm injection. Everything else about the cycle is the same: the same injections, the same egg collection, the same transfer.

How long does one IVF cycle take, stage by stage?

About six to eight weeks from the first consultation to the pregnancy test, and most of that is waiting rather than treatment. Investigation takes two to four weeks, because some tests must fall on particular days of your cycle. Stimulation is eight to fourteen days of injections. Egg retrieval, fertilisation and embryo transfer are single days across the following week. Then the wait, which is nine to fourteen days.

See the same seven stages one at a time, with a diagram for each

What does ovarian stimulation actually involve?

A small injection under the skin each evening, which you give yourself at home, for eight to fourteen days. The needle is short and fine. Alongside it you come in every few days so the follicles can be counted and measured on a scan and the dose adjusted. Bloating, tenderness and tiredness are common. Tell the clinic the same day if the bloating becomes severe or your breathing feels tight.

You will be shown how to do the injection before you go home with the medication, and you can come back and be shown again. Nobody is expected to get it from a leaflet.

The scans are quick and internal, and they are the reason the dose can be changed as it goes rather than fixed at the start.

What is egg retrieval like as a patient experience?

You come in having eaten nothing since the night before. Sedation is given, so you are asleep and will not remember it. Guided by an ultrasound probe, a fine needle passes through the wall of the vagina into each ovary and draws the fluid out of the follicles. It takes around twenty minutes. You wake in recovery, rest for a few hours and go home the same day. You cannot drive afterwards.

There is no cut and no stitch. The route is through the vaginal wall, which is why there is nothing to see afterwards.

Cramping and some spotting for a day or two is usual. Arrange the day off, and arrange for somebody to take you home.

What is embryo transfer?

A small outpatient procedure with no sedation and no needle. A speculum is used, as in a smear test, and a soft, fine catheter is passed through the cervix so that the embryo can be placed in the womb, watched on ultrasound as it goes. It takes a few minutes. Most women describe it as uncomfortable rather than painful. You get up, walk out and go back to ordinary life.

You are usually asked to come with a comfortably full bladder, because it improves the ultrasound picture and helps the catheter follow the right angle.

How many embryos are transferred is a decision made with you beforehand, and it depends on your age and your history.

What is the two-week wait?

The nine to fourteen days between the embryo transfer and the blood test that measures the pregnancy hormone. There is nothing to do during it, which is what makes it hard. Home urine tests taken early can mislead, because the trigger injection given before egg collection can still be in your system. Wait for the blood test on the date you were given. Ordinary daily life in those days does not decide the result.

Rest if resting helps you and work if work helps you. Lying still for two weeks is not a treatment and it will not change what is happening.

The date of the blood test is fixed on the day of the transfer, before you leave.

Does the husband need to be tested for infertility?

Yes, and at the same time as his partner rather than afterwards. A male factor is involved in roughly a third of couples, a female factor in roughly a third, and the rest are a combination or unexplained. Despite that, many couples arrive having tested only the woman, sometimes after a year of investigation. A semen analysis needs a sample and a laboratory and comes back within days. It should be among the first tests, not the last.

There is often reluctance, and it is worth naming rather than working around. The test says nothing about a man beyond what his sperm are doing in a particular week, and a poor result is frequently something that can be acted on.

One low result is not conclusive on its own. A repeat some weeks later is usual, because sperm production varies.

Source: NHS guidance on the causes of infertility

What do people most often get wrong about fertility?

Two come up in nearly every consultation. The first is that stress causes infertility. Stress is real and it makes the whole experience harder to bear, but treating it is not a fertility treatment, and telling somebody to relax has never helped anybody. The second is that age matters only for the woman. Sperm changes with age as well. Both partners are worth testing, at the same time.

Irregular periods simply need regulating

A period that comes when it likes is information, not an inconvenience to be smoothed over. It usually points at what is happening with ovulation, and that is the thing worth investigating.

IVF is the first step

It is not. A good many couples are treated without ever reaching IVF, once what is actually going on has been identified.

Lying still after the transfer helps

It does not. The embryo is not going to fall out. Bed rest after a transfer has been looked at and it does not change what happens.

A previous pregnancy means everything is fine

Difficulty conceiving after having already had a child is common enough to have its own name, secondary infertility, and it is investigated the same way.