# Sticky  A Guide to IVF - Patients perspective



## Mel (Jan 1, 2002)

I would like to thank Sam H who provided the basis and inspiration for this article. Without Sams supportive response to one of our members, this article may not have been produced.



--------------------------------------------------------------------------------


With regards to information on IVF, it really depends whether you are going to be on the long or short protocol but one thing remains the same for all types of fertility treatment - it's a rollercoaster ride!

LONG PROTOCOL

The long protocol takes approximately 6 weeks from start to finish although this can vary and be longer or shorter!  The real difficultly can be planning anything because it depends entirely how you respond to the drugs.

Some hospitals provide people with a planner/flow chart giving details of what should happen at what point, however others don’t and advise you at each appointment.

Down Regulating

For both the short and long protocols you have to stop your natural cycle – putting you into temporary menopause sometimes this is done with the use of a nasal spray, Synarel which leaves an unpleasant taste at the back of your throat and some people inject burserlin.  The effects of this drug can make you very hormonal, hot flushes; headaches etc but some people don’t have any side affects to this drug at all.  Some people call this part of the cycle the “down regulating‿ stage.  Before you commence the next stage you may down regulate for between one and it has been known up to eight weeks!  You will continue with these drugs throughout your cycle up to the stage they collect your eggs.

Once you have started your period you may have to call you clinic (or you may already have been given a date for this when you start treatment) to arrange either a blood test or a vaginal scan (this doesn’t hurt, in fact it’s quite interesting because you can see what is going on, on the screen!) to confirm that your natural cycle has stopped.  This blood test and/or scan will show that the lining of your womb has thinned out (from your last period) in order for your body to be clear ready for the cycle.

Once you have been given the go ahead to start, the next stage is stimulating your ovaries to produce lots of follicles (which will hopefully contain eggs!).

Stimulation

The treatment involves daily injections (normally either self administered or administered by your partner/friend) just under the skin (sub-cutaneously) for approximately 11 days.

After approximately 7 days you will have a vaginal scan, which will show how things are progressing.  In an ideal world you will be producing some small follicles around your ovaries and your womb lining will be growing thicker.

Unfortunately some women do not respond at all to the stimulating drugs at all and the cycle may have to be stopped (generally a decision on this is not taken as early as 7 days into the stimulation routine).  Some women find that they initially do not respond and have their stimulation drugs increased which helps the follicles grow and other women over respond where they produce too many follicles which produce too much oestrogen which can potentially mean that they develop OHSS (ovarian hyper stimulation syndrome).  If this happens the drugs can be decreased to a lower dose, or stopped (called coasting) until the oestrogen levels have dropped and the cycle is safe to continue.

During this time you may feel uncomfortable and your tummy can be distended (and your clothes too tight, elasticated clothes are quite handy sometimes!) as your ovaries are stimulated to produce lots of good-sized follies.

After the first scan on about day 7 you will probably then have scans either daily, every other day or every third day depending on your hospital procedure (and whether it’s the weekend!!).

When your leading follicles have reached about 18mm plus and your womb lining is generally over 8mm you are normally ready for an egg collection date to be planned (if it’s not been pre-planned).

36 hours before the eggs are collected (normally late at night, so keep those match sticks handy!) you or your partner will normally inject yourself into your tummy (sounds awful but it isn’t!) with a drug called “profasi‿ which contains a pregnancy hormone called hCG (Human Chorionic Gonadatrophin), which starts the process of the eggs maturing and being ready to be released from the follicles.  This is equivalent to you “surging‿ naturally.  At this point you stop all other drugs (“synarel‿ or “burserlin‿ and the stimulant drugs).

The following day you can have a drug free day (fantastic!).

Egg Collection

Egg Collection can be done either under general anaesthetic or by sedation, it depends on the hospital policy or you may have a choice!  You may find the procedure fine and have no discomfort or you may find that you can be uncomfortable afterwards.  Paracetomol can be taken to ease any pain.  The Egg Collection can take anything from 20 minutes to an hour but you wont know anything about it!  When you come round from either the anaesthetic or sedation the hospital will tell you how many eggs they managed to release from the follicles.

Generally on the same day your partner will be asked to provide the sperm sample (unless it has already been collected and stored in the freezer ready).

The hospital will then take your eggs and the sperm that you are using and undertake either IVF or ICSI as was discussed with you previously.

Normally the following day you will receive a telephone call at home (nail biting!) to advise you how many of the eggs have fertilised.  This can be difficult and exciting because sometimes no eggs fertilise and there may be different reasons for this but generally there will be some embryos for you.

Embryo Transfer

Most hospitals now will only transfer 2 embryos per IVF cycle.  Some hospitals transfer embryo’s 2 or 3 days after your eggs have been collected.  By the time they are transferred they should be at “around‿ either 4 cells or 8 cells depending on whether you are having a 2 or 3-day transfer.  Sometimes couples want to take the embryo onto more cells to determine which are the strongest (possibly an idea if you have lots of embryo’s), sometimes hospitals recommend this too.  Taking the embryo onto a “blastocyst‿ is generally 5 or 6 days after you have had egg collection and the egg is fertilised.  A blastocyst is an embryo that has many cells (more than 32) and is ready to hatch out.

The embryo transfer is not normally done under general anaesthetic or sedation and you can be required to have a full bladder (difficult if you have to wait for transfer!).  It is similar to a smear test and sometimes you get to see the embryo’s that are being transferred back to you on a screen (very emotional experience!).

The Two-Week Wait

You then have the dreaded 2-week wait (2ww), although some hospitals may make you wait a little longer – torture!  If a blastocyst embryo is transferred you are generally asked to test on day 10 rather than 14 (as the embryo is more developed and “older‿ by the time it is transferred).

A nail biting, knicker checking, every twinge and pain analysing time that is the culmination of the rollercoaster!  Some ladies take the time off work others prefer to keep everything as normal and go back to work - it's a personal choice.

During this 2ww quite a lot of women are on progesterone pessaries “Cyclogest‿ and some women have additional injections of HGC during this time, both ways help to maintain the lining of the womb, so the embryo’s can get snuggled in and hopefully implant into the womb lining.

If you have developed symptoms of OHSS before your embryo’s are transferred back to you your hospital may wish you to wait until your body has settled down as it may be too dangerous to you for your embryo’s to be transferred.  If this is the case your hospital will freeze your embryos and transfer them at a later date.  If you develop OHSS AFTER your embryos have been transferred back to you it is one of the symptoms that can possibly indicate that the embryos are implanting.  If you do find this then you must contact your hospital for advice.

During the 2ww you assume that your body will suddenly start kicking out all the pregnancy hormones and we should all be feeling something 'positive' to say 'YES' we're definitely pregnant!

Symptoms

Lets face it, we have our embryo’s put back between 2-5 days post EC, well the day of EC, is classed as the day of Ovulation, so you then need to allow 6-10 days post ovulation, for the embryo’s to implant (or there about anyway!).  Once implanted, it's not suddenly going to produce mountains of hormones, these will build up over the coming weeks, or months, at which point you may then expect the various symptoms (bare in mind, many women don't experience any symptoms at all!).

I think we are all so desperate for some sign, that our imaginations run wild, we analyse every twinge, every bit of tiredness etc......

Below is some information about early pregnancy symptoms, which has to be the most down to earth stuff read.

Q: What are typical early pregnancy symptoms and pregnancy signs? Can I feel the pregnancy signs and symptoms before missing my period?

Many women have typical pregnancy symptoms even before they miss their period. However, most of the typical pregnancy symptoms and signs are directly related to the pregnancy hormone hCG. Small amounts of hCG enter the blood stream several days after implantation, about 8-10 days after ovulation. Thus, typical pregnancy symptoms typically do not appear until the hCG has reached sufficient levels which is about 1-2 weeks after you miss your period (3-4 weeks after ovulation, or 2-3 weeks after implantation), at a time when the hCG has risen enough. Nothing will really confirm a pregnancy except a positive pregnancy test.

The first symptoms and the time of their appearance are listed here:
• Temperature drop (dip) on Implantation day 
• Implantation bleeding or spottinga slight staining of a pink or brown colour on average 8-10 days after ovulation)) 
• Lower abdominal cramps 
• A positive blood HCG pregnancy test: About 10 days after fertilization/ovulation 
• An elevated BBT curve for 15+ days without a menstrual period 
• A missed menstrual period (amenorrhoea): 
• A positive urine pregnancy test (HPT): As early as 10-14 days after ovulation/fertilization or 3-4 days after implantation. The more sensitive the HPT the earlier the pregnancy test will be positive. 
• Nausea: as early as 2-4 weeks after ovulation (BrJObGyn 1989b;96:1304) 
• Nipple or breast tenderness: 3-4 weeks after conception 
• Fatigue: 3-10 weeks after conception 
• Vomiting: 3-10 weeks after conception 
• Food cravings: 1-2 months after conception 
• Frequent urination: usually after 1-2 months 
• Softening of cervix: usually not before 6 weeks after LMP 
• Constipation: later on 
• Lower back pain: later on 
• Darkening of areola (breast nipple): After 14 weeks 
• Fetal heart beat on sonogram: 8-9 weeks after conception 
• Fetal movements: 16+ weeks after conception

Remember everyone is different and there are many pregnant people that were convinced they were not pregnant and thought their period was about to arrive any moment!

Confirmation

Unfortunately sometimes, some women do not reach the date that they have been asked to test by their hospital as their period arrives earlier than expected.  If this is the case you should contact your hospital and ask them for their advice as they may still wish you to test on your correct test day as some women do experience bleeding and are still pregnant.

At the end of the 2ww some hospitals offer a blood test to confirm whether HCG hormones are present in your body.  The presence of the pregnancy hormone HCG indicates a lovely positive!  Alternatively you may wish to do a home pregnancy test (HPT) and some people do test earlier than the required date, which can make you think that you have a negative when in fact you have possibly tested too early!

If you do get a BFP (big fat positive!) you may have to continue on with the progesterone pessaries until the pregnancy is well established (generally 13 weeks) a small price to pay!  However, some hospitals ask you to stop the cyclogest after the positive test too!

If you do not have a positive test and the test is negative you will cease taking the drugs (on the advice of your hospital) and wait for your period.  This is a cruel time and you will find that you grieve.  Your hospital should offer you a follow up consultation at a date that is suitable for you.

SHORT PROTOCOL

The short protocol generally matches in with your normal cycle and is therefore over a timescale of approximately 4 weeks (rather than the long protocol of 6 weeks).  The short protocol is usually used when a woman has not produced that many eggs under the long protocol or where the woman is a bit older than average.  

The main difference between the short protocol and the long protocol is that unlike in the long protocol where there are 2 distinct stages – down regulating and stimulating, in the short protocol you go straight to the stimulating stage. What usually happens is that on day 3 of your cycle you go to the clinic for a scan and/or blood test to make sure that your womb lining has thinned out after your last period. Assuming that it has you then start the stimulation injections described above and at the same time start to take the down regulating nasal spray or injection. You will then be asked to return to the clinic after a few days and thereafter will have regular scans and blood tests (daily, every 2 days or every 3 days depending on your clinic) until the clinic decide you are ready for egg collection. 

Once the clinic has made that decision the process is exactly the same as under a long protocol as described above (i.e. profasi injection, egg collection, embyro transfer and the dreaded 2ww).

The advantages of the short protocol are that there are fewer drugs to take as you miss out the initial down regulating stage, which is part of the long protocol, and as a result it is also a faster treatment cycle. Most women who have not had a very good response under the long protocol find that they produce more eggs under the short protocol but this is not always the case. 

FROZEN EMBRYO TRANSFER (FET)

Some couples are lucky in that their hospital will freeze good embryo’s that have not been transferred, alternatively if a cycle was stopped before embryo transfer due to the risk of OHSS then the embryo’s will have been frozen.

To use these embryo’s some hospitals will recommend a natural cycle and others will recommend a medicated cycle.

Natural Cycle

When your period arrives you will make an appointment with your hospital to check that your old womb lining is gone/reduced.  Once that has been determined (blood test or vaginal scan) you will have another scan in approximately 7 days which should show that you are producing at least 1 follicle naturally (so that your body has the correct hormones in it).  That follicle will then be tracked until it reaches approximately 18mm and your womb lining approximately 8mm.  You may be asked to use Ovulation Predictor Kits (OPK’s) which will detect your “surge‿ before you ovulate.

Once you have surged you must ring your hospital to advise them.  The surge is the equivalent to having the profasi injection on a full cycle and the day after would on a full cycle be your Egg Collection day.

Depending on the day that your embryos were frozen (i.e. if they were frozen on day 3) then the following day would be your egg collection but this is not necessary on a FET cycle.  You then have to wait 3 days (if frozen on day 3) before the embryo’s are taken out of the freezer and thawed.

This is a difficult time because you don’t know if any of the embryos will survive the thaw, it is possible (and rare) but they sometimes do not.  However it is also rare for ALL of the embryo’s to survive the thaw and generally you are looking for the strongest to survive the thaw.

You may have decided to have the embryo’s transferred back to you on the same day (alternatively you may decide to grow them from the day they have been frozen and try to get the strongest to blastocyst) as they have successfully been thawed in which case you would have embryo transfer followed by the 2ww as described above.  On a natural cycle you may not have any drugs at all including progesterone support.

Summary

It is important to remember that everybody responds differently to all the different stages of IVF, emotionally and physically.  This site is fantastic and the girls will give you all the support that you need as they totally understand what you are going through.

Wishing you good luck!


----------

