By Dr. Joe Massey, MD
You’ve had your new patient consult, been thoroughly evaluated, and made the decision to do in vitro fertilization (IVF). You’ve discussed your insurance and financial investment with your financial counselor at your IVF clinic. Your medication protocol has been determined, you’ve received your medication, and you understand how to use it.
From this point, your IVF cycle largely revolves around the multiple office visits required for monitoring your response to ovarian stimulation. Around the third day of your menstrual period, you come to the office to have a “baseline” examination. At this point, any incomplete lab work is updated, and you may have blood drawn. Some clinics will check to ensure your estrogen level is low.
At minimum, you’ll have an ultrasound to check your uterus and ovaries, which includes a review of the current number of small antral follicles. One of the main objectives is to make sure there is no large follicle left over from a previous cycle, which would be called a cyst. Any cyst over approximately three centimeters is considered to be potentially deleterious to the response of the adjacent ovary and, if present, may lead to cancellation of the cycle.
Assuming your physician decides to go ahead with the cycle, a medication regimen is started with the gonadotropin and the suppression drug, outlined in a calendar tailored specifically for you. Your medication protocol will vary depending on your unique situation. The major driver of the response is the gonadotropin drug, which stimulates the ovaries to produce multiple follicles. The suppression drug prevents the ovaries from ovulating before it’s time to do the egg retrieval.
The reproductive endocrine medical team will start counting the days of stimulation, not days of the cycle. So, for example, on the seventh day of stimulation, followed by further monitoring on day 9 and days 10 or 11, there would be follow-up monitoring days. Sometimes monitoring is done every day, but it’s not usually necessary.
Monitoring Hormone Levels
At each of the subsequent visits, you’ll have blood drawn, primarily to check your estrogen level. The larger the follicles and the more follicles there are, the higher your estrogen level will be. The clinical team can discuss with you how well this is going. An extremely low estrogen level on day 6, for example, would mean the ovaries are not producing the desired number of follicles, and it would cause your team to consider canceling the treatment cycle to try another stimulation regimen in the future.
Assuming everything goes well, estrogen levels rise nicely up to 1,000 pg/ml or more. The ideal is for the morning monitoring ultrasound to reveal six to eight follicles which are growing into the range of 15 to 20 mm in size. Up to a certain point, the more the better. Once the largest follicles are at or more than 18 mm, the entire cohort of follicles is taken into consideration, along with the sizes of the largest ones. Your medical team then decides the best day for the trigger shot. This last injection is a one-time dose of human chorionic gonadotropin (hCG), which is the hormonal equivalent of an LH surge.
Once the time of the egg retrieval is set, the monitoring phase of IVF is over. Roughly 36 hours after you receive the trigger shot, ovulation could begin, and the egg retrieval is timed a few hours earlier than this. Ideally, the eggs are mature thanks to the action of the hCG. If so, they are floating around in the follicles, and are aspirated with a needle.
You will get a time and date for the retrieval along with pre-operative instructions for the all-important day pending.
As a well-known pioneer in IVF, Dr. Joe Massey loves to share in the joy of helping build families. Dr. Massey’s achievements in fertility medicine include involvement in the first pregnancy in the world following assisted hatching in 1988 and in the world’s first pregnancy following intracytoplasmic sperm injection (ICSI) in 1993. He has led a number of clinical trials and co-authored many articles published in medical journals.