I just completed an IVF cycle – except that the cycle was dropped and we weren’t able to do the IVF. They didn’t want to waste the eggs, so we did an IUI cycle instead. People have been asking me some questions about how this all works and how it is different from what we did last year. So I present to you some answers (from my perspective, of course!)What is IVF?
IVF stands for In Vitro Fertilization. It is the process where the egg is fertilized outside the womb (in vitro). The process involves hormonally controlling the ovulatory process, removing eggs from the woman's ovaries (called “retrieval”) and letting sperm fertilize them in a special fluid. The fertilized egg is then transferred to the patient's uterus (called “embryo transfer) with the intent to establish a successful pregnancy.
How is IVF different from IUI?
IUI stands for Intra-Uterine Insemination. Sometimes IUI is also called “artificial insemination.” With IUI, the ovulation process is again controlled, but the egg is not removed from the body. The sperm (which is “washed” in a special way and has the slow ones removed) is injected directly into the uterus with a catheter, giving both the sperm and egg a higher chance of actually meeting.
What about the injections?
For this IVF cycle, they started me on Lupron, which I injected into my abdomen every night with an insulin syringe. The Lupron suppresses the cycle and prevents premature ovulation. It basically puts me into a menopausal-like state. During this time, I went to the fertility office for ultrasounds and bloodwork about every 5 days. They watch the hormone level and the uterus lining and the ovaries. When everything looks good (the ovaries are calm, uterus is calm) they start me on Follistim (follicle stimulating hormone gonadotropins – FSH), which I also inject into my abdomen, that stimulates the ovaries to produce eggs... lots of eggs. Once the Follistim starts, they check my ovaries and hormone level every other day or so until it is at the level where the eggs have grown to a good size. Once we get to where the eggs and hormones look good, I do the “trigger shot.” This final injection is human chorionic gonadotropin (hCG) makes the ovaries release the eggs into the fallopian tubes in the next 48 hours or so. For IVF, I would go into the doctor 36 hours after the trigger shot so that the eggs can be retrieved before they are released. This injection also requires mixing the ingredients and filling the syringe. And this shot is usually the most painful – it burns and is often sore for days. And yes, I gave myself all of the injections except the trigger shot.
How do they check the hormone level and the follicles?
The hormone level is checked by a simple blood test. They draw a tube of blood every few days and send it to the lab. The results are returned that afternoon.
For the follicles, a trans-vaginal ultrasound is used. They ask me to go to the bathroom before the test and strip from my waist down. I always ask if I can keep my socks on. At my last appointment, I asked if they wanted us to empty the bladder because it interferes with the ultrasound or because the ultrasound tech doesn’t want to get peed on. The ultrasound tech said that she’s had every kind of bodily fluid on her at some point, but that they ask you do empty the bladder for “patient comfort.” I lie down on a padded table with my feet in stirrups. The trans-vaginal ultrasound is performed with a tube-shaped probe that is completely covered by a lubricated condom and inserted into the vaginal canal.How do they retrieve the eggs for IVF?
With IVF, I would go in before the eggs are released, exactly 36 hours after the trigger shot. Then they put me out with general anesthesia (like a colonoscopy) and they transvaginally go in and retrieve the eggs with a long tube and a needle – they use an ultrasound to guide them and with the needle, they draw the eggs out of the follicles. They hope to get at least 8 eggs. It is very uncomfortable, so you are given pain medication and also antibiotics.
Then what?
The eggs would then be incubated with the sperm and hopefully be fertilized. They will probably take at least one of them and actually inject the sperm into it (intracytoplasmic sperm injection or ICSI) in case that is the problem (that the sperm can’t get through the egg wall).
The fertilized egg is then put into a special growth medium and left until it reaches the 6-8 cell stage (usually 3 days after retrieval). The embryo quality is then determined based on number of cells and evenness of growth.
The number of embryos transferred depends on the the number available, the age of the woman and other health and diagnostic factors. In countries such as the UK, Australia and New Zealand, a maximum of two embryos are transferred except in unusual circumstances. But in the U.S., embryo transfer is based on individual fertility diagnoses. Most ethical clinics will transfer 2 embryos in women under 35, and 3 in women over 35. This is to minimize the risk of multiple pregnancies which can be risky for both mother and baby(ies).
The embryo transfer is very similar to the insemination – the embryos are inserted into the uterus with a thin, plastic catheter.
OK, what kind of pain/discomfort are we talking here?
The injections are not that bad, in my opinion. It’s a little stressful, especially filling the syringe and trying to minimize air bubbles and whatnot, but the needle is very small and is barely a pin prick. The only one that is difficult is the last one, the trigger shot. It usually burns going in and often leaves a welt and a painful spot for several days.
The blood draw is similar, just a pin prick. And the trans-vaginal ultrasound is only slightly uncomfortable.
I am not a fan of the speculum, so the insemination part is never fun for me. It is painful and uncomfortable. At this last insemination, she had to readjust it several times to get access to my cervix and I had some bleeding. I hold my breath the whole time the speculum is being used.
I also tend to experience a great deal of cramping and abdominal and back pain during the ovulation. There have been times when I’ve spent 24 hours laying in bed crying from it.
And I feel extremely bloated for at least 2 weeks of the process.
Emotionally, it is a roller-coaster. One day, the eggs aren’t growing optimally, the next day they are doing great. The hormones make me a little ditzy and forgetful, and I do tend to be close to tears for the final 3 days or so of the injections. I ask people to be patient and nice to me, as I am extra fragile during this process. Pretty much every cycle I think to myself, "I am not doing this again..." but HOPE always wins.
And the cost?
The most expensive parts are the shots and the procedures. Of course none of it is covered by insurance.
For IUI, a single cycle costs around $3000, most of which is the shots. The Follistim costs about $200 per injection. The procedure itself is about $500. Additionally, there are the office visits, routine blood tests and ultrasounds.
For IVF, the entire cycle is around $12,000. The procedure itself is about $9,000 and the remaining costs are the shots and supplemental medications as well as the office visits, routine blood tests and ultrasounds.
This baby-making is BIG business!
What are the odds?
For IUI, success rates are between 20 and 60 percent. There are many differing opinions on the success, obviously, and different factors affect the success rates.
For IVF, the average success rate is about 35%, with a live birth rate of about 27%.
There is a 10-40% chance of my conceiving twins or more with these fertility drugs. While this would normally be an exciting blessing, multiple pregnancies for me would not be a good thing since I have incompetent cervix and I am at risk for miscarriage, premature birth, and other complications with even one baby, let alone more than one. I had to sign a waiver that I would consider selective reduction of the pregnancies if it becomes necessary for my health or the health of the baby(ies).
What Now?
The insemination was this past Friday. Now we wait 2 weeks to see if it worked! Twice a day, I give myself a vaginal suppository called Prometrium to help the uterine lining. I've had some abdominal discomfort, but it is getting less each day. I'll keep you posted!
