IVF - In Vitro Fertilization Procedures Step by Step

What is in vitro fertilization - IVF?

The IVF process involves:

1 Stimulating multiple follicles and eggs to develop
2 Egg retrieval to get the eggs
3 Fertilizing the eggs in the laboratory
4 Embryo transfer to the uterus

Louise Brown was the first IVF baby in the world. She was born in July of 1978 in England. Louise was
28 (in 2006) when she had her own baby (without IVF).
Hundreds of thousands of children are now born every year as a result of IVF

The process of in vitro fertilization - how is IVF done?

Basic screening tests are performed on both partners at all IVF clinics
In general, some testing of "ovarian reserve" should be done on the female prior to starting the
injections.
We use day 3 FSH and AMH blood testing as well as antral follicle counts for this purpose.
These tests help predict how well the ovaries will respond to the drugs (making sufficient follicles
and eggs).
The number of follicles that develop when we stimulate the woman correlates with the number of
eggs we get at the egg pickup (aspiration or retrieval) procedure.
The number of eggs retrieved correlates with IVF success rates

Consents are signed by all parties

The woman is stimulated with injected medications to develop multiple follicles in the ovaries. Each
follicle contains a microscopic egg. These injections continue to stimulate follicle and egg growth and
development for about 8 - 10 days.
Details about ovarian stimulation protocols for in-vitro fertilization
Details about the subcutaneous injectable medications
Sample in vitro fertilization calendar of a "typical" cycle that shows the days medications are
given, office visits, etc.

Blood and ultrasound testing is done every 1-3 days to monitor the development of the follicles (egg-
containing structures) in the ovaries.

We need to get a minimum number of 3 follicles to develop to maturity in order to be able to proceed
with the egg retrieval. About 90-95% of women under 40 with a normal FSH and normal antral follicle
counts will develop at least this minimum number of follicles.

If this many mature follicles can not be obtained from the stimulation process - we will "cancel" the
cycle (not proceed with egg retrieval). Criteria for cancellation can vary between IVF centers.

When a sufficient number of the woman's follicles are mature, a transvaginal ultrasound-guided egg
retrieval (egg aspiration) procedure is performed to remove the eggs from the follicles. At our IVF
clinic, the average duration of the egg retrieval procedure is under 10 minutes, with a range of about
2-15 minutes. Powerful anesthesia medications are used so that the woman is "out" during this
procedure and does not feel or remember anything.
 Pictures of in vitro fertilization procedures
The egg aspiration procedure in progress - an egg is aspirated from a follicle
Ovary outlined in blue - area between red and blue lines is tissue at top of vagina
The needle is passed through the top of the vagina to get to the follicles and eggs.
The needle is the white line (along the white dots) on the right

The eggs are then fertilized in the laboratory with her partner's sperm. If the sperm (or the eggs) are of
poor quality, the ICSI procedure might be used to aid in fertilization.

The embryos are cultured in the IVF laboratory for 2-6 days.

The embryo transfer procedure is done which places the embryos in the woman's uterus where they
will hopefully implant and develop to result in a live birth. This is like a Pap smear for the woman.
There should be no discomfort.

If there are leftover embryos (of sufficient quality) beyond the number that is transferred, many
couples prefer to have them frozen (cryopreserved) for use in a future cycle. Embryo cryopreservation
can be used for another attempt at having a baby if the "fresh" cycle fails - or as an attempt to have
another child if the fresh cycle is successful.

IVF live birth success rate statistics:

Success rates for IVF procedures vary considerably by the program handling the case. This is an
important factor to consider - and not well understood by many consumers of infertility and IVF
services.

Make sure that you discuss pregnancy and delivery success rates in detail with your doctor
before you start a cycle. You should ask about their pregnancy and live birth rates for couples
similar to you (e.g. same age group and diagnosis).

Get numbers in writing from your center before getting started. Any program will be able to
provide this. If they are unwilling to provide pregnancy and/or delivery rates in writing,
consider going elsewhere - they probably have low pregnancy rates.

A national summary and clinic-specific IVF results for the 2013 calendar year were released in 2015
and posted on the website of The Centers for Disease Control and Prevention, CDC, a US
government agency).

In 2017, the Society for Assisted Reproductive Technology, SART posted clinic-specific IVF success
rates for 2015 cycles
 Day 5 IVF embryo at the blastocyst stage
The cluster of cells on the right side are fetal cells
The other peripheral cells will become the placenta
The fluid-filled cavity of the blastocyst is on the left side

Blastocyst transfer of 2 embryos allows high pregnancy rates and almost no risk for triplets or higher

There are 3 very commonly used ovarian stimulation protocols for in vitro fertilization:
1. Luteal Lupron protocol also called "long Lupron", or agonist "down regulation"
2. Antagonist protocols that involve use of of the GnRH antagonist medications
3. Flare and micro-flare protocols, also called short Lupron protocols, or short protocols are used
for patients expected to have a low response to ovarian stimulation

IVF stimulation protocols in the US generally involve the use of 3 types of drugs:
5 A medication to suppress the LH surge and ovulation until the developing eggs are ready. There
are 2 classes of drug used for this:
GnRH-agonist (gonadotropin releasing hormone agonist) such as Lupron
GnRH-antagonist such as Ganirelix or Cetrotide
6 FSH product (follicle stimulating hormone) to stimulate development of multiple eggs
Gonal-F, Follistim, Bravelle, Menopur
7 HCG (human chorionic gonadotropin) to cause final maturation of the eggs
The ovaries are stimulated with the injectable FSH medications for about 7-12 days until multiple
mature size follicles have developed.

What is the goal of a good in vitro fertilization ovarian stimulation?

With ovarian stimulation for in vitro fertilization, the goal is to get approximately 8 to 15 quality eggs at
the egg retrieval procedure.
We do not want to have overstimulation of the ovaries which can lead to significant discomfort for the
woman and in rare cases can result in ovarian hyperstimulation syndrome, OHSS.
In recent years we have used a Lupron trigger to reduce or eliminate risks for ovarian
hyperstimulation syndrome
Our 2014 study on using Lupron triggers to maintain high success rates and reduce any risks
for hyperstimulation
We also do not want the ovarian stimulation to be insufficient and only give us a few eggs if we might
have been able to obtain more by using higher medication doses, etc.
In vitro fertilization can be successful with a very low number of eggs retrieved, but success rates are
substantially higher when more eggs are recovered.

With the ovarian stimulation, the job of the infertility specialist doctor is to:
Select a proper medication protocol and dosing regimen
Monitor the patient's stimulation progress so that medication doses can be adjusted properly
Trigger with hCG at the ideal time. Triggering to early or too late reduces success and can sometimes
increase the risk for ovarian hyperstimulation (if triggered late).
 Ultrasound of multiple follicles (black areas) in a stimulated ovary
Yellow cursors outline a 15 mm diameter follicle
Most mature sized follicles (about 15-20 mm diameter) will give mature eggs at retrieval

Using the latest 3D ultrasound technology to obtain precise measurements

Quality control throughout the entire process is very important with in vitro fertilization. One of the
ways that we have improved quality control in our program is by using highly specialized ultrasound
equipment.
We use a GE Voluson E8 ultrasound machine with a computer built-in that can outline and accurately
measure the developing follicles.
We have found that this method is more precise and reliable as compared to the traditional method -
which is usually manual measurements in two dimensions.
The computer in the machine traces the follicle borders (in three dimensions). It then calculates a
volume for each one. From the volume it calculates an average diameter for each follicle (as if it was a
sphere).
This technology gives us more accurate and reliable measurements than we had in the past.

Ultrasound picture shows the three planes in a volume of data from one ovary
This patient is near the end of the stimulation - numerous follicles seen in the ovary
Upper left = sagittal plane, upper right = transverse plane, lower left = coronal plane
At lower right is a 3-D view of the follicles (generated by the computer)
 Close-up view of the transverse plane (from the same image above)
Computer generated tracings of follicles are different colors

How is the monitoring of the in vitro fertilization stimulation done?

We try to stimulate the woman to get at least 4 follicles with sizes of 14-20mm diameter.
Ideally, there would be at least 8 follicles between 13-20 mm.
The goal is to get a good number (about 8-15) of quality eggs
Blood hormone levels and developing follicle sizes are monitored.
Ultrasound is used to measure the follicles (discussed above on this page)
Estrogen hormone blood levels are important. Estrogen (actually estradiol) levels are usually
under 60 pg/ml at cycle baseline and rise significantly as multiple follicles develop.
Peak estradiol levels in IVF at the time of HCG are usually between 1000 and 4000 pg/ml.
The stimulating process usually takes about 8-10 days

Graph showing estrogen hormone levels during an IVF stimulation

Estradiol starts low and rises to 1000 to 4000 pg/ml by the time of the HCG injection

The HCG injection is given when the estrogen level and the follicle measurements look best for
successful outcome. The HCG shot is needed to induce final egg maturation.
The egg retrieval is planned for 34-35 hours after HCG injection - shortly before the woman's body
might start to release the eggs (ovulate).
How many follicles do you need in order to get pregnant with IVF?
Usually, it is not difficult to get enough follicles to develop. However, sometimes the response of the
ovaries is poor - and a low number of growing follicles are seen. The ability of the ovaries to stimulate
well and give us numerous eggs can be predicted fairly well by an ultrasound test - the antral follicle
count.

The minimum number of follicles needed to proceed with in vitro fertilization treatment depends on
several factors, including their sizes, age of the woman, results of previous stimulations and the
willingness of the couple (and the doctor) to proceed with egg retrieval when there will be a low
number of eggs obtained.

In our experience, IVF success rates are very low with less than 3 mature follicles.

Some doctors will say that you should have at least 5 that measure 14mm or greater while others
might do the egg retrieval with only one follicle. Most IVF programs in the US want a minimum of
about 3-4 mature (or close to mature) follicles.

Women that are more likely to be low responders to ovarian stimulation would be those that have low
antral counts, those women who are older than about 37, women with elevated FSH levels, and
women with other signs of reduced ovarian reserve.

Consents are signed by all parties

The woman is stimulated with injected medications to develop multiple follicles in the ovaries. Each
follicle contains a microscopic egg. These injections continue to stimulate follicle and egg growth and
development for about 8 - 10 days.
Details about ovarian stimulation protocols for in-vitro fertilization
Details about the subcutaneous injectable medications
Sample in vitro fertilization calendar of a "typical" cycle that shows the days medications are
given, office visits, etc.
Blood and ultrasound testing is done every 1-3 days to monitor the development of the follicles (egg-
containing structures) in the ovaries.
We need to get a minimum number of 3 follicles to develop to maturity in order to be able to proceed
with the egg retrieval. About 90-95% of women under 40 with a normal FSH and normal antral follicle
counts will develop at least this minimum number of follicles.
If this many mature follicles can not be obtained from the stimulation process - we will "cancel" the
cycle (not proceed with egg retrieval). Criteria for cancellation can vary between IVF centers.

IIVF Egg Retrieval Procedure In vitro fertilization egg aspiration for

fertility treatment
In order to get sufficient eggs for the in vitro fertilization process, the woman is stimulated with injected
medications using one of several IVF medication stimulation protocols to develop multiple follicles and
eggs. The injections are usually done by the woman, or by her partner.
See a sample IVF calendar showing the days shots are given, office visits, egg retrieval and embryo
transfer procedures.
8 Eggs develop in fluid filled structures in the ovaries called follicles
9 Each follicle can be seen and measured by ultrasound and contains one microscopic egg
The egg is loosely attached to the follicle wall

Egg retrieval process

Size of follicles for egg retrieval

When the follicles are mature (determined by ultrasound measurements of follicle size and hormone
measurements), the egg aspiration procedure is done to take the eggs out.
About 15 to 20 mm diameter is generally consider a "mature" follicle
More about follicle size for IVF egg retrieval

Anesthesia for egg retrieval

Powerful anesthesia medications are given through an IV so that the woman is "out" during
the egg retrieval procedure. She will not feel pain - or remember anything.
Some clinics use other types of anesthesia, but in the US the women are generally "put to
sleep" - but are still breathing on their own.
Conscious sedation, general anesthesia and even local anesthesia can be used for this
procedure.

Egg retrieval procedure

A needle is passed through the top of the vagina under ultrasound guidance to get to the
ovary and follicles.
The fluid in the follicles is aspirated through the needle and the eggs detach from the follicle
wall and are sucked out of the ovary (see video above).
The oocyte-cumulus complex is pulled from the follicle wall when we aspirate the fluid through
the needle.
The procedure usually takes about 10 minutes at our clinic

The fluid with the eggs is passed to the IVF lab where the eggs are identified, rinsed in culture media,
and placed in small drops in plastic culture dishes. The dishes with the eggs are then kept in
specialized IVF incubators under carefully controlled environmental conditions.

Egg retrieval ultrasound picture

Egg aspiration procedure - an egg is being retrieved from a follicle

The needle is the bright white structure on the right
Ovary outlined in blue, top of vagina in red

After egg retrieval - egg retrieval recovery

When all of the follicles have been aspirated, the woman wakes up quickly and is monitored
closely for about an hour - after which she is discharged home.
 Recovery is usually straightforward with mild to moderate cramping for a few hours or so
afterwards.
Some women will use oral pain medications (such as Vicodin) after discharge from the clinic
on the day of the egg retrieval.

IVF egg retrieval numbers - how many eggs do we get with egg retrieval?
We get about 8-12 eggs on the average at egg retrieval
Age has an effect on the numbers - younger women give more than older women
More details about number of eggs retrieved with IVF and age

What happens in the lab after the eggs are aspirated?

Sperm and eggs are put together in the lab (in-vitro) about 4 hours after egg retrieval, or the
sperm are injected individually into eggs. This injection process is called ICSI.
The following morning we check the eggs for evidence of fertilization
The embryos are cultured in the IVF lab for 2-5 more days before one or more is put into the
uterus by the embryo transfer procedure.
Fourteen days after egg retrieval we look for evidence of the good news we have all been
hoping for.
o We test her blood for HCG - the pregnancy hormone

Ultrasound picture of follicles (black circular areas) in a stimulated ovary

Cursors outline a 15 mm follicle

When a sufficient number of the woman's follicles are mature, a transvaginal ultrasound-guided egg
retrieval (egg aspiration) procedure is performed to remove the eggs from the follicles. At our IVF
clinic, the average duration of the egg retrieval procedure is under 10 minutes, with a range of about
2-15 minutes. Powerful anesthesia medications are used so that the woman is "out" during this
procedure and does not feel or remember anything.

Pictures of in vitro fertilization procedures

The egg aspiration procedure in progress - an egg is aspirated from a follicle
Ovary outlined in blue - area between red and blue lines is tissue at top of vagina
The needle is passed through the top of the vagina to get to the follicles and eggs.
The needle is the white line (along the white dots) on the right
The eggs are then fertilized in the laboratory with her partner's sperm. If the sperm (or the eggs) are of
poor quality, the ICSI procedure might be used to aid in fertilization.
The embryos are cultured in the IVF laboratory for 2-6 days.
The embryo transfer procedure is done which places the embryos in the woman's uterus where they
will hopefully implant and develop to result in a live birth. This is like a Pap smear for the woman.
There should be no discomfort.
If there are leftover embryos (of sufficient quality) beyond the number that is transferred, many
couples prefer to have them frozen (cryopreserved) for use in a future cycle. Embryo cryopreservation
can be used for another attempt at having a baby if the "fresh" cycle fails - or as an attempt to have
another child if the fresh cycle is successful.

Intracytoplasmic Sperm Injection - ICSI and IVF

Highly effective treatment for male factor infertility problems

What is ICSI?
ICSI is an acronym for intracytoplasmic sperm injection
A fancy way of saying "inject sperm into egg"

ICSI is a very effective method to fertilize eggs in the IVF lab after they have been aspirated from the
female
Its main use is for significant male infertility cases

IVF with ICSI involves the use of specialized micromanipulation tools and equipment and inverted
microscopes that enable embryologists to select and pick up individual sperm in a specially designed
ICSI needle.

The needle is carefully advanced through the outer shell of the egg and the egg membrane - and the
sperm is injected into the inner part (cytoplasm) of the egg.

This usually results in normal fertilization in about 75-85% of eggs injected with sperm.

However, first the woman must be stimulated with medications and have an egg retrieval procedure so
we can obtain several eggs for in vitro fertilization and ICSI.
 ICSI fertilization procedure in progress
Needle with a sperm inside is advanced to the left
Shell of embryo has already been penetrated by needle
Membrane of egg (oolemma) is stretching and about to break
Sperm head visible at tip of needle

Who should be treated with intracytoplasmic sperm injection?

There is no "standard of care" in this field of medicine regarding which cases should have the ICSI
procedure and which should not.
Some clinics use it only for severe male factor infertility, and some use it on every case. The large
majority of IVF clinics are somewhere in the middle of these 2 extremes.
Our thinking about ICSI has changed over time, and we are now doing more ICSI (as a percentage of
total cases) than we were 10-12 years ago. As we learn more about methods to help couples
conceive, our thinking will continue to evolve.

Common reasons used for performing ICSI

1. Severe male factor infertility that do not want donor sperm insemination.
2. Couples with infertility with:
a. Sperm concentrations of less than 15-20 million per milliliter
b. Low sperm motility - less than 35%
c. Very poor sperm morphology (subjective - specific cutoff value is debatable)

3. Having previous IVF with no fertilization - or a low rate of fertilization (low percentage of
mature eggs that were normally fertilized).

4. Sometimes it is used for couples that have a low yield of eggs at egg retrieval. In this scenario,
ICSI is being used to try to get a higher percentage of eggs fertilized than with conventional
insemination of the eggs (mixing eggs and sperm together).

How is ICSI performed?

The mature egg is held with a specialized holding pipette.

1. A very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm.

2. This needle is then carefully inserted through the zona (shell of the egg) and in to the center
(cytoplasm) of the egg.

3. The sperm is injected in the cytoplasm and the needle is removed.

4. The eggs are checked the next morning for evidence of normal fertilization.

Fertilization and pregnancy success rates with ICSI

Fertilization rates for ICSI: Most IVF programs see that about 70-85% of eggs injected using ICSI
become fertilized. We call this the fertilization rate, which is different from the pregnancy success rate.

Pregnancy success rates for in vitro fertilization procedures with ICSI have been shown in some
studies to be higher than for IVF without ICSI. This is because in many of the cases needing ICSI the
female is relatively young and fertile (good egg quantity and quality) as compared to some of the
women having IVF for other reasons.

In other words, the average egg quantity and quality tends to be better in ICSI cases (male factor
cases) because it is less likely that there is a problem with the eggs - as compared to cases with
unexplained infertility. Some unexplained cases have reduced egg quantity and/or quality - which
lowers the chances for a successful IVF outcome.

IVF with ICSI success rates vary according to the specifics of the individual case, the ICSI technique
used, the skill of the individual performing the procedure, the overall quality of the laboratory, the
quality of the eggs, and the embryo transfer skills of the infertility specialist physician.

Sometimes IVF with ICSI is done for "egg factor" cases - low ovarian reserve situations. This is when
there is either a low number, or low "quality"of eggs (or both). In such cases, ICSI fertilization and
pregnancy success rates tend to be lower.
This is because the main determinant of IVF success is the quality of the embryos.
The quality of the eggs is a crucial factor determining quality and viability of embryos.

In some cases, assisted hatching is done on the embryos prior to transfer, in order to maximize
chances for pregnancy.

Lupron Down-Regulation Ovarian Stimulation Protocol for IVF

Also called "Long Lupron" or "Luteal Lupron"
Ovarian stimulation protocols for in vitro fertilization using Lupron (leuprolide acetate) or GnRH-agonist
drugs.
There are 2 basic ways that we use the GnRH-agonist medications such as Lupron in conjunction with
the FSH product in IVF stimulation protocols:
1. "Long protocols", also called "luteal Lupron", or "down regulation" protocols
2. "Flare" protocols, also called "short" protocols, or "microflare "

Long protocols - also called "down regulation" or "mid-luteal Lupron" protocols

The "long protocol" is the most commonly used IVF protocol in the US
Many IVF specialists think success rates are higher with this protocol (for most patients)
Lupron starts about 7 days before the next expected period - called "mid-luteal" timing
The FSH drug is usually started within the first 2-7 days after the period begins
The leuprolide acetate dose is often reduced when the FSH product is started
The dose and brand name for the FSH product (e.g. Follistim, Gonal-F, Menopur) varies
according to the preferences of the physician and the patient's situation
Most women get a starting dose between 150 and 375 units of FSH product per day
The dose is adjusted as the stimulation progresses

Ultrasound of multiple follicles (black circles) in a stimulated ovary

Yellow cursors outline a 15 mm follicle

How is the monitoring of IVF stimulation done?

We try to stimulate the woman to get at least 3 or 4 follicles with sizes of 14-20mm diameter.
Ideally, there would be about 8 follicles in this range. We want more eggs because the
number of eggs we get correllates with success rates.
Blood hormone levels and developing follicle sizes are monitored.
Ultrasound is used to measure the follicles
Estrogen hormone blood levels are important. Estrogen (actually estradiol) levels are usually
under 60 pg/ml at cycle baseline and rise significantly as multiple follicles develop.
Peak estradiol levels on the day of the HCG shot are usually 1000 to 4000 pg/ml.
The stimulating process usually takes 8-10 days
 Graph showing estrogen hormone levels during an IVF stimulation
Estradiol starts low and rises to 1000 to 4000 pg/ml by the time of the HCG injection

The HCG shot is needed to induce final egg maturation. It is given when the estrogen level
and the follicle measurements look best for successful IVF outcome.
The egg retrieval procedure is planned for 34-36 hours after HCG injection - shortly before the
woman's body might release the eggs (ovulate).
See a sample calendar that shows timing of office visits and IVF procedures

What if this stimulation protocol does not work well?

Some women do not respond well to the long protocol using leuprolide. They do not make enough
follicles to give a good chance for pregnancy from IVF with this regimen.
The ability of the ovary to stimulate and develop enough follicles can be predicted by an ultrasound
test - antral follicle counts
The AMH blood test and the day 3 FSH blood tests of ovarian reserve can also help to predict
response to the IVF drugs

Stop Lupron Protocol

Some women will be "over-suppressed" by the standard long protocol, or are low responders for some
other reason. A "stop Lupron" protocol is one possibility for better response to stimulation.

With this protocol, the leuprolide is started at the same time in the cycle, but usually at a lower dose,
often at 5 units daily instead of 10 units. It is then stopped completely after the woman gets her period
and the FSH product is started.

The LH suppressing ability of this protocol is not as complete as with a standard long protocol.
However, the risk for a premature LH surge is still low, and blood tests can be done during the cycle to
watch for any LH hormone spikes.
Antagonist stimulation or a microflare protocol are options for IVF stimulation other than the
long protocol.
IVF Medication Protocols for Ovarian Stimulation with Antagonists
Ganirelix Acetate and Cetrotide
This page has details about the antagonist ovarian stimulation protocols for IVF
Read an overview about ovarian stimulation for in vitro fertilization
In order to maximize success rates with in vitro fertilization we need a good number of eggs from the
woman.

We prefer to get about 8-15 high-quality eggs at the egg retrieval procedure.

IVF success rates are strongly correlated with the number of eggs retrieved with IVF.

The woman is stimulated with an injected medication containing FSH (follicle stimulating hormone) to
develop multiple follicles (one egg develops in each follicle).

Shots continue for 7-12 days until enough follicles are mature.

IVF stimulation protocols in the U.S. generally involve the use of 3 types of drugs:
1. GnRH-agonist (gonadotropin releasing hormone agonist, Lupron) or a GnRH-antagonist
(Ganirelix) to suppress the LH surge and ovulation until the follicles are mature.
2. FSH product (follicle stimulating hormone) to stimulate development of multiple follicles
3. HCG (human chorionic gonadotropin) to cause final maturation of the eggs

Ovarian Stimulation Using GnRH-antagonists such as Ganirelix and Cetrotide

Ganirelix acetate became available in the U.S. in the spring of 2000. It has been used in Europe for
much longer. Cetrorelix acetate (Cetrotide) is another GnRH-antagonist that is currently available in
the U.S.
Ganirelix and Cetrotide - as well as Lupron - prevent the woman from having an LH surge. However,
Ganirelix and Cetrotide are antagonists instead of agonists. Ganirelix works by competing with native
GnRH molecules at their binding sites in the pituitary - while Lupron works by "down regulating" the
pituitary's ability to produce the LH surge. This distinction is not important to understand. The bottom
line is that both kinds of drugs, antagonists and agonists, prevent LH surges (in different ways).

Ganirelix or Cetrotide are usually started on (about) the sixth day of giving the FSH product
that stimulates the development of follicles in the ovary. They are commonly given
subcutaneously once daily and continued until HCG is given.

Cetrotide can also be be used as a single shot (in a higher 3mg dose), rather than as daily injections
of the lower 0.25mg dose. When the single 3mg dose is given, Cetrotide is supposed to give 4 days of
suppression (no LH surge for 96 hours). If the patient needs more days of stimulation beyond the 96
hours, the daily 0.25mg Cetrotide injections are given until the stimulation is completed and HCG is
given.

Use of Ganirelix results in less total number of shots being taken during the stimulation cycle than with
the use of Lupron. However, there is some evidence in published literature that there are slightly fewer
eggs retrieved (on average), slightly less embryos available on the day of transfer (on average), and
slightly lower pregnancy rates than with the use of Lupron.

However, this is when all patients are given the same protocol (Lupron vs. Ganirelix). Pregnancy rates
are excellent with Ganirelix when used properly in selected patients. We use it for almost all of our egg
donation cases and see excellent pregnancy and live birth rates with it in the egg donors. More studies
are needed to further clarify this important issue.

Some clinics are reporting that women who are low responders to ovarian stimulation protocols that
involve use of Lupron might be able to stimulate better if an antagonist such as Ganirelix is used
instead.

Whether women that are low responders to stimulating drugs can do better with antagonist protocols
deserves careful study in randomized controlled trials of previous low responders.

At this time we are still not sure which is the best ovarian stimulation regimen for low responders - the
"stop Lupron", the microflare, or the antagonist protocol.
Ovarian Stimulation for IVF in Low Responders
Microflare Protocol Using Microdose Lupron ("short" protocol)
To maximize success with in vitro fertilization we try to get multiple eggs to develop
We prefer to get about 10-15 high-quality eggs at the egg retrieval procedure
IVF success rates correlate with the number of eggs retrieved with IVF

However, some women are low responders to the ovarian stimulating drugs.
They might develop a low number of follicles after being stimulated with high doses of IVF
medications
To improve chances for success, these women should be treated with specific IVF protocols

How many follicles do you need in order to get pregnant with IVF?
Usually, it is not difficult to get enough follicles to develop. However, women with low ovarian reserve
often have a poor response to stimulation - and a low number of growing follicles are seen.
The ability of the ovaries to stimulate and make numerous follicles can be predicted by an
ultrasound test - the antral follicle count, and other ovarian reserve tests.
The minimum number of follicles needed to proceed with IVF treatment depends on several factors,
including follicle sizes, age of the woman, results of previous IVF stimulations and the willingness of
the couple (and the fertility doctor) to proceed with egg retrieval when a very low number of eggs will
be obtained.

In our experience, IVF success rates are extremely low with less than 3 mature follicles
Some IVF specialists will say that you should have at least 5 follicles of 14mm or greater while others
might do the egg retrieval with only one follicle. Most IVF programs in the US seem to want a minimum
of 3 to 4 mature (or close to mature) follicles.
When the response of the ovaries to the stimulation attempt is insufficient - the IVF cycle is canceled,
and often the couple will "convert" the cycle to intrauterine insemination, IUI.

More about IVF cycle cancellation

Women that are more likely to be low responders to ovarian stimulation would be those that have low
antral follicle counts, those women who are older than about 37, women with elevated FSH levels, or
low AMH levels, and women with other signs of reduced ovarian reserve.

We try to stimulate the woman to get a minimum of 3 follicles with a size of 14-18 mm in
diameter with a flare stimulation. Ideally, there would be 6-8 or more follicles in that size range and
more that are somewhat smaller. The goal is to get an ideal number of good quality eggs to work with.

Views of two follicles in an ovary with a low response to stimulation

A 2D plane is shown at the top, 3D view at the bottom
The green follicle measured 19 mm diameter
The yellowish one was 18 mm

Views of multiple follicles - ovary with a good response to stimulation

A 2D plane is shown at top, a 3D view at the bottom

Stop Lupron Protocol for Low Responders

Some women are "over-suppressed" by the standard long Lupron protocol, or are low responders for
some other reason. A "stop Lupron" protocol is one option for trying to get a better response to
stimulation. The "flare-up" protocols are another option.

With a stop-Lupron protocol, it is started at the same time in the cycle as with the luteal Lupron
protocol, but usually at a lower dose, such as at 5 units daily instead of 10 or 20 units. It is then
stopped completely after the woman gets her period and the FSH product is started.

The LH suppressing ability of this protocol is not as complete as with the standard "long" Lupron
protocol. However, the risk for a premature LH surge is low, and blood tests can be done during the
cycle to watch for an LH surge.

Flare Protocol, or Microflare for Poor Response Cases (also called Microdose flare, short
Lupron, or short protocol)
In this type of stimulation, the Lupron (or other GnRH agonist) is started on cycle day 2 in the same
menstrual cycle that we will retrieve the eggs - instead of starting it a week prior to the start of menses.

We are trying to take advantage of an initial "flare-up" response of FSH and LH release from the
woman's own pituitary gland that usually occurs in the first 3 days of agonist administration.
Continuing Lupron for more than 3 days temporarily suppresses the pituitary gland so that it has a low
output of FSH and LH.

The FSH product (e.g. Follistim, Gonal-F) is started on the following day (day 3). The idea is that
Lupron will stimulate release of a large amount of FSH (and LH) that will jump-start (flare-up) the
follicles so that we might have a better ovarian stimulation with more mature follicles and more eggs
for IVF.

The FSH product (e.g. Follistim, Gonal-F) is started on the following day (day 3). The idea is that
Lupron will stimulate release of a large amount of FSH (and LH) that will jump-start (flare-up) the
follicles so that we might have a better ovarian stimulation with more mature follicles and more eggs
for IVF.

Birth control pills are usually given for the month before the flare so that there will not be a leftover cyst
(corpus luteum) that could become reactivated by the high LH levels at the onset of the flare
stimulation.

An example of a microflare protocol is given below - there are variations on the theme:
Birth control pills for 1 month
Stop birth control pills - no meds for 2 days
Start Lupron on the third pill free day. We use a 50ug dose twice daily - AM and PM - for these flare
cycles. 50ug is a very small dose as compared to the usual Long Lupron protocol dose of
0.5mg (500ug). The Lupron must be diluted by the pharmacy or the doctor's office to be able
to inject such a low dose.
Start injections of the FSH product (once or twice daily) on the day after starting Lupron
The Lupron is usually continued at the same dose until the HCG trigger shot is given.
Some fertility specialists believe that lead follicle sizes with a flare stimulation should not be greater
than about 17-19mm - or pregnancy success rates may be reduced.
Some women do not respond well to a flare protocol (or any other protocol) and will not be able to
develop enough follicles to allow a reasonable chance for pregnancy from IVF with their own eggs.
These women are good candidates for IVF with donor e
Early Pregnancy - Including HCG levels and ultrasound findings

Background
When pregnancy begins depends on how "pregnancy' is defined. Does it begin when the sperm first
penetrates the egg? Does it begin when the male and female pronuclei (see picture below) containing
the chromosomal material move close together and decondense in the newly fertilized egg?

Human zygote embryo several hours after fertilization 2 circular structures (pronuclei) in the center contain maternal and
paternal DNA Sperm and egg were put together 16 hours ago

Does pregnancy begin when the male and female chromosomes pair up with each other and
the fertilized egg subsequently divides into a 2-cell embryo?
Does it begin when the embryo implantation begins about 6 to 8 days after ovulation?
Or, does it begin when the woman recognizes that she is pregnant after her missed menstrual
period and positive pregnancy test?

HCG levels in pregnancy

HCG, or human chorionic gonadotropin, is a hormone made by the pregnancy that can be detected in
the mother's blood or urine even before the woman's missed period. This hormone is what we look for
with a "pregnancy test".

HCG is first detectable in the blood as early as 7-8 days after ovulation by very sensitive HCG assays
(research assays). In real life, blood pregnancy tests will be positive (> 2 mIU/ml) by 10-11 days after
HCG injection or LH surge.

In general, the HCG level will double every 2-3 days in early pregnancy.

85% of normal pregnancies will have the HCG level double every 72 hours.

HCG levels peak at about 8-10 weeks of pregnancy and then decline, remaining at lower levels for the
rest of the pregnancy.

There is a large variation in a "normal" HCG level for any given time in pregnancy.

Pregnancies destined to miscarry and ectopic (tubal) pregnancies tend to show lower levels
(eventually), but often have normal levels initially.

Learn about pregnancy after ectopic pregnancy

Some normal pregnancies will have quite low levels of HCG - and deliver perfect babies. Caution must
be used in making too much of HCG "numbers". Ultrasound findings after 5-6 weeks of pregnancy are
much more predictive of pregnancy outcome than are HCG levels.
Day after HCG or LH Average High Low #
For

women that have had an HCG injection as part of their fertility treatment, the hormone takes about 5-
14 days to clear from her system, depending on the dose and the individual woman. This can causes
problems with interpretation of pregnancy tests done earlier than 14 days after an HCG injection.

HCG levels from normal singleton pregnancies (and twins below)

Levels are listed for various days after the ovulatory HCG injection or LH surge
First (same as Third) International Reference Preparation was used
"High" is highest seen in this group of pregnancies
"Low" is lowest seen in this group of pregnancies
"#" is the number of tests done for that day in this group of pregnancies
The values below are from a group of 53 normal singleton pregnancies. Because this is a very small
group of patients and because lab assays vary, it is important not to rely on these values to determine
whether your pregnancy is viable, a single, a twin, etc.
Check with your physician about your own levels

NORMAL SINGLE PREGNANCIES

 mIU/ml mIU/ml mIU/ml
14 48 119 17 12
15 59 147 17 18
16 95 223 33 23
17 132 429 17 21
18 292 758 70 19
19 303 514 111 23
20 522 1690 135 13
21 1061 4130 324 12
22 1287 3279 185 22
23 2034 4660 506 13
The 24 2637 10000 540 16
information in the table above is part of a study carried out by Dr. Sherbahn that compared HCG levels from single, twin and
heterotopic (combined intrauterine and ectopic) pregnancies.

Ultrasound pictures in early pregnancy:

Transvaginal ultrasounds of normal pregnancies at 5.5 weeks of gestation
Gestational sac (black area) is seen with yolk sac inside. An identical (monozygotic) twin pregnancy at
the same stage is shown as well as an early twin pregnancy showing non-identical (fraternal) twins.