On your path toward starting a family, there may be times when, even after months of trying, you are unable to conceive naturally. Alternatively, you might wish to postpone your journey toward building a family.
It is important to know when to seek medical advice in order to consider trying in vitro fertilization (IVF) or egg freezing.
If you want to delay family planning, then egg freezing is a lifesaving option. You can thaw your eggs at any time and proceed with IVF.
However, if you have already started trying to have a child and after several months you still do not see a positive pregnancy test, it is important to seek medical advice by scheduling an appointment. More specifically, if you are under 35 and have not conceived after one year of trying, or if you are over 35 and have had 6 months of unsuccessful attempts.
IVF safely helps thousands of couples with fertility problems each year to make their dream of having a child come true.
To clarify, “trying” refers to frequent sexual intercourse—about two to three times per week—without contraception and during fertile days.
Consultation with the Gynecologist
Investigating possible fertility problems is the first important step as it will shape our treatment plan. The investigation begins with questions and discussion with your gynecologist about your medical history and daily habits.
Next, certain tests will be performed, such as progesterone measurement. Once the results from your and your partner’s tests are available, we will agree on the optimal treatment plan to maximize your chances of success.
Here are some indicative examples of issues a couple might face:
- Endometriosis
- Male infertility (low sperm count and/or reduced sperm motility)
- Fallopian tube blockage
- Erectile dysfunction
- Unexplained infertility
- Cases where other techniques, such as ovulation induction or intrauterine insemination, have failed
- History of pelvic inflammatory disease, fibroids, polyps, irregular menstrual cycles, sexually transmitted diseases, polycystic ovaries
- Advanced female age
At this stage, it will be determined if there is a need for egg donation or a surrogate mother.
Monitoring Your Cycle
If all is well to proceed with your own eggs, the next step involves monitoring your menstrual cycle. Depending on the findings from the initial investigation, medications may be needed to regulate your cycle. For example, treatment might be required to induce your period and ensure that both ovaries start from the same point without cystic follicles developing.
Ovarian Stimulation
Once your cycle and ovarian conditions are ideal, we proceed to the next step: egg retrieval.
Your age and ovarian response are important here. Some women’s ovaries show low response even with medication. In such cases, a mini IVF or natural cycle IVF may be necessary.
However, most commonly, we proceed with ovarian stimulation using pituitary gonadotropins. Ovarian stimulation is necessary to produce multiple eggs instead of the usual single egg. The treatment usually lasts 10-12 days, depending on the protocol best suited to your case.
When tests confirm a satisfactory number of follicles with sizes over 17-18mm and an adequate endometrial thickness, beta-hCG is administered, and 35-36 hours later, egg retrieval is performed.
If natural cycle IVF is chosen, no ovarian stimulation drugs are given. The doctor monitors the growth of the single egg via ultrasound and hormone levels, and it is collected at the right time during egg retrieval.
Finally, for younger women at increased risk of ovarian hyperstimulation, such as those with polycystic ovary syndrome, a protocol using antagonists and agonist trigger can be followed to effectively prevent hyperstimulation without negatively affecting egg quality. In this case, embryo transfer is done in the next or subsequent cycle.
Egg Retrieval
Egg retrieval takes place at the IVF center, where you will stay for a few hours. You should arrive early in the morning and fast for half an hour before the procedure. The procedure lasts only 15-30 minutes and is performed under mild sedation (twilight anesthesia) to keep you comfortable. Eggs are collected with the help of a needle guided by ultrasound.
The eggs aspirated are counted and placed in culture medium. On the day of egg retrieval, the husband provides a semen sample in a sterile container, or a donor sample from a sperm bank is used. Then, the eggs and sperm are placed in an incubator to mature until fertilization. You can return home the same day with a companion and eat something light.
Fertilization and Embryo Development
Eggs are either mixed with your partner’s sperm (IVF) or undergo intracytoplasmic sperm injection (ICSI), where a single sperm is injected into each egg. The next day, the embryologist informs us how many eggs fertilized. Embryos are monitored, and depending on their number and quality, the embryo transfer date is decided.
ICSI is chosen when the male sperm count is very low. Microinjection also helps in cases of azoospermia. In these cases, sperm can be retrieved directly from the epididymis (PESA) or testis (TESA), or testicular tissue (TESE) can be used.
Assisted hatching may be required at this stage. This technique thins the zona pellucida surrounding the embryo to facilitate implantation.
Embryo Transfer
Embryo transfer is usually performed 3 or 5 days later using a thin catheter that passes through the cervix and does not require anesthesia. Depending on the woman’s age and preference, the number of embryos (one or two) to be transferred is determined. If additional embryos have been created but not used, the couple may choose to freeze them for future use.
Pregnancy Test
The final step follows two weeks after egg retrieval and consists of a clinical test for chorionic gonadotropin. If the result is positive, the test is repeated after two days and an ultrasound is performed two weeks later to check the embryo’s development. The detection of heartbeats signals the success of the IVF procedure and the progress towards the long-awaited delivery.
Tests in Case of a Negative Result
In case of a negative result, or even before attempting, if there is a history of miscarriages or failed attempts, additional tests are performed. These tests are mainly blood tests. The couple’s karyotype is a test that excludes chromosomal abnormalities in either the man or the woman.
Blood coagulation tests, known as thrombophilia tests, as well as immunological tests or specific microbial cultures of the endometrium—the so-called microbiome—can explain possible disorders in embryo implantation. Additionally, hysteroscopy, a special camera examination of the uterine cavity, is performed to exclude adhesions, polyps, septum, or fibroids that hinder the development of the gestational sac and cause miscarriage. Hysteroscopy is combined with an endometrial biopsy to exclude atrophy or chronic inflammation.
Preimplantation Genetic Diagnosis
Preimplantation genetic diagnosis involves a biopsy of the embryo at the blastocyst stage, five days after egg retrieval and fertilization. Genetic testing of the embryo is recommended in cases of miscarriages, advanced maternal age, or known genetic disorders such as cystic fibrosis and thalassemia.
When the biopsy is performed, the embryo is frozen, results are awaited over the following days, and embryo transfer is carried out in a subsequent cycle, provided the embryo is healthy and can be used.