In Vitro Fertilization (IVF)

While many couples are able to conceive within a few months of trying, others have more difficulty getting pregnant and struggle with infertility. Luckily there are many options for hopeful parents when it comes to fertility treatments — from medications like Clomid (clomiphene) or Femara (letrozole) to intrauterine insemination (IUI) or surgery.

But some couples need a different kind of help — either because those types of fertility treatments are off the table (such as for same-sex couples) or because they're not successful. That's where in vitro fertilization, or IVF, comes in. Here’s a primer on the basics to help you determine if this assisted reproductive technology can help you get closer to having a baby.

What is in vitro fertilization (IVF)?

During in vitro fertilization, eggs are fertilized by sperm outside of the body in a laboratory. Then one (or more) of those fertilized eggs is transferred into the uterus with the hope it will implant and result in a pregnancy — and a baby nine months later.

The first IVF baby was born in 1978, and since then, an estimated 8 million have followed worldwide (born via in vitro fertilization and other reproductive technologies). Today, practitioners perform more than 270,000 IVF cycles annually in the United States, resulting in over 74,000 babies born each year.

How does IVF work?

There are a number of fertility treatments that your doctor may suggest before turning to IVF. But for women who have severe blockages in the fallopian tubes, ovulation disorders, diminished ovarian reserve, poor egg quality, or endometriosis, IVF could be the best option for conceiving a baby.

Ditto for men who have insurmountable sperm deficiencies, some same-sex couples, couples using donor eggs, or those who might need to screen embryos when there are concerns about genetic problems.

What is the IVF process and how long does it take?

A lot is involved in an IVF cycle. Luckily, you’ll have a whole team of doctors and nurses to help you along in the process. One cycle of IVF generally takes about two weeks, though you might need more than one and the whole thing generally lasts four to six weeks from start to finish. Here’s what you can expect:

• Ovulation suppression. Not all hopeful moms-to-be will start with this step — ask your fertility specialist if your cycle will begin with ovarian suppression. If the answer is yes, you’ll be placed on birth control pills (oh, the irony!) or possibly leuprolide (Lupron) to suppress your natural hormones so that your IVF cycle can be optimally timed.

• Hormone shots. The vast majority of IVF cycles include hormone injections — usually with follicle-stimulating hormone (FSH), luteinizing hormone (LH) or both, though the precise cocktail used will be unique to you — that stimulate the ovaries. (It's also possible to do in vitro fertilization without ovarian stimulation in what's called "natural cycle IVF" or "unstimulated IVF," but those methods are uncommon.) During this ovary stimulation phase, you’ll receive blood tests to monitor your hormone levels plus ultrasounds to see how many egg follicles are growing and how well they’re developing. The ultrasounds will also monitor how well your uterine lining is thickening.

• Trigger shot. When your follicles are just about ready for egg retrieval (in about eight to 14 days), you’ll inject human chorionic gonadotropin (hCG) or another drug such as Lupron (leuprolide) to help the eggs mature and trigger ovulation.

• Egg retrieval. Your eggs will be ready for retrieval approximately 36 hours after the trigger hCG shot. The doctor will retrieve the eggs transvaginally with an ultrasound-guided needle that reaches your ovaries and aspirates the fluid and egg from each follicle. Most doctors try to retrieve 10 to 15 eggs per cycle, though the number could be as low as two or three or higher than 15. Egg retrieval typically takes 20 to 30 minutes and is done under IV sedation, so you won’t feel any discomfort. Because you’ll be groggy after the procedure, you’ll need someone else to drive you home. Once you’re back, plan on taking the rest of the day off, resting and relaxing. Be sure to avoid high-impact activities and even sex until after your pregnancy test.

• Sperm retrieval. On the same day of egg retrieval, the clinic will prepare donor sperm or your partner’s previously frozen sperm, or your partner may produce a sperm sample that day.  

• Fertilization. It’s time for fertilization! Your eggs will either be fertilized using an intracytoplasmic sperm injection (ICSI), when a single sperm is injected into an egg, or standard insemination, in which the retrieved eggs are placed in a petri dish with 50,000 to 100,000 sperm in the hopes that the magic of fertilization will happen. The culture dishes are left in a special incubator and checked 12 to 24 hours later to see if fertilization took place. Although there are many factors, by some estimates about 50 percent of mature eggs become fertilized using standard insemination and 60 to 70 percent are fertilized via ICSI. 

• Checking on the embryos. An embryologist will monitor each developing embryo over the next three to five days, looking for healthy growth and development. By day three after fertilization (cleavage stage), the goal is to have a six- to eight-cell embryo, and by day five, there should be a healthy blastocyst. About 30 to 50 percent of IVF embryos make it to the blastocyst stage. Any extra embryos that aren’t going to be transferred can be frozen for future use.

• Testing the embryos. If preimplantation genetic diagnosis (PGT) is planned, the embryos are biopsied (a few cells are safely removed from the embryo and genetically tested).

• Progesterone boost. Soon after fertilization (usually either on the day of the egg retrieval or the day of the embryo transfer), your doctor may start you on supplemental progesterone via injection, vaginal suppository or vaginal gel. This hormone will optimize your uterine lining in anticipation of the embryo transfer and implantation. The medication is usually continued at least until a positive pregnancy test result and often through weeks 8 to 10 of pregnancy.

• Embryo transfer. Usually three or five days after egg retrieval and fertilization (or if you’re using frozen embryos, whenever your uterine lining is ready for implantation), the embryo or embryos are transferred into your uterus. The number of eggs transferred will depend on your age — it’s recommended that women under 35 have only one or two embryos transferred, for example. Using ultrasound guidance, your doctor will insert a thin, flexible catheter through your vagina and cervix into the uterus, and then gently depress the attached syringe containing the embryo(s), placing it in your uterus with the hope that it will implant and continue to grow just as it would with unassisted conception. Some fertility clinics coat the embryo in "embryo glue" before transfer to help it adhere to the uterine wall during implantation. You will be wide awake for the embryo transfer (no anesthesia necessary) and you’ll likely be able to watch the procedure on the ultrasound monitor if you’d like. Most doctors recommend that you take it easy for the first five days after the embryo transfer. That’s to minimize the chances of uterine contractions that might prevent the embryo from implanting. For the same reason, you’ll likely be advised against having sex.

• The pregnancy test. About two weeks after the embryo transfer, you’ll have a blood test to confirm whether your IVF was successful. As eager as you’ll be to get an early heads-up, don’t be tempted to use a home pregnancy test before you get your blood test results — testing too soon can give you a false positive (if you had a shot of hCG) or a false negative (because it’s too soon for the pregnancy to generate its own hCG).

What is the IVF success rate?

The likelihood that a cycle of in vitro fertilization will result in pregnancy depends on a number of factors, including:

Your age

The younger you are the better your IVF success rate, especially if you’re under 35. That’s because as you age, it becomes less likely your ovaries will respond well to the hormone-stimulating drugs, which in turn means fewer eggs.

What’s more, when you get older, the quality of your eggs will generally diminish (though there are exceptions), which means they may have a harder time implanting in your uterus. Although it can be complicated to calculate, here’s the approximate odds of a live birth per treatment cycle based on age (assuming the use of the woman’s own eggs):

• For women under age 35: 53.9 percent
• For women ages 35 to 40: 26 to 40.2 percent
• For women ages 41 and over: 3.9 to 12.6 percent

Your ovarian reserve

The better your ovarian reserve (the number of high-quality fertilizable eggs left in your ovaries), the higher the chances for IVF success.

Your fallopian tubes

The healthier your fallopian tubes, the higher your IVF success rates. Women with a fluid-filled blockage in one or both fallopian tubes (called a hydrosalpinx) have lower success rates, even though in vitro fertilization bypasses the fallopian tubes altogether. A simple procedure called salpingectomy before attempting IVF can bump up your odds for success.

Your lifestyle

The less healthy your lifestyle (say you smoke, or you’re obese or underweight), the lower your chances for IVF success.

Keep in mind that different fertility clinics have varying success rates. The Society for Assisted Reproductive Technology (SART) and the Centers for Disease Control and Prevention (CDC) track pregnancy and live birth rate by clinics and publish their findings online, so you can size up the success rate of your prospective clinic before signing up for your treatments.

What are the possible side effects of in vitro fertilization? Is it painful?

For couples unable to conceive, in vitro fertilization can deliver the happiest news of all: The baby of their dreams is finally a reality. And more good news: IVF is a safe and often successful procedure. That said, in vitro fertilization does pose a small chance of side effects and can be somewhat painful. Here’s what to look out for during your IVF cycle:

After hormone shots

Your fertility drug injections come with common side effects:

• Breast tenderness
• Mood swings
• Headaches
• Abdominal pain
• Nausea
• Bloating
• Bruising (where the shots were administered)
• Pronounced and unusual fatigue

In rare cases, women may develop mild forms of ovarian hyperstimulation syndrome (OHSS). OHSS can cause your ovaries to become swollen and painful. Symptoms include abdominal swelling, mild to moderate abdominal pain, nausea, vomiting and diarrhea. Call your doctor if you’re experiencing symptoms of OHSS.

After egg retrieval

It’s normal to experience cramping or bloating after egg retrieval, and any pain can be relieved with Tylenol.

After embryo transfer

You might notice some bloody or clear discharge after the transfer. That kind of spotting or discharge is totally normal and not a sign that the embryo(s) is lost. It’s usually just the result of the cervix being manipulated during the procedure. Also not unusual: mild cramping, bloating and even slightly sharp pains a few days post-transfer. Contact your doctor if you have questions about any pain you're experiencing.

Late OHSS, which develops after a successful implantation (usually a week or more after egg retrieval), is much less common than the already uncommon early OHSS, but it usually is more severe. Symptoms of severe OHSS include the following and warrant a call to the doctor right away:

• Rapid weight gain (two or more pounds a day)
• Severe bloating and/or severe abdominal pain
• Decreased urination
• Ovarian tenderness
• Severe nausea, vomiting and diarrhea
• Shortness of breath
• Low blood pressure

And though in vitro fertilization is generally safe for both moms and babies, it may present some other risks too:

Risks for babies

The greatest risks to baby’s health come from the possibility that there will be two or more babies. Multiples come with multiple risks, including prematurity and risks that stem from being born too early. Even singleton IVF babies face some increased risks, including premature delivery and low birth weight.

Risks for parents 

For moms, an IVF pregnancy includes an increased risk of gestational diabetes, hypertension, preeclampsia, placental abruption, placenta previa, and C-section.

The IVF process can also be physically and emotionally trying for you and your partner, if you have one, especially with such high levels of hormones coursing through your body. If you are experiencing anxiety or depression, talk to your doctor so you can get the help you need.

How much does IVF cost?

The cost of a single IVF cycle begins at $12,000, though once you include the additional costs for fertility medication and other add-ons (like embryo freezing, ICSI, PGT, assisted hatching and so on), the costs end up averaging between $15,000 and $25,000 per cycle. The Coalition to Help Families Struggling with Infertility puts the total cost of an IVF cycle in the United States at $23,000.

Keep in mind that it often takes more than one IVF cycle to achieve a viable pregnancy, so the total amount of money spent can ramp up quickly. Using frozen embryos from a previous cycle can lower the cost for subsequent cycles.

Does insurance cover IVF?

The unhappy reality is that IVF can cost a lot of money — more than most couples can easily pay for.

So are you out of luck if you can’t afford the hefty bills? Will health insurance help you foot the bill? Currently only 16 states mandate some sort of insurance coverage for infertility treatments. The good news is that even without the state mandate, a growing number of insurance companies offer coverage or partial coverage for fertility treatments. Check with your employer or insurance company to find out whether any IVF coverage applies to you.

There are other ways to finance your IVF. You can consider looking into your health flex spending account at work — if you have one — to use pretax dollars to pay for health care. If you have access to a health savings account, you can use the tax-deductible dollars set aside in that account to pay for medical costs not covered by insurance.

Some fertility clinics will work with couples to come up with a financing plan to help make treatments more affordable. Many clinics also have a guarantee or refund program for their treatments, meaning that if the treatment is unsuccessful, you’ll get your money back (though those plans will cost more in the first place).

There are also many fertility financing companies that offer low interest financing, fertility savings programs, or other financing packages to help couples facing daunting fertility treatment costs. RESOLVE has a list of companies that offer these programs. And you can turn to organizations that provide grants to select couples facing infertility.

Many couples are launching online IVF fundraising crowdsourcing campaigns. There are a growing number of such crowdsourcing websites you can turn to.

How is IVF done using a frozen embryo?

There’s a definite trend in the United States toward using more frozen embryos in IVF cycles than fresh embryos. That’s because studies have found that women who use frozen embryos are less likely to have a preterm birth and a baby with low birth weight.

How does it work? Eggs are harvested and fertilized in a laboratory as in a standard IVF cycle. Once the embryos have developed to the blastocyst stage they're frozen using a technique called cryopreservation, which can keep the embryos viable but in stasis so they can be thawed and implanted at a later stage.

A frozen embryo transfer (FET) cycle uses less medication than a fresh embryo cycle. You’ll still need some hormones to get your uterus ready, but you’ll skip the ovary-stimulating medications (big bonus!). Another potential bonus: no stressful waiting to find out if the embryos conceived in the lab are healthy. That process was already done before the freezing, so you know the frozen embryo you’ll use for transfer is high-quality.  

If you do choose a frozen embryo transfer, you’ll go through the egg retrieval process as you would for a full IVF cycle but you’ll stop there. Your eggs will be fertilized and the healthiest embryos will be frozen.

Whenever you are ready — whether it’s a year from now or several years from now — you’ll start a new IVF cycle that bypasses all the hormone shots needed for egg retrieval. Your doctor may give you shots that will suppress ovulation. Then you’ll take estrogen as your doctor directs (possibly for 14 days), and progesterone, starting about 5 or 6 days before the procedure. The embryo(s) will be thawed the day of the scheduled transfer, and the transfer process proceeds in the same way as a fresh embryo transfer.

So should you have a fresh versus frozen preference when it comes to your embryos? Definitely talk to your doctor to find out which is best in your case. Some things to consider: If you happen to need multiple IVF cycles to achieve a pregnancy, you’ll see some cost savings if you’re able to use your previously frozen embryos.

If you’ve been struggling with infertility for a long time, the knowledge that in vitro fertilization is an option for you should give you plenty of hope that you will be able to get pregnant and have a baby. The road ahead may not be a short one, but with the right fertility specialists by your side, it’ll be a road with a happy bundle of cuddly joy waiting at the end.