IVF Protocol

Anita was asking for some more info about the IVF protocol, so here it goes.

The basics behind in vitro fertilization (IVF) are pretty simple: harvest some eggs; harvest some sperm; introduce them to each other in a swank, velvet-lined petri dish accompanied by some classic Esquivel or something; once fertilization is achieved, slowly study the embryos’ development for a few days; place one to three of the embryos who are doing the best into a nice and cozy womb for nine months; and, voilà, a baby or two or three arrives.

Of course, there's a bit more to it than that. And lots of meds.

There are a few different protocols, and each doctor includes his or her idiosyncrasies as well. We are doing a "Luteal Phase Lupron Protocol."

Once we were cleared to begin the IVF cycle (we had to wait for one full cycle after the last miscarriage finally ended), Evelin went on a round of birth control pills. It seems odd, but the idea is that the birth control pill allow the doctors to ensure (more or less) the timing of the various meds and procedures involved with IVF and they start the process of "shutting down" the ovaries.

About a week into the pills, we go through a mock transfer. Basically, this is a trial run for the doctor to find out about any potential physical problems (odd shaped uterus, etc.) that could complicate things during the embryo transfer. Basically, it's the same equipment and procedure as would be done to transfer the embryos, just no embryos are involved. [This was done last week -- no problems.] Evelin compared it to a saline sonogram.

Three days before the last BCP, we start Lupron injections. These are fairly small-dose (0.2 cc), subcutaneous injections designed to suppress ovulation and are given each morning. About a week after finishing up the birth control pills, Evelin should start her period. The day after her period she goes in for a Lupron evaluation to see what the ovaries are doing.

At the same time we start the Lupron, Evelin and I both have to take a course of doxycycline (antibiotic) just to wipe out any low-level crud that may be running around waiting to complicate things.

If the Lupron evaluation checks out, the heavy-duty stuff begins, with Gonal-f and Repronex injections (subcutaneous) each night for a week and a half, or so. These stimulate the ovaries to grow and to spit out eggs. Because of Evelin’s history of good response to medications, we are starting with a pretty low dose -- 1.5 amps of Gonal-f and 0.5 amps of Repronex. During this time, Evelin is monitored regularly by the doctors to make sure that everything is progressing at a good, but not too crazy rate. And she may develop a case of ovarian hyper stimulation syndrome (OHSS), which isn't too much fun.

Once the ovaries develop enough follicles that look ready to pop, we use an hCG trigger shot to trigger ovulation. In the past, this shot has been subcutaneous, but this time the docs want it to be an intramuscular injection.

Then Evelin gets another antibiotic Zithromax (a one-dose thing) in preparation for the retrieval about 36 hours after the hCG trigger shot.

Retrieval is a surgical procedure, so Evelin will be under and will not be going to work that afternoon. However, while she's at home resting in bed and I'm taking care of her, the freshly harvested eggs will be introduced to the sperm sample I donate during the surgery in the aforementioned swank, velvet-lined petri dish.

Assuming the introductions go well, some embryos will start to develop. If not, there is another procedure, intra cytoplasmic sperm injection (ICSI), that can be done. Basically, viable sperm are identified and injected through the cell wall of the egg to achieve fertilization. Hopefully, that won't be necessary, but it can be done if need be.

Back at home, Evelin will start to get a whole bunch of new injections, both intramuscular (progesterone) and subcutaneous (Lovenox), to go with the estrogen pills she gets to start taking.

At the fertility clinic, the geneticist will see which embryos are developing and, at three days, extract a single cell to begin the battery of preimplantation genetic diagnosis (PGD) tests. Here the goal is to look for any of 10 major chromosomal abnormalities that could be causing our recurrent miscarriages. The hope is that it will ID the three or so best embryos and rule out any that have problems. If all the embryos look good, then we will still have some big question marks, but will push ahead with the IVF.

Which brings us to day five of embryo development and the transfer. This is what the mock transfer was prepping for: Two or three (probably two) of the best looking embryos are placed into Evelin’s uterus and then we wait. The first 24 to 36 hours, Evelin is on strict bed rest, so we'll have to stock up on magazines and books and maybe move a TV into the bedroom. It also is going to be happening around Thanksgiving and her parents will probably be staying with us (we aren't hosting Thanksgiving this year, but we'll be a base for them so that there aren't too many people at her uncle's house).

Once the bed rest mandate is lifted, we get to wait ... and wait ... and wait ... and wait for a beta check. Home pregnancy tests won't do any good because they will turn up positive, so we have to wait for beta numbers and to see how they are progressing. During this time, the injections, estrogen, baby aspirin, and prenatal vitamins continue.

Once we get good numbers back, then it's the normal pregnancy routine of waiting and waiting and worrying and waiting and thinking about college funds and waiting and getting the nursery set up and waiting and waiting ...