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What you can expect

By Mayo Clinic staff

During the procedure
In vitro fertilization has multiple steps — ovulation induction, egg retrieval, sperm retrieval, fertilization and embryo transfer.

Ovulation induction
If you're using your own eggs during in vitro fertilization, at the start of a cycle you'll begin treatment with synthetic hormones to stimulate your ovaries to produce multiple eggs — rather than the single egg that normally develops each month. Multiple eggs are needed because some eggs won't fertilize or develop normally after fertilization. Several different medications may be needed, including:

• Medications for ovarian stimulation. To stimulate your ovaries, you might take the oral medication clomiphene citrate (Clomid, Serophene) or an injectable medication, such as follicle stimulating hormone (Follistim Aq, Bravelle), human menopausal gonadotropin (Menopur). Clomiphene citrate is less potent than injectable medications.
• Medications for oocyte maturation. To help your eggs prepare for fertilization, you might take the injectable medication HCG (Pregnyl, Ovidrel).
• Medications to prevent premature ovulation. To prevent premature ovulation, you might inject medication such as a gonadotropin-releasing hormone agonist (Lupron) or a gonadotropin-releasing hormone antagonist (Cetrotide).

Your doctor will work with you to determine which medications to use. During treatment, your doctor will likely use vaginal ultrasounds — a procedure that uses sound waves to create an image of the inside of your ovaries — to monitor the development of fluid-filled ovarian cysts where eggs mature (follicles). Blood tests also will be used to measure your response to ovarian stimulation medications. Estrogen levels typically increase as follicles develop and progesterone levels remain low until after ovulation. When the follicles are ready for egg retrieval — generally after eight to 14 days — you'll be given HCG or other medications to help the eggs mature.

Sometimes in vitro fertilization cycles need to be canceled before egg retrieval. Causes for in vitro fertilization cancellation include:

• Inadequate number of follicles developing
• Premature ovulation
• Too many follicles developing, creating a risk of ovarian hyperstimulation syndrome

Your doctor might recommend changing medications to promote a better response during future in vitro fertilization cycles.

Egg retrieval
Egg retrieval can be done in your doctor's office or a clinic. During egg retrieval you'll be sedated and given pain medication. Eggs are generally retrieved 34 to 36 hours after the HCG injection and before ovulation. Typically, transvaginal ultrasound aspiration — a procedure in which an ultrasound probe is inserted into your vagina to identify follicles and a needle is guided through the vagina and into the follicles — is used to retrieve the eggs. Then eggs are removed from the follicles through a needle connected to a suction device. Multiple eggs can be removed in about 30 minutes. After egg retrieval, you may experience cramping and feelings of fullness or pressure. If your ovaries aren't accessible through transvaginal ultrasound, laparoscopy — a procedure in which a tiny incision is made near your navel and a slender viewing instrument (laparoscope) is inserted — may be used to guide the needle. After retrieval, mature eggs are placed in a nutritive liquid (culture medium) and incubated.

On the day of egg retrieval or at the time of embryo transfer, your doctor might recommend that you begin taking progesterone supplements — in the form of oral tablets, injections or vaginal suppositories — to make the lining of your uterus more receptive to implantation.

Sperm retrieval
If you're using your partner's sperm, he'll provide a semen sample at your doctor's office or a clinic through masturbation or another method, such as testicular aspiration — the use of a needle to extract sperm directly from the testicle. Donor sperm also can be used. Sperm are separated from the semen in the lab.

Fertilization
Fertilization can be done using:

• Insemination. During insemination, healthy sperm and mature eggs are mixed and incubated overnight.
• Intracytoplasmic sperm injection (ICSI). In ICSI, a single healthy sperm is injected directly into each mature egg. ICSI is often used when semen quality is a problem or if fertilization attempts during prior in vitro fertilization cycles failed.

If you're an older woman or have had multiple failed in vitro fertilization attempts, your doctor might recommend assisted hatching — a technique in which a hole is made in the membrane (zona pellucida) surrounding the embryo to help the embryo hatch and implant in the lining of your uterus. Assisted hatching is done just before embryo transfer. Preimplantation genetic testing — a procedure in which cells are removed from the embryo and tested for specific genetic diseases — also can be done at this time. Embryos that don't contain affected genes can be implanted in your uterus. While preimplantation genetic testing can reduce the likelihood that a parent will pass on a genetic problem, it can't eliminate the risk. Prenatal testing may be recommended.

Embryo transfer
Embryo transfer is done at your doctor's office or a clinic and usually takes place one to six days after egg retrieval. You might be given a mild sedative. Then the doctor or nurse will insert a long, thin, flexible tube called a catheter into your vagina, through your cervix and into your uterus. A syringe containing one or more embryos suspended in fluid is attached to the end of the catheter, and the fluid is pushed through the tube into your uterus. The procedure is usually painless, although you might experience mild cramping. If successful, the embryo will implant in the lining of your uterus about six to 10 days after egg retrieval.

After the procedure
After the embryo transfer, you can resume your normal daily activities. However, your ovaries may still be enlarged. Consider avoiding vigorous activity, which could cause discomfort.

Typical side effects include:

• Passing a small amount of clear or bloody fluid shortly after the procedure — due to the swabbing of the cervix before the embryo transfer
• Breast tenderness and engorgement
• Mild bloating
• Constipation
• Mild cramping

If you develop moderate or severe pain after the embryo transfer, contact your doctor. He or she will evaluate you for factors such as infection, twisting of an ovary (ovarian torsion) and severe ovarian hyperstimulation syndrome.

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