IVF (In Vitro Fertilization)

What is IVF?

In vitro fertilization (IVF) is a type of assisted reproductive technology (ART) where sperm and an egg are fertilized outside of the human body. IVF is a complex process that involves retrieving eggs from ovaries and manually combining them with sperm in a lab for fertilization. Several days after fertilization, the fertilized egg (now called an embryo) is placed inside a uterus. Pregnancy occurs when this embryo implants itself into the uterine wall.

Why is IVF performed?

People choose IVF for many reasons, including infertility issues or when one partner has an existing health condition. Some people will try IVF after other fertility methods have failed or if they’re at an advanced maternal age. IVF is also a reproductive option for same-sex couples or people who wish to have a baby without a partner.

IVF is an option if you or your partner has:

• Blocked or damaged fallopian tubes.
• Endometriosis.
• Low sperm count or other sperm impairments.
• Polycystic ovary syndrome (PCOS) or other ovarian conditions.
• Uterine fibroids.
• Problems with your uterus.
• Risk of passing on a genetic disease or disorder.
• Unexplained infertility.
• Are using an egg donor or a gestational surrogate.

How long is the IVF process from beginning to end?

IVF is a complicated process with many steps. On average, you can expect the process to last four to six weeks. This includes the time before egg retrieval, when a person takes fertility medication until they’re tested for pregnancy.

How common is IVF?

Approximately 5% of couples with infertility will try IVF. More than 8 million babies have been born from IVF since 1978. It’s one of the most effective assisted reproductive technologies (ARTs) available.

What is the difference between IVF and IUI (intrauterine insemination)?

Intrauterine insemination (IUI) is different from in vitro fertilization (IVF) because in an IUI procedure, fertilization occurs in a person’s body. A sperm sample is collected and washed so only high-quality sperm are left. This sample is inserted into your uterus with a catheter (thin tube) during ovulation. This method helps the sperm get to the egg more easily in hope that fertilization will happen.

With IVF, the sperm and egg are fertilized outside of your uterus (in a lab) and then placed in your uterus as an embryo.

IUI is less expensive and less invasive than IVF. IUI has a lower success rate per cycle.

What are the steps of IVF treatment?

IVF can be broken down into the following steps:

Birth control pills or estrogen

Before you start IVF treatment, your healthcare provider may prescribe birth control pills or estrogen. This is used to stop the development of ovarian cysts and control the timing of your menstrual cycle. It allows your healthcare provider to control your treatment and maximize the number of mature eggs during the egg retrieval procedure. Some people are prescribed combination birth control pills (estrogen and progesterone), while others are given just estrogen.

Ovarian stimulation

During each natural cycle in a healthy person of reproductive age, a group of eggs begins to mature each month. Typically, only one egg becomes mature enough to ovulate. The remaining immature eggs in that group disintegrate.

During your IVF cycle, you’ll take injectable hormone medications to encourage the entire group of that cycle’s eggs to mature simultaneously and fully. This means, instead of having just one egg (like in a natural cycle), you may have many eggs. The type, dosage and frequency of medications prescribed will be tailored to you as an individual based on your medical history, age, AMH (anti-mullerian hormone) level and your response to ovarian stimulation during previous IVF cycles.

The other steps in the ovarian stimulation process include:

• Monitoring: Your ovaries’ response to the medications is monitored by ultrasounds and blood hormone levels. Monitoring can occur daily or every few days over two weeks. Most stimulations last between eight and 14 days. At monitoring appointments, healthcare providers use ultrasound to look at your uterus and ovaries. The eggs themselves are too small to be visible with ultrasound. But, your healthcare providers will measure the size and number of growing ovarian follicles. Follicles are little sacks within your ovaries that should each contain a single egg. The size of each follicle indicates the maturity of the egg it contains. Most follicles greater than 14 millimeters (mm) contain a mature egg. The eggs contained within follicles less than 14 mm are more likely be immature and won’t fertilize.
• Trigger shot: When your eggs are ready for final maturation (determined by your ultrasound and hormone levels), a “trigger shot” is given to finalize the maturation of your eggs in preparation for egg retrieval. You’ll be instructed to administer the trigger shot exactly 36 hours before your scheduled egg retrieval time.

Egg retrieval

• Your healthcare provider uses an ultrasound to guide a thin needle into each of your ovaries through your vagina. The needle is connected to a suction device used to pull your eggs out of each follicle.
• Your eggs are placed in a dish containing a special solution. The dish is then put in an incubator (controlled environment).
• Medication and mild sedation are used to reduce discomfort during this procedure.
• Egg retrieval is done 36 hours after your last hormone injection, the “trigger shot.”

Fertilization

The afternoon after your egg retrieval procedure, the embryologist will try to fertilize all mature eggs using intracytoplasmic sperm injection, or ICSI. This means that sperm will be injected into each mature egg. Immature eggs cannot have ICSI performed on them. The immature eggs will be placed in a dish with sperm and nutrients. Immature eggs rarely finish their maturation process in the dish. If an immature egg does mature, the sperm in the dish can then attempt to fertilize the egg.

On average, 70% of mature eggs will fertilize. For example, if 10 mature eggs are retrieved, about seven will fertilize. If successful, the fertilized egg will become an embryo.

If there are an exceedingly large number of eggs or you don’t want all eggs fertilized, some eggs may be frozen before fertilization for future use.

Embryo development

Over the next five to six days, the development of your embryos will be carefully monitored.

Your embryo must overcome significant hurdles to become an embryo suitable for transfer to your uterus. On average, 50% of fertilized embryos progress to the blastocyst stage. This is the stage most suitable for transfer to your uterus. For example, if seven eggs were fertilized, three or four of them might develop to the blastocyst stage. The remaining 50% typically fail to progress and are discarded.

All embryos suitable for transfer will be frozen on day five or six of fertilization to be used for future embryo transfers.

Embryo transfer

There are two kinds of embryo transfers: fresh embryo transfer and frozen embryo transfer. Your healthcare provider can discuss using fresh or frozen embryos with you and decide what’s best based on your unique situation. Both frozen and fresh embryo transfers follow the same transfer process. The main difference is implied by the name.

A fresh embryo transfer means your embryo is inserted into your uterus between three and seven days after the egg retrieval procedure. This embryo hasn’t been frozen and is “fresh.”

A frozen embryo transfer means that frozen embryos (from a previous IVF cycle or donor eggs) are thawed and inserted into your uterus. This is a more common practice for logistical reasons and because this method is more likely to result in a live birth. Frozen embryo transfers can occur years after egg retrieval and fertilization.

As part of the first step in a frozen embryo transfer, you’ll take oral, injectable, vaginal or transdermal hormones to prepare your uterus for accepting an embryo. Usually, this is 14 to 21 days of oral medication followed by six days of injections. Typically, you’ll have two or three appointments during this time to monitor the readiness of your uterus with ultrasound and to measure your hormone levels with a blood test. When your uterus is ready, you’ll be scheduled for the embryo transfer procedure.

The process is similar if you’re using fresh embryos, except embryo transfer happens within three to five days of being retrieved.

The embryo transfer is a simple procedure that doesn’t require anesthesia. It feels similar to a pelvic exam or Pap smear. A speculum is placed within the vagina, and a thin catheter is inserted through the cervix into the uterus. A syringe attached to the other end of the catheter contains one or more embryos. The embryos are injected it the uterus through the catheter. The procedure typically takes less than 10 minutes.

Pregnancy

Pregnancy occurs when the embryo implants itself into the lining of your uterus. Your healthcare provider will use a blood test to determine if you’re pregnant approximately nine to 14 days after embryo transfer.

If donor eggs are being used, the same steps are taken. The egg donor will complete ovarian stimulation and egg retrieval. After fertilization takes place, the embryo is transferred to the person who intends to carry the pregnancy (either with or without various fertility medications).

There are many factors to take into consideration before starting IVF treatment. To get the best understanding of the IVF process and what to expect, it’s important to consult with your healthcare provider.

What do you do to prepare for IVF treatment?

Before starting IVF treatment, you’ll need a thorough medical exam and fertility tests. Your partner will be examined and tested as well. Some of the preparation you’ll go through includes:

• IVF consultation (meet with healthcare providers to discuss the details of the IVF process).
• A uterine exam, up-to-date Pap test and mammogram (if over 40).
• A semen analysis.
• Screening for sexually transmitted infections (STIs) and other infectious diseases.
• Ovarian reserve testing, and blood and urine tests.
• Instructions on how to administer fertility medications.
• Genetic carrier screening.
• Sign consent forms.
• Uterine cavity evaluation (hysteroscopy or saline-infused sonography (SIS)).

Your healthcare provider will have you start supplementing with folic acid at least three months before embryo transfer.

What can you expect after IVF treatment?

There are some mild symptoms that you can experience after embryo transfer:

• Mild bloating and cramping.
• Breast tenderness from high estrogen levels.
• Spotting.
• Constipation.

Many people will return to normal activities right after their egg retrieval procedure. However, you shouldn’t drive for 24 hours after having anesthesia. Around nine to 14 days after the embryos are transferred, you’ll return to the clinic for a pregnancy test using a blood sample.

How do IVF injections work?

During your IVF cycle, you’ll take injectable hormone medications to encourage the entire group of that cycle’s eggs to mature simultaneously and fully. Your healthcare provider will determine the type of drug, frequency and dosages you need for your treatment. This is based on your age, medical history, hormone levels and your response to previous IVF cycles if applicable. You can expect to inject fertility medicine for around eight to 14 days.

What medications are used for IVF?

Several medications can be used during a cycle of IVF. Some are taken orally, while others are injected, absorbed through your skin or placed in your vagina. Your healthcare provider will outline the exact dosage and timing depending on your treatment plan.

During the ovarian stimulation phase, you can expect to be given injectable hormones:

• Follicle stimulating hormone (FSH): These hormones work to stimulate your ovaries to produce eggs. You may be given one or a combination of both during your treatment. This is done for approximately right to 14 days.
• Human chorionic gonadotropin (hCG): Usually given as one final shot to trigger your eggs to mature and set ovulation in motion.
• Leuprolide acetate: A type of gonadotropin-releasing hormone (GnRH) agonist (initiates a response) that’s given as an injection. It can help control the stimulation process or be used as a trigger shot.

You may be prescribed birth control pills or injections before starting IVF. This provides a level of control over your cycle and allows all of your eggs to start simultaneously. Most people are given estrogen supplements to take before and after embryo transfer. This hormone helps thicken the lining of their uterus. Progesterone is also added to improve the chances of an embryo implanting and growing into a successful pregnancy. Most continue this throughout their first trimester. These medications are either oral, injectable, transdermal or vaginal.

What is assisted hatching in IVF?

Assisted hatching is a technique used in IVF treatment. It involves making a hole in your embryo’s outer shell before embryo transfer into your uterus. This hole helps your embryo “hatch” from its outer shell more easily. To get pregnant, your embryo must hatch and attach to the lining of your uterus. Think of assisted hatching like giving your embryo a head start and increasing its chances of hatching and implanting in your uterus. Assisted hatching is used primarily for those who’ve had several failed IVF cycles.

How much does IVF cost?

The average cost of an IVF cycle in the United States is $15,000. This doesn’t include the cost of medication, which can cost approximately $5,000 per cycle. It’s hard to give an exact amount because the cost depends on your health history and plan for treatment, insurance coverage (certain states may cover treatment) and the treatment center itself.

What are the risks of IVF?

There are several risks associated with IVF treatment:

• Multiple births: A pregnancy with multiple babies carries a higher risk of premature labor.
• Premature delivery: You may have a slightly higher risk of your baby being born early or at a lower birth weight.
• Miscarriage: The rate of miscarriage is about the same as pregnancies from natural conception.
• Ectopic pregnancy: This is a condition where your fertilized egg implants outside of your uterus.
• Complications during egg retrieval: Bleeding, infection and damage to your bladder, bowel or reproductive organs during the egg retrieval process.
• Ovarian hyperstimulation syndrome (OHSS): A rare condition that causes abdominal pain, nausea, vomiting, diarrhea, rapid weight gain, bloating, shortness of breath and inability to urinate.

What are the most common side effects of IVF?

Some experience side effects from the fertility medications used during the ovulation stimulation phase of IVF. These include:

• Nausea and vomiting.
• Hot flashes.
• Headaches.
• Enlargement of their ovaries.
• Abdominal pain.
• Bruising from IVF injections.

After the transfer of your embryo, you should be able to resume normal activities. Your ovaries will be enlarged, and some discomfort may occur. Common side effects after embryo transfer are:

• Constipation.
• Bloating.
• Cramping.
• Breast tenderness (from high estrogen).
• Spotting.

IVF can be difficult — both physically and emotionally. Many people doing IVF treatment struggle with depression and anxiety. Infertility struggles and IVF can leave people feeling disappointed or overwhelmed. Talk with your healthcare provider about how you’re feeling so they can offer support through the process.

Are IVF pregnancies high risk?

An IVF pregnancy isn’t automatically considered high risk. An IVF pregnancy will be considered high-risk if there’s a medical condition that makes the birthing parent high risk. For example, advanced maternal age, expecting multiples or high blood pressure.

How effective is IVF in getting pregnant?

Your age is one of the strongest factors in the success of IVF. Your chance of becoming pregnant through IVF is much higher if you’re under 35 years old, and lower if you’re over 40 years old. The live birth rate also varies and is strongly associated with age. For example, the live birth rate when the birthing parent is under 35 and using their own eggs is around 46%, while the birth rate of a 38-year-old using their own eggs is about 22%.

How long does it take to know you are pregnant after IVF?

It takes about nine to 14 days to test for pregnancy after embryo transfer. The exact timing may vary depending on the practice or fertility clinic. Your healthcare provider will most likely use a blood test to check for pregnancy. Blood tests measure hCG (human chorionic gonadotropin), which is the hormone produced by the placenta during pregnancy.

How soon after a failed IVF procedure can you try again?

Most treatment centers recommend you have one complete menstrual cycle between IVF cycles. The length of a menstrual cycle varies, but you can expect to wait four to six weeks after a negative test to start another cycle. A small break between cycles is usually advised for health, financial and emotional reasons.

When should I contact my healthcare provider?

If you’re in the process of getting IVF treatment, you should contact your healthcare provider if any of the following happens:

• You develop a fever higher than 100.5 degrees Fahrenheit (or 38.05 Celsius).
• You have blood in your urine.
• There is heavy bleeding from your vagina.
• You have severe pelvic pain.

What questions should I ask the fertility clinic?

Selecting a fertility clinic and undergoing IVF is an important decision. Some questions you can ask are:

• What’s your success rate for couples like us?
• What’s your live birth rate per year?
• What’s your pregnancy rate per embryo transfer?
• How many live births are multiples?
• How much does the procedure cost?
• Can we freeze and store our embryos? For how long?
• Do you allow for gender/sex selection?

Can you select the gender during IVF?

Yes, it’s possible to select the sex of your baby during IVF. Before your embryo is implanted into your uterus, your embryo’s cells can be studied (embryonic testing) for either male or female chromosomes. Couples can choose to only implant the desired sex and discard the other embryos. This service is illegal in many countries outside the United States. Within the United States, not all practices or doctors provide this service.

Is there anything I can do to increase my chances of pregnancy with IVF?

Several factors can determine the success of IVF — some within your control and others not. These factors include:

• Age.
• Height and weight.
• Number of previous births.
• Total number of pregnancies.
• Using your eggs or donor eggs.
• Number of IVF cycles.
• Success rate of the fertility clinic.
• Health conditions.
• Your cause of infertility.

Your healthcare provider will work with you to determine how you can increase your chances of becoming pregnant using IVF based on your situation and medical history.

What is the success rate of IVF by age?

Data collected in the U.S .is measured per egg retrieval, not per cycle. The average percentage of live births per egg retrieval in 2019 was:

• Younger than 35: 46.7%
• Ages 35 to 37: 34.2%
• Ages 38 to 40: 21.6%
• Ages 41 to 42: 10.6%
• Ages 43 and up: 3.2%

Why do IVF treatments fail?

IVF treatments can fail for many reasons and at any step in the IVF process. Some reasons an IVF cycle fails are:

• Premature ovulation.
• No eggs are developing.
• Too many eggs are developing.
• Egg isn’t fertilized by sperm.
• Sperm quality.
• Embryo stops growing or will not implant.
• Problems with egg retrieval or embryo transfer.

Your healthcare provider will be able to examine each step of the process with you and determine how to best move forward with future treatments.

Can IVF cause birth defects?

It’s not entirely known if IVF alone is responsible for birth defects. For non-IVF pregnancies, around 2% of all children will be born with a birth defect. Some studies show a slightly higher risk for babies born through IVF. This could be due to delayed conception or related to the underlying cause of infertility.

What is the best age to get IVF?

Research shows that your chances of getting pregnant or having a live birth after IVF treatment decreases beginning at age 35. The success rate declines significantly after age 40.

Should you freeze embryos during IVF treatment?

Embryo cryopreservation is done as part of most IVF programs. Some people choose to freeze and store embryos so they can have another chance at getting pregnant. Extra embryos can be frozen and stored for several years, although not all will survive the freezing and thawing process.

A note from Cleveland Clinic

IVF treatment is a personal and complicated process. Speak openly with your healthcare provider so you understand all the steps involved. Your healthcare team is there to support you and your partner throughout your treatment.