Most centers explain well what happens in IVF cycles up to egg retrieval, but relatively little is explained for the period between retrieval, embryo transfer and first pregnancy test. This is, of course the most stressful period of the whole IVF experience.
So imagine, you just finished your egg retrieval and were sent home after uneventful recovery. You already know how many eggs were retrieved, but the embryologists still do not know how many among those retrieved eggs are mature, immature or atretic (“overcooked”). That they usually know only later, ca. six hours after fertilization.
The following morning you should be receiving a phone call or email from your IVF center that advises you how many of your eggs fertilized. The expectation is that at least 60-80% of mature eggs fertilize, though variations will depend on a multitude of factors, like female age (fertilization rates decline with advancing female age), male factor infertility (abnormal semen fertilizes poorly if spontaneous fertilization is allowed), etc.
Whether embryos are transferred on days 2 or 3 after fertilization (cleavage stages) or at blastocyst stage (days 5-7 after fertilization) should have been discussed with patients before cycle start. Though CHR considers such management inappropriate, most IVF centers now culture embryos routinely to blastocyst stage. As we previously discussed in these pages, especially women with small egg and embryo numbers should, in our opinion, have earlier embryo transfers at cleavage stage (days 2/3 after fertilization). The medications and their timing between egg retrieval and embryo transfer, of course, depend on whether embryos undergo short or extended culture, and most centers provide patients a detailed written schedule.
The embryo transfer usually takes place in the IVF unit. How many embryos are transferred should also already have been discussed before cycle start, though changes may be advised based on the number of embryos available on transfer day and embryo quality. Number of embryos to be transferred should, therefore, be again discussed just before the transfer takes place.
In principle, embryo transfers can be performed with full bladder or with empty bladder. Full bladder transfers have the advantage of using a transabdominal ultrasound transducer during the procedure, while empty bladder transfers require a transvaginal transducer. Both approaches have subjective advantages and disadvantages, but they do not differ in implantation and pregnancy rates.
In contrast to egg retrieval, which is usually done with the patient under sedation, most patients do not need to be premedicated for embryo transfer. The procedure is usually quick: Once the patient is positioned on the exam table, a speculum is inserted into the vagina, like in a routine gynecological examination. The vagina is then flushed with room-temperature warm saline and the cervix is cleaned off mucus. Once that is established, the physician is ready to receive the catheter that contains the embryo(s) through the window that connects the procedure room with the embryology laboratory. On the other side of this wall, embryologists prepared the embryo(s) and loaded it (them) into a transfer catheter. One embryologist now hands this catheter to the physician who carefully feeds the tip of the catheter into the cervical opening of the uterus, and advances the catheter under ultrasound control, so that the embryo(s) at the tip can be easily expelled with a quick push on the plunger of the syringe that is attached to the end of the catheter.
At CHR, patients can observe this process on the TV screen in front of them, which is connected to the ultrasound machine the physician uses to guide the transfer catheter. The whole procedure usually takes no more than five minutes, though complications sometimes can lengthen the process. The most frequent complication is that the catheter refuses to glide into the uterine cavity. This can happen when the entry canal is too narrow or too twisted. In such cases other methods of insertion can be applied but the process becomes more complex and can also be more uncomfortable to the patient.
Once embryos have been successfully inserted, the patient rests for a few minutes before she is allowed to get up. She rests a little more in recovery and is discharged home.
The best thing a patient can do after embryo transfer to maximize their chances of IVF success is to closely follow the physicians' instructions about medications. Beyond that, there really isn't much a patient can do to improve their chance of success after embryo transfer. However, there are many, many false rumors circulating about what is and isn’t advisable after an embryo transfer. So, here is what we tell patients at CHR:
Waiting for the first pregnancy test 10-12 days after embryo transfer is excruciating. We know that, but, unfortunately, have not yet found a better way. Nothing is more exhilarating for our staff than being able to tell a patient on the phone that her pregnancy test was positive; nothing is more devastating than having to notify a patient that her IVF cycle was unsuccessful. But both of these emotions, of course, are even stronger in patients. We really know and understand that!
This is a part of the October 2018 CHR VOICE.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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