Wellness

When to Consider In Vitro Fertilization—and What to Expect

Photo Courtesy of Sarah Sherman Samuel

When to Consider In Vitro Fertilization—and What to Expect

For many, in vitro fertilization, or IVF, is the miracle medical treatment that allows them to have children at their own pace—or at all. It’s the endpoint of many fertility journeys, a last recourse when nothing else works. And because of its reputation for solving otherwise-unsolvable fertility issues, some think of IVF as a sure thing: Take an egg, mix in some sperm, put them in a dish, and plan your baby shower.

Not so fast. While IVF is certainly a powerful tool, according to Dr. Marcelle Cedars, the director of UCSF’s Center for Reproductive Health, it’s not a cure-all. IVF is an intense medical process, and, as such, it’s not right for every patient. It also comes with its own costs, risks, and possibility of failure. Still, there’s good reason for optimism: Since the first IVF birth, about four decades ago, there have been over 5 million much-wanted babies brought into this world—over 5 million success stories to look to for hope.

A Q&A with Marcelle Cedars, M.D.

Q

Can you explain IVF? When is the right time to consider it?

A

IVF, or in vitro fertilization, is the process of taking the egg and sperm out of the body and joining them together in the laboratory, culturing the fertilized egg in the lab, and then transferring the embryo back to a woman’s uterus. IVF was initially developed for women who had blocked fallopian tubes because that’s where fertilization normally takes place. The first IVF birth was in 1978 in the UK, and the first in the US was in 1981. It’s a relatively new field, and it has really changed dramatically since its inception. Now IVF can be used for any cause of infertility. Ultimately, IVF is the last resort when simpler modalities—such as ovulation induction, intrauterine insemination, or surgical correction of anatomic fertility problems—have failed.

The window for IVF, in terms of when someone should consider it, has gotten shorter. We’ve realized the most important factors for success are first, the age of the female partner—because both egg quantity and egg quality decline with aging—and second, the duration of infertility. We now recommend that women under thirty-five begin evaluation for infertility if they’ve not conceived in the first year of trying, and that women over thirty-five begin evaluation if they’ve not conceived after six months.

“IVF is the last resort when simpler modalities—such as ovulation induction, intrauterine insemination, or surgical correction of anatomic fertility problems—have failed.”

We should be able to complete an infertility evaluation and come up with the diagnosis—the third critical factor—within a month, and then make a treatment plan. We’ve shortened this time to try to be more efficient with a woman’s or couple’s time and ultimately improve success rates and decrease time to pregnancy. Depending on the diagnosis, the treatment plan might involve going directly to IVF, especially if there’s a sperm issue, if the tubes are blocked, or if the woman is older and has a shortened reproductive window. For cases where the sperm counts are normal, the woman ovulates, and the tubes are open, we might start with something simpler, like artificial insemination.


Q

What is the typical success rate of IVF?

A

The national average success rate for IVF depends on patient age. It might be 50 percent in women under thirty-five, and it might be 10 percent in women over forty-three.

You want to pick a clinic with a success rate at or above the national average, but beyond that, to compare one clinic to another based on success rates alone can be misleading. Some programs work very hard to maintain success rates, which is very different from doing what’s best for individual patients. Different clinics accept or don’t accept certain patients and vary in how they treat patients in terms of who they cancel and who actually makes it to egg retrieval and transfer.


Q

What should you expect out of the IVF process?

A

Typically, we talk about IVF treatment as a two-month process. There are some preparatory tests that need to be done, and the month prior to the actual stimulation of the ovaries, there’s usually some lead-in to prepare the ovaries.

Stimulation

What we call stimulation—when the patient is taking daily subcutaneous injections—is typically a ten- to fourteen-day time period. That’s the part that’s most intensive for the patient; they’re having frequent office visits for ultrasounds and blood tests. The primary stimulation drug we give is the hormone FSH, or follicle stimulating hormone, which is the same hormone the brain makes to stimulate eggs.

One of the things I think is very important to understand is that the number of eggs we can get in any given cycle is most dependent on the number of eggs or follicles any individual woman has available. All women have a number of eggs available each month, and that number varies from woman to woman. It might be two, or it might be twenty-five or thirty. In a normal menstrual cycle with no medication, one egg goes to maturity and the others die away. And when we stimulate the ovaries for IVF, what we’re really doing is rescuing the little eggs that would have otherwise died. We’re not using up any eggs that wouldn’t have been lost that month anyway. We’re just trying to get more eggs to maturity. That’s the good news. The bad news is if a woman has only two or three follicles in her cohort, I can give her all the drugs in the world, but she’s not going to make more than two or three eggs.

“And when we stimulate the ovaries for IVF, what we’re really doing is rescuing the little eggs that would have otherwise died.”

Most people don’t get significant side effects from the stimulation drug itself, but they do get side effects from what the drug does in the ovaries, particularly if they have a large number of follicles capable of responding. Each egg doesn’t know the other eggs are there, so it grows to the same size and makes as much estrogen as if it were there by itself. So a woman may have an estrogen level that’s ten times as high as it is in a normal menstrual cycle. It’s not necessarily that she’ll get the emotional side effects that a lot of women are worried about, but she might get short-term breast tenderness, bloating, abdominal discomfort, and increased vaginal lubrication and discharge.

Maturation and Retrieval

We measure the eggs’ maturation based on an ultrasound picture of the follicle, the pocket of fluid around the egg, and the level of estradiol in the blood. When it’s time, we give the patient what we call a trigger shot, which causes the final maturation of the egg.

Then we use ultrasound guidance to do egg retrieval transvaginally. We have a needle—not much bigger than a needle used to draw blood—that goes through the wall of the vagina and into the ovary. We can’t see the egg itself, but we can aspirate the fluid around it, and then the laboratory looks under a microscope to find the egg. Patients are given sedation or anesthesia for comfort, and the procedure takes only about twenty to thirty minutes.

Because we go from the vagina, which is not sterile, into the ovary, which is, there’s always a small risk of infection. There’s also a risk of some bleeding, and one in ten thousand or one in a hundred thousand bleeds significantly enough to need to go back to the operating room. Because the bladder sits right on top of the uterus and the bowel sits right below, there’s a risk of injury to the bladder and bowel, but I’m not aware of any serious complications from that.

Fertilization and Transfer

If a patient has a male partner, we typically get his sperm specimen the same day we retrieve the egg. It is possible to get the sperm ahead of time and freeze it, and women who don’t have a male partner may choose to use sperm from a donor agency that has frozen, FDA-approved sperm.

“If a woman has only two or three follicles in her cohort, I can give her all the drugs in the world, but she’s not going to make more than two or three eggs.”

Then, the fertilization process—combining the egg and the sperm in the lab—is fairly quick. And we’re able to confirm fertilization the next day. Patients will typically get a phone call letting them know how many eggs fertilized. Depending on the patient, the plan may be to freeze, transfer, or grow the embryo. If the patient is planning to transfer the embryo, we now have the potential to do genetic screening for abnormalities. If the embryos are being grown right away, they’ll be cultured in the laboratory for three to five days.

Typically, if a patient doesn’t get a transfer of an embryo, she’ll get her period within ten days of egg retrieval. Then, depending on how aggressive her hormonal response was, she still could have a little bit of bloating in the next menstrual cycle, but by the cycle after that, she should be back to normal.


Q

Are there any other risks to know about?

A

There have been a fair number of studies that have looked at IVF and the potential risk of breast, ovarian, and uterine cancers, among others. The best studies come from the Scandinavian countries where they have good data systems that link the women who got fertility drugs to the cancer registries, and most of that data is reassuring in terms of there not being significant long-term risk.


Q

Is there anything important for men to do in preparation for IVF?

A

Men should avoid exposure to heat: hot tubs, saunas. The testicles are outside the body because they need a cooler temperature to function normally, so hot tubs and saunas can have very dramatic negative effect on sperm function. This is a short-term effect—but “short-term” for sperm is two to three months because the sperm life cycle is about seventy to seventy-five days. So if you go on vacation and spend a week in the hot tub, that can knock the sperm out for months.

A healthy lifestyle is very important, just as much for men as it is for women. Certainly no smoking, and cocaine and marijuana can also be bad actors in terms of sperm function. Men who are overweight typically have lower sperm counts as well. These effects can be more long-term—minimum about three months, but they can last up to six to twelve months, particularly for cocaine.

There are some data that suggest antioxidant vitamins are helpful in terms of sperm function, but I don’t think anyone knows what the right combination of vitamins is yet.


Q

Why is age such an important factor in IVF? Do you imagine there will be other options for women beyond IVF in the future?

A

One thing we have yet to overcome with IVF is the age of the egg. It’s an active area of research to try to understand why ovaries and eggs age, even when women are healthy and exercise and have a good diet. But as far as we can tell, the strongest driver of the health of an egg is its chronologic age; until we understand what it is that causes the increased genetic risk as women get older, that’s something that IVF can’t fix.

The father’s age does play a role as well, but the genetic risk seems to come in at a much older age—maybe fifteen years later—than for women. There are also data that suggest that as men get older, there’s an increased risk for the offspring’s neuropsychological development, including the development of autism, schizophrenia, and other neuropsychological issues.


Q

Are you finding that women are coming to you at earlier ages asking to freeze their eggs for that reason?

A

I think they are, but I think there’s a balance to freezing eggs: You don’t want to do it too early or too late. Women in their mid-twenties probably shouldn’t freeze their eggs because the likelihood that they would use those eggs is pretty low. Once women get into their thirties, then it starts to make more sense to have that conversation. IVF is not a panacea. I think people feel that if they have eggs in the freezer, they have a guaranteed baby—they don’t—so sometimes people make life choices that they can’t unwind. They’ll freeze eggs, and then they’ll wait until they’re forty-five to try to get pregnant, and then they’re too old and the eggs they froze don’t yield a successful pregnancy.

“You should never have children before you’re ready—but when you are ready, don’t delay because there are eggs in the freezer.”

It’s a matter of education; people need to understand IVF as an opportunity. But when you’re ready to have children, the strongest driver is, again, age. You should never have children before you’re ready—but when you are ready, don’t delay because there are eggs in the freezer.


Q

Where is IVF research headed?

A

We want to decrease costs to increase access for women, and a lot of the cost is from the expensive embryology laboratory. Currently, researchers are investigating a low-tech vaginal culture system where you put the eggs and sperm together in a small device that a woman then carries in the vagina. The embryos incubate in the device, and then we can remove them and transfer to the uterus in the same process as regular IVF.


Q

For women or couples deciding to do IVF, what’s important in picking a clinic?

A

Go to clinics that are transparent about how they’ll they treat you and what their policies are. You don’t want to go to a clinic that has a certain way that they treat all patients. They should see a wide enough variety of patients that they individualize care so they can optimize it for any individual patient.


Q

There was a recent crisis involving eggs that were compromised at a few different labs. Do you think it will change the way labs protect eggs in the future? Or was that a one-off case?

A

This has been, obviously, a devastating event for patients. I think it has made all egg freezing programs—hundreds in the US and thousands around the world—take another look at their systems and the backups and redundancies and alarms they have in place. There’s no perfect system, but these are more likely rare events than they are a systematic problem. Still, to have two centers within such close proximity of each other compromised is rattling both for patients and practitioners.

RELATED RESOURCES

Picking a fertility clinic can be daunting, but there are many organizations that offer information and guidance to infertility patients. Here are some online resources recommended by Dr. Cedars, who stresses the importance of good, unbiased information when considering IVF:

The American Society of Reproductive Medicine (ASRM) website focuses on reproductive knowledge and empowerment, providing FAQs, educational videos, and commentary on policy and ethics.

The Society of Assisted Reproductive Technology (SART) website provides an IVF success predictor tool and allows you to search clinics based on their location, services, and other data.

The CDC monitors the safety and effectiveness of assisted reproductive technology, provides patient resources, and reports the success rates of fertility clinics across the U.S.

RESOLVE: The National Infertility Association is a non-profit advocacy organization that helps patients navigate their fertility options, insurance coverage, and financing. RESOLVE also organizes infertility support groups, free of charge.


Marcelle Cedars, M.D., is a reproductive endocrinologist and the director of both the Center for Reproductive Health and Division of Reproductive Endocrinology at UCSF, where she connects research with patient care. Cedars’s clinical specialties as an ob-gyn are in vitro fertilization, perimenopause, and PCOS.


The views expressed in this article intend to highlight alternative studies. They are the views of the expert and do not necessarily represent the views of goop. This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.

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