Hormones and shots and procedures, oh my! What is it like to undergo IVF?

People are having children later in life, whether the reason is pursuit of career aspirations, travel, or riding the asymptotic curve to financial security. This truth is never more evident than in the field of medicine, where more and more women are taking the long road of training to become physicians. Some of us (like me) even choose this training as a second career, rendering us older from the start. You've heard saying such as "40 is the new 30", etc., but the reality is that a woman is born with all of her eggs and those eggs age with her. She may follow a perfectly healthy lifestyle and appear younger than her real age in many ways, but her eggs are as old as she is.

As eggs age, their quality declines in the form of DNA damage, which negatively effects their ability to make a healthy embryo that will grow into a healthy baby. By the age of 40, the percentage of eggs that have DNA damage incompatible with healthy embryo formation is approximately 75%! On top of this immutable fact, aging brings the possibility of medical issues that can affect fertility in both a mother and a father. The chance of a naturally-occurring pregnancy during any given monthly cycle of a 40 year old woman is approximately 5-10%, and due to the DNA damage I already mentioned, the chance of a live birth resulting from that pregnancy is even lower. It is truly a miracle in my opinion that women over 40 have spontaneously-conceived, healthy pregnancies.

Enter in vitro fertilization (IVF). IVF is a long and detailed process, requiring lots of resources, money, time, and patience. The first stage of a typical cycle involves, ironically, taking oral contraceptives to reset the hormone milieu and force all eggs into a senescent, follicular stage. The second stage involves stimulating the ovarian follicles with daily doses of a hormone cocktail. It is usually some combination of FSH, LH or an LH inhibitor depending on timing, and possibly GH. There is quite a bit of monitoring at this stage, including almost daily ultrasounds and blood draws to evaluate the growth and maturation of the eggs. The third stage is egg retrieval, in which all fluid-filled cysts within a certain size distribution are aspirated for the contained egg. The eggs are then fertilized with the intended sperm (by various methods depending on the presence or absence of male-factor infertility) and are allowed to grow for 3-5 days into multi-celled embryos. The last stage is embryo transfer, in which selected embryos are injected back into the uterus for implantation. This may occur using the aforementioned, freshly grown embryos approximately 5-6 days after the transfer, or the embryos can be frozen for testing and/or later transfer. Once an embryo transfer occurs, it's up to fate (and continued hormonal supplementation)... after the dreaded "two-week wait", it's time for a pregnancy test!

As you can imagine, the process is not for the faint of heart, nor is it for the person with no flexible time and no extra money. I had to do IVF to get pregnant, and these are my experiences.

Time: If a fresh embryo transfer is planned, all of the steps mentioned above take approximately 6-7 weeks to complete (not including the two-week wait). If the embryos are intended to be tested or frozen, the first three stages themselves take 5-6 weeks. After the egg retrieval, the ovaries must rest and the enlarged follicles must resorb over time. This is achieved by having a period and going back on oral contraceptives for at least 3 weeks. Then the uterine lining is augmented with estrogen supplementation for another 3 weeks prior to the embryo transfer. During this time, other testing may take place for the patient (such as a hysterosalpingogram, hysteroscopy, or endometrial biopsy) and/or for the embryos (such as preimplantation genetic screening for aneuploidy or diagnosis of genetic diseases).

Not only does each pregnancy attempt take a significant portion of a year (during which time a woman's eggs undergo further aging), but each cycle also requires quite a few appointments for monitoring, lab draws, procedures, etc. Although I sometimes had to apologetically make my schedule requests after my practice group's time deadline, I was lucky to have enough vacation time built into my yearly clinical commitment that I could take as much time off as I needed. Not everyone would need to take the entire day off for an hour-long morning appointment, but as an anesthesiologist I found that it was the only way to make things work. A physician who sees patients in a clinic might be able to shift her clinic hours back a bit to make morning appointments - which occur every other day and at times every day during the stimulation phase of a cycle. And at my fertility clinic, the egg retrievals were conveniently performed on the weekends.

Money: With some exceptions, IVF is commonly not covered under health insurance in the United States. That said, I found that certain ultrasounds, lab tests, and medications would occasionally be covered by my insurance based on the fact that they were recognized as appropriate interventions for my preexisting infertility diagnosis. Prices for IVF vary slightly depending on the part of the country where the fertility clinic is located, the medications prescribed, etc. A typical cycle including the stimulation period, monitoring ultrasounds, and the egg retrieval procedure runs $12,000 on average, not including medications (another $3000 - $5000). A frozen transfer at a later date is approximately $3000 - $5000. Preimplantation genetic testing of embryos adds approximately $5000 - $8000 to any particular cycle. A portion of these costs can be offset using "batching" techniques or multi-cycle discounts, tax deductions (in some cases), and an FSA; however, IVF in its many forms is undoubtedly going to present some financial stress for any patient.

"Heart": Egg retrievals are performed across the country using different modes of anesthesia. At the IVF clinic I used, it was treated as a moderate IV sedation procedure with fentanyl and midazolam; however, there are some clinics that do deeper sedation or even general anesthesia. An embryo transfer, regardless of whether it is fresh or frozen, is usually done with oral diazepam, and the patient does not need to be NPO. Prior to either of these procedures, an IVF patient can expect to have many transvaginal ultrasounds, which can be uncomfortable for some women. There are other diagnostic procedures that may figure into an infertility workup or IVF journey treatment plan as well, such as hysteroscopies, biopsies, hysterosalpingograms, etc. In addition to these procedures, the patient must receive daily injections of hormones during the follicle stimulation phase and sometimes additional daily shots after implantation. Most of these shots are subQ, but some of them are IM. I must admit that I myself am somewhat squeamish when it comes to being a patient, but I found the invasive nature of IVF to be tolerable. The mental aspect of the uncertainty, the waiting, the rescheduling of life so that appointments and cycles can be completed, etc. was much more difficult. But if you are a person who does poorly with procedures, this may be an important factor in your IVF decision path.

Speaking of decisions, IVF can take a toll on personal relationships - friendships, family bonds, and romantic relationships. This usually presents in the form of differences in opinion on direction of care, number of IVF attempts, or ethical issues with genetic testing/embryo selection/possibility of multiple gestation/etc. Going through IVF can also impact your feelings about yourself; many women complain of feeling unwomanly, and I was not immune to this myself. It is difficult to accept that you need assistance achieving something that is so basic to human life as reproduction. I dealt with this through therapy, quiet time/meditation, and journaling, but everyone differs in terms of what works for them to manage such stress. I recommend to every woman undergoing IVF that she at least attempt to get therapy for herself, if not couples therapy for her and her partner.

IVF is a physically and mentally involved endeavor. Copious time, financial allocation, and mental fortitude are required. But for many patients with complex infertility issues, it is their only path to genetic parenthood (as it was mine). I'm 32 weeks pregnant now and I am very happy with the path I took to get here. As a "success story" with a little girl on the way, it was all worth it!