Fertility Treatment: What to Expect

Infertility is complicated and influenced by many factors, so diagnosing and treating it can be a complex process. 

John Petrozza, MD, chief, Division of Reproductive Medicine and IVF and director of the Massachusetts General Hospital Fertility Center and Kelly Linden, RNC, BSN, Nurse Manager of the Mass General Fertility Center offer a look at what to expect during your fertility treatment. 

Initial Consultation

Expect to spend much of your first appointment reviewing your medical history and any prior treatment with your doctor. This visit can be overwhelming, but it is important that your care team understands you, your partner (if applicable), and your health and answers any questions or concerns that you have.

You can expect a couple of standard next steps:

• Schedule or review needed tests or procedures to assess your situation and help guide diagnosis and treatment. Some of these may have been done by your referring physician.
• Identify and schedule any consultations that may be needed, i.e. nutrition, cardiology, and social work to ensure that there are no issues that may affect your treatment or pregnancy.
• Review insurance paperwork and schedule financial consultation (if needed). Each insurance has certain requirements and rules regarding testing as well as certain guidelines pertaining to a patient’s medical history (including weight, smoking history) or other medical issues and we want to be sure that you have a full understanding of your coverage.

Preparation for Treatment

Even if you’ve gone through some testing before coming to the Fertility Center for care, it’s possible you’ll need to have more tests done. This can feel like an additional delay, but it’s an important step to help your care team review your individual circumstances and development your individual treatment plan.

Much of the testing you’ll go through during fertility treatment is tied to your menstrual cycle, so this step may take more time depending on where you are in your cycle. During this preparation period, you will undergo testing to help your care team assess what might be causing fertility problems for you and your partner (if applicable). These tests can include:

• Blood testing
• Ultrasound
• Infectious disease testing
• Uterine evaluation
• Semen analysis

Medication and Monitoring

Once your testing and any necessary referrals have been completed, you will return and meet with your care team to discuss the best plan for your fertility care. 

Generally, there will be several options for fertility treatment discussed:

• Continuation of your natural cycle without any medication
• Controlled ovarian hyperstimulation (COH), a process that uses fertility medications such as Clomid, Gonal-F or Letrozole that stimulate your body to mature more eggs than normal (during a normal menstrual cycle, usually only one follicle will ovulate one egg) or perhaps provide an opportunity for you to ovulate more consistently so that you can time exposure to sperm more reliably. You can expect to take anywhere from 5 to 10 days of medication based on your diagnosis
• Intrauterine Insemination (IUI)
• In vitro Fertilization (IVF)
• There may be times where surgery is indicated, for example if you have ovarian cysts, fibroids, endometriosis, or other uterine abnormalities. Many of these surgeries may give you the opportunity to conceive naturally while others may optimize your ability to conceive with assisted reproductive technologies
• Some patients may require the use of donor sperm or donor eggs
• Certain patients may require treatment simply to address genetic issues that may predispose their offspring to specific diseases

Note that your insurance coverage may play a role in deciding your course of action–some insurance plans will allow you to proceed directly to IVF, while others may require several cycles with COH.

Most medical treatments require a thorough understanding of how the medications work, how they are administered, their potential side-effects and treatment risks. We utilize a wonderful on-line teaching platform called EngagedMD which helps walk you through all these areas, asks you questions to ensure your understanding and ensures you understand the process and treatment recommended by your fertility care team. Of course, there is always someone available, 24/7, to ensure that your questions are answered, and physicians and nurses are available during your monitoring to address any concerns.

During this time, you can expect to come in every few days for monitoring visits to keep a close eye on the development of your follicles through different kinds of testing:

• Blood testing
• Ultrasound

Controlled Ovarian Hyperstimulation

Controlled ovarian hyperstimulation is a wonderful treatment and can be quite successful for women with at least one patent (not blocked) fallopian tube, appropriate sperm parameters or using donor sperm and a desire to keep treatments simple. Benefits include the need for less medication, less monitoring and the opportunity to do treatments in sequential cycles if needed.

For women with irregular cycles, the goal is to regulate her cycle and control day-of ovulation to help time introduction of sperm either via intrauterine insemination (IUI) or timed intercourse.

For women with unexplained infertility, the goal is to stimulate the growth of one to two extra eggs and control day-of ovulation to help time introduction of sperm either via IUI or timed intercourse.

Intrauterine Insemination (IUI)

Intrauterine insemination (IUI) is a procedure that assists with insemination. During IUI, either your partner provides a semen sample or donor sperm is used. The sperm is then processed to help ensure we have the best sperm available.

The timing of your IUI depends on your follicle growth. When monitoring shows that your ovarian follicles have grown to appropriate size, egg maturation and ovulation will be triggered and the IUI will then be completed one to two days later. 

A member of your care team will use a small catheter to insert the washed sperm through your cervix into your uterus. Pregnancy testing occurs two weeks later.

In Vitro Fertilization (IVF)

You have likely heard of “IVF,” but many people do not know what exactly IVF entails. Fertility treatments like in vitro fertilization (IVF) are not a single treatment, but rather a series of procedures that you, and your partner (if applicable), will go through over a period of weeks. It can be difficult to predict exactly how long your fertility treatment will take, since your treatment will be tailored to you and every patient and every cycle is unique. Some insurance require IUI rounds before starting IVF.

With the start of you next menstrual period, after testing has been completed and we have obtained financial clearance, either through your insurance company or self-pay, we will order your medications and send you a mock schedule. Once this is done, you would contact us on the first day of your next period, and depending on your specific plan, you will be monitored closely with blood testing and/or ultrasounds.

Triggering and Egg Retrieval

When monitoring shows that your ovarian follicles have grown to appropriate size, final egg maturation is triggered with a human chorionic gonadotropin (hCG) or a leuprolide acetate injection, or sometimes both.

36 hours later, one of our fertility physicians will perform your egg retrieval. This is an outpatient procedure performed under sedation in the Fertility Center on Mass General’s main campus. There is minimal risk associated with this procedure, but you will want to plan to take the day off and arrange for a ride home.

If the plan is to fertilize your eggs, we will either collect a sperm sample from your partner (if applicable) that day or use donor sperm.  If you’re planning on freezing your eggs, these will be frozen using a process called “vitrification.” Your eggs may be frozen at either the mature (MII) state, which is most common, or perhaps at both the mature (MII) and immature (GV) state if indicated based on your history and fertility provider’s recommendation.

Fertilization

After the eggs and sperm have been collected, our embryologists will combine them in our specialized lab to facilitate fertilization. Some patients choose to take additional steps based on previous testing results that may help to increase chances of success:

• Intracytoplasmic sperm injection (ICSI) – the sperm is injected directly into an egg
• Assisted hatching – a hole is poked in the embryo’s outer membrane to increase chances of implantation
• Preimplantation genetic testing – genetic testing is done on the embryos before they are transferred to your uterus to determine whether any genetic defects are present

Embryo Transfer

After three to six days, we will determine how many embryos have been created and evaluate the health and growth of the embryos. Your fertility team will discuss the recommended number of embryos to transfer based on your age, prior treatments and Mass General Guidelines. While this plan typically does not change, it is possible, based on how the embryos are developing, that the physician and embryologist at your transfer may recommend a different number to consider. Please review the Mass General Embryo Transfer Guidelines so that you have a full understanding of how these transfer decisions are made.

At three or five days after fertilization, your embryos may be transferred back into your uterus (the exact timing depends on the status of your embryos), unless they’re going to be frozen or tested. The embryos are placed using a thin, flexible plastic tube. You will not be sedated for this procedure and it is generally painless, but you may experience mild cramping. You will need to come in with a full bladder to make it easier to see your uterus with a transabdominal ultrasound probe. This is different from what you have been doing during your monitoring, where we want you to have an empty bladder to make it easier to see your ovaries with the transvaginal ultrasound probe.

Please understand that our fertility physicians cover the IVF Unit on a weekly basis meaning that one provider will be doing all the egg retrievals and embryo transfers for that week, assisted by one of our reproductive endocrine fellows. It is very likely that this physician will not be your primary fertility physician, but please be assured that everyone on our team are highly qualified and experts in their field.

After Your Transfer: Watchful Waiting

After the embryo transfer, controlled ovarian hyperstimulation, or IUI cycle, you may be given a progesterone supplement that helps support the uterine lining and encourage the embryos to implant.  For many natural cryothaw cycles, controlled ovarian hyperstimulation and IUI cycles, progesterone is not indicated.

You’ll then move into a period of watchful waiting:

• Approximately 12-14 days after your transfer, you’ll have your first pregnancy test via a blood draw in the office
• If that test is positive, you’ll have another pregnancy test via a blood draw in the office two days later
• If the second test is positive, you will have early obstetrical ultrasounds scheduled at approximately six weeks and eight weeks of gestation

If the results of those ultrasounds are positive, you will transition to an obstetrician or midwife to continue your prenatal care.

If the results of a round of treatment are unsuccessful, you’ll be offered a follow-up consultation with a physician to discuss the cycle. We’ll collaborate with you on next steps and answer all your questions and concerns.