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Stages of the In vitro procedure

Although our approach to each patient and his In vitro procedure is strictly individual, every procedure has a certain "scenario" which is to be followed.
IVF is carried out through the following stages:

1. Preparation for in vitro fertilization;
2. Stimulation of the ovaries;
3. Collecting of eggs;
4. Obtaining sperm;
5. Laboratory stage: fertilization and early embryo growth;
6. Embryo transfer into the uterus;
7. Pregnancy test;

This program has its "variations" depending on whether your treatment will be performed with donor genetic material (eggs and / or sperm), whether there will be cryopreservation (freezing of ova and embryos), or if the procedure will be carried out on the basis of a spontaneous cycle.

Stimulation or no stimulation?

The success of the IVF method depends largely on the quality and the number of oocytes collected.
The aim of the stimulation of the ovaries (controlled ovarian hyper stimulation) is to ensure the formation of a larger number of quality eggs by the application of various medicaments.
Stimulation is carried out in accordance with certain schemes, called stimulation protocols.
The decision on which protocol and how your stimulation will be performed should be taken by your physician. Your physician will assess your particular case and take into account the state of your ovarian reserve, age, ovarian response to previous stimulations, comorbidities and other factors.

IVF Stimulation protocols

In vitro Long protocol: It starts with an injection (muscle) of medicament, suppressing the function of pituitary, most often performed on the 20th -21st day of your cycle;

In vitro short protocol:The stimulation begins on the 2nd -3rd day of your cycle;

In vitro spontaneous cycle: Stimulating medicaments are not applied or in some cases can be applied minimal stimulation via pills or a short course of injections prescribed by your physician.

Practical advice according to your stimulation protocol

Every woman reacts differently to different medications. That is why, when deciding on stimulation, applying an individual approach to each case is extremely important for us.
Our team devotes their time and energy to consider the nature of each case and what kind of individual approach to apply to each woman, before the beginning of a stimulation procedure.
We always strive to establish which protocol will be the most suitable for you, so that we can achieve the desired result.

Stimulation - long protocol

The long protocol begins with the so-called block injection approximately on the 20th day of your menstrual cycle.
The injection is intramuscular and is performed by our obstetricians.
The aim is the ovary function to be suppressed. By carrying out analysis of the hormone E2 we determine that the suppression has occurred and then we can initiate the actual stimulation with gonadotropin hormones.
The process of suppression requires about ten days to two weeks’ time, so the block injection is applied in the previous month before the stimulation.
The actual stimulation lasts for ten days to two weeks. The aim is the interference of your own hormones in the process to be eliminated. Thus, the result achieved is: a more adequate follicle growth, more precise and uniform ripening, and sometimes higher number of follicles.

Application of a block injection:

When planning your stimulation, depending on the length of your cycle, your physician will schedule your next visit for the block injection. Usually it is the time between the 19th and 23rd day of your menstrual cycle.
About two weeks later the actual stimulation will start.


When should you schedule your appointment after the blockage?


IMPORTANT: Taking into consideration the suppression of the ovarian function in your previous cycle, the beginning of your cycle is not important for the initiation of the stimulation. What is important is when the ampoules with depressing effect have started to work, i.e. you may now have your monthly cycle, but your physician may decide that your stimulation will start the following week, which is not an unusual situation.
It is necessary that you schedule your visit as your physician advised you – 10-14 days after the day on which you had the block injection.
It is important for you to remember that you must have pronounced bleeding when you come for the visit. So if on the day, determined by your physician, your cycle has not yet come, your visit will be postponed until the day when the bleeding appears.
When you come to the hospital you will be scheduled for blood tests that will allow the tracking of your E2levels and you will have an ultrasound checkup.
Then your physician will give you instructions for the upcoming stimulation cycle.

Stimulation - short protocol

In the short protocol there is no injection to suppress the pituitary gland on the 19th -23rd day of your menstrual cycle.


The short protocol starts from the 2nd -3rd day of your bleeding and begins with the gonadotropin treatment.


The "logics" in this procedure is reversed, compared to that in the long protocol - except for the hormones for stimulation we also use the support of your own hormones. If your ovaries have difficulty to react and you produce a small number of follicles or even have had a failed stimulation in the long protocol procedure, then we need more support, and here come your own hormones to help us.

When should you schedule your appointment?

During the preparation for your In vitro procedure in the previous month, your physician will inform you on what day of your monthly cycle you have to come for a checkup.

Usually this is the second or the third day of your menstruation.

Our recommendations: you should schedule a visit on the first day of your menstrual cycle to start your stimulation-short protocol.

Remember: For the first day of your menstrual cycle is considered to be the day when you have pronounced bleeding. If the bleeding has occurred in the afternoon or in the evening, then the first day of your menstrual cycle is considered to be the following day.

Monitoring during stimulation

Monitoring during stimulation enables the specialist to follow the process of the stimulation (ovarian response) via hormone analyses and vaginal ultrasound examinations.


So the process of stimulation (ovarian response) will be closely observed via hormone analyses and vaginal ultrasound examinations.


Until the day when you will have the puncture, every second day, we will track the number and size of your follicles produced and the thickness of your uterine lining, as well as your hormone levels.


Depending on the results, the stimulation can be controlled by the medical team by changing your medications or their dosages. In some cases, (a weak ovarian response, unexpected side effects, etc.) the simulation may be terminated at the discretion of your physician.


Injections:
Important: Stimulation injections are applied subcutaneously every day in sequence for 10-14 days.


In the manipulation room at Nadezhda Hospital the time for the application of the medicaments for the stimulations is strictly scheduled. You should obtain information about the specific time that most suits you and you should visit the hospital depending on your schedule.


An appointment in advance is not necessary.


Many of our girls prefer to have their subcutaneous injection by doing it by themselves. If you prefer to save time and not come to the clinic, ask our obstetricians and listen to their instructions on how to place the medication.


Should you have any questions or hesitation concerning this stage of the procedure, contact us promptly.

Stimulation with medication – differences in the application

In some cases, your physician may recommend stimulation with Elonva medication.


Elonva is a long-acting medication for stimulation, applied in the form of a subcutaneous injection, and is a modified version of the follicle stimulating hormone (FSH). It replaces the daily placement of medication over a period of about six days and reduces the frequency of your visits to the hospital, as well as the time for the monitoring of the ovarian response.


How different is it from the "conventional" stimulation protocols?


Elonva injection is applied only once on the second or the third day of your menstrual cycle.


Six days after the injection you have to visit your physician. Your stimulation will be continued with other medications, prescribed by your physician. Further, you will be prescribed injections which you will have every day until the end of this stage of the procedure, and you will have to come for checkups every second day so that the process can be observed by your physician.

Spontaneous cycle

Your physician may recommend that you have an In vitro procedure on the basis of spontaneous cycle.

In this method stimulation medications are not apply. You will have only one injection (hCG) (mostly muscle), 36 hours prior to the puncture, by which we will ensure the "timing" of your ovulation.

Sometimes during the spontaneous cycle procedure it is possible a very slight combination with medication to be applied or a short course of injections, that will support the development of the eggs.

In the spontaneous cycle procedure we mostly track and rely on one follicle and our goal is to aspirate one egg, selected under physiological conditions.

Risks in applying this method:

• premature ovulation

• no egg in the follicle

Advantages in applying this method:

• A procedure that is not harmful to a woman’s health.

• While a failure in stimulated In vitro cycle it takes at least three months a new procedure to be initiated, in the spontaneous cycle procedure we have a chance to repeat it every following month.

• At the discretion of your physician and, depending on the woman's wish, the egg puncture in the spontaneous cycle can be performed without application of anesthesia.

When should I schedule my first visit?

On the 9th -10th day of your menstrual cycle if there are not going to be applied other simulation medications.

On 2nd -3rd day of your menstrual cycle if there is to be a light stimulation.

Approximate duration of tracking in spontaneous cycle: 10-12 days.

Examinations and tests: On the first day you will have a vaginal ultrasound examination and blood tests for monitoring your hormone levels and the development of your dominant follicles.

Final stage of stimulationелен

An injection of hCG (Human chorionic gonadotropin):

Your progress during the stimulation will be closely observed until you have a sufficient number of mature follicles. Then you will have an hCG (human chorionic gonadotropin) injection applied, which will enable the egg to reach its final proper development.

The injection will be applied intramuscularly at a specific time.

Once you have the hCG injection applied, "the clock starts ticking" because it is normal your ovulation to occur approximately 40 hours later.

Important: In a stimulated In vitro cycle, the obtaining of the ova must happen before your natural ovulation. Therefore, you must stick strictly to the time for your final injection (30 minutes are not fatal, but an hour and a half definitely is).

Regardless the time scheduled for your visit, you can always rely on an obstetrician or a nurse to assist you in your final step before having the puncture.

Once you have had the hCG injection applied, your medications for stimulation are suspended. Your puncture is planned to be performed 36 hours after the hCG injection.

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