By Andrea Rodrigo BSc, MSc (embryologist), Elena Martín Hidalgo MD (gynecologist), Gorka Barrenetxea Ziarrusta MD, PhD (gynecologist), Miguel Dolz Arroyo MD, PhD (gynecologist) and María de Las Heras Martínez BSc, MSc (clinical embryologist).
Last Update: 10/22/2018

The steps to be followed in IVF cycles do not vary, irrespective of the type of IVF one is undergoing—classical or with ICSI. The ultimate goal is that the sperm meets the egg and is able to fertilize it. In other words it involves a series of steps, namely ten, to getting pregnant.

IVF process in 10 steps

The medical term “In Vitro” Fertilization, abbreviated as IVF, literally means to fuse the gametes (egg and sperm) together in the laboratory. Since this union is done artificially, imitating the natural process, a series of technical steps are required, as one shall see in the following sections.

In the meantime, you can find a brief summary of the process from start to finish in the following explainer video:

Controlled ovarian stimulation (COS)

The intended mother receives a series of medications containing specific hormones for two major purposes:

  1. On the one hand, to trigger the maturation of multiple eggs in the same cycle, unlike in natural cycles, where only one egg matures.
  2. On the other hand, artificial hormones allow for the ovarian cycle to be controlled externally, thereby being able to predict the maturation phase of the oocytes. In other words, COS allows us to foresee when ovulation is going to take place. This increases the chance of success to a large extent.

There exist several medical protocols to stimulate the ovaries, although in general they involve administering gonadotropins and GnRH analogs. Your reproductive endocrinologist (RE) will determine the most appropriate protocol for you.

COS usually lasts between 6 and 10 days. During this time period, all patients must visit their RE regularly in order to monitor follicle growth, and schedule the retrieval day for the most adequate moment.

In the words of Elena Martín Hidalgo, MD, controlled ovarian stimulation is just a process whereby the hormones that typically participate in the reproduction process are administered artificially. According to Dr. Martín Hidalgo, this process can last up to 14 days on average, depending on each case.

Check out this for more information: Ovarian Stimulation Protocols for IVF – Process & Medications Used.

Egg retrieval

Egg retrieval is done via a procedure known as follicular puncture or ovum pick-up (OPU). It is the next step when the oocytes are mature and ready to be harvested. This surgical procedure is performed under anesthesia, and requires an OB/GYN to puncture the ovarian follicles (small “sacs” that contain the eggs), and aspirate their content at the same time. Then, the liquid aspirated is evaluated at the lab in order to collect the eggs.

The procedure lasts about 30 minutes. Further reading: Ovum Pick-Up Procedure: How Are Eggs Harvested in IVF?

Semen collection & preparation

Generally, the sperm sample is obtained by masturbation. A few minutes after ejaculation, the sample goes through a process called sperm capacitation. This procedure is used to remove poor-quality sperm cells and seminal plasma from the sample. Thanks to it, the sample that will be used finally contains sperms of progressive motility only.

When a man is unable to provide a sample through masturbation, other options include a testicular biopsy or microsurgical epididymal sperm aspiration (MESA). This procedures force the patient to undergo ICSI, due to the sparse amount of sperm and their low quality.

Egg insemination & fertilization

This step involves fusing together the egg and sperm cells to mix the DNAs of both parents, giving raise to a new being. The extent to which the embryologist is involved in this process varies on a case-by-case basis.

Classical IVF
The role of the embryologist is to just put the eggs and sperm in the culture plate. The sperms are expected to be capable of penetrating the egg cell by themselves.
ICSI
Conversely, in this case there is more involvement of the embryologist, since the sperm cell is injected manually into the egg cell to force fertilization.

Get more info: ICSI Success Rates Compared to IVF Treatment – Which Is Better?

Fertilization follow-up

Within 16 to 20 hours approximately, the embryologist examines whether the egg has been properly fertilized or if unfortunately some kind of error has led to fertilization failure. For this to be checked, he or she will look for the presence of one pair of polar bodies and another one of pronuclei. They fuse together to create what we know as zygote, as one shall see in the following picture:

Embryo culture

Zygotes or pre-embryos remain in culture so that they can continue growing. During this time period, they will grow from zygote into embryo, and then from embryo to blastocyst. The image above can help you figure out each one of these phases.

A specific incubator that is able to maintain the ideal gas and temperature conditions for embryonic development until the transfer day is used. While in the incubator, embryologists keep track of their state to determine their quality.

Click her to get more info: Embryo Quality & Grading – Does It Affect IVF Success?

Endometrial preparation

In addition to the fertility drugs used for ovarian stimulation, IVF patients receive hormonal medications for endometrial preparation as well. The goal is to enhance endometrial receptivity, which increases the chances for embryo implantation.

An ideal endometrium is one that has a triple line pattern, with a thickness of between 7 and 10 mm approximately. This is the perfect environment for an embryo to implant.

The typical medications prescribed to achieve this goal are estrogens and progesterone, whether they are administered through oral, vaginal, or patch route. In fresh IVF cycles, it is possible to do a natural cycle, that is, with the estrogens that are naturally released by the body. The patient would just receive progesterone artificially in order to support the luteal phase.

Read this next: Endometrial Preparation for Implantation after IVF Embryo Transfer.

Embryo transfer

Based on embryo quality, the best embryo is selected, that is to say, the one with the highest implantation potential. Once chosen, it is transferred back to the maternal uterus using a specific catheter, so that it is able to attach to the intended mother’s womb, marking the start of a new pregnancy.

Other people also read: IVF Embryo Transfer Procedure – Definition, Process & Tips.

Embryo cryopreservation

Normally, a single embryo is transferred per IVF cycle, although in some cases two or even three embryos are transferred.

Embryos of good quality that are not used for the ET procedure are cryopreserved via a technique known as embryo vitrification.

In the words of Dr. Miguel Dolz Arroyo, Gynecologist & Obstetrician specialized in Reproductive Medicine, unused embryos can be:

Used by the couple (parents) to have a second child, or to undergo a second IVF attempt in case of failure after the first one, which removes the need for undergoing the entire stimulation process again; donated for stem cell research; donated to other couples for reproductive purposes; and finally, destroyed once the fertile years of the woman have come to their end.

Pregnancy test

Within 10-15 days (i.e. two-week wait) after the ET, you can take a pregnancy test to find out whether IVF has been success or not. In other words, if the ultimate goal has been achieved: pregnancy.

Both home pregnancy tests and blood tests are valid to detect a pregnancy after an IVF cycle, since they work by detecting the presence of the beta-hCG hormone, hence the common name the pregnancy hormone.

Interview to Dr. Gorka Barrenetxea & embryologist María de Las Heras

To sum up, in the words of Dr. Gorka Barrenetxea, an IVF treatment involves four major parts:

Briefly, an IVF treatment has 4 steps. The first one is the ovarian stimulation; the second one is follicular puncture; the third one is the IVF procedure itself; and the fourth and last one is the embryo transfer into the uterus.

On the other hand, Clinical Embryologist María de Las Heras provides us with a series of interesting details about the follicular puncture step.

How much does IVF cost?

The price of in vitro fertilization varies by country. In the United States, IVF packages using own eggs start from $8,500.

As for the United Kingdom, some patients qualify to get NHS-funded IVF as long as they meet certain criteria established by the NICE (National Institute for Health and Care Excellence). In any case, the cost of an IVF cycle at a private clinic can be £5,000 or more.

Finally, Canadian patients can expect sums of around CAD $7,000 on average if covered by insurance; if you are not, you can expect higher sums. If you are an Ontario resident and have a valid OHIP card, you do not have to pay for fertility treatments.

If you need to undergo IVF to become a mother, we recommend that you use "The Calculator". In 3 simple steps, it will show you a list of clinics that fit your preferences and meet our strict quality criteria. Moreover, you will receive a report via email with useful tips to visit a fertility clinic for the first time.

Also, the report will inform you about the promotions or special prices that the clinics selected offer so you can benefit from them as well.

FAQs from users

What is the process of IVF using frozen embryos?

By Andrea Rodrigo BSc, MSc (embryologist).

IVF with frozen embryos involves just the endometrial preparation and embryo transfer steps. Ovarian stimulation, follicular puncture, and embryo culture are not required, since the embryos were already created and cryopreserved in previous cycles.

How long does IVF treatment take from start to finish?

By Andrea Rodrigo BSc, MSc (embryologist).

In Vitro Fertilization takes approximately a complete female cycle, that is, about 30 days. Since the beginning of the menstrual cycle, marked by the start of menstruation, the intended mother starts stimulating the ovaries. Between 6 and 10 days after that, the follicular puncture for egg retrieval is scheduled. This procedure is used to retrieve the eggs, which will be fertilized in the lab in order to obtain viable embryos. The resulting embryos remain in culture for 3 to 5 days, depending on each case, till they are transferred back to the mother’s uterus. At this point, 15 days will have passed since the beginning.

Approximately two weeks after the embryo transfer, the woman can take a pregnancy test to verify whether it has been successful or not.

Suggested for you

Want to delve deeper into IVF, its differences with artificial insemination, indications, success rates, and more? Then do not miss this guide: What Is In Vitro Fertilization (IVF)? – Process, Cost & Success Rates.

Also, during the feared two-week wait, women experience a series of symptoms and side effects that are often very confusing. Learn more about them here: Symptoms After Embryo Transfer – Most Common Positive Signs.

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References

ACE, Association of Clinical Embryologists (2003). Accreditation Standards and Guides for IVF Laboratories.

Alper M, Brinsden PR, Fischer R, Wikland M (2002). Is your IVF program good? Hum Reprod; 17: 8-10.

Bourgain C, Devroey P. The endometrium in stimulated cycles for IVF. Hum Reprod Update 2003;9:515 – 522.

Brian, K. (2010). The Complete Guide to IVF: An Insider’s Guide to Fertility Clinics and Treatments. Published by Hachette Digital, Londres.

The Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology. Criteria for number of embryos to transfer: a committee opinion. Fertil Steril 2013; 99(1):44-6.

Gianaroli L, Plachot M, van Kooij R, Al-Hasani S, Dawson K, DeVos A, Magli MC, Mandelbaum J, Selva J, van Inzen W (2000). ESHRE guidelines for good practice in IVF laboratories. Committee of the Special Interest Group on Embryology of the European Society of Human Reproduction and Embryology. Hum Repro; 15: 2241-6.

Lenton, E. (1993) Natural cycle versus stimulated cycle IVF. /. Assist. Reprod. Genet., 10,406-08.

Mantikou E, Youssef MA, van Wely M, van der Veen F, Al-Inany HG, Repping S, et al. Embryo culture media and IVF/ICSI success rates: a systematic review. Hum Reprod Update 2013;19:210–20.

Mayer J, Jones EL, Dowling-Lacey D, Nehchiri F, Muasher SJ, Gibbons WE, Oehninger SC. Total quality improvement in the IVF laboratory: choosing indicators of quality. Reprod BioMed Online 2003;7:695- 9.

Nijs, M. and Geerst, L. (1993) Prevention of multiple pregnancies in an IVF program. Fertil. Steril., 59, 1245-1250.

Reproducción Asistida ORG. Video: ¿Qué es la estimulación ovárica? (What is ovarian stimulation?), by Elena Martín, MD. Dec 29, 2015. [See original video in Spanish].

Reproducción Asistida ORG. Video: ¿Cuál suele ser el destino de los embriones sobrantes de FIV? (What is the fate of unused embryos after IVF?), by Miguel Dolz Arroyo, MD, PhD. Nov 13, 2017. [See original video in Spanish].

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Authors and contributors

 Andrea Rodrigo
BSc, MSc
Embryologist
Bachelor's Degree in Biotechnology from the Polytechnic University of Valencia. Master's Degree in Biotechnology of Human Assisted Reproduction from the University of Valencia along with the Valencian Infertility Institute (IVI). Postgraduate course in Medical Genetics. More information
 Elena Martín Hidalgo
Bachelor's Degree in Medicine & Surgery from the University of Salamanca. Specialty in Gynecology & Obstetrics with training at the Virgen de la Salud Hospital of Toledo. Specialist in Reproductive Medicine with over 20 years of experience. Contributor of the Spanish Fertility Society (SEF) as a teacher and trainer of students of Master's Degree in Human Reproduction. Medical Director of clinic Reprofiv. More information
License: 28454504653
 Gorka Barrenetxea Ziarrusta
Bachelor's Degree in Medicine & Surgery from the Public University of Navarra, with specialty in Obstetrics and Gynecology from the University of the Basque Country. He has over 30 years of experience in the field and works as a Titular Professor of Obstetrics & Gynecology at the University of the Basque Country and the Master's Degree in Human Reproduction of the Complutense University of Madrid. Vice-president of the SEF. More information
License: 484806591
 Miguel Dolz Arroyo
MD, PhD
Gynecologist
Bachelor's Degree in Medicine and Surgery from the Medicine Faculty of the University of Valencia (UV) and Doctor in Medicine, finished in 1988 and 1995, respectively. Physician specialized in Obstetrics & Gynecology. Expert in Reproductive Medicine, with more than 20 years' experience in the field. He is the Medical Director and founder of FIV Valencia. More information
License: 464614458
 María de Las Heras Martínez
BSc, MSc
Clinical Embryologist
Bachelor's Degree in Biology from the Pompeu Fabra University and Master's Degree in Biology of Reproduction & Assisted Reproductive Technologies from the Autonomous University of Barcelona, in collaboration with Instituto Universitario Dexeus. Master's Degree in Biochemical Research from the Basque Country University. Clinical Embryologist by the ESHRE. More information
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