If IUI (intrauterine insemination) does not work then the next stage of treatment may be In vitro fertilisation (IVF). The IVF process involves removing the eggs from the ovaries and fertilising them with sperm in a laboratory. The fertilised egg is later placed in the woman’s womb. If there is very low sperm count or the sperm are not very mobile then simply putting the sperm together with the eggs in the laboratory (standard IVF) may fail to achieve fertilisation of the eggs. In these cases Intra-cytoplasmic sperm injection (ICSI) can be used. ICSI involves injecting a single sperm directly into an egg in order to fertilise it. The fertilised egg (embryo) is then transferred to the woman’s womb (for more information on stages, see Human Fertilisation Embryology Authority.
We spoke to one married couple who decided that they did not want to take up the offer of IVF. Those who continued treatment described approaching the first cycle (IVF or IVF with ICSI) with a mixture of excitement, trepidation and anxiety. Many were pleased to be taking a positive step and doing something proactive after months or, in some cases, years of waiting. IVF or IVF with ICSI might provide the answer to their dreams. Looking back, some realised that they had approached their IVF with false hope. Nigel felt that he and his wife were naïve and approached their first IVF cycle with overly high expectations. “I know it doesn’t work for everybody but it will for us.” 
There are several stages to an IVF or IVF with ICSI cycle which people sometimes described as a series of hurdles to get over. 
STAGE 1: Suppressing the natural monthly hormone cycle. This treatment is given either as a daily injection or nasal spray, and lasts for about two weeks. Women sometimes find the idea or practice of injecting themselves (or getting their partner to help) rather a challenge. Mary was at first really worried about doing the injections herself but, like many others, she said that she got used to it. Others found it complicated to get their heads around the different injections, making them anxious. While some described unpleasant side effects from the drugs, such as bloating and mood swings, others experienced no side-effects. 
STAGE 2: Boosting the egg supply is achieved by taking a fertility hormone called FSH (follicle-simulating hormone) also known as gonadotrophin, usually as an injection for about 12 days. This hormone increases the number of eggs produced, meaning that more eggs can be fertilised. Some women experienced ovarian hyperstimulation syndrome (OHSS) at this stage. While some had it mildly, and just felt a little bit bloated, others had it quite severely and needed to stop the cycle until the stimulation had subsided (see ‘Difficult parts of IVF & ICSI treatment’). Carol had been through several cycles and had mild OHSS as well as polycystic ovarian syndrome PCOS (see ‘Causes of infertility’).
STAGE 3: Checking on progress. All through the cycle the clinics monitor the progress of the women with scans and/or blood tests. This can mean a lot of visits to the clinic, which can be difficult to fit in around the working day (see ‘Balancing work and fertility treatment’).
STAGE 4: Egg Collection. When the eggs are ready, they are (usually) collected by ultrasound guidance under sedation. A needle is inserted into the scanning probe and into each ovary. The eggs are collected through the needle. Women had very different experiences of egg collection. Some described it with anticipation mixed with apprehension, others found it very painful and distressing (see ‘Difficult parts of IVF & ICSI treatment’). Clara was surprised to see everyone in operating theatre clothing when they arrived at the hospital, she had been thinking of the egg collection as a sort of “glorified smear test”. The procedure was not too difficult, though the sedation they gave her meant that she had very little memory of it (see ‘Men’s experiences of fertility treatment’).
STAGE 5: Fertilising the eggs' Once the eggs have been collected they are mixed with sperm and cultured in a laboratory for 16-20 hours. They are then checked to see if any of them have fertilised. Those that have fertilised (embryos) are grown for another one-two days before the one or two are chosen for transfer.
For ICSI: The eggs are then collected and each egg is injected with a single sperm from the partner or a donor. After two to three days in the laboratory, those that are fertilised are transferred in the same way as for conventional IVF.
Blastocyst' A blastocyst is an embryo that has developed for five to six days after fertilisation. With a blastocyst transfer, embryos are cultured in the laboratory incubator to the blastocyst stage before they are transferred to the womb.
Women described the fertilisation stage as an anxious period, waiting by the phone for news of whether their eggs had fertilised or not. “So there is always the waiting, waiting, waiting. And you never know what is going to happen. They might all die overnight. You always think the worst”. 
If they have fertilised well, the next stage is to go back to the clinic for the transfer.
STAGE 6: Embryo Transfer. Embryologists will grade the embryos and select those of good enough quality to be transferred back into the woman’s womb. Those of good quality that are left over are often frozen for another cycle (see below). The embryo transfer itself was described as quite straightforward, like an IUI. During the procedure, a doctor or nurse will insert a speculum into the vagina to hold it open so the cervix is visible. A fine tube (catheter) is then passed through the cervix, normally using ultrasound guidance. The embryos are passed down the tube into the womb. After the anxious wait to find out if there are good quality embryos, the transfer marks the start of the longer two-week wait to find out if the cycle has worked and the woman has become pregnant. 
STAGE 7: Waiting' Women often described the two-week wait as one of the hardest parts of the whole fertility journey (see ‘Difficult parts of IVF & ICSI treatment’). Carol had discussed the anxious wait with several other women and concluded that it would probably be a blessing to be anaesthetised for the whole time. 
STAGE 8: Getting the results' Sometimes the result was sadly apparent if, like Fiona, they started to bleed before the two weeks were up. While some did a pregnancy test at home, others left it the clinic to test them and give them their results. 
Frozen embryo cycles

These cycles can be easier to go through, because the woman is not required to take so many drugs, and there is less scanning. Martha was delighted that she became pregnant with the first frozen embryo cycle. However despite being a more straightforward process there are still the emotional highs and lows.
Couples face enormous disappointment if the embryos do not defrost safely, or if the pregnancy does not succeed. “So we defrosted the frozen ones we had from, it was our last shot and they arrested too. So we had no viable embryos, so we lost our embryo transfer, no two week wait.”
Sometimes couples use their frozen embryos to complete their family, for example Catherine had four frozen treatment cycles and one full treatment cycle while her first child was very young. 

​Last reviewed July 2017.
Last updated July 2017.


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