In vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI)

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 na‚àö√òve and approached their first IVF cycle with overly high expectations. ‘I know it doesn’t work for everybody but it will for us.’

Catherine had qualms and wondered whether they were doing the right thing starting IVF. She…

Age at interview 45

Gender Female

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I think that you don’t ever really expect to have to do IVF. All the way through the testing process, and I’d been on Clomid for a while as well, all the way through all of that I didn’t ever actually think that I would get as far as IVF. I thought it was something that happened to other people. I didn’t really think it would happen to us. And I was actually quite scared when all of a sudden I was about to do it and it was all starting to seem real. I suddenly thought, What are we doing? Should we really be messing with nature in this way? Is it really a natural thing to be doing I had all these kind of qualms about it that I didn’t know where they’d come from at all. And it was quite frightening. I don’t know why I was so worried, but I was really quite scared about it all when it got to that point. But once you actually get into it, once you start doing the process, it’s not the actual medical part of it which is so difficult. You expect that to be difficult. You think, Oh, I’m going to have to inject myself. That’s going to be really awful But you learn to deal with those things quite quickly.

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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.

Clara described how taking the drugs was like putting your body into the menopause, which she did…

Age at interview 32

Gender Female

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So after hormone tests you start off down I can’t remember the name. Oh you sort of dampen your body down with sniffing. Some do it with injections. Some do it with sniffing, some do it with injections, and some do even with the pill. But I sniffed for about ten days and that basically puts you into menopause I am not looking forward to menopause. It is not very nice. It made me feel very sort of, very passive, and I didn’t really feel like anything and after that, after ten days they sort of check you, your lining of the uterus, if it is really thin, like a menopausal woman and everything is inactive. Your ovaries are not doing anything. Then you inject, yes I think I remember injecting to stimulate your ovaries to produce more follicles and I think the sniffing is longer than ten days. I am getting the days wrong. But the injection is ten days. I remember that. And then you go for regular scans all the way along to see how many you are producing, because it is dangerous to produce too many and you want to be producing enough. So they are always making sure that it is the right amount of hormone you are getting. And they might tweak it. And you have blood tests at the same time to check the hormones. So they might put it up or down regarding, you know it is depending on what happens to you in the ovary and the bloods.

So that is mostly stuff at home I suppose. You are injecting at home?

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Clare talked about her anxieties about the drugs, were they working or not?

Age at interview 35

Gender Female

Age at diagnosis 31

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So in the February 2006 we started our first IVF cycle. Absolutely terrified. My cycle just happened to coincide with us having to do our first injection on our sixth wedding anniversary. Which was not the most romantic way to spend your wedding anniversary. And we were very very nervous. We didn’t know what to expect, we didn’t know how we were going to react, how we were going to respond to the drugs. In actual fact I didn’t respond too badly to the drugs for the two weeks that I had to do what we call down regulation, which is just switching all the hormones off. I didn’t get all the headaches and side effects that I’d been warned about. But that in itself became an area of anxiety, because I was concerned that I wasn’t getting all the side effects and the drugs weren’t working. But I went for my down regulation scan and blood tests, and they said, No, everything’s fine. You, you know, everything’s switched off Then I started the stimulating drugs. And again I didn’t get many side effects. And again I’m worried about that that meant that I wasn’t stimulating properly, I wasn’t getting enough follicles or wasn’t getting enough eggs. But that proved to be wrong as well. And I did actually end up getting nine eggs at the egg collection stage. Which is about right, about average. We had a fairly good fertilisation rate. We had six eggs that fertilised. And we got, so we got six embryos.

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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‘).

Carol described how each IVF felt slightly different. Sometimes she had lots of side-effects and…

Age at interview 39

Gender Female

Age at diagnosis 27

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An IVF cycle when you first do it, isn’t so bad, because you expect it to be the answer to all your dreams. It doesn’t quite work like that. I have now had five cycles of IVF and three frozen embryo cycles, one up to blastocyst. Each time I have actually had it, either the drug regime we have to tweak slightly because I have developed cysts from using Synarel and now I have had to go on to down regulate with injections to bypass having the cysts. But each cycle is very different and sometimes I might have headaches and feeling sick and nauseous and otherand very irritable. Other times it is almost like nothing is happening so therefore I have not really had any symptoms what so ever in the down regulation phase. Then it’s a question of having the blood test to see if I down regulated. Sometimes I have. Sometimes I haven’t because of the cysts and then I have had to go and have a minor operation to drain the cysts in order to be able to down regulate and from there it is a question of stimulating the ovaries. That is the exciting time because you feel that you are actually doing something positive, you are actually growing eggs inside you, and it is the first time that you feel actually normal. Albeit you kind of very bloated and very uncomfortable. I have had mild ovarian hyperstimulation syndrome each time, because having polycystic ovaries does actually make you more susceptible to that. I have felt very bloated and almost like what I feel to be like an egg bound chicken round about that time, and it is quite worrying some of the twinges that I felt and I thought oh is something going wrong or is that normal. But each time it has been like that. And I have never felt that worried, even though I was at high risk. The trick is to drink copious amounts of water. If you drink three litres a day then that minimises the chances of getting OHSS.

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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‘).

Catherine described being anxious about the egg collection, but with heavy sedation felt very…

Age at interview 45

Gender Female

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But you are, all the time you’re, you’re having to go back to the clinic quite a lot for the scans to check how the follicles are developing. Which is always, you know, you’re always really anxious before each scan and, Is it going to be okay? And, Is, are there going to be any problems And we were quite lucky. Ours actually did go very smoothly. And then it came to the egg collection stage. And I think up till then I’d really persisted in seeing egg collection as some sort of glorified smear test actually, and I didn’t really, I hadn’t really thought about the fact that it was actually an operation. And it wasn’t until we got to the hospital that morning, and we normally go in quite early, and we got there really early and all of the staff around were in kind of operating theatre gowns. And I suddenly realised that this was actually quite a big thing that was about to happen.

And I suddenly got quite anxious about it all. But actually it was fine. You can either do it with a general anaesthetic or with very heavy sedation, and I did it with the heavy sedation thing. And you could, you were kind of aware of, of pain, but you were very distanced from it. It was a bit like watching someone else go through it. And my husband was able to come in with me and sort of sit there holding my hand. Which was actually very reassuring because I didn’t really, when I started to come round, I didn’t really know quite what had happened and what had been going on. But we got, that time we got quite a lot of eggs. And then of course they’ve got to fertilise. Which is the next sort of huge stage.

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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.

Carol described the awful waiting to find out if the eggs have fertilised, and then the two weeks…

Age at interview 39

Gender Female

Age at diagnosis 27

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Well I ought to talk about the egg collection really. Everybody asks how is it, does it hurt? Actually you are out for the count, you don’t know any different, anything about it. Obviously there is a certain amount of apprehension pre starved from midnight. So you go in and everybody asks the same thing, How many eggs, how many eggs did I get And I have every time. Then the most nerve wracking time starts to happen, it is go home and wait to hear whether they have fertilised or if they are fertilised properly. The second time it didn’t work for me. The eggs were too mature and they didn’t fertilise and I have to say, that was a real low point. I knew that there was nothing to actually put back. I found that very, very distressing and the rest of the time, it is just trying to not think about the fact that in a lab not too far away are they going to fertilise or are they not. And the next day after that you get a phone call and usually I have been too nervous to take it, and my husband has taken the phone call to say how many are fertilised and then usually go back to have them put back a day later, and that can be uncomfortable. If I am really honest because I have had the OHSS assessed or a mild version of it and when it comes to inserting the speculum and putting the catheters, I have to have two, obviously I have got two separate chambers and one embryo goes in either side. That has been very, very uncomfortable, but it is a nice uncomfortable because something is happening for the positive so it is bearable. And then the worst part is the two weeks of waiting. That is absolutely dreadful. The first week it is fine, because you do actually feel slightly pregnant because of the hormones. The second week I become neurotic and it is a question of being quite base about it. Doing frantic knicker checks to see if there is signs of blood spotting or every time you actually wipe with toilet paper to see whether there is any pinkness and your imagination goes into like overdrive at that point and one minute I convince myself, yes, it has worked I am pregnant and then the next minute I think, no it hasn’t. And so a swing in the pendulum of emotions is the worse part of IVF where you have an emotional roller coaster. And everybody says and myself included, if we could actually have been anaethetised or sedated for two weeks that would really help. I don’t think it is possibly but it would be wonderful if it could just take away that agonising wait.

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Fiona thought of the transferred embryos as her triplets. She was upset and angry when she…

Age at interview 41

Gender Female

Age at diagnosis 33

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But of course you recover from that, because then you have got the possibility of your eggs, you know, and I think we had, we didn’t have a major collection then. I think was about eight eggs, which by kind of, I guess standards, isn’t that many and then [husband] does his bit and they fertilise them.

We had three fertilised eggs that time and I can remember phoning my Mum and saying, Oh we have got three eggs Every little stage you feel, like you, I suppose, on the journey to your pregnancy but you are very excited and again with hindsight I think you have to be very cautious about that, because you get yourself completely carried away. Three eggs fertilised does not mean three babies, but at the time that is what you think.

So I had those three eggs put back in and I remember lying, not here, we were in another house, but it was on this sofa, naming them, you know, imagining them. My little triplets, they were all in there. Thinking that was it.

I didn’t move. I took the time off work. I am a teacher and they were very, very good at school. I can’t do anything You know. I had a massive high for those few days. Until two weeks later when we were due to have a pregnancy test, I think, on the Monday and on the Saturday I started bleeding.

And then the other thing that I was very shocked and angry about, again was that they didn’t tell you. They say when you start to bleed obviously, you know, it is like a heavy period. Well it wasn’t. It was these massive clots, that I just, to you those are your babies and I found that horrendous.

Poor old [husband], because I just cried and cried. And you can’t stop it can you. You know, it has got to come out. And brutally there are your babies going down the toilet and I just thought that that was horrific. And again I just think how can people keep going through that, horrible experience.

So we knew before we had the pregnancy test. And even when you have bled and you know it has all come out of you, you still go to the hospital thinking maybe I’m still pregnant. Because you are so desperate, and of course we weren’t.

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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.

Lulu found the two-week wait very difficult but did not want to do a test at home. She had a…

Age at interview 40

Gender Female

Age at diagnosis 31

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And then the next two weeksand that had all been fine. I actually hadn’t found that part of the IVF really too bad. But then the next two weeks was the worst. The waiting for that result was actually really quite bad. I was totally neurotic about it. And I got to two weeks and about fifteen days actually I think it was after the embryo transfer and I was like oh I am notthey said do a pregnancy test at home and I thought I am not doing a pregnancy test. I was in pain so I thought my periods was coming on. No point. No point. I am not going to do anything. Soand then they phoned me back lunch time and said, Have you done your pregnancy test And I said, Oh, I can’t see the point. I am not going to And they said, you know, Well why don’t you. You do actually need to do and why don’t you come for a blood test I said, Fine okay. I will come in for a blood test this afternoon

So I went in. So and I drove home and it was a good forty five minutes, fifty minute drive home and by the time I got home there was a message on the answer machine saying, Can you phone us And it sounded so serious.

And I phoned them back and they said, You are pregnant And I just couldn’t believe it. But I couldn’t believe it but I was also sort of tempered by the fact that I had had two miscarriages in my life and that may be this wouldn’t work.

And So I went back and saidthey gave me progesterone to support it. And said, Come back at six weeks Six or seven weeks. There was a heartbeat, and that was it amazing.

So – and – yes and the consultant said, Well if there is a good strong heart beat now he said, That is a really good sign So – and we actually went back at nine weeks for another scan. And again it was fine. And everything went smoothly. I felt pretty sick. But that was okay and that was fine.

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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.

Catherine describes how much easier it was going through IVF the second time around, although she…

Age at interview 45

Gender Female

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So what was it like going through IVF a second time?

It was much much easier actually. I think once you’ve got a child you never feel that sense of isolation in the way that you did the first time round. And although it’s still a difficult process, it’s not easy, you’ve still got the same kind of ups and downs, you, you don’t have that, you know, you’re not this odd, different person any more. You’re someone who actually has a child. It would just be really really truly lovely if you could have another one. And so it doesn’t feel as desperate. I think that one thing that was quite odd about it was I felt really worried about my son when I was doing it again. I really didn’t want me getting upset and having to keep going to the clinic and all of that, I didn’t want that stuff to impact on him at all. And I was quite worried about that, because there were times when inevitably I would get quite upset. And I really really didn’t want him to feel that. And I didn’t want him, I mean he didn’t know what we were doing, he was still really little, but I didn’t want it to affect him at all. And I remember being very conscious of that, and of the fact that I should try not to let it impact on him. And we actually had quite a lot of treatment cycles in that time, mainly frozen. We had four frozen treatment cycles and one full treatment cycle. So there were quite a lot of ups and downs in that period. But I really didn’t want it to upset him. But at the same time I desperately wanted it to work for him, because I just thought, It would be so lovely if you could have a brother or a sister. It would really just be such a fantastic thing And having had a child you kind of knew how wonderful it was and how truly amazing it would be to be able to have another one.

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Intrauterine insemination (IUI)

Intrauterine insemination (IUI) treatment involves a laboratory procedure to separate fast moving sperm from less active sperm, thereby selecting the best quality sperm. The fast...

Difficult parts of IVF/ICSI treatment

Couples sometimes find that dealing with infertility and its treatment is both physically and emotionally demanding. While they were often very grateful for their treatment,...