By Abbe Feder, Fertility Coach
The views and opinions expressed are those of the authors and should not be considered medical advice. Always consult your doctor for the most appropriate treatment.
If you’re reading this, it’s likely because while you know what’s “supposed” to happen to get that beautiful bun into the oven, it isn’t happening. You may have gone down an internet rabbit hole and don’t know what’s next or which phase you’re in or how long to wait.
So, let’s go through it together. From the medically observed “old fashioned” way, to assisted reproductive technology (ART), all the way through to embryologist involvement, I want to break down for you each of the “main” phases of a fertility journey. Keep in mind that with everything fertility-related, nothing is black and white. No two people go on the same exact path to achieving or sustaining pregnancy.
First, let’s go over the basics. It takes two cells to make an embryo. One cell is the egg, the other is the sperm. An embryo becomes a fetus, and a fetus becomes a baby. That may be the only definite, black and white piece of the puzzle.
While we’re all told over and over during our teenage years that pregnancy can happen at any moment, we learn in loose terms later that the window for conception is actually much smaller. And once we’re undergoing fertility treatments, it feels like the window is almost impossibly small to see success. Once ovulation occurs, the egg has a 12-24 hour living window. Sperm is on a slightly longer-term plan. They can live within the uterus for up to about five days.
The stages of a fertility journey
Stage 1: Timed intercourse
Timed intercourse is usually the first phase of fertility treatment. It involves the normal things we do to conceive, but with the guidance of a doctor or fertility specialist (reproductive endocrinologist), who will use blood tests and ultrasounds to ensure things are happening, such as:
A lead follicle is growing (aka maturing) to release
The follicle is going through the various stages to develop into a mature egg
Progesterone levels are changing post ovulation, confirming that you did in fact ovulate
Timed and tracked intercourse allows us to narrow down and optimize this small window of trying to conceive.
Stage 2: Follicle stimulation & ovulation induction
One step further includes the use of follicle stimulating medication, and may also include ovulation induction. Most commonly, oral pills are prescribed a few days into your cycle that stimulate eggs to grow. These pills often cause more eggs to mature, and then possibly release (so there may be a higher risk of multiples). After close monitoring of the follicle(s), the doctor will determine the best time to use what’s known as an ovulation “trigger” shot to mimic the luteinizing hormone (LH) surge that happens in a natural menstrual cycle, further optimizing the ability to time intercourse. This triggers the eggs that have matured to drop at an exact time—usually 36-40 hours after the injection.
The reality in the reproductive world is that we don’t know what we don’t know. We learn at each and every step of the way, and we try to make the best and most informed decision with the information we and our team have in a given moment. This is the key to all fertility treatment, and also the hardest part to remember. Many people want to believe that once fertility medications have been added, they’ve done all the things, so they shouldn’t have to struggle to conceive anymore.
It is, however, a miracle of modern medicine that at each step of the way we get more information. Once we know ovulation is taking place, if we’re still not getting that positive pregnancy test, we can go one of two main ways: intrauterine insemination (IUI) or in vitro fertilization (IVF).
Stage 3: Intrauterine insemination (IUI)
IUI, a type of artificial insemination, is usually one of the first treatments your fertility specialist might recommend, and is sometimes also referred to as the “turkey baster method.” This typically takes what we’ve done in timed intercourse, and bumps it up a notch, especially as it relates to timing. At this point, ideally, we know that ovulation is happening either on one’s own, or with the help of a medical team. Monitoring happens, sometimes the oral stimulants are added, and the doctor is now tracking those follicles to chart growth. The ovulation trigger shot is instructed to be given at a certain time, knowing that 36-40 hours later, you’ll be scheduled to be in the fertility clinic for the actual IUI. And enter: the sperm.
It’s finally time for the swimmers to do their best work. The idea behind an IUI is to optimize timing, along with placement. The eggs are perfectly timed to release and the best of the sperm is put through the cervix and into the uterus (using a catheter) at the same time in hopes of conception. Before the IUI takes place (typically a few hours), the sperm is collected and run through a sperm wash. The wash is a form of preparation where the sperm are separated from the seminal fluid, ensuring that the most potent of the swimmers are injected into the uterus for insemination.
There is debate over how many IUIs are recommended before moving on to other treatments. Some doctors and clinics have their own protocols, some insurance carriers will only cover treatment after a certain number of IUIs, it is the first line of treatment for same-sex female couples, and yes—IUI can work! But when they don’t, it might be time for IVF.
Stage 4: In vitro fertilization (IVF)
Whereas IUI takes timed sexual intercourse up a notch, IVF takes IUI up about 5 notches. As I already mentioned, you don’t know what you don’t know. IVF can give us so much more information, which is why it can be more costly financially, physically, and emotionally.
When reproduction is assisted internally (monitored, IUI), there are still so many unknowns. We may have timing down, but we still don’t know:
- Did the sperm make it near the egg?
- Did the egg actually fertilize?
- Did the fertilized egg indeed grow into an embryo?
- Did it grow to the blastocyst stage (the stage that can develop into a fetus)?
- Did it implant into the right part of the uterus?
While an IVF treatment cycle can’t definitively answer every part of each of these questions, it can answer a lot of them, because a team of dedicated embryologists begins tracking these eggs once they leave the woman’s body during the retrieval process.
The egg retrieval during the IVF process is sometimes considered the most “amped up” part of the ride. With controlled ovarian stimulation (COS) prior to the egg retrieval, the goal is to stimulate the development of multiple eggs to increase the chances of producing a healthy embryo. Normally, during a natural cycle, only one egg grows to become the “queen egg” for the month, and that one, the most mature, drops at ovulation for a shot at conception.
With IVF supplements, you’re giving your body extra medicine to have your brain tell your ovaries to go into overdrive and produce multiple “queen eggs.” Once mature, and at an exact, decided-upon time during the IVF cycle, they will be taken out of your body and given a chance at becoming embryos. You will likely experience some side effects—you do usually get hormonal, can feel extremely bloated because your ovaries are actually expanding, and may be fatigued because your brain and body are performing a modern miracle.
Just as with an IUI cycle, toward the end of the 10 or so days of fertility medications, you’re given a trigger shot, and then 36-40 hours later you’ll have the eggs taken out of your body to mingle with the sperm that will ideally fertilize. When necessary (especially if there’s male factor infertility, or if the sperm need a little boost reaching the egg for any reason), intracytoplasmic sperm injection (ICSI) is performed. ICSI is when the sperm are physically injected into an egg to ensure they are given their best chance at fertilization.
At this point, the dedicated team of embryologists in a given clinic monitor the development daily. Post retrieval, you will be told how many eggs were taken out, and soon after, you’ll be told how many were actually mature enough to attempt fertilization.
This is considered the first day of the embryo life cycle. Ideally, they’re grown for 5 days and are then either transferred back into the uterus with hopes of implantation, frozen for use at a later time (for a frozen embryo transfer or FET), or biopsied for testing and then frozen for later use. If biopsied, cells from the outermost layer of the embryo are sent to a geneticist for preimplantation genetic testing (PGT) who can determine if the embryo is what’s considered “normal,” meaning it has the right number of chromosomes, or “abnormal,” which indicates either a specific genetic issue or an abnormal number of chromosomes. When testing is done, the “genetically healthy” embryos are the ones that are transferred, with the goal that those embryos will lead to implantation and result in pregnancy.
The fertility journey can be heartbreaking, and treatment options are not for the faint of heart. It can be a long and arduous process, and we are uncovering answers only in real time as each layer of questions becomes clear. But it is also miraculous, and can provide hope when all else might feel lost.