Infertility
In-vitro fertilisation (IVF) & intra-cytoplasmic sperm injection (ICSI)
If IUI (intrauterine insemination) does not work, then the next stage of treatment may be in-vitro fertilisation (IVF).
IVF involves removing eggs from the ovaries and fertilising them with sperm in a laboratory. The fertilised eggs are later inseminated into the womb (uterus).
If the sperm count is very low or if the sperm are not very mobile, then simply putting the sperm together with the eggs in the laboratory (standard IVF practise) may fail to achieve fertilisation. In these cases, intra-cytoplasmic sperm injection (ICSI) can then 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 womb.
For more information on the stages of IVF and ICSI, see the Human Fertilisation Embryology Authority (HFEA) (‘Resources and Information’).
Experiences with IVF and ICSI treatment
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 the time approaching the first cycle, either with IVF or IVF with ICSI, with a mixture of feelings including excitement, trepidation and anxiety.
Many were pleased to be taking a positive step and to be doing something proactive after months, or, in some cases, years, of waiting. IVF or IVF with ICSI was described as something that 'might provide the answer to their dreams'.
Looking back, some realised that they had approached their IVF with false hope. For example, Nigel felt that he and his wife were 'naïve' and approached their first IVF cycle 'with overly high expectations'. He said he thought, '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 learnt to deal with the injections quite quickly.
Catherine had qualms and wondered whether they were doing the right thing starting IVF. She learnt to deal with the injections quite quickly.
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.
IVF and ICSI treatment stages
There are several stages to an IVF or IVF with ICSI cycle, which people sometimes described as 'a series of hurdles to get over'.
The stages are as follows:
STAGE 1: Suppressing the natural monthly hormone (menstrual) cycle
This treatment is given either as a daily injection or nasal spray and lasts for about 2 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, which made 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 not enjoy.
Clara described how taking the drugs was like putting your body into the menopause, which she did not enjoy.
Clare talked about her anxieties about the drugs, were they working or not?
Clare talked about her anxieties about the drugs, were they working or not?
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.
STAGE 2: Boosting the egg supply
Boosting the egg supply is achieved by taking a fertility hormone called FSH (follicle-stimulating hormone), also known as gonadotrophin, usually given 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 ‘Impacts of fertility 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 with other cycles none.
Carol described how each IVF felt slightly different. Sometimes she had lots of side-effects and with other cycles none.
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 other… and 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.
STAGE 3: Checking on progress
All through the cycle the clinic monitors the progress of hormones 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 with fertility treatment’).
STAGE 4: Egg collection
When the eggs are ready, they are usually collected by ultrasound guidance while under sedation. A needle is inserted into a scanning probe and into each ovary to collect the eggs.
Women we spoke with had very different experiences with egg collection. Some described it as a feeling of anticipation mixed with apprehension while others found it 'very painful and distressing' (see ‘Impacts of fertility treatment’).
Clara was surprised to see everyone in operating theatre clothing when she and her husband arrived at the hospital. She had been thinking of the egg collection as 'a sort of glorified smear test' rather than as an operation. The procedure was not too difficult, though the sedation they gave her meant that she had very little memory of it (see also ‘Men’s experiences with fertility treatment’).
Catherine described being anxious about the egg collection, but with heavy sedation felt very distanced from the procedure.
Catherine described being anxious about the egg collection, but with heavy sedation felt very distanced from the procedure.
STAGE 5 (IVF): 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 (the embryos), are then grown in the lab for another 1-2 days before one or two are chosen for transfer to the womb.
STAGE 5 (ICSI): Fertilising the eggs
The eggs are collected, and each egg is injected with a single sperm from the partner or a donor. After 2-3 days in the laboratory, those that are fertilised (the embryos) are transferred in the same way as for IVF.
People described the fertilisation stage as 'an anxious period' spent waiting by the phone for news of whether their eggs had fertilised or not. As one person said, ‘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 the eggs have fertilised well, the next stage is to go back to the clinic for the transfer.
STAGE 6: Embryo Transfer
Embryologists grade the embryos and select those of good enough quality to be transferred into the womb. If multiple (extra) good quality embryos are left over at this stage, they are often frozen to be used for another cycle (see below).
The embryo transfer procedure 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 that the cervix is visible. A fine tube (a catheter) is then passed through the cervix, normally using ultrasound guidance. The embryos are then passed down through the tube and into the womb.
After the anxious wait to find out if there are good quality embryos, the transfer marks the start of a longer two-week wait to find out if the cycle has worked and pregnancy has occurred.
Blastocyst transfer: A blastocyst is an embryo that has developed for 5-6 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.
STAGE 7: Waiting
Women often described the 'two-week wait' as one of the hardest parts of the whole fertility journey (see ‘Impacts of fertility treatment’).
Carol 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 to see if the cycle has worked.
Carol described the awful waiting to find out if the eggs have fertilised, and then the two weeks to see if the cycle has worked.
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.
Fiona thought of the transferred embryos as "her triplets". She was upset and angry when she wasnt given all the details of what would happen if it wasnt successful.
Fiona thought of the transferred embryos as "her triplets". She was upset and angry when she wasnt given all the details of what would happen if it wasnt successful.
STAGE 8: Getting the results
Sometimes the result was sadly apparent if, like Fiona, they started to bleed (menstruate) 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 blood test at the clinic; by the time she got home the clinic had phoned to say she was pregnant.
Lulu found the two-week wait very difficult but did not want to do a test at home. She had a blood test at the clinic; by the time she got home the clinic had phoned to say she was pregnant.
Frozen embryo cycles
These cycles can be easier to go through because they do not require 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 same emotional highs and lows.
Couples face enormous disappointment if the embryos do not defrost safely, or if the pregnancy does not succeed. For example, one couple told us '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 felt worried about the possible impact on her young son.
Catherine describes how much easier it was going through IVF the second time around, although she felt worried about the possible impact on her young son.
People may also donate their embryos or participate in an embryo or egg-sharing scheme for others to use.
See also ‘Impacts of fertility treatment’.
Last reviewed: May 2025.
Last updated: July 2017.
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