Case Study - Cerner 2

Stimulating the Ovaries and Monitoring

Once your physician determines it an optimal time to begin your IVF treatment you will enter the “stimming and monitoring” phase of treatment. This will be 10 to 14 days of self-administering injectable medications, and early morning doctor visits for monitoring.

Stimulating the Ovaries and Monitoring

“You’re seeing these syringes and sharps containers and it really kind of hits you... but then the shots weren’t as bad as I thought.”

Hillary F., Progyny Member

The brands can be different, but in general your doctor will place you on medications containing follicle stimulating hormone (FSH), and human menopausal gonadotropin (hMG).

Stimulating the Ovaries

Introduction

While FSH and hMG are working on your ovaries to support follicular growth, your doctor may also prescribe medications that are considered antagonists to help keep you from ovulating prematurely.

Preventing Ovulation

If you have any questions or concerns during the stimulation phase of your IVF cycle you shouldn’t hesitate to reach out to your PCA. They are here to not only help you with questions about your coverage and treatment plan, but to also provide emotional support throughout your treatment.

Follicle Stimulating Hormone & Human Menopausal Gonadotropin Breakdown

Medications to Stimulate the Ovaries - FSH & hMG

Follicle Stimulating Hormone (FSH):

Human Menopausal Gonadotropin (hMG):

• Gonal-f • Follistim • Bravelle (less common)

These are both self-administered subcutaneous injections. You will inject a small needle under the skin daily either in the abdomin or thigh.

The dose is personalized to your age, hormone levels, and the goal for this IVF cycle.

• mood swings • headaches • nausea • mild abdominal pain • bloating • breast tenderness • pain at the injection site • Ovarian hyperstimulation syndrome

• Menopur

Commonly Prescribed Brands:

Potential Side Effects & Risks:

Administration:

Dosage:

Dr. Brian Levine from CCRM NY explains the role of the most common fertility medications utilized during an IVF cycle.

“My mantra is inhale, exhale, and commit. Because the first couple of times, I did not push hard enough with the needle. I was not committed. And that always makes it more painful.”

Another medication that you will encounter during this phase of treatment is human chorionic gonadotropin (hCG), this is often refered to as the “trigger” shot.

Chrissy & Lindsey C., Progyny Members

“I do remember the trigger shot being mentally stressful... I set like 10 alarms, an alarm for every 15 minutes leading up.”

While you are administering injections at home, your physician will need you to come into the fertility clinic for monitoring to evaluate how your body is reacting to the medications.

Morning Monitoring

The Trigger Shot

The image of the alarm clock face nine o'clock.

The importance of timing

Stimulating the Ovaries

Preventing Ovulation

Morning Monitoring

The Trigger Shot

Back view portrait of a woman alone watching the sky sitting on the grass

A red, plastic sharps container (with a biohazard symbol) with needles (syringes) on a black background with copy space.

The Trigger Shot

Demonstrated Outcomes and Value

A Better Member Experience

Benefit Design and Access to Care

Fertility Benefits Evolution

Educated members are able to make better treatment decisions for a healthy, successful pregnancy.

Demonstrated Outcomes and Value

Benefit design and access to care was a top priority for Cerner, but they were also drawn to a personalized service that could better help their members through the physical and emotional challenges of infertility.

A Better Member Experience

Fertility Benefits Evolution

In 2017, with no prior coverage, associates paid out-of-pocket for costly treatments, and faced high costs associated with multiples (twins or triplets). They were eager to add fertility coverage to their benefits package that supported maternity members and growing families. The time was right according to Arielle Bogorad, Senior Director of Worldwide Benefits at Cerner.

With Progyny, everything needed for a comprehensive fertility treatment is contained within a Smart Cycle treatment bundle.

When Cerner decided to partner with Progyny, they were drawn to a benefit design that would do one thing - avoid the status quo.

Benefit Design and Access to Care

Supporting Growing Families: A Progyny Case Study

Cerner members have achieved superior outcomes far above the national average, increasing the rate of pregnancy, with higher live birth rates, and a lower incidence and cost of multiples.

Learning About Medications

Understanding Financial Responsibility

Determining the Start of Treatment

Understanding the Risks

The Care Team

Patients with conventional coverage can often find it difficult to understand what treatments are and aren’t included in their coverage.

Most clinics schedule a conversation with a billing specialist or financial advisor for their patients before treatment begins. This is often called a financial consultation. The financial consultation is where they’ll break down how your treatment protocol and medications can translate into bills you should expect along the way.

Understanding Financial Responsibility

The Morning Monitoring Visit - Lab Work

You will have your blood drawn at each monitoring appointment. The hormones evaluated during your IVF cycle generally include estrogen, progesterone, and LH. During the IVF cycle, your estrogen level should increase, and progesterone level would normally remain low. LH may or may not be checked (dependent on medication protocol). If any of these levels are not where your doctor expected them, they may adjust your medications, and in rare cases, cancel your cycle.

The Morning Monitoring Visit - Intravaginal Ultrasound

An intravaginal ultrasound will be completed at each monitoring appointment. This allows your physician to visually see and monitor your ovaries. They are checking the status of follicle growth in response to your stimulation medication. On average, a follicle is expected to increase in size by approximately 1–2mm a day. Some patients respond more strongly to the medications than expected, so a physician may switch to a lower dosage of medication to avoid complications like Ovarian Hyperstimulation Syndrome (OHSS). While other patients might not be responding as well as hoped, so a physician may elect to increase the dosage to try to jumpstart the stimulation for retrieval.

Determining the Start of Treatment

Studio shot of a smiling attractive middle aged woman standing with arms crossed at dark background.

In the weeks leading up to the beginning of your IVF cycle, there likely will be conversations with physicians, and coordinators about the risks associated with treatment. Many clinics offer in-person classes with a nurse, and others are now offering online courses to prepare you for your cycle.

Once the decision has been made to proceed with IVF, the first thing most clinics will do is to make sure that you are fully informed about the risks and benefits of the IVF process.

Understanding the Risks

See common risks associated with IVF

Common risks associated with IVF

See rare risks associated with IVF

Get to Know Your Care Team

It takes a team to properly manage an IVF journey. Depending on the clinic size and their treatment style, you may interact with anywhere from four to 10+ people at the fertility clinic.

Progyny Patient Care Advocate

Physician

Preparing for IVF

IVF Nurse

Financial Coordinator

Patient

Headaches, cramping, mood swings, mild bruising and soreness at injection site.

Rare risks associated with IVF

Demo Navigation

Phillip S., Progyny Member

“Oh, you got Progyny. And she put a line through everything and a zero. My heart just dropped... Then all the stress just left like any of that was just gone.”

Business people or doctor talking to customer and using laptop at office room.

For Progyny members, your PCA will coordinate with the clinic’s billing specialist. Progyny’s comprehensive coverage allows you and your physician can focus on the best treatment plan, without having to weigh everything against your coverage. Reach out to your PCA for a detailed overview of your financial responsibility.

Your doctor will work with you to determine which fertility drugs, and at what dosage, will be used for your treatment.

Learning About Medications

Amanda L., Progyny Member

“Today we got my medications in order. I'm going into tomorrow being cautiously optimistic and hopeful.”

Follicle Stimulating Hormone & Human Menopausal Gonadotropin Breakdown

Antagonist medication breakdown

Human chorionic gonadotropin breakdown

Progesterone

This is where all the tests and conversations you had during the initial consultation first come into play. While there are many different brands of medications that can be used during an IVF cycle, there are just a handful of medication types that patients encounter in most IVF cycles.

Unlike most prescriptions you’ll receive from a doctor, most fertility medications are ordered through a mail order specialty pharmacy and some may require a prior authorization. Your clinic will work closely with the pharmacy to ensure you receive all your medication in a timely manner.

Obtaining Medications

When you receive your medications, it’s important that you open the box immediately and pay close attention to storage requirements, as some medications may require refrigeration. If you have questions about the medication that is being ordered for you speak to your physician or nurse, and remember, your PCA is always available to guide you through the process.

Progyny Rx

If you have Progyny Rx, your medication coverage is rolled into your overall Progyny coverage. Ask your PCA about your medication coverage today.

The suppression check, sometimes called your baseline morning monitoring appointment, is the final step before you can begin the stimulation process.

The suppression check entails both blood work and an intravaginal ultrasound. If all goes well at your suppression check appointment, you will start fertility medications that day or the following day.

Suppression Check

Your doctor is checking the following things at the suppression check:

Confirm that there is no current pregnancy

Ensure the patient's estradial level is low

Ensure the patient's uterine lining is thin

Confirm there are no significant ovarian cysts

Measuring resting follicle count

cropped view of donor and doctor with syringe obtaining blood sample

Basics and Diagnostics

Preparing for IVF

Stimulation & Monitoring

Follicle Stimulating Hormone & Human Menopausal Gonadotropin Breakdown

Dr. Brian Levine from CCRM NY explains the role of the most common fertility medications utilized during an IVF cycle.

Kelly P., Progyny Member

Dr. Sheeva Talebian (CCRM NY), Dr. Angie Beltsos (Vios), Dr. Celeste Brabec (RRC), and Dr. Michael Homer (Reproductive Science Center) break down what you can expect from the initial consultation.

Romantic young couple standing in mountain together and looking at view. Young man embracing his girlfriend and looking away.

Ectopic Pregnancy

Ovarian Hyper Stimulation Syndrome

Ovarian Torsion

Egg Retrieval Complications

The egg retrieval is a minimally invasive surgical procedure, and while the risks are minimal it's important to be congnizant of them. The risks include bleeding, infection, and damage to the bowel or bladder. Be sure to communicate any pain or discomfort with your physician.

Ovarian Torsion

Ovarian torsion is a condition that occurs when an ovary twists around the ligaments that hold it in place. This twisting can cut off blood flow to the ovary and fallopian tube. Ovarian torsion can cause severe pain and other symptoms because the ovary is not receiving enough blood. Be sure to communicate any pain or discomfort with your physician.

Ovarian Hyper Stimulation Syndrome (OHSS)

In rare instances (1-5%), “ovarian hyperstimulation syndrome” (OHSS) may occur during ovarian stimulation. OHSS is associated with swollen, enlarged ovaries and the collection of fluid in the abdominal cavity. Most cases are mild, but rarely the condition is severe and can lead to serious illness or death. Be sure to communicate any pain or discomfort with your physician.

Ectopic Pregnancy

Ectopic pregnancy, also called extrauterine pregnancy, is when a fertilized egg grows outside a woman’s uterus, somewhere else in her belly. It can cause life-threatening bleeding and needs medical care right away. In more than 90% of cases, the egg implants in a fallopian tube. This is called a tubal pregnancy.

Ectopic Pregnancy

Ovarian Hyper Stimulation Syndrome

Ovarian Torsion

Egg Retrieval Complications

First day of the menstrual cycle

Birth control/regulated cycle

Estrogen patch or pills

First Day of the Menstrual Cycle

If you have a regular menstrual cycle, your physician may recommend that you start treatment on day 2 or 3 of your menstrual cycle. In these cases, you will be directed to call your clinic on the day your period starts to receive detailed adjustments to your protocol.

Estrogen Patch/Pills

In order to regulate your FSH your doctor may put you on an estrogen patch or pill, and then have you come in to start your cycle after the start of the next menstruation cycle.

Birth Control/Regulated Cycle

Taking birth control feels counter-intuitive when trying to have a baby, but there are a few situations in which a doctor might recommend you go on birth control before you begin your treatment cycle:

• If you have unpredictable ovulation your doctor may recommend birth control for approximately two to four weeks in order to regulate your cycle before taking you off birth control to begin treatment. • If you are a “super responder” (meaning your body tends to over-produce follicles/eggs) your doctor may want to suppress your ovaries with a birth control pill before the beginning of treatment. This is common in patients with a history of polycystic ovarian syndrome (PCOS). • If you are traveling to a clinic out of town and need some time to make arrangements, or if you are going on a trip for work, or even just a vacation, your doctor may put you on birth control so you can schedule your cycle start well in advance.

Dr. Brian Levine from CCRM New York talks about a few ways physicians and patients determine the start of an IVF treatment.

Watch our medication administration videos

Medications to Stimulate the Ovaries - FSH & hMG

Follicle Stimulating Hormone (FSH):

Human Menopausal Gonadotropin (hMG):

• Gonal-f • Follistim • Bravelle (less common)

These are both self-administered subcutaneous injections. You will inject a small needle under the skin daily either in the abdomin or thigh.

The dose is personalized to your age, hormone levels, and the goal for this IVF cycle.

• mood swings • headaches • nausea • mild abdominal pain • bloating • breast tenderness • pain at the injection site • Ovarian hyperstimulation syndrome

• Menopur

Commonly Prescribed Brands:

Potential Side Effects & Risks:

Administration:

Dosage:

Antagonist Medications to Prevent Early Ovulation

• Cetrotide • Ganirelix

This is a self-administered subcutaneous injection. You will inject a small needle under the skin daily either in the abdomin or thigh.

Your provider will determine when to start taking your antagonist and at what dosage.

• headaches • nausea • pain at the injection site

Commonly Prescribed Brands:

Potential Side Effects & Risks:

Administration:

Dosage:

Medication to Mature Eggs, The Trigger Shot - hCG

• Novarel • Ovidrel • Pregnyl

This can be prescribed as a self-administered subcutaneous injection where you will inject a small needle under the skin in either the abdomin or thigh. This can also be prescribed as a self-administered intramuscular injection where you will inject a longer needle into the muscle usually in the backside.

Leuprolide acetate or “Lupron” may be used along with or instead of hCG to trigger the final maturation of the eggs and the follicle.

• nausea • abdominal pain • bloating • pain at the injection site

Commonly Prescribed Brands:

Potential Side Effects & Risks:

Administration:

Alternative/Supplemental:

Progesterone

• Progesterone in Oil • Vaginal Suppository

Doctors usually prescribe progesterone supplementation to start on the day the eggs are harvested. If a pregnancy takes place, the doctor may tell you to continue taking progesterone throughout the first trimester. This us usually prescribed as a self-administered intramuscular injection where you will inject a longer needle into the muscle, usually in the backside. This can also be prescribed as a vaginal suppository.

• pain/swelling at the injection site • dizziness or tiredness • mood swings • bloating • nausea • cramps

• vaginal itching or burning • yeast infection

Commonly Prescribed :

Common Side Effects & Risks (injections):

Common Side Effects & Risks (suppositories):

Administration:

Confirm that there is currently no pregnancy

Sounds silly, right? Yes, many people who are pursuing IVF are doing so because of an inability to get pregnant, but it’s important to make sure before beginning an IVF cycle.

Ensure the estradiol level is low

Estradiol is a type of estrogen (the major sex hormone in women) and is secreted by the ovarian follicles as they grow and develop each month. This sets the rest of the reproductive cycle in motion. High levels of estradiol can potentially indicate a problem with your ovarian reserve, which may mean you can have trouble producing enough eggs for retrieval.

Ensure the uterine lining is thin

For a successful implantation an embryo needs a receptive uterine lining. The uterine lining, also called the endometrium, thins and thickens during a menstrual cycle, so to better ensure that the uterine lining is at the optimal level of thickness for the embryo transfer it’s important that it begins at the optimal level of thinness.

Confirm there are no significant ovarian cysts

Many people are startled when they hear the word cyst as they go through their treatment. There are many different types of ovarian cysts, but in context of a stimulation cycle, these “cysts” are simply ovarian “follicles” that contain eggs. During your suppression check, your doctor is checking to see if any of those follicles are too large. A follicle that is larger than the other follicles is called a dominant ovarian cyst. A dominant ovarian cyst can interfere with your IVF protocol as it may indicate that the smaller follicles will not mature during stimulation. When this happens, the doctor may recommend that you postpone treatment until the cyst has resolved itself, or may recommend that a birth control pill be used for several weeks to suppress the ovaries.

Measure resting follicle count

In order to predict how your body will respond to follicle stimulating medication and to personalize your starting dosage of medication, your doctor needs to know what your follicle count is before the start of treatment, which is called the resting follicle count.

Antagonist medication breakdown

Antagonist Medications to Prevent Early Ovulation

• Cetrotide • Ganirelix

This is a self-administered subcutaneous injection. You will inject a small needle under the skin daily either in the abdomin or thigh.

Your provider will determine when to start taking your antagonist and at what dosage.

• headaches • nausea • pain at the injection site

Commonly Prescribed Brands:

Potential Side Effects & Risks:

Administration:

Dosage:

Lab work

Intravaginal Ultrasound

The Morning Monitoring Visit - Lab Work

You will have your blood drawn at each monitoring appointment. The hormones evaluated during your IVF cycle generally include estrogen, progesterone, and luteinizing hormone (LH). During the IVF cycle, your estrogen level should increase, while your progesterone level would normally remain low. LH may or may not be checked (dependent on medication protocol). If any of these levels are not where your doctor expected them, they may adjust your medications, and in rare cases, cancel your cycle.

The Morning Monitoring Visit - Intravaginal Ultrasound

An intravaginal ultrasound will be completed at each monitoring appointment. This allows your physician to visually see and monitor your ovaries. They are checking the status of follicle growth in response to your stimulation medication. On average, a follicle is expected to increase in size by approximately 1–2mm a day. Some patients respond more strongly to the medications than expected, so a physician may switch to a lower dosage of medication to avoid complications like Ovarian Hyperstimulation Syndrome (OHSS). Other patients might not be responding as well as hoped, so a physician may elect to increase the dosage to try to jumpstart the stimulation for retrieval.

Human chorionic gonadotropin

Medication to Mature Eggs, The Trigger Shot - hCG

• Novarel • Ovidrel • Pregnyl

Leuprolide acetate or “Lupron” may be used along with or instead of hCG to trigger the final maturation of the eggs and the follicle.

• nausea • abdominal pain • bloating • pain at the injection site

Commonly Prescribed Brands:

Potential Side Effects & Risks:

Administration:

Alternative/Supplemental:

The Importance of Timing - The Trigger Shot

If you take your shot earlier than instructed and don’t tell your doctor, you might ovulate prior to your egg retrieval, or if you arrive late to your egg retrieval appointment, you may ovulate before they have a chance to retrieve the eggs. Both of these scenarios would result in a cycle with zero eggs. Clarity is key, so be sure you are completely clear on your instructions for both when to do your injection as well has how to mix and inject your trigger shot.

Dr. George Patounakis from RMA of Orlando talks about what you can expect at your monitoring appointments.

The Egg Retrieval

Understanding the Results

Recovery

Egg Retrieval Procedure

Fresh or Frozen Sperm

Introduction

The results of an egg retrieval can be as low as zero mature eggs retrieved and as high as over 20 mature eggs retrieved. You should have a general sense of how many eggs you can expect from your last monitoring visit based on the number and size of follicles from your ultrasound.

The results of an egg retrieval will depend on the factors that brought you to IVF to begin with, and how your body reacts to the medications.

Understanding the Results

What is a “good” number of eggs retrieved?

Are immature eggs on retrieval day a lost cause?

Immature Eggs

Immature eggs aren’t a lost cause as eggs continue to mature naturally after retrieval, sometimes these eggs mature just a couple of hours later and sometimes they will be mature by the next morning. This is called in vitro maturation.

Patients may feel some soreness equivalent to cramping, and drowsiness from the anesthesia.

While most patients can return to work the following day. It is recommended that patients refrain from returning to work the day of the retrieval, just in case they are still experiencing some drowsiness. After the retrieval is complete, you will be transitioned to a recovery area where you will wait to recover briefly from the retrieval and be cleared to leave with your partner or friend who will be driving you home. At some clinics, you will remain to wait for the early results of the retrieval, while at others, you will receive a call with the results.

Egg Retrieval - Recovery

The Morning Monitoring Visit - Lab Work

The Morning Monitoring Visit - Intravaginal Ultrasound

Sarah R., Progyny Member

“The IVF process is very consuming. Emotionally, physically, mentally. I felt like I needed to give myself some space.”

If you have a partner who will be producing a fresh semen sample, they should also be present at the egg retrieval to provide the sample for processing and preparation. If your partner cannot be available on the day of the retrieval, or if they prefer, they can freeze sperm ahead of time to have thawed and prepared on the day; if you will be using frozen donor sperm, the lab will have your vial ready for thawing and processing.

Not all of the decisions are about the woman’s body, but the choice to use fresh or frozen sperm may be more about convenience than effectiveness.

Fresh or Frozen Sperm Preparation

The Egg Retrieval

All of the hard work has been building to one of the most exciting events of any IVF cycle: The Egg Retrieval.

What happens after a canceled cycle?

A canceled cycle could also occur if, during monitoring, your doctor doesn’t see an adequate number of mature follicles on your ovaries, indicating that there aren’t any mature eggs to retrieve. When this happens, it can be extremely frustrating for patients, but it’s important to remember that this isn’t necessarily the end of the road. Your doctor may be able to use this information about your specific body, and how it reacts to medications to prescribe a different protocol the second time around. Many who experience a canceled cycle can still go on to have a successful egg retrieval at a later date. A canceled cycle can be a very stressful time, and it’s important to remember that you can reach out to your care team, or your Progyny PCA for support, or to answer any of your questions.

Dr. Spencer Richlin from RMA of Connecticut demonstrates what you can expect during the egg retrieval procedure.

53.1%

Cumulative live birth rate using frozen sperm

Mayo Clinic. "Frozen, Fresh Sperm Both Effective For In Vitro Fertilization." ScienceDaily. ScienceDaily, 14 May 2004. .

Cumulative live birth rate using fresh sperm

51.6%

Close up Semen centrifuge test sperm laboratory infertility IVF

A Mayo Clinic study shows that couples using in vitro fertilization have the same likelihood of successful pregnancy whether the sperm used is frozen or fresh.

It is recommended that you arrive an hour early to the egg retrieval to allow time to complete any paperwork or consultation that your clinic may require.

The Egg Retrieval Process

Hillary F., Progyny Member

“We had about 15 follicles, which to us seemed like a good number... They told us they had 13 eggs and all 13 eggs were mature. So that was great.”

Risks associated with the egg retrieval

Risks associated with the egg retrieval procedure include:

• bleeding • infection • damage to the bowel or bladder

On the day of the retrieval, once the nurses have prepped you for the procedure, you will be brought back to the retrieval room, and you will likely undergo a light anesthesia. This is a very minimally invasive, and quick procedure, but you may experience a conscious sedation. It’s important to note that you will not be permitted to drive yourself home from your treatment, so you will need to bring someone who can drive you.

There will be several people in the operating room with you: your reproductive endocrinologist who will perform the retrieval, a nurse, an anesthesiologist, and an embryologist. Your doctor will use an ultrasound-guided needle which will puncture each mature follicle of your ovaries one by one and aspirate, or retrieve, an egg. The retrieved eggs are immediately transferred to an embryologist. The procedure typically takes less than 15 minutes.

Female patient having eggs retrieved using vaginal ultrasound

Kelly P., Progyny Member

“We only ended up getting seven eggs that retrieval. Luckily, all seven were mature. So that was a big plus. But unfortunately only four fertilized with ICSI.”

Woman sitting on beach sand and relaxing at sunset time

Mature eggs are the eggs that have completed the process needed to be ready for fertilization. While immature eggs are eggs that did not complete the maturation process while in the ovary prior to the retrieval.

Waist up portrait of smiling gynecologist standing with red-haired woman in medical office. Copy space in right side

The Egg Retrieval

Fertilization & Embryo Development

Suppression Check

The Risks of Multiples

Embryo Development

Why ICSI is used

Insemination vs ICSI

Fertilization

The Embryologist

After fertilization, the embryologist is hard at work making sure that the embryos have the ideal micro-environment to develop. Embryos are stored in incubators, which are designed to mimic the environment in the uterus, primarily by providing a constant body temperature and a specific mixture of carbon dioxide, oxygen, and nitrogen.

After a successful fertilization the process of embryo development begins.

Embryo Development

What is a blastocyst?

Elective Single Embryo Transfer

What is assisted hatching?

Day 3 vs Day 5/6 embryo development

What is a blastocyst?

A blastocyst is an embryo which has been left to develop until day 5 or 6 after fertilization and presents a complex cellular structure formed by approximately 200 cells. You want as many day 5 or 6 blastocysts as you can get, as those are the embryos that have a chance to be transferred or genetically tested. In the past, fertility doctors would routinely transfer embryos at day 3, when each embryo is a bundle of about 8–12 cells in total. Now the consensus is that an embryo that is healthy enough to survive to day 5 or 6 is more likely to result in a live birth. Today, most clinics will probably recommend a day 5 or 6 transfer.

Embryo Development: Day 3 vs Day 5/6

In the past, fertility doctors would routinely transfer embryos at day 3, when each embryo is a bundle of about 8–12 cells in total. Now the consensus is that an embryo that is healthy enough to survive to day 5 or 6 is more likely to result in a live birth. Today, most clinics will probably recommend a day 5 or 6 transfer.

ICSI is often used to help patients with male factor infertility, but there are other reasons a doctor might recommend ICSI.

Reasons Your Doctor May Recommend ICSI

Fertilization can be as simple as joining sperm and egg in a dish, or as precise as placing a single sperm inside a single egg.

Insemination vs ICSI

Dr. Sharon Jaffe from Center for Reproductive medicine talks about the two different fertilization techniques available in an IVF cycle.

Intracytoplasmic Sperm Injection (ICSI)

Insemination

Intracytoplasmic Sperm Injection (ICSI)

ICSI was originally created to fertilize eggs where the sperm may have had difficulty entering the egg alone, usually due to poor sperm motility or low number of sperm available. ICSI is the technique in which an individual sperm cell is introduced into an egg cell manually using a micropipette, which is a tiny needle. The embryologist will select the best-looking sperm from the sample, pick it up in the pipette, and inject it inside the egg. One of the advantages of ICSI is that the embryologist can ensure that a sperm did enter each egg, while with conventional insemination, you have to leave it up to the cells themselves.

Insemination is the process whereby the egg and sperm are left to complete the fertilization process without assistance of an embryologist. It is also known as conventional insemination, as it was the first method of fertilization used when IVF was created. The sperm are placed into a dish with the eggs and by the next morning a sperm should have been able to find its way into an egg to fertilize it. In cases of male factor infertility (the sperm count or motility is low), the sperm may not to be able to enter the egg without assistance. If genetic testing is planned, many embryology laboratories prefer to select a single sperm in an attempt to improve the accuracy of the results.

Fertilization is the joining of mature eggs with sperm. A number of those eggs will fertilize, a smaller number will mature to day three where they are a bundle of 8–10 cells. An even smaller number will mature to day five or six, at which stage they are called blastocysts. Those blastocysts will be evaluated both at day 3 and day 5 or 6 to see if they are developing at the expected rate, and a determination will be made about how many viable (meaning, potentially leading to a healthy baby) embryos you have available for storage and/or transfer.

The joining of egg and sperm may seem straightforward, but there are some choices to make when it comes to fertilization.

Fertilization

The Embryologist

After the egg retrieval, you will enter a new phase of your treatment cycle, one that will require a new member of your care team: the embryologist.

The embryologist prepares both the sperm and eggs, fertilizes the eggs by joining them with sperm, and provides a safe environment for the embryos to develop. They also often perform the embryo biopsy needed in order to test the embryo’s chromosome’s for viability.

Mandy Katz-Jaffe, Scientific & Genetic Director, CCRM

“Our goal is for every patient to fulfil their hopes and dreams of what family means to them in the shortest timeframe possible.”

At this point in your cycle you and your physician will have more information than previous points in the process. You’ll know how many eggs the embryology team has to work with, and you and your doctor will have a clear understanding of how your body reacted to the protocol. Not it's the embryologist’s job to fertilize the eggs and hopefully begin the process of embryo development.

Doctor or lab technician adjusting needle to fertilize a human egg under the microscope

Amanda L., Progyny Member

“After the egg retrieval we had two eggs that were retrieved, and we also had eight eggs donated to us from my sister… of my two eggs one fertilized, and of my sisters seven fertilized.”

Woman doctor working in medical lab with manipulator and microscope

In the body eggs and sperm most often meet in the fallopian tubes, but with IVF everything happens in the lab. In general, there are two ways an embryologist can fertilize an egg, and the process they choose is up to you and your physician.

Insemination

• If you experienced fertilization failure in a previous cycle

• If you plan to genetically test your embryos (PGT-A/PGT-M) then your physician will recommend ICSI to reduce the occurrence of genetic contamination of the samples when sent off for genetic testing

• For patients whose egg retrieval resulted in fewer eggs than expected (ICSI may have a higher fertilization rate)

• For cycles where you will be using frozen eggs

Data from CDC's National ART Surveillance System demonstrate the increased use of ICSI over time:

ICSI used for cycles with male factor infertility

76.3%

ICSI used for cycles without male factor infertility

15.4%

Trends in use of and reproductive outcomes associated with intracytoplasmic sperm injection. http://www.ncbi.nlm.nih.gov/pubmed/25602996

93.3%

1996

2012

1996

66.9%

See live birth rates by fertilization technique for patients with previous fertilization failure

ICSI

26%

Conventional Insemination

Comparison between intracytoplasmic sperm injection and in-vitro fertilization (IVF) with high insemination concentration after total fertilization failure in a previous IVF attempt. Kastrop PM et al. https://www.ncbi.nlm.nih.gov/pubmed/10374096

For patients with previous complete fertilization failure ICSI resulted in significantly improved live birth rates.

See percentage of IVF procedures using ICSI with and without a male factor diagnosis

ICSI and your Progyny coverage

At Progyny, it is our goal to help you achieve a successful pregnancy, so we have included coverage for both conventional insemination and ICSI in your SMART Cycle benefit. This is another reason it’s a good idea to make sure your care team understands that you have this coverage before you start your treatment. You don’t want to miss out on any of the advantages that this coverage affords you. Don’t hesitate to speak to your PCA about the nuances of your Progyny coverage.

ICSI is included in your Progyny coverage

IVF Lab & Fertilization

Of the eggs that fertilize, some will develop into a blastocyst.

Woman scientist working with pipette in laboratory dripping egg cell in solution

Embryo Selection & Genetic Testing

Suppression Check

PGT-M

PGT-A & Clinical Outcomes

PGT-A

Risks of Multiples

Embryo Selection

Euploid vs Aneuploid

Expanded carrier screening panels test for hundreds of recessive disorders. If you and your partner test positive for a variant in the same gene, you will be offered the opportunity to speak to a genetic counselor about your options, including PGT-M. If an embryo carries both the maternal and paternal variant or mutation, the baby will carry the disease, so this test can identify embryos destined to carry the disease so that they can be ruled out for transfer.

PGT-M is a powerful option for people at high-risk of passing on a specific single gene disorder, like cycstic fibrosis

Preimplantation Genetic Testing - Monogenic Diseases

What is preimplantation genetic testing for structural rearrangement (PGT-SR)?

Transferring a PGT-A tested euploid embryo can significantly increase success rates per transfer, and because it allows the physician to perform a single embryo transfer, reduces the likelihood of multiple gestations drastically. For older patients, transferring a PGT-A tested euploid embryo brings success rates as high as they would be for a non-tested embryo at a much younger age, making it a great tool for women of advanced maternal age to safely increase their success per transfer.

PGT-A with an elective single embryo transfer can lead to superior clinical outcomes.

PGT-A and Clinical Outcomes

Is PGT-A included in coverage for Progyny members?

Reduced time to pregnancy

Reduced rate of miscarriage

Increased implantation rate

PGT-A is included in your Progyny coverage

If PGT-A feels like a wise choice, it’s because it likely is, but some patients choose to forgo testing. This often happens because of cost. PGT-A, like any technology, can be costly, so when paying out-of-pocket, it can be difficult for some patients to pay for the test. Progyny has removed that obstacle for our members. PGT-A is covered in every SMART Cycle used for IVF. At Progyny our mission is to help everyone have a healthy baby, and by covering PGT-A, we are standing behind that mission. For patients with this coverage, the most frequently recommended transfer strategy when multiple embryos are available is to test them, discard aneuploid embryos and transfer one euploid embryo. The remaining euploid embryos will then remain frozen at the clinic for future potential transfer attempts.

PGT-A and increased implantation rates

When transferring PGT-A tested euploid embryos, the implantation rate far exceeds the implantation rate for untested embryos.

This game changing technology, often called PGT-A, and formerly called PGS and CCS, has helped bring IVF success rates with a single embryo transfer up to previously unreachable levels.

Elective single embryo transfer (eSET) is the intentional transfer of one embryo when there are multiple embryos of appropriate stage and quality available. PGT-A allows patients and doctors to elect to transfer one embryo at a time while maintaining high success rates, and reducing rates of miscarriage, and time to pregnancy.

Preimplantation Genetic Testing for Aneuploidy

Risks of Transferring Multiple Embryos

The embryo grade will tell you how well an embryo has developed compared to the expected average, but it isn’t an accurate indication of chromosomal abnormality. In fact, two embryos on day 6 after fertilization could have developed to have the exact same grade but one of them could be aneuploid and the other euploid.

Euploid embryos can lead to a healthy baby, and aneuploid embryos can’t. Unfortunately, it’s impossible to detect which embryos are euploid just by looking at them.

Embryo Selection

See common risks associated with IVF

Rare risks associated with IVF

Ectopic Pregnancy

Ovarian Hyper Stimulation Syndrome

Ovarian Torsion

Egg Retrieval Complications

Ovarian Torsion

Ovarian Hyper Stimulation Syndrome

Ectopic Pregnancy

Ovarian Torsion

Egg Retrieval Complications

Ovarian Hyper Stimulation Syndrome (OHSS)

Ectopic Pregnancy

Philip S., Progyny Member

“We don't have a problem getting pregnant, it was a problem of having a viable embryo that will stay and make it a full term to become a baby.”

Euploid vs Aneuploid Embryos

Not all embryos can lead to a live birth, so selecting embryos with a greater chance to result in a healthy baby is critical.

A healthy embryo contains 46 chromosomes, 23 of which are contributed by the sperm, and 23 by the egg. When an embryo has 46 chromosomes it’s called a euploid embryo and has the potential to develop into a healthy baby.

The chart below demonstrates that the rate of aneuploidy increases with age. This coinsides with a reduced IVF success rate.

Egg Donor

61%

54%

% Euploid Embryos

IVF Success Rate

< 35

51%

48%

35-37

43%

35%

38-40

30%

22%

Preimplantation Genetic Diagnosis for Aneuploidy and Translocations Using Array Comparative Genomic Hybridization - Santiago Munné - Curr Genomics. 2012 Sep; 13(6): 463–470. Published online 2012 Sep. doi: 10.2174/138920212802510457 PMCID: PMC3426780

41-42

18%

11%

41-42

12%

analyzing Chromosome of human being on screen

Transferring an abnormal embryo significantly decreases implantation rates, and increases rates of miscarriage. For patients experiencing reccurent pregnancy loss the most common cause is chromosomal abnormality of the embryos.

In the past, because it was impossible to know which embryos were aneuploid and which were euploid, doctors would frequently transfer two or more embryos at a time to increase the likelihood that they are transferring a euploid embryo.

But, as you might expect, transferring multiple embryos dramatically increases the likelihood of a multiple gestation (twins, triplets, more).

Transferring multiple embryos brings serious health risks to both mom and babies.

The risks associated with multiples

Dr. Candice Perfetto from Center for Reproductive Medicine lays out the most significant and common risks associated with multiple gestation pregnancies.

How does PGT-A work, and when can you expect to receive your results?

How does PGT-A Work?

In order to test embryos using PGT-A, an embryo needs to be biopsied, meaning a few cells from the part of the embryo that will become the placenta are removed for testing. Keep in mind that the cells that will become the actual baby are not involved in this process and remain intact within the embryo. The embryos are then frozen (vitrified) so that the physician can await test results before making a decision on which embryo to transfer. The biopsied cells are shipped to a laboratory where the chromosomes of each cell can be categorized and counted. The results of this test usually come back in about a week, and your physician will tell you how many euploid embryos you have available for transfer.

When do the results of the test come back?

The results of this test usually come back in about a week, and your physician will tell you how many euploid embryos you have available for transfer.

Dr. Ravi Gada from Dallas-Fort Worth Fertility Associates discusses the risks of transferring multiple embryos, and the ways in which PGT-A can empower single embryo transfer.

Does PGT-A ”fix“ abnormal embryos?

Reduced pre-term labor

Dna test infographic. Genome sequence map, chromosome architecture and genetic sequencing chart abstract data. Molecule structure genetic test. Genealogy sequence vector illustration

Embryo Selection & Testing

What is recurrent pregnancy loss?

Recurrent Pregnancy Loss

Recurrent pregnancy loss is classically defined as the occurrence of three or more consecutive pregnancy loss; however, the American Society of Reproductive Medicine (ASRM) has recently redefined recurrent pregnancy loss as two or more pregnancy losses. A pregnancy loss is defined as a clinically-recognized pregnancy involuntarily ending before 20 weeks. A clinically-recognized pregnancy means that the pregnancy has been visualized on an ultrasound or that pregnancy tissue was identified after a pregnancy loss.

PGT-A/CCS Approved Embryo

66.4%

47.9%

Untested Embryo

Blastocyst biopsy with comprehensive chromosome screening and fresh embryo transfer significantly increases in vitro fertilization implantation and delivery rates: a randomized controlled trial. Scott et al. https://www.ncbi.nlm.nih.gov/pubmed/23731996

PGT-A and reduced rate of miscarriage

Miscarriage is perhaps more common that most people realize. According to some studies up to 1 in 4 pregnancies result in a miscarriage, and the overwhelming majority of miscarriages are due to chromosomal abnormality of the embryo. By removing aneuploid embryos from the equation the rates of miscarriage plummet well below the national average for women 35 years and older.

< 35 Maternal Age

13%

35 Maternal Age

10%

15%

38 Maternal Age

16%

21%

41 Maternal Age

13%

28%

43 Maternal Age

18%

43%

PGT-A Approved

Not Tested

PGT-A and reduced time to pregnancy

Most people who enter an IVF treatment have been trying for months or years to have a baby, and IVF itself can take multiple months to complete. For this reason, many patients prioritize reducing their time to pregnancy. PGT-A allows patients to select a healthy embryo for their first transfer, giving each transfer the best possible chance of success, and therefore reducing the number of transfers needed, and the time associated with multiple transfers.

PGT-A and reduced pre-term labor

Most IVF births make it to term, but that isn’t the case when discussing pregnancies resulting from a multiple embryo transfer. Due to complications associated with multiple gestation pregnancy the chances of experiencing a pre-term birth are increased dramatically when multiple embryos are transferred. Transferring one euploid embryo will decrease the chances of experiencing a pre-term labor.

No, PGT-A does not alter or ”fix“ an embryo's chromosomal makeup

It’s important to understand that PGT-A can improve success rates, but it doesn’t do so by changing, or “correcting” aneuploid embryos. If an embryo has too many or too few chromosomes there is no way salvage that embryo. PGT-A can increase success rates by ruling out embryos that won’t lead to a live birth, in favor of embryos with a high likelihood to result in a live birth.

What is a mosaic embryo?

Mosaic is the term now assigned to embryos found to possess both normal and abnormal cells during PGT-A. Mosaic embryos can result in the birth of a healthy euploid baby with no apparent evidence of mosaicism, although they appear to have roughly half the chance of implanting as the normal-range embryos. You should speak to your physician if you have any questions about mosaicisms.

Preimplantation genetic testing for structural rearrangement (PGT-SR)

Some patients may be healthy but carry a rearrangement of DNA called a translocation. These patients can produce some healthy eggs or sperm, but in many cases, will produce gametes that yield embryos with an abnormal chromosomal content. These embryos are likely to not implant or to miscarry. If you are at risk of passing on a translocation, your doctor may recommend that you undergo PGT-SR (structural rearrangement).

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If you’re interested in PGT-M you should reach out to your PCA for more information on the coverage and which labs are able to preforms this test.

The Embryo Transfer

Suppression Check

Obtaining Medications

Embryo Transfer Procedure

How many embryos to transfer?

Mock Transfer & Mock Cycle

Natural vs Artificial Cycle

Fresh vs Frozen

There are various protocols used to prepare the endometrium for an embryo transfer, but it generally breaks down between a decision to move forward with a natural cycle or an artificial cycle.

For those pursuing a frozen embryo transfer there are two different ways to prepare.

Natural vs Artificial Cycle

Frozen embryo transfer artificial cycle

Fresh vs Frozen Embryo Transfer

Once you have your cohort of embryos it’s time to think about the embryo transfer.

Excerpt from the podcast This is Infertility - click here to listen to Sarah's full story

Sarah R. Progyny Member

“It’s very valuable to have someone that understands the journey. Sue wanted to hear my story the other day when we were chatting. It felt good to have that kind of person in my life helping me through this process.”

Jennifer K. Progyny Member

Female Doctor Meeting With Patient In Exam Room

Fertility doctors are physicians who are double board-certified in Reproductive Endocrinology and Infertility (REI). The physician’s role is to lead the charge by using their expertise and experience to recommend diagnostic tests and treatment options, and to make sure that a patient is aware of any risks associated with their treatment.

Physician

Healthcare people group. Professional doctor working in hospital office or clinic with other doctors, nurse and surgeon. Medical technology research institute and doctor staff service concept.

Your nurse (or team of nurses) will help make sure that you have the support that you need as you administer medications at home and come to the office for morning monitoring visits. If you’re ever unsure on what to do next, you can always ask your nurse.

IVF Nurse

Business accounting concept, Business man using calculator with computer laptop, budget and loan paper in office.

Most clinics will arrange a meeting for their patients with a financial coordinator. For Progyny members, this is typically a very short conversation, as your comprehensive coverage will make the financial side of IVF straight forward and manageable. It’s important that you tell the financial coordinator that you have Progyny coverage. If they have any questions that you need help with you should reach out to your PCA.

Financial Coordinator

close up portrait of young business woman in modern office

Yes, that’s you! It is important to remember that this is your body. The doctor is the expert, but ultimately the choices being made will be your own. The support team is here to provide the education to make the best choices, and it’s your job to make sure you are getting the support that you need. When making the decision to go through with IVF, you’re also making the decision to commit to your care team. It’s important to understand the style of clinic you are working with, familiarize yourself with their style, and feel comfortable with the environment they have created.

Patient

Navigating your fertility treatment

Patient

A fresh embryo transfer will happen approximately 5–6 days after your egg retrieval, where one embryo is transferred, and the remaining are frozen for potential future transfer. In contrast, a frozen embryo transfer means the entire cohort is frozen approximately 5–6 days after the egg retrieval to preserve them for a transfer planned at a later date.

Waiting for the results of preimplantation genetic testing

Allowing your body to rest and reducing risk of OHSS

Schedule and logistics

Waiting for results of preimplantation genetic testing

If you are utilizing PGT-A, PGT-M, or PGT-SR to test the embryos for chromosomal abnormalities, single gene mutations, or chromosomal rearrangements you will need to wait for those results before you can transfer an embryo.

Allowing your body to rest from the recent surgical egg retrieval

The stimulation process is an effective way to maximize your follicle count, and ultimately the number of eggs available at retrieval, but it does put stress on your body, and can leave your body in a less than optimal position to receive an embryo. For this reason, many physicians prefer a frozen cycle so that your body can return to normal, and your uterine lining can be adequately prepared for implantation.

Schedule and Logistics

Sometimes this decision is as simple as logistics. Many patients need to travel for their treatments, and that can make a fresh transfer difficult. Others just want to time their transfer for after a trip, event, or work obligation. A frozen transfer strategy frees you to make these important decisions.

A natural cycle times the frozen embryo transfer to when your body would ovulate naturally, while an artificial cycle utilizes estrogen and progesterone, or sometimes gonadotropin releasing hormone, to mimic the body's cycle and help prepare the endometrium for implantation.

Frozen embryo transfer natural cycle

Medical clinic: Ultrasound, sonography, ultrasound examination. Workplace of the doctor of ultrasound diagnostics.

Frozen embryo transfer with a natural cycle

A natural cycle is a frozen embryo transfer timed to when you ovulate naturally. Your natural ovulation cycles prepare your body for potential embryo implantation, so when done right a natural cycle could result in appropriate conditions in the uterus for implantation. A natural cycle can also be supplemented with an hCG trigger shot which can ensure that ovulation occurs. A supplemented cycle will also likely utilize progesterone for luteal phase support after the transfer. Some instances when a natural cycle may be recommended: For patients who want to avoid extra hormones, and for patients who have experienced many failed artificial cycles.

Frozen embryo transfer with an artificial cycle

In order to help thicken the endometrium your doctor may recommend an artificial (or synthetic) cycle. This usually includes taking estrogen and progesterone to mimic the body’s cycle and increase endometrial receptivity. Some artificial cycles include gonadotropin-releasing hormone (GnRH) as well. Some instances when a natural cycle may be recommended: For patients who don’t ovulate regularly, and for patients who prioritize predictability, and control. Some clinics only do artificial cycles by default.

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The right time to start treatment depends on your body, your physician, and maybe even your schedule.

There are a few different ways your physician can make sure your treatment starts at an ideal time.

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Infertility is a journey that is complex and emotionally challenging for anyone involved, but there tends to be a lack of focus on the feelings and emotions of male partners. In today’s episode, we hear from Philip Schmidt, who shares his perspective on experiencing an infertility journey. We’ll learn how Philip and his wife pursued both adoption and fertility treatments and within a few months, welcomed not one but two children into their family. We also hear from Dr. Stephanie Gustin, a reproductive endocrinologist and fertility expert at the Heartland Center for Reproductive Medicine, who adds clarity to the infertility diagnosis recurrent pregnancy loss.

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Episode 31: Endometriosis and Fertility: Trying IVF After Being Diagnosed

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This is the second episode in our four-part series on endometriosis and we’ve broken this episode into two parts. In part 2, we continue hearing Amanda’s story about how she came to discover she had endometriosis, and how that impacted her infertility journey. After paying out of pocket for four unsuccessful rounds of IVF, Amanda Lesesne had an exploratory laparoscopy which revealed stage three endometriosis. After having the endometriosis tissue removed, she decided to try IVF for the fifth time. This time she entered the process with renewed hope, a new financial situation (she now has Progyny Fertility Benefits), and an audio recorder. In part two, we follow Amanda in real time as she experiences her fifth cycle of IVF.

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Episode 63: The Frustrations and Hopes of an Unfinished Fertility Journey

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When experiencing something as challenging as infertility, it can be helpful to hear stories, advice, and guidance from those who have been through it. However, we usually hear from people who were successful in growing their families. But what about those who are still going through treatment, and are uncertain of where their fertility journey will lead them? How can you make it through without setting expectations of having a picture-perfect ending? In today’s episode, we hear from Kelly Partner, who wanted to share her story while the ending was still unknown. Kelly and her husband have been trying to have a baby for over a year, which has been filled with rounds of IUI, a male infertility diagnosis for her husband, and multiple pregnancy losses.

It is not uncommon to have monitoring appointments every other day or even daily up until your egg retrieval. These monitoring appointments are usually scheduled very early in the morning so you can carry on with your day afterwards. In these visits they will draw blood for lab work and perform an intravaginal ultrasound.

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A study by the Reproductive Medicine Associates of New Jersey reported that almost 58% of people are forced to forego fertility treatment due to the anticipated financial burden. And for those who go forward with treatment, the high price tag forces many individuals, couples, and families to spend thousands of out-of-pocket dollars. Even if their employer provides coverage, a number of plans will exclude same-sex couples with unrealistic diagnostic requirements. But what if your employer covered your treatment and made it accessible to everyone? In this episode, we hear from Lindsey and Chrissy Callahan who were eager to start a family when they learned their employer-sponsored Progyny benefit would make their dream of having a child a reality.

The timing of the egg retrieval is tied to the timing of the trigger shot, so it’s important that you arrive to your egg retrieval on time. If you are late to your appointment, it’s possible that you could ovulate before your doctor has a chance to retrieve any eggs. This would result in a “canceled cycle,” and it could require that you start another round of IVF from scratch. So, make sure to plan for traffic and take extra precautions to ensure you arrive on time that morning—you don’t want to miss it!

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Episode 51: PCOS and Fertility: An IVF Baby After Ectopic Pregnancies

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One of the most common questions people ask when they find out they have Polycystic Ovary Syndrome (PCOS) is, “Does this mean I can’t get pregnant?” PCOS is a hormonal imbalance that often presents itself with several symptoms, and yes one of those symptoms may be infertility. But, while PCOS itself isn’t curable, it is possible for women with PCOS to get pregnant. In today’s episode, we’ll hear from Sarah Rivera, who was diagnosed after experiencing two life–threatening ectopic pregnancies. Because of her experience, she decided that IVF was the safest way to proceed, and because she had coverage for fertility treatments provided by her employer, she was able to pursue parenthood at her own pace.

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When Cerner decided to partner with Progyny, they were drawn to a benefit design that would do one thing -- avoid the status quo.

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Episode 46: Genetic Testing: Can it be Non-Invasive?

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We’ve covered the cost effectiveness of pre-implantation genetic testing for aneuploidy, or PGT-A. In today’s episode, we are going to learn about something called non-invasive pre-implantation genetic testing for aneuploidy (they don’t have an acronym for it yet because it’s still in clinical trials). We’ll hear from Dr. Mandy Katz-Jaffe, a Reproductive Geneticist and the Scientific and Genetics Director at CCRM. She’ll break down how this test could work, the advantages this could have for patients, and where they are in the process of clinical trials.

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When an embryo has an extra chromosome, one too few chromosomes, or a mixture of extra and missing chromosomes it is an aneuploid embryo. These embryos either won't implant, will miscarry, or in some rare instances result in a live birth with a serious genetic disorder like Down Syndrome or Edward Syndrome.

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Once you arrive at the clinic you will change into a hospital gown and enter a surgical room to begin the procedure. Like the egg retrieval, you will go through a series of verifications to ensure that the correct embryo is being transferred. Depending on the clinic, and your personal preferences, your doctor may prescribe valium for the transfer procedure.

The embryo transfer is a very quick procedure that is often compared to a pap test.

Embryo Transfer Procedure

What to expect after the embryo transfer?

The transfer does not typically require anesthesia and patients typically report that the transfer is not unlike a pap test. You shouldn’t experience any pain following the procedure, but you may feel some discomfort or cramping. This is normal and isn’t cause for concern, but many doctors recommend that you avoid unnecessary stress in the days immediately following the procedure. The embryo cannot fall out, so you don’t have to worry about moving freely.

Prior to the implementation of modern technology like PGT-A it was a common practice to transfer two embryos, but that is no longer considered best practice, and the standard of care is now to transfer a single embryo.

The decision to transfer one embryo, which is called an elective single embryo transfer, or eSET, is a decision about reducing harmful risks. When multiple embryos are transferred the rate of twins or triplets increases dramatically.

How many embryos to transfer?

Infant Mortality

Cerebral Palsy

1.2%

Source: Luke, Pharoah

Increased Health Risks & Gestational Number

Can embryos fall out after a transfer?

Sometimes, you may be asked to complete a mock transfer or mock cycle to prepare for a transfer.

During a mock transfer the physician simulates a transfer, making sure they can access the uterus, that they have the correct catheter, and that there’s not going to be any issue when the embryo is loaded and ready for transfer. Think of it as a test run.

Mock Transfer & Mock Cycle

Dr. Lorna Marshall from Pacific NW Fertility explains when a doctor may recommend a mock transfer or a mock cycle.

Intracytoplasmic Sperm Injection (ICSI)

Insemination is the process whereby the egg and sperm are left to complete the fertilization process without assistance of an embryologist. It is also known as Conventional insemination, as it was the first method of fertilization used when IVF was created. The sperm are placed into a dish with the eggs and by the next morning a sperm should have been able to find its way into an egg to fertilize it. In cases of male factor infertility (the sperm count or motility is low), the sperm may not to be able to enter the egg without assistance. If genetic testing is planned, many embryology laboratories prefer to select a single sperm in an attempt to improve the accuracy of the results.

Insemination

ICSI is included in your Progyny coverage

A mock cycle is a somewhat rare procedure that includes undergoing all of the blood work, ultrasounds, and medication that are part of a typical transfer cycle. Then, at the time that a transfer would have occurred, your physician instead takes a biopsy of the endometrial lining, which is analyzed to see if it would have been the correct timing to transfer the embryo.

Reducing the risk of OHSS

Some doctors will recommend a frozen transfer for women who are susceptible to OHSS. OHSS is Ovarian Hyper Stimulation Syndrome, and it can develop as a result of a patient’s reaction to the medications associated with IVF. For women with PCOS, or women who are high responders to the medications, it may be recommended, and in some cases required, to let your system return to baseline before transferring an embryo.

Lindsey C., Progyny Member

“I had no idea what was involved in the transfer prep. 10-15 days before the transfer I took the (estrogen) pills, and 5 days out I took progesterone shots.”

Episode 8: LGBTQ+ Family Building: Building a Family with an Inclusive Fertility Benefit

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Dr. Julie Lamb from Pacific NW Fertility breaks down some of the benefits of a frozen embryo transfer.

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0.5%

0.2%

Excessive L&D Bleeding

% of births

Singleton

Twins

Triplets

Close-up of a pregnant woman during medical visit

The embryo is brought into the operating room by the embryologist. It is customary for the physician to perform an ultrasound guided transfer. This ensures that the embryo is placed optimally in the uterus. You may be able to watch the process on a screen at some clinics.

A speculum is placed in the vagina so your doctor can visualize the cervix. Then, using a catheter inserted through the cervix and into the uterus, the embryo is placed into the endometrial cavity.

Woman Having Eggs Implanted As Part Of IVF Treatment Supported By Husband

Philip S., Progyny Member

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“They had this little petri dish and you see all these little specks... This is nuts. She's carrying my embryo across this room right now.”

The Embryo Transfer

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Implantation, BETA, & Results

Suppression Check

Obtaining Medications

Embryo Transfer Procedure

How many embryos to transfer?

Mock Transfer & Mock Cycle

Natural vs Artificial Cycle

Fresh vs Frozen

Of course, sometimes beta blood tests come back negative for pregnancy. After a negative result from an IVF treatment, some patients feel that they need to take a break to physically and emotionally recover after a stressful time, while others feel that they want to do another transfer, or perhaps start another cycle, as quickly as possible. It's important to have an open and honest conversation with your doctor about the best next steps for you.

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A negative pregnancy test after an embryo transfer can be very difficult, but it doesn't have to be the end of the road.

After a Negative hCG Test

Five tests to identify the cause of repeated IVF implantation failure

In the months after a positive pregnancy test you'll be returning to your fertility clinic for monitoring, and continuing medications to support the pregnancy.

Monitoring includes testing hCG levels and ultrasounds for the next 6–8 weeks before “graduating” to your OBGYN for the remainder of your pregnancy. You will also likely be put on a few different medications to help make sure your body has everything it needs to support the pregnancy. Typically, these include estrogen and progesterone, hormones that support healthy fetal growth and prevents early pregnancy loss.

Monitoring and Pregnancy Support

After the wait it’s finally time for the hCG test. This test is sometimes called the BETA blood test.

hCG is human chorionic gonadotropin or “the pregnancy hormone.”

If this test results in a positive outcome it’s certainly a time to celebrate, but you should be mindful that this is extremely early in the pregnancy. In the next 48 hours, you will go back to your reproductive endocrinologist for a second blood test to ensure hCG levels are roughly doubling, indicating the pregnancy is progressing normally.

The hCG Blood Test

Dr. Brian Levine from CCRM New York talks about what they are looking for with the hCG blood test, and what you can expect after a positive result.

Sarah R., Progyny Member

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“I focused a lot on being outside... I pushed away all of the negativity in my life. I need to focus on me and what I'm doing.”

It’s not likely that you will feel any different if you are pregnant in the 8–9 days between the transfer and the hCG blood test, so try not to read too much into how you feel during this wait.

If you are finding the waiting period difficult, check out our emotional support page for guides and support tips. You can also reach out to your PCA who is always available for support and guidance.

Sometimes referred to as “The Two Week Wait” the period between the embryo transfer and the blood test to determine the results is usually approximately 8 to 9 days.

The Two Week Wait

Two-Week Wait: Coping Methods

Two-Week Wait: Survival Guide

Implantation

Ideally, after the transfer, the embryo continues to divide, and expand, and hopefully attaches itself to the endometrial lining in order to receive oxygen and nutrients needed for successful pregnancy. This is called implantation.

Partners and the importance of emotional support

Good Luck on Your Family Building Journey

This brings us to the end of this guide for IVF. We wish you the best on your journey.

Progyny members: Remember, regardless of how you choose to move on, you should know that your Progyny PCA is still available to you for support. If you have any questions, concerns, or if you just want to chat, don’t hesitate to reach out to your Progyny Patient Care Advocate. We are always happy to help you navigate your fertility journey.

For those who want more children down the road, IVF can provide a wonderful opportunity to preserve your fertility in the form of frozen eggs or embryos.

If you are fortunate enough to have viable embryos remaining in storage you can choose to keep those embryos for future family building, donate them either to science, or to another person or couple in need, or ask that they be terminated.

IVF as Family Planning

When an embryo implants the early placental cells produce human chorionic gonadotropin (hCG). Within a week, hCG can be detected through a blood test. The levels of hCG will increase rapidly in a positive pregnancy. If the first blood test returns positive, it will be repeated in the next days to confirm the pregnancy is progressing.

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Progyny members: At this stage in your treatment it's important to remember that you have unlimited access to your PCA. You can reach out to them with any questions, or concerns, or you can give them a call just to chat if you need someone to talk to.

Kelly P., Progyny Member

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“I pretty much email her on a weekly basis... She always responds with very emotionally thoughtful messages.”

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Two-Week Wait: Partner Checklist

Should you take a home pregnancy test before the hCG blood test?

Doctors typically don’t recommend that you do a home pregnancy test after fertility treatment since these tests only detect hCG presence, not the exact levels of the hormone. In addition, for those who’ve utilized a fresh transfer it’s still possible that there is hCG in the system from the trigger shot which could result in a false positive test.

Chrissy & Lindsey C., Progyny Members

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“Spoiler alert here: if you do get a positive pregnancy test... your prize is you get to continue those shots until 12 weeks.”

Episode 8: LGBTQ+ Family Building: Building a Family with an Inclusive Fertility Benefit

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Are IVF pregnancies considered high risk?

Are IVF pregnancies considered high-risk pregnancies?

An important thing to understand is that IVF pregnancies are comparable to natural pregnancies; they are not considered high risk pregnancies. That being said, around the 20th week, the American Institute of Ultrasound in Medicine suggests pregnancies be monitored with a special ultrasound as a preventative measure to evaluate for the presence of cardiac side effects. Other than that, medically speaking, you should experience your pregnancy as if you conceived naturally.

Dr. Ravi Gada from Dallas-Fort Worth Fertility Partners talks about some reasons an embryo wouldn't implant, and what people can do next.

Frozen embryos do not age the way that people do, and maintain their fertility potential as the years progress.

Lily flower on the dark background. Condolence card. Empty place for a text.

10 frequently asked questions during a fertility journey

Hillary F., Progyny Member

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“As hard as it is... if you just have a little bit (of hope) you know you can keep going.”

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Kelly P., Progyny Member

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“I just say, whatever your feelings are they're valid, and I hope you can find a person to validate them.”

Philip S., Progyny Member

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“I would just say having people around you that you feel comfortable with who are not going to give you the standard responses to a loss or infertility.”

Episode 61: Overcoming Failed Fertility Treatments: A Male’s Perspective

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Chrissy & Lindsey C., Progyny Members

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“Making sure you're talking about it and sharing stories... talk to your friends, you're not alone. This shouldn't be so lonely and scary.”

Episode 8: LGBTQ+ Family Building: Building a Family with an Inclusive Fertility Benefit

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Sarah R., Progyny Member

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“Find people willing to support you through the process. Going at it alone can be difficult.”

Episode 51: PCOS and Fertility: An IVF Baby After Ectopic Pregnancies

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Amanda L., Progyny Member

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“I think about all the time... if you knew the answer, if you knew everything was going to be OK, and you knew that you'd have a child, would this journey be as hard?”

Episode 31: Endometriosis and Fertility: Trying IVF After Being Diagnosed

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“I want for people to talk to their doctor early, in their mid-20's, and start having that conversation and get tested regularly.”

Jennifer K. Progyny Member

Episode 63: The Frustrations and Hopes of an Unfinished Fertility Journey

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Mountain landscape with hiking trail and view of beautiful lakes Ponta Delgada, Sao Miguel Island, Azores, Portugal.

white cloud and bright blue sky for background

Modern living room with nature view 3d rendering Image. There are decorate room with wood. There are large window overlooking the surrounding nature and forest

A stunning, long path lined with ancient live oak trees draped in spanish moss in the warm, late afternoon near Savannah, Georgia.

Hour glass and calendar concept for time slipping away for important appointment date, schedule and deadline

Estrogen patch or pills

Birth control/regulated cycle

First day of the menstrual cycle

Blood Test & Results

Episode 51: PCOS and Fertility: An IVF Baby After Ectopic Pregnancies

Listen to more episodes of This is Infertility

Episode 38: #InfertilityUncovered: Support Through Progyny’s PCA's

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This episode follows the experience of Jennifer Kattula, a patient who is covered by the Progyny Fertility Benefit, and takes a deep dive into an invaluable resource she found along the way: the Progyny Patient Care Advocate (PCA) team. Infertility is a disease that demands support, and today we will examine what real supportive care looks like by having a chat with a few of our devoted Patient Care Advocates here at Progyny. We’ll hear a few of the heartwarming stories and rewarding experiences that keep our PCA’s dedicated to supporting Progyny members each and every day.

Woman using cellphone and laptop inside house and drinking coffee / tea.

Progyny Patient Care Advocate

Your Progyny Patient Care Advocate (PCA), is your personal fertility concierge. Your PCA can help you find the right doctor, book appointments, understand how your coverage works with your treatment plan, and help smooth out any obstacles that pop up along the way. As a Progyny member you have unlimited access to your PCA, so give them a call today.

Patient Care Advocate

Sarah R., Progyny Member

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“I really felt taken care of. I would say that it was as good a portion of the benefit as the financial portion, because it’s a lot to take in, and you just need someone to guide you.”

Jennifer K. Progyny Member

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Physician

IVF Nurse

Financial Coordinator

Patient

Navigating your fertility treatment

Patient

Watch our medication administration videos

See what Progyny members are saying about the Patient Care Advocate program

Follicle Stimulating Hormone & Human Menopausal Gonadotropin Breakdown

Antagonist medication breakdown

Lab work

Intravaginal Ultrasound

Human chorionic gonadotropin

What happens after a canceled cycle?

Risks associated with the egg retrieval

What is a “good” number of eggs retrieved?

Insemination

Intracytoplasmic Sperm Injection (ICSI)

ICSI and your Progyny coverage

What is a blastocyst?

The risks associated with multiples

How does PGT-A work, and when can you expect to receive your results?

Is PGT-A included in coverage for Progyny members?

Waiting for the results of preimplantation genetic testing

Allowing your body to rest and reducing risk of OHSS

Schedule and logistics

Can embryos fall out after a transfer?

What to expect after the embryo transfer?

Should you take a home pregnancy test before the hCG blood test?

Five tests to identify the cause of repeated IVF implantation failure

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All clinics and journeys are different, but click below to get to know some members of the care team that you are likely to encounter as you pursue your treatment.

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Dr. Nabil Arrach, CEO of Progensis, a genetic testing laboratory, explains mosaicism in PGT-A tested embryos.

Dr. Nabil Arrach, CEO of Progensis, a genetic testing laboratory, talks about why patients may need to utilize PGT-SR.

Episode 38: #InfertilityUncovered: Support Through Progyny’s PCA's

Progyny Patient Care Advocates (PCAs) are nurses and fertility experts trained to provide a high-touch, highly personalized concierge service for all fertility and family building needs. Each member is assigned a dedicated PCA that provides inbound and outbound support on everything from understanding treatment options to providing emotional support.

hCG helps mature the eggs and prepare them for retrieval approximately 36 hours later. You will be given very specific instructions on when to do your trigger shot as well as how to mix and inject it. Leuprolide acetate or “Lupron” may be used along with or instead of hCG to trigger the final maturation of the eggs and the follicle.

The purpose of these medications is to stimulate follicular growth, maturing eggs for retreival. Patients typically take medications for 10-14 days, but your dosage and schedule is personalized and should be discussed with your physician.

This is a delicate balance, where you and your doctor are working to maximize the number of eggs that will be available for retrieval, while simultaneously making sure no eggs ovulate before the retrieval day. Your provider will let you know when to start your antagonist. This medication is also a daily injection.

In 2017, Cerner decided to provide fertility coverage to their workforce. The time was right according to Arielle Bogorad, Senior Director of Worldwide Benefits at Cerner.

Peacefulness in us. Delighted peaceful positive African American couple sitting in the cafe and touching hands of each other while expressing peacefulness and love

SET Rate per Transfer

85.5%

34.5%

Cerner

National Average

Pregnancy Rate per IVF Transfer

60%

54.1%

Twinning (Multiples) Rate

2.7%

16.3%

Live Birth per Transfer

50.8%

44.8%

1. Cerner results based on Progyny internal data book retrieved in 2018; 2. Society for Assisted Reproductive Technology (SART) preliminary 2016; 3. Progyny Live Birth rate is projected based on reported Clinical Pregnancy rate and Miscarriage rate; 4. CDC 2016 ART Fertility Clinic Success Rates Report

See what Progyny members are saying about the Patient Care Advocate program

Cerner members described high satisfaction from the quality of service to the overall value and experience.

Arielle Bogorad isn‘t only a decision maker at Cerner, but she is also a Progyny member.

Members can utilize their Smart Cycles for whichever treatments they and their physician determine to be necessary throughout their fertility journey.

See what our members say about the Smart Cycle plan design

What our members say: The Progyny Smart Cycle

Progyny members Emily, Ian, Lindsey, and Chrissy break down their experiences with the Progyny Smart Cycle.

The value of the Progyny Patient Care Advocates

Progyny Patient Care Advocates, and Progyny members break down the value of the PCA program.

One year after implementing Progyny, they decided to expand their benefit by adding Progyny Rx, an integrated fertility pharmacy solution to further support their members and achieve cost savings.

Download a printable version of the case study

The value of the Progyny Patient Care Advocates

Progyny Patient Care Advocates, and Progyny members break down the value of the PCA program.

Download the Case Study PDF

We make the Cerner case study available here. Email needed to download - this way we can see which prospects are serious (enough to download a document anyway).

Educated members are able to make better treatment decisions for a healthy, successful pregnancy.

Since Cerner rolled out its benefit, more than 100 people have been able to conceive, with superior outcomes far above the national average.

A Focus on Outcomes & Value

SET Rate per Transfer

Healthier Pregnancies

85.5%

34.5%

Cerner

National Average

Greater Pregnancy Success

Pregnancy Rate per IVF Transfer

60%

54.1%

Cerner

National Average

Fewer Disruptions, Lower High Risk Pregnancies and Lower Costs

Twinning (Multiples) Rate

2.7%

16.3%

Cerner

National Average

Live Birth Rate

Live Birth per Transfer

50.8%

44.8%

Cerner

National Average

*Cerner results based on Progyny internal data book retrieved in 2018; 2. Society for Assisted Reproductive Technology (SART) preliminary 2016; 3. Progyny Live Birth rate is projected based on reported Clinical Pregnancy rate and Miscarriage rate; 4. CDC 2016 ART Fertility Clinic Success Rates Report

Benefit design and access to care was a top priority for Cerner, but they were also drawn to a personalized service that could help their members through the physically and emotionally challenging journey of infertility.

In 2018, Cerner members had almost 5,000 interactions (calls and email) with their PCAs. Cerner described a flood of associate satisfaction from the quality of service to the overall value and experience. Cerner members have ranked the quality of their PCA at 97% and their overall experience with Progyny 4.6 out of 5.

A Better Member Experience

See what Progyny members are saying about the PCA program

The value of the Progyny Patient Care Advocates

Progyny Patient Care Advocates, and Progyny members break down the value of the PCA program.

With Progyny's Smart Cycle bundled benefit design, Cerner can provide a benefit that supports all paths to parenthood, connects members to a premier provider network accross the United States, and ensures the best treatment the first time, without any barriers to care.

One year after implementing Progyny, they decided to expand their benefit by adding Progyny Rx, an integrated fertility pharmacy solution to further support their members and achieve cost savings.

Dr. George Patounakis from RMA of Orlando talks about what you can expect at your monitoring appointments.

When Cerner decided to partner with Progyny, they were drawn to a benefit design that would do one thing - avoid the status quo.

A Fertility Benefits Evolution

See what our members say about the Smart Cycle plan design

What our members say: The Progyny Smart Cycle

Progyny members Emily, Ian, Lindsey, and Chrissy break down their experiences with the Progyny Smart Cycle.

Supporting Growing Families

Arrielle Bogorad, Senior Director of Worldwide Benefits at Cerner talks about the need for fertility coverage and what Cerner was looking for in a fertility benefit.

With Progyny, Cerner implemented a comprehensive fertility benefit that improved the member experience and reduced costs - helping over 100 people grow their families.

Cerner is a global health care information technology company with over 29,000 associates, headquartered in Kansas City, MO.

In 2017, Cerner decided to provide fertility coverage to their workforce. The time was right according to Arrielle Bogorad, Senior Director of Worldwide Benefits at Cerner.

Download the Case Study PDF

The value of the Progyny Patient Care Advocates

Progyny Patient Care Advocates, and Progyny members break down the value of the PCA program.

We make the Cerner case study available here. Email needed to download - this way we can see which prospects are serious (enough to download a document anyway).

Each member has a dedicated Patient Care Advocate that provides unlimited support and advocacy throughout their fertility journey.

Industry Healthcare Information Technology

Headquarters Kansas City, MO

Associates 29,000

PCA Interactions

Overall Experience with Progyny

Quality of PCA

~5,000

4.6 out of 5

97%

Download a printable version of the case study

Through this comprehensive benefit design, Cerner provides a benefit that supports all paths to parenthood, connects members to a premier provider network across the United States, and ensures the best treatment the first time, without any barriers to care.

Through a differentiated benefits plan design, personalized member support, a premier network of fertility specialists, and an integrated pharmacy experience, employees can pursue effective and cost-efficient treatment to build their families, while Cerner saves in treatment costs and reduced high-risk maternity and NICU expenses.

Cerner

National Average

Cerner

National Average

Cerner

National Average

With Progyny, Cerner implemented a comprehensive fertility benefit that improved the member experience and reduced costs – helping over 100 people grow their families.

(calls & emails)

Cerner began its third year with Progyny in 2020.

With Progyny, Cerner implemented a comprehensive fertility benefit that improved the member experience and reduced costs – helping over 100 people grow their families.

(calls & emails)

Cerner began its third year with Progyny in 2020.