Increasing the number of follicles available in a given cycle to maximize the chances of achieving pregnancyIVF, OR IN VITRO FERTILIZATION, is a method for increasing a patient’s fertility odds by:
Increasing the number of follicles available in a given cycle to maximize the chances of achieving pregnancy
Assisting with the fertilization of mature eggs through procedures such as ICSI (intracytoplasmic sperm injection) and assisted hatching
Allowing for genetic testing of embryos to eliminate any which are not chromosomally normal (PGD or PGS)
Circumventing tubal issues
Overcoming sperm issues
IVF should always be performed by a board certified reproductive endocrinologist/infertility specialist—at a reputable clinic with a highly regarded laboratory. Take the time to find out which office has the best reputation in your area, and don’t shy away from spending a little extra for the best clinic you can find. The cost of having to undergo multiple cycles due to physician mistakes is not worth the money saved in the long run. That’s not to say it will work the first time you try at a reputable clinic, but you want to hedge your bets wherever possible, and in this case, you get what you pay for.
It is important to remember that IVF is merely a strategy for maximizing an individual’s fertility wherever it is in that moment. IVF is not a cure for infertility, especially when it is due to advanced maternal age or severely compromised sperm. As we get older, our eggs are more and more likely to divide abnormally, which leads to problems such as Down syndrome. While IVF does increase the number of chances you and your partner get in a cycle to create a healthy embryo, it has no impact on whether or not the embryos will actually cooperate and divide normally. That doesn’t mean it won’t help, or even significantly increase your odds of achieving a healthy pregnancy, but it’s not magic.
When taken at face value, IVF success rates can seem pretty dismal. However, keeping in mind that a healthy couple in their prime reproductive years has roughly a 1 in 5 (20 percent) chance at pregnancy in a given cycle can lend a little bit of perspective to projected IVF outcomes.
Here are the success rates for live birth outcomes for IVF in the United States, according to the American Pregnancy Association:
30 to 35 percent for women under age 35
25 percent for women ages 35 to 37
15 to 20 percent for women ages 38 to 40
6 to 10 percent for women over age 40
The IVF Cycle 
Following is a brief overview of each step in the IVF cycle. If you are considering this type of treatment, you will of course go over all of these phases in detail with your doctor.
On day 2 of the menstrual period, a woman goes into the fertility office to have her E2/FSH levels drawn. She also undergoes a transvaginal ultrasound to count and measure the number of antral follicles (the ones that are candidates for responding to the medications).
In an optimal cycle, all of the potential follicles should be about the same size. If one follicle is already bigger than the rest (a lead follicle), then the cycle should be delayed until the next month. An early lead follicle will absorb a disproportionate amount of medication and result in a less than ideal outcome. Don’t let impatience get the best of you here. It’s best to wait until the conditions are optimal than rush ahead.
Once the lab results are in (later on day 2) and the follicles are confirmed synchronized, IVF medications are self-administered via injection, usually starting that very evening. It is critical to follow instructions to a tee and to call the office if you have any questions or concerns. Getting off track could sabotage the cycle.
After a few days of injections, the patient returns to the clinic to check for progress via ultrasound and blood work. It is expected that E2 levels continue to rise with each passing day, as the developing follicles are continuing to secrete more and more estrogen as they grow.
Cycles that become significantly desynchronized may be canceled at any time, though some doctors will push through and allow the larger follicles to become overmature in an effort to save the smaller majority. We personally find this practice to be problematic, as it is often the larger “lead” follicles that are the most likely to be healthy. Once again, patience is key, and it’s better to wait it out for an ideal cycle.
The process of self-administering medications typically lasts 10 to 12 days, with frequent visits to the doctor for monitoring and blood work. Once the RE determines that the follicles are at the peak of their maturity (measured by E2 levels), then an HCG trigger shot is administered, roughly 36 hours before retrieval.
Follicle aspiration (retrieval) is a minor surgical procedure, which is performed by an RE in order to remove all of the developed follicles from a woman’s ovaries for fertilization in the lab. The procedure is performed in a sterile operating room under heavy sedation (she will be asleep), by inserting an ultrasound-guided needle through the wall of the vagina and into the ovaries, one side at a time. The RE skillfully suctions the follicles and surrounding fluid out of the ovaries, and they are immediately assessed for maturity.
Once the procedure is over, the follicles are taken to the lab where they are stripped of their outer membrane to reveal the single-celled ova and then fertilized with her partner’s sperm, or donor sperm—from a sample given that same morning—or from a frozen sample.
Ova are fertilized one of two ways: naturally or via ICSI.
NATURAL FERTILIZATION is the process whereby sperm and egg are placed together in a petri dish and left to fertilize on their own. This method allows for “natural selection” to occur.
ICSI (intracytoplasmic sperm injection) is the process whereby a single sperm is corralled into a pipette and skillfully injected into the ova’s cytoplasm. This procedure is typically performed when a man’s sperm parameters are poor, in order to increase the odds of having a healthy sperm meet the egg.
The day following retrieval and fertilization (considered day 1 in IVF terms), the follicles are assessed. Normally fertilized ova will have two nuclei and are referred to as 2PNs (two pronuclei). If a “freeze all” cycle was planned, embryos are often frozen at this stage because this gives them the highest thaw rate. If a fresh cycle is occurring, then the 2PNs are left to continue growing for two to four more days. Embryos can also be frozen as day 5 (or sometimes day 6) blastocysts, if there any left over at the time of transfer.
Embryo transfer usually occurs on either day 3 (cleavage stage) or day 5 (blastocyst stage). The choice between these two days is related to how many embryos there are to choose from, how old the mother-to-be is, or clinic preference.
Many clinics routinely do day 3 transfers, while others feel that day 5 offers better results. The difference in development between a day 3 embryo and a day 5 blastocyst is considerable. Typically, there is an attrition rate of roughly 50% or more during these two days. What this means is that embryos that are not chromosomally normal or are otherwise compromised won’t make it through the complex cell dividing that must take place to go from the four-to-eight-cell embryo stage to the hundred-plus-cell blastocyst stage. Hence, it is presumed that embryos that survive to the blastocyst stage have a greater chance of being chromosomally normal than their day 3 counterparts.
For this reason, significantly fewer blastocysts are transferred on day 5 than embryos on day 3. The decision of how many to transfer is between a couple and her doctor, and should take into account her age, past cycles, and guidelines put forth by the ASRM (American Society of Reproductive Medicine).
Here are the ASRM recommendations by age for number of embryos to transfer:
Under 35: one embryo for favorable prognosis/blastocyst transfer; one or two embryos for favorable prognosis/cleavage-stage transfer; two embryos for all others
35 to 37 years: two embryos for all patients; three embryos for women with less favorable prognoses who receive cleavage-stage embryos
38 TO 40 years: two embryos for favorable prognosis/blastocyst transfer; four embryos for less favorable prognosis/cleavage-stage transfer; three embryos for all others
41 to 42 years: three embryos for those receiving blastocysts; five embryos for those receiving cleavage-stage embryos
The procedure for transferring embryos is quite simple, especially when compared to the complexities of the rest of the IVF cycle. Mom-to-be is placed on an exam table, in the same position she would be in for a Pap smear. A speculum is inserted and her cervix is cleaned off with the same media that are currently housing her embryos. Next, a catheter is inserted into the cervix, and threaded to about 1 cm (approximately half an inch) from the top (fundus) of her uterus. Then, a thin, flexible catheter containing the embryos for transfer is inserted through the already placed catheter and threaded to the top of the uterus as well. At this point, the embryos are pushed gently into the cervix, at the optimal spot for healthy implantation to occur.
In order to guide the catheter to its ideal location, ultrasound is typically used on the abdomen. Usually, a woman is asked to drink plenty of water prior to transfer so that her bladder will help to flatten out the uterus, making it easier for the doctor to find the ideal location. Most women find that the full bladder sensation is the most uncomfortable aspect of embryo transfer.
Following transfer, a woman is usually left to rest for 15 to 60 minutes and then released to go home for a day or so of modified bed rest (some clinics recommend much longer periods of rest).
One of the greatest fears that couples have following embryo transfer is that their newly placed embryos will somehow fall out when she stands up. This definitely won’t happen. First, the uterus is not on a vertical plane, and second, the inside of the uterus is cavernous, with lots of ridges that can catch an embryo where it lands. One of the clinics we work with very frequently allows patients to get up to relieve themselves immediately following transfer, without any compromise to their pregnancy rates. So, worry not. If it’s a healthy embryo, standing up won’t ruin your chances.
Finally, the two-week wait begins. During this time, blood work may be done to make sure that the patient’s body has enough estrogen and progesterone to ensure pregnancy can be sustained. At last, about 14 days following retrieval, blood work is done to check for HCG in the bloodstream. A number above 50 confirms pregnancy, but lower numbers can sometimes catch up. Very low numbers indicate a likely chemical pregnancy, which means that while implantation did occur, the embryo is not growing. Follow-up blood work will confirm whether or not a pregnancy is chemical or viable.
When a positive pregnancy is confirmed, blood work is generally done every few days to ensure a healthy rise in HCG levels until six to seven weeks gestation, when an ultrasound is performed to check for a fetal heartbeat. A healthy rise in HCG is indicated by numbers that double every other day—if it goes up even more than that, it’s a good thing.
Patients will generally stick with their fertility specialist through about the eight-week mark, at which point they are “graduated” to their OB-GYN or midwife of choice. In the case of high-risk factors or multiples, your RE might want you to see a high-risk perinatologist.
Chinese Medicine Can Support IVF Chinese medicine has been used for thousands of years to help regulate the reproductive systems in men and women. While it is quite difficult to draw exact parallels between Eastern and Western medical models, we can hypothesize how the mechanisms of acupuncture, in particular, may influence a woman’s fertility in the following ways:
Affecting neurotransmitters, which in turn influences the menstrual cycle, ovulation, and fertility by increasing the release of gonadotropin-releasing hormones (the stuff that your hypothalamus sends to your pituitary to tell it what to do, such as release FSH)
Improving blood flow to the uterus, by reducing the amount of uterine sympathetic (fight-or-flight pathway) nerve activity
Stimulating the release of endorphins (opioids that your brain makes), which directly inhibits the stress response
The Manheimer study, published in the British Medical Journal, evaluated whether acupuncture improves the rates of pregnancy and live birth on women undergoing IVF. The data looked at 1,366 women undergoing IVF and concluded that acupuncture given with IVF does indeed improve pregnancy rates in a way that is both significant and clinically relevant.
Yet another study from the Journal of Alternative and Complementary Medicine analyzed 1,069 women undergoing IVF (using their own eggs on a fresh cycle). The researchers concluded that a combination of herbs, acupuncture, nutrition, and lifestyle changes, termed “Whole System Traditional Chinese Medicine,” dramatically reduced biochemical pregnancies and improved live birth rates by 77 percent.
The Paulus study, published in 2002 in the Journal of Fertility and Sterility, looked at the effects of acupuncture on pregnancy rates when it was performed immediately before and after embryo transfer. The results were impressive, increasing the presence of a fetal sac at six weeks gestation from 26.3 percent in the non-acupuncture control group to 42.5 percent in the group who received acupuncture. That’s a 16.1 percent difference, which is quite clinically significant in IVF-land. More studies are being published every year, confirming the powerful impact of Chinese medicine on fertility.
Beyond treatment directly supporting the embryo transfer, we see patients in the days between egg retrieval and embryo transfer to help detox the body from all those medications and prepare the uterus for implantation. We also see patients three to five days after embryo transfer to assist with implantation and at least one more time to help ease worry during the dreaded two-week wait.
While we look to studies for validation that our work is providing meaningful clinical results, the true test of the benefits of incorporating Chinese medicine, a healthy diet, and appropriate herbs and supplements into your life is YOU. The fertility journey can be fraught with unexpected hairpin turns. Your ability to cope with the ups and downs of the ride is fully dependent on your physical, emotional, and mental state. Not to mention the untold benefits to your future offspring who will depend on you for every cell in their bodies once conception occurs.
The value of making the necessary lifestyle changes while trying to conceive are not just reflected in the increased statistical outcomes of using Chinese medicine, they are reflected in the way you get through each day with adequate sleep, abundant energy, and a positive outlook. We are not saying that every day will be filled with unicorns and butterflies, but we can say for sure that bringing your entire being into balance will make the journey much smoother.
Generally speaking, we don’t prescribe Chinese herbs during IVF because no one wants to risk any interactions that could interfere with progress. In reality, it is sometimes appropriate to consider using herbs during IVF, especially if it isn’t your first cycle, you’re on the older side, or you have a complicated medical condition. The bottom line is that you should NEVER self-prescribe herbal medicines during IVF treatments, you should work with a qualified Chinese medical fertility specialist, and your RE should be aware of what you are doing.
In terms of supplements, whatever you plan to do for prenatal nutrition (whether a focused, food-based approach or a supplement), it is ideal to be well into the routine of it for at least three months before conception.
Aside from Chinese herbs, other supplements commonly used during IVF include coenzyme Q10 and DHEA. CoQ10 is an antioxidant touted for its benefits to heart health. Some studies have suggested that CoQ10 can increase the amount of mitochondria (the cell’s powerhouse) in the ovaries, which could make cell division more successful when an egg is fertilized.
DHEA is a hormone made by the adrenals that is the precursor to testosterone, the building block of estrogen. Side effects from DHEA can include increased body odor and acne. Women with PCOS should steer clear of DHEA.
As with anything taken during this time, be sure to check with your medical support team (RE, acupuncturist, etc.).
MINI FERTILITY CLEANSE FOR WOMEN UNDERGOING MEDICATED FERTILITY TREATMENTS
After all of the injections and hormones of an IVF (or medicated IUI) cycle, the three to five days between egg retrieval and embryo transfer can serve as a great opportunity for a very gentle cleanse.
Think of this as your chance to clear your body of anything it doesn’t need, making way for implantation in fertile ground.
If your partner isn’t one for helping in the kitchen, we recommend that you make bone broth and Bieler’s Broth (page 105 to 106) ahead of retrieval so it’s ready to serve when you get home by the eve of your transfer.
Note that if you are doing a “day 5 transfer,” continue with variations of days 2 and 3 until the morning of your transfer.
Clear heat and toxicity, nourish Jing and Blood, activate Qi, and warm the Uterus
FOLLOWING YOUR PROCEDURE, drink a cup (235 ml) of hot water with the juice of half a lemon, a pinch of cayenne, and a teaspoon of honey to help cleanse the liver and heal from your procedure.
LUNCH (OR WHENEVER YOU’RE HUNGRY): Bieler’s Broth (page 105), made with bone broth instead of water
SNACKS (ANY TIME THROUGHOUT THE DAY): Freshly squeezed or pressed green juice with ginger; cut-up veggies; apples; chicken broth seasoned to your liking; Bieler’s Broth (page 105); Fertility Tea (page 118)
DINNER: Roasted chicken (use the bones to make more broth) with sautéed veggies (broccoli, asparagus, zucchini, etc.), cooked in coconut oil or butter and roasted sweet potato with butter
DAY 2
Clear heat and toxicity, activate Qi, and nourish Jing and Blood
BREAKFAST: Hot water with lemon and honey (cayenne if you’d like); fruit salad (whatever is in season); and soft-boiled eggs (or eggs any way)
LUNCH: Bieler’s Broth (page 105) or leftovers from dinner, or a mason jar salad
SNACKS: Same as Day 1
DINNER: Quinoa, soaked at least 8 hours and cooked in bone broth; and veggies sautéed in coconut oil
DAY 3
Nourish Jing and Blood, and clear heat and toxicity
BREAKFAST: Hot water with lemon and honey (no cayenne); boiled eggs; and fruit
LUNCH: Sweet potato with butter; mason jar salad with chicken
DINNER: Bacon Tomato Quiche with Cauliflower Crust (page 94); and Wilted Dandelion Greens with Lemon and Feta (page 117)
DAY 4 (DAY OF TRANSFER)
Nourish Jing and Blood, and soothe the nervous system
BREAKFAST: Hot water with lemon and honey and Creamy Egg Drop Soup (page 95)
LUNCH: Leftover Bacon Tomato Quiche with Cauliflower Crust (page 94)
DINNER Magical Chili (page 96) and a simple salad
SNACKS: Green juice with ginger or Fertility Tea (page 118)
Exercise and IVF While we believe moderate exercise is a very important part of a balanced lifestyle, there are times when you have to hold back for your own safety. IVF medications that stimulate your ovaries to produce multiple follicles can result in ovarian swelling. This “swelling” occurs along a spectrum from mildly bloated to terribly uncomfortable, depending on how much medication you receive and how responsive your ovaries are to it.
One of the risks with IVF stimulation is a condition called ovarian hyperstimulation syndrome (OHSS), wherein the ovaries become very enlarged, heavy, and painful. There is also small risk associated with exercise during this time that could result in a twist (torsion) in your fallopian tubes—something you definitely want to avoid.
Ovarian torsion is very painful and extremely serious, which is why the general recommendation is to lay low while the follicles are on the rise. Walking is usually fine, unless true OHSS is at hand, in which case you may have to tread very lightly until things settle down again. In severe cases of true OHSS, it can take several months to resolve.
Your fertility specialist will likely tell you to avoid all vigorous exercise from the start of medications through your pregnancy test, and we suggest you heed this advice. Gentle walks outdoors are fine, and we highly encourage them, especially if you can get out in nature for a while. Meditation, prayer, breath work, and journaling are all great stress busters to double up on while exercise is off-limits.