Embryo Transfer and Progesterone Pessaries - Could IVF be any more fun? The Preggers Kitchen IVF Series
For me, this is where IVF really comes into its own. Messy pessaries that ruin your pants, popping things up your bum, nerve wracking calls from the embryologist and full frontal genital exposure during embryo transfer. This is where the going gets tough. This article answers the questions I was faced with in the week following egg collection: Should the progesterone pessaries go up the front (vagina) or back (bum)? What are the stages of embryo development and how many usually make it to that all important 'blastocyst'? Do I get a choice of how many embryos are transferred back? Does embryo transfer hurt? What's the advice I should be following post transfer?
Why do you have to take progesterone after IVF?
Immediately following egg collection I was popped on progesterone. The artificial control of hormones during an IVF cycles does not just stop at down regulation and stimulation of the ovaries. In addition, progesterone support is provided for the period after egg collection until either a negative pregnancy test or for most or all of the first trimester (depending on your clinic’s policies). According to FertilityAuthority.com the egg retrieval process during IVF typically removes the cells that would normally create progesterone after ovulation. The progesterone supplements are needed to thicken the uterine lining and prepare the body to support the embryo, so the embryo will successfully implant and grow. Therefore, supplementation is provided to support the body.
Progesterone is available in different forms:
Intramuscular injections (ouch!)
Pessaries/suppositories (very commonly proscribed and a tiny bit gross)
Oils and gels
What do progesterone pessaries do?
My clinic use pessaries. Oh what a treat. The pessary is smaller than it appears in photos (aren’t we all) and is approximately the size and shape of a third of my little finger, and I have wee hands. Everyone posts pictures of the pessaries held close up to the camera, making it appear that a baton is expected to be placed where a baton should never go. But that is not the case.
My pessaries were small white bullets with a smooth waxy texture. I was prescribed 800mg of progesterone a day, which was one 400mg pessary to be inserted in the morning and another in the evening. The timings for actually taking it each day were not as specific as the stimulation injections, allowing me to play fast and lose, fitting them around my daily rituals.
The amount of progesterone proscribed seems to vary from around 400 to 800 a day, depending on the IVF clinic. The length of time you stay on progesterone also varies. At my clinic, they pop you on it from egg collection until either a negative pregnancy test or 12 weeks of pregnancy. Other clinics seem to pull people off progesterone from 9 weeks pregnant. The placenta takes over the production of progesterone from the second trimester and therefore, as scary as it is to come off the little bullets, don’t panic. Clinics base their advice and procedures on well-established research, so if they take you off progesterone at 9 weeks don’t freak out. It is highly unlikely that they have gone rouge and more likely that it is based on research and hundreds of women going through IVF before you. They wouldn’t place you or your baby in unnecessary risk, so try to stay calm.
How do you put in a progesterone pessary? Up the front or up the back? The age old question
A question that arises frequently with pessaries and is much debated is the classic ‘front or back?’ (vagina versus bottom). Admittedly, this is only a debate commonly had in IVF circles (and possibly porn groups?!) rather than tea point chatter at work or at your local book group. Although you could always pose the question there and marvel at the perplexed and horrified faces it induces.
There seems to be no clear answer to this conundrum. My clinic initially said back door, as did the sticky label on the box. The clinic nurse who wrote out the prescription to the pharmacy said that it didn’t matter either way, another nurse from the clinic advised to try the back door unless it caused irritation of the bowels and then go front. NetDoctor.com says back door for some aliments but for IVF it should be the front. Friends on Instagram were instructed to go via back door because it leaks out of the front and is less effective, others had been told that the front is more effective because it is closer to the womb. In all honesty, what is needed here is a shrugging shoulders emoji because the advice is totally mixed. And for that reason I decided to mix it up too, hoping to experience the best of both worlds. Let me tell you, there is little that can be described as 'best' about either route.
Vagina– Is easier but messier. The waxy exterior melts and the progesterone is then absorbed into the body within 30 minutes. In order to reduce the mess and to ensure full absorption, I heard of clinics advising people to lie down for half an hour after insertion, something that I did rigidly. This may not be possible for the morning pessary, depending on your timetable. Using the front door requires the wearing of panty liners (trust someone who lost a good sweep of well-loved and well-worn pants). On the whole, I chose this route.
Bottom – Is more awkward to insert but gloop free and it does not feel as weird as you may anticipate. It is definitely worth a try and after a few times I was in the swing of it, wondering theoretically what other tiny household objects I could insert… The waxy shell does not leak out, but instead waits until you pass a bowel movement and coats that instead, which is much more civilised. I was advised not to go for a number two until at least 30 minutes after inserting the pessary to ensure that it had been fully absorbed. Whenever I had a scan or medical appointment (embryo transfer, viability scan etc) I popped it up the back to spare the mess for the medical staff. This route can cause irritation (either constipation or diarrhoea) which would necessitate a change to the other entrance.
To whom would you give your IVF candle?
The mess the pessary creates is identical to melted wax. Given that my IVF was in November/December and the festive season was fast approaching, I was tempted to collect the wax to create a homemade gift for the person who made the most insensitive comment during the year, or who blocked me from their life during my IVF and years of infertility. I could scrape it off my pants, boil it down, add a wick and present my IVF candle along with a sweet little hand written note: ‘Merry Christmas! Thanks for all your support over the year(s). Couldn’t have done it without you! xx' Don't worry. I didn't. But when someone made a hurtful comment, or couldn't face meeting me for a coffee because my situation made them feel awkward, just the thought that they were a contender for my IVF candle put a much needed (vindictive) smile back on my face.
As touched on above, be warned: Pessaries are the enemy of pants. If you are going private with your IVF, then pants should be factored into your IVF expenses as I cycled through them like there was no tomorrow. The waxy exterior of the pessary melts, leaks, then forms an unsightly, thick and hard crust in the gusset. That sounds gross doesn’t it. Well, it is. Can the waxy crust be washed out easily in the washing machine. No Sir! That would be far too easy. A nice hot pant washes simply encourages the wax to become engrained into the very fabric of the pants, requiring immediate disposal. For me, it took a while before the epic battel of pants versus pessaries drew to a close. Pessaries initially took the upper hand (before I realised that panty liners were the answer to my prayers) resulting in heavy losses from my underwear drawer. But the pants eventually regained control on implementation of a consistent strategy of panty liners, lying down for 30 minutes post insertion and a bulk pants replacement purchase from M&S (good old M&S, hey). Given the state of my frumpy, shapeless and faded pants prior to IVF, it could be argued that pessaries did me (and Joe) a huge favour by necessitating a wholesale uplift.
What are the side effects of progesterone for IVF? What it feels like to be on cyclogest
Low mood - Personally, I hate progesterone. I hated it in a natural cycle as it induced severe blues which saw me slump into a toddler tantrum style pit of ‘I don’t want to’. I had no desire to do anything other than go home and go to bed, my outlook was negative and a quick weep was required most days. Maybe this was the stress of infertility rather than the progesterone, but I felt a similar sense of doom when on my pessaries, leading to a rather negative two week wait for the pregnancy test. Be aware of how progesterone changes your mood and if your body or emotions cope very poorly, speak to your clinic about changing the style or brand for a future cycle.
Bloating - It made me bloated. Oh so bloated. Or was that the trigger injection for egg collection (which can encourage the growth of the other non-harvested follicles)? I blossomed into a hippo. My snuggly fitting trousers would no longer do up. I would relieve the discomfort by sitting at my desk at work with my trousers unbuttoned and a hope that my top was long enough to hide my state of undress.
Mimicking pregnancy symptoms - Progesterone messes with your mind by mimicking the same symptoms as early pregnancy. It was impossible to tell whether my (thankfully) larger and sore (not so thankful) boobs were the result of HcG surging through my veins or progesterone pumping into my body. They both produce both, which means that anything can mean anything and nothing means anything. It is a complete mind f*ck and your symptoms cannot be trusted.
To end the discussion of pessaries on a little bit of light relief, the difference in male and female responses to IVF drugs was made apparent by the difference in mine and Joe’s trail of thought on progesterone pessaries.
ME: When will it end? The bloating, the discharge. It feels like forever, has it been forever? Have I always been subjected to Satan’s waxy tears?
JOE: (coyly) Sooooo, I was thinking, now that you are used to things going up your bum… One meaningful look from me and he decided against finishing the sentence.
Whilst I was scrabbling around with my pessaries, working out the best place to insert them and bunkering down into a daily routine, I was also dealing with the worry of how my little eggs were coming along and what, if anything, I would have to transfer back in the following days.
What are the stages of embryo development?
The eggs harvested during egg collection are left overnight to fertilise with the sperm (if straight IVF is taking place as opposed to ICSI). The fertilised eggs are kept in a culture in a incubator for 5 days or so, hopefully developing from a single cell egg to a blastocyst containing over 100 cells. Apparently, only 50% of embryos are ever capable of reaching the (good quality) blastocyst stage, all part of natural selection. Add in PCOS creating potentially crappy eggs, like me, and this percentage drops even further. It is expected that the number of embryos still in the running to be the 'chosen ones' will drop off of at each stage of development, so 7 fertilised eggs is highly unlikely to result in 7 blastocysts. Limit expectations now my friend.
The embryos are left in a culture for days so that the embryologist can select the best developed to transferred back. They are looking for healthy cell division, for example how many cells the embryo has, how quickly the cells are dividing and how even they appear. Waiting until day 5 closely mimics the process for people who can conceive naturally (it still baffles me how anyone can do that) as the egg travels down the fallopian tube for a few days before reaching the womb. As not all embryos reach the 5 day blastocyst stage, the embryologists keep a close eye on progress and will provide updates on whether it is advisable to have a transfer earlier, at days 2-3 (cleavage stage). This may occur if either there is a clear front runner for the best embryo, or if there is a fear that none may make it to day 5 in the lab. Opposite to the phrase my mum uses when she embarrassingly farts in public, embryos are 'better in than out' and placing them back inside the womb could result in better development than in the lab. According to the Human Fertilisation and Embryology Authority, in the UK roughly half of women have a day 2-3 (cleavage stage) transfer and the other half have a day 4-5 (blastocyst) transfer.
The emotionally nerve wracking calls from the embryologist
IVF may have been physically less demanding then I was anticipating, but emotionally it was a whirlwind with the toughest element being the dreaded calls from the embryologist. Immediately after egg collection we were informed us of the number of eggs collected, when I was sipping on my water and off my tits on drugs. But the numbers matter less than the quality and at that stage of my first ever IVF, the quality was anyone’s guess. Given we had been trying for over three years, there were no problems on the male side but still no baby, I guessed that my little eggs safely fell into the ‘could be improved’ category.
Embryo development is like the TV show Big Brother, in that everything is measured in days – Day 1 fertilisation report, Day 3 progress update, Day 5 transfer etc. In contrast, the embryo development saga is short, usually only lasting for 6 days, arguably something that the producers of Big Brother should take on board to make it more palatable for viewers. The embryologist called most days with updates on how our little embryos were developing, like an overqualified assistant at a very high end and technologically savvy nursey. I felt a connection to them. To the embryos, not the embryologists (although I’m sure they were lovely too). It was our combined DNA, growing in a petri dish (or at least that is how I imagined them) and that felt special.
Day 1 - Fertilisation report
The first call was the morning after collection. How many have made it out of the starting blocks? This was the call that scared me the most. I had low numbers of eggs collected in comparison to my fellow PCOS sisters, only 9. And there was a strong chance that those 9 could have been, well, very crap. So I was desperate to have a high number fertilise. The call came when I was ‘relaxing’ in the bath (in reality I was a nervous wreck, staring at my mobile which was precariously balanced on the edge of the bath waiting for it to ring, whilst Roger the cat sat on the window sill and stared at me). I tried not to swish the water as I spoke to the clinic, as it is always disconcerting to realise that the person you are talking to is naked, it puts a different and more informal slant on the conversation. It was good news. 7 had fertilised overnight, phew. The embryologist informed me that my next call was going to be on Monday, Day 3, where they would update me on how my little ones were getting along. I thanked her, hung up the phone and burst into uncontrollable tears. Roger was alarmed. Not enough to move an inch, that’s not Roger’s way, but he showed his discomfort in a slightly wider eyed-stare which I took to be a cat version of an affectionate and supportive cuddle.
Day 3 – progress report
The call was received in the morning when I was on the train into work. In a hushed voice I confirmed that ‘it was fine to talk’ and was informed that all 7 embryos were still developing and I would be having a day 5 transfer. ‘They are of varying quality, mind’ cautioned the embryologist. I responded with ‘Yes of course, that’s fine’ a totally nonsensical thing to say given that a) I wasn’t entirely sure what that meant, b) I sounded like I was expecting it (‘oh yes, of course’), when really I was adrift at sea and c) telling her ‘that’s fine’ like the embryologist was controlling the situation and had decided to provide me with a mixed bag of embryos. Perplexed, but not wanting to explore what ‘varying in quality’ meant on a busy commuter train, I just basked in the extreme relief that we were having a 5 day transfer, thanked her and hung up.
FERTILITY PROBLEMS: ASSESSMENT AND TREATMENT (CLINICAL GUIDELINE [CG156]) PUBLISHED DATE: FEBRUARY 2013 LAST UPDATED: SEPTEMBER 2017
Many couples get called daily with embryo updates, but given that day 2 fell on a Sunday (Sunday’s don’t exist in the world of our IVF clinic) and it was confirmed on day3 that we would transfer on day 5 (therefore negating the need for a day 4 update) we only endured two nail biting calls. The final embryo results were revealed in person at the day 5 transfer.
How many embryos are transferred back during IVF?
Multiple pregnancies tend to be more complicated and risky than having a singleton (does anyone else always hear 'simpleton' when this is said?) and so clinics tend to be reluctant to transfer more than one embryo. However, although a single embryo transfer is the default setting, there are factors that come in to play when deciding on the number to be transferred, such as the woman's age (with women over 40 being legally allowed 3 embryos transferred), the quality of the embryos and relevant history (such as previous failed IVF cycles or previous pregnancies). The consultant will discuss (or that should possible read 'negotiate') with you on the number to be transferred back, but they are trying to balance the chance of a pregnancy with the risk of multiple pregnancy.
In my case, because I was under 35 (just), it was our first round of IVF and the embryo turned out to be of good quality, there was no question in the clinic's mind that only one would be transferred.
Does the number of embryos transferred impact on the chances of a successful pregnancy?
According to the Human Fertilisation and Embryology Authority (and let's be honest, they are the chaps in the know) the answer is 'NO'. As the table below shows, for most women having IVF, transferring one embryo is just as successful as having a double embryo transfer and your chance of having a multiple pregnancy is much lower. Birth rates are just as good for single embryo transfers as they are for double embryo transfers when you take into account the remaining frozen embryo. Effectively, if you put only one in rather than two, you’re just ‘saving up’ your second embryo and giving yourself a second chance of conceiving at a later date. Although what wasn't completely clear to me was whether it compared the same quality of embryo (i.e. does the table below compare success rates of a medium quality single transfer with the transfer of two medium quality embryos, or is it comparing a top quality single transfer with lower quality double transfers?). Still, a very interesting table.
The results are in - final embryo numbers and quality
Until entering the transfer room, we had no idea of the quality of the embryo to be popped back in, or numbers that made it to blastocyst. Our clinic usually only transfer one embryo, unless there is reason to consider a multiple transfer (such as multiple failed previous IVF cycle, advanced age, poor quality of embryos etc). This was not a surprise and had been discussed on a number of occasions previously. When discussing the quality of our embryo, the consultant didn’t explain it in the technical grading system that I have heard others using 5AA, 3BC etc. Instead, we were told that luckily ours was a top quality embryo, I think he said ‘couldn’t get any better’ but my memory is hazy and that may have been a fabricated memory to keep me positive. An image of the embryo in the lab next door magically appeared on a television screen in the corner of the room. ‘Look at that! Beautiful, just beautiful’ he said, gazing at it with professional pride. I couldn’t stop staring. Joe and I had made that. It was a combination of our DNA, our own little bundle of living cells.
An embryo transfer top tip from me - decide beforehand whether you want to take a photo of your embryo. I did, my husband didn’t, but we had not discussed it. So, under the watchful gaze of the consultant, who I could barely look in the eye given this was his second tinkering with my muff in less than a week, we started having a very civilised mini domestic. It had never occurred to me that we wouldn’t take a photo. In my mind, IVF accords you an opportunity that frustratingly fertile people never have, the opportunity to show a child what they looked like as a clump of cells, just 5 days old. It is incredible, science at its best. I wanted it for a scrap book as I had been collecting all sorts of IVF tat along the way, like my wrist band from egg collection etc. But Joe was convinced that taking a photo would be a jinx. I didn’t want to jinx it and so Joe won the domestic and the photo idea was no more. I continued to stare at our embryo, trying to etch it into my memory bank to be accessed at a later date. During the car journey home post transfer I tried to persuade myself that having no photo was totally fine. Totally. But the discussion with Joe was neither reassuring or convincing it went like this:
ME: “It’s ok not to have a photo as I remember what it looked like.”
JOE: “Yeah, you know what it looked like to me? When I was in the army the chap next door to me asked us all to check out whether he needed to see a doctor, as he had craters on his nob.”
ME: “Are you saying that our beloved embryo looked like a gen wart?!”
JOE: "No! No, silly. Not like a gen wart, like a bellend covered in gen warts.”
So no photo and just a festering mental image of a severe STD to remind me of our little blastocyst.
What happens during embryo transfer? Be ready for full exposure
The embryo transfer room looks like any other treatment room in the clinic, a medical bed and some basic equipment alongside a couple of chairs, save for the fact that there is also a 1970s style service hatch built into the wall. My grandma used to pass cups of tea through hers to guests sitting on her sofa in the living room. In this instance it allows the embryologist to pass all my hopes and dreams through the hatch, whilst I’m on the bed with my pants off.
The actual process of embryo transfer is a wee bit exposing. And that is a huge understatement. The only way to get through is to leave your dignity at the door and collect it on the way back out. I lay on a bed, my bottom near the edge, with the consultant sat on a chair between my parted legs. Pants off, obviously. Then the bed was raised so that my lady parts were eye height for the consultant. His face was but inches from my nether regions. All I could think was that he has got to be paid a lot of dosh to do this job. Transfer was like my vagina’s very own opening night on Broadway.
Curtains: open those legs wide.
Lights: a lamp adjusted to shine far too many watts on an area that only appreciates a dimly lit bedroom.
Action: embryo inside a long thin tube (a pokey pokey device – not the medical term) passed through the serving hatch to the consultant.
Audience: silence in the room whilst everyone: me, my husband, the fertility nurse, the consultant and the embryologist all concentrated their thoughts towards my vagina and what was occurring down there. Admittedly, I was only actually flashing the embryologist who watching through the hatch, and the consultant who was just inches from my genitals. Everyone else stayed away from the X Rated end of the room.
Is embryo transfer painful?
As always, I was fearful that the procedure would be painful. After all, having a thin plastic straw like device inserted through the cervix to the top of the uterus sounds painful, right? But it turned out to be a non-event. It was like a SMEAR test, just if the SMEAR test had been performed by a true artist rather than a rushed and slightly rough handed practice nurse. I hardly felt a thing. It is also a very quick process, taking approximately 5 to 10 minutes. This isn't always the case and I've heard horror stories of non-compliant cervixes and 20 minutes of poking. If you have a naughty cervix that is difficult to handle, it is likely you know this from the multitude of tests you are subjected to during infertility. In that case, definitely speak to your clinical team before the transfer to put your mind at rest. For the rest of us (the lucky ones) it is a doddle.
I also did not experience any cramping post transfer, but if it did occur then my clinic had advised that it is safe to take Paracetamol in early pregnancy for pain relief, provided that the recommended dosage is not exceeded and you have no known allergies to the drug.
Can an embryo fall out after transfer?
Discharge may be experienced after transfer, because it wouldn't be IVF as we know and love it without muck, mess and discharge. This is apparently due to the consultant cleaning the cervix with saline prior to the procedure, and not your embryo falling out. I've heard of the embryo in the uterus being described as a like "a pearl in a peanut butter sandwich". I've always thought of peanut butter sandwiches to be a very American thing and how a single pearl would end up in there is anyone's guess. But the point is that one can laugh, sneeze, cough, jump up and down and that little embryo is going nowhere.
I took the day off work after transfer. It isn't strictly necessary, but the whole process was more emotional then I was expecting and I would not have been able to concentrate on work that afternoon. And that was it. Embryo on board.
What can I do to increase my success after egg transfer? Clinic's advice post embryo transfer
Here is what my clinic advised post transfer:
Try to have the day of transfer as a rest day.
Do not have a bath the day of transfer (but you can shower) and you can return to normal bath routines from the following day.
Avoid becoming overheated - no sauna's, jacuzzi's or sunbathing.
Exercise is fine but nothing too strenuous.
Do not swim in a public swimming pool until your test is either negative or you are at least 12 weeks pregnant. This is due to the small risk of infection.
You are able to have sexual intercourse if you so wish (get in!)
The clinic encourages drinking 2 litres of water (although the fertility nurse on the phone advised me they are less strict on the quantity post egg collection provided that you stay hydrated) and to follow a diet suitable for pregnancy.
It is important to keep your bowels regular (its always about bowel movements isn't it). Lactulose is available from supermarkets and pharmacies and is safe to use in pregnancy to help to prevent constipation. Follow the recommended dosing on the packaging.
Continue with all prescribed medication until the pregnancy test result.
Although not physically demanding or painful, the days and procedures following egg collection are emotionally stressful. Be prepared for a rollercoaster, as I was definitely not strapped in for the ride. Even though there is nothing you can do about embryo development at that stage, it doesn't prevent the constant worry. All I can recommend is to be kind to yourself and to remain flexible in terms of commitments, as you may be called into the clinic for transfer at any time.