The IVF Cycle Step by Step — What Actually Happens, and When

This is IVF treatment step by step: what actually happens, in what order, and where the
plan can change. An IVF cycle is not one continuous procedure — it is a sequence of steps
spread across roughly two to six weeks, with decision points along the way. This is what
that sequence looks like at Jananam Fertility Centre, and how we decide what happens next.

Before the cycle starts: tests and planning

Before any medication begins, we assess ovarian reserve, sperm parameters and the uterine
cavity, and correct treatable background conditions.

Existing medical conditions such as thyroid disorders, diabetes, hypertension and vitamin D
deficiency should be corrected before starting, and folic acid supplementation should be in
place. Where weight is a factor, this is the point at which it makes the most difference —
achieving an ideal BMI can positively affect egg quality, sperm quality, embryo quality and
implantation.

Decision point. Ovarian reserve results shape the whole plan. Where reserve
is reduced, we may plan for more than one stimulation from the outset — see
dual stimulation and egg accumulation —
rather than assuming a single cycle will be enough.

Step 1 — Ovarian stimulation (roughly 8–12 days)

This is the first active stage of IVF treatment step by step, and the longest of the
early ones.

Daily injections of gonadotropins encourage the ovaries to develop several follicles at once,
instead of the single follicle of a natural cycle. Monitoring is by ultrasound scan and blood
tests every few days to track how the follicles are growing.

The dose is individualised. In diminished ovarian reserve our strategy is egg accumulation
and individualised stimulation rather than simply increasing medication doses —
raising the dose in ovaries with limited reserve does not reliably produce more eggs.

Step 2 — Trigger injection and egg retrieval

When the follicles reach the right size, a trigger injection matures the eggs, and retrieval
is scheduled about 34–36 hours later. Retrieval is a short transvaginal ultrasound-guided
procedure under sedation, usually taking 20–30 minutes.

Decision point. In women at risk of ovarian hyperstimulation syndrome — some
women with PCOS in particular — we use a GnRH agonist trigger and freeze all the
embryos. This significantly reduces the risk, and means no transfer happens in this
cycle.

Step 3 — Fertilisation in the laboratory

On the same day, the eggs are fertilised. In conventional IVF, sperm are placed around the
egg. In ICSI, a single sperm is selected and injected directly into a mature egg.

Decision point. We use ICSI for severe male-factor infertility, surgically
retrieved sperm, previous complete fertilisation failure, frozen eggs, and any embryos being
prepared for genetic testing. We tend to favour ICSI where it reduces the risk of unexpected
fertilisation failure — but it is not automatically better IVF, and the choice is
individualised.

Not every egg retrieved will be mature, and not every mature egg will fertilise. This is the
first point at which numbers drop.

Step 4 — Embryo culture to blastocyst (days 2–6)

Fertilised eggs are cultured in the laboratory and assessed as they divide. Many are grown
to the blastocyst stage, around day 5 or 6.

Numbers narrow again here: not every fertilised egg becomes a blastocyst, and not every
blastocyst is chromosomally normal. Embryo development depends on egg quality, sperm quality
and laboratory conditions together.

Step 5 — Genetic testing, where indicated

Decision point. We commonly recommend PGT-A for women aged 38 and
above, and may consider it after repeated IVF failure or recurrent pregnancy loss.
Couples with specific genetic conditions may need PGT-M; chromosomal rearrangements may need
PGT-SR. The ESHRE guidelines
set out where testing is and is not indicated.

If embryos are tested, they are biopsied and frozen while the genetic results come back. A
transfer in the same cycle is not possible — testing necessarily means a frozen transfer.

Step 6 — Freezing, and why we usually do

More than 90% of our embryo transfers are frozen embryo transfers. We
generally favour FET because it lets us prepare the endometrium under more controlled
conditions.

During stimulation, gonadotropin injections can push estrogen and sometimes progesterone well
above physiological levels, which in some patients may affect endometrial receptivity.
Freezing the embryos and transferring in a later cycle allows the lining to be prepared with
a natural or medically supported protocol instead.

Fresh transfer may still be considered in appropriately selected patients where stimulation
response, hormone levels and endometrial development are all favourable.

Step 7 — Preparing the lining and transferring the embryo

Where the lining is slow to respond, the question of endometrial receptivity comes up. We
have stopped offering the ERA test after
using it in more than 750 patients, and we explain why on that page.

In the transfer cycle, the endometrium is prepared and monitored, and the embryo is
transferred in a short outpatient procedure that needs no anaesthesia.

Decision point — how many. We transfer the smallest number of embryos that
gives a good chance of pregnancy. With PGT-A tested euploid embryos we prefer single embryo
transfer regardless of age. Under 35 with a good untested blastocyst, we usually recommend
elective single embryo transfer; at 35–37 we still advocate single transfer if blastocyst
quality is good; at 38 and above we may discuss two blastocysts depending on the situation.
We do not transfer more than two embryos under any circumstance.

Step 8 — The wait, and the pregnancy test

A blood test for beta-hCG is done around 9–14 days after transfer, depending on the stage of
the embryo transferred. A scan follows a few weeks later if the test is positive.

Bed rest during this period is not required. Normal daily activity is appropriate.

If the cycle does not work

The most common mistake we see in couples who have had a cycle fail elsewhere is
waiting too long to resume treatment. A long gap can reduce future chances
further. The UK regulator, the
HFEA,
publishes a comparable outline of the same sequence.

What matters is understanding the likely reason for failure and having a clear backup plan.
If frozen embryos remain, they may still be transferred after suitable investigations. If
none remain, the next step depends mainly on age, ovarian reserve and sperm quality.
Knowing IVF treatment step by step makes that conversation easier, because you can see
which stage actually failed. How we weigh those decisions is set out in
how Dr. Vani decides.

IVF treatment step by step: common questions

What are the main steps of an IVF cycle?

IVF treatment step by step runs as follows: ovarian stimulation for roughly eight to twelve days, a trigger injection, egg retrieval about thirty-four to thirty-six hours later, fertilisation in the laboratory by conventional IVF or ICSI, embryo culture to the blastocyst stage around day five or six, genetic testing where indicated, freezing, then preparation of the uterine lining and embryo transfer, followed by a blood pregnancy test.

Why are most embryo transfers at Jananam frozen rather than fresh?

More than 90% of our embryo transfers are frozen embryo transfers, because freezing lets us prepare the endometrium under more controlled conditions. During stimulation, gonadotropin injections can push estrogen and sometimes progesterone well above physiological levels, which in some patients may affect endometrial receptivity. Transferring in a later cycle allows the lining to be prepared with a natural or medically supported protocol.

When is PGT-A genetic testing recommended?

We commonly recommend PGT-A for women aged 38 years and above, and may consider it after repeated IVF failure or recurrent pregnancy loss. Couples with specific genetic conditions may require PGT-M, while chromosomal rearrangements may require PGT-SR. If embryos are tested they are biopsied and frozen while results come back, so testing necessarily means a frozen transfer.

How many embryos are transferred in one cycle?

We transfer the smallest number of embryos that gives a good chance of pregnancy, and we do not transfer more than two embryos under any circumstance. With PGT-A tested euploid embryos we prefer single embryo transfer regardless of age. Under 35 with a good untested blastocyst we usually recommend elective single embryo transfer, and at 38 and above we may discuss two.

Is bed rest needed after embryo transfer?

No. Bed rest after embryo transfer is not required, and normal daily activity is appropriate. A blood test for beta-hCG is done around nine to fourteen days after the transfer, depending on the stage of the embryo transferred, and a scan follows a few weeks later if the test is positive.

Written and medically reviewed by Dr. Vani Sundarapandian, MD, DGO, FRCOG (UK) —
founder and Medical Director, Jananam Fertility Centre, Chennai.
Cycle timings are typical and vary between patients; the protocol decisions described are
Jananam’s own.