As a Pilates instructor, you may commonly encounter clients who are undergoing IVF treatments and it is important to not only understand the process that your clients are going through, but also the potential implications of performing Pilates during this time.

This article has been designed to provide a guide to instructing IVF clients, however be mindful that different fertility specialists may have differing views on exercise during IVF. As such, it is important that your clients follow all recommendations from their fertility specialist and check with their fertility specialist to see if they recommend performing exercise during this time as this recommendation may be dependent on the client’s specific health history. 

WHAT IS IVF?

In vitro fertilisation (IVF) involves multiple procedures in order to create an embryo in a laboratory setting. IVF may have different outcomes depending on the individual’s preferences. For example, the goal of IVF could be to freeze eggs, freeze embryos, or implant an embryo.

The main stages of IVF are as follows – 

1. Complete Initial Tests and Ultrasound Scan

Before beginning IVF, the patient will complete a range of tests including an ultrasound scan to ensure that they are suitable to begin IVF and don’t present any contraindications.

2. Inject Hormones to Stimulate the Ovaries

The patient begins injecting hormones to stimulate the ovaries. The most common hormones contained in the injections are follicle-stimulating hormone (FSH) and luteinising hormone (LH). This process is all about preparing the follicles and ovaries for the egg retrieval (Mayo Clinic, 2022). When not participating in IVF, a typical cycle only produces one egg per month, but during IVF, multiple eggs are needed to increase success rates. As such, this stage requires patients to inject specific hormones over the course of 1-2 weeks. These hormones help stimulate the ovaries to produce more eggs, mature the follicles, prepare the uterus, and prevent ovulation before the retrieval. During this course of hormone injections, the ovaries grow up to 10 cm in size, compared to their usual 1-2 cm.

3. Egg Retrieval

After the ovaries have been stimulated sufficiently and the fertility specialist feels that there are enough follicles present, the eggs are ready to be collected. This is often called the egg retrieval or egg “pick up.” This process of egg retrieval is most commonly conducted under general anaesthetic as a day procedure in a hospital where the eggs are collected from the ovaries. During this procedure, a needle is guided through the vagina and into the follicles and the eggs are removed from the follicles via a suction device.

4. Sperm Retrieval and Preparation

Sperm retrieval and preparation usually occurs at the same time as the egg retrieval. If fresh sperm is being used, the person will produce the sample the morning of the egg retrieval. If using frozen or donor sperm, this will be prepared by the IVF lab. It is also possible to freeze the eggs without fertilising them and these cases, the remaining steps would be skipped.

5. Fertilisation

Following egg retrieval, the eggs are fertilised with the sperm to become embryos.

6. Embryo Development

The fertilised embryos begin developing and IVF scientists monitor specific developmental markers to ascertain viability of the embryos. Different IVF companies grow or develop the embryos for different periods of time. It is important to note that not all eggs will fertilise and not all embryos will be viable if they don’t reach these developmental milestones). This may be a particularly challenging time for people undergoing IVF as they wait for the embryos to develop and find out how many viable embryos they have.

7. Embryos are Frozen for Later Use OR Embryos are Transferred

Once the embryos are developed, IVF patients have the option to either transfer an embryo into the uterus (an “embryo transfer”) or freeze the embryo(s) for later use. 

If a client opts to transfer an embryo into the uterus, then this procedure is usually performed awake under ultrasound. It is a relatively simple and pain free procedure (similar to a pap smear). If a patient is having an embryo transfer, then they likely will be taking additional progesterone hormones before and after the transfer to hopefully improve pregnancy outcomes.

Following an embryo transfer, the IVF patient should act as if they are pregnant in hopes that the transfer is successful. Two weeks after the embryo transfer, the patient is able to perform a pregnancy test and find out if the transfer was successful and if they are clinically pregnant. This two week wait may be another challenging or anxious time for patients while they wait to see if the pregnancy takes.

POSSIBLE SHORT TERM SIDE EFFECTS OF IVF

Leading up to the egg retrieval, clients undergoing IVF may experience a range of side effects from the hormone injections, such as –

• Nausea
• Fatigue
• Headaches
• Vomiting
• Bloating
• Cramping
• Tenderness and abdominal pain
• Hot flashes
• Dizziness
• Soreness and/or bruising around the injection site on stomach or thighs
• Mood swings

Most clients will be taking progesterone hormones in the lead up to an embryo transfer and following the transfer to prepare the body for pregnancy. The progesterone can cause some side effects such as – 

• Abdominal bloating and discomfort
• Headaches
• Tenderness
• Nausea
• Vomiting
• Mood swings
• Tiredness
• Muscle and joint pain

COMPLICATIONS FROM IVF

Ovarian Hyperstimulation

Ovarian hyperstimulation can occur when there is an oversupply of IVF hormones in the body, causing the ovaries to inflame, leak fluid, and create pain. This overstimulation occurs in approximately 5% of IVF clients. However, patients with polycystic ovarian syndrome (PCOS) are more at risk of developing the condition.

The swelling combined with fluid leaking from the ovaries can cause discomfort, chest pain, nausea, vomiting, constipation, bloating, and puts clients at a higher risk of developing blood clots or kidney failure (Cleveland Clinic, 2022). These symptoms can range from mild to severe, with acute cases requiring hospitalisation. 

Ovarian Torsion

Ovarian torsion is a rare, but painful, complication of IVF treatment which occurs in less than 1% of IVF patients. Ovarian torsion occurs when an ovary twists, cutting off blood supply and causing intense abdomen pain, cramping, and nausea. The ovary may twist due to cysts forming on the ovaries or due to the size of the stimulated size and weight of the ovary. Pelvic exams and ultrasounds can help form a preliminary diagnosis of ovarian torsion.

TO EXERCISE OR NOT TO EXERCISE

There is conflicting research on the pros and cons of exercise during IVF treatments (Siesta, 2020). However, there is a general consensus that high intensity exercise is not recommended for anyone undergoing IVF treatment. It is also not recommended that clients embark on a new exercise regime at this time. For example, a client should not begin training for a marathon!

Some clients may feel comfortable continuing to perform exercise at a lower intensity while others may prefer not to exercise at all during this time. For clients who do choose to perform exercise, they may find low level exercise to be helpful in reducing stress associated with the IVF process (Sortisa et al., 2020). 

Most research warns against IVF patients being completely sedentary (for example, staying in bed) as this can reduce blood flow (Sortisa et al., 2020). 

At the end of the day, all clients should be guided by their fertility specialist and follow all recommendations made by their healthcare providers as these recommendations may be based on the individual client’s medical history and specific situation.

PILATES IMPLICATIONS DURING HORMONE STIMULATION

As mentioned above, if a client wishes to continue exercising during IVF and has been given approval by their fertility specialist, then the following guidelines would apply – 

Exercise Intensity

• Avoid strenuous and high intensity workouts – clients should workout at a low intensity only (eg. keep springs or resistance light)
• Always work within the client’s limits and stop any exercise if the client experiences any pain or discomfort or if they report their heart rate significantly increasing
• Encourage clients to drink plenty of water during their class

Adjusting Workout Duration

• For some clients, you may need to shorten the workout duration to 20-30 mins 

Class Types

• Small classes or private one on one classes may be more suitable to clients undergoing IVF as they may require more modifications and it may be easier to just program a specific, lower intensity workout tailored to their needs

Limit Position Changes When Programming

• Due to abdominal discomfort, some clients may take longer to transition between positions – try to program fewer transitions between exercises and keep clients in the same position for longer 

Change the Focus of Your Classes

• It is common for clients to experience weight gain during the IVF treatment and it is important to be aware that your clients’ reason for exercising during this time may be different than normal
• As an instructor, be sensitive to what your client is going through and don’t focus on the weight loss or toning benefits of exercise. Instead, exercise at this time is more about stress relief and gently moving the body for improved blood flow and overall health
• You may wish to avoid “aesthetic” based instructing cues such as “this exercise is amazing for sculpting and lifting the buttocks” – be aware that this may not be a goal for the client at this time

Clients May Experience Difficulty Activating the Abdominals

• One of the main side effects of the hormone injections is abdominal bloating, cramping, swelling, bruising or soreness – these symptoms are likely to make it challenging for clients to engage their abdominals
• Clients may not wish for you to touch or palpate their T-Zone during this time due to abdominal discomfort
• If clients struggle to activate their T-Zone, this may affect their ability to stabilise their torso

Inversions, Roll Down Positions and Positions where the Hips are Higher Than the Torso

• Due to the risk of ovarian torsion, avoid any exercises which feature inversions (eg. Walkover on the Cadillac) or place the hips in a higher position than the torso (eg. Pelvic Curl or Hamstring Curl)
• Exercise caution with exercises which involve rolling or twisting through the waist as some clients may find these exercises uncomfortable as the ovaries grow in size and if abdominal discomfort is present (eg. Saw, Rolldown Stretch). Avoid these positions and exercises if the client experiences discomfort

Prone Lying Positions

• If clients are experiencing significant abdominal discomfort then they may find it too uncomfortable to lie on their stomach in a prone position 

Jostling Movements

• Be mindful that certain movements may cause discomfort once the ovaries grow in size (for example, performing Footwork on the reformer where the carriage moves in and out with momentum may cause discomfort in some clients)

Some Pilates Equipment May Feel More Comfortable Than Others

• Be aware that some clients may feel more comfortable using different pieces of Pilates equipment 
• For example, the sitting series on the Wunda Chair (eg. Footwork) may be a great option on this piece of equipment compared to performing Footwork on the Reformer where the carriage momentum and movement may “jostle” the ovaries and cause abdominal discomfort
• However obviously other exercises on the Wunda Chair would need to be avoided as per the guidelines above (such as the Pike exercises on the Wunda Chair) 

Sitting and Standing Exercises May Feel Better

• As the ovaries grow, clients may feel most comfortable in sitting and standing positions 

Stretching

• Gentle stretches are encouraged, however keep in mind the above guidelines (ie. avoid stretches which fold the body over or involve inversion etc)

Ovarian Hyperstimulation

• The side effects from ovarian hyperstimulation can range from mild to severe
• Clients with mild hyperstimulation may still wish to continue exercise, however it is highly unlikely that clients with moderate or severe hyperstimulation will want to exercise as they will likely be experiencing significant pain and/or discomfort

Ovarian Torsion

• Avoid exercise until cleared to resume by a healthcare professional
• Avoid high intensity exercise (such as weight lifting)
• Avoid inverted positions 
• If a client has previously experienced an ovarian torsion during an IVF cycle, it is not recommended that they exercise at this time

Exercise Alternatives

• Some clients may not feel comfortable performing Pilates classes during an IVF treatment, but they may still feel comfortable performing other low intensity forms of exercise  – this may include walking, swimming (avoid flips) or walking in a pool
• If a client does not feel comfortable or able to exercise at all, then it may be worthwhile to encourage them to engage in other stress relieving activities such as painting, colouring books or meditation

PILATES IMPLICATIONS FOLLOWING EMBRYO TRANSFER

An embryo transfer may occur within a few days of completing hormone stimulation and egg retrieval. If this is the case, all of the above guidelines still apply as it may take a few weeks for the ovaries to return to normal size. Please follow all of the above guidelines plus the additional guidelines below. 

Embryo transfer may also occur at a later date where there is a significant period of time following the egg retrieval. If this is the case, some of the above implications related to ovarian torsion and hyperstimulation will not apply. 

Treat Clients as if They are Pregnant

• Once a client has had an embryo transfer they should be treated as if they are pregnant and as such all regular pregnancy Pilates guidelines for the first trimester apply (refer to the Studio Pilates Matwork Course for more information)

Intensity

• High intensity or strenuous activities should be avoided
• Ensure that the client stays cool and avoids overheating
• Encourage clients to drink plenty of water during their class

Clients May Experience Difficulty Activating the Abdominals

• The client will likely be on progesterone hormones leading up to the embryo transfer and following the transfer
• Abdominal bloating may continue to make it challenging for clients to engage their abdominals
• Clients may not wish for you to touch or palpate their T-Zone during this time due to abdominal discomfort
• If clients struggle to activate their T-Zone, this may affect their ability to stabilise their torso

SUMMARY

Going through IVF can be physically, mentally and emotionally challenging. While it is not advised for clients to be completely sedentary during IVF treatment, it is also a time for clients to be gentle on their body, reduce exercise intensity, and only work within their limits. All clients should liaise with their healthcare provider or fertility specialist to ascertain if exercise is recommended for them based on their specific needs. 

Some clients may not feel able to perform Pilates at all during IVF treatment. In this case, if their fertility specialist still recommends light exercise, then stretching, walking or swimming may be more suitable options. If a client does not feel able to perform any form of exercise during this time, then they may benefit from engaging in other stress relieving activities such as meditation. 

If you are instructing clients undergoing IVF, avoid making weight loss the goal at this time. Instead, the focus of exercise during IVF treatment should be focused on general health, stress relief and hopefully supporting pregnancy outcomes.

BROWSE COURSES

UPCOMING COURSE DATES

REFERENCES

Craciunas, L., & Tsampras, N. (2016). Bed rest following embryo transfer might negatively affect the outcome of IVF/ICSI: A systematic review and meta-analysis. Human Fertility, 19(1), 16–22. https://doi.org/10.3109/14647273.2016.1148272 

Cleveland Clinic. (2020). Ovarian hyperstimulation syndrome (OHSS): Symptoms. Cleveland Clinic. (2022). Retrieved 16 November 2022, from https://my.clevelandclinic.org/health/diseases/17972-ovarian-hyperstimulation-syndrome-ohss#:~:text=OHSS%20used%20to%20occur%20in,women%20receiving%20hormonal%20fertility%20treatments 

Evenson, K. R., Calhoun, K. C., Herring, A. H., Pritchard, D., Wen, F., & Steiner, A. Z. (2014). Association of Physical Activity in the past year and immediately after in vitro fertilization on pregnancy. Fertility and Sterility, 101(4). https://doi.org/10.1016/j.fertnstert.2013.12.041 

Kucuk, M., Doymaz, F., & Urman, B. (2010). Effect of energy expenditure and physical activity on the outcomes of Assisted Reproduction treatment. Reproductive BioMedicine Online, 20(2), 274–279. https://doi.org/10.1016/j.rbmo.2009.11.011 

Mayo Foundation for Medical Education and Research. (10 September 2021). In vitro fertilization (IVF). Mayo Clinic. Retrieved November 16, 2022, from https://www.mayoclinic.org/tests-procedures/in-vitro-fertilization/about/pac-20384716 

Monash IVF. (2022). IVF – in vitro fertilisation treatment: Monash IVF. Monash IVF Australia. Retrieved 16 November 2022, from https://monashivf.com/services/fertility-treatment-options/ivf-in-vitro-fertilisation/ 

Office on Women’s Health. (17 February 2021). Weight, fertility, and pregnancy. Retrieved 16 November 2022, from https://www.womenshealth.gov/healthy-weight/weight-fertility-and-pregnancy 

Rao, M., Zeng, Z., & Tang, L. (2018). Maternal physical activity before IVF/ICSI cycles improves clinical pregnancy rate and live birth rate: A systematic review and meta-analysis. Reproductive Biology and Endocrinology, 16(1). https://doi.org/10.1186/s12958-018-0328-z 

RESOLVE: The National Infertility Association. (9 February 2022). Optimizing fertility. RESOLVE. Retrieved 16 November 2022, from https://resolve.org/learn/infertility-101/optimizing-fertility/ 

Sõritsa, D., Mäestu, E., Nuut, M., Mäestu, J., Migueles, J. H., Läänelaid, S., Ehrenberg, A., Sekavin, A., Sõritsa, A., Salumets, A., Ortega, F. B., & Altmäe, S. (2020). Maternal physical activity and sedentary behaviour before and during in vitro fertilization treatment: A longitudinal study exploring the associations with controlled ovarian stimulation and pregnancy outcomes. Journal of Assisted Reproduction and Genetics, 37(8), 1869–1881. https://doi.org/10.1007/s10815-020-01864-w 

The Practice Committee of the American Society for Reproductive Medicine. (2008). Ovarian hyperstimulation syndrome. Fertility and Sterility, 90(5), S188–S193. https://doi.org/10.1016/j.fertnstert.2008.08.034