Should I Seek Fertility Advice?
According to UK figures collated by the National Institute for Clinical Excellence (NICE), about one in seven couples experience some difficulty in having a baby. Dramatic advances in medical science mean that many previously misunderstood fertility problems can now be overcome. However, many couples remain unsure if and when to seek professional help.
How long should a couple try for a baby before suspecting that there may be a genuine difficulty? This is not always an easy question to answer, after all there is only one opportunity each month to fertilise a single egg. Furthermore, not all egg/sperm combinations are successful, and the majority of potential embryos naturally fail to develop, so one cannot expect a pregnancy every time. In the absence of other medical symptoms, generally 6 -12 months of unprotected intercourse without pregnancy is considered an appropriate time to seek the advice of a fertility specialist. Seeking to understand the reasons for infertility has lead doctors and scientists to develop a plethora of sophisticated diagnostic procedures and treatments. Most cases of infertility can now be understood and a plan for dealing with the situation can be formulated.
So what do we know about the causes of infertility? In men, it is a case of semen quality, though it is just as important for men to seek medical advice for infertility as women. The main factors in assessing semen quality include the number of sperm present, the proportion of sperm that are actively swimming and the quality of the sperm structure or shape. Injury to the testes, infection, autoimmunity and some inherited structural or genetic problems can lead to a reduction in male fertility. These can often be diagnosed simply by the analysis of a semen sample produced by masturbation into a sterile container and sent to the seminology laboratory. Many of these problems are temporary or can be reversed. In most situations the sperm sample can be vastly improved by selecting the best sperm in the laboratory and using these to fertilise the egg.
Fertility problems in women are a little more complex, as might be imagined. One of the most talked about issues is that of maternal age. It is becoming increasingly common for people to delay starting a family, often due to the pressure of work, establishing a career, travel or indeed gaining life experience before the undertaking the responsibility of parenting. Women begin their reproductive lives with a fixed number of eggs in their ovaries, usually with only one maturing and being released each month until the menopause. As a woman passes the age of 35 the number of high quality eggs remaining starts to decline, along with her fertility. In this case it is obviously better to seek professional advice sooner rather than later.
However, there are many young and otherwise healthy women who are concerned about their fertility. Hormonal abnormalities, dysfunction of the fallopian tubes, failure to ovulate, endometriosis, pelvic infection and irregular menstrual periods are all commonly encountered. A consultation with a fertility doctor usually entails ultrasound scanning of the ovaries and womb, a painless, quick and non-invasive procedure that can give information about the number of developing eggs, and even estimate the ‘ovarian reserve’ or length of reproductive life remaining. This is backed up by a medical history and the taking of a blood sample to measure hormones such as estrogen and progesterone along with anti-mullerian hormone, providing a vital insight into the progress of a womans menstrual cycle and overall reproductive health. All these are considered as part of the process of understanding the situation in the individual woman, and the treatment is tailored accordingly. In some cases the patency of the fallopian tubes may be assessed by passing a small amount of echo contrast fluid through the tube under ultrasound guidance. The procedure only takes a few minutes and will indicate whether the tubes are blocked. Once the evaluation is complete the fertility doctor will discuss the range of treatments available and advise what is best for the individual patient.
What treatments might be offered? Clearly this depends upon the exact problem, but there are a few common options. If the problem is with ovulating, for example, due to polycystic ovary syndrome, medicines such as clomiphene (Clomid), tamoxifen or metformin may be appropriate. Where sperm count might be slightly sub-optimal a treatment such as intra-uterine insemination (IUI) might be chosen. In this technique, the semen sample is prepared in the laboratory so that a small volume of fluid containing high numbers of the most vigorously swimming sperm is introduced into the womb just before ovulation is due. In other cases, in-vitro fertilisation (IVF) may be the best option, for example, in the case of blocked fallopian tubes. In-vitro simply means ‘in glass’ and this is where the term ‘test tube baby’ originates, although no test tubes are involved in reality! It seems deceptively simple to mix sperm and eggs together until the eggs are fertilised, but it requires closely controlled laboratory conditions and highly skilled embryologists to maintain. Nevertheless, this is essentially what happens.
Fertilisation itself is not always simply a case of mixing the eggs and sperm. For example, where there are sperm present, but they are hardly swimming or not swimming at all, a single sperm can be manually injected into an egg. This requires sophisticated microscopic manipulation equipment but results in fertilisation just as if a swimming sperm had encountered the egg naturally. The procedure is called intra-cytoplasmic sperm injection (ICSI). Cytoplasm is just the scientific name for the inside of the egg, and the resulting embryos are transferred just as in the standard IVF procedure.
Not all sperm/egg combinations are viable even in the absence of any medical intervention. The chances of success for a single treatment cycle are greatly improved by collecting many eggs. In order to do this it is necessary to take over a menstrual cycle, stimulating the ovary to develop more than one egg. By doing this 5-10 good quality eggs might typically be collected and attempts made to fertilise them all before selecting the most viable embryos for transfer or freezing. The treatment ususally involves stimulating the ovaries to produce several eggs by using follicle stimulating hormone (FSH). The FSH is administered by the woman herself, usually via daily subcutaneous (just under the skin) injection. Endogenous FSH production is turned off by administering gonadotrophin releasing hormone (GnRH). The stimulation with FSH continues for around 10-12 days. The development of eggs in the ovaries is monitored using ultrasound and ovulation is induced at the right time by giving a ‘trigger’ of another hormone called human chorionic gonadotrophin (hCG). Shortly after this the eggs are collected and transferred to the laboratory to meet the prepared sperm. Egg collection is relatively quick and painless, and carried out under mild sedation.
Once the resulting embryos have been allowed to grow and develop in-vitro, in the care of the embryologist for a few days, the best one or two are selected for transfer to the womb. Spare embryos can in be frozen for use later if required. The embryo transfer itself is conducted by the physician in the IVF centre and only takes a few minutes. Rest is usually advised for a short time following the transfer. Pregnancy tests and luteal phase support often using progesterone (which helps maintain the lining of the womb in a receptive state) may be appropriate during this time.
Chances of Success
What are the chances of success? IVF clinics will typically quote 30-40% success rates for a single cycle for women under 35 years old, but naturally, this depends upon individual circumstances and the type of treatment. Maternal age is the biggest predictor of likely success, and success rates are a little lower for women between 35 and 40. For women over 40 success rates are considerably lower, but there is more individual difference here as some women use up their supply of eggs sooner than others. The number of eggs remaining in an individual woman can be assessed using ultrasound for antral follicle count (AFC) or Anti-mullerian hormone (AMH) determination and these tests give an indication of the likely number and quality of eggs that might be obtained. Cumulative pregnancy rates involving more than one cycle are of course higher. All IVF clinics in the UK are licensed by the Human Fertilisation & Embryology Authority (HFEA). The HFEA ensure that clinics comply with best practice and also publish success rates for different age groups and treatment types (www.hfea.gov.uk). Caution should be exercised when comparing overall success rates, as treatment types and patient groups can differ between clinics. In a few cases, after careful evaluation, the option of sperm or egg donation may be offered. This is something that the IVF clinic will discuss in detail if appropriate.
Advances in Fertility Treatment
Over the last decade IVF success rates have gradually increased, mainly as a result improved techniques for handling embryos in-vitro and ever more advanced diagnostic procedures. It has become routine to freeze sperm or embryos and store them almost indefinitely. The science of egg freezing has lagged behind, but new developments now make this a possibility and younger women are being given the option of freezing the high quality eggs of their youth for use later in their life.
The other major advance on the horizon is the genetic testing of embryos before implantation. This involves removing a single cell from the developing embryo and analysing its genetic make up to detect any abnormalities. In this way it is possible to avoid transferring abnormal embryos which may fail to develop or carry a genetic disorder. These treatments are usually only appropriate for certain people, such as parents worried about passing on a known genetic illness or a woman with repeated implantation failure, and are best targeted to certain people under the advice of the fertility doctor. However, as science progresses we may see technologies more widely used in the future.
There is now more help than ever for people concerned about their fertility, a huge array of science, technology and expertise available to everyone. However, it is important not to overlook simple lifestyle and emotional factors that can impinge on fertility, a good diet, not smoking or drinking too much and maintaining a healthy weight. We live in a world where we are used to getting what we want, when we want it, but fertility has never been like this. Anxiety, overwork and stress can all be contributory factors to reduced fertility. In fact many IVF centres provide councillors to discuss the implications of treatment and outcomes along with relaxation or support groups in many cases. The best course of action is to be positive, happy and seek the right professional advice.
Science Director Concept Fertility Clinic www.conceptfertility.com