Fertility treatments – Dr. Jessica Farren and Dr. Linda Farahani

While the wide range of fertility treatments now available is incredible, it can sometimes be a little overwhelming – a sea of acronyms and pros and cons. Here we break down the commonly available treatments.

Medicines

Common medicines prescribed to patients include:

  • Levothyroxine – A medication used when women have thyroid problems that could interfere with conceiving
  • Dopamine agonists – A medication prescribed to encourage ovulation in women who have raised prolactin hormone

Ovulation induction

Your Doctor may prescribe fertility medicine to help with ovulation problems.

  • Clomifene – encourages the monthly release of an egg (ovulation) in women who don’t ovulate regularly or who can’t ovulate at all
  • Letrozole – an alternative to clomifene that may be offered to women with ovulation problems
  • Metformin – particularly beneficial for women with polycystic ovary syndrome (PCOS)
  • Gonadotrophins – can help stimulate ovulation in women, and may also improve fertility in men

IVF

During IVF,  healthy eggs are removed from a woman’s ovary and fertilised with sperm in a laboratory – hence the phrase Test Tube Baby (IVF stands for “in vitro” – latin for ‘in glass’  fertilisation)! Once an egg has been successfully fertilised (which sometimes involves something called ‘ICSI’ – injecting the sperm directly into the egg), the embryo is then returned to the uterus to develop. While this specific IVF procedure may sound simple, there are actually quite a few steps that need to be taken before arriving at this point. When you decide to undergo IVF you will firstly take medication to suppress your natural menstrual cycle as well as medication to boost your egg supply. After careful monitoring to ensure that your eggs have matured, doctors will then collect or ‘harvest’ your eggs. The eggs will be collected from your ovaries via your vagina. Once the eggs have been collected, fertilisation will take place, and any embryos created will be grown in the laboratory. Three to five days later , a healthy viable embryo is put back in the womb. For most women the recommendations are that only one embryo is put back into the womb, although on occasion your doctor may recommend two. The NHS then advises waiting 2 weeks to take a pregnancy test, to see if the procedure has worked.

Is it right for me?

IVF can be an effective and excellent treatment for fertility problems such as low sperm count and tubal blockage, and can also be beneficial for women with ovulation problems, for example due to PCOS. Many women decide to try IVF often after other fertility treatments, such as hormone medications (more on these in a later blog), or conceiving naturally have proved unsuccessful. It is important to remember that it’s normal to take up to 12 months to conceive naturally (when having sex 2-3 times a week). It’s a very personal decision, so it’s important to discuss whether it’s the right course of action for you with your doctor, your partner and your support system.

What are the risks?

As with all medical procedures, there are certain risks and side effects that come with IVF. Many women going through the treatment will have minor side effects to the medication prescribed, such as headaches, hot flushes and fatigue. The main serious complication is called Ovarian Hyper-Stimulation Syndrome (OHSS) in which your ovaries become too large, and it can cause a dangerous amount of bodily fluid retention. This can occasionally require you to be admitted to hospital. IVF also increases your risk of both ectopic pregnancy and multiple births (twins or triplets). There is also an increased risk of blood clots developing in the lungs and lungs, and all women undergoing IVF are encouraged to stay hydrated and active (and by this we mean your usual daily activities, not choosing this time to run a marathon!). An important risk to remember is that there is the possibility that it won’t work.

IVF can be a physically and mentally demanding process, so looking after yourself and your mental wellbeing should be a high priority.

How can I access IVF?

The NHS guidelines advise that three cycles of IVF should be offered to women under 40, and one cycle to women aged 40-42 (providing there is no evidence of low ovarian reserve) who have been trying to conceive naturally for 2 years, and have no children. However, what is offered varies according to where you live, and is constantly changing, – and sadly only 12% of commissioning groups across the UK are able to offer this – with the majority only offering one cycle.

You should speak to your GP about what is available in your area, and can also consult the website www.fertilityfairness.co.uk or the website for your local Clinical Commissioning Group (CCG).  Often, the criteria only require you to have been trying for one year over the age of 35 – so you should consider seeing your GP sooner if you’re approaching 40.

If you’re not eligible for NHS treatment or you decide to pay for IVF, you can have treatment at a private clinic. The cost of private treatment can vary, but one cycle of IVF usually costs at least £5,000.

uThe success rate of IVF often depends on the cause of infertility, and tends to decrease as you get older. For women under 35, the rate of successful pregnancies is around 29% and this drops to 15% when you are in your late thirties. The NHS will generally not advise women over 42 to undertake the treatment, as the success rate is low (3%), however private clinics will conduct the procedure with women who are much older. Almost all pregnancies above the age of 45 involve donor eggs.

IUI

What is it?

Intrauterine insemination (IUI) is a medical procedure where a catheter is inserted into the vagina and guided towards the uterus. A sperm sample is then inserted in to the catheter, leading it directly to the womb, aiming to get the sample as close to the released egg as possible.

Depending on your situation you may decide to use your partner’s sperm or donor sperm. If using your partner’s sperm, he will be asked to produce a sperm sample on the day of your IUI procedure. The sperm sample can be prepared in a number of different ways. Sperm washing is a common method where the sperm is ‘washed’ to create a concentrated sample of healthy, viable sperm. In cases where donor sperm is being used, the procedure is almost identical, but the sperm will have been collected previously, and frozen until the day it is required. This sperm will have been screened for diseases and tested to ensure it is viable.

It is important that IUI is timed so that the sperm reaches the egg at the right time. Ideally, IUI should be performed within a time period of 6 hours before or after ovulation. If you have a regular menstrual cycle, it is possible to work out the approximate time of ovulation yourself (it’s usually 12-16 days after your period). You can also use an ovulation prediction kit (OPK) to help accurately narrow down the window, and in some cases blood tests can be introduced. In some circumstances, medicines are prescribed to help stimulate the release of one or two eggs before the IUI procedure, this is known as stimulated IUI or superovulation with IUI. A cycle of stimulated IUI will be closely monitored with ultrasound scans, firstly to determine the timing of ovulation which helps to increase the chances of success, but also to reduce the risk of multiple pregnancy (twins, triplets or even more!)

Is it right for me?

IUI can be good option in a number of different circumstances. NHS funding for IUI is not the same across the UK, and is usually only offered to couples where vaginal intercourse cannot take place, either for physical or psychological reasons; or where there is a medical condition such as HIV which makes it unsafe to have unprotected sex. It is not routinely offered to other couples as the evidence shows that the success rates are not much better than regular sexual intercourse.

IUI may also be accessed privately. For female same-sex couples and single women who are wanting to have a baby, they will only be eligible for NHS funded IVF treatment if they have had 6 cycles of IUI in a clinical setting which has been unsuccessful. This IUI treatment would have to be self-funded.

Before you are able to proceed with IUI, you, and your partner’s fertility will need to be assessed, to ensure it is the right approach for you. If a low sperm count, endometriosis, or damaged fallopian tubes is the cause of your infertility, it is unlikely IUI will be a successful treatment for you, but this should be discussed with your doctor.

What are the risks?

This is a fairly simple medical procedure and whilst the woman being inseminated may experience some discomfort, the serious risks are very minimal. It’s not uncommon to have some lower abdominal cramps, similar to period pains, for a day or so after the treatment, but most women have the procedure and then return to their day as usual. If you are taking fertility medications, such as Clomid, Letrozole, and hMG to improve the success rate of IUI, these can come with their own side effects, including headaches, fatigue and effected mood due to the change in hormones, as well as the potential risks of multiple pregnancy and ovarian hyperstimulation syndrome.

How successful is it?

Whilst less expensive and less invasive than IVF, treatment with IUI is less successful. As with all fertility treatments, the age of the woman will have a significant impact on the success rate of IUI. Your doctor will also take into account the length of time you have been trying to get pregnant, as well as the underlying reason for subfertility and work with you to decide if IUI is the best treatment for you. The average couple has a 20% chance of getting pregnant with each menstrual cycle, but after one year of trying the chance of conceiving in any given cycle will have fallen to 1.5-3%. In this situation it is important that any treatment offered can give better odds than this.

Frozen sperm has been proven to be less successful than fresh sperm, which is something to consider, especially if you are using donor sperm. You can increase the chances of conceiving by IUI by taking medication (eg. clomiphene) to stimulate ovulation and trying to monitor your cycle carefully so you have the procedure at the optimal time for fertilisation.

Egg and sperm donation

If you or your partner has an infertility problem, you may be able to receive eggs or sperm from a donor to help you conceive. Treatment with donor eggs is usually carried out using IVF.

Although it is relatively easy to obtain donor sperm from a sperm bank, it is harder and more expensive to find a donor egg. In the UK, there are companies and fertility clinics in the UK that help couples find donor eggs, and your fertility clinic can provide this information. If you are eligible to have NHS funded IVF treatment, the cost of the cycle may be free, but you may still have to pay to find a donor egg.

All couples planning on using donor eggs or sperm to help them conceive are required to undergo counselling. This will be provided by the fertility clinic.

Anyone who registered to donate eggs or sperm after April 1 2005 can no longer remain anonymous and has to provide information about their identity.This is because a child born as a result of donated eggs or sperm is legally entitled to find out the identity of the donor when they become an adult (at age 18).

Surrogacy

Some couples may require the help of a surrogate to help them have a baby (a woman who would carry and deliver the baby, but would not be the parent of the baby). This may be the case for same-sex male couples, or in the case of heterosexual couples if the female partner did not have a uterus, or had a medical condition that made it dangerous for her to carry a pregnancy. If this situation applies to you, your GP or fertility doctor can help provide you with information.