Treatment Options
Self-Help
Couples should aim to have regular intercourse every 2 to 3 days throughout the menstrual cycle. Self-ovulation monitoring is expensive and has not been demonstrated to significantly improve the chance of pregnancy. It is therefore probably not necessary. Couples who use these kits often report high levels of stress around the time of ovulation, which is probably counterproductive.
Smoking can drastically reduce the chance of conception. Both partners should avoid smoking and drink in moderation. Reduce caffeine in the diet is also recommended. Eat well and aim for a healthy weight. Ideally the woman’s body mass index (BMI) should be between 20 and 25 (BMI = W / H2, where W is weight in Kg and H is height in meters).
Women should take folic acid before trying for a pregnancy to reduce the chance of a spinal problem in the baby (spina bifida and other neural tube defects). Women should also be immunised against Rubella before starting treatment.
Conventional Treatment
One in seven couples will need help in having a child. Your specialist will arrange various tests to look for the underlying cause of your fertility problem. In some cases the solution may be simple and just require a change in lifestyle or body weight. Other couples may require drugs to correct anovulation (absence of ovulation). Some problems will require ‘high tech’ assisted reproductive techniques (ART) or surgery.
At first, a detailed medical history will be taken from both partners. The female partner will have a blood test to check ovulation. If indicated, a more detailed hormone profile will be performed. Immunity to rubella will also be checked. Immunisation will be offered if necessary, before starting treatment. Imaging of the pelvis with an ultrasound is often useful as a baseline investigation to assess the pelvic organs or if a specific problem such as polycystic ovaries or fibroids are suspected.
The fallopian tubes and uterine cavity can be assessed as an outpatient by using either a special ultrasound technique (HyCoSy) or an x-ray known as a hysterosalpingogram (HSG). In both these tests, a contrast medium is passed into the uterus and its passage along the fallopian tubes is observed. In some women, diagnostic surgery, under a general anaesthetic, may be required to further investigate any abnormalities identified on the ultrasound scan or HSG. This may also be necessary if the woman has a history of painful periods, previous pelvic surgery or pelvic infection. At the time of diagnostic surgery, dye is passed through the fallopian tubes to assess whether the tubes are patent (dye test).
The male partner will have a semen analysis to assess the sperm. If the sperm count is very low, a blood test will be arranged in the male partner, to check the level of hormones. A karyotype blood test will be performed to check the chromosomes are normal and a screening test for cystic fibrosis may be suggested. If sperm are not seen in the semen analysis, it may be necessary to explore the testicles surgically to look for sperm, which can be used for treatment. If the problem is a blockage in the tubes which transport sperm from the testes to the penis, the chance of finding sperm with a surgical retrieval is around 80%. If there is testicular failure, the chances are less than 20%.
Treat the Underlying Cause
If an underlying cause is found it will be treated if possible. Weight loss or gain may be suggested. If ovulation is not occurring, it may be stimulated using drugs. In some cases it may be possible to repair damaged fallopian tubes.
For other patients, the assisted reproductive techniques (ART) of intra-uterine insemination (IUI) or in-vitro fertilisation (IVF) may be suggested. Intracytoplasmic sperm injection (ICSI) is used as an added step in IVF if the sperm count is extremely low to improve the chance of fertilisation occurring. If no sperm is found, insemination treatment with donor sperm may be considered.
Ovulation Induction
If a patient is suffering from irregular or absent periods, or is experiencing problems with ovulation, this procedure is normally recommended. The treatment uses hormones to stimulate the ovaries. The aim is to encourage the development and release of one to two eggs per menstrual cycle. It is most useful for women who normally do not ovulate every month.
Intrauterine Insemination (IUI)
This procedure is normally used when the cause of the infertility is a mild problem with the sperm (mild male factor). It can also be used in unexplained infertility. It is a relatively simple and painless procedure involving the introduction of a specially prepared sample of concentrated semen high up into the womb at the time of ovulation. Careful ultrasound monitoring is used to monitor the treatment. Fertilisation occurs naturally in the fallopian tube.
It is common practice to gently stimulate the ovaries with hormones to produce one or two eggs, to increase the chance of success (stimulated IUI). The risk of twins however is higher if stimulation is used, compared to natural IUI (20% compared with less than 1%). The pregnancy rates for IUI treatment depend on the cause of the infertility. In women under 38, the chance of achieving a pregnancy is around 12-15% for mild male factor infertility, but is less than 10% for unexplained infertility. Pregnancy rates are 1-2% lower if IUI if is performed in a natural cycle rather than a stimulated cycle.
Pregnancy rates are also lower in older women and in couples who have been trying for a long period of time. The rates quoted are 50% lower in women by 40 years of age and there is probably no benefit over attempting natural conception in women over 43 years of age. Generally it is also better to go straight to in vitro fertilization (IVF) treatment if the length of infertility is greater than three years duration. Your specialist will discuss your individual case in more detail with you.
In Vitro Fertilisation (IVF)
This procedure is normally used in where there is damage to the fallopian tubes, endometriosis, male infertility, unexplained infertility or in couples in whom there are multiple factors causing infertility. Stimulatory drugs are given to make the woman produce a larger number of eggs than usual. Egg development is monitored by ultrasound but instead of allowing ovulation to occur, the eggs are removed from the ovaries (egg collection). Egg collection is performed, by passing a needle though the vagina, under sedation or general anaesthetic using ultrasound guidance. The man usually produces a semen sample on the day of egg collection. The fresh semen is then processed in the laboratory to select the higher quality sperm. These are then mixed with the eggs. In this treatment, sperm and eggs are mixed outside the body, in a test tube, in order to achieve fertilisation. Hence the term ‘test tube baby’.
The following day the eggs are checked for evidence of fertilisation. The resulting embryos (fertilised eggs) are then grown in the laboratory for a period of 2 to 5 days. In the UK one embryo or two embryos, are placed in the woman's uterus. The pregnancy rates do vary from clinic to clinic and are dependant on the cause of the subfertility and the woman's age. The pregnancy rate is however only slightly improved by using one versus two embryos. The risk of twins, on the other hand, is much higher. It is less than one percent if one embryo is transferred and this rises to twenty percent if two embryos are transferred. There is currently a movement around the world, particularly in Europe and Australia, towards replacing only one embryo.
Some couples may have enough good embryos left over after transfer to consider freezing them in case future treatment is required. The pregnancy rates from ‘frozen’ IVF cycles are only slightly lower than with a ‘fresh’ IVF cycle. A frozen embryo transfer cycle is however much more straightforward. No stimulation of the ovaries is required and the risk of complications is lower.
Research is currently ongoing to confirm the best time to replace embryos in the womb after IVF. In a routine IVF or ICSI cycle, embryos that are 2-3 days old, composed of 2-8 cells each, are transferred to the womb. It is thought that transfer of embryos that have reached the ‘blastocyst’ stage, may increase the chance of pregnancy. Blastocysts are actively maturing embryos that have been grown in the laboratory for a longer period (up to 5 days).
In theory, this should permit the selection of the most robust embryos. Not all embryos will survive to this stage, so the process is only usually considered when a couple generate more than 6 embryos in a single treatment cycle. The other theoretical advantage is that embryos are placed in the womb at a more physiological stage of their development. When a pregnancy is conceived naturally, the egg is fertilised in the fallopian tube, and the resulting embryo divides many times as it is transported towards the womb. The first four days of development normally occur in the fallopian tube.
The composition of nutrients and growth factors available to the embryo are different in the fallopian tube than in the uterus. A naturally conceived embryo only usually enters the womb at the blastocyst stage. Thus IVF embryos that are transferred at the blastocyst stage of maturity should have a better chance of survival and implantation. When all embryos are grown to blastocyst stage, spare embryos after the embryo transfer, may still be frozen. However, a disadvantage of the treatment is that these more complex embryos are less likely to survive the freezing process than embryos frozen earlier at the 2-8 cell stage. Research is still ongoing and practice varies from clinic to clinic.
The Human Embryo and Fertilisation Authority (HFEA) strictly regulate all ART in the United Kingdom.
Intracytoplasmic Sperm Injection (ICSI)
This treatment is used for couples where the semen quality is poor and fertilisation is unlikely to occur with normal IVF. It is also the treatment required for men whose sperm is collected by surgical sperm retrieval (SSR). The ovarian stimulation and egg collection procedure are identical in couples having IVF and ICSI. In ICSI, however, the technique used in the laboratory to achieve fertilisation, involves injecting a single healthy sperm directly into each mature egg collected. The resulting embryos are transferred as in an IVF cycle. The average fertilisation and pregnancy rates using ICSI are as good as those achieved in routine IVF.Sperm Donation
This procedure is recommended for men who have an untreatable condition causing an absence of sperm in their semen (azoospermia), or a genetic disorder they do not want to pass onto their children. The donor is usually anonymous at the time of treatment. However, a recent change in the law in the UK will allow offspring to trace the donor. Donor sperm is also used for female couples, and single women wishing to conceive. Counselling is recommended for anyone considering treatment with donor sperm.
Egg Donation
Egg donation is used in woman with premature ovarian failure, poor egg quality or persistent failure with IVF treatment. It may also be used where the mother has an inherited condition she does not want to pass on to her children. Donated eggs can be used for both IVF and ICSI treatments. The donor is stimulated to produce a number of eggs with ultrasound monitoring and undergoes an egg collection in the same way as a patient undergoing routine IVF. Meanwhile, the recipient is given drugs to promote the growth of the endometrium so it is ready to receive embryos. The donated eggs are fertilised using sperm from the recipient’s partner. Embryos are replaced inside the womb in the usual way.
Although most egg donors remain anonymous, known donation may be permitted after counselling of the parties involved. Potential donors are matched as closely as possible with the recipient couple. Characteristics such as height, race, hair and eye colour are routinely considered.
Counselling
Fertility treatment can affect couples emotionally and in some cases financially. Support and understanding may be needed for both partners during this difficult time. To help couples, most clinics offer counselling. Some couples also find joining a support group helpful.
