Infertility treatment options

Types of treatment available include Ovulation Induction, Intrauterine Insemination or IVF treatment.

In Vitro Fertilisation – IVF

IVF treatment involves the stimulation of the ovaries to produce a good number of follicles (6-12) within the ovaries that hopefully contain eggs. The eggs are collected and fertilised in the laboratory and embryos are replaced between 2 and 5 days later.

IVF treatment is a much more advanced and complicated treatment. The treatment itself involves taking a number of injectable drugs that are designed to suppress natural ovulation but induce multiple egg production. Treatment for IVF can take anywhere between 3 to 5 weeks depending upon the type of stimulation protocol chosen.

IVF treatment is suitable for most types of infertility problems but where there are severe male factor problems associated with very poor sperm parameters, once eggs have been obtained, the sperm is then injected into the egg in a process known as intracytoplasmic sperm injection (ICSI) to aid fertilisation.

Ovulation Induction

In those women who do not ovulate on a regular basis or do not ovulate at all, ovulation induction is achieved either using a mild fertility drug known as Clomiphene or in some instances injectable drugs known as Gonadotrophin. Clomiphene is a tablet taken from the 2nd to the 6th day of a bleed and will induce ovulation in most women. Some women will however not respond to Clomiphene and will require injections for induction of ovulation.

When Clomiphene is used a scan is performed usually on approximately day 10 of the cycle to ensure that ovulation is going to occur and to exclude over stimulation of the ovaries. If ovulation has occurred with one or two of the follicles within the ovary then Clomiphene can be taken subsequently without the need of the scan. If injectable drugs are required for the ovulation induction, scanning is always necessary as there is an increased risk of over stimulation of the ovaries. The particular type of treatment required will obviously depend upon the individual needs of the woman.

Intrauterine Insemination

Intrauterine Insemination is a form of assisted conception used for the treatment of women who do not ovulate in conjunction with ovulation induction, where there is very mild male factor sperm problems and in those couples with unexplained infertility. It is necessary to have proven tubal patency in at least one tube in order for intrauterine insemination to be performed. This treatment involves obtaining a sperm sample at the time of ovulation and washing it to produce a small volume of highly motile sperm, which is then placed high inside the uterus by means of a small catheter.

Egg Collection

When ready to proceed with an egg collection, a ‘trigger’ injection is given. The timing of this is very specific so that the eggs are collected at the correct time. The trigger injection is given 35-37 hours before the eggs are collected and is always given in the evening.

Your partner will be asked to produce a sperm sample on the day for fertilisation of the eggs. You should refrain from intercourse 72 hours prior to the day of egg collection to maximise the quality of the sperm. It is, however, important to have ejaculated 72 hours prior to the egg collection as a prolonged abstinence can also decrease the quality of the sperm.

Egg Freezing

There is increasingly good evidence that pregnancy rates using frozen/thawed eggs are similar to pregnancy rates using fresh eggs in young women and egg freezing has become a viable option for women who wish to preserve their reproductive potential.

Many women, for social, educational and financial reasons, often delay starting a family until their late thirties by which time the chance of conceiving is reduced and they can find themselves with sub-fertility problems. It is well known that egg quality and quantity diminish as women get older and the success rates for pregnancy even from IVF treatment declines.

Egg freezing offers women the potential to freeze eggs at a time when such an intervention has a good chance of leading to a live birth, which is ideally at less than 35 years. However, whilst live birth rates from egg freezing decline with age, live birth rates have been recorded to occur as late as 42 from frozen eggs.

Clinical pregnancy rates are approximately 35% (dependent on the age of the women at the time of freezing. This will be lower for women more than 35years old).

There are no reported increased risks in chromosomal abnormalities, birth defects and developmental problems in children born as a result of egg freezing compared to the general population.

The Egg Freezing Process:

An egg freezing treatment cycle starts exactly the same way as an IVF treatment cycle. It requires the woman to take daily injections to stimulate the ovaries to produce a ‘good number’ of eggs. The number of eggs produced will depend upon the age of the woman and her ovarian reserve and the dose of drugs used for stimulation will be adjusted accordingly.

The stimulation process usually takes 12 to 14 days during which time 2 to 3 scans are required to assess the ovaries. An egg collection is performed on approximately days 14 to16 of the treatment and is performed under sedation and takes approximately 30 minutes to perform. The eggs are assessed in the laboratory and those eggs of correct maturity are frozen using a technique known as vitrification.

The treatment can cause mild bloating but this usually settles within 5 days of the egg collection. Risks such as ovarian hyperstimulation syndrome seen in women undertaking IVF treatment is extremely low as embryos are not being replaced.

Tests

  • Prior to undertaking treatment a pelvic ultrasound is required to view the ovaries and check the antral follicle count which is used as an indicator of ovarian reserve. The accessibility of the ovaries to the egg collection process is also assessed.
  • Ovarian reserve is also assessed by an AMH test which is a blood test and can be taken at any time in the menstrual cycle.
  • Blood is also taken for screening for Hepatitis B surface antigen, Hepatitis B core antibody, HIV and Hepatitis C.

Egg Donation

Some women unfortunately undergo premature ovarian failure and require the use of egg donation in order to conceive. Other women may consider egg donation if they have responded very poorly to IVF treatment, only producing very small numbers of eggs.

There are very few ‘anonymous’ egg donors within the UK and many women will need to find their own donor for treatment or may consider going abroad for their treatment.

Embryo Transfer

How many embryos to transfer?

The HFEA have stipulated that in the UK, three embryos can be transferred in women who are 40 years or older. In women less than 40, only two embryos can be transferred and clinics should be encouraging women to have an elective single embryo transfer.

The reason behind this regulation is that a multiple pregnancy is a high risk pregnancy and it is better and safer for both the woman and the baby if the woman conceives one baby at a time.

The literature has shown that in women over the age of 40 replacing two embryos instead of one will lead to an increase in the chance of achieving a pregnancy and that that pregnancy is most likely to be a singleton pregnancy. In women less than 40 and particularly less than 37, replacing two embryos in preference to one will not increase the chance of pregnancy but will increase the risk of a multiple pregnancy.

However, when deciding upon the number of embryos to transfer, the decision should take into account not only the age of the woman but also the quality of embryos and number of previous failed cycles. The decision on how may embryos to transfer can often not be made therefore, until the day of embryo transfer. Certainly there is evidence to suggest good pregnancy rates in older women where good quality elective single blastocysts are transferred.

ICSI (IntraCytoplasmic Sperm Injection)

ICSI is the preferred choice for fertilisation of eggs where:

  • there has been previous failed fertilisation (seen in approximately 1% of IVF cycles)
  • there have been poor fertilisation rates (< 25% of mature eggs fertilised)
  • where the sperm parameters are poor (low sperm count, poor motility, low numbers of normal forms)
  • where sperm is surgically retrieved from the epididymis or testes

You will, of course, be advised if ICSI is required.

Occasionally, the sperm quality on the day of egg collection is suboptimal for IVF and the embryologist from the laboratory will recommend ICSI but only if it is considered really necessary.

Patient Information Sheets

Nuada Gynaecology makes Patient Information Sheets available to assist patients in understanding their condition and treatment in general. We recommend that patients consult with their specialist to fully appreciate their own personal programme of care.

*All files are in pdf file format and open in a new window.

More information & further reading

Clinical evaluation of three different gonadotrophin releasing hormone analogues in an IVF programme: a prospective study.
El-Nemr A, Bhide M, Khalifa Y, Al-Mizyen E, Gillott C, Lower AM, Al-Shawaf T, Grudzinskas, JG – 2002
http://www.ncbi.nlm.nih.gov/pubmed/12069736

Laparoscopic management of pregnancies occurring in non-communicating accessory uterine horns. 2004
Alfred Cutner, Ertan Saridogan, Roger Hart, Pranav Pandya, Sarah Creighton
http://www.sciencedirect.com/science/article/pii/S0301211503004664

Uterine adherence to anterior abdominal wall after caesarean section
l-Shawarby S, Salim R, Lavery S, Saridogan E. 2011
http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.02965.x/full

Controlled ovarian hyperstimulation for low responders in in vitro fertilization/intracytoplasmic sperm injection: a low-dose flare protocol
Datta A, Vitthala S, Tozer A, Zosmer A, Sabatini L, Davis C, Al-Shawaf T. 2011
http://www.sciencedirect.com/science/article/pii/S0015028210028517

Successful pregnancy and delivery following IVF treatment in a patient with endometrial polyp diagnosed by saline infusion sonohysterography at oocyte retrieval.
Kassab A, Zosmer A, Gillott C, Tozer A, Al-Shawaf T. 2007
http://bioline.org.br/request?mf07012