1. We are struggling to conceive. How long should we wait before we contact a fertility clinic?
There have been fantastic advances in reproductive medicine in recent years, including genetic disease screening, healthier approaches to IVF, and even artificially created sperm (from stem cells). More and more people can now benefit from assistance, but don’t jump the gun. We know that trying to become pregnant is very stressful, but the best way is still using mother nature. If after one year of trying you still cannot conceive, then you should seek counselling. Since it is a little tougher to become pregnant as you get older, if you are over 35 years old, we recommend seeing a specialist after six months.
2. What can cause female and male infertility?
Many different factors may contribute to fertility problems and complicate pregnancy. Some of these are elective, like having your tubes tied or a vasectomy. These procedures were specifically intended to prevent you from getting pregnant and will need to be circumvented or reversed.
For men, other issues may surround the actual ability to have sex (any reason the prevents the actual depositing of sperm in the vagina) and exposure to chemicals like tobacco, pesticides, and drugs which affects quantity and quality of sperm. Mostly we see patients whose male factors centre around the quality of sperm: how many are present, motility (how well they swim), abnormal sperm production due to genetic disease, overall health, undescended testes, and trauma. We see damage related to cancer and its treatment.
For women, many more issues may arise. Cancer and its treatment is a reoccurring cause. With that come other medical conditions like thyroid imbalance, delayed puberty, amenorrhea (lack of a period), eating disorders, and even excessive exercise. But more frequently we can categorize female factors into categories. Ovulation disorders affect how the ovaries mature and release eggs. Specific diseases like PCOS (Polycystic Ovary Syndrome) fall into this category. Fallopian tube issues arise when there is damage or blockage, usually from an inflammatory disease or STI, and the egg has a problem descending. Uterine issues involve the quality of the uterine environment, a delicate system necessary for an egg to be fertilised and sustain life. Common issues here may involve the uterine lining being abnormal, irregularly shaped cervix, or tumours (uterine fibroids). Endometriosis is an increasing contributing factor which is when the uterine lining grows abnormally or outside of the uterus. This can negatively affect all aspects of the reproductive system. Early menopause, or primary ovarian insufficiency is when the ovaries stop working, sometimes due to autoimmune diseases or toxins from smoking, drugs, or other medical treatments.
Another cause is vaginismus, when a fear or pain of sex makes penetration impossible through involuntary vaginal contraction. Age plays a factor since a woman’s fertility peaks much sooner than a man’s. Overall health is a big one, and can result in complications carrying a pregnancy to term. Weight is another big factor we see, since obesity can lower a woman’s fertility greatly.
3. What tests will I go through before my IVF treatment?
Ultimately this depends on what brought you in. But across the board you can expect the following: BMI (body mass index, including height and weight), vitals (blood pressure, temp, etc), blood tests, pregnancy tests (many patients come in already pregnant!), genetic tests (background, pre-disposition for disease or abnormalities), hormone tests (to ensure that your hormones are corresponding with your menstrual cycle), ultrasound (to inspect your follicles).
4. How does the process of IVF treatment work?
In Vitro Fertilization literally translates to ‘Fertilization in a tube’. Typically, we will start by controlled ovarian stimulation to mature more eggs than the normal one per month. This is done through a careful regiment of hormone injections or oral medications. We monitor your follicles as they mature using frequent ultrasounds. Once the follicles have reached a mature state, we will perform an egg retrieval which is a minor procedure during which your eggs are collected from the follicle. We introduce sperm to the best of the mature eggs for fertilization in a petri dish in the lab. The lab then monitors the initial development of the embryo (a fertilized egg) and when it’s ready, the embryo will then be transferred back to your uterus. At that time you will take additional medicine to prepare your uterus to receive and hold the egg. Once the embryo transfer is completed, you will be monitored and tested for pregnancy.
5. Is mini-IVF™ safer than conventional IVF?
I hesitate to say it’s safer because that implies that conventional IVF isn’t. They are different protocols designed to attain similar results. Mini-IVF™ is the New Hope Fertility Center’s trademarked protocol. It is gentler on the body due to less medication. IVF medications carry their own risk, for example, of overstimulation of the ovaries. Mini-IVF™ reduces this risk greatly. Many centres still transfer multiple embryos in the hope that one will implant and develop. We practice transferring only a single embryo to avoid the risk of having multiple births (twins). This has to do with the transfer itself, not IVF. Egg retrievals and transfers, present in all forms of IVF, carry minimal risk. Miscarriage is a risk with IVF. But frequently there are mitigating factors and nothing that couldn’t happen naturally as well. IVF, allows us the opportunity to do genetic screening and select the best embryos in order to avoid common causes of miscarriage. Birth defects that have been associated with IVF can be both screened out during your cycle and incidence lessened with lower medication levels. Nowadays IVF is considered safe for you and the baby. In general, the largest risk is financial stress, and Mini IVF™ is less expensive overall than conventional treatments. It is also the best way for women with diminished ovarian reserves to become pregnant.
6. How likely am I to get pregnant after IVF treatment?
This varies from fertility centre to fertility centre, doctor to doctor, and technique to technique. Mini-IVF™ has just been proven to be equally successful as conventional IVF, completely eliminating Ovarian Hyper-Stimulation Syndrome, and reduces the multiple pregnancy rate. Success also is dictated by your age, overall health, life style, and your partner. We have seen that success rates drop as your age increases. Also, using a donor egg in many circumstances increases your success rates. For UK clinics you can visit: www.hfea.gov.uk/, for the USA you may visit: www.sart.org
7. What other options could I consider?
There are several options available depending on the cause of your fertility troubles. You can start with IUI (intrauterine insemination). Sometimes this is all the help that you need. Then there are the various forms of IVF: Conventional, Mini-IVF™, Natural IVF, Ultra-Mini IVF™. Other options fall under these categories. With each type of IVF you need to decide if you are doing a fresh embryo transfer or a frozen embryo transfer. You might have retrieved 22 eggs. What do you do with the remainder of eggs or embryos while you go through your treatments? Freezing them allows you to try repeatedly. Your egg or a donor egg? Your partner’s sperm or donor sperm? You carrying the baby or a surrogate carrying the baby? Many of these decisions come down to cost and availability. Once your egg and sperm get into the lab setting, other options to consider are genetic screening (looking for genetic markers that alert us of chromosomal abnormalities, diseases, or other conditions that complicate pregnancies). Also gender selection might be available to you, allowing you to choose a boy or a girl. We try to stay away from anything that can be construed as a ‘designer baby’ meaning we won’t let you choose hair colour, eye colour, height, etc.
8. I may have to use donated eggs or sperm in my treatment – what are the rules about this?
The rules vary country to country, sometimes city to city even. The best thing to do is to cross that bridge when you need to and rely on the guidance of your doctor for suggestions. Egg donation is totally legal in the USA and government regulated. Many women in the UK are finding it better to travel overseas for treatment, and New York is one of the leading cities in the world for medical tourism. If you are planning on this, try to set up a phone consultation first. You might be able to work remotely with a dr for most of your treatment, and travel minimally. Also, we suggest being very careful about your source of donated eggs. Many places are putting restrictions on UK eggs for women who lived through specific times when there were medical scares, like Mad Cow Disease. Consider the source of your egg carefully. Also consider what country it was donated in and what country you are receiving it from. Places like Thailand might be very inexpensive, but they may lack the government oversight that ensures the eggs are disease free and genetically healthy.
9. What is Vitrification (cryopreservation)?
Vitrification is the newest technology in tissue freezing. Brought to popularity in America by Dr John Zhang, this is a ‘flash freezing’ process where tissue is submerged in liquid nitrogen to arrest development and preserve the tissue. This technique prevents the formation of ice crystals which can damage an egg, sperm, embryo, or ovarian tissue. We freeze eggs at a temperature of -196˚ C almost instantaneously. We use cryoprotectants to dehydrate the tissue, helping to prevent those harmful ice crystals from forming. Using vitrification, we can store tissue indefinitely with no side effects upon thawing. Egg freezing is an option for women who wish to preserve their fertility at an age when their eggs are most viable. We can preserve your fertility in advance of cancer treatments like chemotherapy which may adversely impact your ovaries or testes. In adolescents (and adults as well), we can remove part of, or all of an ovary in preparation of medical treatments, and implant it later when they are ready to start a family of their own. When considering a clinic to do freezing with, make sure you work with one that not only performs vitrification, but one that has a track record of successful live births from their own frozen eggs. Most women freeze for an average of five years. Take the time frozen +1 year to get pregnant +9 months to carry to term = roughly seven years of egg freezing experience. This is a good metric to rate fertility clinic’s experience with this relatively new technique.
Dr John Zhang, MD, PhD, MSc, Medical Director at New Hope Fertility Center
