For couples who have been trying to conceive for more than three years without success, the likelihood of pregnancy occurring within the next year is 25% or less.

Deciding to seek help

It is a good idea for a couple to visit their GP if they have not conceived after one year of trying.

Women over the age of 35, and anyone who is already aware they may have fertility problems, should see their GP sooner. The GP can check for common causes of fertility problems, and suggest treatments that could help.

A couple will only be diagnosed as being infertile if they have not managed to have a baby after two years of trying.

There are two types of infertility:

Primary infertility: where someone who has never conceived a child in the past has difficulty conceiving

Secondary infertility: where a person has had one or more pregnancies in the past, but is having difficulty conceiving again

The treatment offered will depend on what is causing the fertility problems and what is available from your Primary Care Trust.

Some couples consider private treatment. This can be expensive and there is no guarantee it will be successful.

It is important to choose a private clinic carefully. Ask your GP for advice, and make sure you choose a clinic that is licensed by the Human Fertilisation and Embryology Authority (HFEA).

CAUSES

Infertility can be caused by many different things. In 25-30% of cases, a cause cannot be identified.

Infertility in women

Ovulation disorders

Problems with ovulation (the monthly release of an egg) are one of the most common causes. Some women  stop releasing eggs at all and while others ovulate in some cycles only.

Ovulation problems can occur as a result of a number of conditions:

·         Polycystic ovary syndrome (PCOS) - a condition that makes it more difficult for the ovaries to produce an egg.

·         Thyroid problems, both an overactive thyroid gland (hyperthyroidism) and an underactive thyroid gland (hypothyroidism) can prevent ovulation.

·         Premature ovarian failure where a woman’s ovaries stop working before she is 40.

Womb and fallopian tubes

If either of these parts of the reproductive system are damaged it may be difficult to conceive naturally. This can occur following a number of factors:

·         pelvic surgery can sometimes cause damage and scarring to the fallopian tubes.

·         Cervical surgery can also sometimes cause scarring of the neck of the womb.

·         Cervical mucus defect - when ovulating, mucus in the cervix becomes thinner so that sperm can swim through it more easily. If there is a problem with the mucus, it can make it harder to conceive.

·         Fibroids - benign (non-cancerous) tumours that grow in, or around, the womb. Fibroids can reduce fertility, although exactly how they do this is not yet known.

·         Endometriosis - where small pieces of the womb lining start growing in other places, such as the ovaries. These new tissue growths can block or distort the pelvis. These make it difficult for an egg to be released and become implanted into the womb. Endometriosis can disturb the way that a follicle (fluid-filled space in which an egg develops) matures and releases an egg.

·         Pelvic inflammatory disease - an infection of the upper female genital tract, which includes the womb, fallopian tubes and ovaries. It is often the result of a sexually transmitted infection (STI). PID can damage and scar the fallopian tubes, making it difficult for an egg to travel down into the womb.

·         Sterilisation - this process is rarely reversible, and if you do have a sterilisation reversed, it will not necessarily mean that you will become fertile again.

Medicines and drugs

The side effects of some types of medication and drugs can affect your fertility.

·         Non-steroidal anti-inflammatory drugs (NSAIDs). Long-term use, or a high dosage, of NSAIDs, such as ibuprofen or aspirin, can make it more difficult to conceive.

·         Chemotherapy – can sometimes cause ovarian failure, which means the ovaries will no longer be able to function properly. Ovarian failure can be permanent.

·         Neuroleptic medicines are antipsychotic medicines often used to treat psychosis. They can sometimes cause missed periods or infertility.

·         Illegal drugs such as marijuana and cocaine can seriously affect fertility, making ovulation (the monthly cycle where an egg is released from the ovaries) more difficult.

Age

The biggest decrease in fertility begins naturally during a woman’s mid thirties. Among women who are 35, 95% will get pregnant after three years of having regular unprotected sex. For women who are 38, only 75% will get pregnant after three years of having regular unprotected sex.

Infertility in men

Semen

Male infertility is caused by abnormal semen (the fluid containing sperm that is ejaculated during sex). Some possible reasons for abnormal semen:

·         Decreased number of sperm

·         Decreased sperm mobility

·         Abnormal sperm structure

Many cases of abnormal semen are unexplained, but there are several factors that can affect semen and sperm:

Testicles

If the testicles are damaged it can seriously affect the quality of semen. This may occur if the male has had:

·         a testicle infection

·         testicular cancer

·         testicular surgery

·         congenital defect (a problem from birth)

·         undescended testicles

·         trauma to testicles

Absence of sperm

The absence of sperm in semen is known as obstructive azoospermia. This could be due to a blockage in one of the tiny tubes that make up the male reproductive system, which may have been caused by an infection or surgery.

Sterilisation

A vasectomy is the surgical procedure for male sterilisation. A vasectomy can be reversed, but reversals are not usually successful.

Ejaculation disorders

Some men experience ejaculation problems that can make it difficult for them to ejaculate. Ejaculation problems include:

·         retrograde ejaculation - semen is ejaculated into the bladder

·         premature ejaculation - ejaculation occurs too quickly

Hypogonadism

This is an abnormally low level of testosterone, the male sex hormone that is involved in making sperm. This could be due to a tumour, taking illegal drugs or a rare genetic disorder.

Medicines and drugs

Certain types of medicines can sometimes cause infertility problems in men:

·         Sulfasalazine -an anti-inflammatory medicine

·         Anabolic steroids – long-term use or abuse can reduce sperm count and sperm mobility.

·         Chemotherapy

·         Herbal remedies – root extracts of Tripterygium wilfordii (a Chinese herb), can affect the production of sperm or reduce the size of testicles.

·         Alcohol – drinking more than three to four units of alcohol a day could make it difficult to conceive.

Infertility in both men and women

There are a number of factors that can affect fertility in both men and women.

·         Weight - being overweight, or obese, reduces both male and female fertility. In women, being overweight can affect ovulation. Being underweight can also have an impact on fertility, particularly for women, who will not ovulate if they are severely underweight.

·         Sexually transmitted infections (STIs)- chlamydia can damage the fallopian tubes in women, and cause swelling and tenderness of the scrotum (the pouch containing the testes) in men.

·         Smoking

·         Occupational and environmental factors - exposure to certain pesticides, metals, and solvents can affect fertility in both men and women.

·         Stress - may affect your relationship. Stress can contribute to a loss of sex drive, which in turn can reduce the frequency of sexual intercourse. Severe stress may also affect female ovulation and limit sperm production.

DIAGNOSIS

Fertility testing and investigation can be complex and takes time. Your GP will be able to carry out an initial assessment to investigate factors that may be causing fertility problems.

It is always best for both partners to visit their GP because fertility problems can affect a man or a woman and sometimes both partners.

Your GP, they will want to discuss your full medical, sexual and social history to help them identify what may be causing fertility problems.

After taking a history, your GP may carry out a physical examination, or refer you for tests. Your GP may:

·         Check your body mass index (BMI)

·         examine your pelvic area, to check for infection, lumps or tenderness, which could be an indication of fibroids, ovarian tumours, endometriosis, or pelvic inflammatory disease (PID) (see causes of infertility)

You may be referred to a specialist infertility team at an NHS hospital or fertility clinic for further tests and procedures:

Specialist tests for women

Progesterone test

To establish whether the woman is ovulating. The test is taken seven days before the period is expected to start.

Hormone tests

If the periods are irregular, the level of follicle-stimulating hormone (FSH) and luteinising hormone in the blood may be tested along with thyroid hormone, prolactin and testosterone.

Chlamydia test

A swab of the cervix is used to test for chlamydia. Chlamydia is treated by prescribed antibiotics.

Thyroid function test

1.3% and 5.1% of infertile women have an abnormal thyroid gland.

Hysterosalpingogram

This is a type of X-ray taken of the womb (uterus) and fallopian tubes after a special dye has been injected. This will outline the cavity of the womb and detect any blockage of the fallopian tubes.

Hysterosalpingo-contrast-ultrasonography

This is a type of ultrasound scan. A small amount of fluid will be injected into the womb through a tube that is put into the cervix (the womb opening). Ultrasound is used to confirm whether fluid passes through the tubes.

Laparoscopy

A thin, tubular telescope is used to look more closely at the womb, fallopian tubes and ovaries. Dye may be injected into the tubes through the cervix in order to highlight any blockages. A laparoscopy is usually only used if there is a strong chance that there is a problem, for example, if there has been an episode of PID in the past.

Examination and tests for men

The GP may examine the genitals.

Further testing may include:

·         semen analysis –to determine sperm count, sperm mobility, or detect abnormal sperm

·         chlamydia test – a sample of urine will be tested

TREATMENT

This will depend on the underlying cause and what is available from your primary care trust (PCT).

Fertility treatment funded by the NHS varies across the UK.  All patients have the right to be referred to an NHS clinic for the initial investigation.

If you have an infertility problem, you may wish to consider private treatment. This can be expensive and there is no guarantee of success.

You should find out which treatments are offered, the success rates of treatments, the length of the waiting list and the costs. Ask for a personalised, fully costed treatment plan that explains exactly what is included, such as fees, scans and any necessary medication.

If you decide to go private, you can ask your GP for advice, and make sure you choose a clinic licensed by the Human Fertilisation and Embryology Authority (HFEA). The HFEA is a government organisation that regulates and inspects all UK clinics that provide fertility treatment, including the storage of eggs, sperm, or embryos.

There are three main types of fertility treatment:

·         medicines to assist fertility

·         surgical procedures

·         assisted conception

Medicines to assist fertility

These are usually prescribed for women although, in some cases, they may also be prescribed for men.

·         Clomifene  - to encourage ovulation

·         Tamoxifen  - alternative to clomifene that may be offered to women with ovulation problems.

·         Metformin  - beneficial for women with polycystic ovary syndrome (PCOS).

·         Gonadotrophins - can help to stimulate ovulation in women, and may also improve fertility in men.

·         Gonadotrophin-releasing hormone and dopamine agonists - may encourage ovulation in women.

Surgical procedures

·         Fallopian tube surgery – if the tubes are blocked or damaged surgery may be necessary.

·         Laparoscopic surgery  - for endometriosis, fibroids and in some women with PCOS if ovulation medication has not worked.

·         Correction of any blockages in the epididymis in men and surgical extraction of sperm.

Assisted conception

Intrauterine insemination (IUI)

Intrauterine insemination (IUI) involves sperm being placed into the womb through a fine plastic tube.

Sperm is collected and washed in a fluid and then passed through a tube that enters the cervix and extends into the womb. This is performed to time with ovulation in order to increase the chance of conception. The woman may also be given a low dose of an ovary stimulating hormone to increase the likelihood of conception.

IUI tends to be used when infertility cannot be explained. IUI is also used if the man has a low sperm count, decreased sperm mobility, erectile dysfunction or premature ejaculation.

IUI can be used if the woman has mild endometriosis

The success rate for IUI in women under 35 is around 15% for each cycle of treatment.

In-vitro fertilisation (IVF)

During IVF the fertilisation of the egg occurs outside the body. The woman takes fertility medication to encourage her ovaries to produce more eggs than normal. Eggs are then removed from her ovaries and fertilised with sperm in a laboratory dish. A fertilised embryo is then put back inside the woman's body.

There are several different methods that can be used during IVF and intracytoplasmic sperm injection (ICSI). You can read more information about these, and other, fertility procedures on the Human Fertilisation and Embryology Authority website.

The success rate for a cycle of IVF is 29% for women under 35 years of age. The success rate decreases as the woman’s age increases.

Egg and sperm donation

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.

Anyone who registered to donate either eggs or sperm after 1 April 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 upon reaching the age of 18.

COMPLICATIONS

Medication side effects

·         nausea

·         vomiting

·         diarrhoea

·         stomach pains

·         headaches

·         hot flushes

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) can occur after taking medicines that stimulate the ovaries, such as clomifene and gonadtrophins, and can develop after a round of in-vitro fertilisation (IVF). OHSS causes your ovaries to swell and produce too many follicles (small fluid-filled sacs in which an egg develops).

Around one-third of women will experience mild OHSS after one cycle of IVF. Less than 10% will develop moderate or severe OHSS after one cycle of IVF.

Mild symptoms may include:

·         nausea

·         vomiting

·         abdominal pain

·         bloating

·         constipation (when you are unable to empty your bowels)

·         diarrhoea

·         dark, concentrated urine

Severe OHSS is a potentially life-threatening condition and can lead to:

·         thrombosis (a blood clot in an artery or vein)

·         liver and kidney dysfunction

·         respiratory distress (difficulty breathing)

You should seek medical attention immediately if you experience any of the symptoms of OSHH.

You may need to go to hospital so your condition can be monitored and treated by healthcare professionals.

Ectopic pregnancy

 An ectopic pregnancy occurs when the fertilised egg implants outside your womb. If a fertilised egg implants itself in the fallopian tube and continues to grow, it can result in a miscarriage, and there is a risk of the tube bursting.

If you are receiving fertility treatment, your chance of having an ectopic pregnancy is around 4%. This is higher than the usual rate of ectopic pregnancies, which is around 1%. You may be more likely to have an ectopic pregnancy if you have already had problems with your fallopian tubes.

Pelvic infection

Infection can occur following the procedure used to extract an egg from the ovary. However, the risk of serious infection is very low.

Multiple pregnancy

Having more than one baby significantly increases the risk of developing complications for both mother and babies. Multiple pregnancy is the greatest health risk of fertility treatment.

Possible complications include:

·         Premature birth and low birth weights

·         The babies dying within the first week of life is five times higher for twins, and nine times higher for triplets

·         Cerebral palsy (impacts on brain and nervous system) – there is a five times higher risk for twins and 18 times higher for triplets than for single babies.

·         High blood pressure (hypertension) during pregnancy – this occurs in 25% of women who are carrying more than one baby.

·         Diabetes of the mother during the pregnancy – the risk is two to three times higher for women carrying more than one baby than it is for those carrying a single baby.

In the UK, one in four births after IVF results in twins or triplets. This is higher than the usual rate of multiple pregnancy, which is around 1 in 80 births.

Stress

Infertility can be stressful and cause significant strain in relationships. Support groups can be helpful and many couples find it helpful to talk to a counsellor. Your GP should be able to refer you to a counsellor as part of your fertility treatment.

PREVENTION

For some, adopting a healthier lifestyle through simple lifestyle changes, or staying up to date with regular health checks and tests, may help to prevent infertility.

Weight

Therefore ensuring you maintain a healthy weight will make it easier to conceive.  Women should aim for a body mass index (BMI) of 19–25 for the best chance of getting pregnant.

Men with a BMI over 29 may have reduced fertility, and your GP may recommend that you lose weight. Regular exercise and a healthy diet can help maintain a suitable weight.

Diet

A nutritious, balanced diet of at least five portions of fruit and vegetables a day is beneficial. Include carbohydrates such as wholemeal bread and pasta, and lean meat, fish, and pulses for protein. Green, leafy vegetables are high in folic acid, which can help prevent birth defects.

Stress

Stress can often affect fertility because it may lead to you having sex less frequently. For the best chance of becoming pregnant, you need to have sex every two to three days. Talk to your partner if you are feeling stressed and consider using counselling. Regular exercise in moderation may be helpful.

Medicines and drugs

Illegal drugs such as marijuana or cocaine can affect fertility, and can seriously damage the development of your baby if you fall pregnant. You should therefore avoid using them.

You should also avoid using some prescription medicines if you are trying to get pregnant. Ask your GP for further advice.

Health checks and tests for women

Make sure you are up-to-date with your cervical screening tests (smear tests). You should also visit your local sexual health clinic (GUM clinic) to make sure you do not have any sexually transmitted infections. Infections such as chlamydia may not have symptoms but can cause infertility.

If you would like to tell us your story so we can help and inform other women; there is more infromation available HERE

This interview was recorded in April 2010.

 

IVF: Text Version

Hi there, today we are here to discuss IVF. IVF is a subject frequently reported about in the press and seems to cause a great deal of controversy and confusion. We are here today to clear up some of these myths by speaking to Mr. Stuart Lavery, consultant gynaecologist and specialist in reproductive medicine and surgery at Hammersmith and Queen Charlotte’s and Chelsea Hospital, London.

Hello Stuart and thank you very much for joining us today.

Hi, good morning.

Can I start by asking you at what point you would recommend couples actually start to think about IVF?

It really depends on the individual circumstances of the particular couple. There are all sorts of reasons why people may have difficulty conceiving, and IVF is only one of the potential solutions. Normally we recommend people should consult their doctor if they have been trying regularly for at least a year and if conception hasn’t happened, then it is sensible to seek some advice to see how things need to be looked into. That doesn’t automatically mean you need to be instantly signing up for IVF, because there are all sorts of things that can be done to improve you chances of things happening naturally. Sometimes there may be specific things that have happened to you in the past such as abdominal surgery, problems with your ovaries, irregular periods, and if anything like that has happened it may be sensible to seek medical advice earlier.

Is there a long waiting process for IVF?

It really depends whereabouts you live in the country. NHS provision for IVF has actually been one of the big good news stories about funding recently, and funding is now much more widespread and access to that funding is much quicker for couples. In our own clinic at Hammersmith we have increased our NHS provision of IVF by over 100% and waiting times are now in the region of about 12 weeks. So although this is not ideal this is a significant improvement on how waiting lists were until quite recently.

How would you suggest a couple goes about choosing the right clinic?

This is a very difficult question. There are all sorts of important issues that couples should take into account. One of them should be geography – you don’t want to have to travel too far for your clinic, you want a clinic that is reasonably accessible. The reputation of the clinic is important, what are the results like and what do patients and professionals feel about the clinic. Many clinics may have extremely good reputations but may not necessarily come near the top of the league table, because they will often take on patients who are more challenging and who have a lower expectation of success. So the opinion of your GP will be important and the opinion of friends and colleagues will be important. Then there are certain intangibles when you visit a clinic - whether you feel comfortable and confident in the environment and with the professionals you are dealing with.

Are there any tests you must have to make sure that IVF is needed?

Yes and important accurate diagnostic tests are really important. The reason for that is that IVF may not be the most sensible option; these tests will also give you an idea about an accurate expectation of your success. This is important to know upfront because there are massively varying expectations of success depending on your own particular circumstances and the clinic you may visit. The sort of test that would be standard would be an investigation on the female side of hormonal status. This would look into issues about ovarian reserve, so how many eggs you still have left. Issues about whether you are ovulating regularly and then checks of your anatomy such as an ultrasound scan to look at your ovaries and your uterus, and a test of your fallopian tubes to make sure your tubes are not blocked, this is usually called an HSG although there are some other alternatives. On the male side a good and accurate semen analysis is important to see what contribution the male factor may be making.

Once a woman has decided on IVF how long will the process take?

Again this will vary according to where she lives in the country. For most centres access to NHS IVF care is within 18 weeks, if a patient is having a treatment privately then really there shouldn’t be any waiting list. She may be able to embark on treatment with her next period, following all of the investigations.

What can women do to prepare for the process and continue to do throughout the treatment?

There are several things you can do to try and optimise your chances of IVF working. It is important that women are on folic acid supplementation, as this is very important for embryonic development. There are certain lifestyle factors that can be addressed; smoking will significantly reduce the chances of success from IVF both on the male and the female side, so stopping smoking is absolutely critical. The role of alcohol and caffeine intake is a little bit more controversial, some people will recommend complete abstention from alcohol and coffee, and other people will just recommend that these things are only taken in moderation. A persons weight is also important, if you can get your Body mass index down to less than 30kg per square metre, this is also associated with both safer treatment and more effective treatment.

What types of diseases in women can cause problems in fertility?

The main problems that we tend to see in this country, are problems with ovulation, so the issue where a woman may have eggs but she may not be releasing them in a regular or predictable fashion. Some people will also have blocked fallopian tubes and so they may be producing good quality eggs each month but the eggs and sperm may be blocked from meeting. In many situations there will be a mixed factor, so it will be partly male; there may be some problems with the sperm count, and also partially female and this accounts for an increasing proportion of patients.

Can a couple’s lifestyle help their fertility?

Yes, most importantly by how often and how frequently they have sex. It is amazing that we all live busy lifestyles in 2010 and it is sometimes amazing in the fertility clinic when couples address how frequently they are having intercourse and it’s not as often as they should. So there are certain lifestyle issues one can address in terms of how busy you are and how much time you give to each other, to enable you to have an active sex life around the time when the woman may be fertile. Other issues include modification of diet and then environmental influences such as alcohol and smoking.

What are the ideal conditions for IVF?

Ideally one needs to be as physically, mentally and emotionally prepared for it as possible. So you need to get yourself in good physical shape; having a good diet, you need your weight to be under control, you need to make sure that you have removed things from your environment such as smoking and excess alcohol intake. Then you need to realise this will be a stressful time consuming treatment and that you need to give enough time and space in your busy life to allow you to focus on this treatment. It will involve many trips to the clinic, it will be emotionally stressful, your hormones will be manipulated to a degree and therefore it is important you have some good support systems around you, to allow you to cope with the stresses of the treatment.

Could you outline the main stages of IVF treatment?

Initially a full and accurate series of investigations are needed, this will tell you first of all is IVF the sensible way forward? and may also indicate the type of IVF that you should have, because there are many variations of IVF, both in terms of the protocols, the treatment doses and the different ways that eggs can be fertilised. Most IVF treatments in the United Kingdom will last approximately six weeks. The first two weeks is dedicated to daily injections which shut a woman’s hormonal system down (essentially temporarily put the ovaries asleep) and during that time the woman may feel the hormonal side affects such as hot flushes or night sweats. The second two weeks consists of daily injections to stimulate the ovaries to grow and mature the eggs, and during that time the woman will need to attend the clinic on several occasions for monitoring, which will include blood tests and scans. When there are sufficient eggs that are mature, she will need to undergo a very minor operation to collect the eggs which is usually done through the vagina and a very fine needle is passed through the vagina into the ovaries and the eggs are aspirated. That morning the husband will give us a semen analysis and in the afternoon we will put the eggs and sperm together. Hopefully the two will be interested in each other and the next morning we will know whether any embryos have formed. These embryos are kept in culture for between two and five days, and then the best one, two or three embryos are transferred to the uterus.

What kind of difficulties can occur during an IVF cycle?

There are really hurdles to get over at every stage, it is not an easy treatment. Initially we need to see will the woman respond to the drugs, so will we be able to stimulate the ovaries and collect eggs. Then surgically, will we be able to find the eggs and successfully get them out of her body. We then need to make sure the eggs and sperm interact properly to give us embryos and then will those embryos grow and develop in the culture medium in the laboratory, before we put them back in the woman. The most difficult stage is that last phase when the embryos are put back into the woman’s uterus, because at the moment we don’t have a great understanding of what makes certain embryos stick and implant, and what makes other embryos fail to implant. This is the particular area of IVF which is the most common place for us to fail in 2010.

How long must they wait to find out if the treatment has been successful and the embryo has implanted?

Usually one will know about 12 days following the embryo transfer whether you are pregnant. This is usually done with a pregnancy test, either a urine test or a blood test and if you do have a positive blood test, we will do an ultrasound scan about 14 days later, and at that stage we should actually see a pregnancy sac and possibly a heart beat within the uterus.

If a pregnancy does not occur, how soon can the process be repeated?

This is quite variable. It is important to realise that the IVF puts a huge physiological stress on the body, the ovaries are swollen and enlarged, sometimes to six or seven times their normal size. If one goes in again with further treatment too quickly then the quality and the quantity of the eggs that will be collected will be compromised. So most units will recommend a two-three month break in between treatments.

Are there any particular complications or side affects a woman can experience whilst undergoing IVF?

Yes and these are important, this is treatment that is not risk free. Initially there will be some side affects from the drugs and that can be associated with feeling temporarily menopausal. So you may have hot flushes, night sweats, sleep disturbance and emotionally can be more of an up and down time. But perhaps the worst side affect that you can experience in IVF is the ovarian hyper stimulation syndrome. This is quite rare but quite serious, and it is where the woman’s body shows an excess response to the drugs that are given. So instead of producing a controlled number of eggs such as 8-12, the woman can produce between 20 or 30 eggs and she can become very unwell and require admission to hospital. So it is something that every IVF unit should be monitoring closely to try and prevent.

How high is the success rate? And does this differ for different ages and types of infertility?

It’s particularly sensitive to the age of the woman. All of the success rates are usually available on clinics websites and national data is collect by the HFEA, who collate this data and all clinics success rates are available to patients on the HFEA website. The biggest thing that determines them is female age and for patients who are relatively young; under the age of 35 are coming through for treatment, they can expect success rates of over 50% per attempt. As we get older then success rates decline rapidly, so by the time we reach 40 success rates are more down to in the region of 20%, and they fall even faster over the age of 40.

How high is the possibility for multiple births during IVF?

This is a very important issue and clinics and the HFEA are doing an enormous amount of work to try and reduce the risk of multiple pregnancy. Many patients are often quite happy to get pregnant with a twin pregnancy or even a triplet pregnancy but they may be unaware of the inherent dangers in multiple pregnancy; particularly in terms of increased risks of miscarriage or in terms of premature birth and babies being in intensive care units. So many units these days for young women in their first cycle will recommend that only one embryo is transferred and this has led to a massive reduction in the field of multiple pregnancy, particularly twins. Under the age of 40, we are no longer allowed to put 3 embryos back, and so we can only do that over the age of 40. So multiple pregnancy is a very important issue and it is something that must be very closely discussed between the couple and their doctors when the decision is made about how many embryos to return.

Is there a higher chance the baby will be born through birth defects with IVF?

There is quite a lot of data available now on IVF babies because of the amount of IVF babies that have been born. There does appear to be a very small increased risk of birth defects from babies born as a result of IVF. Most of those birth defects can be explained by the increased age of women undergoing IVF and also by the increased incident of multiple pregnancy in IVF. But even if one were to control for these two variables, so to only look at young women who had one baby on board, there still seems to be a very small increase in risk of problems to the baby. What we don’t yet know is, is that a result of the IVF procedure itself, so something technical related to putting the eggs and sperm in the laboratory or is it something intrinsic to that couples eggs and sperm, where nature has meant it has been quite difficult for them to reproduce and IVF may be forcing the issue by allowing them to become pregnant, or it could possibly be a combination of the two.

Are there age limits?

There are age limits on the NHS. Most people will allow you to have treatment on the NHS up until your 40th birthday. The chance of IVF working beyond the age of 44 is actually very remote. So even if you were a private patient, it is unusual to have treatment over the age of 44.

On the lower end are there restrictions?

Yes and we think this is slightly strange. Many health authorities will only fund treatment over the age of 23 and I have several patients who are 20/21 who are trying to conceive. For example there may be a problem with their husbands sperm so there is no way these women can get pregnant without IVF, but the health authority is making them wait until they are 23 until they have a baby, so that seems to be slightly unfair.

Is that private as well?

No, privately there would be no minimum age gap.

Can I ask what kind of research is being done around IVF? And how the research helps in the treatment of IVF?

IVF remains a very new treatment, even though we have been doing it for a few years we are still learning an enormous amount about the field. Most research at the moment is concentrating on the area of implantation. So that area where the embryos are returned to the uterus and the issues that make some embryos stick, latch-on and give a pregnancy and other embryos not implant. So people are looking at issues within the lining of the uterus to see whether there can be some factors that make a uterus more welcoming or more friendly to an embryo or equally more hostile. We can learn an enormous amount both about fertility and about miscarriage. The second area of research is looking at the embryo. At the moment the fact is that we used to judge whether an embryo is good quality by what it looks like and so if an embryo is growing quickly and has crisp nuclei we extrapolate that it is a good quality embryo, however the really important issues are the genetic and chromosomal make up of the embryo. So there are some very new tests available which allow us to examine the embryo or the egg from a genetic perspective and then only transfer the egg or the embryo into the uterus that’s deemed to be normal from a genetic point of view. These things are very exciting but they are very new and so we need to approach them very cautiously and not get swept away by our enthusiasm.

I’d just like to say thank you very much for joining us today, it has been a very useful discussion.

You are very welcome, thank you.

To find out about our research follow these links:
 

• Correlation of receptors to the outcome of IVF treatment

• Investigating the possibility of removing and freezing part of a woman’s ovaries prior to her having cancer treatment. Then re-implanting to help fertility.

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: www.rcog.org.uk/womens-health/patient-information

• Human Fertilisation and Embryology Authority: www.hefa.gov.uk/

• NHS Choices website also has a range of health information. This can be found at: www.nhs.uk