We have developed this fertility and IVF resource to supply you with all the latest information and answer you questions about fertility and IVF. If you have any questions or need any more information please contact us on 07 5667 7711 or via our contact form
Age and Fertility
Increasingly many couples are delaying having a family, due to a variety of reasons, until their late 30s and 40s. Unfortunately fertility in women declines with age. As a woman becomes older, the effect of ageing upon her eggs reduces their ability to fertilise and divide properly, leading to chromosomal abnormalities such as Down’s syndrome and an associated higher risk of miscarriage.
The incidence of Down’s syndrome in women at 32 years is 1 in 725. This incidence increases to 1 in 109 for women aged 40 years. The risk of miscarriage also increases with age. For example, the risk of miscarriage at age 25-29 years is 10%, while the risk at age 40-44 is 34%. There is also an increased incidence of gynaecological conditions as women age such as fibroids, pelvic inflammatory disease and endometriosis which may also impair fertility.
There is limited evidence to suggest that semen quality in men over 40 years of age may result in a slight rise in some genetic conditions in children born.
In the general population, the chances of becoming pregnant with your own eggs after the age of 40 years is estimated to be 5% per menstrual month, compared to 20% per menstrual cycle for women younger than 40 years.
Treatments such as In Vitro Fertilisation (IVF) cannot reverse the effects of ageing on fertility.
In IVF ageing has a number of effects on the success of treatment, including impaired egg quality and quantity, lower numbers of follicles when stimulated with fertility hormones for IVF, lower numbers of eggs retrieved with IVF, lower rates of fertilisation with IVF, and increased rates of miscarriage with IVF pregnancies.
Previous pregnancy does not necessarily indicate that pregnancy is possible in women in their 30’s or 40’s.
What is menopause
Menopause is a normal change in a woman’s life when her period stops. That’s why some people call menopause “the change of life” or “the change.” During menopause a woman’s body slowly begins to run out of eggs and at the same time will produce less and less of the hormones oestrogen and progesterone. This often happens between the ages of 45 and 55 years old, with the average age being 51 years. When a woman has reached menopause she will have no eggs remaining within her ovaries. Menopause is diagnosed when a woman has not had a period for 12 consecutive months. Menopausal symptoms gradually occur between 2 to 6 years before the onset of the last menstrual period. This time is called peri-menopause (from the time the period becomes irregular until the first year after the final period).
As women approach menopause the slowing down of oestrogen and progesterone production begins to fluctuate and cause noticeable changes within the woman’s body. Symptoms are variable and include; irregular menstrual cycles, alteration in menstrual flow, hot flushes, night sweats, generalised aches and pains, headaches, vaginal dryness, reduced sex drive, urinary frequency, fatigue, mood swings, sleeping difficulties and vagueness.
Not all women will be symptomatic. It is estimated 20% of women will have no symptoms, 60% will have mild symptoms, and 20% will have severe symptoms.
Premature menopause is diagnosed if menopause occurs before the age of 40 years. Premature menopause may occur naturally but is often linked to surgical removal of the ovaries due to disease or cancer. Premature menopause may also occur resulting from chemotherapy or radiotherapy.
Hormone Replacement Therapy (HRT)
HRT helps relieve the symptoms of menopause and prevents or slows down the development of osteoporosis and heart disease, which are common problems that occur in women after menopause. Any decision about HRT is an individual one and should be made after the woman has talked to her doctor about benefits, risks and/or other alternatives.
Women who plan to use donor eggs, who do not menstruate (anovulatory), or women who do not have functioning ovaries, will commence on HRT to prepare the uterus for implantation of the embryo. HRT mimics what happens in a normal menstrual cycle and the endometrium will prepare for the embryo even though you do not have functioning ovaries.
IVF and Donor Eggs
For some women where IVF treatment using their own eggs has been unsuccessful, or women who are menopausal, IVF treatment with donor eggs may be their best chance to achieve a pregnancy.
Dr. Davidson, in conjunction with City Fertility Centre, operates an active Donor Egg Program where both known and clinic recruited egg donations are available. Currently there is a waiting list for anonymously donated eggs, so potential recipients are strongly encouraged to recruit their own donor. Please contact Dr. Andrew Davidson’s offices for more information.
What are the possible complications of IVF Treatment?
The risks of IVF should be understood before a patient embarks on treatment. As with any medical or surgical procedure, a few patients undergoing IVF treatment will experience side effects and complications. The most common complications associated with IVF treatment are the failure of treatment, problems experienced as a consequence of ovarian stimulation, the risk of multiple pregnancy, the risks associated with egg collection and the possibility of ectopic pregnancy.
Failure of IVF treatments
This is the most common complication of treatment. The likely reasons for this failure are cancelled cycles (approximately 10% of treatment cycles will be abandoned before egg collection), failure to collect eggs (about 1%), failure of fertilisation (about 5%), and failure of the embryo to implant. This may be due to a significant portion of embryos being chromosomally abnormal and this proportion increases with advanced maternal age. The IVF (in-vitro fertilisation) procedure is considered by some to be one of the most stressful infertility treatments. Failure of treatment can result in emotional strain, psychological stress and depression. Some couples may require psychological counselling. In addition, couples may encounter difficulties if a multiple pregnancy occurs.
Problems Associated with ovarian stimulation by fertility drugs
The fertility drugs used to stimulate ovulation are associated with several complications. There is no drug that is absolutely safe and completely free of side effects. The fertility drugs that stimulate ovulation are rarely associated with complications, however the potential problems associated with fertility drugs which may occur include: ovarian hyperstimulation syndrome (OHSS), multiple pregnancy, and adnexal torsion (ovarian twisting).
Side effects of ovarian stimulation by Fertility drugs
There are several side effects associated with the use of fertility drugs. Puregon or Gonal F injections may induce a variety of mild side effects including bruising and soreness at the site of injections, abdominal tenderness and swelling, breast tenderness, mood swings and occasional nausea. There is also a small risk of a generalised allergic reaction. Other drugs such as GnRH (Synarel or Lucrin) analogues may cause headaches, mood changes, hot flushes and vaginal dryness in some women. These effects are usually short-lived and are no cause for concern. Approximately 15% of patients will develop functional cysts while on GnRH agonist’s regimes (Synarel). These cysts may produce oestrogen, and sometimes are associated with poor IVF outcomes. If this happens, the patient will be advised to continue taking GnRH agonist drugs until the cysts resolve by themselves. Aspiration of the cyst may be required.
Ovarian Hyperstimulation Syndrome (OHSS)
This is the most serious complication of IVF. Any patient undergoing ovulation induction is at risk of developing OHSS, although some more than others. The fertility medications used to stimulate the ovaries may cause side effects. Excessive stimulation of the ovaries is called ovarian hyperstimulation syndrome (OHSS). OHSS may be classified as mild, moderate or severe by symptoms and signs. The worst cases appear to be associated with pregnancy. Severe OHSS is a life threatening complication following ovarian stimulation. The majority of women will develop mild to moderate OHSS, with symptoms invariably resolving within 1 to 2 weeks. If a pregnancy occurs, recovery from the syndrome may be delayed, sometimes taking up to 10 weeks for the symptoms to resolve. Symptoms include abdominal discomfort, a bloated feeling, nausea, slight weight gain and mild abdominal swelling. Very rarely, in about 1-2% of women, the symptoms may become so severe, hospitalisation is necessary. Symptoms include nausea, vomiting, marked abdominal pain, diarrhoea and dehydration. Fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. There is a reduction in the amount of urine produced. These symptoms require constant monitoring by the doctor whilst the woman is in hospital. Women diagnosed with severe OHSS may take up to 4-6 weeks to recover from their symptoms. Complications associated with severe OHSS include blood clotting disorders, kidney damage and twisted ovary (ovarian torsion). Despite careful monitoring, a small number of women (about 3-5% of total treatment cycles) may develop OHSS.
Within Australia generally only one or two embryos are transferred in each IVF attempt in order to reduce the incidence of multiple birth. If two or more embryos are replaced this could result in high-order multiple pregnancies. Although the prospect of twins or triplets may seem attractive to some couples, multiple pregnancies are associated with increased risks of maternal and foetal complications. In addition, multiple pregnancies place enormous strains on the parents, including financial difficulties, emotional distress and physical exhaustion.
In 2002, within Australia, multiple pregnancies occurred in 18.9% of all IVF pregnancies, twin pregnancies occurred in 18.3%, and triplet pregnancies occurred in 0.6% of all IVF pregnancies (NPSU Report, Assisted Conception Australia and New Zealand 2002). Multiple pregnancies within Australia have demonstrated a steady decline. Since 1993 2.0% of deliveries were triplets or higher order multiples. By 2002, this figure had decreased to 0.6% of deliveries being triplets and there were no quadruplet or higher order deliveries. This decrease is due to careful management of the number of embryos transferred to the uterus, to reduce complications resulting from multiple pregnancies.
The term adnexal torsion refers to when the stimulated ovary twists on itself, cutting off its own blood supplies. Ovarian torsion is a rare complication of IVF treatment. The overall risk is about 0.2%. It is greater in the presence of OHSS. Ovarian torsion may cause severe pain and tenderness in the lower abdomen. If not treated early enough the twisted ovary may die. Treatment is surgery to untwist the ovary and even removing it in some cases.
The risk of ovarian and breast cancer
Doctors have used fertility drugs in Australia since the 1960’s, triggering women’s ovaries to produce eggs. This approach has proved successful in assisting many women with fertility problems to become pregnant and have children. In the past 20 years the use of fertility drugs has increased markedly following the development of IVF, GIFT and ICSI. The growth in the numbers of women seeking help to become pregnant provided an opportunity for a study within Australia (the largest of its type anywhere in the world) to be conducted, to address concerns that women on fertility drugs might be at increased risk of cancer. Reassuringly, findings of the study indicated cancers of the breast and ovary were no more common in IVF patients overall than in the general population. Cancers of the breast, ovaries and uterus are associated with diseases of older women who have never undergone fertility treatment. Lastly, there was no evidence of any link between the number of treatment cycles or type of fertility drug used and increased cancer incidence.
Risks of egg collection
As with any surgical procedure, there are potential risks associated with egg collection. Such risks depend on whether the egg collection is performed by vaginal ultrasound or laparoscopy, and include bleeding, infection, or injury to other internal organs. In addition, there are risks of complications associated with the use of a general anaesthetic, although this is rare in healthy women.
Ectopic pregnancy is any pregnancy that occurs outside the cavity of the womb and is a potentially life threatening condition. Ectopic pregnancy is a well known complication of assisted conception treatments. The reported incidence of ectopic pregnancy after IVF treatment varies between 1-2% of all pregnancies. This is higher than is reported after natural conception, which is about 1 in 100 to 300 pregnancies, because IVF patients are already at risk of tubal disease. After one ectopic pregnancy, the risk of recurrence is between 10-20%.
Blastocyst Culture and Transfer
A blastocyst is an embryo that consists of around 100 to 150 cells. It is at the blastocyst stage of development (5 days after fertilisation) that an embryo would normally move out of the fallopian tube and into the uterus. Once in the uterus, the blastocyst starts to attach to the uterine lining in a process known as implantation. IVF embryos can be transferred on the second or third day following egg retrieval when the embryo is at the four- to eight-cell stage of development. The embryos must continue to grow for two or three more days within the laboratory to reach the blastocyst stage before they are ready for transfer to the uterus.
Recent advances in IVF laboratory methods and culture media have allowed for the successful culture of embryos to the blastocyst stage. Blastocysts may have a better potential to implant into the uterine wall than earlier stage embryos. Many embryos stop growing at the four- to eight-cell stage, probably because of an inherent problem. There is now evidence from research studies that suggest although embryos may have a normal appearance, up to 60% may be chromosomally abnormal. These genetically abnormal embryos usually fail to develop past the 8-cell stage. Therefore, fewer embryos will have the ability to grow to the blastocyst stage. Potentially, extending culture to the blastocyst stage allows selection and transfer of embryos that are more likely to be genetically normal. However, there is no guarantee of this! Those that successfully reach the blastocyst stage are probably more developmentally competent than earlier stage embryos. As well, their stage of development when replaced into the uterus is very similar to what it would be in a natural conception cycle.
What are the pros & cons of Blastocyst transfer?
The advantage of attempting to grow embryos to the blastocyst stage is that they are potentially more likely to be genetically normal and should have a greater chance of implantation because the stage of development matches the uterine environment. The extended culture to blastocyst stage has identified the embryos most able to implant following a single embryo transfer.
The disadvantage of attempting to grow embryos to the blastocyst stage is that fewer embryos will “survive” or grow to this stage (probably about 30 – 50% of the embryos). There is a possibility (up to 10%) that none will reach the blastocyst stage, and therefore no embryos will be available for transfer. The availability of “extra” embryos for freezing is also significantly reduced. There is also a greater risk of having twins if two blastocysts are transferred, plus an increased risk of identical twins. Therefore you need to discuss how many embryos to safely transfer with Dr Davidson. There is an additional fee for blastocyst transfer.
Who is eligible for Blastocyst transfer?
Blastocyst culture may not be suitable for every couple. Couples who have had repeated, unsuccessful attempts with IVF or ICSI (despite having many good quality embryos in appearance replaced to the uterus on day 2 or 3 after egg retrieval) may be offered blastocyst culture as an alternative treatment. Women 40 years of age or older may also consider blastocyst transfer. The ability to select the most viable embryos for transfer should improve chances of achieving a pregnancy. The embryos will be cultured in the IVF laboratory for 5 days after egg retrieval. To maximise the chances of obtaining a blastocyst, we suggest at least 4 good quality embryos (6 to 8 cells) to have continued to progress in development by the third day after egg retrieval.
Embryo Glue or Transfer Media
For pregnancy to occur, the developing embryo must implant into the lining of the female’s uterus (endometrium). The series of scientific events involved in implantation are highly complex.
However, research has shown that a glycoprotein called hyaluronan plays an important role in assisting embryos to implant. Hyaluronan is a naturally occurring substance found in the uterine cavity and fallopian tubes.
Hyaluronan appears to assist implantation in several ways:
- by increasing the cell to cell adhesion of the embryo and uterine lining
- interaction with growth factors that facilitate implantation
- the by-products of hyaluronan promote angiogenesis – the growth of new blood vessels
- human oocytes and embryos have surface receptors for hyaluronan
- hyaluronan may play a role in preparing the endometrium for implantation to be more receptive to embryos
Studies in Colorado showed that the addition of hyaluronan to the embryo transfer media significantly improved the implantation rate of human embryos (Schoolcraft et al., 2002) More recent studies (Urman at al., 2008), have shown an increase in pregnancy rates when embryos were transferred at either the cleavage stage or the blastocyst stage in a hyaluronan enriched transfer media.
Based on these findings commercial media containing hyaluronan have been developed to maximise implantation of IVF embryos. The embryos which are selected for transfer are placed in a small volume of this transfer media. When the transfer procedure takes place the embryos are loaded into the transfer catheter, along with a tiny volume of the transfer media, and released into the female’s uterus.
Although one of the names of these media suggests that it can glue the embryos in place, this is not the case. Hyaluronan transfer media does not guarantee implantation, but may assist it. There is some evidence to suggest that females over the age of 38 years show the most benefit with a significant increase in pregnancy rates when a transfer media with hyaluronan is used (Balaban et el., 2004). There have also been studies that indicate frozen/thawed embryos may have increased pregnancy rates when transferred in a hyaluronan transfer media.
City Fertility Centre was one of the first clinics in Australia to introduce the use of Embryo Glue®. Should you wish to discuss the use of this media in your treatment cycle please contact our office.
Assisted hatching is a scientific technique that can improve the implantation of embryos into a woman’s uterine lining by creating an opening through which the embryonic cells can hatch out. Pregnancy cannot occur unless the human embryo hatches.
The unfertilised oocyte is surrounded by a membrane called zona pellucida. The zona pellucida ensures that only one sperm enters and fertilises the egg. After fertilisation, the embryo begins to cleave into a two cell, then a four cell, and so on. It is at this early cleavage stage that assisted hatching can be performed on embryos.
It has been shown that women older than 37 years of age have a tendency to produce oocytes with a harder and/or thicker zona pellucida than younger women. The same can be said for women with a high level of follicle stimulating hormone (FSH).
The problem of a harder zona pellucida is that the embryo may not hatch and thus not attach to the woman’s womb. Hatching of the embryo is necessary to achieve pregnancy. It has been reported that up to 75% of normal embryos may never hatch. Laboratory procedures involved in IVF may add to the hardening of the zona, as the embryo is not continually exposed to the enzymes present in the natural environment of the fallopian tubes.
There is also evidence to suggest that the process of freezing and thawing embryos causes the zona to harden and using assisted hatching can be beneficial.
Dr Andrew Davidson, in conjunction with City Fertility, offers laser assisted hatching, which is a gentle and safe way to weaken a part of the zona pellucida. Several studies have shown that using a laser is superior to chemical and manual hatching. Laser assisted hatching has several advantages including; minimal handling of the embryo, and delivering fast and exact control over the drilling of the hole.
Laser assisted hatching is performed by the scientists, prior to the embryos being transferred back to the uterus.
Recent meta-research (comparison of different relevant research) showed that women who have undergone repeated IVF treatments without results, increase their chances of a pregnancy by use of laser assisted hatching.
Women contemplating ovarian stimulation should be aware that the procedure carries risks that are comparable with the risks of elective surgery. OHSS is a potential threat to every woman undergoing ovarian stimulation during ovulation induction or IVF treatment. The fertility medications used to stimulate your ovaries may cause side effects. Excessive stimulation of the ovaries is called ovarian hyperstimulation. OHSS may be classified as mild, moderate or severe.
Incidence of OHSS
Despite careful monitoring during treatment, a small number of women (about 3-5% of all treatment cycles) may develop OHSS.
The symptoms usually begin 3-5 days after the hCG (Ovidrel or Pregnyl) trigger injection, provoked by each injection of hCG. Sometimes the symptoms may be delayed, occurring up to 7 days after the embryo transfer.
The majority of women diagnosed with OHSS will experience a mild form of the syndrome, which invariably resolves within a few days. Mild OHSS is a relatively common side effect of ovarian hyperstimulation. Women may complain of abdominal discomfort, a bloated feeling, nausea, slight weight gain and mild abdominal swelling. Approximately 70% of women will recover from their symptoms within 1-2 weeks.
In a small proportion of women, the degree of abdominal discomfort can be quite pronounced. 20% of women diagnosed with moderate OHSS symptoms may take up to 2-4 weeks to resolve. If a pregnancy occurs, recovery from the syndrome may be delayed. It may take up to ten weeks for the symptoms to resolve if you are pregnant. Later the pregnancy can be expected to proceed normally.
Very rarely, in about 1-2% of women, the symptoms may become so severe, hospitalisation is necessary. Women will experience progression of symptoms including nausea, vomiting, marked abdominal pain, diarrhoea and dehydration. Fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. There is a reduction in the amount of urine produced. These symptoms require constant monitoring by the doctor whilst the woman is in hospital. Women diagnosed with severe OHSS may take up to 4-6 weeks to recover from their symptoms.
Management of OHSS
Most women with mild symptoms of OHSS respond well to drinking plenty of oral fluids, including electrolyte replacement drinks (2 to 3 litres daily) and by taking simple analgesia to assist with pain management. Symptoms are self limiting and will resolve spontaneously.
Hospitalisation is required for the treatment of severe OHSS and is aimed at restoring the woman’s fluid and electrolyte balance, controlling pain, preventing clot formation, and in some very serious cases, termination of pregnancy. Occasionally very serious complications associated with severe OHSS develop, including blood clotting disorders, kidney and liver impairment and twisted ovary (ovarian torsion).
Women at risk of developing OHSS include:
- women with polycystic ovaries
- younger women (<35 years of age)
- women who develop high oestrogen hormone levels and a large number of follicles or eggs in response to ovarian stimulation
- women who have had administration of a GnRH agonist
- women who have been prescribed low dose hCG injections (Ovidrel or Pregnyl) for luteal phase support
- women with a slim build
- women who have developed OHSS during previous ovulation induction or IVF treatment
Treatment options if you are at risk of developing OHSS
If you’re at risk of developing OHSS during ovulation induction or IVF treatment, your doctor might suggest several options to prevent or minimise symptoms of OHSS including;
- Coasting. Your doctor will advise you to reduce or stop ovarian stimulation injections whilst continuing your synarel nasal spray for a few days before egg collection. This allows your oestrogen levels to decline to an acceptable level before proceeding to egg collection.
- Proceeding with the egg collection but freeze all of the resulting embryos (In a freeze-all cycle, the eggs are collected and fertilised then cryopreserved). Because pregnancy or further hormone injections will worsen the risk of OHSS, a freeze-all cycle is a safer option. This gives the ovaries time to settle down before attempting pregnancy at a later date. The woman can return for treatment and have the frozen embryos transferred back to her uterus. A frozen embryo transfer cycle does not require any stimulation of the ovaries.
- Withholding hCG administration and cancelling your treatment cycle. This may occur if the potential risk for development of OHSS is considered too great by your doctor. Your doctor will tailor your future treatment aiming to minimise, or prevent this syndrome potentially developing again.
Polycystic ovary syndrome (PCOS) is the name given to the condition in which women with polycystic ovaries have an associated hormonal imbalance within the ovaries. PCOS also describes the appearance of the ovaries when they are seen on an ultrasound (cyst-like). PCOS is the most common reproductive endocrine disorder in women of reproductive age, affecting approximately 5% of women.
Normally the ovaries produce estrogen, progesterone and testosterone. In PCOS, estrogen is usually produced in normal amounts, testosterone (androgens) is produced in excessive amounts and progesterone, which is released after ovulation (the release of the egg from the follicle), may be produced irregularly or not at all. It is still unclear what causes PCOS. While PCOS is not curable, there are several approaches to achieving hormonal balance.
Signs and Symptoms of PCOS
Women who have PCOS may have irregular or no menstrual cycle, infertility due to lack of ovulation, hirsutism (excessive hair), acne and weight gain (disproportionate to kilojoules intake). Women with PCOS are noted to have a higher than normal miscarriage rate if they become pregnant. 75% of women with repeated miscarriages are reported to have PCOS. Women who have a Body Mass Index (BMI) >29 will take longer to conceive (normal BMI ranges from 20-25). Other related symptoms may include mood swings, breast pain, abdominal pain, aching joints, dizziness and chronic fatigue-like symptoms.
A lack of ovulation in women with PCOS results in continuous exposure of the uterine lining to estrogen. This may cause excessive thickening of the endometrial lining of the uterus
and result in heavy, irregular bleeding. The incidence of uterine cancer may be increased due to years of continuous stimulation of the endometrium by estrogen unopposed to progesterone.
Women with PCOS may be at increased risk for developing the metabolic syndrome which is characterised by abdominal obesity, cholesterol abnormalities, hypertension and insulin resistance that impairs blood sugar regulation. Women with PCOS have an increased risk for developing non-insulin dependent (Type 2) diabetes and possibly heart disease.
Diagnosis is made by a careful medical history and examination, ultrasound of the ovaries (noted to contain many cysts) and measuring hormone levels including:
- Testosterone (usually elevated).
- Sex hormone binding globulin (SHBG), free androgen index (FAI) and dehydroepiandrosterone sulfate (DHEAS), to see if increased androgens are primarily from the ovaries or adrenal gland.
- FSH (normal or low) and LH (usually 2-3 times elevated to that of FSH levels).
- Diabetes and insulin resistance testing.
- Prolactin (to rule out pituitary associated causes).
- Thyroid function test: low levels of thyroid hormones can lead to symptoms that mimic PCOS.
- Raised homocysteine levels: an independent cardiovascular risk factor has been noted in women with PCOS.
If the ultrasound and the blood tests are normal it does not mean the woman does not have PCOS.
Treatment depends on the presenting problem you are concerned with. If infertility is not your immediate concern,the oral contraceptive pill (OCP) can be prescribed to reduce acne and hirsutism and maintain regular menstrual periods.
Obesity is common in women with PCOS. Diet and exercise that results in weight loss has been shown to improve the frequency of ovulation, improving fertility and lowering the risk of associated problems common to PCOS, such as diabetes. Women who have a BMI >29 who are not ovulating will increase their chances of conception if they lose weight. Several studies have demonstrated a weight loss between 6 to 10 kilos to be associated with a return of spontaneous ovulation in 90% of women, and subsequent increased pregnancy rates. Overweight women are also noted to have a higher miscarriage rate. Another study reported a weight loss of 10 kilos reduced the miscarriage rate from 75% to18% in women with PCOS.
If you would like further guidance regarding your diet, an appointment to see a qualified dietician at City Fertility Centre can be arranged for you. Please contact the IVF Nurse Co-ordinators for more information on this service.
Prophylactic B-Group vitamins have been noted to reduce homocysteine levels, implicated in cardiovascular disease in women with PCOS.
If fertility is your main goal, treatment with medication, such as metformin, can increase the body’s sensitivity to insulin, leading to regular ovulation. Ovulation may also be induced with clomiphene citrate (clomid or serophene), an orally administered fertility drug. Ovulation can be induced in up to 80% of women using clomiphene with subsequent pregnancy rates comparable to the general population (approximately 20-25% of healthy fertile couples become pregnant each month they try). Clomiphene is usually only prescribed by your IVF Doctor for up to 6 menstrual cycles. If the woman does not become pregnant, injectable fertility drugs, administered at low doses (FSH) may be used to induce ovulation. The aim of these drugs is to produce only one mature egg, similar to a natural menstrual cycle.
FSH injections however are associated with a greater chance of multiple pregnancy and side effects.
Sometimes IVF is offered to women with PCOS who want to conceive when other treatments have failed.
Ovarian drilling or diathermy has been used to treat women with PCOS, and is a minimally invasive operation performed through a laparoscope. The ovaries are “drilled” or cauterised. This procedure has been shown to induce ovulation in some women with PCOS. Ovarian drilling or diathermy may be used to induce ovulation, as an alternative to IVF, in women who may not have responded to oral or injectable fertility drugs.
What is Endometriosis ?
Endometriosis is a common and often painful condition affecting about 10% of women in their reproductive years. It occurs when the tissue that normally lines the uterus (endometrium) is found outside the uterus. This is commonly found on the ovaries, fallopian tubes, and the tissue lining the pelvis.
It is believed endometriosis develops on the surface of tissue or organs where it has implanted, grows, and causes inflammation. These implants respond to female hormones such as oestrogen, as does the lining of the uterus. It is unknown why endometriosis causes pain in women. However, sometimes these deposits bleed and the blood cannot escape from the body during a period, so it bleeds directly onto the surface of the surrounding organs and tissues. The body’s reaction to endometriosis may cause inflammation, scarring and, sometimes, the development of adhesions between organs so that they stick together. On the ovary, the patches can increase in size and burrow in to form cysts, known as chocolate cysts.
What causes it?
The cause endometriosis is not clear. However, a leading theory is ‘retrograde menstruation’. This backward flow of menstrual bleeding through the fallopian tubes and into the pelvis might cause the endometrial cells to implant on abdominal organs. Researchers also think that it could be genetic, since female family members sometimes share the condition.
What are the symptoms?
The symptoms of endometriosis can vary. Some women have no symptoms at all, while others have severe pain. The most common symptom is pelvic pain that feels like period pain.
Pain may be in any of the following forms:
- period pain – immediately before and during period
- pain during or after sexual intercourse
- abdominal, back and/or pelvic pain outside of menstruation
- painful bowel movements or urination
- abdominal pain at the time of ovulation
Bleeding maybe any of the following:
- heavy bleeding, with or without clots
- irregular bleeding, with or without a regular cycle
- premenstrual spotting
Other symptoms may be extreme tiredness and difficulty in becoming pregnant.
How is Endometriosis is diagnosed?
If a woman has Endometriosis in her ovaries an ultrasound may be able to show it, but not always. The only way to definitely diagnose endometriosis is through laparoscopy.
Laparoscopy is a surgical procedure which involves inserting a long, thin telescope (laparoscope) into the abdomen through an incision near the navel. Gas is then pumped into the abdomen to separate the organs for better visualisation. The surgeon will look for signs of endometriosis and may take tissue samples for testing. Endometrial implants may also be removed at this time.
What are the treatement for Endometriosis?
Endometriosis can be treated in several ways, depending on the severity of the condition. The best treatment depends upon whether the primary goal is to become pregnant or to treat pain.
Hormone therapies may be used as a treatment in mild endometriosis, or as an added or combined therapy prior to, or after, surgery, especially in moderate to severe forms. The aim of hormonal therapies is to suppress the growth of endometrial cells which can lead to a reduction in pain symptoms. These therapies usually aim to stop any bleeding, including the period, and are not suitable whilst trying to gecome pregnant. Hormone therapies include GnRH (gonadotrophin-releasing hormone) agonists, progestogens, androgenic steroids (e.g. Danazol), and the oral contraceptive pill.
Procedures such as laparoscopy (key hole) or laparotomy (open surgery) can surgically remove endometrial implants or adhesions (scarring) that result from endometriosis. Unlike drug treatment, surgical treatment may improve women’s fertility. If a woman’s symptoms persist despite drug and conservative surgical treatment a hysterectomy (removal of the uterus) may be suggested. This type of surgery is usually only chosen as a last resort and in cases where all other forms of treatment have failed.
Treatment of Infertility
In women with mild endometriosis, the use of fertility medication that stimulates ovulation (clomiphene citrate, gonadotropins) combined with Intrauterine Insemination (IUI) enhances fertility. In Vitro Fertilisation (IVF) procedures are effective in improving fertility in many women with endometriosis. The decision when to apply IVF in endometriosis associated infertility takes into account the age of the patient, the severity of the endometriosis, the presence of other infertility factors, and the results and duration of past treatments.
Pre-implantation Genetic Diagnosis (PGD), also known as Embryo Screening, is a state-of-the-art procedure used in conjunction with in vitro fertilization (IVF). PGD is generally recommended to detect numerical or structural anomalies in the chromosomes of embryos. When embryos are affected by certain chromosomal conditions, these can prevent implantation to the uterine lining, lead to pregnancy loss, or result in the birth of a child with physical problems and/or mental retardation.
PGD can help prevent adverse outcomes by identifying affected embryos as they are developing in the laboratory and before they are transferred to the womb during the IVF cycle.
PDG for Aneuploidy
Normal human cells (i.e. embryonic cells) contain 46 chromosomes in 23 pairs. We receive 23 chromosomes from each parent. The first 22 pairs of chromosomes are the same for men and women. The 23rd pair determines our sex. A female has two “X” chromosomes, whereas a male has an “X” and a “Y.” As such, the woman can only pass an X to her child in her egg. The man passes either the X or the Y in the sperm, therefore determining the sex of the child. If an error occurs, and the egg or sperm has an extra or missing chromosome, the embryo created by that egg or sperm will have an extra or a missing chromosome resulting in a condition called aneuploidy. Having an extra chromosome is known as trisomy (tri = three of a given chromosome) and having a chromosome missing is known as monosomy (mono = one of the chromosome). When aneuploidy involves the larger chromosomes, the embryo may not attach to the wall of the uterus or may stop developing soon after attaching and result in a miscarriage.
However, if the aneuploidy involves chromosomes such as the 13, 18, 21, X or Y, the pregnancy may still carry on until birth, even though the pregnancy has a chromosomal disorder. The most common of these is an extra number 21, known as Down syndrome or trisomy 21 (three chromosome 21). Other common aneuploidies are Klinefelter syndrome (XXY), trisomy 13, and trisomy 18. The features of the chromosome condition depend upon which chromosome is extra or missing, but can include physical differences and mental retardation.
Aneuploidy and Maternal Age
As a woman advances in age, the chance of aneuploidy in her pregnancies increases because her eggs are also ageing. Females develop their total number of eggs while still in their mother’s womb, and as a result, they are born with all the eggs they will have in their lifetime. In males, sperm is made every 65-75 days; therefore, the sperm is not as old as the man. Based on this, the theory regarding aneuploidy risk and advancing maternal age is that, over time, the chromosomes in the egg are less likely to divide properly, which results in the egg having an extra or missing chromosome. Therefore, the risk of aneuploidy increases with maternal age.
The purpose of PGD for aneuploidy, is to select only chromosomally normal embryos for embryo transfer. The aim is to achieve pregnancies, a reduced number of pregnancy losses, and a reduced number of affected offspring.
How is PGD performed?
To test an embryo, one blastomere or embryonic cell is removed through a microscopic opening made in the outer protective membrane of the embryo. This takes place during the third day of development (5 to 8-cell stage). This is performed using microscopic pipettes and a laser by a highly trained scientist. The embryo is then kept in culture in an incubator while the cell’s DNA is analysed.
The PGD analysis
The biopsied cells are analysed using a technique called FLUORESCENCE IN-SITU HYBRIDIZATION or fIsh. This technique uses probes, small pieces of DNA that are a match for specific chromosomes. Each probe is labeled with a different fluorescent dye. These fluorescent probes are applied to the biopsied cell and attach to the chromosomes. Under a fluorescent microscope, the number of chromosomes of each type (colour) can then be counted. The geneticist, therefore, can distinguish normal cells from cells with aneuploidy. This cell that is removed from the embryo for analysis is fixed to a glass slide and repeatedly heated and cooled in this process. As such, it cannot be used for another purpose or returned to the embryo. This analysis causes no extra inconvenience to the patient as it is accomplished in 1-2 days.
Advantages of PGD
1. Reduction in the chance of having a child with aneuploidy
According to current figures, the chance for a woman delivering a baby with aneuploidy is on average 1% if she is 35-39 years of age and ~3.5% if she is 40-45 years of age. PGD does lower the chance of having an affected baby. However, the science does not yet allow us to test all of the chromosomes at present. We therefore recommend that prenatal testing be performed in the resultant pregnancy via chorionic villous sampling or amniocentesis in order to confirm our diagnosis from PGD and to rule out other aneuploidies for which the test does not cover.
2. Increased Implantation rate
It is well known that the pregnancy rate after IVF decreases dramatically with maternal age. Aneuploid embryos have much lower survival rates than normal embryos, and rarely implant to achieve an ongoing viable pregnancy. It appears likely that the decrease in pregnancy rates with maternal age is mostly caused by a corresponding increase in the number of aneuploid embryos. By performing PGD for aneuploidy and transferring only chromosomally normal embryos, we may be able to increase the chance of pregnancy for these older patients.
3. Reduction in pregnancy losses
In women aged 35 and over, approximately 35% of pregnancies are miscarried. Aneuploidy accounts for 50% or more of these losses. By transferring only chromosomally normal embryos, the number of pregnancies going to term should increase. Recent studies have detected a significant reduction in pregnancy losses after PGD, from 23% to 9%. The increase in implantation rate and the significant decrease in pregnancy loss rate resulted in a significant increase in ongoing pregnancies and delivered babies.
Issues associated with PGD
1.The risk of embryo biopsy
While PGD is a relatively new procedure in IVF, the micromanipulation techniques required to perform it have been in use for many years. The risk of accidental damage to an embryo during removal of the cell(s) in the hands of an experienced embryologist is very low, and it is currently calculated at less than 1%. Other Assisted Reproduction procedures such as Intracytoplasmic Sperm Injection (ICSI), Fragment Removal and Assisted Hatching are all performed by making microsurgical openings in the covering of the egg or embryo and none have been found to have other than mostly positive effects on implantation and viable pregnancy rates.
2.Removal of cells from the embryo
No part of the future foetus will be affected because one or two cells are removed from an embryo approximately two days after fertilization. At this developmental stage all cells in an embryo remain totipotent (until about the fourth day). These cells have not differentiated yet, meaning that each cell by itself could potentially grow into a whole and perfect foetus. The biopsy procedure merely delays continued cell division for a few hours, after which the embryo reaches the same number of cells as before and continues its normal development. It is possible that embryo biopsy may lower embryo implantation rates slightly, while selection of chromosomally normal embryos via PGD may increase them. Therefore, the balance between potential biopsy damage and beneficial effects of PGD seems to be positive.
The accuracy of PGD for aneuploidy is approximately 90%. This means that the error rate is 10%. Within this chance of misdiagnosis, there is a false negative rate, a false positive rate, the chance for no result and the chance for mosaicism. Mosaicism is defined as the embryo having cells with different chromosome make-up. Typically, all cells of the embryo have the same chromosomal make-up as they originate from the same fertilized egg. However, it is possible for cells of the same embryo to have differing numbers of chromosomes.When the cell analysed has a different chromosomal complement than all the others in the embryo a misdiagnosis occurs. Due to the chance of misdiagnosis as well as the presence of aneuploidies, for which testing is not available, we recommend prenatal testing as stated earlier.
Summary of reasons to consider PGD
- recurrent miscarriage
- over 4 unsuccessful IVF cycles
- family history of structural chromosomal condition
- advanced maternal age
- family history of X-linked disease
- severe male factor infertilityMFS11
The first human pregnancy from a frozen and subsequently thawed embryo was achieved in Australia in 1984. The method used to preserve that embryo is called “slow freezing” and it is still the preferred method for preserving embryos throughout the world today. Slow freezing is a reliable and established technique that has served the IVF community well for over 20 years.
Slow-freezing cools the embryos gradually, approximately – 0.3° C /minute until it has been cooled to below -30° C and is therefore fully frozen. Thereafter, storage of frozen cells is in liquid nitrogen (-196° C). During the freezing of any cell the water must be removed from the cells without damaging the cell or embryo. This is required as water expands in volume as it freezes, and ice formation inside a cell causes the cell to rupture. There is also an associated rate of cell loss during thawing, with approximately 15-20% of frozen embryos not surviving the thawing process. This is particularly an issue with blastocyst stage embryos where slow freezing has not been as successful compared to day 1, 2 or 3 embryos.
An alternative procedure called vitrification has been developed internationally and adopted by City Fertility Centre to enhance the survival capability of oocytes and blastocysts during and after the cooling process.
What is Vitrification?
The idea of vitrification was first described in 1860, and was successfully used on red blood cells in 1937 by Swiss-American Basile J. Luyet. However it wasn’t for another fifty years that Rall and Fahy described vitrification as a potential alternative to slow-cooling. The word “vitrum” in Medieval Latin means “glass”.
Vitrification of oocytes and blastocysts is the process by which the solution containing the oocyte or embryo is cooled so rapidly that the water molecules do not have the time to form ice crystals and instantly solidify into a “glass-like” structure.
This concept is based upon the idea that if the cell is dehydrated to a certain degree and then cooled fast enough, everything will “freeze” in place and damage will not have time to occur; crystals will not be able to organize themselves and a vitrified amorphous, a glass-like solid, will form instead of ice. Vitrification cools the embryos an amazing 7,000 times faster than conventional slow freezing techniques (2,000-2,500 Celsius per minute). Since no ice forms, the risk of rupturing the cell is reduced.
Vitrification involves exposure of the cell to high concentrations of cryoprotectants for brief periods of time, followed by rapid cooling by touching a block which has been cooled in liquid nitrogen. The high osmolarity of the vitrification solution rapidly dehydrates the cell and liquid nitrogen quickly solidifies the cell, so that the remaining intracellular water does not have time to form damaging ice crystals and hence, drastically reduces the survival rate for thawed embryos.
How are embryos vitrified?
The oocyte or blastocysts are suspended in a drop of fluid on a tool with a tiny hook on the end. The droplet is lowered onto a metal block that has been cooled by liquid nitrogen where it hardens into a glass-like bead.
After investing heavily in vitrification training, our Brisbane Laboratory Supervisor Ms Emmy Hung has established a vitrification program at City Fertility Centre.
Egg & Ovarian Tissue Cryopreservation & Storage
Egg (oocyte) and ovarian tissue freezing (cryopreservation) are considered to be developing or experimental techniques for fertility preservation in women. This is a rapidly progressive area in which success rates for thawing, fertilisation and subsequent pregnancy have been demonstrated. These techniques have the potential to be helpful for women with cancer, as chemotherapy and radiation treatment can often have a harmful effect on fertility, rendering many of these women menopausal following completion of their treatment. Women who are at risk of early menopause or who have a genetic disorder which could limit fertility, or women who wish to have children at a later date, can also have eggs or ovarian tissue collected and stored. Lastly, couples who may have a moral or a religious objection to storing embryos resulting from IVF treatments may prefer to store unfertilised eggs instead.
In egg freezing, a woman’s mature eggs are developed and removed using standard IVF techniques. They are then frozen before being fertilised with sperm in the hope that they can be thawed, fertilised and transferred back into the woman’s uterus later.
In ovarian tissue freezing, a portion of the ovary or ovaries are removed laparoscopically, divided into small strips, then frozen and stored. Later they may be thawed for transplantation back into a woman’s body, or for use with in vitro maturation, a technique in which eggs are matured in the laboratory, rather than in a woman’s body.
It’s important to remember that both egg and ovarian tissue freezing are experimental techniques and there is no guarantee frozen/thawed eggs or ovarian tissue could result in a pregnancy.
Our ability to freeze any cell depends on many factors, but most significantly on how much water the cell contains. Because water expands in volume as it turns to ice, cells must be dehydrated prior to freezing to prevent the cell from rupturing. The addition of a cryoprotectant, which does not expand upon freezing, can greatly reduce the risk of cell rupture.
Scientists have been freezing and thawing sperm with success for over 100 years. In many ways sperm are ideal for freezing, as they exist as individual cells, they are the smallest human cells, and they contain very little water. It is thought that sperm can be stored perhaps indefinitely after being added to a solution of cryoprotectant, and then frozen to -196 °C.
In contrast to the sperm, the oocyte is the largest human cell and it contains much more water. The oocyte is also much more sensitive and is very intolerant of the chemical and physical stresses that are created during freezing and thawing. Further, the availability of oocytes is much more limited. When an oocyte is ovulated, or retrieved from the ovary during an IVF cycle, ideally it is ready to be fertilised by a single sperm. In anticipation of fertilisation, the oocyte prepares to discard half of its DNA in a process called meiosis. Any changes in the physical or chemical environment around the oocyte can disrupt meiosis, leading to an oocyte with too much or too little DNA. Hence, even after we overcome the hurdles of sensitivity and cell water content, these other obstacles to freezing and thawing oocytes successfully remain.
Wider application and success with oocyte freezing depends on continued improvements with the technology and on careful selection of oocytes to freeze. While many researchers are continuing to improve the freezing process, much of the success so far has been with the use of good quality or young oocytes.
Ovarian Tissue Cryopreservation
The alternative approach of freezing an abundance of immature oocytes contained within ovarian tissue has been the subject of intensive research within the international IVF community over the past 5-10 years. For this to be successful, the oocytes contained within the immature (primordial) follicles had to be shown to be able to survive freezing, and also to be able to go on to mature to a stage where they can be fertilised normally.
Having established optimal methods for ensuring that the follicles and immature oocytes in ovarian tissue could withstand storage at very low temperatures in the late 1990’s, the IVF community began searching for ways in which we could prove that these follicles and oocytes could undergo normal development to maturity. We now know this is possible. Using a technique by which small samples of previously frozen tissue are grafted into a special type of laboratory mouse which cannot reject the graft (xenografting), we have been able to show that multiple mature follicles and oocytes are able to develop within the tissue frozen by this method. Importantly, we have also been able to show that this ability to develop mature follicles and oocytes is reproducibly true for small samples of tissue frozen from a wide range of patients.
A number of groups worldwide have now started to take the first tentative steps towards applying this technology by grafting frozen/thawed tissue back to patients. Early reports of evidence of transient ovarian function following grafting provided only limited encouragement, but more recently there has been some more encouraging evidence that ovarian function, and even fertility, may be reinstated following grafting of cryopreserved tissue.
The potential disadvantage of using ovarian tissue harvested due to cancer is the theoretical possibility that these cancer cells will still be present in the ovarian tissue and may re-establish within the body once grafted.
Similar to the early days of IVF, this technology is still in its infancy but the potential benefits to a particularly vulnerable group of young women are enormous. Future progress in assisting the ability to preserve future fertility will potentially have major implications for this group of women, both medically and socially.
How long can we continue to cryopreserved our eggs or ovarian tissue?
Dr. Andrew Davidson follows national guidelines as recommended by The National Health and Medical Research Council (NHMRC 2004) regarding egg or ovarian tissue storage. The maximum storage time in which eggs or ovarian tissue can be kept in storage is 5 years at City Fertility Centre, however a couple do have an option to renew consent to store for a further 5 years. If after the maximum 10 year storage period the eggs or ovarian tissue have not been used, donated to another couple, or donated for research, and no alternative arrangements have been made by the owners of the stored eggs or ovarian tissue (and the owners remain untraceable), disposal will be arranged.
If your cryopreserved eggs or ovarian tissue is reaching the 10 year storage limit and you wish to extend the storage time, a written letter of application must be made to the Scientific Director of City Fertility Centre.
If you should decide to dispose of your cryopreserved eggs or ovarian tissue at City Fertility Centre, please contact the IVF Nurse Co-ordinators to discuss options available to you. Signed consent forms are required prior to disposal.
We ask all patients with stored cryopreserved eggs or ovarian tissue to keep City Fertility Centre informed of their current contact details. There is a six monthly storage fee.
Storage fees will cease if you consent to dispose of your eggs or ovarian tissue.
Removing Eggs or Ovarian Tissue from Cryopreservation
The following options are available to you if you should decide to no longer keep your eggs or ovarian tissue cryopreserved:
- removal from cryopreservation (thawed and discarded)
- donation to another couple
- donation for research
Whatever option you should decide, appropriate consent forms with your signature is required prior to releasing your cryopreserved eggs or ovarian tissue. Please contact the IVF Nurse Co-ordinators to discuss these options. At this point your storage fees will be discontinued.
What happens to stored eggs or ovarian tissue in the event of separation or divorce?
In the unfortunate event that a couple decide to separate or divorce and eggs or ovarian tissue are in storage, the female partner is advised to contact the centre at which the eggs or ovarian tissue is stored. The eggs or ovarian tissue will remain in storage until the female partner has come to a decision regarding the fate of her eggs or ovarian tissue.
What happens to stored eggs or ovarian tissue in the event of death?
If both partners die whilst eggs or ovarian tissue is in storage, the eggs or ovarian tissue will be discarded. In the event of death of the female partner the prior legal consent of the deceased would be fulfilled. For remaining eggs or ovarian tissue to be used by the surviving male partner, City Fertility Centre would require a court order regarding the eggs or ovarian tissue prior to any further treatment commencing at our centres. It is advised you obtain legal advice in regard to egg or ovarian tissue ownership and disposal.
We appreciate that for some couples the decision to release cryopreserved eggs or ovarian tissue from storage may be a difficult decision to make. The counselling staff at City Fertility Centre are available to assist couples to make a decision that they feel most comfortable with. To make a counselling appointment please contact City Fertility Centre and a time can be arranged to suit you. Please ask to speak to the IVF Nurse Co-ordinators for more details.
A healthy lifestyle is recommended prior to and during pregnancy. You may be surprised to learn that your diet, lifestyle and environment all have a profound bearing on your individual reproductive health and on the health of a baby. Put simply, preconception care involves making sure that there is an adequate supply of all factors essential to the health of sperm, eggs, fertilisation, a healthy pregnancy and including delivery of a healthy baby.
Given the formation of mature sperm takes approximately 2 months and maturation of eggs requires approximately 100 days prior to ovulation, your reproductive health TODAY is actually your health, diet, lifestyle and environment 2 to 3 months PRIOR.
Therefore to ensure healthy sperm and eggs, preconception care should be implemented a few months prior to conception. However some recommendations may take longer to implement and a couple should ideally work towards implementing and maintaining these dietary, lifestyle and environmental changes even during fertility treatments, to maximise their chances of conception.
Diet & Exercise
You are what you eat. Optimal wellbeing is essential for overall health, including fertility fitness. Following a sensible diet and exercise programme can help boost your reproductive health. Women who are either markedly overweight or underweight may have difficulty conceiving.
Both partners should eat a variety of foods. Whole grains, legumes, vegetables, fruit, nuts and seeds. Eat a healthy diet with at least five servings of fruits and vegetables a day, along with whole grains and some good quality protein such as meats, fish, eggs, or milk. Drink at least 8 to 10 of glasses of filtered water a day.
To maintain fitness and help keep your weight under control, aim to undertake moderate, regular exercise for an average of 30 minutes per session, three times a week.
A good quality vitamin and mineral supplement taken daily is recommended for men and women, in conjunction with a well balanced sensible diet prior to and during your fertility treatment. Importantly, a vitamin and mineral supplement on its own does not make up for poor food choices. Men may want to consider supplements of Vitamin E, C, zinc and selenium (found in most multivitamin preparations) if they wish to “boost” their sperm count. Zinc is a necessary cofactor for the production of the principal male sexual hormone testosterone. Zinc has been shown to be essential in improving sperm count, motility and fertilisation. It is also vital for the operation of many of the enzymes that govern men’s sexual function. Vitamin E, C and selenium are powerful antioxidants which help to protect sperm against free radical damage and increase sperm health.
Women may enhance their fertility with Zinc, Vitamins C, B6 and E as they play an important role in regulating hormone levels. Low levels of magnesium, potassium and zinc have been associated with decreased fertility.
If you would like further guidance regarding your diet, an appointment to see a qualified dietician at City Fertility Centre can be arranged for you. Please contact the IVF nurse co-ordinators for more information on this service.
Taking folic acid before pregnancy and for the first three months of pregnancy can reduce your chance of having a baby with neural tube defects, such as spina bifida and anencephaly. We recommend that women planning a pregnancy increase their dietary intake of folic acid, a minimum of a month prior to, and particularly in the month of treatment. We also recommend a folic acid supplement (0.5mg or 500mcg daily) a minimum of a month prior to, and particularly in the month of treatment. Folic Acid supplementation should also continue for the first three months of pregnancy. Recent studies indicate an adequate intake of vitamin B6 is necessary for full absorption of folic acid.
Folic acid is a water soluble vitamin found in many fruits (particularly oranges, berries and bananas) and leafy green vegetables such as spinach, silverbeet, broccoli, brussel sprouts, cabbage, endive and avocados. It is also found in cereals, legumes and liver. It is available in tablet form, which can be purchased from a chemist or health food store.
There is a clear relationship between weight and fertility. As the body’s weight moves away from the normal range (above or below), fertility decreases. Pregnancy may still occur, but not at the normal rate, and the miscarriage rate is also higher than average. Weight loss may be essential before you start any other treatment program.
Both male and female patients are advised to stop drinking alcohol prior to treatment. In women, it may raise the risk of birth defects. In men, it may affect sperm counts.
Apart from the long-term health risks, women who smoke have 2.5 times higher incidence of infertility, have a 50% higher increase in miscarriage, premature birth and low birth weight babies than non-smokers. This is directly related to the fact smoking decreases uterine blood flow and circulating oxygen to the cells of the body, including the reproductive systems. Women who smoke also have poorer responses to fertility treatments, earlier onset of menopause, and lastly a higher rate of intrauterine growth retardation, congenital abnormalities and infant death.
Men who smoke have noted reductions in sperm count, motility and normal appearances of sperm. There is an associated higher incidence of impotence, increased birth defects, and higher rates of childhood cancer and asthma in their children.
Some medications may have an adverse effect on either female or male fertility or they may become ineffective when taken with certain supplements. Should you be taking any medication, please speak to Dr Davidson or the staff at City Fertility Centre to ensure that this is suitable.
The use of any recreational drugs should be avoided due to adverse health effects on the person and unborn baby. Cocaine use in pregnant women may increase the risk of permanent kidney damage in the baby. Marijuana and anabolic steroids may affect male sperm counts.
Caffeine may have an affect on a woman’s fertility and increase the risk of miscarriage. Caffeine is present in tea, coffee, coca-cola products, chocolate, some foods and medicines. Caffeine reduces the absorption of iron, and destroys B-complex vitamins. Ideally caffeine should be avoided by men and women prior to and during fertility treatment and pregnancy. A caffeine free alternative can be taken instead.
Lubricants may affect sperm quality and should be avoided if you are trying to conceive. All lubricants must be avoided during collection of semen for testing at the City Fertility Centre laboratory as the lubricant may damage the viability of the sperm.
Certain household products or occupations expose people to toxins including heavy metals, chemicals, and organic solvents (for example, oven cleaners, ammonia-based cleaners, fertilisers, furniture polishes, pesticides, certain cosmetics and paints). Heavy metals such as lead, cadmium, mercury, copper and aluminium interfere with essential enzyme systems important in reproductive health and foetal development.
Herbal Remedies and Complementary Therapies
Many herbal remedies are considered beneficial to overall well being and can be safely taken prior to your treatment or inbetween treatments. However at City Fertility Centre we do advise you to stop herbal remedies when you commence medications during treatment. Many herbal remedies will affect a hormonal action which may interfere or counteract the action of your fertility medications. Herbs should be used with the same caution you would use with any other drug. If you or your partner are taking herbal supplements, please advise your clinician.
There exists an ever growing range of complementary therapies offering different kinds of help and support to couples who plan to have children. Issues around fertility can provide an emotional strain on couples, and many of the complementary therapies available may benefit you as part of an integrated health plan to help improve your health and emotional wellbeing before, during and after fertility treatment.
Complementary therapies including, yoga, acupuncture, massage, meditation and aromatherapy are often used by patients in conjunction with fertility treatments. There is very little direct evidence to suggest these therapies may assist with fertility issues, however there is a strong body of evidence which supports these therapies as having the ability to induce relaxation and reduce emotional and physical stresses. Focusing care on your mind and body will help overall in improving coping responses in daily life and during treatment.
IVF can be a very emotionally and physically challenging time. In the lead up to, or during IVF treatment, understandably you may feel stressed or anxious. This is quite a common experience shared by many patients. It is important to ensure you get adequate rest and relaxation during treatment. Let go of all daily non essential activities and concentrate on your own well being first. Maintaining a positive state of mind improves your health and well being and your chances of a successful pregnancy. A degree of stress in your life is inevitable, but how you deal with it is important. At City Fertility Centre our qualified counsellors are available to assist couples suffering from stress as a result of their infertility problems. Support groups also welcome couples looking for help in coping with the stress of infertility.
When discussing any medication, it is important to keep in mind some concepts when discussing “side effects.” Side effects are really those symptoms, usually minor, most commonly suffered by a significant proportion of patients taking the medication; for example headaches or nausea.
There are also “adverse effects.” These are more serious events, usually rare and often unpredictable. An example includes ovarian hyperstimulation syndrome (OHSS).
Overall, fertility medications are generally safe and usually associated with only very mild side effects, relatively rare and treatable adverse effects (most commonly OHSS) and no known significant long term effects.
Below is a list of some of the most common side effects patients mention, as well as some of the more common adverse effects. It is by no means an authoritative or exhaustive list. It is always important to read the enclosed medication literature supplied within the medication packaging for a fully comprehensive list of side effects and adverse effects.
The most common symptoms and side effects:
Clomiphene (Clomid, Serophene®)
Clomiphene is prescribed for ovulation induction in anovulatory (absence of ovulation) women, but widely used for unexplained infertility in women who do ovulate regularly on their own.
- most common side effects include hot flushes, night sweats, dizziness and mood swings.
- adverse reactions include OHSS, abdominal pain or bloating, and temporary visual disturbances.
- long term effects include possible increased incidence of noninvasive (“borderline”) ovarian tumours (not proven to be causative). Most recent studies find no link with invasive ovarian cancer.
GnRH agonists (Lucrin, Synarel)
Lucrin and Synarel are used widely in Australia, to prevent premature ovulation in IVF cycles.
- most common side effects include mild headache, hot flushes and mood swings which are temporary and variable.
- adverse reactions include those patients with undiagnosed pituitary tumours experiencing a type of pituitary “stroke” when on Lucrin. This is very rare but potentially serious.
- long term effects include bone loss in long-term users,but this is not significant for the short courses used for IVF.
Gonadotropins (Puregon, Gonal-F)
- Puregon and Gonal-F are prescribed for ovulation induction in women undertaking IVF to recruit multiple eggs.
- most common side effects include tiredness, skin redness over the injection site, abdominal tenderness and swelling, breast tenderness, mood swings, nausea and dizziness.
- adverse reactions include OHSS (vomiting, diarrhoea, breathlessness, excessive abdominal pain and swelling) and multiple pregnancies.
- long term effects: Most recent studies are reassuring that there is not an increased risk in breast cancer. There appears to be a slight increase in women diagnosed with ovarian or uterine cancer following IVF treatment, however these diseases are prevalent in the general community in older women who have never undergone IVF treatment, and therefore it cannot be established gonadotropins are the causative agents. These studies are ongoing because this class of drug has only been in wide use for about 25 years.
GnRH Antagonists (Orgalutran, Cetrotide)
Prescribed in use for IVF to prevent premature ovulation.
- most common side effects include redness of the skin over the injection site, headache and nausea.
- adverse reactions include allergic reaction.
- long term effects include bone loss in long-term users, but this is not significant for the short courses used for IVF.
hCG (Pregnyl or Ovidrel)
Pregnyl or Ovidrel are prescribed to induce ovulation prior to egg retrieval in IVF or insemination (IUI) cycles, or to support the lining of the uterus after embryo transfer.
- most common side effects include slight abdominal discomfort at the time of ovulation, and redness of the skin over the site of injection.
- adverse reactions include OHSS (if a patient has multiple follicles in response to gonadotropins, hCG administration plays a key role in the development of OHSS). This is not seen in natural cycles and rarely in patients prescribed clomiphene.
- long term effects: None known.
Progesterone (Progesterone pessaries, Crinone applicators)
Progesterone is prescribed to support the lining of the uterus after embryo transfer in IVF treatment. These supplements are inserted vaginally. Progesterone is normally produced by the human ovary in the luteal phase and in early pregnancy so are widely used in fertility treatment.
- most common side effects include uterine cramping, abdominal discomfort (mild) and bloating, breast tenderness or headache.
- adverse effects include local vaginal reactions such as irritation or itching. Severe local skin reactions to progesterone are fairly rare. Allergic reactions include swelling of the face, tongue or other parts of the body and/or shortness of breath.
- long term effects: questions have been raised as to whether high doses of progesterone in early pregnancy may be associated with urinary tract abnormalities in the foetuses of the mothers taking progesterone. There has never been any such association proven.
Luveris is prescribed to assist the stimulation of follicular development in women with severe Luteinising Hormone (LH) or Follicle Stimulating Hormone (FSH) deficiency. It is usually used in conjunction with gonadotropins.
- most common side effects include redness of the skin over the injection site, headache and nausea.
- adverse effects include OHSS (if a patient has multiple follicles in response to gonadotropins, hCG administration plays a key role in the development of OHSS) or allergic reaction.
- long term effects include foetal abnormality in pregnancy, but only if administered during pregnancy. Long term carcinogenic studies have not been carried out.
We see counselling as an essential part of the service provided to all of our patients undergoing treatment. It is quite common for people to experience a range of emotions after the diagnosis of a fertility issue. Emotions may be heightened before, during and after treatment. Counselling is available to our patients at any stage.
Counselling is not a requirement prior to commencing treatment, however counselling is encouraged. Emotional responses vary from person to person, ranging from disbelief, blame, guilt, anger, isolation, grief and loss. Dealing with infertility and it’s treatment may be demanding and stressful. Counselling can support coping processes, reduce levels of stress and foster coping skills before, during, and after treatment, and even after all treatment has ceased. Counselling may also be beneficial for a variety of other concerns including relationship difficulties, issues with friends and family, depression and anxiety. Counselling allows thoughts and feelings to be explored and discussed privately.
Psychological Health and Infertility
Infertility and its treatment is widely recognised as a highly stressful life event, for both women and men. For this reason, mental health professionals can provide an essential component of infertility treatment. Unfortunately, while there is widespread agreement regarding the role of mental health support during fertility treatment, it seems that only a minority of patients actually participate in counselling sessions.
The association between stress and general health has been widely demonstrated. Poorer mental health can influence a patient’s vulnerability to physical illness, as well as their perception of the nature and meaning of symptoms. Stress is implicated as the cause of a diverse range of physical illnesses and has been found to influence the course and outcome of illness. A relationship has been clearly demonstrated between stress and fertility rates, and also between stress and success in assisted reproductive technologies. Higher levels of stress, depression and anxiety have been related to lower pregnancy rates. Unfortunately, for many couples, stress results from the infertility itself, but often also as a result of its treatment.
There are a number of direct biological mechanisms through which psychological distress might increase the risk of infertility. These relate to psychoendocrinology (such as elevated prolactin or cortisol levels), psychoimmunicology (such as impaired immune defences) and maladaptive behaviours (such as smoking, alcohol consumption, and poor nutrition). The clearest associations have been demonstrated in regards to the effect of stress altering levels of corticotrophin-releasing hormones and decreasing levels of luteinising hormones, thereby impacting on fertility.
Infertility treatment has been demonstrated to contribute to stress, depressed mood, increased rates of anxiety, problems with relationships, feelings of guilt and isolation, social adjustment problems, and sexual dysfunction. Higher than realistic expectations of treatment success can specifically contribute to the development of depression in IVF patients. Many studies have demonstrated that the stress associated with infertility treatment is a major cause of patients ceasing intervention.
Fortunately, treatment studies demonstrate that it is possible to reduce stress in individuals diagnosed with infertility. A range of studies have demonstrated that psychotherapeutic interventions, such as counselling, psychotherapy, hypnotherapy, relaxation, cognitive therapy and cognitive behavioural group interventions can reduce the stress of infertility and its treatment, and even result in improved rates of pregnancy.
If you are concerned that the infertility you are experiencing, or its treatment, is causing you stress, or if you have other significant stress occurring in your life, you may benefit from contact with a counsellor. Counselling offers the potential to learn more effective strategies for managing your stress, and an opportunity to problem solve your way through some of these stresses. The goal of counselling is to improve your general level of emotional and psychological functioning and assist in your goal of creating a family. For more information, contact CFC for an appointment with the counsellor.
Treatment which involves the use of donor gametes (egg, embryo or sperm) requires counselling prior to commencing treatment. Donors, recipients and spouses/partners must attend counselling to discuss the legal and psychosocial issues relating to this type of treatment.
Our experienced counsellors are registered psychologists or social workers and members of the Australian and New Zealand Infertility Counselling Association (ANZICA).
Types of Counselling
Therapeutic counselling: Aims to help people cope with the consequences of infertility and treatment, and to help resolve issues which may be caused from a diagnosis of infertility. It includes helping people adjust expectations and move towards acceptance of their individual situation.
Decision making counselling: At significant points during treatment, people may require counselling to help them make decisions involving the management of their treatment.
Supportive counselling: Provides emotional support and assistance to people at times of high stress.
Crisis counselling: Is available to people who experience a crisis or adverse outcome whilst undertaking treatment.
Implications counselling: Counselling is available to enable people to understand the implications of their treatment involving themselves, their family or children born as a result of treatment.
There are a number of factors that can influence your fertility that you have no control over, but there are several things you can do to maximise your chances of conception. Some of these factors will affect both male and female partners, but we will endeavour to cover them separately for males and females.
Diet & Exercise
It is recommended to follow a sensible diet and exercise program both before and during pregnancy.
Women who are either markedly overweight or underweight may have trouble conceiving. A healthy balanced diet rich in lean proteins and fresh fruit and vegetables is important.
Regular moderate exercise for an average of 30mins per session at least 3 times per week is recommended.
Smoking in women has been shown to increase the risk of miscarriage and also the risk of premature birth and low birth weight babies. This is in addition to all the long term health risks associated with cigarette smoking.
Alcohol consumption should be eliminated entirely or at least restricted prior to and after conception. In women, it has been shown to increase the risk of birth defects.
The process of trying to conceive can be stressful and research shows that women under stress produce prolactin which can interfere with regular ovulation. Find ways to relax, like yoga or meditation.
Caffeine comes in many disguises, not just our daily coffee. High consumption of caffeine has been shown to increase the risk of miscarriage, so limit your daily consumption to just 1-2 cups of coffee daily. Remember though that chocolate, colas and energy drinks all have caffeine in them so you may be consuming more than you are aware of.
You need to be taking a folic acid supplement at least one month before trying to conceive.
Studies have shown that these drugs can increase the risk of birth defects, and also cause medical problems in the mother.
These may affect the sperm quality so should be avoided if you are trying to conceive.
We are faced with a myriad of environmental toxins on a daily basis. If you work with or around toxins, you need to be using protective face masks etc. Talk with your doctor or specialist if you have any concerns.
Diet and Exercise
As with the female, diet and exercise play an important role in the production of healthy sperm. Men should also try to maintain a healthy body weight and perform regular moderate exercise. A diet rich in lean proteins and fresh fruit and vegetables is recommended.
Men need to keep in mind that sperm is produced at slightly below body temperature, so it is important to exercise at a sensible pace and not overheat yourself.
Because of overheating, sperm quality can be affected. The testes are outside the body to keep them cooler for a reason. Avoid hot spas, saunas, tight jeans, or even sitting with your laptop on your lap.
Apart from the long term risks associated with smoking, studies have also shown problems with sperm DNA Fragmentation.
Excessive consumption affects sperm quality, making it harder to conceive. Limit your intake if trying to conceive.
Studies have shown that the semen quality declines during periods of stress. Find ways to lower your stress levels, like going for a walk or playing golf with your friends.
There are both positives and negatives with caffeine intake for men when trying to conceive. It has been shown to boost mobility, however consuming more than 3 cups per day, or 300mg of caffeine, can result in sperm DNA damage. If smoking, alcohol and caffeine are combined there is a dramatic decrease in sperm quality.
Zinc deficiency can reduce testosterone levels and semen production. Taking a supplement can improve the DNA quality. We recommend taking a supplement with antioxidants and Zinc. There are several formulations available so ask your doctor or pharmacist for advice. You will need to begin taking this 3 months prior to conception.
Studies have shown Marijuana to have a major impact on sperm quality and quantity. It is not advisable to use any form of recreational drug when trying to conceive or after conception.
We are faced with a myriad of environmental toxins on a daily basis. If you work with paints, diesel fumes or pesticides, to name a few, you need to be using protective face masks etc.
Pollutants can cause DNA damage to sperm. Give them a wide berth whilst trying to conceive or take all safety measures possible whilst using them. Talk with your doctor or specialist if you have any concerns.
There is a common misconception that if you “save it up” and don’t ejaculate until ovulation then you will have more sperm and achieve fertilisation. This is definitely not the case. If you “save it up” the sperm become sluggish and tend to have more chance of DNA damage. You need to ejaculate regularly to keep the sperm healthy and motile. For best results you should try and ejaculate every two days, especially when your partner is ovulating. Often we are asked “can you ejaculate too much?” If you are ejaculating daily this will not cause a problem with most males. The quantity will not be as much but the quality should be good.
There are many concerns a new mum will experience following the confirmation of an early pregnancy. Wanting to ensure a safe and healthy pregnancy is a common experience shared by many women. Below is a list of some of the most commonly asked questions relating to the early stages of pregnancy. It is by no means an authoritative or exhaustive list, however it may help to alleviate some of those initial concerns until you are able to visit your doctor.
Is it normal to have spotting in the first month of pregnancy?
When an embryo implants into the uterine lining a small amount of vaginal spotting or bleeding may occur. The embryo is in touch with the mother’s blood, so oxygen passes to the developing embryo. Sometimes, as the blood bathes the embryo (about day 26 of the conception cycle), a small amount of blood leaks out of the uterus and into the vagina. This is called an implantation bleed and is quite common. This spotting or bleeding is often mistaken for a menstrual period although it is much lighter. Spotting or bleeding during the first few weeks of a pregnancy is common, however bleeding during pregnancy should always be evaluated by the IVF doctor or general practitioner. In most cases the pregnancy will progress without further complications.
Is it common to feel sharp cramps across the lower part of my abdomen during pregnancy?
Most women experience cramps or mild, stabbing pains not unlike menstrual pain, and cramping during pregnancy. This results from the stretching of muscles and ligaments that support the uterus, as the embryo begins to grow in the womb. Sometimes this is also associated with backache. It is common and usually subsides around 20 weeks of the pregnancy. Back pain is probably the result of softening of the supporting ligaments and discs due to the elevation of progesterone. However, it could be related to bladder or kidney infection, so be sure you do not have an underlying urinary infection.
Can I take medicat during my pregnancy?
It will depend upon the medication. Certain medications are not suitable to ingest during pregnancy as they may cause harm to the baby. If a medication has been prescribed during your pregnancy by your doctor, it is best to discuss with your doctor the risks and benefits of the medication in relationship to the reason the medication has been prescribed. The decision to use medication can be a difficult one. However when the potential benefits of the medication outweigh the potential risks of the medication to the mother and baby, medication may be the appropriate treatment. If you are purchasing an over the counter medication from a chemist or pharmacy, it is always advisable to check with the pharmacist if the product is safe to take during pregnancy, or read the enclosed patient information leaflets contained within the medication packaging. This will reduce a great deal of anxiety regarding the safety of medications administered during pregnancy.
What can I take to stop feeling nauseous?
About three quarters of pregnant women have nausea (and sometimes vomiting) during their first trimester. For some, it’s worse in the morning and gets better over the course of the day, but “morning sickness” can strike at any time. The nausea usually starts around 6 weeks but can come on as early as 4 weeks and tends to worsen over the next month or so. About half of the affected women feel complete relief by about 14 weeks. For most of the rest, it takes another month or so for the nausea to ease up, though it may return later and come and go throughout pregnancy. By and large it is best if you can avoid any medications that may cause birth defects. While there are no magic cures for morning sickness, there are some natural alternatives which have individual success for each woman. Vitamin B6 (also known as pyridoxine) relieves nausea for some women. Pregnant women who do not suffer nausea need only 1.9 milligrams of this vitamin a day to help make antibodies, red blood cells, and neurotransmitters. The usual dose recommended for easing nausea and vomiting is much higher (10 to 25 mg, three times a day). However it is advisable to check with your healthcare provider before taking large doses (The amount of vitamin B6 in supplements varies by brand). Amounts greater than 100 milligrams per day have been associated with nerve damage.
Acupressure bracelets are also a natural alternative to medications. When applied to a specific acupuncture point around the wrist accupressure therapy bracelets control nausea and vomiting. Some women have found these bracelets beneficial in alleviating morning sickness, but they may not work for every woman.
Can I fly during my pregnancy?
Flying is generally safe during pregnancy. Usually the advised times to safely fly are from the 4th to 6th month of pregnancy. By then the physical and emotional adjustments within the first trimester have resolved. Airline services vary, but usually allow pregnant women to fly up to 28-30 weeks of pregnancy. Later than this is not advisable. Ask about flying restrictions before you book your ticket. Check with your doctor if you are unsure.
I feel so tired. Is this normal?
Many women feel wiped out during pregnancy, especially in the early stages. During the early weeks of pregnancy, your body is working hard, pumping out hormones and producing more blood to carry nutrients to your baby. To accommodate this increased blood flow your heart pumps harder and faster. Plus, progesterone is a natural central nervous system depressant, so high levels of this hormone may make you sleepy. In addition, the possibility of pregnancy can bring about a range of feelings and concerns that may sap your energy and disturb sleep.
I have frequ urination and I am constipated. Is this normal?
Many pregnant women find themselves running to the bathroom more often than usual during the first trimester of pregnancy. This is caused by the enlarging uterus pushing on your bladder. Constipation is another common early indication of pregnancy. An increase in progesterone causes digestion to slow down, so food passes more slowly through the gastrointestinal tract, which can lead to constipation. Increasing your fibre and fluid intake will help to avoid constipation. Sometimes a natural remedy to help alleviate constipation can be purchased from your local pharmacy or chemist.
Why am I getting headaches?
If you’re pregnant, you may be troubled by frequent, mild headaches. Early in pregnancy, headaches may be the result of increased blood circulation caused by hormonal changes.
Does exercise help during pregnancy?
Because exercise promotes muscle tone, strength, and endurance, it can help you carry the weight you gain during pregnancy, prepare you for the physical stress of labour, and make it easier to get back into shape after the baby is born. Being active during your pregnancy can also reduce the physical discomforts of backache, constipation, fatigue, and help you sleep more soundly at night. Some women need to take extra care when exercising. Check with your doctor before starting any exercise if you have a history of threatened miscarriage, had a previous premature delivery, are at risk of premature labour, have a low lying placenta, pre existing medical condition, bleeding, high blood pressure or expecting twins. Walking, swimming, stationary cycling, aqua aerobics, yoga and Pilates are all considered suitable forms of exercise in pregnant women. It may be safe for you to keep up high intensity workouts during a healthy, uncomplicated pregnancy, without compromising the baby’s health. However, remember to let your doctor or midwife know you plan to continue your workout routine, especially if you need to take extra care during your pregnancy.
The flood of hormones in your body in early pregnancy can make you unusually emotional and weepy. Swings in your mood, from bliss to deep gloom are also common, especially in the first trimester. Pregnancy can be a cheerful time, but not always, and not for every woman. At least 10 per cent of pregnant women suffer from bouts of depression. Fifty per cent of women suffering from severe depression during pregnancy go on to develop postnatal depression, but therapy during pregnancy can reduce that number dramatically. If you experienced many difficulties trying to get pregnant, or have had a miscarriage in the past, you may find yourself worrying about the safety of this pregnancy. Other common issues experienced by pregnant women include general anxiety, sleeping problems, relationship difficulties or other stressful life events. Remember to take it easy and talk about your concerns with your spouse, family or friends. However, if you remain concerned that your mood is not lifting, talk to your doctor or midwife, or consider making a counselling appointment with one of our qualified counsellors at City Fertility Centre. A counselling appointment time can be arranged to suit you. Please ask to speak to the IVF Nurse Co-ordinators for more details.
Faintness and Dizziness
It’s common for pregnant women to be lightheaded or dizzy. These sensations usually result from circulatory changes as your blood vessels dilate and your blood pressure drops. Early in pregnancy, faint feelings may also be triggered by low blood sugar.
Preconception Care Fact Sheet
Recommended advice provided within the Preconception Care Fact Sheet should also be maintained during your pregnancy.
Interpreting Semen Analysis Results
It is well documented that male factor infertility accounts for 30% of couples experiencing infertility. Therefore, the importance of a complete and thorough evaluation of the male partner cannot be underestimated, as ultimately clinical decisions are based on these results. Research has shown that laboratories do vary widely in their ability to provide accurate semen analyses. Semen analyses are best performed by scientists with extensive experience following the guidelines and criteria of the World Health Organisation.*
The evaluation of the male partner begins with a simple laboratory test called a complete semen analysis, commonly known as a “sperm count.” However there is certainly more involved than just counting the sperm. Semen analysis is done on a sample of seminal fluid collected after masturbation. Generally, it is preferable that men produce their samples in the comfort of their own home and deliver the sample to the laboratory within one hour. For patients who live further afield, City Fertility Centre has a discreet private room available.
In order to obtain an accurate result, it is recommended that the analysis is performed after the couple has abstained from sexual activity for 3-5 days. Less than 2 days may result in a reduced sperm count. Abstinence periods of greater than 7 days results in a greater incidence of dead and morphologically abnormal sperm. It is a common misunderstanding of some male patients that they can improve their semen by “storing it up”.
In the laboratory, the City Fertility Centre scientists analyse the following parameters; volume, sperm concentration, sperm motility (the number moving and progression of sperm) and sperm morphology (the shape of the sperm head, mid-piece and tail). In addition, the presence of antisperm antibodies can also be detected.
A normal sperm, as shown below, consists of three main regions that each play an essential role in achieving the ultimate goal of fertilising the egg. City Fertility Centre scientists assess the morphology of each of these regions in order to give an overall incidence of normal morphology.
1. THE HEAD, which is oval in shape and contains the genetic information of the sperm. It also has a region known as the acrosome that is responsible for the release of enzymes involved in the fertilisation process.
2. THE MID PIECE, contains mitochondria which are responsible for generating the energy required to “swim” towards the egg.
3. THE TAIL, this contains microtubules that propels the sperm along the female’s fallopian tubes.
Normal Ranges and Glossary of Terms Used
When parameters fall outside the normal ranges as defined above, the following terms are used:
- OLIGOZOOSPERMIA – reduced number of sperm present.
- TERATOZOOSPERMIA – reduced number of normal shaped sperm
- ASTHENOZOOSPERMIA- reduced number of motile/ progressive sperm
- AZOOSPERMIA- no sperm present in entire ejaculate.
In the human it takes 64 days to produce a fully functional mature sperm. Although many of the factors that can affect this process are as still scientifically unknown, the following have been proven to have a negative effect upon sperm quality.
- excessive alcohol
- recreational drugs
- some herbal supplements
- prolonged exposure to chemicals such as pesticides and heavy metals
- illness – in particular fevers
Intrauterine Insemination (IUI)
IUI is generally recommended when the semen result is normal or with mild parameters. Motile sperm are separated and concentrated from the seminal fluid and inseminated into the uterus. This can improve fertility by increasing the number of motile sperm that reach the egg. The sperm washing procedure separates the motile sperm from the seminal fluid and activates sperm motility.
In Vitro Fertilisation (IVF)
IVF is generally recommended when there is mild/ moderate male factor infertility. The semen sample is washed and concentrated, and by directly placing eggs and sperm together in the laboratory the chances of successful fertilisation are increased. The resulting embryos are then transferred into the uterus. (see our IVF page for more information).
Intracytoplasmic Sperm Injection (ICSI)
ICSI is performed in conjunction with IVF and usually recommended for severe male factor infertility. This technique maximises fertilisation rates by directly injecting a single sperm into an egg using micromanipulation pipettes. The introduction of this technique has revolutionised the options for treatment of infertility. (see our ICSI page for more information).
Sperm Aspiration (PESA, TESA)
Sperm aspiration is performed in conjunction with IVF and ICSI. In men diagnosed with azoospermia, sperm may be obtained directly from the epididymis or testicular tissue. There are two main reasons why sperm may be absent from the semen.
1. Obstructive azoospermia is the result of a blockage in the male reproductive tract. Sperm production in the testicle is normal but the sperm are trapped inside the epididymis, as seen in patients who have undergone vasectomies.
2. Non-obstructive azoospermia is the result of severely impaired or non-existent sperm production. A diagnostic procedure is usually recommended to confirm the presence of sperm.
Male infertility is a common problem in couples trying to conceive and the diagnosis of this can only be made by a complete semen analysis. Although the actual fertility of a semen sample cannot be completely determined until it is known to achieve fertilisation, careful and thorough analysis of all the semen’s parameters by a specialised laboratory can allow treatment options to be appropriately considered.
In most cases of male factor infertility, the exact cause of the problem often is not known. There are now a variety of effective infertility treatments available. Using the right technology, even couples with severe male factor infertility today have options to achieve the birth of their own biological child. As recently as 15 years ago the only options for these couples were donor semen, adoption or childlessness.
*WHO Laboratory Manual for the Examination and Processing of Human Semen (Fifth Edition)
The methods for evaluation of male infertility have typically been limited to a semen analysis measuring count, motility and morphology of the sperm. Up to 8% of infertile men have been shown to have high levels of sperm DNA fragmentation despite a normal semen analysis*. New studies suggest that sperm with certain levels of DNA fragmentation serve as a strong predictor of reduced male fertility.
The development of a healthy embryo is initiated when the chromosomes from the female (in the egg) come together with chromosomes from the sperm. These chromosomes consist of strands of DNA (deoxyribonucleic acid). These strands of DNA can become damaged.
Research indicates that sperm with high-levels of DNA fragmentation have a lower probability of producing a successful pregnancy. A review of data on hundreds of semen samples show that patients with a DNA fragmentation level of greater than 30% are likely to have significantly reduced fertility potential, including a significant reduction in full term pregnancies and a doubling of miscarriages. Sperm that appears to be normal by traditional semen analysis parameters (motile, morphologically normal sperm) may even have extensive DNA fragmentation. In an effort to achieve the most effective measurement of male fertility potential, Sperm DNA Fragmentation Analysis is an option.
The sperm are captured within an inert agarose gel. This is treated with an acid denaturant which removes already fragmented DNA.The remaining material is then treated with a lysing agent which frees the intact DNA into the agarose gel. This agarose is then stained to highlight the released DNA, and evaluated to determine the degree of fragmented versus intact DNA.
Causes of sperm DNA damage:
- drugs, chemotherapy & radiation therapy
- cigarette smoking & environmental toxins
- genital tract inflammation
- testicular hyperthermia (use of hot baths, saunas, laptop computers & prolonged periods of driving)
- hormone factors
- infrequent ejaculation
- male’s age
Treatment for Sperm DNA Damage
Depending on what caused the damage to the sperm DNA there may or may not be a way to improve the sperm DNA. Some ways that may help improve sperm DNA is to change to a healthier lifestyle – stop smoking, avoid exposure to toxins, and take a daily supplement of antioxidants and zinc. Further clinical options can be discussed with Dr Davidson
*Sperm DNA fragmentation: Mechanism of origin, impact on reproductive outcome, and analysis. D. Sakkas et al Fertility and Sterility, Volume 93, Issue 4, March 2010.
This is the procedure of freezing sperm cells in order to preserve them for future use. Sperm cells have been frozen and thawed successfully for more than 40 years. By using special technologies and then keeping it in liquid nitrogen (-196°C) sperm can be stored for many years while still maintaining a reasonable quality.
Unfortunately, life is unpredictable. There are many situations that could interfere with your future fertility. These may include:
- chemotherapy or radiation therapy
- certain types of pelvic or testicular surgery
- high risk occupations or sports
- diabetes may cause erectile difficulty
- male away from home on day of assisted reproductive treatment
Please ask your GP or specialist doctor for a referral form to see Dr Davidson, or City Fertility Centre. At your first appointment we will arrange blood tests for Hepatitis B, Hepatitis C and HIV. We routinely screen for these infections because they may be transmitted through the semen to a female partner or an unborn child, and to minimise the risk of contamination during storage. Once you receive your blood test results please contact us to arrange a specific time to deliver your specimen within one hour of production, or to book a time to produce the sample at our facility. At this time you will need to sign consent forms for the freezing and storage of sperm, which last for up to ten years at a time.
Everyone’s situation is different. Most men freeze between two and five samples. Some choose to freeze many more samples. In many cases the time interval prior to surgery, chemotherapy or radiation therapy will be the deciding factor. We recommend abstaining from intercourse and ejaculation for at least two days, but not longer than five days before the first sample, and for about two days between the samples.
There is a fee for freezing each semen sample. This fee includes six months storage. After six months storage costs apply for storing one or more samples at City Fertility Centre. This annual storage fee is regardless of the number of samples stored and is not refundable. Please phone City Fertility Centre to ask about our current rates.
City Fertility Centre does not charge oncology patients for freezing sperm.
Sperm can be frozen indefinitely. Scientifically there is no limit to the length of time that sperm can be stored in a frozen state. Damage can occur to the sperm during freezing and thawing, not while it is frozen. The duration of time in storage does not influence the success rate. You must update us about any address changes. If we cannot reach you to collect the storage fee and to confirm that you want to maintain the frozen samples, we will thaw and destroy your semen samples. If you no longer require your sperm frozen please contact the clinic for the disposal of your samples and consent forms.
Please inform Dr Davidson that you wish to utilise your frozen sperm sample. There are several treatment options, depending on the number and quality of sperm available. Your partner will need to undergo some basic fertility investigations. Frozen sperm can be used for intrauterine insemination (IUI) if the quality of the thawed sperm is good enough. If sperm quality is reduced due to illness or other factors, it may be necessary to undertake Invitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI) where individual sperm are injected directly into the eggs.
At City Fertility Centre we offer industry leading pregnancy rates. Once sperm is thawed successfully, the success rates for an IUI cycle are 10-20% per cycle, and for an IVF cycle 40-50%, depending on age and medical history. Please feel free to discuss your individual situation with Dr Davidson and enquire about your personal chance of success.
Research has shown no difference in the rates of abnormalities or birth defects among children conceived with fresh versus frozen sperm. However, there are some theoretical concerns that chemotherapy drugs may have unknown effects on the sperm or the offspring. If possible, it is best to freeze the specimens before chemotherapy begins.