Dear Patients,
We are pleased to announce that we are beginning a collaboration with Care Fertility and their Laboratory, which remains at the cutting edge of scientific research. In light of this, our contract with London Women’s clinic has come to an end. Please note that this transformation doesn’t affect patients’ gametes or embryos storage.
From 1st April 2024, our office has moved to a new premises at 92 Harley Street.
Please bear with us during this transformation and we can reassure you that we are still highly dedicated to providing the best one to one care.
Thank you for your support,
Fertility Plus Team
A large cohort study of more than 1200 women having IVF in China has found that ‘unhealthy sleep characteristics’ do indeed have some adverse effect on outcome by reducing the number of oocytes retrieved and their ability to fertilise.
A meta-analysis reporting last year found 33 eligible studies from an opening total of more than 1200. However, despite the volume of studies, no firm conclusions were drawn other than that ‘sleep may be an original and innovative parameter to consider in the reproduction field’.
Now, a large prospective cohort study analysing the sleep patterns of 1276 women having IVF in China indeed suggests that ‘unhealthy sleep characteristics’ – short nocturnal sleep, inadequate sleep time, poor sleep quality and having trouble falling asleep – may inhibit the quantity of oocytes and their potential for maturity and fertilisation.(2) Specifically, women who slept less than seven hours a night and reported trouble falling asleep had fewer IVF oocytes retrieved (-11.5%) and of lower quality than those sleeping seven-to-eight hours (the reference duration). Additionally, those who reported poor sleep quality had a 20% lower fertilisation rate than the women who reported good sleep quality. And women with trouble falling asleep on more than three occasions a week had fewer MII oocytes and embryos available than those with no trouble falling asleep.
However, analysis did curiously find that women who slept from nine-to-ten hours per night had a lower chance of clinical pregnancy than those within the reference duration of sleep, reflected in an adjusted odds ratio of 0.65.
Moreover, the strong positive associations between sleep duration and fertilisation rate, number of oocytes retrieved and good quality embryos, and pregnancy rate was only evident in women over 30 years or those with poor reported sleep quality – thus suggesting that an effect of nocturnal sleep duration on implantation and clinical pregnancy is modified by age. But unlike some other studies, this analysis did not find any adverse effect of shift work on implantation and pregnancy rate.
This, however, was a complicated study in which sleep patterns were self-reported and with multiple covariates integrated into the analytical model (age, BMI, smoke exposure, alcohol consumption, stimulation protocol, infertility diagnosis, and FSH and AMH levels at day 3). pregnancy and clinical pregnancy.
The complexity of the study means that definitive conclusions are hard to draw, but the authors seem confident that ‘short sleep duration and disorders were associated with impaired oocyte quantity and quality’. However, they concede that the underlying mechanisms are poorly understood, but note that the ‘dysregulation of clock genes . . . may cause diminished ovarian reserve, abnormal reproductive hormone sensitivity of theca cells, disturbed DNA repair and eventual reduction in oocyte quality’. They also note that a disrupted circadian rhythm can reduce levels of melatonin in follicular fluid and trigger oxidative stress damage to oocytes.
Interestingly, ‘season’ was one of many covariates included in the study model, with the timing of egg collection allocated to spring, summer, autumn or winter. While the majority of retrievals (48%) took place in the summer, there are no details of seasonality-affected results.
However, a recent retrospective study analysing more than 3000 frozen transfers with oocyte retrievals performed in a single US centre between 2012 and 2017 found that patients with egg collections carried out in summer months had a 45% greater chance of clinical pregnancy (OR 1.45) and 42% of live birth than those with retrieval dates in winter.(3) However, there was no association between the date of embryo transfer and treatment outcome, suggesting to the authors ‘that any seasonality effects on in vitro fertilization success are related to ovarian function and not uterine receptivity’.
In IVF, the routine policy is to take the embryo to a blastocyst stage, that is a day five stage. The uniqueness of the blastocyst stage is that embryos start dividing at a faster rate. Until day four they are dividing in very much an arithmetic progression of doubling while between day four and day five they go into a far more accelerated growth and division of the cells taking place with cells which are called the inner cell mass which forms the baby, and the outer cell mass that forms the placenta, thus at this stage the embryo is ready to start the process of implantation.
There is good evidence to suggest that embryos that do not reach this stage may not be of sufficient quality to implant. Often we are told that it is possible that embryos that do not reach this stage could be genetically abnormal. Whilst this has been based on hearsay evidence, there has been a study which looked at screening these embryos through a biopsy when they did not reach a blastocyst stage, which is a morula stage on day six. This was a study undertaken and published in Human Reproduction 2018, and routinely morulas, which are day four embryos which never became blastocysts, even by day six (while they should become by day five a blastocyst) were biopsied and sent for genetic analysis. These were exactly the embryos which were slowly progressing.
A huge number of morulas were biopsied, close to 1260 and 3014 blastocysts were biopsied. What was shown is that blastocysts which had an aneuploidy under the age of 35, 40 per cent of good blastocysts are abnormal, while by the age of 40, almost 78 per cent of blastocysts are abnormal, but when you started doing a biopsy of embryos which were slow, it identified that the abnormality rate ranges between 57 to 68 per cent, and this worsened as women reached 38 to 39 and 80 per cent of these embryos were abnormal.
Thus there is no doubt that with advancing age and embryos not reaching a blastocyst stage, the percentage of embryos which are abnormal increases, thus there is some logic towards not transferring these embryos in older women, while in younger women it may be reasonable to try and see whether transferring these in a fresh cycle would give a better chance of pregnancy.
Myo-inositol treatment has been used for a significant number of years to cure polycystic ovaries. It is not a drug, but a nutritional supplement. What we know is that there is a role of Inositol in signalling of insulin, and a defect there may cause insulin resistance. There is some role of Inositol in human reproduction, and what we are aiming to see if a supplement of Myo-inositol may help improve outcome in polycystic ovaries.
There is some evidence in women with irregular periods with polycystic ovaries, giving Myo-inositol did improve the chance of menstrual cycles. There is a threefold increase vs placebo and slightly increased ovulation rates. Unfortunately, there was no change seen in pregnancy rates when they were compared with a placebo drug or with metformin, so at present we do not know whether Myo-inositol is helpful, but there seems to be some evidence to demonstrate that it helps in lowering the hormonal profile.
We are often asked if covid-19 vaccine reduces female fertility and whilst there were no trials specifically done on pregnant women, there is some evidence in trials to draw conclusions and it is reassuring.
In the article below, Viki Male, Lecturer in Reproductive Immunology at Imperial College London looks at the data available across the key covid-19 vaccines and it is reassuring.
Viki Male says, “In fact, multiple strands of evidence tell us that COVID vaccines do not reduce fertility. Pregnant people were not included in the first round of trials, and participants were asked to avoid becoming pregnant, but nonetheless a number of people became pregnant by accident. The accidental pregnancies occurred equally across the vaccinated and the unvaccinated groups, which tells us that vaccines did not prevent pregnancy. The people who became pregnant have been followed closely, and have had normal pregnancies”
For the latest data by Viki Male, please visit @vikiLovesFACS.
We now have good UK data to show that pre implantation genetic screening by embryo biopsy, in women over the age of 35 years, improves the live birth rates and reduces the number of attempts taken to obtain live birth.
This study, published in Journal of Assisted Reproduction and Genetics on November 12th 2021, examines the live birth and other outcomes reported with and without preimplantation genetic testing for aneuploidy (PGT-A) in the United Kingdom (UK). A total of 2464 PGT-A outcomes were reviewed.
See the article here.
Here we aim to explain the basics of IVF and ICSI treatments (In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI)), establishing the main differences between each.
IVF (In Vitro Fertilisation) is one of the most commonly used fertility treatments. . The process involves retrieving the woman’s eggs and placing them into a laboratory dish that contains prepared sperm, that has been provided by the male party. When placed together in the dish, the sperm will penetrate and attempt to fertilise the eggs naturally, creating embryos. These embryos are then monitored by an embryologist for up to 5 days and then when the time is right, the strongest are selected and transferred back to the womb at the right time, or frozen for later use.
IVF was originally designed to assist with fertility issues due to blocked or damaged fallopian tubes. However, due to its success, it now treats a broader range of infertility problems. This includes:
Before proceeding with any form of fertility treatment, it is important to understand the risks involved. Potential IVF risks include:
Poor Response: When going through IVF, tests are conducted to predict ovarian response. However, sometimes, an inadequate response might occur. This essentially means that the ovaries fail to respond to stimulation, making it difficult to collect any eggs.
No Eggs: Although rare to happen unexpectedly, you may find that no eggs can be collected when attempting IVF. This links to poor egg quality, which might suggest that another form of fertility treatment (such as an egg donor) is needed.
Ectopic Pregnancy: Unfortunately, up to 5% of IVF and ICSI pregnancies may be ectopic. This means that the pregnancy occurs outside of the womb, affecting miscarriage rates by around 10%.
Ovarian Hyperstimulation Syndrome: As the name suggests, OHSS occurs when the ovaries get overstimulated. Although a rare risk of IVF, it’s important to be aware of, as a small number of OHSS cases require hospitalisation.
Just as with any form of treatment, always speak to your fertility consultant about the risks involved with IVF or ICSI.
ICSI stands for Intracytoplasmic Sperm Injection. It is a type of IVF that similarly involves the retrieval of eggs and then selecting a single sperm and injecting it directly into an egg. The fertilised egg is then transferred into the womb at the right time, in the same way as it is with IVF.
ICSI is often recommended for those affected by male infertility (sperm-related infertility). Sperm-related infertility includes, but is not limited to, low sperm count, poor sperm motility or abnormal sperm shape.
ICSI might also be recommended to those with the following problems:
ICSI was introduced in 1992, making it a slightly more modern type of fertility treatment than IVF. Whilst many babies have been born using ICSI, it is not yet known if there are any long-term risks involved for children conceived by ICSI. Current known risks are the same as the IVF risks mentioned earlier in this guide.
The main difference between IVF and ICSI involves the contact made between the sperm and the egg. With ICSI, each egg is injected with a single sperm. With IVF, the sperm naturally penetrates the egg.
ICSI is a form of IVF, meaning that the two treatments have a lot of similarities. Once both treatments have witnessed the sperm fertilise the eggs, the process remains the same for both types of treatment. The embryos are monitored in an incubator for up to five days, at which point the strongest embryos are replaced back into the womb.
IVF is one of the most common and effective forms of fertility treatment, with over eight million babies born through IVF and counting! However, this treatment isn’t suitable for everyone, and your fertility specialist may recommend an alternative treatment based on your specific circumstances.
Simply put, there’s no “one-size-fits-all” approach when it comes to fertility treatments. Each body works differently and therefore may require a different approach.
IVF and ICSI are both key types of fertility treatment that are responsible for thousands of pregnancies each year. Although very similar treatments, ICSI involves injecting sperm into an egg, whereas this process happens naturally during IVF. For this reason, ICSI treatment is more tailored to those with issues relating to male infertility.
When it comes to deciding what form of fertility treatment is best for you, your fertility specialist should always guide you.. Here at Fertility Plus, we can talk you through your options and help to find the most suitable treatment for your situation. You can contact us to book a consultation.
For some patients, going to a fertility clinic can feel like a nerve-wracking experience. One way to feel more relaxed about your appointment is to prepare a few essential questions in advance, so you can be sure that your consultant answers everything you need to know. Here are nine important questions to ask your fertility consultant.
1. What Is My Diagnosis And How Does It Interfere With Fertility?
The first question to ask is what your specific diagnosis is and how it affects fertility. There are many causes for infertility, so your consultant should explain to you what the issues are and how they directly correlate to your infertility. Following on from this, they need to explain whether those conditions may change over time, will they get worse, stay the same or if there’s potential for them to improve.
2. What’s Your Clinic’s Success Rate Overall, And For Patient’s With My Condition?
It’s worth checking in with your consultant as to how successful they’ve been with treatments for patients in the past. Finding an IVF clinic in London that has had success with IVF cycles and live births for their patients, as well as a clinic that has worked with patients with similar backgrounds to you and your partner can help increase your chances of success.
3. Are Less-Invasive Treatments Available?
Once your consultant has explained the potential treatments available to you, you should ask if there are more conservative treatments available and how these compare to the treatments they recommend in terms of success rates and the associated risks. Every treatment, whether it’s assisted conception, surgery or medication, comes with its own pros and cons and side effects, so you should weigh up what those are and discuss the options with your doctor.
4. What’s The Estimated Timeline For My Circumstances?
The process of your treatment and the timeline may differ from the projections your consultant gives you. For most people, a single cycle of IVF can take between four and six weeks, but it depends on the individual’s circumstances – some women, for example, may not have the first stage of treatment which suppresses hormone production, which can reduce the time by several weeks.
5. How Many Embryos Are Typically Retrieved And Transferred To A Patient Like Me?
The number of embryos retrieved will depend on your health and your age, so this is a valuable question to ask your consultant as they may suggest just taking a single embryo or several. The latter will increase your chances of getting pregnant, however a single embryo retrieval is safer for the mother and baby. It can also be worth asking whether they prefer fresh or frozen embryos. ‘Fresh’ embryos, or non-frozen embryos, are transferred shortly after the eggs are fertilised while freezing can take a few extra weeks but might increase the chances of conceiving for some patients.
6. How Many Cycles Of Treatment Are Recommended Before Trying Other Options?
This will vary between clinics and specialists, so it’s a valuable question to ask. Some consultants recommend skipping a menstrual cycle between each treatment cycle, and there may be a set number of tries they suggest before switching to another treatment. It will help you set out expectations early on and will help you plan ahead if you’re not seeing the right results from your sessions.
7. Do You Recommend Any Additional Lifestyle Modifications?
While your treatment will be the main focus of your fertility journey, there are ways that you can support the treatment by modifying your lifestyle. Your consultant is the expert in terms of the specific treatment you’re receiving so they’re the best source of advice in terms of the changes you can make to increase your chances of getting pregnant. They may suggest increasing the amount of exercise you do each week, or cutting back on alcohol or giving up smoking, for example. They will have access to your medical history, and you can discuss your current lifestyle choices with them so they can provide additional guidance to aid your treatment.
8. How Often Will I Be Communicated With For Updates?
The wait for updates is difficult – you want to know whether the treatment has been successful or if there are any problems, so knowing how often the clinic will be in touch can provide peace of mind. Most clinics have standard protocols for contacting patients with updates, whether that’s daily after retrieval or only getting in touch when they have news to update the patient with. You should also check who your point of contact will be if you have any follow-up questions or need further information after your appointment, so you’re not wasting time being moved between different members of staff.
9. Will I See The Same Doctor Each Visit?
Patients place their trust in their fertility consultant and like to build a rapport with them so it’s important to know whether you will see your doctor every visit or if this can’t be guaranteed. At Fertility Plus we do our best to have a one to one approach with our patients, meaning they see the same doctor each visit unless in exceptional circumstances.
Don’t Be Scared – Be Prepared!
Understanding which questions you want answers to before your appointment with your fertility consultant will ensure you maximise the time you have with them. It will also help you to feel better prepared and less overwhelmed by the prospect of speaking with your fertility consultant, as you’ll have the right information to the key questions before you start your treatment.
At Fertility Plus, we treat every patient as an individual, with a personalised treatment plan for each patient. We believe this helps the patient feel comfortable throughout their journey and provides the best outcomes possible.
Infertility is a term used for people who have difficulty getting pregnant despite regular unprotected sex; it affects an estimated one in seven couples. While it’s a problem that affects many people, it can feel incredibly isolating and frustrating. There are many reasons why you or your partner may be experiencing difficulties conceiving and there are several treatments available depending on the cause of your difficulties. We’ve outlined the main types of fertility treatment to help you on your path to conception.
There are many reasons why you might be experiencing infertility and tests will be able to determine the most likely cause. Infertility problems can affect either partner, and common causes include irregular ovulation, low quality semen, blocked or damaged fallopian tubes, or endometriosis.
There are other factors that can impact your fertility, including age, weight, stress, environmental factors such as exposure to certain pesticides or solvents, or excessive smoking or alcohol consumption. Certain STIs such as chlamydia can also affect fertility.
The treatment you’ll receive will depend on the cause of the issue, and what your doctor recommends, but the three main types of treatment for fertility are:
There are several medicines available for fertility issues, including clomid tablets which contain clomiphene to encourage ovulation in women who don’t ovulate regularly or at all, and Tamoxifen which is an alternative to clomiphene for ovulatory issues.
Gonadotrophins can stimulate ovulation and can also be used to improve fertility in men with fertility difficulties, and Metformin may be prescribed for women suffering with Polycystic Ovary Syndrome (PCOS).
It’s important to speak to your consultant about the side effects of these medications, as they can vary from nausea and headaches to vomiting and hot flushes. Likewise, if you’re already taking medication, it’s essential that you confirm with your consultant that there are no contradictions with your fertility medication to avoid negative side effects.
Surgical procedures are used to investigate infertility in more depth and to aid fertility. For example, fallopian tube surgery may be prescribed to repair broken or scarred fallopian tubes, helping to break up scar tissue so that the egg can travel through more easily.
For women with endometriosis, where parts of the womb lining grow outside of the womb, laparoscopic surgery can help to remove cysts and submucosal fibroids which may have developed in the womb.
There are also surgical procedures for infertile men, such as correcting epididymal blockages which prevent sperm from being ejaculated. Surgical extraction of sperm can also be prescribed for men who either have an obstruction preventing a normal release of sperm, who have no vas deferens tube which drains sperm from the testicles, or who have had a vasectomy.
As with any surgery, there are associated risks, such as the potential for complications. It’s important that you and your partner weigh up the pros and cons of each option before deciding on the best surgery for your situation.
IUI, which is also referred to as ‘artificial insemination’, is the process of inserting sperm into the womb surgically via a plastic tube through the cervix. The highest quality sperm are selected in order to increase the chances of successful implantation, and this process is often coupled with other treatments such as the FSH injection.
IVF is one of the most common infertility treatments and it describes the process of fertilising an egg outside of the body and then implanting it into the womb where it grows and develops if it implants successfully. ICSI is a form of IVF, however the key difference is the sperm is directly injected into the egg to create fertilization.
Finally, there’s egg or sperm donation that can be used to help couples conceive. Treatment using donor eggs or sperm is typically carried out using IVF.
It can help to make lifestyle choices to assist your fertility treatments, to improve your health and wellbeing and put your body in the best health for pregnancy and parenthood. Excessive tobacco and alcohol consumption in men and women can be damaging to the body, including contributing to infertility, so it’s worth cutting back or avoiding completely to boost your health.
If you’re on any prescription or non-prescription medication, discuss this with your GP as there are certain drugs which can affect your fertility – your GP may be able to prescribe an alternative in its place if the medication you’re taking may affect your fertility. However, don’t stop any medications suddenly without first discussing it with your doctor.
There’s a lot to consider when choosing infertility treatments, from the length of the treatment to the side effects and risks associated with each. Coming to terms with infertility can be emotionally draining, so it’s important to make the decisions as a couple, where relevant, and seek advice and guidance where possible to ensure you’re making the right choices for you and your relationship.
The dangers that smoking can have on our health have long been known. What many people don’t realise, however, is the link it has to infertility. This article will take you through the dangers of smoking, including how it might affect fertility.
According to the NHS, smoking can affect fertility. It has been found that smoking, including passive smoking, can “affect your chances of conceiving and also reduce semen quality”.
Unfortunately, it is not possible to know if you are experiencing any of the above problems which is why if you have been struggling to conceive it is important to seek professional help to get to understand if there is a fertility problem. Fertility tests and assessments include fallopian tube testing, which looks to see if damage or blockage to the fallopian tubes is interfering with conception, Ovarian reserve testing which looks at the “female fertility potential” ie how long you have left to have a baby along with other tests as indicated.
In terms of semen quality, male fertility tests are also available; they help to see if poor sperm quality is interrupting conception.
As mentioned previously, passive smoking (also known as secondhand smoke) is also harmful and might also affect fertility.
Passive smoke is the smoke that you unintentionally inhale when around cigarettes – breathing in this secondhand smoke can be just as harmful as smoking a cigarette itself.
No matter their gender, if your partner is a smoker, they might be harming their and your chances of being able to conceive.
There are many factors that can affect fertility, which is why there is no direct answer to this question. However, if you are looking to get pregnant or currently have trouble conceiving, quitting smoking is a great place to start.
Quitting smoking will be beneficial to your overall health. It usually takes around four weeks for withdrawal symptoms to alleviate, and within just one year of quitting, your risk of suffering from a heart attack halves.
Stopping as soon as possible will be a very sensible decision, but as a general rule of thumb, most people quit around four months before trying to get pregnant.
There are over 50 health risks associated with smoking, meaning even if you aren’t trying to conceive, trying to stop should be a top priority.
According to the NHS, smoking is responsible for 7 out of every 10 cases of lung cancer. Not only this, but it can also cause cancer in other areas of the body, including the mouth and bowels.
Smoking can also damage your heart and blood circulation, increasing the risk of developing serious conditions like coronary heart disease. It also causes havoc with your respiratory system, linking to problems like asthma and recurring colds.
It’s all well and good knowing how important it is to stop smoking, but we can’t ignore the fact that it is an addiction. Your body is addicted to the nicotine in cigarettes, making it extremely challenging to quit. With that in mind, however, it’s not impossible.
With the right help and guidance, you can quit this habit for good and get your health back on track.
What’s important to remember is that you don’t have to go on this journey alone. Your doctor will be equipped with a lot of tactics to help you quit smoking, including prescribing medication or signing you up to support clinics.
If both you and your partner smoke, agreeing to quit together will help. Quitting together allows you to support and motivate each other, rather than lure each other back into temptation. Doing it together will also minimise the risks associated with secondhand smoke.
There is a lot of online resources available to help your quitting journey, including the NHS’ Better Health hub. Here, you will be able to find a series of guides and information on addiction.
When trying to quit smoking, always remember the reason why you’re doing it. Whether looking to improve your health, increase your fertility chances, or protect an unborn child, keep these “goals” in mind at all times. This should help you to stay on track and see the bigger picture.
If you’ve been struggling with fertility for quite some time and have made good progress with your quitting journey, it might be time to reach out to a fertility expert. Smoking addictions can increase the chances of needing fertility treatment like IVF, which is something we offer at Fertility Plus.
Do not hesitate to get in touch to discuss your concerns and options further. We are here to help, no matter the circumstances.
Before starting any form of fertility treatment, it’s important to know exactly what to expect. If you are considering (or have been recommended) IUI treatment, this guide will provide a great place to start your journey. Read on to discover exactly what IUI treatment is, including the processes and timeline involved with it.
Intrauterine insemination (IUI) is a form of fertility treatment that involves placing sperm inside a woman’s womb. The main aim is to increase the chances of fertilisation due to allowing more sperm to reach the egg. During IUI treatment, the sperm will either come from your partner or sperm donor, depending on your situation.
To put it simply, IUI involves separating fast-moving sperm from slow or non-moving sperm. The semen comes from masturbation and the separation process is carried out in the laboratory. Once the sperm has been collected, it is placed into the women’s uterus, as close as possible to the time of ovulation.
Read on to discover more about the IUI timeline. Here, you will learn what to expect before and during treatment.
Before undertaking IUI, you will need to have a consultation with a fertility specialist. This will help to ensure that you understand what the treatment entails and also helps to ensure that the treatment is right for you. This will further be confirmed through a range of fertility tests, as part of the IUI timeline.
Fertility tests are important to carry out. This is because there are some circumstances in which IUI might not be the best option. Your consultant will outline these to you before offering the treatment.
Once it has been agreed that IUI is the best fertility treatment for your situation, the planning will begin. For the best chances of IUI success, your IUI cycle should begin around 12 to 16 days before your next period. This is usually the time in which a woman ovulates.
Of course, menstruation varies between individuals (particularly those with an irregular menstrual cycle). Your fertility specialist may give you an ovulation prediction kit (OPK) to assist here.
During this pre-treatment stage, you might be offered one of the following:
Natural IUI is the most common and simple form of IUI. It follows the same process as stated above, following the pattern of your natural menstrual cycle. This form of IUI is most suited to those with regular cycles.
If you have irregular menstrual cycles or struggle with other ovulation-related issues, you might be offered stimulated IUI. With a stimulated IUI cycle, vaginal ultrasound scans will be conducted to track the development of your eggs. Once the egg is mature, you’ll be given a hormone injection. This injection stimulates the release of the egg, allowing for the rest of the IUI treatment to be carried out as normal.
As IUI focuses on injecting sperm into a woman’s womb, it’s important to ensure that the sperm is strong. If you have a partner that’s able to donate sperm, then they can do this for you. If not, you will have the option to use donated sperm.
If you decide to use your partner’s sperm, they will need to masturbate into a specimen cup on the day of treatment. Once collected, the sperm will be filtered, resulting in a concentrated pool of “healthy” or “strong” sperm.
No matter your sexual orientation or relationship status, frozen sperm from a donor can be used during IUI. This sperm is usually frozen for six months prior to ensure that it is free from any infection or disease.
When the sperm is ready, a speculum is inserted into the vagina to keep it open. A catheter will then be guided into the womb – the sperm sample will pass through this. The insemination will take no longer than a few minutes and is usually painless.
We will advise you to take a 15 to 20 minute rest before heading home.
There are a lot of factors involved when it comes to determining IUI success rates. One of the main ones is a woman’s age. For women aged under 36, the clinical pregnancy rate sits at 10 to 12% per treatment cycle.
For full clarity and confidence, it’s best to speak to your fertility specialists to discuss both risks and success rates.
Compared to other fertility treatments, IUI involves a really quick procedure that takes just minutes to complete. If you wish to know more about intrauterine insemination or want to discuss your options further, do not hesitate to get in touch with our specialists today.
Planned changes to the UK fertility legislation means that frozen sperm, eggs and embryos will be able to be stored for up to 55 years, over five times the current storage period.
Read more about the planned changes here.
The use of this triangle is to simplify the explanation of the ovarian reserve and its use in clinical practice. We are well aware of AMH is being a marker for ovarian reserve which comes from the small pre-antral, pre-antral and the small antral follicles. The antral follicle count is a visible indicator of the ovarian reserve and relevant to stimulation. Whilst the AMH also tells us about the inhibitory control of the follicles, the antral follicles tell us the response of the follicles to hormonal changes.
In the figure the bottom half of the triangle is indicated by the pre-antral follicles which predominantly secrete AMH. The middle part of the triangle is by the antral follicles which are divided into the large antral follicles and the small antral follicles. These antral follicles which are more receptive to stimulation and will respond to hormonal stimulation. Finally in the top of the triangle is the role that the ovary fulfils which is to have a dominant follicle.
The follicles move from the pre-antral zone to the small and finally to a large antral follcile . There is evidence that this is a continuous phenomena with the antral follicle counts changing. At the same time there is an invisible loss from the small Piri antral and the pre-antral follicles indicated by the decline in AMH . Thus the AMH declines first as the woman starts ageing.
At the site of the antral follicles ,the small antral follicles are more likely to go into atresia or be recruited at a later part of the cycle. Large antral follicles have less inhibited control of AMH and are more likely to respond to stimulation. Follicles that go into atresia at this stage we call is visible atresia.
Thus by reviewing the antral follicle count and measuring follicle counts of more than 4 mm and those which are less than 4 mm we can divide the antral follicle into smaller the last both of which respond differently to stimulation. The AMH tells us to a large extent about the inhibitory response of the ovary and how easy or difficult stimulation would be. Often for women it is the antral follicle’and the variations in the follicles that matters at stimulation rather than AMH.
It is important to note that age alone is the best indicator of quality while the antral follicle count and the AMH tell us more about quantity.
The UK fertility watchdog, the HFEA, has advised clinics to develop their own policies to keep patients safe. We are committed to keeping patients and have made several changes in our pathway to ensure we address issues of social distancing, PPE (personal protective equipment) and testing strategy for office and treatment appointments, which are outlined below.
For patients who require fertility treatments, our treatment centre, London Women’s Clinic (LWC) have their own policies and code of practice which will be issues to patients at the appropriate time.
Due to the social distancing policy of Government still being in place, we would like you to attend for your appointments without your partner unless it is absolutely essential to sign treatment consents in person. We will aim to keep him/her informed via web-based appointments as required as well as video calls at the time of the appointment.
Video Consultations and Virtual Open Evenings
Wherever we can we will see patients remotely and plan treatments and discuss results of various tests through virtual appointments.
Our appointments are being spaced apart to allow additional cleaning to protect all involved at the time of the appointment, therefore we will be able to see limited number of patients, although we are trying to extend our opening hours and will be as flexible as we can.
We are running regular virtual open evenings to meet people who are considering fertility treatments, looking for a clinic and doctor but want to do so from the safety and comfort of their own home. Feedback from patients on these sessions has been very positive.
We will be sending the a questionnaire to be filled in prior to every appointment that you have with us at our clinic or at the treatment rooms for those undergoing procedures. Please do help us by filling this in as we cannot proceed further without having received this in advance. If anything has changed between answering the questions and visiting us, please update us. This is purely to triage every visit to maintain safety of all involved. The questionnaire can also be downloaded here.
Patients undergoing insemination, embryo transfer or egg collection procedures as part of your IVF/ICSI/IUI treatments, must undergo COVID 19 throat and nose swab (Viral RNA test) and blood test (Antibody test) for added precautions. Both partners, if applicable, need to have these tests at least once prior to the procedure. It is worth mentioning that different clinics may have different approach with regard to testing, however European (ESHRE) and British fertility society (BFS) advice on this issue is very similar to our recommendation.
There will be additional costs involved at £150 for each person having these tests and you will need to self-administer these tests as per the instructions. If you have already had these tests carried out recently, please provide us the evidence and we can then make a clinical decision whether you need to repeat them or not based on your individual clinical situation.
These tests are carried out to rule out any active infections of COVID 19 and also to work out whether you have been exposed to the infection of COVID 19 in past few weeks/months. We appreciate this is not a perfect approach as no one has been able to define a perfect approach as yet to eliminate transmission of this virus, we are trying to minimise and mitigate the risks as much as we can based on available scientific methods.
We will ask both partners, if applicable, to sign a health and safety document to confirm and agree to the all the steps we are employing to protect you and us while this pandemic is still active.
We may check body temperature, if necessary, prior to the appointment. Please note that appointments and treatments may have to be cancelled should you develop any symptoms at any stage through treatment.
We highly recommend you wear face masks while attending the appointments at our office. We will be taking all necessary precautions by wearing appropriate PPE where needed as per Government and professional body guidelines.
The RCOG (Royal college of Obstetrics and Gynaecology) and WHO (World Health Organisation) guidelines are clear that women who are pregnant do not appear to be at any significantly increased risk of catching the COVID 19 virus and hence it seems safe enough to plan and carry on with a pregnancy.
Unfortunately, there is no fool-proof method to prevent the transmission of COVID 19 and we cannot guarantee that you will never be exposed to this virus, but we are trying our best to keep the risk to the minimum possible. You of course have a choice of not carrying on with the appointment or treatment and we will always respect that choice, should you exercise that.
We understand that you are likely to have many questions and recommend to all patients to read more information on coronavirus and pregnancy and fertility, at the RCOG and HFEA websites.
We look forward to meeting you to initiate some normality in life and achieve the goal of creating a family.
The menstrual cycle is divided into the follicular phase followed by ovulation and the luteal phase. The stimulation of ovaries in IVF is carried out usually in the follicular phase. The old concept is that follicles are recruited in the beginning of the cycle and ovulation occurs in the middle of the cycle. Though a large number of follicles start being recruited in the early part of the cycle and hence stimulation in the beginning of the period is considered to be normal.
There is evidence from cancer patients where stimulation is done randomly and also from research where follicles seem to be recruited at different times. There is some evidence that some women recruit follicles in the luteal phase better than in the follicular phase. Please also note that the recruitment window (that is where follicles can be recruited) is longer and wider in the luteal phase is increasing the possibility of recruiting more follicles.
It has been proved reasonably well that egg quality does not worsen whether you stimulate in the follicle or phase and luteal phase. This gives an option of better stimulating protocols which will allow for a better response and possibly more eggs and embryos. Any luteal phase stimulation or random stimulation necessitates freezing of embryos.
RCOG has guidance regarding COVID-19 vaccination and fertility in response to myths that have been circulated.
Dr Edward Morris, President at the Royal College of Obstetricians and Gynaecologists, said: “We want to reassure women that there is no evidence to suggest that Covid-19 vaccines will affect fertility. Claims of any effect of Covid-19 vaccination on fertility are speculative and not supported by any data.”
Click here for details.
The Anti-Mullerian hormone is often regarded as a test which looks at the quality of eggs. Infact there is increasing evidence that AMH may not be a quality of eggs, but more a quality of numbers of small pre-antral follicles (small eggs in the ovary).
In earlier studies in the United States, the level of AMH did not prevent women from getting pregnant naturally. It seemed to be all age dependent. Age tends to be the most important factor. AMH does tell us about the number of eggs which remain, and its decline may tell us about how the ovaries’ eggs have started to decline. Other than that, except at very low levels, it does not seem to tell us hugely about what quality of eggs would be available.
There is no doubt that in IVF you require more numbers, and a low AMH may limit the number of eggs that may be available for IVF. A study published in 2019 in the RBM online looked at live birth rates in modified natural IVF, with women with very low AMH levels; 638 cycles were evaluated and there was no doubt that there was a weak correlation of AMH with live birth rates. Thus in this study, they used a modified natural cycle, where they added a small amount of FSH injections, an antagonist was added to block ovulation, and Indomethacin was given to lower the chance of eggs being released.
They looked at the live birth rates per cycle and it was between 11.6 per cent for a very low AMH to 17 per cent for a high AMH, and with a normal AMH it was 12.6 per cent. Per transfer again, chances of pregnancy remain very much stable. Cancellation rates were almost similar in all the three cycles, thus while AMH concentrations were a reliable marker of mild and natural IVF, its role in achieving a pregnancy in a natural cycle is limited and at present we feel that it is still very early to label women with a very low AMH as being infertile and having a lower chance of pregnancy, while pregnancy seems to be age-related. Some women tend to have a slightly better antral follicular count and may stand a better chance of pregnancy.
Progesterone is the main drug and hormone that in fact supports pregnancy. Its role in IVF is to support the second stage of pregnancy where the embryos are implanted, and in frozen cycles, as well as the donor cycles, progesterone becomes the main hormone that supports pregnancy.
There has been a huge debate whether progesterone has to be used as a vaginal preparation or injectable format. Multiple studies have been published, some indicating there is no difference in this treatment, while others indicate that the injections may be better.
A study was done when the progesterone was used in oocyte donation cases. There was some evidence showing lower progesterone levels at the time of transfer in oocyte donation cycles concerned with higher miscarriage rates, so in these cases, women who received oocytes were given either vaginal progesterone, and if they were pregnant, they were given an injectable weekly progesterone which is not available in the UK. Later on there was another group that was given weekly progesterone along with vaginal progesterone after embryo transfer, and in fact what was seen is that if you gave intramuscular throughout from embryo transfer, the live birth rates were the maximum, and in fact if you did not give any intramuscular progesterone, the live birth rates dropped to less than 16 per cent, while when you gave progesterone when HCG was positive, the live birth rate went up to 24 per cent.
Thus the evidence came up from this study that if you were to give injectable progesterone, the rate of miscarriage would drop as well as the chance of having a live birth rate was much better. It is likely that women having egg donation may suffer from prolonged hormonal deficiency, and in fact progesterone may decrease the uterine contractions. Thus progesterone may give us a much better chance of pregnancy, and giving injectable progesterone may increase the same progesterone levels and have a better impact.
Those of FSH and the level of the ovarian reserve marker AMH have an impact on oocyte quality. It is important to realise that egg reserve is measured in two ways, the AMH test, which to a large extent tells us about the ovarian resistance as well as tells us how many small follicles are present and which can be detected, and the antral follicular count, which tells us about the immediate recruitment of the follicles. IVF depends on stimulation of these antral follicles in order to get eggs.
Often, we manage to get a good stimulation of two follicles though in about ten to 20 per cent of cases, we see that the response to stimulation is variable and is not what we expect. There are studies that investigate the dose of FSH of the stimulating hormone as well as the oocyte quality, and a study published in Fertility and Sterility 2017 looked at various groups of patients; those who had a very low AMH, those who had a normal AMH and those who had a very high AMH. The study looked at the varying doses of medication which were given. Surprisingly the higher the AMH, the higher amount of drugs may be needed to stimulate the ovary, and this is in fact right, though with the high AMH, quite often a mild stimulation works. There are cases in which the follicles refuse to budge and may not be stimulated.
On the other hand, there is increasing evidence that if the ovarian reserve is low and AMH level is low, in those cases, giving a high dose of medications in fact goes against the recruitment of the follicles and they are not able to grow. This study does give us an idea that it is very important to look at the AMH, to understand what the AMH means and not have a finality attached to it. A low AMH to a large extent tells us that the ovarian reserve may be on the lower side, but does not tell us about quality, and in those cases often it’s a mild stimulation that works better, while in some cases of polycystic ovaries where the AMH is high, mild doses may not work, and thus trying to fine tune these areas are more likely to give us a much better response.
Ovum donation (OD) is a significant and important treat-ment option, not only for older women (as more than half of women aged over 45 years undergoing in vitro fertili-sation (IVF) treatment will use donor oocytes), but also for younger women. Reasons for women using donor ovum are many and include primary ovarian failure, surgi- cal oophorectomy, after radiotherapy or chemotherapy, poor oocyte quality, multiple failures of IVF, genetic disorders, Turners syndrome and advanced maternal age. Modern society where child bearing is delayed will only see this method becoming more prevalent.
Obstetric complications with IVF pregnancies are well documented. However, until recently OD had not previously been investigated as a separate subtype of this. It could be postulated that there may be more complications with OD pregnancies as the embryo is immunologically different to the mother. The subsequent allograft reactions can cause problems with placental development and function leading to pathol- ogy. Initial studies investigating OD pregnancies were inadequate due to small sample size and inappropriate control groups. Studies specifically comparing to spontaneous pregnancies alone are not suitable when we already know that IVF in itself increases the risk to both mother and baby. Recent research has optimised the control group by using women undergoing IVF with autologous ovum. Ovum donation has now been shown to be an independent risk factor for hypertensive disease in pregnancy, post-partum haemorrhage and increased risk of caesarean section. Neonatal outcomes are less clear-cut, although there is some evidence to suggest there is increased risk of small for gestational age babies and preterm delivery. It is now clear that OD pregnancies are higher risk than IVF pregnancies with autologous ovum and they should be treated as such. Women with ovum donation pregnancies should have obstetric-led care, in a unit which has ready access to both blood transfusion and cell salvage. Future research should investigate how to reduce the risk of ovum donation to these women.
If you are considering ovum donation, discuss the risks and complications with your fertility expert of for further information please contact Fertility Plus.
Ovulation is triggered mainly by two types of medications; HCG, which is available as Ovidrel, Gonasi or Pregnyl and Suprecur which is an analogue trigger. Both triggers act in different ways. The HCG trigger mimics the LH hormone (the hormone that starts the process of ovulation). When we look at the efficacy of this, often in IVF, we use an analogue trigger to lower the incidence of ovarian hyperstimulation syndrome. Though when we use this trigger, we know that freezing of embryos gives us a much better pregnancy rate, while using HCG gives a much better pregnancy rate during a fresh cycle.
Often it is asked, what if we give this during an intrauterine insemination cycle and use a Suprecur trigger when a woman gets more than three or four follicles? A study published in Fertility and Sterility in 2017 looked at randomising women who were given the analogue trigger which is Suprecur, and doing IUI along with an HCG trigger, and what that demonstrated is that even when nature was used to its best by doing IUI, with an HCG trigger the pregnancy rates rose to a significant 32 per cent, while it dramatically dropped to less than ten per cent in an agonist trigger. Thus there is good evidence now coming up in cases of stimulation of the ovaries in an intrauterine insemination cycle, where it is better to have a low stimulation, getting between one and three follicles and to use an HCG trigger.
The Pill is one of the main contraceptives used in the western world, it has been used for almost 40 years and has been extremely successful in delaying pregnancy. We have managed to get more evidence about the long term and short term aspect of the Pill on the ovarian reserve.
The ovarian reserve is the sum total of eggs which are present in the ovary and which can be recruited. It is a test that looks at numbers, and the anti-Mullerian hormone is one of the tests that can give us an idea of the number of small eggs that are left in the ovary. In a study which was published in Gynaecology magazine in 2015, it looked at the effect of long term hormonal contraception. For almost a year 145 women were seen, those were on the oral contraceptive Pill, the oestrogen and progesterone combined, for a mean period of around 11 years. AMH was collected after a year of stopping the Pill. What it did show was that 44 women had never used the oral contraceptive Pill, and when they had a look at it after a year, there was no difference between the ovarian reserve of those who were on the Pill for a long period and those who were not on the Pill for a long period or not taking the Pill at all.
This gives us a much better idea; it tells us that after a year of being Pill free, there is no difference between the number of follicles which have been generated and can be measured in an ovary which was exposed to the Pill for a long time and that which has not been exposed to the Pill. Also it tells us that the Pill is not protective; it does not protect the ovarian reserve and it does not improve the chance of pregnancy once you have been off it. Age tends to be the most important factor that looks at success, and thus with an advancing age, the quality of eggs also tends to go down.
This was a paper which was published in Human Reproduction Update 2011 where it looked at multiple studies. Ten studies were evaluated, and it was suggested that though aspirin may thin the blood and may help the chances in some cases of miscarriage, it does not improve pregnancy rates.
In 1997 was a first study to come out which suggested that aspirin may improve chances of pregnancy. Recent studies have indicated that they do not improve the blood flow in IVF patients, and also do not improve pregnancy rates. There is some evidence that they may lower the chance of getting pre-eclampsia in pregnancy and thus its use in pregnancy is continued.
The recommendations based on international evidence -based guideline for the assessment and management of polycystic ovary syndrome 2018 (1)
PCOS creates an insulin resistant state and can have significant metabolic effects. There is a huge amount of information of decreasing weight and its impact of reducing the symptoms and the biochemical aspects of PCOS. What is less know is whether dietary interventions are effective for improving weight loss, metabolic, fertility and emotional wellbeing. Whether specific dietary composition in lifestyle intervention is successful is controversial though it is marketed extensively.
Having reviewed the recent evidence which reviewed outcomes from a high protein diet to a high carbohydrate diet no evidence was found for the majority of anthropometric, metabolic, fertility and emotional well being; ie. the type of diet was not found to be effective in these studies. However it was found that regardless of the type of diet, diet aimed at reducing weight was of benefit to women with PCOS. Two large systematic reviews showed that there was no benefit with a specific diet and hormone level changes as well as insulin changes did not predict response . It was noted that weight loss was possible and patient complaint with low fat diet and reduced energy diets, though adding different micronutrient content seemed unjustified (2,3).
Is metformin alone, or in combination, effective for management of PCOS?
Metformin is a low cost, readily available medication that has been extensively used as an insulin sensitiser for over seven decades in DM2 and for several decades in PCOS. Insulin resistance is documented on clamp studies in 75% of lean women and 95% of overweight women and addressing this has underpinned the use of metformin in PCOS. Metformin is currently widely used by women with PCOS, yet the efficacy of metformin in terms of improving clinical outcomes remains uncertain. Side effects do cause concern, and metformin use in PCOS is generally off label.
In PCOS, evidence indicates that metformin is effective overall in improving weight but I suspect that this is mainly due to the side effects of metformin; nausea, vomiting and diarrhoea!
We know that AMH is a test that tells us more about the ovarian reserve and we also know that AMH declines as age advances, because it looks at the small follicles in the ovaries, but there are other factors which also have an impact on AMH.
When we come to the basics, the AMH is produced by granulosa cells, they are small cells of small and pre-antral follicles. The quantity of AMH also corresponds to the pool of these follicles. In a study published in the Reproductive Biology and Endocrinology in 2013, evaluated what happens to AMH during pregnancy; this was a study done on 554 women. What was noticed is that the AMH levels continued to drop during pregnancy and the levels significantly dropped as the pregnancies progressed. Once delivery took place there was a further drop to AMH. This was quite often age-related. Younger women saw a more dramatic drop, while older women did not see a much more dramatic drop, which is probably due to them having a low AMH.
When you look at the implication of this treatment it is important to realise that women who come in for treatment for their second baby just after they have had a delivery should be asked to wait for a couple of months until their egg reserve starts recovering, and this is something we learn from the study, not to rush into another treatment.
There is inadequate evidence to make a recommendation about the use of metformin for irregular menstrual cycles. Any efficacy in regularising menstruation usually takes at least 5 months. Weight loss has proved more efficient than metformin in restoring menstrual regularity.
The latest PCOS guidelines make the following recommendations regarding the use of metformin for non-conceptional indications:
We don’t often think that religion and fertility are connected, but for some patients undergoing fertility treatments consideration of the attitudes that their religion has towards assisted conception can be significant. The post below focuses on catholicism and fertility and is an extract from the paper “Religious attitudes to gamete donation” (Roy Homburg, Fatima Husain, Anil Gudi, Mark Brincat and Amit Shah), published in the European Journal of Obstetrics & Gynecology and Reproductive Biology.
The Catholic Church has a long tradition of pronouncements on family issues and particularly on the place of children within a family.
The original Church Fathers differentiated between conception and the entry of the soul that made a human being a person. This distinction was muddied with the discovery of DNA and whether it was the ‘new DNA’ or other reasons the shift occurred whereby human life was decreed as starting from conception.
The Catholic Church has a central authority in the person of the Pope who in certain matters is aided by the College of Cardinals and Bishops. From time to time documents are promulgated that are expected to be enforced throughout the world. There is teaching, which is subject to interpretation and which allows more flexibility. On matters of doctrine there is Dogma, which cannot be altered and has to be adhered to. Reproductive technology falls with the remit of teaching.
The Catholic Church is always conscious of suffering, and has always tried to help and protect the most vulnerable in society. Its
‘Option for the poor’ is a modern reflection of that teaching that has remained consistent. So of course the Catholic Church empathizes greatly with the plight of the infertile couple, particularly since the Catholic Church is family orientated, with the family being the basic building block. The Church does not allow divorce, intending to give greater stability to the family unit, and encourages the procreation of children (Go forth and multiply), so that it has strict teaching on, say, contraception. The central dilemma in the reproductive technology debate is who is the ‘poorest’ for whom the preferential option should be made. In the mind of the senior prelates and fundamental teaching, this is the embryo, whose human life started at conception and who is defenceless. It is this equation with a human life, from conception, that has led to what many regard as the rigorous and difficult position on reproductive technology that the Church has taken. It is the quality of life of a child produced with reproductive technology that is therefore debated, and the inevitable loss of numerous embryos regardless of in what condition they are lost. These are ‘’wasted” according to the strict parameters, in achieving a single successful outcome. Of course, as science develops it is increasingly obvious that if we were to compare like with like, far more embryos are lost, once again in whatever condition, in normal unprotected sexual intercourse in a fertile couple where some 60 to 70% of embryos are chromosomally bizarre and will not implant. Furthermore, of those that do implant some 20–25% will miscarry.
It is the inefficiency of reproductive technology that is one of the major problems.
The other issue is the use of gametes, or embryos, or indeed a uterus as a commodity and not as a gift of nature i.e. a gift from God. Thus oocyte donation and sperm donation are rejected because children born from such procedures will not have the reassurance of being brought up with a known and certain identity of their father and their mother.
Surrogacy is regarded with disdain since it is felt that this constitutes the exploitation of the poor and the under privileged either economically or psychologically. Of course the issue of mothers and sisters or friends volunteering has to be debated further but in general, apart from the crisis in identity, it is the protection from exploitation of the under privileged that is also taken into consideration. Thus sperm donors, oocyte donors, and surrogacy are seen as areas where the under privileged need to be protected from exploitation by the wealthier more powerful members of society.
One of the major problems is the so called quality control of PGS, or various form of PGD and is abhorred. The selection of the ‘perfect’ is Anathema since nobody who is born or conceived is to be disposed of. The church accepts imperfection with love and neither blames God nor the parents for such an event, as is made clear in the Gospels.
Donum Vitae the key document (1987) that deals with this subject speaks of “the right of every person to be conceived and to be born within marriage and from marriage”. The techniques are thus seen as dehumanising.
Finally consideration is made once again on the exploitation and with the commercialization of the couple undergoing treatment. As long as the success rate continues to be so (relatively) poor and the expense of resources so disproportionately large, a religion like the Catholic Church, concerned with the wellbeing of such a diverse multinational and multi ethnic community all over the world, has to have serious misgivings. The Church’s largest population are deprived and underprivileged so the elements of social justice come into the equation, and this includes the protection from possible exploitation, once more of the poor and vulnerable. The perceived vulnerable are the infertile couple and deserve protection.
Catholics have debated this issue continuously and dissected reproductive technologies to their core. The above constitutes genuine misgivings, if not a horror of certain technologies that bring not life, as is the practitioner’s intention, but the opposite. It is up to those involved in the field to argue eloquently, with intelligence and not in a dismissive and arrogant way and for a common language to be found.
Also this is a challenge to carry on proceeding with the development of science such that the ideal fertility treatment, even through reproductive technologies, will be found that will be more efficient, less wasteful and safer, both for the individuals involved and for the babies delivered. Reproductive technologies have done well, but the Catholic Church demands that in the treatment of infertility, practitioners do better, much better.
Ovulation is triggered mainly by two types of medications. One is HCG, which is available as Ovidrel or Gonasi or Pregnyl, and other is Suprecur, which is an analogue trigger.
Both act in different ways. The HCG trigger mimics the LH hormone (the hormone that starts the process of ovulation). When we look at the efficacy of this, often in IVF, we use an analogue trigger to lower the incidence of ovarian hyperstimulation syndrome. Though when we use this trigger, we know that freezing of embryos gives us a much better pregnancy rate, while using HCG gives a much better pregnancy rate during a fresh cycle.
Often it is asked, what if we give this during an intrauterine insemination cycle and use a Suprecur trigger when a woman gets more than three or four follicles. A study published in Fertility and Sterility in 2017 looked at randomising women who were given the analogue trigger which is Suprecur, and doing IUI along with an HCG trigger, and what that demonstrated is that even when nature was used to its best by doing IUI, with an HCG trigger the pregnancy rates rose to a significant 32 per cent, while it dramatically dropped to less than ten per cent in an antagonist trigger, thus there is good evidence now coming up in cases of stimulation of the ovaries in an intrauterine insemination cycle, it is better to have a low stimulation, getting between one and three follicles and to use an HCG trigger.
Luteal phase defect essentially is when the second phase of a cycle after ovulation is not supported well. This second phase depends on the corpus luteum, from where the egg has been released, to start secreting progesterone and it is this progesterone that supports the endometrium (lining of the womb).
There are cases in which a few days after ovulation there is a slight bleeding or spotting of blood that tends to occur, and this can slowly result in a period. To a certain extent this signifies a defect in the luteal phase. It is in fact extremely difficult to diagnose since its diagnosis requires a histopathological, a biopsy, evidence which is very difficult to obtain. Thus to a large extent it is what we observe from the evidence from how the treatment is carried out.
Luteal phase defect can be endometrial which means the defect lies in the progesterone activity in the endometrium or the defect could lie in the corpus luteum where the secretion is inadequate which may reflect on the quality of egg.
Both tend to mean very much the same. Often it is the quality of the egg that is released which may also determine what is left behind and thus supporting the endometrium, but sometimes the secretion of hormone is adequate and the progesterone effect on the lining of the womb, the endometrium, is not adequate.
There are different ways to treat luteal phase defects, one of the simplest is to add a small amount of HCG, the pregnancy hormone, a few days after ovulation, which helps to sustain and prolong the life of the corpus luteum. This is what a pregnancy tends to do. Pregnancy generally prolongs the life of the corpus luteum and thus allows for the corpus luteum to continue to work. By mimicking this, you can often extend the life of the corpus luteum and in a large number of cases prevent the spotting. Another treatment option is to add progesterone, a high dose of progesterone given after ovulation may also enable the support of the endometrium.
Ultimately, there is no fixed treatment and to a large extent the decision is made on a case by case basis depending on how the response is.
Unexplained infertility is where we do not find any cause of infertility, this is often after undertaking tubal tests, reviewing ovarian reserve, sperm is extensively seen and there are no fibroids or endometriosis as seen by a laparoscopy. In these cases this is known as unexplained infertility.
Often women are asked to follow IVF as a treatment of unexplained infertility. However, it is important to realise that IVF is an aggressive treatment involving surgical procedure where eggs are collected, and thus rather than rushing into IVF, it is reasonable enough to understand whether IUI may be an alternative treatment which would give us very good results.
In a study done at the Homerton Fertility Centre and published in Fertility and Sterility, IVF versus intrauterine insemination (IUI) was compared in a randomised control trial; 407 women were given three cycles of IUI with FSH injections or one cycle of IVF. Studies indicated that as long as there were between one and three follicles in the IUI cycle and IUI being performed over 24 hours later, the success rates suggested that the live birth rate in three cycles of IUI approached 26 per cent, which is exceptionally good and comparable to a cycle of IVF.
This is one of the questions we are often asked; whether IUI, intrauterine insemination, can challenge IVF. One of the reasons why IUI fails is because it aims towards minimising the number of follicles grown. It is important to know for which conditions we are doing IUI. The two main conditions where IUI seems to work very well is in unexplained infertility and in male factor infertility where the sperm counts are mildly low.
Change the drugs: the drugs that are used are either Clomiphene, Letrozole or HMG, and there is very good evidence that FSH injections which we give at Fertility Plus, give a much better success rate to intrauterine insemination.
Increase the number of follicles: it is common sense to realise that the more follicles or possibly eggs that you have will in fact give a better chance of fertilisation and thereby pregnancy, and that is something which we aim to look for, though this will slightly increase the chance of twins.
Timing: the timing of IUI generally should be just before ovulation and 24 hours after, and some doctors believe they can do it at 36 hours, but the accepted timing is between 24 and 36 hours.
Continue to have sex: it is also recommended that to continue to improve the chances the couple Also continue to have sex. This allows them to supplement and improve the chances of pregnancy.
Sperm: lastly often if there is a poor sperm count, the chances of pregnancy are reduced, and thus we have to think about a slightly new technique which is that of a consecutive ejaculate, and that is something where the man produces once again within 30 minutes, and some reports would suggest that there is a slightly better chance of pregnancy.
Endometriosis affects about ten per cent of women in the reproductive age group and between 20 to 25 per cent of women who have painful periods seem to have endometriosis.
A significant proportion of women who come to a fertility clinic also have endometriosis and have ovarian cysts in the form of endometriomas. In these cases, laparoscopy is the best treatment for this, and laparoscopy where we open the cyst (endometrioma), strip the cyst wall, gives better pregnancy rates, lowers the chance of recurrence and pain.
The question “does it also reduce ovarian reserve?” is often asked. AMH is a test that is done to check ovarian reserve. In a study which was done in Serbia, 54 patients in early follicular phase had an AMH test done and then had surgery. Of the cysts removed, they were opened, the cysts were stripped away and endometriosis treated. 37 of these had endometriomas at one side and 17 had bilateral endometriosis. The AMH test was done six months and 12 months later. There was almost a significant drop of AMH from 3.3 to 1.4 nano ml/l in six months and then 1.72. There were also bilateral endometriomas which were treated, there was a continual dramatic decline to very low levels from 2.55 to 0.98 (plus or minus the variables).
This evidence clearly indicates that endometriomas, the surgical stripping of endometriomas and coagulation leads to unwanted and inevitable damage to the ovarian reserve, more so with bilateral endometriomas.
If you are concerned about endometriosis and fertility, contact your GP or fertility specialist.
We don’t often think that religion and fertility are connected, but for some patients undergoing fertility treatments consideration of the attitudes that their religion has towards assisted conception can be significant. The post below focuses on judaism and fertility and is an extract from the paper “Religious attitudes to gamete donation”.
‘Be fruitful and multiply and fill the earth’ (Genesis 1:28) was the first commandment given to Adam after he was created. Similarly ‘He did not create the world to be desolate but rather inhabited’ (Isaiah 45:18) is a further basis for the importance of fertility for orthodox Jews. Rachel, the matriarch, declared to Jacob,’ Give me children, otherwise I am dead’ (Genesis 30:1). Indeed, these may account for the very liberal laws regarding infertility treatment in Israel,
Unlike secular Jews, orthodox Jews have some limitations regarding reproduction. Orthodox women are not allowed to have sexual contact with their husbands during menstruation and for seven days after the bleeding stops, after which they take the ritual bath and become ‘clean’ again. For the majority of women, this strictly kept law is not a problem but for those with a short cycle in whom ovulation occurs before the ritual bath, pregnancy is obviously out of the question. The only way round this situation is to delay ovulation which has been done using estrogens, clomifene and even GnRH agonists. The irony is that this law was designed to encourage fertility and ‘save’ the sperm until the fertile window.
Artificial insemination with donor sperm is generally frowned upon. Although not regarded as adultery, it is generally discour- aged. Egg donation is generally rejected outright although it is condoned by some if the husband consents. It is the question of who is the mother according to Jewish law which has created a fascinating philosophical discussion, as yet unanswered.
Interpretation of biblical writings and Jewish law into 21stcentury reproductive technology is attempting to keep up with the pace of progress. An account of these interpretations is made all the more complicated by the fact that the Jewish religion today, in addition to orthodox Judaism, has Conservative, Reform and Liberal branches. Furthermore, the state of Israel has laws which bind its, mainly Jewish, population. The following is an attempt to relate to the diversity of opinion on donor gametes within the Jewish religion.
When the husband’s sperm and the wife’s eggs are used, there is general rabbinical agreement that in-vitro fertilization (IVF) is permissible in accordance with Jewish law (halacha).
There are some caveats involved in this agreement. The procurement of a sperm sample is problematical as’ spilling of seed in vain’ is prohibited. This is usually overcome as a sperm sample for the purposes of IVF is regarded as pro-creative and not wasted. Sampling semen for a laboratory examination is, however, inadmissible for the strictly orthodox. As this examination is such an essential part of the initial infertility investigations, semen may be obtained from the vagina or from a condom with a pin-pricked hole in it, both following normal sexual intercourse.
An almost obsessive demand for the establishment of paternity and lineage, assumed for a baby conceived naturally but not assumed in the IVF laboratory by orthodox Jewish couples, presents a problem. Despite the fact that the vast majority of IVF centres are meticulous in their identification of the sperm, eggs and embryos, strictly orthodox couples demand the presence of a trained observer in the laboratory to oversee the procedures and ensure that they are performed according to the halacha.
In orthodox Judaism, artificial insemination with the husband’s sperm is permissible if the wife cannot become pregnant in any other way. Regarding the use of donor sperm however, opinion is much more divided and it is generally frowned upon. Artificial
insemination by a donor is not thought of as adultery as no sexual relations are involved but is, nevertheless, unacceptable by the vast majority of rabbinical authorities.
The Conservative movement in Judaism, mainly based in the USA, have a slightly more liberal view on AID. They allow donor insemination while stipulating that the use of anonymous donors is strongly discouraged. Most Conservative rabbis prefer that non- Jewish donor sperm be used to prevent ‘adultery’ between a Jewish man and a Jewish woman and to prevent future genetic incest among the offspring of anonymous donors.
Reform Judaism has generally approved artificial insemination by a sperm donor. In all streams of Judaism, the sperm donor is regarded as the father so that the child would not, by Jewish law, be considered the child of the infertile husband.
It is interesting to note that in Jewish orthodox circles, a male (sperm) factor is easily the most prevalent cause of infertility. For infertile couples in these circles, it is surely very good news that the use of intra-cytoplasmic sperm injection (ICSI), an IVF procedure involving direct injection of a single sperm into the egg, is now producing such good results. The need to use donor sperm to resolve severe male infertility is consequently diminishing since the advent of ICSI.
In the orthodox Jewish community, the attitude on whether to permit egg donation is deeply divided. Some rabbis reject this procedure unequivocally while others condone the use of donor eggs if the recipient has her husband’s consent.
The fascinating question of who is the mother in the case of egg donation, the genetic (donor) or gestational/birth (recipient) mother, has unique relevance in the Jewish religion. The determination of who is a Jew depends on whether the mother is Jewish.
If both the genetic and gestational mother are Jewish then, although the question of who is the real mother is debatable, the Jewish identity is not in doubt. However, many infertile Jewish women receive eggs from non-Jewish donors. In this situation even the wisdom of Solomon would probably have a problem deciding whether the baby is regarded as Jewish or not. Other religions do not have the same problem whereas traditional Judaism places great emphasis of the religious status of the baby at birth. This also has an impact in adult life for orthodox Jews as, for example, having a bar-mitzvah or permission to marry.
It is, therefore, not surprising that the debate of who is regarded as the mother following egg donation has generated a good deal of heat, if not light. There are rabbis who consider that the genetic mother is the true mother and if the eggs have been donated by a non-Jewish woman, the more stringent of these contend that the baby should be ‘converted’ to Judaism. Others regard the gestational mother as the true mother and this is also the view of the Conservative stream. For the Reform Jews, this is not a problem as if either the mother or the father is Jewish then the child is regarded as Jewish. Finally, Israeli law categorically states that the gestational mother is the mother of a child born following egg donation for all intents and purposes.
From the wide divergence of opinion expressed within the Jewish religion, it seems clear that the scriptures cannot provide all the answers to the moral and ethical problems posed by the rapid advances in assisted reproductive technology. The opinions are necessarily based on interpretations of the written word which, for all the wisdom therein, could not possibly have anticipated the ‘science fiction’ age in which we live today. The fact that fertility is at the forefront of Jewish philosophy will ensure the continuation of the debates and will continue to provide a source of fascination for those inside and outside this religion.
For some individuals and couples undergoing fertility treatments, the consideration of their religious attitudes towards fertility can be significant. For fertility practitioners it’s important to be aware of these attitudes in order to have the most understanding of their patients. In this blog, an extract from a research article ‘Religious attitudes to gamete donation’, we explore the relationship between fertility and hinduism.
Children have always been important since time immemorial and the continuity of the family unit has been of major significance in Hindu culture. Indian mythology is full of stories about what couples have done in the past to overcome their problem of infertility. Hindu Religion has tried to understand the natural hurdles infertile couples may face to fulfil their social obligations and made alternatives available.
The following story of sage Agastya from the great Hindu epic Mahabharata (written 2000 years ago) tells us why Hindus are so obsessed with children. Besides social factors like ‘someone to take care of me in my old age’, it directs our attention to a profound religious demand for a child.
Each individual is bound by Dharma to produce one child who must perform the annual ceremony of Shraadha (offering oblations to ancestors). This child is a Dharma Putra. The Shraadha offerings enable the ancestors to nourish themselves in their abode – Pitr loka. Without a Dharma Putra to make that offering, ancestors suffer torture, hunger and thirst on Pitr Loka
Dharma is essentially duty that must be performed for the well- being of self and society. Failure to do so leads to social anarchy and cosmic chaos. Producing a child is one’s earthly duty and necessary
for maintaining the stability of society. One can only renounce the world after they had fulfilled all worldly duties.(Manusmriti 3:37)
When a man could not produce a child from his wife, he was given the benefit of the doubt and allowed to marry again, and again. If despite this, he failed to father a child, it confirmed his sterility. The Scriptures suggest that another man (in the same lineage) be invited to cohabit with the wives (with the permission of the husband). This practice is known as niyoga. (Bühler, George,1886).
In the Mahabharata, when king Vichitravirya dies, his mother invites the sage Vyasa to produce children through her widowed daughters-in-law. Children thus produced were called children of Vichitravirya (the legal father), not the children of Vyasa (the biological father). The donor is not allowed to give his name to the offspring conceived from his donated sperm. The children born from such an act would be children of the legal husband and retain rights of inheritance from the legal father
King Pandu could not have sexual intercourse with his wives. Since he could not father offspring for succession, he renounced the throne. Dharma demanded children. His senior wife Kunti quoted that Dharma permitted demi-gods to impregnate his wives to have children who would be known as the child of Pandu. Thus came the five warrior kings of the Mahabharata who were acclaimed to be the righteous and the heroes of India (CandrabalıTripat.hı, 2005).
In the Kathasaritsagar, a collection of stories written in the 11th century A.D., there is a story of a king who makes an offering of rice balls to his ancestors. As he is about to throw the offering in the river, three hands reach up – one of a farmer, one of a priest and one of a warrior. The oracles revealed,’ The farmer is the man who married your mother, the priest is the man who made your mother pregnant and the warrior is the man who took care of you.’ The king is advised to give the rice ball to the farmer because scriptures describe him as the true father. (Penzer, 1924),
Through many centuries, religious law allowed for donor insemination when approved by the couple and like today, the family name would continue and this would be accepted by society.
In the Bhagavata Purana, there is a story that suggests the practice of surrogate motherhood. King Kamsa imprisoned his sister Devaki and her husband Vasudeva because oracles had informed him that her child would be his killer. He killed six children of Devaki and Vasudeva. The Gods intervened and had her transfer the seventh foetus from the womb of Devaki to the womb of Rohini (Vasudeva’s other wife). A child conceived in one womb was incubated in and delivered through another womb.
Hindu mythology contains numerous incidents where sexual interactions serve as a non-sexual and often a sacred purpose.
From the many stories expressed in the Hindu texts, it is clear that the scriptures provide an indication to the moral and ethical problems faced by the rapid advances of infertility technology. There is no doubt that having a child is the forefront of a Hindu couple’s duty and the philosophies have given some evidence that different techniques may be tried to help the couple to conceive. Though ART was not known in ancient times, examples are cited demonstrating that the ancient sages understood the problems of infertile couples and justified treatments outside natural means of conception.
Folic acid is involved in gametogenesis, fertilisation and pregnancy, and thus may play an important role in human reproduction.
In the 1990s it was recommended that folic acid be given between a dose of 0.4 and 0.8 mg to prevent neural tube defects. There were some controversial studies in the mid-1990s that may have suggested that folic acid supplementation may increase spontaneous abortion. This was successfully challenged by other studies, and in the recent Cochrane review, based on three randomised control trials, suggested that folic acid in both doses of 0.8 mg and 0.4 mg in two studies, plus a multivitamin supplementation before and during pregnancy, did not increase abortion rates.
In another observational study called the Nurse Study 2 (NHS 2) suggested reduced spontaneous abortion risk among women using folic acid before or during early pregnancy particularly, and recommended that this be taken.
There is a lot of talk around vitamin D and pregnancy rates and outcomes but what exactly is known about the relationship between vitamin D and assisted reproduction? Here we look at the studies that have evaluated the effect.
Vitamin D Modulatory Process
It is well known that vitamin D receptors are distributed across reproductive systems including ovaries, uterus and endometrium. Furthermore it is known that vitamin D stimulates egg production, most follicular maturation and regulates successful implantation, and it may be involved in polycystic ovarian syndrome.
Vitamin D and Reproductive Outcomes
In animals there seems to be a strong association between reproductive outcomes with vitamin D. Women participating in the NHS 2 study, Nurse health study number 2, vitamin D was unrelated to infertility. Similarly it was not associated with either/or probability of conception in healthy Danish women or conception in less than one year among Italian women undergoing routine aneuploidy screening. Furthermore meta-analysis of 10630 pregnant women revealed no association between low vitamin D levels and miscarriage rates, though extremely low levels of less than 29 gram per ml were associated with increased risk of miscarriages in a small number of women.
Vitamin D and Assisted Conception Outcomes
Though vitamin D may give a positive benefit for reproductive outcomes, vitamin D on ART outcomes are inconsistent. In a large meta-analysis of 11 studies of women undergoing ART, it was found that women deficient in vitamin D levels had a higher probability of live birth, but no association with vitamin D with probability of miscarriage was noted. Similarly another study found in PCOS patients that vitamin D of great than 30 nanogram per ml was associated with lower live birth rates. This proved other studies which showed there was no association between vitamin D concentrations and the assisted conception outcomes. Furthermore two further randomised control trials did not improve pregnancy outcomes. Neither giving 50 thousand international units of vitamin D for six to eight weeks for deficient women, nor administering a megadose of 300 thousand in women with PCOS improves outcome.
In summary we could suggest that vitamin D can affect reproduction, though at present evidence is limited. Extremely low vitamin D levels are related to worse outcomes in ART.
The empty follicle, or not getting any eggs on an egg collection is one of the most distressing things that tends to happen. Does empty follicle syndrome occur, the answer is yes.
There are three types of empty follicle syndrome;
In a case presented in Human Reproduction they evaluated a woman who underwent nine cycles of IVF with HCG trigger. In the eighth cycle there were no eggs, in the ninth cycle an analogue trigger was given 40 hours before and a double trigger was done, and 16 eggs were obtained after eight cycles of IVF, thus signifying that sometimes changing the trigger significantly changes the outcome of pregnancy.
Studies among sub-fertile women suggest a variable outcome in women taking foliate supplementation on ART outcomes.
In small randomised control trials women who took folic acid 0.4 mg had 16 per cent higher probability of pregnancy compared to placebo. In addition, two studies, the MTHFR mutation (low MTHFR allele activity and low serum foliate levels) was associated with poor ovarian response, fewer oocytes and lower gonadotrope cell production. An ART study in Boston, the EARTH study, showed that consuming more than 0.8 mg foliate compared to consuming less than 0.4 of foliate before conception had a higher rate of pregnancy. This has also been challenged by other studies which show in three European studies that it did not show a benefit, but this study may be challenged that certain patients were excluded.
In summary we could say that folic acid supplementation before and during pregnancy is not associated with the risks of miscarriage, but may still improve the chances of women achieving and maintaining pregnancy.
In a study done in Human Reproduction in 2011, this question was answered to a meta analysis, is aspirin effective in women undergoing in vitro fertilisation? Aspirin has often been given to women undergoing IVF with the hope that it improves blood flow of the endometrium and allows the embryo to implant.
In the study ten studies were looked at in which aspirin was given and it confirmed that it did not improve blood flow in IVF patients and it did not improve pregnancy rates. There is some evidence that aspirin prevented the occurrence of preeclampsia during pregnancy, though the evidence is small. It is concluded that aspirin does not improve pregnancy rates in IVF and its routine prescription in IVF cycles is not good.
It is common practice to trigger ovulation at 18 mm size follicle. Surprisingly all this has been standardised, and all the evidence which has been obtained has been obtained on the basis of studies done in the 1980s and 1990s, however many of the studies were done on those of IVF rather than on Clomiphene or Letrozole.
In an analysis of 988 cycles published in Fertility and Sterility, in a retrospective analysis they looked at the best time to trigger ovulation, rather than triggering at 18 mm; triggering at 22 and 23 mm seemed to give the best chance of success as well as improving the endometrial lining. By waiting for the follicles to grow larger, the endometrial thickness varied and improved, thus it may be important to wait and trigger ovulation around a slightly later time so as to improve the chances of pregnancy.
We are often asked which is best; fresh or frozen embryo transfer. At Fertility Plus, we often favour frozen embryo transfers as this allows us to manage the timing better, but let’s understand a bit more about the evidence behind fresh and frozen transfers.
A large study published in a New England Journal of Medicine in January 2018 using women in China who did not have polycystic ovaries in their first IVF cycle between 20 and 35, had a stimulation and were given an HCG trigger. Of these women, 1077 had a frozen transfer and 1080 had a fresh transfer, results showed no difference between the live birth rates between fresh (50%) and frozen transfer (49%). The first trimester loss (miscarriage) was similar, though in a frozen cycle the second trimester loss was significantly lower at 1.5 per cent compared to 4.5 per cent fresh embryo transfer.
Whilst showing no significant difference between fresh and frozen in the case of women without polycystic ovaries, in the cases of polycystic ovaries freezing of embryos would significantly improve pregnancy rates.
The advantage of a frozen cycle is whereby the acute stage of hormonal treatments are phased out and embryo transfer is done at a much better time when the ovaries do not have to work extra, hence at Fertility Plus we generally favour frozen embryo transfer.
Sensationalist media sometimes even call it ‘the end of civilisation’ which is nothing more than scaremongering, but the question does remain …. “have sperm counts declined?”
This question has been a controversial question, and the first time it was mentioned was in 1992, where it was suggested that there is a genuine decline in sperm quality over the past 50 years. This controversy has progressed unabated and has never been answered due to the lack of proper studies which have been conducted.
The reason why it’s important is that sperm counts are linked to male fertility, and semen analysis may be the only accepted way of assessing, or rather being the first stance of assessing male infertility. There are reports that suggested the economic burden that male infertility gives. It is also known that these sperm counts are the cause of male infertility and also the cause of multiple environmental factors such as endocrine disrupting chemicals, pesticides, heat, lifestyle factors, diet, stress, smoking, body mass index, all may be responsible for a decline in sperm counts.
In one of the largest systematic reviews done, published in Human Reproduction Update in November 2017, a team looked at 2510 full articles and looked at a huge number of studies between 1973 and 2011. This statistical evaluation reported a significant decline in sperm counts between 1973 and 2011, driven by a 50 to 60 per cent decline among men unselected by fertility from northern Europe to America, Europe, Australia and New Zealand. The research also indicated that there is no evidence of levelling off which means of slowing down of that declining trend.
The causes which could be environmental or lifestyle in early childhood as well as in adult life, the endocrine disruption that comes in men from chemical exposures or maternal smoking during the critical times of male reproductive development, the exposure to pesticides that may have a role in adult life. The worrying factor is that we don’t know. At present, research is inadequate, but it is concerning that sperm counts are declining. A more robust long-term study is needed, and while this is on, it may be time to improve on how men look at health.
If you are considering starting a family it is worth the male partner doing the following:
If any medications are being taken they should be reviewed with a doctor.
As part of a patient’s treatment sometimes additional fertility procedures can be recommended; endometrial scratch is fertility procedure that we can recommend in certain cases, especially where there have been failed cycles. In this article, I explain endometrial scratch and the evidence supporting it.
Endometrial scratch is an additional fertility procedure where the endometrium (lining) is disturbed prior to an IVF cycle. This helps the embryo implant in the womb which is an essential part of fertilisation.
Before IVF, the womb lining is scratched with a small sterile plastic tube, which triggers the body to repair, releasing chemicals and hormones that make the womb lining more receptive to an embryo implanting.
There is reasonably good evidence that suggests that by doing an endometrial scratch prior to an IVF cycle or prior to embryo replacement success rates may be improved. This evidence now comes from previous two or more failed cycles where this intervention could be helpful.
There are no risks associated with endometrial scratch, so it is considered a safe procedure.
Endometrial scratch is still relatively new and we are unaware whether there may be an improvement in pregnancy rates if it is done before an intrauterine insemination cycle.
In one of the largest studies which was published in Fertility and Sterility in 2017, an analysis was done of 23 studies of a total of 1871 cycles in which the endometrial scratch was done in the cycle prior. The evidence suggested that a scratch may improve the chances of a pregnancy in an intrauterine insemination cycle.
Though doing this may seem better, its evidence is not as good as that in IVF. The studies also concluded that the evidence was not as robust as performed in the IVF studies, and thus this should be taken more cautiously.
The HFEA regard endometrial scratch as a procedure which consistently shows benefit however further evidence is needed and as such there is a large clinical trial underway in the UK called the Endometrial Scratch Trial.
Endometriosis is one of the most common diseases found in reproductive women, with a significant impact on quality of life as well as fertility. For a long time, we are not entirely certain if oocyte quality is affected by endometriosis. In one of the reviews of literature published in 2017 in the general ovarian research, the effect of endometriosis was discussed. It is known that endometriosis causes distortion of the pelvis and also may release inflammatory markers (cytokines). It’s also known that it may impair endometrial receptivity.
The impact of endometriosis could be on mitochondrial content (the battery of the cell), show granulation, which is the breakdown of cytoplasm, measure spindle abnormalities in the cell and also may harden the zona, the outer shell of the cell. It is known that women with endometriosis have an imbalance in oestrogen, seen in IVF. They have lower levels of oestrogen during the IVF cycle, and it seems that the progesterone requirements are also altered in an IVF cycle.
It is known that in women with endometriosis the eggs obtained have a hardening of the outer shell. There seem to be more immature than mature eggs, and also the spindle which is required to maintain the apparatus of the oocyte also seems to be altered in some cases of endometriosis. Mitochondria which are the batteries of the cell seem to be lower in endometriosis. In simple terms, is oocyte quality in endometriosis affected? Yes, there is a seven per cent more reduction in fertilisation, we get fewer eggs, fewer oocytes and less fertilisation.
The answer is no. Surgical intervention seems to have a negative impact on the ovary. Three to six months of long down regulation was suggested to improve pregnancy rates, but this has not been proved. There is some evidence that ICSI, rather than IVF, must be done to improve chances of fertilisation.