Fertility Options webinar common questions

The questions people ask during our Fertility Options Webinars can be a great resource for others who are trying to figure out what to do so we’re going to be sharing them with you all. First up is Genea Deputy Medical Director Dr Mark Livingstone who covered a wide range of topics in a recent session.

What are the options for women with PCOS who want to have a baby?

PCOS means that a woman has a lot of follicles in the ovaries, usually related to an imbalance of hormones within the ovary. That imbalance means that the follicle where the egg comes from can’t develop every month so there’s no ovulation and therefore the woman can’t become pregnant. One of the simplest treatments for PCOS is that if the woman is overweight, to lose weight. Because if you lose weight then you drop the level of insulin in the ovary, you drop the level of testosterone in the ovary and that makes the hormonal balance much better because there shouldn’t be too much testosterone in the ovary, there should be more oestrogen, female hormone. That’s one approach. We also sometimes give patients Metformin, a medication which reduces the insulin level in the ovary. Again, to try to get that balance correct and let her follicle grow. We can use tablets to try to bring on ovulation, such as clomiphene or letrazole. We’ve moved more towards letrazole now because it has higher success rates. We can also use injections to bring on ovulation or sometimes we will use IVF, especially if the partner has a low sperm count.

Is it normal to have a regular cycle over 30 days?

Well, it can be. Not everyone has a 28 day cycle as per the text books with ovulation Day 14. Some people have a 32 day cycle and that’s quite normal, as long as ovulation happens.

What is IUI with hormone stimulation?

That’s where we get the sperm, wash it and put it into the uterus at the right time but we also use some stimulation to try to increase the number of eggs. Now that does mean that there is more chance of a multiple pregnancy which we don’t really want to happen. So I don’t do a lot of IUI with hormone stimulation. As a rule, IUI is more likely to be a treatment for those patients who cannot have intercourse, donor sperm or partner is overseas.

What can be done to naturally boost fertility without going to a clinic?

Well, there are a few things:

• Maintaining a healthy weight
• Stop smoking
• Not drinking too much
• Keeping yourself healthy
• Taking folic acid

While there are lots of other things talked about, they’re largely unproven to improve your chance of pregnancy.

Weight loss is quite a big topic in our community at the moment because there are a lot of overweight people and it does contribute to infertility through lack of ovulation.

What are some of the causes and treatments for unexplained infertility?

Unfortunately, we don’t have a cause because unexplained infertility means that we’ve checked for the basics – the four things we’re looking for:

• Ovulation – there’s an egg being released;
• Is there sperm and is it good quality?
• Can they get together, are the fallopian tubes open?
• Is there a normal lining of the womb for an embryo to implant in?

If those four things are normal then we’ve diagnosed unexplained infertility, meaning we haven’t got a reason why it’s not happening. Now, you could do a laparoscopy to look for endometriosis and that’s got to be done to say it’s definitely unexplained infertility because with endometriosis there are not always symptoms to suggest that you’ve got the condition. With unexplained infertility, treatments depend on how long you’ve been trying and how old you are. When you’re younger you’ve got more time on your side so people will try naturally for a bit longer before going on to treatment. However, for a couple who is in their late 30s or early 40s you would be thinking of boosting the chance of pregnancy a bit more quickly. You could do ovulation induction and IUI but most people will tend to go towards the IVF process, not because they can’t get pregnant at all but because it hasn’t happened after a certain amount of time.

I’ve tracked my cycle and my GP has done all of the tests in preparation to go to a clinic and they’ve all come back normal, what should I do?

You should see a Fertility Specialist if you’ve been trying to conceive and it’s not happening. They will be able to take you through a specialised approach to figuring out what’s happening. I do have people who come to see me who have been trying for 18 months and I will say, look maybe we won’t do anything straight away, we’ll give it another few months but if it doesn’t happen by a certain point in time then we can move forward so at least there is a plan in place and you know what the next steps will be.

Can you provide more information on the pre-IVF testing rebate that’s available in NSW?

The NSW Government is giving everyone doing pre-IVF tests such as blood tests, AMH or ultrasound or sperm test a $500 rebate if you’ve had out of pocket expenses. You need a form from your doctor to say that you’ve been trying for more than six months if you’re over 35 or more than 12 months if you’re under 35. Find out more about the pre-IVF testing $500 rebate.

Will I see you as a specialist or will I have another doctor for my procedure?

At Genea, I do all of my own procedures, seven days of the week. The only exception to that is when I’m on leave. At Genea, that’s how it happens. At other clinics, they will do say, egg collections Monday, Wednesday and Friday but we do them the day that is correct for you rather than putting you into a clinic schedule. So if somebody needs an embryo transfer on a Sunday, I’ll do the embryo transfer on the Sunday. I’ll also talk to people at the end of the cycle and talk to them about result on the day their pregnancy test is due.

From my scans, they found an intramural fibroid, is it high risk?

It depends on the fibroid. So, fibroids are little growths in the wall of the uterus and they can be anywhere. If you imagine your uterus is like a pear, turned upside down. A little growth in the wall of the uterus isn’t a problem if it is on the outside, if it’s on the skin of the pear so to speak. They’re not too much of a problem unless they’re very large. Intramural means it’s in the wall of the uterus, they’re not too bad as long as they are less than 5cm. Above that size, they might divert the blood flow away from the lining of the womb and might lower your chance of pregnancy. The ones that we are worried about are sub-mucosal. They are the fibroids that bulge into the cavity of your womb. Imagining again that your uterus is like a pear, the cavity is like the core and that’s where the baby would grow. If you’ve got one bulging into the womb then we do tend to treat those because they do affect the chance of pregnancy.

Are there similar chances of infertility with stage 1 infertility as compared with stage 3 or 4.

When it comes to getting rid of endometriosis, the more you get rid of the better it improves your chance of pregnancy but if everything is normal apart from the endometriosis and it’s been over six months since you had your laparoscopy to remove endometriosis a lot of people might consider other options such as moving on to IVF, again not because you can’t get pregnant but because it’s not happened by that point in time. If you’ve just had an operation to clear the endometriosis, you want to give it a few months to see if that will improve your chance of getting pregnant. Obviously, sperm count is also a factor, along with the patency of the tubes etc.

Has any research been conducted on the effects of immune conditions on fertility, I have ulcerative colitis.

Immune conditions are a difficult subject because there are a lot of immune tests and we haven’t always got the answers to the specific immune conditions that are diagnosed. I haven’t seen any studies showing that ulcerative colitis patients do worse with fertility treatment than other patients. Sometimes during pregnancy, the ulcerative colitis tends to get a little bit better because pregnancy damps down immune responses. Some of the medications that we use for immune conditions, such as steroids, can have quite significant effects on mums and babies. For example, prednisalone can sometimes cause a cleft palate in a baby. So we have to judge when we test for immune conditions and judge what treatments are used.

Is there a provision to select the most healthy sperm?

Well if the sperm is normal, we simply mix the sperm and eggs together in the IVF process. ICSI is a little more traumatic. It does mean stripping the cells from around the outside of the egg and injecting the sperm directly into the egg, so that’s more invasive for the egg and may actually affect embryo quality. If we’re doing ICSI, then yes we choose the best sperm by selecting the best normal moving sperm to inject into the egg but if the sperm is normal we will opt for IVF. We test these things beforehand, checking sperm numbers, movement, shape and also to see if there is any DNA damage in the sperm. Especially in smokers, they can have a lot of DNA damage which can mean a lesser chance of pregnancy and more chance of miscarriage.

How do you improve a man’s sperm quality and motility?

That’s a difficult one. There’s a lot written on female fertility but there’s not so much on male fertility. Obviously, these things are important: stop smoking, don’t smoke cannabis as that really affects sperm, multivitamins won’t do any harm, maintain a healthy weight, don’t drink too much alcohol and don’t drink too much coffee or caffeine drinks. People have also asked about bike riding and whether that affects male fertility. The short answer is that you can’t tell unless you stop the bike riding and see if things improve. I will say though, sperm is best produced in a cool environment, that’s why the testicles are outside of the body. We definitely don’t advise that men have hot baths or go into saunas if you’re trying to improve sperm motility or if it is a problem. But the issue of bike riding is less clear cut because lots of people who ride bikes don’t have any issues at all. But men should certainly try to wear loose fitting underwear, boxer shorts etc and perhaps don’t take a 30km ride on a Saturday and a Sunday. Then you can see if it does improve things.

Can frozen eggs undergo PGS after fertilisation? Does it put more risk on the embryo?

PGS is testing the embryo to look at the chromosomes and to do it you have to biopsy or cut off some cells and then freeze the embryo to wait for the results to come back. We used to recommend that approach, however, we’ve now changed our minds on that. With frozen eggs, it’s best to thaw the egg, fertilise with sperm (you’ve got to do ICSI) and then grow the embryo to Day 5 and I think it is better to put an embryo straight back into the uterus rather than refreezing it. Although, embryos that have resulted from a frozen egg still do quite well but the extra testing involved in biopsying the embryo may actually affect implantation so I would tend not to do the testing.

Is there any treatment that makes the embryo stick properly once it has been transferred?

There’s not. There are various things that we have used as adjuncts, clexane and a little bit of progesterone etc but there’s not really anything. I’m afraid, it’s a little bit down to luck.

What ovulation kits do you recommend?

There are lots of different ovulation kits and sometimes it’s cheaper to get them over the internet. I can’t tell you a particular brand but the urine ones are probably better than the saliva ones.

How do you improve egg quality with supplements?

There’s no proof that we can, that’s the bottom line. I can’t say that anything gives you a definite improvement in egg quality. Folic acid is the only thing that must be take to reduce the risk of spina bifida.

Should endometriosis be treated before starting IVF?

This is controversial. I see a lot of people with unexplained infertility who have been trying for two years to get pregnant with no symptoms of signs of endometriosis. The symptoms we’re looking for with endometriosis are heavy painful periods, pain during sex, spotting before a period and a family history of endometriosis. The longer you’ve been trying, the more likely it is that there is something that is stopping you from getting pregnant. Also with ultrasound we can sometimes see what is called a chocolate cyst and there’s a blood test which can sometimes return a high result, a CA125. If I have patients and the woman doesn’t have any of those symptoms or signs, we have the options of continuing to try to conceive naturally, doing a laparoscopy to check for and remove any endometriosis or IVF. If we do the laparoscopy and we don’t find anything, we won’t change the chance of pregnancy. Some people will want to do the operation regardless of this because they want to know that they have tried everything before going to IVF. Others will decide to go straight to IVF because IVF will boost your chance of pregnancy by collecting more than one egg, taking the guess work out of fertilisation, putting the best embryo back in to the uterus. So IVF will lift your pregnancy rate, laparoscopy might lift your pregnancy rate provided you find something wrong and get rid of the endometriosis. Now we’re not sure if endometriosis affects IVF success rates, some studies say yes, some studies say no. That’s why it’s not mandatory to do a laparoscopy before IVF. We know getting rid of endometriosis improves natural pregnancy rates. So a lot of people choose to go straight to IVF but I say if you’ve had two cycles of IVF and not become pregnant and you have unexplained infertility then we should revisit the laparoscopy in case you are someone who doesn’t have signs or symptoms of the condition. That’s one of the problems with endometriosis, you can have people with every symptom and sign and you don’t end up finding a lot of endometriosis once you investigate and there are also people with no symptoms or signs and you will find it upon surgical investigation.

If a woman is almost 40 years old and has been more than a couple of months continuously with no luck, do you think it is best to see a Fertility GP now or just keep trying naturally for another couple of months?

Well, it doesn’t do any harm to do the investigations now as she is almost 40. The reason for that is that you can check sperm to see if you actually got a chance, you can check the tubes are open, you can check ovulation is happening, you can check there’s nothing anatomical in the uterus that would be holding you back. And then you’ve got the confidence to try naturally for another few months. A large number of people who I see don’t necessarily go onto IVF. Instead, they will have other treatments or get pregnant on their own.

Does a gluten free, dairy free, red meat free diet improve quality?

There’s no proof it does. If you’ve got coeliac disease, the gluten free will of course help. But there’s not a definite improvement in quality if you remove those things from your diet.

Is it better to transfer fresh or frozen embryos?

Well, if you’ve only got one embryo and you freeze it and try to put it back in a natural cycle, there is a one per cent chance it won’t survive defrosting. If that happens, you’ll wish you popped it straight back in. So we tend to put one embryo back fresh and then freeze any spare ones because fresh and frozen have pretty similar success rates.

Why do some clinics transfer embryos on Day 3 and some on Day 5?

Genea changed to Day 5 embryo transfers in approximately 2002 because if you’ve got five embryos on Day 3 and only two on Day 5, that has helped you sort out the best embryos without going through a failed transfer and losing time. So it gives you a higher pregnancy rate, much more quickly. You don’t have as many frozen embryos to go through. If you’ve got five in the freezer and three of them weren’t actually going to make it to Day 5, we don’t believe they were going to form a pregnancy anyway.

If I’ve conceived naturally two years before, does it prove my tubes are normal? Do I need an HSG?

An HSG is a test to see if your fallopian tubes are open. All we can really say is that at that point in time, one of your tubes was open. Now unless there’s been some other infection or operation or something that would affect your tubes, it should be open but we can’t say for sure that both tubes are still open. Now sometimes, people will flush tubes to try to see if flushing might improve your chance of pregnancy.

Do you provide hormonal blood testing to see if levels are too low or high before trying anything?

Yes, we do lots of tests beforehand. I don’t know if you’re talking about before doing IVF or in IVF but during IVF there are lots of hormonal tests. In particular, before an embryo transfer to check if it’s safe to put an embryo back into the uterine cavity.

I’ve heard of women with endo being hospitalised with pelvic infection after egg collection due to endocysts in the ovaries. How do you ensure endocysts are not infected or punctured during an egg collection?

We try to avoid them and we don’t go for the follicles which would be behind those cysts. Now I have to counsel people that they may not get as many eggs because if you’ve got a big cyst between the needle and the follicles then the best way to avoid infection is not to go for those follicles. Obviously you also give antibiotics but sometimes you will inadvertently puncture what we can an endometric cyst in the ovary. It may be very small and it may be difficult to get to the ovaries without doing that. So we would use antibiotics and care but it’s not a guarantee. Anyone, even without a cyst could get an infection because you are putting a needle into your body. Even sometimes as minor as getting blood taken could lead to an infection.

What is your approach to patients requiring multiple embryo transfers in one go?

No. Very rarely I will put two embryos back but you’ve got to be a certain age group, you’ve got to have had lots cycles etc. Lots of people want to put more than one embryo back but there are too many risks for mum, too many risks for the babies and we want you pregnant with a safe pregnancy, we don’t want you to have a twin pregnancy. And the risk is that with putting two embryos back, you could end up with triplets. For a long time now we’ve been putting one embryo back, mostly from a safety perspective. Less risks for mum, less risks for the babies.

Do you test for Asherman’s Syndrome in women who have had previous miscarriages or terminations?

Asherman’s Syndrome is where there are adhesions, little bits of tissue stuck inside the uterus. If you get a cut on your arm, your clothes will stick to it and if you’ve had a termination or miscarriage or you’ve had surgery on the lining of the womb, sometimes that could cause things to stick together. So yes, we do look out for that. We usually do an ultrasound before doing IVF to see if there are any areas stuck inside. It’s not an absolute for every single person. If the lining is thin, it alerts me to someone who may have or had have adhesions.

My husband and I have already had our testing done through our GP. Do we need to get fresh testing done or can we book in to see a Fertility Specialist straight away?

You can see a Fertility Specialist straight away. You have a choice of seeing a GP to do preliminary tests or coming to see a Fertility Specialist straight away. Always bring all of the test results with you. That’s something really important to remember. It saves you having to repeat things and it gives us the whole picture during the consultation.

How long does it take for a cycle with frozen eggs?

Well, it depends on your cycle but if you’ve got a 28 day cycle you’d do some blood tests where you live on Day 10, Day 12 and Day 14 to see when you’re going to ovulate, maybe with one ultrasound. On the day of ovulation we thaw the eggs, you might thaw six eggs and inject with sperm. Five of the eggs might fertilise. We then grow them through to the Day 5 stage and you might have two embryos and you’d usually put one of those back into your uterus and freeze the spare one. So it would be one trip to Sydney for the embryo transfer. The rest of the blood tests before and after the transfer could be done outside of Sydney.

How recent do the preliminary tests need to be?

We want the tests to have been conducted in the last 12 months. Old tests will give us an idea, something from 10 years ago is not going to be that relevant but a sperm test within the last couple of years, an ultrasound within the six months would be good. Anything that needs to be done, I will just order if the tests you have are out of date and we’ll organise it, you don’t have to worry about that.

If I’ve had treatment elsewhere, is it possible to transfer embryos?

Yes, no problem at all to transfer embryos from other clinics to Genea. In fact, if people have frozen embryos at another clinic and they’re going to have treatment at Genea, it probably saves money to move them over to Genea and pay one freezing fee and keep them all together rather than having them in two different locations and paying double. We actually have a Transfer Co-ordinator who organises that for our patients.

How accurate is the AMH as an indication of your egg reserve?

It gives us an idea of egg reserve, so the number of eggs we might get from IVF. AMH, follicle numbers and size of ovaries gives us an idea how many eggs you’ll produce but sometimes they don’t all marry up.

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Disclaimer: Please note that this is a Genea Group blog and as such information may not be relevant for all clinics. We advise that you consult clinics directly for further information.