Expert / 13 August, 2019 / Dr Larisa Corda
Subfertility generally describes any form of reduced fertility with a prolonged time of unwanted non-conception. Treatment options for subfertility are many and varied.
The most important thing you can do is make sure you and your partner have had a full medical evaluation beforehand to see if any cause can be found and if this treatment is necessary for you. Ultimately, treatment could be all about reversing an identified cause. In up to a third of cases, no obvious clinical reason can be found for subfertility, whereas sometimes women may elect to become single mothers or men and women may wish to have children in a same sex relationship, in which case fertility treatment is a necessity.
This treatment typically involves the stimulation of egg or sperm production, or the handling of eggs, sperm or embryos. But before any of this starts, it is vital to get yourself into the best possible state of health through lifestyle changes that will improve any underlying medical conditions that could be behind the subfertility, as well as boosting your chances of pregnancy whether naturally or through assisted reproductive treatment. This is the foundation of The Conception Plan, which I use to improve a couple’s natural chances of conception, as well as those undergoing treatment. There is no cure nor substitute for a poor lifestyle, and if this is not implemented first, it could compromise the outcome of any expensive reproductive treatment you have. So, the correct fertility boosting lifestyle is absolutely crucial to success and committing to this sooner rather than later will give you the best possible chance of conceiving.
There are times when a doctor may recommend surgery prior to undertaking any fertility treatment, if the lifestyle changes alone are not enough to improve the clinical picture. For example, this can be done for endometriosis, polycystic ovaries, blocked fallopian tubes, scarring in the womb, or for male related infertility due to a previous vasectomy, or problems with ejaculation where sperm needs to be retrieved surgically from the testes.?“‘
The specific treatment plan will depend on the cause of subfertility, whether it’s male or female related or both, and will take into account your entire clinical picture. But before you start, it’s important that you discuss the options in detail with your doctor who will help to guide you towards the best decision. Clinics vary in their approach to fertility management, and one of the commonest issues I hear from patients is that they feel they are given conflicting advice. Clinicians will have different opinions based on their own expertise, experience and beliefs. Fertility treatment is constantly developing and as we gain more understanding based on research, different opinions may start to emerge. It does not mean to say that some doctors are wrong or right. They just have different opinions on how they would approach treatment, and as long as this is justified, my suggestion would be to go with the clinic that is most in line with your own beliefs and values and where you feel most supported. Which brings me to the next really important point, and that’s to ensure that you get adequate emotional support throughout this whole experience. Never underestimate the toll that the level of commitment required for treatment can take. It is hardly ever an easy road and treatment may require several attempts before it’s successful. This is normal and it’s important that you have the necessary support available to look after yourself during this time.
So, what are some of the options for fertility treatment. They can be broadly categorised into the following:
These can be used to stimulate ovulation, but also sperm production in some cases of male infertility. These include clomid, letrozole and gonadotrophins.
Ovulation disorders account for about 25 percent of female factor infertility cases. This is the most common reason for fertility drug treatment and includes conditions like polycystic ovaries.
The same drugs can also be used during an IUI cycle and are almost always used during IVF treatment, unless you are having natural IVF. The aim of these drugs is to encourage follicular growth and ovulation. All drugs have side effects and before starting any of these, the indications for using them must be made clear as well as the benefits. There are also risks of multiple birth and so monitoring is required when taking these drugs.
There are situations within your treatment cycle when a doctor may wish to introduce other medication either to help boost the response to treatment or to help them to gain more control of your cycle by suppressing the reproductive response, or to reduce the risk of certain complications. This is too complex and varied to discuss here, and must always be discussed in full with your doctor, but includes things such as metformin, aspirin and progesterone.
Intrauterine insemination is a procedure that involves placing specially washed sperm directly into the uterus. This treatment is normally recommended in patients who are young and have no obvious cause behind subfertility, in situations where donor sperm is used, certain cases of male infertility, or in conjunction with medicated treatment for female related infertility or where sex is not possible for a couple. It is generally speaking not as successful as IVF, which is why it tends to be recommended predominantly for younger patients, but new studies are suggesting that perhaps we should be using IUI more often as a first resort in some patients. More often than not, it tends to require several rounds of treatment to be successful.
As problems with fallopian tubes can be relatively common, it is best to check that there is no obstruction that could diminish or prevent the IUI from being successful. This is done with the aid of a hysterosalpingogram or hysterosonography, two techniques that involve injecting dye into the fallopian tubes to see if they are patent or not. This can also be done during a laparoscopy, especially if the operation is being done to treat an underlying condition such as endometriosis. Some blockages can potentially be reversed, although not always, which is why some doctors recommend IVF in these situations.
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If medicated treatment or IUI has failed, or if a woman has blockages affecting her fallopian tubes or doesn’t have them at all, if a woman is older or donor eggs are being used, or the sperm are suboptimal in quality, then IVF or ICSI can be used to help.
In IVF, fertility drugs are used to stimulate the ovaries to produce eggs, during which you will be monitored via scans and blood tests. These eggs are collected in an outpatient operative procedure where you are put under sedation. The eggs are then fertilised with sperm from your partner or donor to create embryos, which are then allowed to grow and develop before being implanted into the womb or stored by freezing.
The process of transfer is one that needs discussion with your doctor as sometimes this is done immediately after the IVF, and at other times it is done later either because the embryos are sent for testing via something called pre-genetic screening or diagnosis. At other times your doctor may elect to get the womb in the best shape possible for pregnancy before implantation by carrying out a procedure such as hysteroscopy, that can also be done before you start the IVF. Or to recommend a frozen transfer on the basis of needing to let any adverse symptoms settle before implantation. Sometimes embryo batching is done with several rounds of IVF before implantation, where embryos are created and frozen, in order to select the embryo with the highest potential to implant first. The day of transfer is also something that can be a complex area and needs to be discussed with your doctor as this can be individualised for each patient depending on their circumstances.
ICSI is usually done if sperm are poor in quality or number or if IVF has not been successful. This is where one sperm is preselected and directly injected into the egg. ICSI has had some concerns over whether children born via this method could have their own ability to reproduce affected, but nothing has conclusively been proven by studies nor has it been possible to be clear on whether this is due to the procedure itself or the fact sperm which are suboptimal are being used, and therefore may carry certain abnormalities.
In terms of risk of cancer in patients undergoing IVF or to their offspring, this has not been proven though some studies are suggesting that the hormonal environment created by using large quantities of stimulation drugs could potentially have adverse effects. If you’ve had breast or ovarian cancer or have a higher risk of this, these decisions must be undertaken with your doctor and a doctor who specialises in cancer medicine or oncology.
We do use IVF to help preserve fertility in patients who have been diagnosed with cancer and require chemo or radiotherapy. The process of egg freezing for women who want to preserve fertility for the future also involves the same stimulation as used in IVF, but instead of embryos being created, eggs are collected and frozen for future use.
There are some concerns growing over the effect large doses of drugs could be having on a patient and also their children. Some studies are beginning to show links between high doses of gonadotrophins used in IVF and low birth weight, as well as poorer egg quality. In addition to which, high doses of drugs can end up overstimulating a patient, tipping them into something called ovarian hyperstimulation that can present a risk to their health. Drugs used in greater quantities carry more side effects such as nausea and abdominal pain, not to mention significant costs.
With this in mind, there is a growing movement towards milder IVF, which uses smaller doses of drugs over a shorter period of time, in order to focus on optimising egg quality rather than aiming for a larger quantity of eggs, and therefore improving the chances of creating better quality embryos that will ultimately produce healthier babies. Sometimes IVF can be done in the absence of any stimulation drugs. This is called natural IVF, but success from this can be lower as it usually only results in one egg.
There are times when even IVF is not enough and a couple may need to look at egg or sperm donation, or surrogacy as an option. Egg donation is used in situations where a woman has low ovarian reserve or in other words, her biological clock has been accelerated and the quality and quantity of her eggs has been diminished. It is also used in women who have gone through the menopause or where repeat IVF attempts with own biological eggs has failed, or for a male couple who wish to use a surrogate.
Sperm donation is required in cases of severe male factor infertility, or if a single woman or lesbian couple wish to have a child. IUI or IVF can be used with this but it’s important to only obtain donor sperm via a regulated clinic and not any of the web forums that exist, where sperm donors are not screened and where women can put themselves and their children at risk.
In rare cases, embryo donation may be used for a combination of the above reasons.
Donors can generally be known or unknown. If a donor is found via a clinic, then they will be anonymous, though in the UK, since 2005, every child born through egg or sperm donation is allowed to find out the identity of their biological donor when they reach the age of 18.
Surrogacy is needed for a woman who may not have a uterus, or if she has a severe condition that makes carrying a pregnancy very difficult. Sometimes it is used after repeat failed IVF attempts, and it’s also required when a male couple wishes to have a child.
Because surrogacy in particular can be incredibly expensive and legally challenging, many patients can opt to go abroad for treatment. This can also be the case for IVF, in order to seek lower costs. Whilst this is fully understandable, it’s really important that you do your research and ensure you are going to a clinic that has a good record of success because unlike in the UK, where every clinic is monitored, the same may not apply abroad, and where clinics may potentially go against certain recommendations, such as implanting more than 2 embryos into the womb and hence significantly increasing the chances of multiple birth, thus placing your own health at risk. Always do your research beforehand and make sure you feel safe wherever you decide to go.
Dr Larisa Corda is an obstetrician and gynaecologist and is one of the UK’s leading Fertility experts.
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