Tuesday 18 December 2018

What are your options?

Sometimes the cause of infertility is difficult to diagnose, writes Áilín Quinlan. But there are tests available and steps you can take if you are finding it difficult to conceive

Stock image
Stock image

You've been struggling to conceive, and your GP has now advised you to explore your options in terms of fertility treatment.

One of the first things you need to realise is that your age is crucial and time may be of the essence when it comes to pregnancy and birth emphasises Dr Hans Arce, Medical Director of the Repromed fertility clinic in Dublin.

"The main limiting factor in fertility is the age of the woman," he says.

"The younger the female, the higher the chances; the older the female the lower the chances.

"This is the message that needs to come out. It's not getting out in Ireland.

"We need to understand that nature intends us to have children in our teens and early twenties and that as we age our fertility needs help.

"If you are younger than 35 and have been trying for a year, see a fertility expert," he advises.

"If you're over 35 and have been trying for six months, see a fertility expert," he says, adding that couples who decide that they want a baby when the woman is over the age of 40 should not delay in consulting a fertility expert.

Explains Dr John Waterstone, Medical Director of the Waterstone Clinic:

"Basically, if you leave it too late, your eggs may be too old and you may have to resort to egg donation from a younger woman.

"Some women are very aware about the age factor, but others walk in the door at 42 and they almost get offended when I explain that they may have difficulties because of their age.

"Women are leaving it later and later to have children, and if you leave it too late you may have to resort to egg donation."

"The number of egg donation treatment cycles taking place in Europe is doubling about every four years, and this is reflecting the fact that women are leaving it very late in life to have a child."

One in six couples struggle to become pregnant, observes Dr Minna Geisler, Consultant in Reproductive Medicine, adding that problems can result from a range of factors.

"Both men and women can have fertility issues. The rule of thumb for couples with fertility issues is that one-third are related to male issues, one-third to female factors, and, in one-third of cases, both partners have an issue. "

However, she points out, there is also a high proportion of couples who experience unexplained sub-fertility.

Once you realise that you and your partner may have an issue with fertility, the first step is to have some basic investigations carried out, says Dr Geisler, who is based at the Waterstone Clinic.

A hormone profile should be carried out, either by your GP or by your fertility clinic, she advises. A woman should also undergo an Anti-Mullerian Hormone (AMH) test, she says, adding that this test, normally carried out at the fertility clinic, measures a woman's ovarian reserve.

In fact, according to Dr John Kennedy, Medical Director of SIMS IVF, the AMH test as "a very good screening test of the ovarian reserve." It is, he says, something he would encourage all women in their late 20s or early 30s to undergo, "just to establish where their fertility is at."

The AMH test should be a screening test incorporated into everyone's health care assessment, he believes.

Meanwhile, the male partner should have a semen analysis carried out, something which can be carried out at the GP's surgery or at the fertility clinic.

Another recommended test is a transvaginal ultrasound scan which, Dr Geisler explains, looks at the health of the womb and checks for abnormalities such as fibroids and polyps. It also assesses the ovaries and measures the number of follicles on each ovary, which gives an indication of the state of the woman's ovarian reserve.

"It may also be recommended that a woman undergo tests to check the functioning of her fallopian tubes," says Dr Geisler, who emphasises that subsequent treatment options depend on the underlying cause of the sub-fertility .

"For some couples we would recommend ovulation induction treatment, using Clomid, but this is really reserved for situations where a woman is not ovulating regularly."

Combining Clomid with Timed Sexual Intercourse can work well, says Dr Arce who explains that this method can prove beneficial for couples where, he emphasises, the woman has not been ovulating regularly, and also in a situation where the man has good quality sperm.

However, if a woman has been ovulating regularly and the man's sperm is normal, he adds, a clinic may suggest the couple try Intra Uterine Insemination (IUI):

"This is where you encourage the female to ovulate one or two eggs and inject the sperm directly into the uterus. You are getting the sperm closer to the egg - and in higher numbers."

Another option is InVitro Fertilisation or IVF, as Dr Geisler explains:

"During IVF treatment, the woman takes medication to ensure that her ovaries produce a number of mature eggs.

"These eggs are collected through a special procedure performed in the clinic. The harvested eggs are mixed with her partner's sperm to facilitate fertilisation.

"The embryos that result are monitored and the most promising is elected for transfer back into the woman's womb three to five days after egg collection."

Generally speaking, she says, IVF has a 38% success rate but she emphasises, success is dependent on the woman's age and her ovarian reserve.

Where sperm quality is poor, clinics may use a technique called Intracytoplasmic Sperm Injection (ICSI) which involves injecting a single sperm directly into each egg, Dr Arce explains.

Another option for, says Dr Kennedy, is to use donor sperm.

"This is an option for couples where there is a severe male factor. It is also an option for single women who wish to become pregnant, or for women in a same sex relationship. Donor sperm can be used in conjunction with IUI or IVF."

Another option is egg donation, says Dr Arce, who points out, however, that it is important that eggs are donated by young women. Nature ideally wants us to have babies in our teens or 20s, he explains, so, if a woman decides at the age of 42 that she would like to have a child, her chances of a normal pregnancy are very low, at about 10%. With eggs from a young donor in her late teens or early twenties, the chances of a woman in her early forties having a normal healthy pregnancy resulting in a baby, can rise up to 50% he says.

Surrogacy is theoretically, at least, another option - this is where a childless couple 'commission' a surrogate mother to either be artificially inseminated or have an embryo transferred to her womb in order to become pregnant. The surrogate mother carries the child to term with the intention of giving custody of the child to the commissioning couple.

However, says Dr Kennedy, surrogacy is an extremely difficult situation in Ireland:

"There is no provision here for the commissioning mother to be recognised.

"Under Irish law the woman who carries the baby for nine months and gives birth to the baby, is recognised as the mother.

"We need to catch up on that," he said, adding that proposed draft legislation to cover surrogacy was "woefully inadequate" and would reduce the ability of Irish couples to avail of this technique.

"I am concerned about that."

You've been struggling to conceive, and your GP has now advised you to explore your options in terms of fertility treatment.

One of the first things you need to realise is that your age is crucial and time may be of the essence when it comes to pregnancy and birth, emphasises Dr Hans Arce, Medical Director of the Repromed Fertility Clinic in Dublin.

"The main limiting factor in fertility is the age of the woman," he says.

"The younger the female, the higher the chances; the older the female the lower the chances. This is the message that needs to come out, and it's not getting out in Ireland.

"We need to understand that nature intends us to have children in our teens and early twenties and that as we age our fertility needs help.

"If you are younger than 35 and have been trying for a year, see a fertility expert," he advises.

"If you're over 35 and have been trying for six months, see a fertility expert," he says, adding that couples who decide that they want a baby when the woman is over the age of 40 should not delay in consulting a fertility expert.

Dr John Waterstone, Medical Director of the Waterstone Clinic explains. "Basically, if you leave it too late, your eggs may be too old and you may have to resort to egg donation from a younger woman.

"Some women are very aware about the age factor, but others walk in the door at 42 and they almost get offended when I explain that they may have difficulties because of their age.

"The number of egg donation treatment cycles taking place in Europe is doubling about every four years, and this is reflecting the fact that women are leaving it very late in life to have a child."

One in five couples struggle to become pregnant, observes Dr Minna Geisler, Consultant in Reproductive Medicine, adding that problems can result from a range of factors.

"Both men and women can have fertility issues. The rule of thumb for couples with fertility issues is that one-third are related to male issues, one-third to female factors, and, in one-third of cases, both partners have an issue."

However, she points out, there is also a high proportion of couples who experience unexplained sub-fertility. Once you realise that you and your partner may have an issue with fertility, the first step is to have some basic investigations carried out, says Dr Geisler, who is based at the Waterstone Clinic.

A hormone profile should be carried out, either by your GP or by your fertility clinic, she advises. A woman should also undergo an Anti-Mullerian Hormone (AMH) test, she says, adding that this test, normally carried out at the fertility clinic, measures a woman's ovarian reserve.

In fact, according to Dr John Kennedy, Medical Director of SIMS IVF, the AMH test is "a very good screening test of the ovarian reserve." It is, he says, something he would encourage all women in their late 20s or early 30s to undergo, "just to establish where their fertility is at."

Meanwhile, the male partner should have a semen analysis carried out, something which can be carried out at the GP's surgery, or at the fertility clinic.

Another recommended test is a transvaginal ultrasound scan which, Dr Geisler explains, looks at the health of the womb and checks for abnormalities, such as fibroids and polyps. It also assesses the ovaries and measures the number of follicles on each ovary, which gives an indication of the state of the woman's ovarian reserve.

"It may also be recommended that a woman undergo tests to check the functioning of her fallopian tubes," says Dr Geisler, who emphasises that subsequent treatment options depend on the underlying cause of the sub-fertility .

"For some couples we would recommend ovulation induction treatment, using Clomid, but this is really reserved for situations where a woman is not ovulating regularly."

Combining Clomid with timed sexual intercourse can work well, says Dr Arce who explains that this method can prove beneficial for couples where, he emphasises, the woman has not been ovulating regularly, and also in a situation where the man has good quality sperm. However, if a woman has been ovulating regularly and the man's sperm is normal, he adds, a clinic may suggest the couple try Intra Uterine Insemination (IUI).

"This is where you encourage the female to ovulate one or two eggs and inject the sperm directly into the uterus. You are getting the sperm closer to the egg - and in higher numbers."

Another option is InVitro Fertilisation or IVF, as Dr Geisler explains. "During IVF treatment, the woman takes medication to ensure that her ovaries produce a number of mature eggs.

"These eggs are collected through a special procedure performed in the clinic. The harvested eggs are mixed with her partner's sperm to facilitate fertilisation.

"The embryos that result are monitored and the most promising is elected for transfer back into the woman's womb."

Generally speaking, she says, IVF has a 38pc success rate, but she emphasises, success is dependent on the woman's age and her ovarian reserve. Where sperm quality is poor, clinics may use a technique called Intracytoplasmic Sperm Injection (ICSI), which involves injecting a single sperm directly into each egg, Dr Arce explains. Another option says Dr Kennedy, is to use donor sperm. "This is an option for couples where there is a severe male factor. It is also an option for single women who wish to become pregnant, or for women in a same sex relationship. Donor sperm can be used in conjunction with IUI or IVF."

The aforementioned egg donation is also an option says Dr Arce. The chances of a woman in her early forties having a normal healthy pregnancy resulting in a baby, can rise up to 50pc this way.

Surrogacy is theoretically, at least, another route - this is where a childless couple 'commission' a surrogate mother to either be artificially inseminated or have an embryo transferred to her womb in order to become pregnant. However, surrogacy is an extremely difficult situation in Ireland, added Dr Kennedy. "There is no provision here for the commissioning mother to be recognised. Under Irish law the woman who carries the baby for nine months and gives birth to the baby, is recognised as the mother.

"We need to catch up on that," he said, adding that proposed draft legislation to cover surrogacy was "woefully inadequate" and would reduce the ability of Irish couples to avail of this technique.

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