Everyone who undergoes fertility treatment will have their own unique journey.
The first step will be to have a consultation with us. This is led by one of our three Consultants, although additional information is sometimes taken by one of our highly trained specialist nurses. At this appointment a full history is taken for you and your partner, which helps us to make an assessment of possible causes of infertility and what action to take. At this appointment we will look at the results of any tests you may have already had.
For those who are at the start of their fertility journey we will recommend the following tests:
In around one-third of couples, fertility problems are due to problems with overall sperm numbers, percentages moving, or low numbers of normal looking sperm. All men will be asked to provide at least one sperm sample for analysis to find out if this is contributing to the delay in pregnancy occurring. Blood tests may also be required to test hormone levels according to the semen analysis result.
Women who have periods will undergo blood tests at the beginning of their cycle, as well, as on day 21 of the cycle. This is to check the various hormones which are closely linked to how well the ovaries are working. Some hormone imbalances, such as polycystic ovarian disease, can cause ovulatory problems affecting whether the egg is being released. If you are not having periods at all, or they are irregular this can be a sign that you have ovulation problems.
All women will have a test for Chlamydia.
Other tests will include an ultrasound scan to check the appearance of the ovaries and womb (uterus); this is usually a transvaginal scan, whereby a small ultrasound probe is placed into the vagina. This helps us determine if you have conditions such as polycystic ovaries, uterine polyps, endometriotic cysts and fibroids which can reduce the chance of a pregnancy from happening.
If necessary, we will arrange a special ultrasound scan test (HyCoSy) to check that the fallopian tubes are open. A special foam (ExEm) is injected through the cervix into the cavity of the womb and along the tubes. This allows us to confirm that the tubes are patent. If there is a blockage, or damage of your fallopian tubes, this can prevent the eggs from travelling along the tubes and meeting the sperm, which will stop you getting pregnant, or certainly make it more difficult for the pregnancy to implant into the womb.
Once we have the results of all the tests we will discuss the range of options available and devise an appropriate treatment plan. At this appointment we may also offer pre-treatment advice to enable treatment to start as soon as possible.
Our counselling services are available to all our patients. There are some treatments where counselling must be undertaken before treatment can begin.
Ovulation is the release of an egg from the ovaries and is necessary for pregnancy to occur. Where this does not happen naturally, medication can be used to stimulate ovulation. This is called Ovulation Induction.
There are a number of different medicines which can be used depending on the cause of infertility. Your consultant will take you through this and all treatments but a short summary of the ovulation induction treatments are listed below: –
- Clomiphene citrate (Clomid) is given as a tablet.
- It is most commonly used for women who have infrequent or very irregular menstrual cycles.
- Side effects are uncommon, usually mild, and include hot flushes, headaches, hyper stimulation and visual disturbances.
- As with all fertility drugs there is an increased risk of multiple pregnancy, so the starting dose will be low; usually 50mg on days two to six of the cycle, only increased gradually if necessary and as instructed by the clinical team.
- The dosage will be determined by the progesterone hormone levels on the monitoring blood tests (usually carried out on or around day 21 of the cycle) or ultrasound scan findings.
- Ultrasound monitoring helps us assess the thickness of the womb lining (endometrium) as well as the growth of the developing follicles in the ovary.
- A course of treatment is usually no more than six months.
- The drug increases the release of Gonadotrophin releasing hormones that lead to ovulation by blocking estrogen receptors.
- The injections are all self-administered, subcutaneously (just into the skin), at a similar time each day.
- Couples are taught at the start of their treatment on how to give the injections.
- The treatment is started within the first two or three days of the cycle and lasts on average, between seven to twelve days. Side effects are generally uncommon.
- Several different drugs are used, the Gonadotrophin Injections usually contain a mixture of Follicle Stimulating Hormone (FSH) and smaller quantities of Luteinising Hormone (LH) in varying proportions.
- The injections stimulate the growth of follicles on the ovaries; the follicles are the fluid filled areas in the ovary that will contain the developing eggs.
- The progress of treatment is monitored using transvaginal (through the vagina) ultrasound scans.
- The first scan usually takes place after the first seven days of injections, with further scans arranged according to the ovarian response.
- These scans will record the number and size of the follicles.
- Once the follicles, each containing an egg, have reached the correct size, the patient is asked to take a second type of injection, called human Chorionic Gonadotrophin (hCG).
- hCG is also given subcutaneously, as a single timed injection which will trigger the final maturation of the egg in the follicle; this results in ovulation (release of the egg) within 37-40 hours of the injection.
- The timing of intercourse is crucial to the treatment, therefore advice will be given, or alternatively this treatment may be combined with Intrauterine Insemination
Stimulated Intrauterine Insemination (IUI)
In some cases, couples can improve their chance of conceiving by having Gonadotrophin injections (as previously described) combined with a timed injection of sperm directly into the uterus. This is more commonly known as Stimulated Intrauterine Insemination (IUI).
During the Ovulation Induction
- The daily Gonadotrophin injections are monitored by regular ultrasound scans.
- The first scan usually takes place after 7 days of injections.
- Generally, additional scans are carried out at two to three day intervals (however this may vary depending on the scan results).
- Due to the small risk of multiple pregnancy associated with the treatment, it is important that the monitoring detects if there are too many follicles developing. In which case the treatment cycle may need to be abandoned.
- Once the follicle has grown to the correct size, ovulation will be induced with an injection of human chorionic Gonadotrophin (hCG).
- This is administered around 24 hours before the insemination is performed.
- The majority of cycles are ready after 8 – 12 days.
During the Insemination
- The IUI procedure is similar to a cervical smear test.
- A speculum is inserted into the vagina to allow the nurse or doctor a good view of the cervix (neck of the womb).
- A fine catheter with a small balloon on the end is then passed through the canal of the cervix.
- Once the catheter is in place, the prepared sperm is injected into the uterus.
- After resting for around 15 minutes, the catheter is removed.
- You are then free to go.
In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI)
For patients, IVF and ICSI are quite similar.
The key difference between them is in the way that the eggs and sperm are manipulated in the laboratory on the day of the egg collection.
In-Vitro Fertilisation (IVF)
For IVF, the eggs are mixed with the specially prepared sperm, they are then moved to an incubator to fertilise.
Is IVF right for me?
Several drug combinations can be used in IVF treatment. The drugs are usually given as injections to stimulate the ovaries to produce a number of follicles, each of which should contain an egg. Following the consultation an appropriate drug protocol can be decided upon. The treatment may take between 2 and 5 weeks to get to the stage of egg recovery.
At the egg recovery procedure, the eggs are retrieved from the ovarian follicles and then assessed to be combined with the sperm to create embryos.
The main indications for undergoing IVF treatment are:
- Tubal disease (where either one or both of the fallopian tubes are blocked)
- Ovulation Problems, including Polycystic Ovarian Disease
- Unexplained infertility
Intra- Cytoplasmic Sperm Injection (ICSI)
ICSI is a highly skilled procedure which involves a single prepared sperm being injected directly into the egg. The eggs are then moved to an incubator to allow fertilisation to take place.
Is ICSI right for me?
Similar drug protocols are used to stimulate the ovaries in ICSI as are used in IVF.
For ICSI to take place, the eggs need to be at the right stage of maturity to then be injected with the individual sperm.
The main indications for undergoing ICSI treatment are:
- Male factor infertility (poor quality sperm count- reduced numbers of sperm, poor motility, low numbers of normal looking sperm)
- Azoospermia (no sperm in the ejaculate)- in this case it may be possible to extract sperm surgically to be used either fresh or frozen with the ICSI procedure
- Previous poor fertilisation rate with IVF treatment
- Previous failed fertilisation with standard IVF