Frequently asked questions
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I am 35 years old and about to start my first IVF treatment. My consultant has suggested that I should only have a single embryo replaced to reduce the risk of having twins. I can only afford this one cycle of treatment and I'm worried that a single embryo transfer will reduce my chance of success.
I can fully understand your concerns. Many couples in your position would prefer the risk of having twins than the risk of not having a baby at all. But it's not as simple as that. There is no doubt that it is far safer to be born as a single baby than as a twin (see Elective Single Embryo Transfer information).
Your worry that IVF birth rates would fall following single embryo transfer might be correct if that policy was to be applied to every patient.
As a generalisation, the eggs of women below the age of 36 are more likely to fertilise and produce good quality embryos with a higher chance of a successful pregnancy than those of an older woman. (It's for this reason that only women below the age of 36 can be considered as potential egg donors.)
So being below the age of 36 places you into a potential group for single embryo transfer. This means that your assisted conception unit will have set themselves guidelines to both preserve your interests and at the same time reduce the risk of a multiple pregnancy.
For example, your centre may have a policy of transferring (whenever possible) a single good quality blastocyst (day 5 embryo). As blastocyst transfers in themselves have a higher successful pregnancy rate, transferring a single blastocyst makes sense as this reduces the risk of a multiple pregnancy. If the number and "quality" of the embryos should indicate the need for an earlier transfer on day 2 or 3, your centre's policy may be that an elective single embryo transfer will only be considered if there are at least two top quality embryos available to choose from. If these types of conditions cannot be met, the embryologist may recommend that you have a double embryo transfer.
You can be reassured that that clinics definitely do not want to reduce their success rates. But success includes safety and a happy outcome for you and your baby. Account is always taken of your own wishes. I would strongly recommend that you discuss your concerns with either your consultant or the senior embryologist on the unit.
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For religious reasons I strongly object to embryos being frozen or discarded. My husband has a very poor sperm count which is why I have been advised to have ICSI treatment. I have heard that it is possible to have IVF in a natural cycle. Is this the answer for me?
In "natural IVF" the one or two eggs that mature in a cycle are retrieved for IVF or in your case ICSI treatment. The first problem that might arise is that either no eggs can be retrieved or the eggs are unsuitable for ICSI. In that case you could embark on another attempt with your next cycle if you so wished. The second problem is that even if ICSI is performed on a single egg, there is no guarantee that fertilisation will take place. You must be aware that the successful live birth rates for natural IVF are very poor. For 2005 the HFEA reported live birth rates of less than 4%.
A possible alternative is "mild IVF". In this treatment, significantly lower amounts of stimulation are given to the ovaries over a shorter period of time. As a result fewer eggs are obtained. The problems of natural IVF remain, but there might also be the risk of having more embryos fertilise than you need for transfer.
If these options are unacceptable to you, an alternative option to consider is donor insemination. It is worthwhile to discuss your concerns with your fertility specialist.
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My fallopian tubes are severely damaged. My consultant says they should be removed before I have IVF treatment. Is he right?
If at laparoscopy your tubes are blocked or severely damaged it is most unlikely that you will ever become pregnant by natural means. If a distorted tube is open, and you did become pregnant, there is the risk of the pregnancy implanting in the tube as an ectopic pregnancy.
If the diagnosis has been made at HSG x-ray (see Hysterosalpingography information), it is worthwhile to have a laparoscopy and dye test performed to obtain a clearer picture of the state of health of your pelvis (see Laparoscopy & Dye Insufflation information).
If one or both tubes are grossly distended with fluid (known as a hydrosalpinx) there is evidence that the fluid within the tubes could interfere with the implantation of an embryo during IVF treatment. In this situation fertility experts feel that it is better to either clip the affected tube close tits junction with the uterus or remove it completely. This can be carried out by laparoscopy as a day case. If on the other hand there is no gross distortion of the tubes it does raise the option of tubal surgery (see Tubal surgery information).
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My partner has a zero sperm count. We have been told that donor insemination is the only way I can conceive. A good friend has offered to donate sperm for us. Is this allowed?
Yes it is possible for your friend to become your sperm donor in the same way that a brother can donate sperm for his brother. But it is very much in your interests that treatment is only done through a licensed assisted conception unit. If you have insemination with your friend's sperm other than through a licensed centre, your friend will be the child's legal father and have the legal responsibility that this status brings. When treatment is carried out through a licensed centre with your partner's consent, your partner will be the legal father and it is his name that will appear on the baby's birth certificate. The donor will have no legal responsibilities.
Your friend will need to have counselling to ensure that he fully understands the implications of becoming your sperm donor. You and your partner will also require counselling so that the centre can satisfy themselves that both of you are fully aware of the potential pitfalls in using a known donor who is also a close friend.
Although his sperm are only going to be used for yourselves, your friend must understand that he has to go through the full screening programme for sperm donors (see Donor Insemination information). This is for your reassurance and safety. You must also appreciate that there will be some delay before you can start treatment. Only after the donor has had two consecutive negative HIV blood tests 6 months apart can sperm be released for your treatment.
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Two tests have shown that I have no sperm in my samples. I can't come to terms with the idea of us having a baby using donor sperm. This is causing arguments now but I can't help the way I feel. I feel angry and useless as a husband and as a man.
From being little children most of us grow up in the expectation that one day we will become a parent. To receive the news that one is sterile is devastating. Your reaction is totally normal and the range of emotions you are going through is also normal.
Men are very good at confusing virility with sterility. Your measure as a man does not depend on whether you can get a stream of women pregnant! You are not judged on your sperm count. You are judged on how good a friend you are, your reliability at moments of crisis, being supportive to friends and family.
There is an excellent little book called "Male Infertility --- Men talking" by Mary-Claire Mason (Routledge £12.99, or through libraries). This book focuses on men's experiences of their own infertility and how they have coped with it.
Having a zero sperm count does not mean that you cannot be a father. There is even the possibility that sperm can be retrieved from your testicles for micro-assisted fertilisation and ICSI (see ICSI information).
Finally there are the options of donor insemination and adoption.
There is no doubt that you can be a dad depending upon how far you wish to take up your options.
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My GP has told me that my very poor sperm count is due to a varicocele, but that doctors don't believe in removing these anymore. We don't really want to resort to donor sperm. Is there anything that can be done?
A varicocele is a cluster of varicose veins around the spermatic cord close to the testicle. Veins contain blood at normal body temperature. In the past it was thought that when a varicocele was found in a man with a poor sperm count, the increased blood flow and heat carried in the varicocele was the cause the problem. There was a vogue to either tie off or remove a varicocele.
From a fertility point of view such treatment has had disappointing results and usually makes little difference to low sperm counts. On an individual basis it probably is worthwhile to tie of an enormous varicocele.
You do however have some options before resorting to the use of donor sperm.
It is worthwhile to keep the testicles cool. Wearing boxer shorts instead of snug Y-fronts is advisable. Avoid long hot soaks in the bath which can literally ?cook? the testicles! Cold water spraying over the scrotum and testicles for 2 minutes twice daily can also have a remarkable effect in improving sperm production. It takes about 74 days to produce a sperm, so you need to be carrying out these DIY manoeuvres for that length of time before having the sperm count reassessed. If there has been an improvement don't stop!
Your specialist can set up a "dummy run" sperm preparation to see how your sperm prepare for assisted conception techniques. If your sperm count is "very poor" the sperm may not prepare adequately for IVF. But the presence of any live sperm raises the option of micro-assisted fertilisation through ICSI (see ICSI information).
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I have been told that I need to have an operation to remove an undescended testicle. Why is this? I don't want to do anything that might reduce my fertility as I have no children. I thought that an operation could be done to bring the testicle down to the scrotum.
The testicles are very sensitive to increases in temperature. This is why they lie in the scrotum where the temperature is about 1.5° cooler than body temperature.
If a baby boy is delivered and it is noted that the testicles have not yet descended into the scrotum, he is observed over the next few years. If by the age of 4 - 5 they have still not descended, his parents should be strongly advised that he has an operation to bring the testicles down from the groin or abdomen and anchor them in the scrotum. This operation is called an orchidopexy. If the operation is deferred until after puberty, he will be permanently sterile.
When, as in your case, an adult is found to have an undescended testicle there is little point in carrying out an orchidopexy because sperm production within that testicle has stopped permanently. But it must not be left where it is. There is good evidence that undescended testicles can over time undergo malignant (cancerous) change. There is no need for you to panic over this as you do not have cancer. The recommendation to you to have this testicle removed is purely precautionary and is very sound advice.
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We have a 7- year old son through donor insemination. We decided early on not to tell anyone about our treatment apart from our parents. We haven't told our son. We now wish that we had. How should we deal with this?
You are right to have at last made the decision to tell your son. With other people "in the know" it would have become an impossible secret to keep from him.
A 3- year old child will accept any story about his or her origins as long as that story is given in an atmosphere of love and security. The same really applies to your 7-year old son. But you are likely to get a lot more questions! It's important that when you decide to tell "the story" that you are both there to tell it together, You could show your son pictures of sperm on the internet and explain how these little tadpoles are grown inside daddy and placed inside mummy to make a baby. You could then say that daddy had run out of sperm which made you very sad because you wanted him so very much. The solution to the problem came when a very kind man at the hospital gave some sperm to put into mummy. And that's how he was made.
Don't go into long explanations because they aren't necessary. You will find that questions will come (sometimes at embarrassingly awkward moments!). By the time he's 10 he'll probably know more about donor insemination than most doctors!
I would also strongly recommend that you get in touch with Donor Conception Network (see links) who will be able to provide you with children's literature and give you other ideas on how to tell the story.
The key to all the information you give, both initially and when the questions flood in later, is how much daddy wanted him. That should do much to avoid the taunt from an angry teenager: "Don't tell me what to do! You're not my father anyway!"
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I am a single woman of 40. I haven't met my Mr Right but I don't want to miss out on being a mum. My GP says that IVF clinics won't consider treating me because I haven't got a partner. Can you advise me?
Your GP is partly right because not all assisted conception units will offer treatment to single women. The HFEA have a "Find a Clinic" website (see links) where you will be able to find which clinics will see and treat single women.
This treatment will not be available to you on the NHS as strictly speaking you do not have infertility.
Before your are accepted for treatment using donor sperm, you will need to see the clinic's counsellor so that the clinic can satisfy themselves that you fully understand all the implications of your decision (see donor insemination information).
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I have had 2 miscarriages. I have recently found out that I have small fibroids. Are they the cause of my miscarriages? Is it best to have them removed before I try to get pregnant again?
Miscarriages are extremely common. The majority are due to an abnormality in the genetic make up of the embryo. Abnormalities in the anatomical structure of the uterus can also be a cause of miscarriage. One example of this is when there is a developmental abnormality in the uterus with a thin wall or septum dividing part or all of the cavity of the uterus. If an embryo implants onto the septum instead of the main surface of the uterus, the blood supply is insufficient to maintain the growth of the pregnancy. If your fibroids are grossly distorting the shape of the cavity, the implantation of an embryo over a fibroid could have the same effect. You describe your fibroids as being small. They can be on the outer surface of the uterus, in the wall and under the endometrium lining (subserosal fibroids) (see Fibroids & Myomectomy information).
It is important that you ask for the advice of your specialist. You do not have the problem of recurrent miscarriages. If the fibroids are on the outer surface or within the wall they will not be causing you any problem at the present time. They may grow bigger during pregnancy or with time, but do not warrant removal.
If the fibroids are distorting the shape of the cavity it may be worthwhile to consider their removal. The final decision will depend upon their number, size and the degree of distortion they cause, your specialist's opinion and not least, your own point of view once you have all the necessary information. Small subserosal fibroids can be removed at hysteroscopy.
Even small fibroids are distorting the cavity, there is still the probability that a future pregnancy will be successful.
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I've been told that I have polycystic ovaries because my periods are very irregular. I'm moderately overweight. We've been trying for a baby now for over a year. Can this be treated?
Polycystic ovaries are ovaries that are enlarged by multiple tiny cysts. About 20% of women have polycystic ovaries. Polycystic Ovary Syndrome (PCOS) is the commonest cause of failed ovulation causing infertility. It occurs in 10% of women in the UK.
You certainly have some of the features of PCOS. These may include:
- infertility
- irregular or occasionally absent periods
- failure to ovulate
- obesity
- increased body and facial hair (hirsutism)
- increased oiliness of facial skin and acne
- thinning of scalp hair
PCOS is a complex condition and is caused by an excess production of male hormones (androgens eg testosterone). Women with PCOS tend to have what is known as insulin resistance which means that they need higher levels of insulin to control blood sugar levels. Obesity increases insulin resistance. The high levels of insulin increase the production of androgens by the ovaries.
There is also a pituitary hormone imbalance with reduced output of Follicle Stimulating Hormone (FSH) and raised levels of Luteinising Hormone (LH). As a result of a low FSH, the egg follicles in the ovaries are not stimulated to mature. The follicles are not primed and therefore ovulation (which normally follows LH release) does not occur. Instead the ovaries become enlarged by poly- (many) cysts (egg follicles) which produce more androgens. Periods are usually very irregular with longer unpredictable cycle lengths.
The diagnosis of PCOS is made on the basis of your symptoms, finding polycystic ovaries at ultrasound and by raised levels of LH and androgens (and, when measured, of insulin).
There are a number of ways in which PCOS can be treated:
Weight reduction. It is very much in your interests to lose weight. This can be difficult because of your insulin resistance. Even the loss of only a few pounds may be sufficient to restore your cycle to normal and trigger off ovulation. Another reason why it is important for you to lose weight is that women with PCOS who are very overweight have a much greater chance of developing diabetes later in life.
Clomifene. Clomifene stimulates the pituitary gland to release its stores of FSH to stimulate egg growth.
Metformin. Metformin is a drug used in the control of diabetes. It is particularly helpful in PCOS patients who are very overweight and can assist with weight loss. Metformin also increases the sensitivity of the ovaries to respond to clomifene.
FSH. Giving FSH bypasses the pituitary gland and can be very effective in stimulating egg follicles to grow (see Ovulation Induction information).
Ovarian "drilling" / electrodiathermy. This is performed at laparoscopy. By destroying some of the androgen producing tissue in the ovaries it can kick-start ovulation particularly when used in combination with clomifene.
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I am very overweight with a body mass index of 38. I also smoke about 20 cigarettes a day. My consultant says I can't be referred for IVF treatment because of my weight. When I try to stop smoking my weight just goes up. I see many women who look much larger than me go into the antenatal clinic next door. Most of them seem to smoke outside when they leave. This seems so unfair.
An infertility clinic is really a pre-conception clinic. One of their major aims is to make sure that you are as fit and as healthy as possible when you do become pregnant. So the clinic will make sure that you are immune to Rubella (German Measles) and are taking folic acid. If you are very overweight they will advise you and help you to try and lose weight. If you are a heavy smoker they will strongly advise you to stop smoking.
The extremes of weight problems are associated with infertility. Very underweight women can stop having periods altogether, their periods only returning when they regain some weight. The very overweight woman's periods are often irregular. Ovulation, if it occurs at all, becomes unpredictable. Your fertility can be significantly reduced if your body mass index (BMI) is above 30.
Not only does obesity make it more difficult for you to become pregnant, it can cause some major risks for you and your baby if you succeed. Blood pressure problems are much commoner. Diabetes requiring insulin treatment can develop. If you are delivered by Caesarean section, the operation is more difficult, wound healing problems are greater and the risk of a deep vein thrombosis (DVT) is increased.
It is virtually impossible for you to diet and try to lose weight once you are pregnant. The answer must be significant weight reduction before pregnancy. You will know what your dietary ?mischief-makers? are. Get professional help.
Most women will say that they will stop smoking immediately once they know they are pregnant because the motivation is so great. But you have to get pregnant first! Smoking at your level will halve your fertility. Your success rate from IVF treatment will also be halved. Smoking significantly increases the rate of miscarriage and stillbirths. Those babies that do not die usually have low birth weights.
Don't try and do everything at once. Tackle the smoking first. Feel good about yourself as each day goes past without a cigarette because it's a real achievement. Your GP will be able to prescribe nicotine patches and other assistance on the NHS if required.
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I am 36 years old and haven't got a partner. I'm worried because my mother had an early "change of life" at 38 years of age. Is it possible to have tests to predict when my menopause will be?
You are being very wise to look into this now rather than assume that a premature menopause is unlikely to happen to you.
You are born with all the eggs you will ever produce. Most of these are lost by the time you reach puberty. Thereafter you lose about 1,000 eggs each month of which only 1 ? 2 actually reach the point of ovulating.
Sometimes an individual's body clock ticks faster than it should and the "egg bank" in the ovaries is depleted quicker than usual. The menopause can occur very abruptly and without warning.
Follicle Stimulating Hormone (FSH) and oestradiol (oestrogen) hormone blood levels can be taken between the 2nd ? 4th day of the period and give you information on how your pituitary gland and ovaries are working at the time of the blood test, but are of little help in assessing your ?ovarian reserve?.
The screening of other hormones alongside FSH can be used to predict your ovarian reserve.
Anti-Mullerian Hormone (AMH) levels tend to fall as the reserve of egg follicles in the ovaries becomes less. This can be measured on any day of the cycle.
Inhibin B hormone levels also decline when the number of egg follicles is reduced. This needs to be measured between days 2?4 of the cycle.
Test kits have been developed (eg Plan Ahead) which measure AMH, Inhibin B and FSH levels taken on day 2-3 of the cycle. From these tests your ovarian reserve can be calculated and compared to the average reserve for women of your age. The test means that for the next 2 years your ovulation reserve can be forecast. Depending on the result you can decide to delay trying for a family or act promptly if the the test indicates that you are at risk of a premature menopause in a few years time.
Another test to consider is a special vaginal ultrasound scan to perform an antral follicle coun (AFC). This scan can be carried out on any day of the menstrual cycle and measures the number of 2.0 ? 8.0 mm follicles in the ovaries. A count of 20 ? 40 at any age can predict infertility occuring in 10 ? 15 years with the menopause occuring 10 years later [ A high count of more than 30 may also be suggestive of polycystic ovarian syndrome (PCOS)]. A count of 10 implies that infertility is likely in the near future with the menopause being 10 years away. A count of less than 5 follicles is predictive of significant infertility which may not respond to fertility drug treatment. unless fertility treatment is received.
Linked to the number of antral follicles is the actual size and volume of the ovaries, the ovaries becoming smaller on scan as the number of follicles falls.
It is important to remember that while these tests may give you some reassurance about current and future fertility, they cannot cover all the causes of infertility.