The changing fertility landscape: What should women know in 2015?

It is close to 40 years since Louise Brown, the world’s first IVF baby, was born. A pioneering development, it paved the way for those facing heart-breaking struggles to conceive. Since this initial breakthrough the IVF industry has seen many more, and continues to grow apace both in scale and sophistication. The latest figures from the HFEA show that, in the UK, more women than ever are undergoing IVF procedures – with almost 50,000 women undergoing 64,000 cycles in 2013. From the moment of Louise’s birth, medical experts have driven a constant development of fertility treatments and procedures, seeking to ensure that no one must needlessly face the tragedy of infertility.

Yet sometimes the sheer scale of opportunity and choice in the IVF arena can be overwhelming to comprehend. The past 5 years in particular have seen some revolutionary changes in the fertility landscape – both scientific and social. Landmark medical developments have been made in areas such as egg-freezing, fertility MOTs, low-drug IVF and womb transplants. Socially IVF is rapidly widening in its accessibility, and has seen a significant rise in uptake amongst single women and same-sex couples. 

Further, the transfer of this information to the public is often still very much lacking, and outdated information will ultimately only limit the opportunity for IVF to become a safer and more reliable process for those who need it. In this new landscape it is therefore important to know what opportunities and options now exist, and how we can be sure to make the most of these advancements. 

Socially, arguably one of the most pertinent developments has been the rise in single women seeking IVF treatment. Since 2007 the number of women embarking on IVF alone has more than doubled, rising from 259 to 632 in 2012, and when the next set of figures are released it is expected we will once again see a significant rise. At our regular clinic open days, it is not uncommon for around a quarter of the attendees to be single women. This has been supported by a rise in sperm banks and the availability of donor sperm, and even a growing role for parents and grandparents in both financing and supporting their offspring to start a family without a partner. We are becoming much more accepting of alternative family models, and this is especially important for women who may be facing an imminently declining fertility but not have a partner to seek children with.

In aiding the prevention of infertility, Fertility MOTs are undoubtedly one of the most crucial new medical developments, as they rapidly provide women with indispensable knowledge on their fertility timeline. One of the most difficult parts of being an IVF doctor is treating women who simply had no idea their fertility was declining, and are now facing difficult hurdles that could have been prevented. Relatively simple and straightforward, a Fertility MOT can now be carried out in one visit and results are available within the hour. If the results should highlight a cause for concern, women are then empowered to take proactive steps to either pursue pregnancy or take preventative measures to protect their future fertility chances.

This brings us to egg-freezing, a procedure that has seen significant technical advancements over the past few years, and has really become a key step in ensuring no woman need gamble her ability to have children over pursuing her career. The key benefit of egg-freezing is that, because egg quality deteriorates with age, it preserves better quality eggs for use at a later time. Thanks to the pioneering development of a new method of preservation called ‘Vitrification’ (or fast freezing) by Professor RC Chian, it is now an incredibly effective way of preserving eggs for use in assisted IVF conception. In the past, the only available method of egg freezing involved a slow freezing process, which was less successful as it allowed ice crystals to form within the egg, potentially destroying the cell’s structure. To overcome this Vitrification first dehydrates the eggs and, using a specialised freezing technique, freezes them so quickly that ice crystals are prevented from forming. This has led to a new generation of women essentially futureproofing their fertility by holding their eggs on ice.

For those undergoing IVF treatment, we have also seen IVF become a gentler and safer process. Over recent years there has been growing awareness that what has become ‘conventional’ IVF, is not the safest or most effective. Conventional IVF involves the use of strong, potentially dangerous, stimulatory drugs. Intended to boost the number of eggs collected, these drugs are both incredibly expensive and can lead to complications such as Ovarian Hyper Stimulation syndrome (OHSS) in mothers and low birth weights in babies. It has now been shown that harvesting a smaller number of quality, naturally produced eggs offer just as high a success rate as a high number of stimulated eggs. This has given rise to a growing number of women choosing to undergo Natural and Mild IVF treatments, which work within a woman’s natural cycle and use little to no drugs. While Conventional IVF involves around 4-5 weeks of daily injections, Mild IVF involves only 5-9 days, and Natural IVF absolutely zero. It is important that women have the knowledge, and thus the power, to challenge clinics who may automatically place them on high dosage treatment cycles without considering individual needs – resulting in unnecessary risks.

Both in the UK and internationally, IVF and fertility treatments are widening in both accessibility and scope. 2015 has the potential to see more women than ever seek IVF treatment that is safer, or take the time to ensure their future fertility is protected. One of the most important considerations for women navigating the fertility industry is to ensuring that you are informed, empowered, and have the confidence to seek what is right for you, your body and your future. 

Egg-freezing: 12 frequently asked questions

Egg freezing has been across the news this month, as Apple and Facebook announce that they are to offer free egg-freezing for female employees. Yet I find among patients there is often still much misinformation surrounding the egg-freezing process, and so below I have put together the 12 most frequently asked questions and their answers.

1.Why do women freeze their eggs?

Previously, it was mainly used for women diagnosed with cancer to preserve their fertility before cancer treatment. Nowadays, it is used by women who want to postpone having children. It could be for a number of reasons - not having an ideal partner, pursuing education or career, caring for parents or just to take pressure off relationships.

2. Do all women of similar age have the same number of eggs in their ovaries?

Not always. If you have a family history of early menopause, you are at risk of having an early menopause and thus fewer eggs for your age. Please ask your mother for her age at menopause. If you have taken steroids or have had ovarian surgery, you may have fewer eggs for your age. Endometriosis of ovaries can also affect egg quantity and quality.

3.How can I find out how many eggs are there in my ovaries?

You need to see a fertility expert and have a detailed ultrasound scan and blood test for Anti Mullerian Hormone (AMH). An antral follicle count (AFC) with Doppler blood flow scan can give more information.

4.What does the egg freezing process involve?

The egg freezing cycle involves taking daily injections of follicle stimulating hormone (FSH) from the second day of your period for around 10 days with a small needle under your skin. You will have 3-4 ultrasound scans and blood tests to monitor the growth of your follicles. Once your follicles have ripened as shown by scan and oestrogen levels in your blood, you will receive a trigger injection under the skin to mature the eggs. The egg collection is planned 36 hours afterwards.

5.How are eggs collected?

You are given mild sedation so that you will not feel any pain. Eggs are collected by a doctor emptying the fluid from follicles by passing a needle through the vagina into the ovary. The procedure lasts for around 15-25 minutes. You will be told about how many eggs are collected after the procedure. You will need to rest at home after your egg collection.

6.How can I make sure that I reduce my risks and increase chances of having good eggs?

It is important that you do not smoke, eat healthily and are not under-weight or over-weight. Modern stimulation protocol within your own cycle with the use of GN RH analogue for trigger can help to obtain good quality eggs and also eliminate health risks such as ovarian hyperstimulation syndrome. Checking blood flow to your follicles during monitoring can help to identify good eggs. Aiming for "quality" is paramount.

7.How many eggs should I freeze?

It depends on your age and egg reserve. If you are under 36, we aim to freeze around 12 eggs. If you are older, we are likely to get fewer eggs for freezing. It is important that very high doses of stimulation are not given just to get very high number of eggs. It can compromise the quality of eggs and put your health at risk.

8.What is the best method for freezing?

The best method for freezing eggs is rapid freezing also known as vitrification. It avoids formation of ice crystals. The survival rates for eggs with this method can be more than 80%. If you freeze 12 eggs, 8 or 9 eggs are expected to survive

9.What is the best time to freeze eggs?

The earlier is better for egg freezing. The ideal age would be from mid twenties to early thirties.

10.What is the success rate?

The success rate depends on the age of the woman and method of egg freezing. With younger women and the use of vitrification provide highest success rates. Recent research confirms the need to freeze around 12 eggs for women under 36 to have up to 50% chance of having a child later, compared to 7% for an older group of women with fewer eggs. The success rate reduces with age of eggs.
It is not a cast iron insurance policy but it is offers some women a chance of conceiving with their own eggs if they do not leave it too late.

11.How many babies have been born following egg freezing?

There are nearly 2000 healthy babies born following egg freezing.

12.How much does it cost?

The total cost of one cycle of egg freezing could be around £3500- £4500. Always question if high doses of drugs are prescribed, as they cost more and may not be necessary. There is an annual storage fee of around £200 and the current standard storage time is 10 years in the UK.

Male fertility: everything you need to know

When talking about fertility, much of the rhetoric focuses on female fertility. As a result, knowledge about sperm and how to best protect male fertility is often severely lacking. For couples with infertility problems, male infertility is a contributing factor in up to 50% of cases, and actually the sole cause in about 30% of cases. So what do we need to know?

A normal, healthy sperm count is usually considered as about 15 million sperm or more per ml, however it’s not just the number which is important. You also have to assess quality indicators such as motility (speed of movement) and morphology (normal shapes), with normal progressive motility being around 32% or more and normal morphology being around 4% or more. If we take this last stat you can see men may have up to 96% abnormal shaped sperm, yet still be considered to have a normal sperm sample as long as other parameters are within the normal range. As soon as the sperm sample does not meet the above parameters it does not mean the man is infertile, but rather that fertility problems are much more likely to occur and the chances of naturally conceiving are reduced.

So why don’t more men, or women for that matter, usually know these details? I feel the real issue here is that they simply not realise that up to half of infertility issues could be due to sperm problems. Through my experience, when compared to women, men are less likely to talk about fertility problems with family and friends. Women tend to share and talk with each other about fertility issues, and getting pregnant seems to be considered a female issue. In reality, men want to be fathers as much as women want to be mothers, but it’s just not a topic they want to bring up in pubs or offices. If awareness of the issues around infertility were better known, I think men would be more proactive about understanding and improving their fertility. Therefore raising awareness around male fertility and how to protect this is just as important as helping women to improve their fertility.

Once we’ve got prospective fathers aware of the importance of sperm count, what can they do to protect it? When looking at this we must first be aware that there is a fundamental difference between sperm and egg production, one well highlighted in the description:

“Men’s testes are like factories, whereas women’s ovaries are like warehouses”.

Men produce brand new sperm every 2 to 3 months, and so their lifestyle in the preceding months is incredibly important in determining the quality of sperm. Lifestyle issues such as high alcohol intake, smoking and taking recreational drugs, all negatively affect sperm function. Stopping smoking and recreational drug-use is an obvious first step. As regards to alcohol intake, there are no quantitative studies, but we advise to reduce alcohol intake and not drink more than 8 units in 48 hours i.e. no bring drinking! Stress can also have a negative impact on sperm quality, and it is important men look to keep this to a minimum. Other factors include anything that contributes to an intermittent increase in scrotal temperature, such as taking hot baths, sitting at a desk or on a sofa for long periods of time, and long distance driving without taking a break.

If men are worried about any of these issues, or would like to seek help, then the first step should be to seek advice from their GP. If concerned or worried, sperm tests are available at most fertility clinics, and they can offer considered medical advice on receipt of results. At my Create Fertility clinics we run free Open Days for men and women, because in tackling fertility issues both are just as important.

The female fertility window: we need more education and less speculation

The past week has seen an explosion of comment and opinion surrounding Kirstie Allsopp’s bold statement that she would rather her hypothetical daughter focused on positioning herself for pregnancy, as oppose to attending university.

Her supporting argument is that, while men have the luxury of fathering children well into their senior years, after 35 female fertility ‘drops off a cliff’. This fact is sadly one which cannot be debated away. As a fertility and IVF specialist, I have treated many women who thought, as we live longer and healthier lives, they had more time for motherhood – only to be left heartbroken.

Yet simply telling women to have children younger, and give up on career prospects, is not the answer. Women should take action early to preserve their fertility. What is needed is the availability of accurate fertility information, plus unfettered access to modern reproductive treatments. Services such as Fertility MOTs provide women with clear facts on their ovarian egg reserve, and enable us to make informed decisions on protecting our fertility.

So, what options does a career-minded young woman have if she chooses to leave pregnancy until later?  There are two main alternatives. She may pursue her career, and if her egg reserve is too low for natural pregnancy when she finally wants to have children, can opt for egg donation. Or alternatively (and this is an increasingly attractive alternative), she can take advantage of the tremendous advances in egg-freezing, or ‘vitrification’, that allow women to bank healthy fresh eggs that can be fertilised when ready to start a family. If the latter, then one or two egg freezing cycles should be carried out before her early 30’s, while egg reserve and quality are good.

What needs to be remembered in this debate is that yes, nature provides women with a much more limited fertility window, but through the delivery of comprehensive education and greater access to services such as Fertility MOTs and egg-freezing, women can take control of their fertility and make the choices that are right for them – with the freedom to pursue any and every ambition.

To read more about Dr Geeta Nargund's work, visit the Create Fertility website

How can we reduce health risks for babies born from IVF treatment? Time to act

A recent study from Australia found that, compared with women who conceived naturally, women undergoing IVF were at significantly higher risk of having a premature, severely underweight or stillborn baby or one which dies within a few weeks of birth.

The effects were also found, although to a lesser extent, in ICSI cycles. Overall there was a 2 to 5 fold increase in these complications when babies were conceived following IVF. Some of these facts were already known from other studies, but what was revelatory was that conceptions following implantation of a frozen embryo had a much reduced incidence of complication. For example a baby born after IVF was over half a pound lighter than a spontaneously conceived baby, but this did not apply in those babies born after frozen embryo transfer. 

In response to this the authors of the paper postulate that implantation of the embryo transferred in a fresh stimulated IVF cycle can be compromised by high levels of oestrogens. These high levels are derived from the use of stimulating drugs, used to boost the number of eggs produced, and which do not occur when a frozen embryo is transferred into an un-stimulated or natural cycle. So now we have proof that avoidance of high oestrogen levels, common practice in conventional stimulated IVF cycles, will not only reduce health risks for the mother but for the baby as well. 

As someone who has championed mild and natural IVF for many years I feel vindicated by these findings. The association of frozen embryo transfer cycles and better outcome has been reported before this, and prompted discussion as to whether freezing all embryos for later transfer should become routine if conventional stimulation is used. However this is an expensive and unnecessary option. The logical way to reduce the health risks associated with high oestrogen levels in IVF, for mothers and babies, is the adoption of mild and more natural IVF protocols. Babies born following modified natural cycle IVF have been shown to be heavier than those born from conventional IVF, which fits in with the findings of this study that un-stimulated endometrium is healthier for the growth of babies. Furthermore, maternal complications such as ovarian hyperstimulation syndrome (OHSS)can be avoided in mild IVF cycles. Conventional IVF is still the common form of IVF practiced in the UK but following this study, it will be increasingly difficult to justify transfer of fresh embryos in cycles with high oestrogen levels.

Two unexplained findings from the study are also worthy of comment. Women who conceived following a period of infertility but who were never treated had a higher risk of unfavourable pregnancy outcomes. However the authors could not confirm whether the women were self-medicating with fertility drugs or were having therapies through specialist clinics which might have influenced the outcomes.

Finally, there is one further important lesson from this study. The Australian team were able to link the data from women having IVF treatment to their pregnancy and delivery database, which allowed the correlation of treatment and outcome to be obtained. In the UK almost 50,000 IVF cycles are carried out each year but no reliable outcome data is obtained because there is no linkage of the IVF database to the UK perinatal database. This must be addressed as a matter of urgency.