Assisted conception (or ‘fertility treatment’ or often referred to collectively as Assisted Reproduction Technology “ART”) is a general term to describe all the methods used to help a woman achieve a pregnancy when she is having difficulty conceiving. Some of the more complex activities are currently regulated by the Human Fertilisation and Embryology Act 1990.
The world’s first ‘test-tube baby’. Louise Brown. was born in the UK in 1978. Her birth offered hope to infertile couples across the world. Since then. thousands of couples have made use of in vitro fertilisation (IVF) and other assisted conception techniques. The success rates of these treatments continue to improve.
Today. assisted conception treatments are tailored to individual patients’ unique conditions. These procedures are usually paired with more conventional therapies. such as fertility drugs. to increase success rates. On average. one in five couples who use assisted conception techniques gives birth to a baby or in some cases twins or even triplets depending on the technique.
However. the procedures are invasive and expensive. In addition. although no long-term health effects have been linked to children born using the new reproductive technologies. most doctors recommend reserving such procedures as a last resort for having a baby.
What are the reasons for having assisted conception?
No one knows for certain how many couples have difficulty conceiving. since some will decide not to seek medical treatment. In the UK. however. approximately one in six couples do seek medical help to have a baby. In most cases there will be one or more causes that a specialist can pinpoint and. possibly. treat.
Contrary to popular belief. infertility is not just a woman’s problem. In fact. it strikes men and women almost equally. About 35 per cent of cases can be attributed to men. 35-40 per cent to women. and the rest to multiple factors affecting both partners. some of which remain unexplained.
The three most common reasons for assisted conception are that the woman’s ovaries are not producing eggs. her fallopian tubes (tubes from the uterus to the ovary) are damaged or that the man’s sperm are too few or unhealthy. These reasons account for about 90 per cent of all cases. Treatments are available for both male and female fertility problems.
Ovulation and egg quality
Conditions in this category include polycystic ovary syndrome. poor egg quality. and irregular ovulation or failure to ovulate (because of hormonal deficiencies or imbalances). These problems. especially deteriorating egg quality. are often age-related. and apply most often to women aged over 37.
Possible solutions: Treatments include fertility drugs. in vitro fertilisation (IVF). and use of a donor egg.
Blocked fallopian tubes
Infections. endometriosis. scar tissue. adhesions. and damaged tube ends (fimbria) can result in blocked or otherwise abnormal fallopian tubes. Even if you ovulate regularly. blocked tubes make pregnancy next to impossible. since your egg can’t get to your uterus. and sperm can’t get to your egg.
Possible solutions: The main treatment is usually IVF. However. if the blockage is found to be limited to a small area it might be possible to clear it by keyhole or open tubal surgery to remove the blocked portion. Infections such as chlamydia tend to damage the whole length of the tube and are less amenable to surgery. A laparoscopy is usually carried out to determine which is the most appropriate treatment for you.
In men. infertility can be the result of a blocked vas deferens or epididymis. poor sperm quality. low sperm motility (the sperm’s ability to move). a semen deficiency. or not having enough (or any) sperm to begin with.
Possible solutions: Just as women often undergo surgery to open blocked fallopian tubes. men may have an operation to clear their blocked tubes (again. a full assessment. including hormonal tests and an evaluation of sperm motility. precedes surgery). If something else is at the root of the problem. fertility drugs may boost sperm production. or a man’s sperm can be used to artificially inseminate his partner. Other options include using donor sperm or injecting sperm directly into the egg (intracytoplasmic sperm injection or ICSI).
A minority of cases include pelvic inflammatory disease (PID). recurrent miscarriage. endometriosis (also under blocked fallopian tubes) or some other unexplained condition as a reason for assisted conception. Discuss possible solutions and treatments with your GP who will refer you to an infertility specialist if necessary.
What are the Treatment Options ?
Your treatment options will vary according to the cause of your infertility. Your doctor may well suggest trying the least invasive options first. The newer and more high-tech treatments. such as in vitro fertilisation (IVF). are considered a last resort. largely because of their cost and complexity. However. drug treatment and surgery are very effective. In fact. of those couples who successfully go on to have children. most are treated with fertility drugs or surgery only.
The right treatment for each couple depends on many factors. including:& ;
- the age of the woman
- the quality of the man’s sperm
- how long the couple have been infertile
- whether or not the woman has had a previous pregnancy.
Your treatment options – from least to most invasive – are:
When hormones are out of balance or in short supply for women (and. in some cases. for men). these drugs may get your reproductive system back on track.
Artificial insemination (AI)
In some cases. sperm just need a shortcut to the egg. A concentrated dose of your partner’s sperm placed in your uterus or fallopian tubes can aid fertilisation. AI. also known as Intrauterine insemination (IUI) can also help couples where the man’s sperm is unable to get through the woman’s cervical mucus. Donor sperm may also be used.
Blocked tubes. endometriosis. fibroids and ovarian cysts – all implicated in fertility problems – are often treated with surgery.
Assisted Conception Treatments
Fertility drugs and other conventional treatment options are combined with high-tech procedures. such as egg collection. to treat low sperm counts. fallopian tube problems. or ovulation problems. These procedures include in vitro fertilisation (IVF). gamete intrafallopian transfer (GIFT). zygote intrafallopian transfer (ZIFT). intracytoplasmic sperm injection (ICSI). and the use of donated eggs or sperm. The use of a surrogate mother is considered by some couples.
Investigations and treatment for infertility are normally undertaken in a specialised fertility clinic. To decide what treatment to use. some routine tests are carried out by the specialist. To see whether the woman is ovulating (producing eggs) her blood is tested for the levels of some hormones called progesterone. luteinising hormone. follicle-stimulating hormone (FSH) and testosterone. She will have an ultrasound scan of the womb. tubes and ovaries.xx
The specialist may decide to carry out a laparoscopy an operative procedure to examine the inside of the abdomen using a long. thin instrument (laparoscope) and a hysterosalpingogram (a special X-ray of the womb and fallopian tubes). These tests show whether the ovaries look normal and whether the tubes are damaged or blocked.xx
The man needs to produce a sample of semen for a sperm test to check the numbers of sperm. whether they are motile (able to move normally) and whether they have a normal structure.
What happens during treatment for female infertility?
Ovulation induction is a technique that stimulates the inactive ovary to produce eggs. At its simplest it involves the woman taking a drug called clomiphene for six days each month. This method is most often used for women who have conditions such as polycystic ovary syndrome. in which the ovaries do not produce eggs.
Ovulation induction is also the first stage of preparation for in-vitro fertilisation (IVF). which is the treatment needed by most women whose tubes are damaged. Three hormones are used: one to suppress the ovaries. one to stimulate several eggs to develop simultaneously and one to ripen the eggs. The aim is to control the timing of the woman’s cycle accurately so that eggs can be removed to be fertilised on a specific day. A normal monthly cycle will produce only one egg but this method produces several ripe eggs at once to increase the chances of a pregnancy. This is called ‘superovulation’.
The first hormone. buserelin. is usually given as a nasal spray taken every day from the first day of the period. After two weeks the woman has an ultrasound scan to make sure the ovaries are inactive. She then starts the next hormone. FSH. which is given by a daily injection. A second scan is done after 10 days of taking FSH to make sure enough eggs are developing and then the woman has one injection of HCG (human chorionic gonadotrophin). The eggs should then be ready for collection 36 hours later.
Egg collection is the process of removing the ripe eggs in order to fertilise them. It is carried out in an operating theatre while the woman is awake. but with an injection of a strong painkiller and a tranquilliser. A speculum is put into the vagina. similar to the procedure for a smear test. A thin needle is passed through the vagina and into the ovary to collect the eggs (the doctor can see the ovaries by using an ultrasound scanner on the abdomen). The procedure takes about 20 minutes in total.
The eggs are mixed with the partner’s sperm on the same day and after 12-18 hours they are checked under a microscope to see if they have fertilised. Embryos (fertilised eggs) can be introduced into the womb using a thin tube passed through the cervix (neck of the womb). This is done about 36 hours after fertilisation and it is very quick and painless. The final stage is a pregnancy test after about 12 days.
What happens during treatment for male infertility?
If the man has a very low sperm count or the sperm are not motile enough. the specialist may advise the couple to have intracytoplasmic sperm injection (ICSI). The woman undergoes ovulation induction and the embryos are transferred as described above. but in the fertilisation process the sperm is actually injected into the egg through a very fine glass tube. This technique can result in pregnancy even with sperm of very low motility.
Surgical sperm collection may be suitable for men who have no sperm at all in their semen. This may be because the man has a blocked vas deferens. the duct that takes sperm from the testis. or because he has had a vasectomy; sometimes the testicles simply produce very few sperm. Sperm can be sucked out of the tubes below the level of the blockage or from the testicle itself. Both of these procedures are carried out with a fine needle under local anaesthetic at the same time as the woman’s eggs are being collected. The eggs can be fertilised by ICSI and then transferred into the womb.
IVF can be carried out with donor sperm or donor eggs. The sperm and embryos can also be frozen for future use. You will need to discuss these methods with your specialist. There are other techniques that are similar to IVF. such as GIFT (gamete intrafallopian transfer). but these are undertaken less often because they tend to be less successful.
Donor insemination :
If the man has no sperm at all (azoospermia) or very few sperm present (severe oligospermia) donor insemination (sperm donation) may be the only option open to them. Sperm is inseminated into the womb after ovulation has been precisely timed.
Egg donation :
This may be offered to women who have undergone a premature menopause. which may occur for a variety of reasons. or to women who consistently respond poorly to ovarian stimulation in IVF. If you are unable to conceive using your own eggs. an egg donated by another woman can be used. The donor must be prepared to undergo stimulation of the ovaries with drugs and egg collection as if she were undergoing IVF herself. The eggs are then fertilized with sperm from the infertile woman’s partner and the embryos replaced in the infertile woman’s womb. This procedure can also be done with a donated embryo.
Gamete intrafallopian transfer (GIFT):
‘Gamete’ refers to the basic genetic contribution from each partner — a sperm or an egg. In GIFT. your eggs are removed. mixed together with your partner’s sperm in a dish in a laboratory. then placed into your fallopian tubes. Fertilisation happens inside your body and the embryo implants naturally. A variation on this technique is Zygote Intrafallopian Transfer (ZIFT). ‘Zygote’ is a term used to refer to a newly fertilised egg. In ZIFT. your collected eggs are fertilised with your partner’s sperm in a dish in a laboratory and then replaced in your fallopian tubes.
Another woman carries your embryo. or a donor embryo. to term and gives the baby to you after birth.
Cryopreservation (Embryo freezing and storage).
Clinics are only allowed to replace up to 3 embryos during a treatment cycle because of the risks of multiple pregnancies (it is normally 2 with the exception of& ;some circumstances). Ask if the clinic has freezing and storage facilities so that any spare embryos can be frozen for future treatments. If any spare embryos are not required for further treatment you can donate them to others for treatment. donate them for research purposes or allow them to perish. It is very important that you discuss these options between yourselves and with your clinic as joint consent must be given. There is usually an annual cost associated with freezing and storage although this is fairly minimal.
What are the possible complications of assisted conception?
Ovulation induction increases the chances of having a multiple pregnancy. The most important maternal complications associated with multiple gestation are pre-eclampsia, preterm labor and delivery, and gestational diabetes as well as the potential risks involved with prolonged bedrest (venous thromboembolism) and cesarean delivery. Prematurity, and the complications associated with it (including increased infant mortality and increased incidence of cerebral palsy), is the greatest risk for the child.
Ovulation induction can also produce a rare condition called ovarian hyperstimulation syndrome, in which the ovary is overstimulated and produces an excess of the hormone oestrogen and which occurs in about 0.5 per cent of cycles. Also, any technique that involves the introduction of instruments into the body can cause infection or damage to internal organs.
What are the chances of a Multiple Pregnancy ?
Multiple gestation, especially triplet and higher order pregnancy, is not the desired consequence of assisted conception technologies since it increases the risk of complications for both mother and baby. The goal of any reproductive technology is the birth of a single healthy child and the conception of twins or higher is considered a complication. Ovulation induction increases the chances of having a multiple pregnancy (twins, triplets etc). The rate of multiple pregnancy is increased compared to spontaneous conception. Unlike natural conception where the chance of having a multiple birth is relatively low (1 in every 65 pregnancies), assisted conception brings with it a high chance of a multiple birth (roughly 1 in 4 IVF deliveries is of twins i.e. the chance of twins is approximately 20 to 25 per cent.). Although most twins are born healthy, the chance of complications during pregnancy and delivery is much greater than with a singleton. The high incidence of multiple births following IVF is largely due to the fact that more than one embryo is usually transferred to the womans womb during an IVF cycle. This is done to increase the chance of conception.
Will we have to pay for treatment?
For many years in the UK, there was no central government guidance on what health authorities should offer couples seeking infertility treatment, so what was available on the NHS depended on where you lived and what treatments were offered locally – a situation sometimes referred to as “babies by postcode”.
However, the government has announced that, from April 2005, all infertile couples will be entitled to one free cycle of IVF on the NHS, provided that the woman is under 40 years old and that the couple meet local eligibility criteria. Priority will be given to couples who don’t yet have any children.
Until then, every couple has the right to be assessed for treatment but not all couples will be deemed by their Primary Care Trust as eligible for treatment. You may also find that what is available to you is rationed. For example, you may be offered fertility drugs, but nothing else, GIFT, but not IVF, tubal microsurgery, but not IVF, or a maximum of three cycles of IVF. However, some Primary Care Trusts offer no help at all for infertile couples.
Most Primary Care Trusts also have criteria determining who they will fund for treatment. You may find that you need to be married, under 35, or to have lived in the district for a certain number of years. There are also long waiting lists for treatment in many areas.
Many couples, where they can afford it, use a mix of both NHS and private treatment. To be treated at a private clinic, you have to conform to the clinic’s eligibility criteria (a clinic may not treat you if you are over 45, for example). Costs vary widely between clinics, often by several thousand pounds. Always ask in advance what the full cost of each treatment cycle is likely to be. Don’t forget the hidden costs, too, of taking time off work and travel expenses – you may need to make many journeys to the clinic.
Although all clinics have their own price list you can expect IVF or GIF or Egg Donation to cost between £1000 – £3000 per attempt. NHS units will probably not charge for basic infertility investigations and some treatments. However they may have to charge for the more advanced assisted conception techniques but usually less than at a private unit.& ;Basic investigations, i.e. blood tests, semen analysis etc, can be expected to cost £150 – £200 and consultations can cost as much as £100 each time at a Private unit. The cost of drugs used in assisted conception is rarely covered. One average cycle may cost from £500 – £750.
What is the outcome of assisted conception?
Success depends largely on the cause of your infertility and your age – younger women are more likely to get pregnant than women over 40. Making sure you are in the best of health, perhaps limiting alcohol and caffeine, improving your diet, and giving up smoking can go a long way toward bettering your odds of getting pregnant (a dad-to-be’s diet matters, too).
Don’t discount the emotional stresses involved. Find a willing friend, support group, or professional to talk to before tackling infertility and also while you’re going through fertility treatment.
Your clinic will give you figures relating to the various types of treatment on offer and you may like to compare these to the national average success rates. The most recent information on IVF and donor insemination statistics is available from the Human Fertilisation and Embryology Authority (HFEA) which monitors the clinics that provide these treatments. To give you an idea of the success rates for IVF, the national average “take-home baby rate” is around 17 per cent.
However, do not judge a clinic by its statistics alone; it may specialise in treating older women, for example, where success rates are naturally lower. If a clinic has a great deal of experience in treating your particular problem, that clinic may be your best option. Another factor to bear in mind is how long the clinic has been established. The HFEA a government body that licence fertility treatment and research clinics in the UK, now provides information about choosing a clinic which allows patients to search for clinics in their location and see success rates and the different services they offer. It is designed to help you make informed choices. It contains a full list of information which you may want to consider before beginning treatment and questions to ask at prospective treatment centres.
The HFEA have recently updated their website and focused especially on making it as informative as they can for patients, i.e. allowing them to see exactly what to expect when embarking upon fertility treatment or considering donation.
Your doctor may suggest you move on after three tries with any treatment option; some experts believe a treatment isn’t likely to work if it hasn’t by your third round. But keep in mind that each couple’s case is individual; six attempts with IVF is certainly not unheard of.
Human Fertilisation Embryology Authority,
30 Artillery Lane, LONDON
Tel: 020 7377 5077
British Infertility Counsellors Association,
69 Division Street
Sheffield, S. Yorkshire.
DC Network (Donor Conception Network)
PO Box 265, SHEFFIELD S3 7YX
Tel: 0208 245 4369.
Set up by and for parents of Dl children and those contemplating or undergoing treatment using donated gametes.
COTS (Childlessness Overcome Through Surrogacy),
Loandhu Cottage, Gruids Lairg, Sutherland, SCOTLAND IV27 4EF.
Tel: 01549 402401.
Multiple Birth Foundation,
Queen Charlotte’s &; Chelsea Hospital,
Goldhawk Road, LONDON W6 OXG
National Infertility Awareness Campaign,
PO Box 2106, LONDON W1A 3DZ.
Tel: 0800 716345 (Freephone).
Clare Brown IN UK
Tel: 08701 188088