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Fertility Treatments and Assisted Reproduction Techniques (ART)

Infertility is commonly defined as the inability to become pregnant after one year or shorter when circumstance dictate e.g. women is >34 years old, of unprotected sexual intercourse using no methods of birth control whatsoever. Infertility affects 1 in 6 couples.

Monitoring the menstrual cycle with scans and hormone tests to determine antral follicle count (AFC) and ovulation including endometrial development, and advise with regards to timed intercourse. The results of these initial tests may determine whether further treatment required.

In the work up the initial step suggested is a semen analysis.

A pelvic ultrasound examination of the uterus, ovaries and fallopian tubes, is recognised first-line test for women to undergo when they are having difficulty conceiving. It includes assessing the AFC, which can hint at diminished ovarian reserve (DOR).

Gynaecological endocrinology covers hormonal imbalance. Normal hormones balance is essential for a woman’s reproductive system, and regulate from menstruation and fertility to menopause and libido. A major women endocrine dysfunction is PCOS.

Polycystic Ovary Syndrome (PCOS)

Around a quarter of cases of female infertility can be linked to problems with ovulation, majority are caused by polycystic ovary syndrome (PCOS).

The name suggests that the ovary has been inflicted with cysts, leading to anxiety in women who are affected by the condition. This is far from the truth, as there are in fact no cysts. The small fluid filled areas seen represent follicles (egg sacs) that have not matured, or which have not progressed on the normal pathway because of a hormonal imbalance. The imbalance may not only affect the ovary but also other elements of the endocrine system such as the production of Insulin and male hormones. It is important to make an accurate diagnosis and offer appropriate therapy. This includes life style improvement, and ovulation induction therapy.

One of the most common treatments for infertility is ovulation induction for women who have trouble to ovulate, particularly who have PCOS. It involves stimulating the ovaries using medication or fertility drugs either in form of tablets (clomifene or letrozole) or gonadotrophin subcutaneous (under the skin, self administered) injections. These medications are frequently used alongside Intrauterine Insemination (IUI). The treatment is monitored very carefully with scans and sometimes blood tests.

When patients are diagnosed with serious health conditions like cancer and other debilitating conditions, their ability to have children after undergoing treatment can be a big concern. If you are planning to start a family or have more children once you are well, it is important to take steps. Best to preserve your fertility as soon as possible following your diagnosis.

The advances in freezing embryos and in particular eggs with the use of vitrification (rapid freezing), has made fertility preservation more accessible to both single women and women with a partner who decide to postpone starting a family.

For both groups of women (young women with cancer and those who decide to delay starting family) we will offer the best advice and independent counselling on what you want to achieve. It is only when you are sure of your decision and you are safe to proceed that treatment will go ahead. We understand that in many instances this needs to be accomplished in a very short period of time.

Infertility affects one in six couples, and In Vitro Fertilisation (IVF) is one of the most common and effective treatments available. During this process the ovaries are stimulated with drugs to induce a number of eggs to mature, these are then retriever under light anaesthetic by inserting a thin needle guided by ultrasound through the vagina to the ovaries.  Each egg then is mixed to thousands of sperms in a laboratory dish and the normally fertilised eggs (identified one day after the egg collection) are observed in the laboratory over the next few days. The resulting embryo(s) is placed inside the uterine cavity via a catheter through the cervix (embryo transfer, ET). ET may need to be done on second, third or fifth day following the egg retrieval process. Excess suitable embryos can also be frozen for future treatment.

IVF is a popular procedure with couples who experience unexplained infertility, or for women with blocked, damaged or missing fallopian tubes.

Intracytoplasmic Sperm Injection (ICSI)

When male factor (low quality sperm on repeated testing) is present, or previous cycle of standard IVF showed low rate of eggs fertilisation, ICSI is suggested. This follows similar path to IVF except that to assist in the egg fertilisation, each egg is injected with one sperm. The process of fertilisation is carried in the laboratory and under high magnification special microscope. The remainder of the process is similar to IVF.

IVF and ICSI are well established, safe, and effective treatment option for infertility with over 140,000 IVF cycles reported each year in the US and 45,000 cycles in UK. The pregnancy and miscarriage rate is age dependant. Newer technology is enabling these rates to be better. You will receive advice and have the opportunity to talk the options with Dr Shawaf.

Pre Implantation Genetic Testing for Aneuploidy (PGT-A)

PGT-A (PGS) remains controversial and requires more scientific evidence. Cells from the part that will form the placenta (trophectoderm) of a blastocyst embryo (embryos 5 days following egg collection), are separated (biopsy). The cells will be sent to a genetic laboratory to be examined for chromosome numbers. The embryos biopsied are frozen. Results may take up to 3 weeks. Transferring euploid embryo (normal numbers and no missing segment) has been reported to result in lower miscarriage and in some group of women higher life birth.

Mosaic embryos (with a mixture of normal and abnormal chromosome) are noticed in 20% of embryos examined, which can be between about 7% of patients with only mosaic embryos. This is causing controversy and confusion on if these embryos can result in healthy baby or not and the accuracy of the biopsy. Research is continuing in this exciting technique.

Frozen Embryo Transfer

Embryos are frozen usually for a 10 years period at present. The success rate at present is almost similar to fresh embryos, particularly if embryo is frozen at blastocyst stage.

Transfer can be in a naturally monitored cycle when women have regular cycles. The day of thaw and transfer is in the period following ovulation depending on when the embryos where cryopreseved. It can be in a medicated cycle with hormone supplements if the menstrual cycle is very irregular, or in menopause. You will be offered and explained the options and with you a choice of best option is made.

PGT-A (PGS) remains controversial and requires more scientific evidence. Cells from the part that will form the placenta (trophectoderm) of a blastocyst embryo (embryos 5 days following egg collection), are separated (biopsy). The cells will be sent to a genetic laboratory to be examined for chromosome numbers. The embryos biopsied are frozen. Results may take up to 3 weeks. Transferring euploid embryo (normal numbers and no missing segment) has been reported to result in lower miscarriage and in some group of women higher life birth.

Mosaic embryos (with a mixture of normal and abnormal chromosome) are noticed in 20% of embryos examined, which can be between about 7% of patients with only mosaic embryos. This is causing controversy and confusion on if these embryos can result in healthy baby or not and the accuracy of the biopsy. Research is continuing in this exciting technique.

Embryos are frozen usually for a 10 years period at present. The success rate at present is almost similar to fresh embryos, particularly if embryo is frozen at blastocyst stage.

Transfer can be in a naturally monitored cycle when women have regular cycles. The day of thaw and transfer is in the period following ovulation depending on when the embryos where cryopreseved. It can be in a medicated cycle with hormone supplements if the menstrual cycle is very irregular, or in menopause. You will be offered and explained the options and with you a choice of best option is made.

IUI consists of placing washed sperm into the patient’s uterus at time of ovulation. Typically of benefit when no cause for infertility is found (unexplained infertility), single women with donor sperm used and if there is difficulty with intercourse. If a male patient is suffering from mild sperm malfunction, IUI can be suggested.

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