Unable to conceive
It can erode confidence, destroy relationships, and still carries a hidden social stigma.
Its a journey, personal and intrusive, obsessive and despairing at times, and sometimes very expensive, but it has a start, a middle and an end. The finish line sometimes isn’t where you imagined, but usually you can get there with our help.
Every month a woman should grow and release an egg that can be fertilised and form a pregnancy, but one in 3 women cannot conceive because ovulation either doesn’t happen at all, or is inconsistent, which in turn results in irregular periods, and a higher incidence of miscarriage.
The commonest causes of ovulation problems include:
- Polycystic Ovarian Syndrome (PCOS)
- Excessive weight loss or weight gain
- Thyroid dysfunction
- High prolactin levels
- Inadequate hormone production by the brain
- The menopause
An ultrasound scan and some blood tests will detect the cause.
This is one of the fastest growing causes of fertility problems. Women are leaving pregnancy until later in life when not only egg number and quality are reduced, but it is also more likely that co-existing gynaecological or general health problems can upset fertility.
- At 30 years, the chance of pregnancy per month is 20%
- At 40 years, the chance of pregnancy per month is 5%
Miscarriage rates increase with both maternal and paternal age.
- At 30 years, the risk of miscarriage is 12%
- At 40 years, the risk of miscarriage is 33%
Fetal abnormalities increase with maternal age
- At 30 years, the risk of Downs syndrome is 1 in 800
- At 40 years, the risk of Downs syndrome is 1 in 100
Male age is less significant but sperm quality does decline as a man gets older. Other general medical problems, impotence and medications may also contribute.
The incidence of achondroplastic dwarfism, schizophrenia and autism are all increased with older fathers, especially those over 55 years.
Fertility treatments, including IVF are of limited benefit for age related issues, but in some cases, genetic tests for the parents and embryo can be helpful. We do not offer IVF for women aged 45 and over, as it is rarely beneficial.
Egg donation IVF (using a young woman eggs) is the most effective treatment for age related infertility.
There is lots of exciting scientific research into the possibility of making eggs from stem cells, but these will not reach safe clinical practice for some years.
Women have the option to freeze eggs or ovarian tissue when they are younger, thus arresting the ageing process and effectively stopping the biological clock. This is likely to become a popular way to effectively delay motherhood in the future. Similarly, men who have sperm frozen in earlier life, may have a better chance of fatherhood as they get older.
Closed or non-functioning fallopian tubes account for around 25% of fertility problems.
The sperm must be propelled up the tube just before ovulation, the wide fimbrial end of the tube next to the ovary must catch the egg as it releases, and when egg and sperm get together and fertilise in the tube, the resulting embryo must be wafted back down into the womb again in time to implant.
Tubes can be damaged by previous, often asymptomatic, sexually transmitted infection (repeated episodes of chlamydia are particularly harmful). Function is affected by endometriosis, and scarring outside the tube, as a result of adhesions after surgery. Some women are born with only one fallopian tube.
Immune causes of infertility are uncommon. Immune diseases such as systemic lupus erythematosis and autoimmune thyroid disease, some inherited clotting problems, and gynaecological disease such as endometriosis all influence the immune response to a pregnancy, and in particular, to an implanting embryo.
Blood tests can help detect such problems, and various medications (Steroids, Heparin, Intralipid) and procedures (endometrial scratch, lipiodal infusion) can be used to help.
Testing for natural killer cells is rarely required but can be arranged.
The womb is normally a triangle shape inside, but 5% women will have an abnormally shaped womb.
Sometimes this is not a barrier to pregnancy, but women with an abnormality do have an increased risk of infertility, miscarriage and premature birth. Fibroids and polyps that grow inside the womb can have the same effect.
Previous womb surgery or infection, can cause scar tissue to form in the cavity that can prevent pregnancy and can only be removed with another operation.
Fibroids and polyps can also be removed surgically, and an abnormally shaped womb can be made into the normal triangle. Women who were born with only half sized ‘unicornuate’ wombs, often need a stitch in the womb neck in early pregnancy to help prevent premature birth.
Sperm problems contribute to almost 50% of cases of delayed conception.
Sperm number, quality and function are important, as is the health of the supporting fluid, most of which comes from the prostate gland. Sperm production can be affected by the following:
- Hernia repair
- Testicular trauma or surgery
- Testicular cancer
- Diabetes (poorly controlled affects ejaculation (dry runs))
- Hormone imbalances
- Cystic fibrosis
- Other genetic problems (such as Kleinfelters disease)
- Infections (STI or prostatitis)
- A varicocele (a varicose vein around the testicle)
- Medications (some can also cause impotence)
- Chemotherapy and Radiotherapy treatments
- Heat (saunas, cycling and tight pants!)
- Recreational drug use
- Cigarette smoking, and nicotine vapes and gum (although the latter are much less harmful)
- Prolonged exposure to industrial chemicals
- Anabolic steroids
Sperm quality varies on an almost daily basis, but adjusting lifestyle factors, and taking a specially formulated multivitamin supplement containing antioxidants, such as Condensyl®, and an omega 3 supplement, can also help.
Remember sperm are constantly being produced (about 1000 sperm are produced every time your heart beats). When you are trying to conceive, you should have sex at least twice a week, and I recommend once daily around ovulation (when the egg releases…normally day 11-16) as sperm quality deteriorates the longer the sperm hang around inside you, so don’t store them up!
Some couples cannot have penetrative sex. Some men cannot get erections, and some cannot ejaculate during vaginal sex.
Whilst this may not be a barrier to a good relationship, although it usually is a significant issue, it will of course mean that getting pregnant is tricky.
Once physical causes and the effect of medications have been excluded, sex therapy strategies over a long period of time, can overcome these problems, but often not within the time frame for having family for most.
We can offer self insemination kits with advice about what to do. We can arrange intra uterine insemination, and provide medication and penile vibrators to help with erectile issues. We can perform abdominal ultrasound scans, and provide vaginal procedures under anaesthesia for those women with significant vaginissmus.
Endometriosis affects about 1 in 10 women. It often runs in families. It may be completely asymptomatic or it can cause pelvic pain, bowel issues, heavy painful periods and general fatigue. It can significantly affect fertility even if asymptomatic.
Endometriosis can impact on ovary health and decrease ovarian egg reserve. It causes tubal dysfunction, and defective egg sperm interaction, and it reduces implantation.
The only way to establish the diagnosis is to have a keyhole surgical procedure called a laparoscopy.
Endometriosis can be treated surgically with laser or diathermy to remove the inflammatory deposits, or in some cases, ovarian cysts, and pelvic scar tissue. Surgical treatment will improve fertility in both symptomatic and asymptomatic women.
Some with mild disease can become pregnant without surgery, and pregnancy itself is a great treatment, but it is a progressive disease that can reappear between pregnancies, and get worse with age.
All medical treatments for endometriosis are contraceptive, but we may suggest them between pregnancies to prevent recurrence.
Fibroids are benign growths in the womb wall (uterus) that enlarge it, and can cause heavy periods, pelvic swelling and discomfort.
Many women with fibroids have no difficulty getting pregnant, but if the fibroids are large, multiple or inside the cavity of the uterus, then they may need to be removed surgically (myomectomy / trans cervical resection of fibroid). Sometimes medical treatment to shrink them is recommended for a few months before fertility treatment.
An ultrasound scan is a quick, painless way to assess the ovaries and uterus.
Pelvic scans are normally done vaginally. We have in house scanning with Miss Matthews, who is able to talk you through all the findings as she does the scan.
Of course, once you are pregnant, we can also give you your first photo!
Routine blood tests to investigate fertility problems include your reproductive hormones and a check on your thyroid gland.
Other tests the doctor may consider include: a full blood count, vitamin D, CA125 (a marker for endometriosisis), male hormone levels, a test for sickle cell disease or thalassaemia, and a check to see if you are rubella immune.
If you are of Jewish descent we can arrange a connective tissue gene disorders test profile. Even if that is not the case, patients and partners can have comprehensive genetic screening tests if they wish to include more common single gene disorders such as cystic fibrosis and a check for the BRA1C gene that increases the cancer risk for women.
If a patient is a carrier for a condition, they can choose to have pre-implantation genetic tests on embryos created through IVF, to prevent having an affected baby.
Those patients with PCOS may have a fasted sample arranged to assess insulin resistance, and clotting and immune profiles may be required depending on the past medical history.
All patients having IVF or IUI treatments, and their partners, are required to have a blood test for HIV, Hepatitis B and C, and syphilis.
There are several ways to check if fallopian tubes are open, although there is no test to assess whether they work properly (tubes can be open but non functioning).
All tubal tests include a check of the uterine cavity, which can pick up polyps, fibroids and adhesions that would need to be removed before pregnancy. The shape of the cavity is also defined (it can be heart shaped or divided by a septum).
Once you have been assessed by Miss Matthews she will decide which test is best for you.
Usually the test involves a quick X-ray procedure lasting 10 minutes and performed just after your period finishes (Hysterosalpingogram HSG). Miss Matthews performs all her HSG tests personally. We are able to tell you if your tubes are open and everything is normal immediately.
Sometimes a laparoscopy and hysteroscopy keyhole operation is recommended. This is usually the case if Miss Matthews feels you may have endometriosisis, or if there are obvious abnormalities on ultrasound that need to be investigated and treated.
A small telescope is inserted into your womb to have a look at everything, and another goes directly into your tummy cavity to assess the womb, tubes and ovaries. The tubes are checked by passing some blue dye through the womb cavity. This type of surgery is usually done as a day case but you should ask for at least a week off work afterwards, depending on other procedures that may also be performed, such as treatment to endometriosis, or removal of an ovarian cyst or uterine polyp.
Our routine sperm test is much more detailed than the one your GP might do. It is a two page report, and as I say to the boys, it is always like a school report in that there is always a “could do better” bit!
Sperm tests don’t just look at the number of sperm. They assess if they look normal, are swimming in the right direction, how fast they swim, and whether there is anything in the seminal fluid that might stop them working properly, such as infection, blood or antibodies. It also looks at the fluid itself, whether there is any inflammation, and contains the right sugars and pH balance to help the sperm.
Sometimes more detailed sperm tests are required when levels of DNA damage and chromosome abnormalities, and levels of healthy antioxidants can be measured. This can be very useful for older men, when the sperm production is low, or when lifestyle factors are obviously contributing to fertility issues... it is sometimes a way for me to wave my big stick and say "right you, stop drinking and smoking and get off that bicycle and do some other exercise right now" - be warned!
Sperm samples are produced onsite in comfortable, private surroundings at Andrology Solutions on Wimpole St. Appointments must be made in advance, and 3-4 days abstinence is recommended. The results take a week to report.
There are both tablets (Clomiphene, Letrozole, Tamoxifen) and injections (FSH/HMG) that may be used to help the ovary work more efficiently and release an egg at the right time every month. They are usually the first treatment considered for women with PCOS, but can be useful for some other women too.
These drugs are safe for you and your baby. One of the most commonly used tablets called Clomiphene, should only be used for a maximum of 9 months, but Miss Matthews will have changed to another treatment long before that if there has been no news. All of the tablets and injection treatments can result in the growth of more than one egg per month, and although that may improve your chance of pregnancy, it will also increase the chance of having a multiple pregnancy, so it is very important that you come for tracking scans when you use these drugs, to check that they are working, but also to avoid the possibility of triplets or more!
When injections are recommended, these are self administered daily every month, for about 12 days, into the tummy fat. I know it sounds very painful but they are easier to do than you think! The needle is the size of an acupuncture needle. Some patients with a needle phobia feel happier for their partners to do the jabs daily, and if really necessary, we can arrange for a nurse to come to your house daily.
Intra-uterine insemination can be a useful treatment when sperm quality is slightly low, when a couple have certain sexual problems, and it is often recommended when there is no obvious explanation for a couples fertility issue, as a prelude to IVF.
The treatment is usually performed at the Andrology Clinic on Wimpole St by Miss Matthews. A sperm sample is specially prepared to select out the best, good looking swimmers, and those are carefully played inside the womb cavity just around the time the egg is released. Injection ovulation induction treatments are often used beforehand to encourage the growth of 1-2 eggs and boost the chance of success.
Intra-uterine insemination is also the standard treatment for younger or single healthy women when donor sperm is required.
Women with endometriosis, fibroids, ovarian cysts or pelvic scarring often have compromised fertility, and will benefit from surgery.
Most reproductive surgery is performed laparoscopically. The keyhole technique results in less risk of bleeding or infection, and has a much quicker recovery time compared to open surgery. Occasionally tubal surgery can be used to provide a permanent solution for women with blocked tubes, but more often now, the tubes are simply by-passed by doing IVF treatment.
Sometimes blocked tubes can also be swollen and easily seen on ultrasound. These ‘hydrosalpinges’ contain fluid that is toxic to embryos, so they need to be removed surgically prior to any IVF treatment.
Hysteroscopic surgery describes surgery that is done inside the womb cavity. A narrow telescope is inserted through the cervix to inspect the uterus, and special instruments used to remove polyps, fibroids, adhesions or to fix an abnormally shaped uterus.
Miss Matthews does all her surgery at the renowned Portland Hospital for women and children, in central London. She works with a dedicated team of specialist nurses, the best equipment, and expert anaesthetists to make any operation experience as comfortable and efficient as possible. There is no waiting list.
Extra cases can usually be accommodated within a week, or scheduled according to your availability.
Almost 1 in 20 babies born in the UK today, is as a result of IVF treatment.
The technology is 41 years old this year (2018), and since Louise Brown was born all those years ago, the science, the complexity, the safety, the acceptability, and the success have rapidly grown.
Laboratory techniques have developed particularly rapidly in the last 10 years.
The success rates at the CARE London IVF laboratory where our babies are made, have been consistently in the top five in the country. Patient age is the biggest factor affecting success, but we are doing well in all age groups, even for women over 40, more of whom are looking for treatment these days.
Our IVF success rates (clinical pregnancy rates) for a first embryo transfer cycle for 2017 were:
|Miss Matthews||CARE London||UK average*|
|‹ 35 years||75%||48%||42%|
* Approximate figures based on the HFEA data from 2014.
As you can see, Miss Matthews has a significantly higher pregnancy rate than the main clinic at CARE London, and of course the national average figures. Part of the reason for that might be that we only do embryo transfers with frozen embryos, not fresh ones. We believe very strongly that an IVF cycle should be split in two parts.
The first part involves trying to stimulate the ovary to grow as many eggs as possible (without running a risk of overstimulating the ovaries) and collecting those eggs. A period will follow about 10 days later.
The second part starts with a period, and involves getting the womb lining (uterus) into optimal condition for implantation. This usually takes 15-20 days. A pregnancy test is taken 9-12 days after embryo replacement.
IVF Treatment Steps
- Initial assessment including scan, blood tests and sperm test
- Consent forms completed
- Pre treatment scan and injection teach (treatment schedule given)
- Daily injections to stimulate egg growth start day 2 of a period and continue for 10-15 days
- A blood test may be required on day 6
- Alternate day scans to monitor response start day 7-8
- Last day for sex is 3-4 days prior to egg collection procedure. You will be advised
- The date for egg collection is only predictable 4 days beforehand
- Fasting for 8 hours before egg collection procedure
- Egg collection under sedation anaesthesia takes 5-10 minutes
- Sperm sample produced onsite as required
- Approximately 2 hours at CARE London clinic
- A hot water bottle and ibuprofen or paracetamol is likely to be the only pain relief required afterwards
- Back to work the following day
- Expect a phone call that day from the embryologist at the laboratory to tell you how many eggs have fertilised
- Expect regular daily updates on embryo development and quality
- The decision about when to freeze embryos will be discussed with Miss Matthews
- Embryos frozen day 2, day 3, day 5 or day 6 of development
- An endometrial scratch is usually routine a few days before the period when embryo replacement is planned (this can be the month after the egg collection, or any month thereafter)
- 2-3 scans are normally required over 2 weeks, to monitor endometrium
- Daily hormone tablets, pessaries, suppositories, and sometimes daily injections, may be required
- Embryo is thawed on the day of replacement
- Phone call from the embryology team to confirm embryo survival
- Embryo replacement normally requires no anaesthetic and takes 10 minutes
- Scan confirms correct embryo placement in the womb cavity
- A blood test several days later checks hormones levels
- A positive home pregnancy test is followed by several blood tests the following week to check pregnancy hormone levels
- A negative test is followed by a review with Miss Matthews
- The first pregnancy scan is performed at 6-7 weeks of pregnancy (3-4 weeks after the embryo transfer)
- Another pregnancy scan is performed at 9 weeks of pregnancy, when harmony and nuchal prenatal screening tests can be booked for you (at 10 and 12 weeks)
- A final review at 12 weeks of pregnancy after the nuchal test to stop hormone support. The patient may opt for NHS or private antenatal care. Miss Matthews can arrange the latter for you with a consultant in London
- The first gynaecological review can be the 6 week postnatal visit, or when the period returns after breast feeding has stopped
Women with previous miscarriages , or IVF failure following the transfer of good quality embryos, should be investigated for uterine issues that may have influenced implantation.
This may be hormonal, structural (is there scar tissue in the womb or is it an abnormal shape?), or immune in origin. Certain treatable auto-immune conditions, such as systemic lupus (SLE), are known to affect miscarriage rates. Other immune and inherited or acquired clotting disorders may play a role. A simple blood test can investigate the most common abnormalities.
Recently there has been much publicity about the role of natural killer cells in failed implantation and some fertility units will routinely test for blood levels of these immune factors, and implement specific additional treatments for those having IVF, such as immunoglobulin and intralipid infusions, steroids, Humira® and other anti-TNF immune modulator drugs.
Unfortunately the body of evidence so far suggests that the blood test for natural killer cell levels has no association with levels of these cells in the uterus, and so many people are likely to be over-treated with potentially quite toxic medication. We do very occasionally test blood levels of natural killer cells and test cytokine activity, but the test is expensive, and in most cases, irrelevant.
Interventions that we may recommend to improve implantation rates include:
- Surgery to correct a womb abnormality
- Hormone treatment to improve womb lining
- An endometrial scratch (biopsy of the womb lining to improve implantation - routine prior to embryo transfer)
- Lipiodal® uterine bathing (using poppyseed oil to improve the immune response - research ongoing)
- Oral steroids from egg release / embryo transfer to 12 weeks of pregnancy
- Daily heparin injections from egg release / embryo transfer / positive pregnancy test
- Aspirin tablets
- Genetic testing of embryos (PGS/NGS)
- An ERA test to check endometrial receptivity
- Rarely, intralipid infusions may be recommended
Egg donation treatment provides an option for prematurely menopausal women, and those with a low ovarian reserve, to have a baby. Egg donors in the UK are anonymous to the woman receiving the eggs at the time of treatment, but they must remain contactable for any resulting child when the child reaches 16 years of age.
Women who are donors in the UK receive very limited compensation. Many women choose to go abroad for egg donation treatment, where the donors are paid and usually anonymous, so recruitment numbers are much higher. The choice of donors is better abroad as a result, and the waiting time for treatment almost negligible. The cost and success rates in popular European countries like Spain and Greece, is similar to treatment in the UK. I work very closely with excellent fertility units in both Barcelona and Malaga.
All egg donors are under 35 years. They are screened for genetic problems, and would not be accepted into a programme if they had a history of cancer or other serious health issues, including mental health issues. The donors family medical history is also carefully considered, and donors are screened for HIV, Hepatitis and Syphilis. Donors are matched according to skin, hair and eye colour and build. Some fertility units will match by photograph.
In the USA, a patient can choose their own donor, and more information is available, including the donors educational background and job. The patient may be able to listen to a recording by the donor, and see pictures of them as a baby. Donors may choose to stay anonymous, or be contactable for resulting children. Treatment in the USA is approximately 3 times the price of treatment in Europe. We work with some excellent units in Washington and Los Angeles.
Women in the UK can also choose their own known egg donor. Often this applies to family members, or close friends, who may donate to each other if they are eligible (known donation is acceptable when the donor is up to 38 years of age). All family members, spouses and partners of all parties involved must receive specialist fertility counselling before treatment.
Sperm donation is required for couples where the man produces no sperm, and for single women having fertility treatment.
Sperm banks in the UK offer a limited choice of sperm, but are worth checking out first before considering importing sperm from abroad, which is the most popular option. Like egg donors, the sperm donor must be under 35 years, be fit and healthy both physically and mentally, be screened for HIV, Hepatitis and Syphilis and genetic diseases, and of course he must have a normal sperm test. As with egg donors, the men in the UK, although anonymous at the time of the donation, must remain available should any resulting children wish to contact them when they become adults.
We work with several excellent sperm banks both in Europe and in the USA. We can help guide you in your choice of donor, and advise how much sperm, and what type of sperm preparation is required. We can then arrange delivery of the sperm to the fertility unit for you within in a matter of weeks, whether you need insemination, or IVF treatment.
There is an option to use a known sperm donor in the UK. Men with no sperm may choose another family member to donate on their behalf. Single women sometimes have a friend who will offer to donate for them. Known donors are assessed and tested in the same way as anonymous donors. Counselling is essential prior to treatment, and the frozen sperm must be held for 6 months to confirm that the donor is free from HIV, Hepatitis and Syphilis before it can be released for use. This may be a consideration if the woman planning to use it is older.
Men who donate sperm have no parental or financial responsibility for any resulting children.
Patients who cannot hold a pregnancy and gay men need to use a surrogate to help build their family.
The law in the UK only permits surrogacy for couples. Surrogacy UK is a wonderful resource for those considering surrogacy, and thanks to the internet, the world has become a much smaller place, so finding the right surrogate (usually best done through an agency) is much easier than even 10 years ago.
The portrayal of surrogacy in the media has also normalised this form of fertility treatment. Commercial surrogacy is very well organised in USA, but apart from the UK, surrogacy is also available in Mexico, the Ukraine and Russia where treatment may be cheaper, but is less well organised and rigorous. The legal side is easily taken care of in UK and USA. A solicitor must be involved as legal contracts must be drawn up, and a parental order needs to go through the UK courts. Unfortunately surrogacy is still illegal in many countries.
We will happily help you find a surrogate and a lawyer, and liaise with your fertility clinic abroad to freeze and ship sperm, eggs or embryos as required.
Many patients in the UK travel each year to countries as diverse as India, Mexico, Canada, the Caribbean, Russia, the Ukraine, Cyprus, UAE, Greece, Spain, Denmark, and USA, to have fertility treatments. Sometimes it is because treatments such as IVF are cheaper, even with the additional cost of travelling and staying there. Sometimes it feels better to have such an important treatment with doctors who speak your native language.
Most often though, people travel abroad to access types of treatment, such as egg donation and surrogacy, that are difficult under the UK HFEA legislation, which limits the commercialisation aspect, resulting in long waiting lists and limited choices.
Countries with a different legal framework can offer quicker access and a bigger choice when it comes to choosing an egg donor or a surrogate. This is particularly the case if you need a donor or surrogate from a specific ethnic or religious background.
We work with several clinics in USA, Spain, Denmark and Dubai, and we can co-ordinate your treatment, arrange drugs, scans and blood work as required, and liaise directly with the foreign clinic on your behalf. Often patients doing it alone feel rather insecure, especially when there is a language barrier, and having initial investigations and the start of the treatment at home in the UK will save you money and time. We can recommend reputable clinics for various treatments, but will work with your chosen clinic where ever it is, but at the same time assessing as best we can, whether it really provides safe, effective treatment.