Ovulation induction involves taking medications which stimulate the ovaries to produce eggs. Medications are usually oral and include Clomiphene, Tamoxifen and Femara. Treatment usually begins during the menstrual cycle and continues for a total of five days. Research – and indeed our own experience – suggests that Femara works better for patients with PCOS.
Your treatment is monitored via a series of ultrasound scans which determine whether follicles are being produced, and whether they rupture to release eggs. Follicles are the small fluid-filled structures which develop in the ovaries, each of which will hopefully contain an egg. A blood test performed around Day 21 determines the level of the pregnancy hormone, progesterone, giving us additional information about the effectiveness of the treatment.
If the treatment proves appropriate, it is usually continued for between 6 and 9 months. Occasionally, an injection of HCG (human chorionic gonadotropin) may be given midcycle to further optimise ovulation.
In situations where tablets have not resulted in pregnancy, or a woman is not responding to treatment or is having significant side effects, injections of FSH and/or LH (Gonadatrophins) may be prescribed.
As there is a greater chance of multiple pregnancy when injections are used in preference to tablets, more scans may be necessary, and as with oral treatments, HCG is given midcycle to prime ovulation. While the scans will need to be done at The Scotia Clinic, you may have your bloods taken at your GP if it’s more convenient.
The Scotia Clinic is a licensed clinic with the Health Products Regulatory Authority (HPRA) for the provision of Intrauterine Insemination (IUI) and donor inseminations.
With IUI, a sample of fresh sperm is specially prepared to be passed into the cavity of the womb with a very fine catheter. The procedure is painless and is performed when the woman is most fertile. In a majority of situations, medications for ovulation induction are administered and scans are performed to time the IUI .This treatment is usually performed in the event of suboptimal semen analysis, hostile cervical mucus or unexplained infertility.
Donor Insemination, referred to as IUI (D), may be used where the man is producing no sperm or very few sperm. It may also be used where the man has a genetic problem which could be passed on to offspring. Single women and women in same sex relationships also opt for donor sperm treatment.
EU Legislation now requires additional blood tests for viral screening prior to undergoing IUI. To be clear, this is a legal regulatory requirement.
The other key legislative change that you should be aware of is the removal of anonymity from donation. It should be noted however that the statutory instrument to oversee this has not yet been implemented in Ireland.
Surrogacy is an arrangement where one woman (the surrogate) carries a pregnancy for someone else. Surrogacy usually involves an IVF process, where the man’s sperm is used to fertilise either his partner’s eggs or donor eggs, depending on the medical situation.
Surrogacy can be very costly, and can give rise to a variety of legal issues. It is important that couples who are considering this option liaise with clinics in which the proper structures and regulatory processes are in place. At The Scotia Clinic, we liaise with Dr. Scott Sills firstname.lastname@example.org in California, where a well-structured surrogacy service has been provided successfully for many years.
Egg Donation and Egg sharing
Egg donation may be the only option available to women who cannot produce their own eggs. Women with Turners Syndrome, those who have undergone premature menopause or had radiotherapy or chemotherapy in the past may fall into this category.
It can also happen that a woman who has undergone IVF finds that her eggs are of poor quality and fail to fertilise.
While some patients may know someone who is willing to be an egg donor, most link into egg donation programmes overseas. The Sims Clinic in Dublin, for example, is part of a European Donor Egg Programme.
Embryo donation may be a suitable treatment option for couples who fail to produce any embryos after IVF. While it is not available in Ireland, this service is provided in a number of UK clinics with which the Scotia Clinic has links.
When couples pursue this treatment option, we always try to provide as much of the care as possible in Kerry.
Pre Implantation Genetic Diagnosis is a complex treatment in which embryos are tested for genetic problems prior to being placed into the womb. In most situations, patients who wish to access this treatment travel abroad to clinics where it has been carried out for many years. Conditions which can be tested for include Cystic Fibrosis and Haemophilia.
Although the chances of becoming pregnant have risen steadily throughout the last decade, less than half of couples will achieve a pregnancy per IVF attempt.
As a result, most couples experience the disappointment of a negative pregnancy test at the end of what is often a stressful process. Having said that, most will conceive if they have the patience and fortitude to undergo multiple treatment cycles. That’s especially true if the woman is under 36 years of age.
IVF treatment has evolved into a medically safe procedure, with little short-term risk to the woman. Improvements in drug manufacture, in the quality of ultrasound scanning equipment and in egg collection techniques have improved safety and reduced side effects significantly over the past decade. At the same time, improvements in laboratory practice have been highly effective in reducing the risk of laboratory error. Initiatives led by the HPRA have also brought about a reduction in the number of multiple pregnancies that follow IVF treatment.
Multiple pregnancy is associated with the risk of premature birth and, as a result, with lifelong handicap, though these problems can be avoided if no more than one or two embryos are replaced in a treatment cycle. As pregnancy rates from frozen embryo transfers have improved, more and more centres across Europe recommend single embryo transfer to those patients who have the highest chance of an IVF pregnancy. Couples expect a healthy child from their treatment and this is best facilitated by achieving a single pregnancy at a time.
Super ovulation with Gonadotropins drugs is common in IVF treatment. It facilitates the production of a number of eggs, which in turn provides a selection of embryos from which to choose one or two for transfer, with the possibility of freezing the remainder.
Super ovulation does however carry the risk of ‘ovarian hyper stimulation syndrome’ (OHSS), which occurs when patients over-respond to the drugs used. As drug doses have been reduced over the years, the risk of OHSS has fallen, but cases do still occur, particularly in women with polycystic ovary syndrome. While some studies have suggested a slightly higher rate of ovarian cancer among IVF patients than among similar women in the general population, more recent studies have failed to confirm this finding. Moreover, women who have had children have been found to be healthier and to live longer than those who remain childless, so IVF treatment, when successful, may bring health benefits.
Nevertheless, it makes sense to keep drug doses as low as possible and to maximize the chances of pregnancy from a single cycle of IVF treatment by using both fresh and frozen embryo treatments whenever possible. Specific risks to offspring have been identified for patients undergoing ICSI for male infertility.
Infertility in men can arise because of micro deletions of DNA that cause azoospermia. Men who find themselves in this situation can still have children following the collection of sperm from the testes. However, they also have a high chance of passing their infertility on to their sons. Other patients may have conditions such as cystic fibrosis or chromosome disorders, both of which should be screened for before treatment begins. Couples are always offered genetic counselling to help them to decide on the best approach to their problem.
Recently, several studies have shown a small increase in the risk of an imprinting disorder called Beckwith – Wiedemann Syndrome which causes handicap in offspring. While the risk is low, ICSI should only be used where the magnitude of the sperm problem rules out a realistic chance of pregnancy after IVF alone. A further drawback to ICSI is that the woman (who may well be fertile) has to go through the processes of drug injection and vaginal ultrasound guided egg collection, since her eggs have to be in the laboratory to allow sperm injection to take place. There are therefore the same risks of ovarian hyper stimulation syndrome and multiple pregnancies as seen in IVF
While many people may see multiple pregnancies as a bonus, twin pregnancies are associated with a higher risk of premature birth and also with lifelong medical problems. This is why, where possible, IVF clinics will recommend that one blastocyst or embryo is returned to the uterus in order to reduce the risk of multiple pregnancies.
As newer techniques such as vitrification (the freezing process for embryos) improve, additional embryos can be frozen to be returned to the uterus in a future cycle.
Egg freezing has become an acceptable medical treatment in the last few years as vitrification freezing techniques improve. As that improvement process continues, it becomes more likely that eggs will survive being thawed in the future. While much of the publicity surrounding egg freezing has focused on delaying pregnancy for social reasons, we would occasionally recommend egg freezing to women prior to cancer treatments or any surgery where there is a risk of losing her ovaries – such as for endometriosis.
Pre implantation genetic diagnosis (PGD) is a laboratory test, performed on eggs or embryos during an IVF cycle that enables couples to check whether their pregnancy may be affected by a chromosomal disorder or an adverse genetic condition. It can be used to screen for many genetic conditions, including single gene disorders and chromosomal abnormalities, decreasing the risk of miscarriage and failed implantation and therefore, increasing the chances of a successful pregnancy.
Many couples ask for PGD to test for aneuploidy (the presence of an abnormal number of chromosomes in a cell) such as Down Syndrome It is thought that a large proportion of early miscarriages may be due to aneuploidy, the risk of which increases with the age of the female partner.
Others ask for PGD to test for specific single gene disorders and for genetic conditions that run in the family, such as cystic fibrosis or muscular dystrophy. It can also be used to screen eggs and embryos of individuals who carry a chromosomal translocation, significantly decreasing the risk of miscarriage or birth defect.
At The Scotia Clinic, we liaise with IVF Clinics in Dublin, Cork and Europe. When patients travel abroad for treatment, we can provide much of their care in Kerry before they leave. Couples can also attend The Scotia Clinic for all of their tests and treatments, including scans, blood tests, drug treatments and so on.
We send the results to the relevant IVF centre, and the healthcare professionals there will make decisions about the timing of egg retrieval and so on. On their return to Ireland, couples are given all the backup treatment they need, including managing OHSS, the provision of pregnancy scans and so on.
Couples who undertake shared care/Satellite IVF with us have their care plan implemented at their IVF clinic abroad, where egg retrieval and embryo transferral also take place.
Fertility treatment can be a frustrating and a disappointing experience. At The Scotia Clinic, our resident counsellor, Mary Casey, is there to help couples to cope with all of the stresses that they meet along the way.
Counselling can be very helpful at all stages of the process, from trying to decide which treatment to choose, through the anxiety of drug treatment, egg collection and embryo transfer, and of course pregnancy testing.
Couples who achieve pregnancy may also have to deal with miscarriage or ectopic pregnancy. Again, counselling can be very helpful in coping with these sad events.
Treatment options for male fertility are expanding all the time. The Scotia Clinic now liaises with Mr. Kevin McEleny, a recognised male fertility expert in the UK. Consultations with Mr. McEleny are organised via Skype. He will assess blood tests, semen analysis and scans, and will recommend treatments such as Testicular Micro Dissection (Micro TESE) or other specialist procedures, where appropriate. The treatments can then be carried out on his operating lists in Dublin.
A MircoTESE is a procedure carried out to retrieve sperm from the testicles of men in situations where there is limited sperm production.
The aim is to locate areas of sperm production within the testicles. Using an operating microscope, tubules in the testicle are meticulously examined, selected and removed. The wound is closed using dissolvable stitches and a dressing applied. A surgical support keeps the dressing in place. The procedure is carried out under general anaesthetic and takes between two and three hours.
The specimens are then carefully examined by an embryologist using a microscope. If suitable sperm is found, it will then be used for fertility treatment. Surplus sperm may be frozen for future use – if you have agreed to this in advance.
Unfortunately, it is not possible to tell you on the day of the operation if we have been successful in finding suitable sperm.
Recent research suggests that scratching the uterine lining causes a ‘repair reactive’ which may increase embryo implantation rates. The new lining which grows after scratching is thought to be more receptive to an implanting embryo, which thereby increases the chances of pregnancy.
Endometrial Scratch is a procedure developed from this research. The lining of the uterus (the endometrium) is gently ‘scratched’ using a thin catheter (a fine, flexible, sterile, plastic tube) which is passed through the cervix.
Embryo implantation should occur five to six days after natural fertilisation or following embryo transfer, when the embryo embeds into the lining of the uterus to continue its development.
Scientists believe that the genes which are responsible for implantation of embryos are sometimes not ‘switched on’ at the time when embryos are supposed to implant. It’s now thought that endometrial scratching may ‘switch on’ the genes that are responsible for the preparation of the endometrium for implantation, which increases the chances of pregnancy. More research is underway to understand exactly how this works.
Although the patient may experience some discomfort, this is not a painful procedure and no anaesthesia is required. In essence it is quite similar to an embryo transfer.
A speculum is gently inserted into the vagina so the cervix can be seen. The cervix is cleaned with sterile gauze, then a thin, flexible catheter is inserted through the opening of the cervix and the uterine lining is gently ‘scratched’. Inserting and moving the intrauterine catheter up and down may cause mild abdominal cramping, similar to period pain.
The catheter is withdrawn at the end of the procedure. Some mild bleeding is common afterwards, and patients may feel generally unwell.
Endometrial scratching is a new technique so no meaningful data on its success rate exists. Data from clinical trials does however indicate improvements in treatment outcomes in women who have previously had multiple treatment cycles.
Additional Infertility Services
Support services for Fertility Couples
At The Scotia Clinic, our staff provide a range of support services. These include:
- Acupuncture/Traditional Chinese Medicine – Eithne Griffin 086 6066865
- Reflexology – Eithne Griffin 086 6066865
- Meditation – Eithne Griffin 086 6066865
- Counselling – Mary Casey 0874185952
- Fertility Massage – Alexandra Rowan 086 221 5201
Counselling Services/ Mind Body Programme
Many people can find the process of fertility treatment very stressful. Research has also demonstrated that stress can have a negative impact on fertility treatment and early pregnancy. If you feel you might benefit from counselling or stress management, our staff may be able to assist you in identifying an appropriate support service.
There is now clear evidence that a high BMI can negatively impact fertility treatments and may be associated with early miscarriage. We strongly recommend that women embark on weight reduction prior to starting treatment, as even a 10% reduction in weight will improve matters. We use a GI Dietary programme which is particularly beneficial for women with PCOS as it assists in improving insulin resistance.