Infertility is a complex medical challenge. You may have a specific problem that requires an individualised approach. You may have had a poor outcome in a previous IVF cycle and wonder what can be done to improve the outcomes in a future cycle. Here are some scenarios with possible solutions.

I have repeated unsuccessful IVF treatment cycles. What can I do?

 

<<Arri to do>> (consider a table)

 

I am not in a position to try to conceive a pregnancy at the moment. Can I freeze my eggs for later use?

 

<<Arri to do>>

 

I have high BMI (overweight). What is the impact of that on fertility and IVF? What can I do?

A high body mass index (BMI) is unfortunately linked to reduced fertility in women and men. A woman with a high BMI often needs larger doses of IVF medications, and may have poor development of ovarian follicles (which are sacs containing the eggs), poor quality eggs, poor endometrium (lining of the womb) and a higher risk of miscarriage and other pregnancy complications. So, it really helps if you are able to lose weight before you have fertility treatment. The ideal is if you are able to get below a BMI of 30. If this is not possible, it would be better if you are able to get below a BMI of 35, which is the cut-off for offering treatment at CARE Fertility Birmingham Clinic. You can find out your BMI by entering your height and weight on to a BMI calculator; just search ‘BMI calculator’ on Google. << ask Ashraf to help develop a simple BMI calculator>>

We find patients who lose weight often have 4 successful elements to their approach:

  1. They set reasonable weight targets (rather than unrealistic ones which are difficult to achieve), and keep a record of their progress on a diary.
  2. They eat healthy AND exercise (rather than doing one or the other). Note we said ‘healthy eating’ rather than ‘dieting’! Yes, you may need to control the calories you consume (dieting), but healthy eating in the form of reducing meat (that includes chicken!), fats and sugar and increasing fruits and vegetable should be the first step.
  3. They often take part in a group program, which keeps them motivated. You and your partner can form a group! Or you can find a group near you on Google.
  4. They practise ‘stimulus control’ which is a fancy term for not keeping the wrong sort of food visible in your kitchen! For example, this may mean swapping the tin of biscuits on your dining table with a bowl of fruits.

Some patients may benefit from medicines such as orlistat or sibutramine, or bariatric surgery. You may want to discuss these with your doctor, but even such medical treatment can only help if you are already losing weight through exercise and healthy eating.

I have polycystic ovary syndrome (PCOS). What is the impact of this on fertility and IVF? What can I do?

You may have been diagnosed with PCOS because of infrequent or absent menstrual bleeds, symptoms such as acne, excessing hair growth or weight gain, presence of too many follicles on pelvic ultrasound scan (‘polycystic ovaries’) or higher than expected levels of male-type hormones in your blood test.

Many women with PCOS do not ovulate (releasing eggs from their ovaries). Sometimes, losing weight is all that is required for you to start to ovulate. If losing weight alone is not enough, then there are several medicines (including clomifene, letrozole, metformin and FSH injection) that can help achieve ovulation. A key-hole operation called ‘ovarian diathermy’ may be suitable for some women. Many women with PCOS, however, will need IVF to help them achieve a pregnancy.

Women with PCOS having IVF may produce a large number of eggs, but many of these eggs could be of poor quality. Another potential problem is the development of a serious condition called the ovarian hyperstimulation syndrome (OHSS). With OHSS, fluid can accumulate in the abdomen, around the chest and sometimes even around the heart; clots can develop in the legs, chest or other parts of the body. Patients with OHSS can become very unwell. So, IVF clinics take special care to do all they can to reduce the risk of OHSS developing.

The first step in preparing for IVF is to ensure your body weight is as best as it can be. You can find some advice on this in our previous question. You may be started on a course of metformin to reduce the risk of OHSS; metformin is often started about a month before your IVF cycle. You are likely to have a ‘short antagonist protocol’ and a gentle ovarian stimulation with a low dose FSH injections. You will have ultrasounds, and often oestradiol blood tests, to monitor the progress of follicular (egg sac) development. If too many follicles develop, you may have your FSH injection dose reduced, or altogether omitted for a few days. Omitting FSH injections is called ‘coasting’. The final egg maturation (‘trigger’) injection may be with an ‘agonist trigger’ rather than the usual HCG injection; we will guide you on all of these steps, so don’t worry about trying to remember it all. You may also be given a course of cabergoline tablets to reduce the risk of OHSS.

If there is significant risk of OHSS, we may suggest not going ahead with a fresh embryo transfer, but instead freezing all the embryos for a transfer a month or two later. During and after IVF treatment, we will ask you to look out for OHSS symptoms, such as bloating and abdominal distension, nausea and vomiting, breathing difficulty, not passing much urine and leg pain.

 

I have been diagnosed to have a cyst in the ovary. What is the impact of this on IVF?

The impact on IVF will depend on what type of ovarian cyst you have. There are at least three types of ovarian cysts: ‘simple’ cysts, which are thin walled and have fluid inside them without any solid contents, endometriotic cysts, and tumours (which can be benign, such a dermoid cyst or extremely rarely cancerous tumours).

Simple cysts can be ‘functional’ (which means they secrete the hormone oestrogen) or ‘non-functional’ (which means they do not secrete oestrogen). If it is a small simple cyst, they you can go ahead with IVF treatment. If it is a large simple cyst or one that is persisting over several months, then your doctor may advise some blood tests (tumour markers: CA125, AFP, HCG and LDH) and aspiration or removal of the cyst. There is some evidence that the presence of a simple cyst can be associated with a poor ovarian response to IVF medicines, but there is no evidence that aspirating or removing the cyst improves the outcomes. So, you will need to have a good discussion with your doctor about the best way forward.

If it is an endometriotic cyst, you may need to have it removed. Please see below.

If it is a tumour, then you will need a consultation with a gynaecologist. A small benign tumour, like a dermoid cyst, may not need anything being done to it. A larger cyst or one that has a cancerous appearance will require an urgent medical consultation.

Finally, there are women who tend to develop ovarian cysts time after time. In such a situation, using contraceptive pill before starting IVF and using an ‘antagonist’ protocol may be of helpful.

I have endometriosis. What is the impact of this on fertility and IVF outcome?

Endometriosis can be found in the pelvis, or it can also implant inside the ovary and cause an ovarian cyst – this is called an endometrioma. Endometriosis causes inflammation and scarring. It can distort or block the fallopian tube.

Research evidence shows endometriosis reduces your fertility chances. We carried out a comprehensive analysis of the data a few years ago. We found that endometriosis was associated with reduction in fertilization, implantation and pregnancy rates. If you have endometriosis in the ovary, that may mean we gather fewer eggs during IVF treatment.

How can we treat endometriosis? There is still much debate about how to treat endometriosis to improve fertility outcomes. The treatment will depend on the extent of the disease, and the clinical history. If the endometriosis is mild, then surgery to remove the endometriosis is an option. It can improve natural pregnancy chances. If that does not work, most doctors will advise IUI, or intrauterine insemination, combined with ovarian stimulation. Couples usually have 3 to 4 cycles of IUI treatment. If that does not work, then IVF treatment is often recommended.

If a patient has moderate or severe endometriosis, then it may be reasonable to go straight to IVF treatment. There is some interesting data suggesting pre-treatment with a medicine called GnRH analogues for 3-6 months before IVF can improve the pregnancy chances.

If a patient has an endometrioma, that is an endometriotic cyst in the ovary, what we do depends on the size of the cyst. Generally, if the cyst is more than 4cm, many doctors will recommend removal of it through key-hole surgery, before proceeding with IVF. If the endometriotic cyst is less than 4 cm, patients can normally go ahead with IVF without needing surgery first. These are the treatment principles, but please seek a fertility consultation to understand what may be the right course of action for you.

I have adenomyosis. I am due to have IVF. What is the right course of action for me?

Adenomyosis is when the glands and the tissues (called the ‘endometrium’) from the lining of the womb invades into the muscle of the womb (called the ‘myometrium’). Symptoms include painful and heavy menstrual periods. Adenomyosis is diagnosed on ultrasound scan, or occasionally on MRI scan. It is linked to a 28% reduction in pregnancy rates and doubling in the risk of miscarriage rates after IVF treatment. The difficulty is that we have limited evidence on how we can manage patients with adenomyosis. It appears a long GnRH analogue protocol may be better than a short protocol. If a long protocol with fresh embryo transfer does not work, then it may be helpful to consider freezing all embryos in a future IVF cycle, then having 3 months of treatment with GnRH analogue, and then having a frozen embryo transfer. It is well worth having a detailed discussion with a fertility specialist if you have a diagnosis of adenomyosis.

I have fibroids. What does this mean to my fertility and IVF treatment?

They are benign growths made up of uterine muscle and fibrous tissues. They are very common, but many women don’t know that they have fibroids as they don’t always cause symptoms. But in some women, they can cause heavy periods, painful periods, constipation, backpain, and discomfort during sex. They can also be linked to infertility and miscarriage. They can affect the movement of the sperm and embryo, disturb the blood flow to the lining of the womb, and compromise implantation.

It is important to appreciate that not all fibroids are the same. Whether they have an impact on fertility or not and whether they need removal or not depends on, firstly, the number of fibroids, secondly size of the fibroids, and thirdly the location of the fibroids. You will need to have a clinical consultation to determine the right course of action for you. Here we provide some general advice.

Fibroids are categorised into three groups depending on where they are in the uterus. First, and the most problematic ones, are the submucous fibroids. They sit near the womb lining, and distort the womb cavity, and increase the risks of infertility and miscarriage. A meta-analysis, which is a synthesis of many studies, showed submucous fibroids were associated with a 72% reduction in implantation, 64% reduction in pregnancy rates, and a 68% increase in miscarriage rates. So, it is not surprising that there is very little debate about whether they should be removed. Almost all clinicians would agree that they should be removed, and the good news is that the removal can be done through an operation through the vagina, without needing a cut on the abdomen.

The second type of fibroid is called intramural, and here the fibroids sit in the muscular wall of the uterus, but without distorting the womb cavity. The evidence of their association with poor fertility outcome is less clear-cut, but a study by our group did find a 15% reduction in pregnancy rate with this type of fibroids. However, we do not know if removing these fibroids will improve outcomes of fertility treatment – the evidence is simply not there. If removal is considered necessary, an operation called myomectomy will be needed. This is a major operation. It can be done via keyhole or open surgery. There are significant risks with this operation, including the risk of severe haemorrhage that may on occasions result in the catastrophic complication of removal of the uterus to control the bleeding and save the patient’s life. So, the decision for this operation should not be taken lightly. We would not normally recommend removal of intramural fibroids unless the fibroid is large, the patient has a history of repeated negative IVF cycles or miscarriages, or she has symptoms such as pain or heavy menstrual bleeding.

The third type of fibroid is called subserosal; the fibroids here develop outside the wall of the uterus. They do not have any impact on infertility or miscarriage, and do not generally need treatment.

Finally, a question that we get asked commonly these days: is there any way of treating fibroids without surgery? The answer is yes, and no! Yes, there are ways of reducing the volume of fibroids by using medicines such as GnRH analogue or by a technique called uterine artery embolization, but no, these approaches are not only unhelpful for patients who are having infertility treatment. Uterine artery embolization has been linked to premature failure of the ovaries and miscarriages. It is best to avoid uterine artery embolization if you are trying to have a baby.

Let us leave you with this final comforting thought: many women with fibroids don’t even know that they have them, and more often than not they have successful pregnancies without any medical intervention at all.

I have an endometrial polyp (polyp in the womb cavity). Would this affect my IVF chances?

Polyps are benign overgrowths in the lining of the womb. They are usually diagnosed on a pelvic ultrasound scan, often before a patient starts an IVF treatment, but occasionally only during the IVF treatment cycle. Polyps can be associated with failed implantation and miscarriage. So removal of polyps should be considered before starting an IVF treatment cycle. Polyp removal can be done through simple keyhole surgery, called ‘hysteroscopy’.

If a polyp is identified only during an IVF treatment cycle, the patient is left with the difficult decision about whether she should stop the IVF treatment and have the polyp removed, before proceeding with a new IVF cycle. We normally advise that the IVF treatment does not need to be stopped if the polyp is small (less than 1.5 cm). If however, the polyp is large (more than 1.5 cm) or there are many polyps then we would advise the patient stopping the IVF treatment and having the polyp removed. There is also the option of proceeding with egg collection and freezing the embryos for future frozen transfer, 2 or 3 months after removal of the polyp(s). Your fertility consultant will advise you on the best cause of action.

I have been told my womb lining (endometrium) does not develop well and I have a thin lining in fresh or frozen IVF cycles. What can be done?

The lining of the womb, known as endometrium, needs to be ‘receptive’ to an embryo for implantation and pregnancy occur. It is very well established that a very thin endometrium is associated with lower pregnancy and higher miscarriage rates. But what is ‘very thin’ endometrium? Most people will define this as less than or equal to 6mm. So, if you have a lining that is 7mm or more, then you are on safe grounds, although a lining between 10 – 15mm is ideal. It is important to note that it is not just the thickness of the womb lining that matters, but also its appearance. An appearance that we call ‘triple line’ is considered best.

So, what can be done? Unfortunately, there are no straight forward answers. If the lining is consistently thin, then it is important to assess the inside of the womb cavity with a keyhole camera (hysteroscopy) to see if a reason, for example scar tissues, could be seen. If the lining is thin during a fresh IVF cycle, then the option of freezing all the embryos should be considered. While the embryos are safely in the laboratory, we can try to thicken the womb lining in a frozen cycle, and if we achieve a good endometrial thickness, then we can thaw the embryos and transfer them. In a frozen cycle, high dose oestrogen tablets and patches can be used to thicken the lining. Some clinicians add medicines such as aspirin, steroids, pentoxifylline, tocopherol and Viagra to thicken the endometrium, but there is no clear evidence to support their use. Your IVF consultant would be able to advise the best way forward.

I have been told I have scar tissues (‘adhesions’) in the womb. What can be done?

<<Abey to help>>

I have been told I have a ‘uterine septum’. What will you advise?

 

<<Abey to help>>

The IVF clinic found fluid in my womb cavity during an IVF cycle. What can be done in a future IVF cycle?

 

<<Arri to do>>

I have a hydrosalpinx (fluid filled blocked fallopian tube). What will be your advice?

 

<<Arri to do>>

I had a history of Chlamydia when I was young? What is the implication of this for my IVF treatment?

 

<<Arri to do>>

 

I have a low AMH. What are my prospects with IVF?

Anti-Mullerian hormone, or AMH, is rapidly establishing itself as the centre-piece of fertility investigations. It is a blood test, and it can be done at any time in a menstrual cycle.

Here is a general guide to interpreting AMH results:

  • If the AMH result is <1pmol/l, this means the egg store is extremely low, and natural or IVF pregnancy chances are extremely poor. Your doctor may suggest that you should consider donor egg treatment.
  • If the AMH result is between 1-5 pmol/l, this means egg store is low. Treatment with your own eggs is possible, but there is a risk of cancellation of an IVF cycle if no eggs are obtained.
  • If the AMH is between 5-14 pmol/l, this suggests a satisfactory store of eggs, and a good outcome can be expected from IVF treatment.
  • If the AMH is between 14 – 30, this means a good store of eggs, and the prospects for good outcome from IVF are excellent.
  • AMH >30 pmol/l indicates a high store of eggs. On the face of it, this may seem a good thing, but patients with high AMH are at risk of ovarian hyperstimulation syndrome, or OHSS, which can be a serious condition. Very high AMH is therefore not ideal. Having said that, they are many steps that we can take to reduce the risk of OHSS, and your doctors and nurses will take special care to minimise the risks associated with OHSS.

If your AMH is not normal, we would advise a consultation with a fertility specialist. Your specialist will not interpret the AMH result in isolation, but will also look at your age, clinical history, and the results of other egg store tests. The fertility specialist will then be able to give you the percentage chances of pregnancy with IVF using your own eggs versus donor eggs. The percentage chance of pregnancy will vary from clinic to clinic, so it is not possible to give a single simple answer, but your fertility clinic should be able to help.

My thyroid tests results are not normal. What does this mean for my IVF treatment?

 

<<Rima Dhillon to help>>

 

Difficulty producing semen sample