From treatments to tests, Tara Corristine looks at the factors that can help and hinder conception
Age old issue
Irish first-time mothers are among the oldest in Europe, something Dr Bart Kuczera, specialist fertility consultant with Beacon Care Fertility, can attest to. “Age is the main factor that affects fertility, and the age of the female is the issue because optimal fertility ends around 35. Most patients who attend clinics are about 35 and one third are 40 and older. Above the age of 38, the drop in fertility is the fastest, and every half a year makes a difference. For a naturally fertile couple at the age of 40, the chance of spontaneous conception is one in 20 per month.”
Under and over
A healthy bodyweight is one of the first steps towards a successful pregnancy and being undernourished and underweight can be more harmful than a high BMI. “We have couples who live über- healthy lifestyles: jogging, marathon-running, and we cannot convince them that they are doing too much,” says Dr Kuczera. “They feel they are keeping their body slim when in fact it’s slim and exhausted. Women need fatty tissue to balance their hormones and if they don’t have enough, they can stop having a menstrual cycle. It’s difficult to make them pregnant and their risk of miscarriage is higher.”
Men at work
An ageing population, rising obesity and our ever-evolving lifestyle has lead to an increase in male infertility, and it is now thought to be a factor in one third of cases. “We are definitely seeing more men with much poorer fertility than we did ten years ago. It’s possibly down to health, and as tests improve, we are picking up on things we didn’t before,” explains Dr Mary McCaffrey, consultant obstetrician gynaecologist at The Scotia Clinic in Kerry. “Studies have suggested that guys sitting with their laptops in their laps all day, which heats the testes, is bad for them. Now they are saying that it might be the radiation from constant exposure to Wi-Fi. We are eating so much processed foods and being exposed to chemicals, like parabens, in so many ways. People use more recreational drugs, guys may be using steroids or testosterone in the gym and perhaps not appreciate the damage this is doing.”
Did you know?
Most sperm is abnormal, with as little as 4pc meeting the vitality and motility markers. Double heads or tails are common, as are crooked and misshapen sperm. Volume of semen, sperm concentration and sperm count are also important and can be assessed through a semen analysis. “The question we are trying to answer,” points out Dr Kuczera, “is what treatment is the best use of the sperm. If the ejaculate is very scarce, you would repeat the test in about two to four weeks to establish if it is a continuous problem or a one-off. If it’s confirmed, many treatments are not available. Testing men is just as important as female assessment.”
New tests are helping to improve not just the quantity and motility of sperm, but the quality. Sperm DNA fragmentation looks at the DNA make-up in the sperm: are they properly formed, is the DNA shattered or fragmented meaning that some genetic information may be missing. This test is helpful where the male partner is older or there have been recurrent miscarriages. Where a patient has little to no sperm in their ejaculate, Testicular Sperm Extraction or TESE extracts sperm directly from the testes and freezes it for future treatment.
Know your meds
Fertility drugs are used to address hormonal or ovulation issues. Clomiphene causes the release of hormones needed to trigger ovulation and if a pregnancy hasn’t occurred within six months, a follicle-stimulating hormone called gondatropin can be injected directly into the body to stimulate the ovaries. However, these drugs require daily injections, can only be taken for a limited time and can result in multiple pregnancies. It is also recommended that regular ultrasound scans be performed while on these medications.
Access all areas
A HyCoSy test checks for blockages by injecting dye into the uterus and monitoring the flow through the fallopian tubes. According to Dr Kuczera, it is particularly important where insemination is required. “It is the number one method to assess whether the tubes are open. You are looking at whether there is much discomfort, or if the passage of the dye is quick and unobstructed.”
Single women or same-sex couples can opt for intrauterine insemination (IUI) using a sperm donor, where a concentrated amount of sperm is deposited into the uterus. This is also an option where the male partner isn’t producing enough sperm or there is a genetic condition that could be passed on. Ovulation is monitored and patients are inseminated with sperm that has been prepped, and success rates vary from 8pc to 12pc. This method is becoming less popular as success rates in IVF are higher, reveals Dr McCaffrey. “People think IUI is a really easy option: it’s less involved and less technical. Pregnancy rates with IUI in the best case are 12pc so they could end up doing three or four cycles to achieve the same pregnancy rate as IVF. You might spend the same money and then may have to consider IVF, at which point it might be less successful. It’s a balancing act.”
IVF, or in vitro fertilisation, is where the eggs are fertilised outside the woman’s body and treatment begins with a two-week course of injectable hormones to stimulate the ovaries and produce an abundance of follicles, each of which will hopefully contain an egg. After a vaginal scan, the eggs are retrieved, examined and transferred into a petri dish where a concentrated preparation of the best sperm is added. The fertilised egg is transferred back into the womb and any additional embryos can be frozen for subsequent transfers. “The process takes approximately a month from starting stimulation to pregnancy and the likelihood of success is related to the age of the woman and the number of attempts,” Dr Kuczera explains. “For some patients who have had one or two treatments already, their chances are poorer. If you are under 35, one in three couples will have a child from a round of IVF, sometimes not with the first transfer but with a surplus frozen embryo. If you are over 35, but under 40, the chances are one in four, to one in five. At your first attempt at 40, it’s one in six, one on seven, and these are the average figures.”
Just the one
The likelihood of having an ‘instant’ family is declining as more and more European clinics seek to avoid multiple pregnancies. According to Dr Kuczera, “In Ireland, we could technically transfer two embryos but the healthiest pregnancy is the singleton, and all effort is made to identify the embryo with the best fertility potential.” Dr McCaffrey points out that a multiple pregnancy increases the chances of losing the whole pregnancy. “There has been research that shows that if you put back two and one isn’t great, your body may spend so much time trying to sort that one out that the whole pregnancy goes nowhere.”
Dr McCaffrey advises couples to watch out for expensive and unnecessary treatments such as natural killer cell testing where a blood test looks for signs that the immune system is preventing a pregnancy. The problem, she says, is it could be the cells in the lining of the womb causing the problem, and that won’t be reflected in a blood test. More and more research suggests that an endometrial scratch can be valuable: “A small scratch is made in the lining of the womb before IVF and the theory is that the while it is regenerating, it is more likely to incorporate an embryo, and to prevent it from being rejected. A mild male fertility hormone call DHEA has been shown to improve the quality of eggs when used in women, and research shows that Coenzyme Q10 supplements are helpful to improve the quality of eggs and sperm.” The benefits of these treatments should be weighed against the costs. “That’s why it’s important to go to a reputable clinic. We are inspected every two years by the Health Products Regulatory Authority and they question everything. We have to be very accountable and transparent.”