Why is age important?
Age is an important independent factor affecting female fertility. Women are waiting longer to begin a family. Age related decline in fertility may take place at a quicker pace than what most women expect. This is due to age related decline in the number and quality of eggs in the ovaries. Decline in natural fertility accelerates after the age of 35 years and this decline is not completely offset by assisted conception treatments. The chance of a live birth following IVF treatment with fresh embryo transfer varies with age. This is 32% for women below 35 years of age and declines to 13.6% for a woman who is 40 years of age (National averages, HFEA).
Age and egg quality
Advancing age also has an impact on egg quality. An important reason for decline in egg quality is due to increased frequency of genetic abnormalities in the egg with increasing age. This results in lower success with assisted conception and an increase in miscarriage.
Women who are over 35 years of age should seek advice sooner from their GP if they are finding it difficult to achieve a pregnancy.
What is ovarian reserve?
Women are born with a fixed number of egg containing follicles in the ovaries. At birth this may number around 1 million. By the onset of puberty this number would have dropped to around 300,000. Only about 300 would be ovulated during the reproductive years and the rest of the egg containing follicles are lost by a process called atresia. This process of atresia is gradual and is not offset by pregnancy or being on the contraceptive pill. This rate of loss of egg containing follicles may vary from woman to woman. Smoking accelerates this loss of egg containing follicles (ASRM, 2012). This decline in egg quantity is called ‘loss of ovarian reserve’. Blood tests for hormones such as follicle stimulating hormone (FSH), Anti-mullerian hormone (AMH) and an ultrasound for checking the antral follicle count (AFC) give an assessment of ovarian reserve.
What about women with other medical conditions?
Thanks to advances in medical care, we can offer assisted conception treatment to women with underlying medical conditions, such as Diabetes, heart disease, blood disorders, kidney disease etc. Women with underlying conditions are often referred for such treatment directly by their medical consultant team or by their GP.
Every woman with a pre-existing medical condition is assessed individually to ascertain the risks to her with assisted conception treatment and pregnancy. Often there is a delay in starting treatment as an assessment is requested from their medical consultant regarding suitability to proceed with assisted conception treatment and risks with pregnancy. An opinion is sought from the pre-conception clinic at the Saint Mary’s Hospital to assess risks in pregnancy to the mother and baby. Changes to medications may be requested prior to starting assisted conception treatment.
In situations where the woman has a life threatening medical condition, the decision to proceed with any treatment will be taken jointly in a multi-disciplinary meeting. Rarely, assisted conception treatment may be refused based on input from different specialties. If attending the clinic for your first appointment, you should bring a list of all medications and medical correspondence.
Research has shown IVF is more successful when women are within the ideal weight range for their height. There are also added risks to a pregnancy when women are overweight. As such we will only offer NHS-funded treatment to women who have a BMI between 19-30. A healthy balanced diet for both partners can help increase success. Women are also advised to take folic acid supplements daily (0.4mg) when trying to conceive.
Both partners MUST NOT smoke when undergoing NHS-funded IVF treatment as, aside from the known damage to health this causes, smoking decreases success rates of IVF. If either of you smoke, you will be referred back to your GP and can only be re-referred once you have been smoke-free for 3 months.
NICE guidelines advise not drinking to excess and drinking no more than 1 or 2 units of alcohol once or twice a week. A unit of alcohol is about the same as a small glass (125 ml) of wine or a half-pint of beer or lager. If you are a man, your fertility is likely to be affected if you drink more than 3 or 4 units of alcohol a day. Drinking excessive amounts of alcohol can affect the quality of a man’s sperm.
It is also important for women to have an up-to-date smear test before starting a treatment cycle as you will not be able to have this done routinely once pregnant.
What might delay my starting treatment?
You will receive an information pack along with your clinic appointment letter and this will hopefully explain how your treatment will work.
Once you have been accepted for treatment you will have a 45 minute ‘teach’ appointment with the nurses to be shown how to use your medications and you will be able to go through any concerns you may still have at this time. If the nurse feels you would benefit from another clinic appointment prior to starting treatment, this will be arranged for you.
You will be informed at your initial clinic appointment that Saint Mary’s Hospital can only carry out a finite number of treatment cycles per week and so you cannot be guaranteed treatment in any given month. Occasionally we will also have to accommodate minor closures such as over Bank Holidays and Christmas and so we may not be able to accept your request for treatment at these times.
If it has been more than 3 months since you had your initial scan and blood tests, we may need to repeat a few of these tests to make sure no new issues have arisen.
Please be aware that we are obliged to have a closure period once every year to ensure essential safety checks and maintenance of theatres and laboratories can be carried out.
This may include equipment checks, servicing and environmental checks such as air quality and cleaning.
This closure period takes place in December but this will affect some treatment requests from November as the need for theatre or laboratory services may fall within the closure period.
If you have any queries regarding the impact this may have on your individual treatment cycle please contact the IVF Nurses on (0161) 276 6000 (option 2).
Why might our treatment be delayed once we’ve started?
If you are going through a ‘long’ IVF cycle or planning for a frozen embryo transfer, you may have a late period whilst on a drug called ‘Buserelin’. This could in turn move all the scheduled appointment dates on by at least one week. Your nurses will aim to let you know as best as possible when you will need to attend the Department, but we ask that you would appreciate the need for flexibility due to the nature of the treatment and its dependence on your menstrual cycle.
Why might our treatment be cancelled?
Although great care is taken to make sure you are definitely ready to start treatment, sometimes unforeseen issues arise.
The most common reasons leading to a cancelled cycle include the risk of ovarian hyper stimulation syndrome (OHSS), poor response, development of a hydrosalpinx, and presence of fibroids, cysts or polyps.
The risk of OHSS is around 6% and certain groups of women are at higher risk of developing this, such as young women or those who have polycystic ovary syndrome (PCOS).
Symptoms include bloating, shortness of breath, chest pain, nausea and/or vomiting and trouble passing urine. If you think you are developing these symptoms you must ring The Department immediately on (0161) 901 5225, or you can call the Emergency Gynaecology Unit (EGU) on (0161) 276 6204 out of hours.
The clinicians will have taken extra measures to help those at increased risk such as planning extra monitoring blood tests and a lower start dose of stimulation. Even when early OHSS symptoms arise, measures can be taken to salvage the treatment, by ‘coasting’ stimulation, or by planning to freeze all suitable embryos after egg collection as symptoms can worsen with pregnancy. However OHSS symptoms can arise suddenly or unexpectedly and in such cases it can be safer to cancel a treatment cycle. In 1% of cases women may need to be hospitalised for treatment of the OHSS.
Despite having your stimulation dose tailored to you with your AMH result, sometimes women unexpectedly respond poorly to the treatment, or may respond worse than expected. Often you would be warned of this if your AMH or antral follicle count was low at the time of your initial investigations, or if a previous cycle had also had a suboptimal outcome.
The nurses will explain your response to treatment to you after each scan or blood test appointment and if less than 3 follicles have grown, the consultant would decide to cancel your cycle. Sometimes, if circumstances allow, your IVF cycle may be converted to an IUI cycle whereby you are inseminated with your partner’s or your donor’s sperm. If this option is chosen for you, the nurse will fully explain what this entails.
If treatment is cancelled, the cycle cannot be restarted. It will count as one of your NHS-funded cycles.
Ovarian cysts can develop either before or during a treatment cycle and often are not harmful.
If simple cysts are seen on either ovary at the baseline scan before treatment, these can affect your oestradiol hormone levels and they will often be raised. For treatment to start we need your oestradiol to be <200. If the hormone level is too high we would ask you to re-request treatment on the first day of your next period and we would test again. Simple cysts often disappear of their own accord.
More complex or large cysts may need to be removed prior to starting treatment and we would explain how this is done should it be needed. Each case is individual.
Fibroids are not harmful and you will often not have any symptoms. However if a fibroid is seen on your scan, this may need treating before continuing on to embryo transfer, especially if the fibroid is ‘submucosal’ (i.e. in the layer of tissue lining your womb) or is indenting the lining of your womb as this could affect implantation of your embryos. If a fibroid becomes apparent during your treatment, the doctor may speak to you about having further investigations. This may involve having any embryos that are suitable resulting from your treatment frozen after egg collection and having the embryo(s) replaced at a later date once you have had the necessary investigations. The procedure you may need is called a laparoscopy. This would confirm the diagnosis and possibly treat the fibroid at the same time. The doctor will discuss the options with you if the situation arises.
Fluid can collect inside the fallopian tubes and this is called a ‘hydrosalpinx’. Previous scans may not have shown any signs of a hydrosalpinx yet it can quickly develop during treatment and can be as a response to the hormones. If fluid is also noted in the cavity of your womb this could be problematic for your embryos as the fluid itself can be toxic to the embryos, or it may physically prevent implantation. There are two options for treating a hydrosalpinx and these are, either to have any embryos that are suitable resulting from your treatment frozen and then have surgery on your tube(s). The embryo(s) would then be replaced at a later date. Another option may be for the doctor to attempt to drain the fluid from your tube at the time of egg collection. The doctor will discuss the options with you if the situation arises.
A polyp is a soft outgrowth from the ‘endometrium’ or lining of your womb. If during an ultrasound scan a polyp is detected, depending on its size the doctor may discuss with you the need to have this removed as it could lead to difficulty in becoming pregnant. If a polyp becomes apparent during your treatment, the doctor may speak to you about having any embryos that may be suitable frozen after egg collection and having your embryo(s) replaced at a later date once you have had the necessary surgery. The procedure you may need is called a hysteroscopy. This would confirm the diagnosis and possibly treat the polyp at the same time. The doctor will discuss the options with you if the situation arises.