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Hope through science

By Irish Pharmacist - 30th Jan 2023

IVF

Couples with fertility difficulties sometimes face a long and difficult road to conception, but advances in fertility treatment provide hope

It is estimated that approximately one-in-six couples in Ireland struggle with fertility problems. However, according to the HSE, some 85 per cent of couples conceive a child naturally after one year of trying (the Executive defines ‘trying’ as unprotected sex every two-to-three days for one year). Ninety-five per cent of couples usually conceive successfully after two years.

Despite these high rates, the process of conception is complex and requires each step of the reproduction process to happen successfully. The physiological steps are as follows:

1. One of the woman’s ovaries releases a mature egg.

2. This egg is picked up by the fallopian tube.

3. Sperm ‘swim’ up the cervix, pass through the uterus, and move into the fallopian tube in order to reach the egg for fertilisation.

4. The fertilised egg then travels down the fallopian tube to the uterus.

5. The fertilised egg implants on the inside of the uterus and subsequently grows.

There are two basic types of infertility: Primary infertility, where the woman who has never been pregnant has problems conceiving, either through a flaw in the reproductive system of her or her partner; or secondary infertility, where the couple have had previous successful pregnancies, but are having difficulty conceiving again. A GP will refer a couple to specialist clinic if necessary. However, despite advanced modern testing being thorough, in 20 per cent of cases of infertility in Ireland, no specific cause is ever found.

There are a number of risk factors associated with infertility, some of
which are within the patient’s control. These include:

  • Body weight: A BMI over 30 is known to reduce fertility in both men and women. In addition, if a woman is underweight and has a BMI of less than 18, this can affect successful ovulation.
  • Smoking: Quitting the habit will improve the quality of sperm in men, and also for women, quitting smoking increases the chances of successful conception. Second-hand smoke can also affect the chances of becoming pregnant.
  • Age: This is a factor for women more than men, and fertility may decline from the mid-30s.
  • Alcohol consumption: Similar to smoking, excessive alcohol can reduce the quality of a man’s sperm.
  • Sexually-transmitted infections: These can have a negative effect on fertility.
  • Stress: When under severe stress, fertility can be affected.
  • Environmental exposure: For men, exposure to some metals, solvents and certain pesticides can affect sperm health.

While some of the above factors can be addressed, many couples find themselves unable to conceive due to physiological reasons. For these couples, in-vitro fertilisation (IVF) represents an option to greatly improve their chances of conceiving. IVF can help couples to overcome whatever may be preventing fertilisation.

Causes

The issues that can interfere with fertilisation are varied, but may include damage to the fallopian tubes. This could be caused by a number of factors, including previous surgeries (also surgeries to the lower abdomen), pelvic inflammatory disease, tubal ligation, fibroids or polyps in the uterus, ectopic pregnancy, or endometriosis. In addition, a submucosal fibroid can grow from the muscle wall and into the fallopian tube, which can also affect fertility by blocking the tube.

Sometimes, ovulation disorders can affect fertility and mean that an egg is not produced each month. Ovulation disorders can be a result of:

  • Excessive exercise.
  • Polycystic ovarian syndrome.
  • Unhealthy BMI or stress (as stated above).
  • Hormonal problems (such as
    thyroid gland).
  • Over-production of the hormone prolactin.

Early menopause also prevents conception. Although menopause in women under the age of 40 happens to only one-in-100 women, it obstructs successful pregnancy and is also termed ‘premature ovarian failure’.

As mentioned above, another potential cause of infertility is an excess of prolactin. Prolactin is the hormone responsible for milk production/lactation and certain breast tissue development — high levels in the bloodstream can manifest as irregular periods, infertility, or erectile dysfunction in men.

In terms of male fertility, around four-in-10 couples cannot conceive because of reproductive issues, which are most commonly problems with the man’s sperm. The sperm count may be low, the sperm may not be as mobile as they once were, or they may be abnormal under microscopic examination. This can result in them having difficulty in penetrating the egg.

Low sperm count is considered to be a contributory factor if the man has less than 15 million sperm in a millilitre of semen. However, the quality of the sperm is also an important consideration. A wide range of varied factors can influence sperm quality — aside from the obvious risk factors, sperm can be damaged by cocaine or cannabis, genetic disorders, certain medications, hormone problems, and surgery or tumours on the testes, among other factors. Chemotherapy or radiation therapy have the potential to eliminate sperm completely. Certain issues, such as hormonal problems, can be treated with the right medications.

Ovarian assessments may also be carried
out to establish the number of
eggs that remain

Testing

A range of tests in a fertility clinic or hospital department will investigate the potential causes of infertility and specialists will recommend a course of treatment individualised to the couple’s circumstances. These may include fertility assessments, and the earlier a problem is detected, the better the chances of achieving a positive outcome. The clinic may recommend further diagnostic testing to follow-on from basic testing.

Female fertility assessment may involve BMI assessment, as being either over- or underweight can affect prospects of female fertility. Ovarian assessments may also be carried out to establish the number of eggs that remain — some couples decide to have a child later in life, and the amount of fertile time a woman has left in life can be established. A vaginal ultrasound scan may also be appropriate to look for any abnormalities. Other ultrasound tests may be necessary, such as on the fallopian tubes, and an x-ray may also be necessary to check for blockages in these tubes. There are other specialist tests that may be required, such as screening for undetected infections.

Male fertility assessment can
involve a semen test to assess motility and sperm count, as well as other diagnostic factors. A couple may also
be tested simultaneously.

As well as offering lifestyle advice, a fertility specialist may recommend medical or surgical treatment if a problem is detected. Medications can sometimes help if a fallopian tube is blocked, or to help stimulate ovulation. For women with polycystic ovarian syndrome, a medication commonly used for diabetes treatment (metformin) is sometimes used to improve fertility.

Some clinics use genetic testing if it is suspected that the infertility is caused by an inherited condition. In this procedure, pre-implantation genetic testing assesses an embryo for inherited disease prior to both implantation and the pregnancy itself. One important aspect of this is to minimise the risk of passing the condition on to future generations.

Some of the diseases that have the potential to be passed on to the next generation include cystic fibrosis, Beta Thalassaemia (an inherited blood disorder in which the body makes suboptimal levels of beta globin), and Fanconi anaemia (a rare disease passed down through families that mainly affects bone marrow).

Procedures

Specialist clinics will also offer a number of other procedures to assist fertility. These are broadly described as:

  • IVF: This is where a woman’s eggs are fertilised with a man’s sperm in a laboratory in a bid to create embryos. The embryos are assessed for quality and the best one is then transferred to the womb, usually followed by medication to help the ovaries to produce eggs. When these eggs have been retrieved, they are mixed with sperm to form embryos, which are then inserted in the womb. Remaining embryos that are of good quality can then be frozen for later use if necessary.

The HSE estimates that approximately one-in-four IVF procedures results in a successful pregnancy.

  • Intrauterine insemination (IUI) is where a sample of a man’s sperm is injected into a woman’s womb using a small plastic tube. This may be accompanied by medications to stimulate ovulation.
  • Intracytoplasmic sperm injection (ICSI): This is where the sperm is injected directly into the egg. Only one sperm is required for ICSI, so this method may be preferred if the male has a low sperm count, or if the sperm have reduced motility and poor ability to penetrate the egg.
  • Sometimes, surgery may be required to improve the chances of conceiving. Typical instances where surgery is necessary include when unblocking or repairing fallopian tubes, or in treating endometriosis. Surgery may also be necessary to remove scar tissue from the pelvis, or laparoscopic drilling for polycystic ovarian syndrome may be required.

This is a basic guide only and different clinics may vary in their approach.

There are some potential complications associated with fertility treatment that the couple should be aware of. These include the potential for twins and other multiple pregnancies, which are more common after undergoing fertility treatment. The potential for an ectopic pregnancy is also increased following fertility treatment.

Another potential complication of fertility treatment is ovarian hyperstimulation. When ovaries are
over-stimulated, this can result in some cysts on the ovaries, so these women will be monitored by the clinic using ultrasound scans. The symptoms of ovarian cysts include bloated stomach, nausea and vomiting.

Stigma

Research into Irish couples with fertility issues, published in the journal Human Fertility, examined the journey of 12 Irish couples along their IVF treatment and their final outcomes. The research, which was funded by the Health Research Board, showed that these couples were initially shocked by their inability to conceive, as they felt they were ready to have a child in terms of finances and other life circumstances. While they stayed patient, the couples increasingly experienced feelings of stigma, social exclusion and regret. Finally, the couples sought medical advice and began their IVF journey and they stated that going through the procedures stiffened their resolve.

The authors wrote: “The findings suggest that health policy should raise awareness of infertility and advise women to become aware of it — just as in the past, when health policy addressed contraception. Increased public knowledge would reduce the stigma attached to the inability to have a baby. In the Irish case, infertility diagnosis should be reviewed with a view to giving eligible couples earlier access to IVF.”

References on request

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