Normal Fertility and Success of Fertility Treatment FAQ

How does the age affect the fertility in men and women?

Fig 1 Fig 2 Fig 1 and 2: age related decline Girls are born with a fixed number of immature eggs in their ovaries. The number of eggs decreases as women get older. At birth, most girls have about 2 million eggs, at adolescence that number has gone down to about 400, 000, at age 37 there remain about 25,000. By age 51 when women have their menopause, they have about 1000 immature eggs, but these are not fertile. At every menstrual cycle one of the immature eggs will mature and be released during ovulation. The eggs that are not released die and get re-absorbed into the body. The quality of the eggs also gets poorer as women get older. All other things being equal the number and quality of the woman’s eggs determines her fertility. Women’s fertility will continue to decrease every year, whether or not she is healthy and fit because the number and quality of the eggs decreases with age. Even if a woman is not ovulating (for example if she is taking the contraceptive pill, or is pregnant), the number of eggs continues to decline at the same rate. How quick a woman’s fertility declines will depend on a combination of genetic and lifestyle (e.g. smoking) factors. Men are not born with their sperm. Men produce sperm daily. Men’s fertility also starts to decline around age 40 to 45 years. The decrease in fertility is caused by the decrease in the number and quality of the sperm they produce. Men can have fertility problems even if they can still have sex and have an ejaculation. If you are concerned about your age and your fertility, you may consider having your fertility tested.

What are the chances of success using donor egg IVF as compared with my own eggs?

The chance of success using donor eggs depends largely on the age of the donor, and only women under the age of 36 years are accepted as donors. Therefore, it has very good chances of success.

The national data (from HFEA website) showed

What are the causes of infertility/fertility problems? Why I cannot get pregnant?

One in seven couple struggles to get pregnant. Four key factors are required for natural pregnancy. 1. Sperms, 2. Normal womb, 3. Open tubes (called fallopian tubes) 4. Eggs released by ovary every month When something goes wrong in any or some of these organs, it leads to difficulty in getting pregnant. 30% of the time the problem can be in men 40% of the time it is something wrong in women 10% combined both have something that causes difficulty in getting pregnant 20% Unexplained means the couple have open tubes, normal womb and normal sperm count One of the reasons there is an increased in demand for fertility treatment is from same-sex couples. Due to medical advances, cancer survival is great, that lead to patients coming for fertility treatment afterwards. We do fertility preservation in a few cases before cancer treatment.

When should women/couples seek help? How likely are you to get pregnant?

The straight young couple is advised to try one year provided the periods are regular, normally 80% of couple conceive within a year. After one-year start seeking help and investigations, it takes time on NHS to get referrals and appointments, if all investigations are normal, they are advised to try for two years as remaining 50% of 20% get conceived in the second year. After two years of trying its time for treatment. The same-sex couple should seek help when they are in a stable relationship and ready to start a family. If there is a known medical condition such as polycystic ovaries, or womb surgery or endometriosis in women or testicular problems in men, the couple should seek help earlier than this. Age of the women is the top predictor of the success of fertility treatment, currently, NHS funding criteria do not permit IVF after a certain age. Most of the time the upper age limit is 40 years. Therefore, older women especially above 37 -38 should seek help sooner than later.

Would the GP then refer you for “tests” to find out what may be the cause of your fertility problems? (For example, PCOS or thyroid conditions?) What's the route couple take if they're struggling to conceive?

First thing as mentioned above, when a couple decides to have a baby, timing to seek help is important. GPs normally check medical history, advice on lifestyle measures such as stopping smoking, getting height and weight ratio (BMI) within the normal range as these can stop couple getting pregnant and part of funding criteria. Start folic acid. Baseline tests are done by GP such as sperm test, hormonal tests, which helps to diagnose PCOS thyroid conditions, problems with sperms. Normally General Practitioners (your doctors) are advised to refer a couple to secondary care to fertility consultants for further tests and treatment. Conditions like PCOS, thyroid, any polyp or fibroid in the womb, endometriosis could be treated in a hospital setting with secondary care. If requires the consultant from these hospital settings refer them to sub-specialist consultants in tertiary centres with IVF units and other facilities like ours at Birmingham Women’s Hospital. Certain special circumstances require referral to territory centres or IVF centres directly. Special circumstances include clear indications for assisted conception such as blocked tubes, no sperms, same-sex couples, premature stopping of the function of ovaries, surrogacy, fertility preservation.

What are some common causes of fertility problems in women?

Egg release: Subfertility is most commonly caused by problems with ovulation, the monthly release of an egg. Some problems stop an egg being released at all, while others prevent an egg being released during some cycles but not others. Ovulation problems can be a result of: Polycystic ovary syndrome (PCOS) when periods are not regular, there could be abnormal facial hair growth, Thyroid problems – both an overactive thyroid gland and an underactive thyroid gland can prevent ovulation Premature ovarian failure – where a woman's ovaries stop working before the age of 40, this can happen due to genetic problems, as a result of cancer treatment, it can be associated other autoimmune conditions, it could run in families. Therefore, is a sister, cousin or mum had a history of premature ovarian failure, women should seek help sooner than later. Tubes are required for meeting egg and sperm what we call fertilization and then the transfer of fertilised egg. Any damage to the tube can cause subfertility or ectopic pregnancy. Scarring from surgery, sexually transmitted infections, and chlamydia damages tube. Womb: poly, fibroid in the cavity of the womb, some conditions from birth can have womb abnormalities. In some conditions, there is the absent womb. Endometriosis: when tissue like lining of the womb (endometrium) is present outside the womb is called endometriosis. It can cause fertility problems. Please check information on endometriosis in relevant section.

What about fertility problems in men? If a couple of trying to conceive, would the man be tested at the same time as his partner? Are men or women more prone to fertility problems?

Sperm test has three main parts, how many sperms are there, that is count, How they move, that is motility and how they look that is called morphology. World Health Organization defines criteria for normal sperm parameters. If one test shows some problem, we may repeat the test as various things can change sperm levels, such as any other sickness, medications at the time of the test, how the test was performed etc. If count is less than normal, poorly moving or lazy sperms or not having a good number of normal-looking sperms are the main cause for subfertility in men. Smoking can cause sperm problems. Damage to testicles, due to surgery or trauma, undescended testis, genetic problems such as extra chromosomes, cystic fibrosis are other medical causes. Sometimes it could be due to no obvious reason. It is worth mentioning about Muscle building injections what we call anabolic steroids, testosterone supplements.

What about couples that struggle to maintain a pregnancy, after how many miscarriages should they seek help? What would be the path for these couples?

“Human conception is one of the most ineffective conceptions in nature,” Thirty per cent of pregnancies is lost between implantation and the sixth week. Clinically miscarriage is only called miscarriage after diagnosis of pregnancy, therefore many implantation failures go unaccounted for. Having one miscarriage can be devastating enough but having one after another is often a very traumatic experience. Miscarriages are divided into two categories, the first, sometimes called “sporadic” or “spontaneous” miscarriage, refers to when women lose one or two pregnancies in a row. Most sporadic miscarriages are attributable to unpreventable “chromosomal abnormalities in the baby and cannot be predicted or prevented. Fortunately, they are not very likely to happen again. It’s nature’s mechanism to miscarry those embryos, which are not destined to develop into a healthy fetus. The risk for chromosomal abnormalities goes up as a woman age. But no one’s sure just why that is, it could be the quality issue of eggs and embryos. There are many possible causes for recurrent miscarriage, including genetic and hormonal problems; infection and thrombophilic (blood-clotting) defects; uterine problems and cervical weakness. Unfortunately, even after investigation, it’s not always possible for doctors to identify the cause for recurrent miscarriage. Nearly 50% of recurrent miscarriages are unexplained. However, most couples who have had recurrent miscarriage have a good chance of having a baby in the future. The quality of a man’s semen also seems to play a role. “Poor sperm quality can be the cause of miscarriage in about 6% of couples. Although three or more consecutive pregnancy losses are called recurrent miscarriages, we advise the couple to seek help after two miscarriages one after another. The couple can get a referral to the hospital, many hospitals have recurrent miscarriage services. Fertility experts are trained to manage recurrent miscarriages. There are national centres such as ours for miscarriage research. Couples with some medical issues are treated accordingly. Couples with an unexplained recurrent miscarriage should be offered appropriate emotional support and reassurance. There is good evidence that appropriate care improves the success rate.

At what stage would “infertility” be diagnosed, and how is it diagnosed?

By definitions, no pregnancy after 2 years of trying is defined as subfertility. Absolute infertility is when there are no gametes that mean no sperms or eggs. It is diagnosed with the tests.

Can you tell me about what fertility treatments there are, and what’s available within the NHS?

Fertility tests are available on the NHS. Any operations such as camera tests and keyhole surgery are available on the NHS. Ovulation induction using tables in PCOS as per local guideline is available on NHS. The treatment which requires funding approval includes assisted conception treatment such as IUI, IVF, ICSI, and egg or sperm storage. There are criteria for such funding. These criteria are different from place to place. IVF funding is a classic example of a postcode lottery. CCG contacts IVF treatment to local NHS or private IVF unit and within the contract, the criteria are clearly defined. The criteria are various with local CCG and where the patient’s GP is based. For example, Scotland funding is available for three cycles of IVF. In some part of England, it can range from0 to three cycles. National guideline-recommended 3 IVF cycles to eligible women under 40, only 12% CCG follow this. Please check the availability of funding for your treatment with your doctors. At p4 fertility, our team is happy to advise you on NHS funding within West-Midlands based on your details. Visit fertility fairness website for further information.