Fertility Options
There are many ways we can help improve your chances
We provide you with a range of choices as part of your treatment plan than can help improve your chances of getting success
Ovulation Induction and IUI
If you are having problems with ovulation or irregular cycles, and if entirely natural methods seem inappropriate or have been tried properly without success, we may suggest an ovulation stimulation or boosting drug as a next step.
This is only appropriate if your partner has good quality sperm and your fallopian tubes are clear
You can usually take ovulation stimulation drugs for up to six cycles, during which time we would usually provide you with some fertility awareness coaching (in order to make sure you have optimally timed sex – you might be surprised at how many couples do not) and also monitor you closely to check that the drug is having the desired effect. This would involve having a number of scans and a blood test for progesterone to confirm that ovulation is occurring.
Most women will ovulate with the use of these drugs and many will conceive. However, there are situations where ovulation may not occur despite the use of ovulation-boosting drugs.
IUI
One of the many things that makes our approach different from traditional approaches to assisted fertility treatment is our simple, step-by-step approach to helping you to get pregnant.
“We won’t recommend that you opt for IVF if there is a reasonable chance that
either nature or more low-level assisted fertility approaches might be worth a try first” - Dr. Rofena
We may recommend IUI if:
You are experiencing ovulation problems
When there are sperm issues. This may require the sperm to be washed to improve sperm quality
However, it is critical that:
Your fallopian tubes are open and healthy
There are no significant problems with sperm numbers or quality
The IUI procedure for men
The male partner provides a sperm sample, and we separate fast-moving sperm from more sluggish or non-moving sperm. The fast-moving sperm are then placed into the woman’s womb close to the time of ovulation.
IUI success rates
Success rates for IUIs are lower than that of IVF or ICSI (the clinical pregnancy rate of women aged 36 or less is between 15-20%) but the procedure is much quicker and less expensive and, depending on your individual circumstances, can sometimes be done without fertility drugs to boost egg production though, as you would expect, this reduces the likely success rate further.
For some couples this will be the most sensible first step.
Genetic testing
Pre-implantation Genetic Testing for Aneuploidy (PGT-A) is a genetic screening test performed on embryos produced during an IVF treatment cycle. PGT-A gives information about your embryo’s genetic health to help us select healthy embryos for transfer.
Is genetic testing right for me?
We may recommend PGT-A if you have
experienced recurrent miscarriages
had previous unsuccessful IVF treatment which cannot be explained
if you are providing eggs for treatment and your age is 36 or older
if you have had a child or pregnancy affected by chromosomal abnormality
Sometimes, despite all our hopes, pregnancy doesn't go as planned. If you’ve faced heartache with recurrent miscarriages, unexplained difficulties with previous IVF treatments, or if you’re over 36 considering egg donation, you might be searching for insights. Or perhaps you've known the pain of a pregnancy affected by a chromosomal abnormality. These can be tough experiences, and in these circumstances, we often suggest exploring PGT-A.
What exactly is PGT-A, you ask? Imagine a tiny, growing embryo. It should have 23 perfectly matched pairs of chromosomes, totalling 46, which is just right for a healthy development. Each chromosome is like a thread of inherited information—one thread from the sperm and one from the egg. Normally, these threads combine and copy as the embryo grows, maintaining the perfect number.
But sometimes, this delicate process encounters a hiccup. The sperm or egg may have an off-number—either too few or too many chromosomes. When these join, they create an embryo whose cells don't have the regular 46 chromosomes. This is what we call aneuploid. These embryos might not grow further, may not implant after IVF, or could result in a painful loss if they do implant. In rare cases, an embryo with an unusual number of chromosomes develops to term, leading to conditions like Down's syndrome (an extra chromosome 21) or Turner's syndrome (one less X chromosome in girls).
Step 1 - IVF
Embryos are produced through an IVF cycle.
Step 2 - Embryo biopsy
5-6 days after fertilisation, embryos should reach the blastocyst stage. Blastocysts contain approximately 100 to 200 cells arranged into an inner cell mass and an outer ring of cells called the trophectoderm.
The inner cell mass is made up of undifferentiated stem cells that will go on to form the foetus. The trophectoderm is a layer of cells that will become the placenta.
A few trophectoderm cells are carefully removed by our embryologists and sent to the genetics laboratory for assessment, while we freeze your embryos and keep them safe.
Step 3 - Embryo freezing
To freeze and thaw your embryos, a process called ‘vitrification’ is used. Vitrification involves much more rapid cooling than other less advanced methods of freezing, and it prevents ice crystals from forming.
This preserves the quality of the cells and improves the chances of success when they are thawed. Vitrification has greatly improved the success of embryo freezing and it’s now a very reliable practice.
Step 4 - PGT-A
Testing is carried out using cutting-edge technology to analyse the number of chromosomes present within the embryo’s cells.
Step 5 - Embryo transfer
Embryos that are identified as having the correct number of chromosomes and therefore most likely to result in a healthy baby, are selected for transfer. Alternatively, your embryos can be frozen for future use.
Benefits of PGT-A
PGT-A testing can help identify the embryo with the best chance of developing into a healthy baby. PGT-A testing can’t change the number of viable embryos available for transfer but, by transferring only those that have the usual number of chromosomes, the time taken to establish a pregnancy can be shorter and the misery of failed cycles and risks of miscarriage can be reduced.
Where patients have undergone multiple rounds of IVF and have no explanation for the treatment failure, PGT-A testing can sometimes provide answers and help with decisions about future treatment options.
Data from our partner clinic, Care Fertility (where the embryo testing is performed) shows that in the year to 30 September 2019 clinical pregnancy rate per embryo transferred across patients of all ages following PGT-A was 49%[1] compared with 38% in non PGT-A cycles.[2]
[1] Based on 573 single euploid embryo transfers resulting in 281 pregnancies with a foetal heartbeat
[2] Based on 2645 embryo transfers resulting in 1016 pregnancies with a foetal heartbeat
What are the risks of PGT-A and blastocyst biopsy
Although testing is generally very accurate, PGT-A testing may result in a false positive or false negative result in around 3% of cases. In the case of a false positive result, an embryo that may have implanted and developed may be discarded. In the case of a false negative result, an embryo with more or fewer than 46 chromosomes may be transferred.
It is very likely that following PGT-A testing there will be fewer embryos available for transfer or future use.
There is a small unquantified risk that removing cells from an embryo may affect development or cause changes during growth in the womb and lead to issues in later life.
Chromosome abnormalities can also arise spontaneously as embryos divide. Where this happens early in development, some cells of the embryo may be chromosomally normal and others abnormal. Depending on where these cells are in the embryo, the biopsy may take cells that are all abnormal, all normal or a mixture of the two. Embryos with both chromosomally normal and abnormal cells are known as mosaic and the presence of mosaicism can lead to false positive or false negative PGT-A results but this is identified in fewer than 9% of cases.
As with any treatment there can be financial and emotional costs where treatment including PGT-A is not successful
Recurrent Miscarriage and Implantation Failure
The information below information sets out how we investigate recurrent miscarriage or repeated treatment failure where a good quality embryo has failed to attach and implant into the uterus (known as implantation failure). You will also find explanations for some of the treatments that we can offer you if your fertility is affected by any of these scenarios.
Who can be helped by investigations and treatments for recurrent implantation failure and miscarriage?
At the Zita West Clinic, we think you might benefit from specialist investigations if you have
had two or more consecutive miscarriages or two or more failed IVF cycles (especially after transfer of an embryo known to have the usual number of chromosomes following PGT-A testing)
miscarried a baby where tissue analysis showed there were no chromosomal abnormalities
an existing autoimmune illness (rheumatoid arthritis, lupus, Crohn’s disease, thyroid illness or psoriasis for example)
had previous pregnancies where you had a small for dates baby (known as fetal growth restriction) or significant pre-eclampsia (high blood pressure in pregnancy).
What are the causes of recurrent implantation failure and miscarriage?
Sadly, there are likely to be many reasons why an embryo doesn’t attach in the uterus or miscarries in early pregnancy. Medical science has yet to help us fully understand all the possible reasons but in general terms miscarriage or implantation failure can arise either because the embryo is not viable or because the environment of the uterus isn’t as it should be.
The embryo
We do know from scientific evidence that genetic abnormalities in embryos increase with the age of the egg provider. It is also possible for a perfectly healthy person to have rearrangements in their chromosomes that don’t cause any problems for them, but cause serious genetic imbalances in embryos created with their eggs or sperm. Genetic abnormalities can lead to failed implantation and miscarriage.
The endometrium
The conditions in the uterus have to be just right for an embryo to implant.
There is a carefully coordinated interaction between an embryo and the endometrium at the time of embryo attachment. There is very limited time when the embryo is able to attach called the “window of implantation”. The embryo transfer procedure is carefully timed to make sure the embryo is in the uterus at the right time to implant but there are studies that suggest the window of implantation can be slightly earlier or later in some women. This asynchrony might be a factor in repeated implantation failure.
While it’s normal to have bacteria in the vagina and uterus, occasionally the levels and type of bacteria can change. Although this change doesn’t cause any outward signs of infection it can be associated with changes in the conditions inside the uterus (the uterine environment can become more acidic for example) and this can affect fertility. Sometimes even very low-grade infections in the uterus can affect the cells lining the uterus causing inflammation that may affect an embryos ability to implant.
Our bodies are usually protected from bacteria and viruses by our immune system which works by killing and removing cells that it recognises as invaders because of their different genetic code. When attacking invaders are detected by the immune system, chemical signals called cytokines are released that cause inflammation. It is believed that the immune response in the uterus is usually moderated to allow an embryo to implant and grow without being attacked by the immune system or triggering inflammation. Some scientists believe that in some cases of miscarriage, the mother’s immune system may fail to accept an embryo because it has a different genetic code and that having an illness caused by a more vigorous immune system than usual (known as an autoimmune illness) could be a risk factor in implantation failure or miscarriage.
Finally, the preparation of the uterus for implantation and support of the growing embryo is dependent on a good blood supply. Some studies have suggested that there is an increased risk of miscarriage where the woman carrying the pregnancy has a higher than usual risk of their blood clotting as small blood clots can restrict vital blood flow.
How are these possible causes of implantation failure or miscarriage investigated?
We do two stages of tests to investigate possible causes of implantation failure or miscarriage
Stage 1 tests rule out the more straightforward medical problems that can cause recurrent IVF failure or miscarriage.
The tests we recommend if you are planning to carry a pregnancy might include:
Thrombophilia screening to check whether you are at risk of your blood clotting more easily than it should. This screening looks at levels of anticardiolipin antibodies, antithrombin III, Factor V Leiden, activated protein C resistance, protein C, protein S, lupus anticoagulant, polymorphism of PAIP factor II and prothrombin.
Screening for auto-immune antibodies that might be present if your body is making antibodies against itself including anti-nuclear, thyroid peroxidise and anti-mitochondrial antibodies,
An Endometrial Receptivity Array test (ERA or ER Peak) to pinpoint the time when the lining of your uterus is most likely to be receptive to an implanting embryo (the window of implantation).
EMMA (Endometrial Microbiome Metagenomic Analysis) to check the microbiome of the womb to ensure that there is the correct balance of probiotic, or protective bacteria present.
ALICE (Analysis of Chronic Infective Endometritis) screening which is a more focused test than EMMA and looks specifically for bacteria that cause chronic, low grade infection of the womb lining (endometritis),
The tests we may recommend if you are providing eggs:
Karyotype screening for chromosome abnormalities or rearrangements (although such abnormalities are thought to cause fewer than 1% of cases of recurrent miscarriage)
The tests we may recommend if you are providing sperm:
Karyotype screening for chromosome abnormalities or rearrangements
CARE SOS screening to determine is the sperm is under significant oxidative stress that can lead to DNA fragmentation
Stage 2 tests are more in-depth investigations we may recommend if you are planning to carry a pregnancy. These tests include:
TH1/TH2 intracellular cytokine ratios. Cytokines are chemical messengers produced by immune cells. Cytokines produced by TH2 immune cells are thought to support pregnancy whereas the cytokines produced by TH1 immune cells may inhibit pregnancy. For successful pregnancy it has been suggested that the TH2 cytokines should be dominant and that If the TH1 cytokines are dominant this may impact adversely on pregnancy outcomes.
What treatments are available if the tests show something that might be affecting fertility?
We offer a range of treatment options and we specifically tailor to the findings of your own investigations.
Thrombophilia – if you are planning on carrying the pregnancy and any of your test results show you might be at increased risk of blood clotting (thrombophilia) we may recommend treatment with low dose aspirin or an anticoagulant (blood thinner) called heparin if you are planning to carry the pregnancy.
Immune abnormalities -the presence of auto-immune antibodies, antiphospholipid antibodies and/or positive lupus anticoagulant screening may be associated with an increased risk of thrombophilia and inflammatory immune response. If your test results show the presence of these autoantibodies and you are planning to carry the pregnancy, we may recommend treatment with heparin (to moderate blood clotting and the immune response) and steroid treatment to dampen the inflammatory response.
If level 2 specialist blood tests show an increased TH1:TH2, cytokine ratio cell numbers and/or activity, then we may recommend treatment with steroids, low dose aspirin, heparin and/or intravenous intralipid infusion.
ERA or ER Peak testing – if your test results suggest that the window of implantation is earlier or later than expected then embryo transfer can be timed to be in synchrony with your own window of implantation.
EMMA and ALICE screening – if these test results show the presence of bacteria that may make the uterus or endometrium a less than ideal environment then the screening also identifies which antibiotics and/or probiotics can be prescribed by your doctor to improve the balance of bacteria in your uterus.
Chromosomal abnormalities – if tests identify a chromosome imbalance or abnormality then we can offer treatment using pre-implantation genetic testing (known as PGT-A) to help us select only those embryos with the normal number of chromosomes for treatment.
DNA damage or oxidate stress in the sperm – if tests suggest there may be high levels of DNA damage or oxidative stress in sperm then we may suggest antioxidant supplements or the use of ICSI.
What are the costs?
You can find information about the costs of these therapies in the Zita West Clinic fees schedule. You should be aware that the tests and investigations can be expensive.
What are the risks of the treatments?
Intralipid, steroid and anticoagulant treatments can have side effects, some of which are serious. If you are considering using any of these therapies your doctor will make sure the medication or treatment is safe for you and explain the possible risks and/or side effects.
HFEA comment
Are the treatments safe and effective?
The independent regulator of fertility treatment, the Human Fertilisation and Embryology Authority (HFEA), has developed a ‘red-amber-green’ rating system for treatments that are optional extras in fertility treatment. They consider that the only way to be confident that a treatment is effective enough to be used routinely is to carry out a randomised controlled trial (RCT). In an RCT, patients are assigned randomly to two groups: a treatment group, given the new treatment and a control group, given either a of proven efficacy or placebo.
The HFEA has given reproductive immunology tests and treatments (the name given to treatment using intralipid and steroid) and ERA a red rating because it considers that there is no evidence these tests or treatment increase the overall chances of having a baby. We recommend that you read the information on the HFEA website before making a decision about having the tests and treatment outlined here.
