Infertility affects many people. Up to one in six couples have difficulties in conceiving and many seek medical advice and treatment. Some couples will need only advice or reassurance. Others may need drug therapy or surgery and some will need to be referred to a licensed clinic that specialises in assisted conception techniques.
There are many possible causes of infertility or sub fertility, in both men and women. There are also many possible treatments. These include:
- drug therapy to control ovulation if a woman is not producing eggs regularly;
- surgery to clear blocked or damaged Fallopian tubes;
- insemination using the husband or partner's sperm if there is a problem of sperm quality or if it is failing to reach the egg;
- insemination using donor sperm (Dl) if the husband or partner has no sperm or risks passing on an inheritable disease;
- IVF with the woman's own eggs where, for example, the woman's Fallopian tubes are severely damaged;
- IVF with donated eggs where the woman cannot produce eggs.
The kinds of things that may affect the outcome of infertility treatment are age, the cause of infertility and, with IVF, the quantity and quality of sperm. It is important that you understand fully the cause of infertility in your own case so that you can have reasonable expectations about how a particular treatment might help.
Intrauterine Insemination (IUI)
Intrauterine insemination (IUI) has a long history and is much less "hi-tech" than some other methods of assisted conception. In IUI, sperm is introduced into the woman's uterus (womb) at around the time of ovulation, with the aim of getting the sperm nearer to the egg.
The procedure, which used to be called artificial insemination (AI), is often combined with fertility drugs. IUI can help couples where the man has a low sperm count or poor motility (the ability of the sperm to move), as long as there are sufficient levels of healthy, motile sperm to make the treatment worthwhile. If not, IVF or ICSI will be more suitable. Different clinics use different criteria to decide whether the quality of sperm is sufficient for IUI.
Because sperm is placed directly inside the woman, IUI can also help couples who are unable to have intercourse because of disability, injury, or difficulties such as premature ejaculation.
It is also used for women with mild endometriosis, and is often used as the first line of assisted conception treatment for couples with "unexplained infertility". Women without a male partner may also want to have IUI using sperm donated through a clinic.
Donor Insemination (DI)
If a couple cannot conceive because of problems with the man's sperm, it may be suggested that they consider insemination using donated sperm, usually known as donor insemination (DI). Dl can also be used if the male partner carries an inherited disease which might be passed on to a child of the couple. DI involves the use of sperm from a donor who has undergone HIV and other health screening. This will involve sperm being quarantined for at least six months.
The sperm is placed in the woman's vagina, in the cervix (neck of the womb) or in the womb itself (known respectively as vaginal, cervical or intrauterine insemination). One or more such inseminations may be carried out around the time at which the woman's egg is released from her ovary.
Clinics can vary in the way they provide this treatment. Some suggest that you monitor your own menstrual cycle at home, to establish the best moment for insemination. Others may monitor your cycle by asking you to attend for a series of hormone tests or ultrasound scans to determine the best time for the insemination.
Alternatively the clinic may propose that you take drugs to control your cycle, so that they can fix the best time for insemination.
In Vitro Fertilisation (IVF)
IVF involves the collection of eggs and sperm which are mixed outside the woman's body in a culture dish or test tube. Any resulting embryos are left to grow for at least a day to check that they are developing normally and then up to two embryos are transferred into the woman's womb.
IVF treatment may be appropriate if, for example, a couple's infertility is caused by the woman having blocked Fallopian tubes or if the man has very few sperm.
Every month, several egg follicles develop in a woman's ovaries but normally only one of these follicles becomes fully mature and releases an egg into the woman's Fallopian tube for possible fertilisation. IVF involves retrieval of one or more eggs from the ovaries prior to release. This procedure is done under sedation or general anaesthetic.
Most IVF clinics usually recommend that the woman takes drugs which cause the ovaries to mature several eggs in one monthly cycle. This procedure is called stimulated IVF, and it increases the chances of later producing several embryos. Other clinics prefer not to stimulate the ovaries, but collect the one egg that is naturally produced. This is called natural cycle IVF.
After collection, the eggs are mixed with the man's sperm in a dish to be fertilised. They might then produce one or more embryos. The mixture is placed in an incubator while the fertilisation process takes place and later usually one embryo is placed in the woman's womb although sometimes two may be transferred depending on other circumstances like your age and number of cycles you've had previoulsy.
There are risks associated with stimulating ovulation using drugs. The main risks are over-stimulation of the ovaries (Ovarian Hyperstimulation Syndrome - OHSS).
The clinic will discuss with you the prospect of transferring one or two embryos and the pros and cons of using drugs to stimulate the ovaries. You should discuss the options with your consultant.
Intra Cytoplasmic Sperm Injection (ICSI)
Variations of IVF techniques such as ICSI are being developed and may be appropriate where the male partner has very few sperm. With ICSI, a single sperm is injected directly into the egg previously retrieved from the woman, if the egg fertilises, it can be transferred to the womb in the usual way.
This is a relatively new technique and you should ask the clinic for specific information about the costs and its live birth rate from this treatment.
IVF using donated eggs, sperm or embryos
IVF treatment may be available using donated sperm if the male partner is infertile, or donated eggs if, for example, the woman has no eggs. Donation might also be used if one of the couple is at risk of passing on a serious inherited disease.
IVF treatment using donated embryos may also be offered if both partners are infertile but the woman is able to carry a baby to full term.
Availability of these treatments will depend on whether the clinic has access to donated eggs and sperm and if it has embryo storage facilities. Egg donors are usually women who have completed their families and who wish to help others. They can be women who are undergoing sterilisation or who are themselves having IVF treatment.
Similar selection and screening criteria apply as for sperm donors, except that there is no six month storage period, as eggs cannot at present be safely frozen. Sperm donors are recruited and screened in the same way as for Dl.
Embryo freezing and storage
While many embryos may be produced during IVF treatment, the clinic is permitted to replace only up to two embryos in a woman's womb during any one monthly treatment cycle.
Most IVF clinics have storage facilities so that spare embryos can be frozen for use in a later treatment cycle if required. This may avoid the need for repeated drug stimulation, egg retrieval, sperm collection and fertilisation.
However, not all embryos survive freezing, and the live birth rate from frozen embryos is usually lower than from fresh embryo transfers. You should find out before you start IVF at a clinic whether embryo freezing and storage are available.
If you decide that any embryos are not needed for your own treatment, they can either be donated for the treatment of others or for research, or they can be allowed to perish. You have the choice.