Emotional responses vary but you will probably find it helpful to use the same strategies now that you have used to deal with other problems in your life.

The help that you gain can come from outside yourself: by reaching out to friends whom you know you can talk to and trust, by becoming involved in Genesis Support Group (WA Self Help Group) by talking to professionals, by reading books.

But perhaps the most useful help you can get is the help that comes from within yourself. Try to maintain your sense of humour and remember that you are a worthwhile person. Value and care for yourself, whatever happens – whether you are able to have a baby or not.

The present may seem black but you will recover. You will find that you do have the capacity to survive this experience. At times in the future the feelings of deep sadness and regret may return. This is to be expected in a sensitive, feeling person. However, it will no longer be the central focus of your life.

The emotional responses to the crisis of infertility are not however only the result of social pressures; they may also flow from your own life experience. This will vary depending upon your past and present relationships, your individual personality and many other factors such as your expectations of adult life, your cultural background and religious faith.

Some of the wide range of emotions you may experience with the discovery that you have fertility problems are expressed very clearly in comments like these:

EMOTIONAL RESPONSES TO INFERTILITY
What sorts of emotions then, are you likely to experience when you discover that you have a fertility problem? One of the emotions that may confront you is a strong sense of surprise. Infertility, as we said earlier, may have been something you never even thought about.

Because of this it may take you quite a while to fully realise its implications. One way you may attempt to deal with this crisis is to convince yourself that for you it is not a big problem. Often the pain of this experience is so intense that you may not be able to cope with it all at once.

Thus you may deny that you feel upset by your fertility problems; and you may even deny that you ever wanted children in the first place. While these emotions can cause you to delay seeking assistance, they may also be useful in that they help you to gradually realise what the experience of infertility will mean to you.

Also, you may find yourself feeling angry and depressed. These emotions may be directed inwards upon yourself, or they may be directed at your partner, or the doctors, nurses, scientists, social workers, family or friends.

At the root of these feelings could be the idea that you are less than a whole human being, and that you have in some way failed – that you have let yourself, your partner or your family down. For women who expected motherhood to play a central role in their lives, this experience can be especially devastating.

Sometimes it can seem as though your world is crumbling and that nothing else matters. It is essential here to remember that there are other parts of your life that are important to hold onto, such as your work, your hobbies and your own special interests and abilities.

Feeling that you are not living up to the expectations of your partner, feeling that you are letting him or her down, can place great stress upon your relationship. Infertility is still a subject that your family and friends are likely to feel uncomfortable with, so you may have very few people with whom you can discuss your feelings. This problem can make you feel even more isolated and make the whole experience more difficult to deal with.

When you discover that you have fertility problems, often the main focus of your relationship as a couple can become the desire to conceive a child.

As one woman described it:

Because of this obsession, the pleasurable aspects of sex in your relationship can be lost. Intercourse can begin to seem pointless and you may feel useless and inadequate as a sexual partner. The stresses created by this perceived loss of purpose in your relationship, are often shown as resentment and disappointment and overcoming them may require a lot of effort from both you and your partner.

You will need to acknowledge that although you make up a couple, you are also individuals with separate feelings which need to be considered, however different they may be.

Finally, one of the most important and complex aspects of the experience of infertility is the sense of sadness and loss it creates. What you are mourning is the ABSENCE of experience.

It is important to stress here that not everyone experiences all these losses, and your experience of them may differ greatly from the experiences of others.

Some of the losses associated with infertility are even more difficult to define. Waiting for treatment and the continual hope that “this will be the time” can leave your emotions painfully suspended, creating a continual “hoping against hope” attitude. The nature of infertility is such that you may never know definitely whether you are able to conceive or what is causing the problem. Your grief therefore has nothing to focus on and this frustration can place great strain upon your relationship.

Infertility therefore is an experience that continually fluctuates in intensity and directions, so that at different times you may have different needs and experience different emotions. There are no set “stages” in this experience, and while at one time your emotions can be mystifying and frighteningly intense, at another you may simply feel numb.

There may be moments when being infertile dictates every facet of your life, whilst at other times you may act to change the direction of your life. The way you learn to deal with the experience of infertility will also be different at different times. One day a particular strategy may help you a lot, but later on you may find it useless. At times you may find the pain you experience very destructive, but at others you may find it a useful motivating force in your life.

It is important to acknowledge that emotional responses to infertility vary greatly, as do people’s methods of coping with them. Each person has to find their own way of coping with their situation, and sometimes might need help to do this.

EMOTIONAL RESPONSES TO INFERTILITY

Our trained staff at the Centre for Assisted Reproduction Private Limited are always willing to listen to you and talk to you.

Men and women who are either under or over their ideal weight have a higher risk of experiencing infertility. The body mass index (BMI) is the routine measure used to assess whether a person is under or over their ideal weight.

BMI is calculated as weight (in kilograms) divided by height (in metres) squared. A BMI of less than or greater than the desired weight (see below)

BMI Description
<20 Underweight
20-25 Desired Weight
25-30 Overweight
>30 Obese

can lead to fertility problems. Being under or over the desired weight for both males and females can disrupt the hormonal balance that is necessary for normal egg and sperm production.

The impact of weight on female reproduction

Research from as early as the 1930s demonstrated a link between excess body weight and polycystic ovary syndrome (PCOS). Excess body weight can lead to menstrual cycle irregularity, infertility, an increased risk of miscarriage and difficulty achieving a good response to assisted reproductive procedures.

It also appears that excess weight as a teenager has a significant effect on subsequent fertility. This was the conclusion of a number of large research studies from the Netherlands, Japan, the United Kingdom and Australia. Conversely, being under weight can also lead to disruptions in the normal menstrual cycle and subsequent fertility problems.

The effect of weight on success of assisted reproductive procedures

Recent research has shown that a lowered or elevated BMI significantly reduces the chance of achieving a pregnancy after in vitro fertilization and embryo transfer (IVF-ET). In this study of nearly 400 couples, 21.8% of the female partners had a BMI below the normal range and 22.3% were above the normal range.

The results suggest that being either underweight or over weight can have a negative effect on IVF outcome leading to a decreased chance of pregnancy from these procedures.

The effect of weight loss on fertility

In the 1950s it was shown that reducing weight in overweight women could restore menstrual cycle regularity. This study has since been confirmed by studies from Italy, the United Kingdom and Australia which demonstrated that a weight reduction of 5% is enough to restore normal menstrual cycle function in up to 60% of overweight women.

Furthermore, several studies have shown that if an overweight female partner reduces her weight before undergoing IVF the chance of becoming pregnant is dramatically improved.

Obesity and pregnancy outcome

Many articles report that obesity has a significant negative impact on the out come of pregnancy and the offspring. Obese women who become pregnant have an increased risk of hypertension; pregnancy related diabetes, urinary infections Caesarian sections and assisted delivery.

In addition, the miscarriage rate was reported to be much higher in overweight women. Other studies have shown an increased incidence of Down’s syndrome in the children born from overweight mothers.

Does body weight effect male fertility?

The potential for obese males to have a reduced sperm count does exist. For example, obesity can lower levels of the male hormone testosterone (which is directly linked to sperm count) that is converted to estrogen by fat cells.

Obese males can also develop an “apron” of fat around the genital area heating up the testicles and potentially reducing sperm numbers. Obesity can often lead to poor health in general but no studies to date have shown that obese men have reduced sperm counts.

Folate is a soluble B vitamin found naturally in foods such as citrus fruits, green leafy vegetables and pulses. The synthetic form, folic acid, can be taken in dietary supplements. The benefits for women of high folate levels are well established in preventing birth defects, but this is the first time a reproductive benefit for men has been shown. The normal recommended daily allowance (RDA) of folate for humans is 200 micrograms, and 400 micrograms for women trying to conceive and during pregnancy.

The study, published in the journal Human Reproduction, looked at samples from 89 healthy, non-smoking men aged between 22 and 80, and information about their diet and supplementary intake. They found that men who ingested high levels of folate – between 722 and 1150 micrograms per day – had 20-30 per cent lower levels of abnormal sperm than men with low folate intake.

The researchers were looking at forms of ‘aneuploidy’ in the sperm. Aneuploidy is an abnormal number of chromosomes in cells. If these abnormal sperm fertilise an egg, the resulting fetus can have the wrong number of chromosomes, something that can lead to chromosomal disorders such as Down’s syndrome. Other risk factors also include miscarriage during pregnancy.

The researchers targeted specific chromosomes – chromosomes 21, X and Y – as these are associated with the common types of aneuploidy in live births.

Brenda Eskenazi, professor of epidemiology and maternal and child health at UC Berkeley’s School of Public Health, was the co-principal investigator of the study. She says: ‘in previous studies, we and others have shown that paternal micronutrient intake may contribute to successful conceptions by improving the quality of the sperm. This study is the first to suggest that paternal diet may play a role after conception in the development of healthy offspring’.

The scientists warn that this is not conclusive evidence yet, and both men and women should take a serious look at their diet and lifestyle when trying to conceive. Smoking, drinking excessively and unbalanced diets are highly likely to affect fertility.

In the US, folic acid has been added to breads, flour, cereals and other grain products since 1998 to ensure women get their RDA of folate. A decision on whether folic acid should be added to bread and flour in the UK is due next year.

HOW DOES ENDOMETRIOSIS OCCUR?

The exact causes of endometriosis are still not fully understood. It is believed that endometriosis occurs as a result of normal tissue from the uterus escaping into the fallopian tube and out into the pelvic area at the time of menstruation (“retrograde menstruation“). These tissue fragments are then thought to implant and grow onto the surrounding pelvic tissue and, sometimes, organs.

Because these fragments are made of the same tissue as the lining of the uterus, they too respond to the hormonal changes that occur during the menstrual cycle and, therefore, “bleed”. Whereas menstrual blood can escape from the body, this has no exit and, as a result, the areas surrounding the implants of tissue become irritated or inflamed.

Some of the blood and tissue may form into cysts (fluid filled lumps) – sometimes known as “chocolate” cysts, due to the colour similarity. The continual release of blood contributes to the formation of scar tissue. If the endometriosis is severe, bands of this scarred tissue (“adhesions”) may develop.

EFFECTS OF ENDOMETRIOSIS ON FERTILITY

Endometriosis and infertility are definitely related. And although some women with endometriosis remain fertile, endometriosis is regarded as one of the most common factors associating with infertility in women over 25 years. It has been further estimated that between a third and a half of all women with infertility problems have some degree of endometriosis.

Why it causes infertility is unclear. For women with severe endometriosis, their fallopian tubes may be so damaged that it is impossible for the egg to reach the sperm. Other women may have “chocolate cysts” on their ovaries which impair ovulation. But even where it is mild or where the endometriosis is not found on the tubes or ovaries, women can remain infertile.

ENDOMETRIOSIS

SYMPTOMS OF ENDOMETRIOSIS

Pain is the major symptom, though its intensity may vary. It may be experienced as a sharp stabbing pain, a constant or intermittent dull ache, or as a severe cramping pain.

This pain may be felt:

With periods (mild, moderate or severe pain);

• during ovulation (mild, moderate or severe pain midway between periods).
• in the bowel during menstruation, or bowel movements or when passing wind;
• during or after sexual intercourse

Other symptoms may include:
• infertility;
• diarrhoea or constipation
• heavy or irregular bleeding (sometimes involving the loss of large clots of blood or tissue)
• pre-menstrual tension

The severity of your symptoms has little to do with the extent of your endometriosis. Some women may have severe pain from just a slight build-up of tissue, whereas other women may have only the mildest symptoms despite an extensive build-up of tissue.

DIAGNOSIS

The presence of endometriosis may be diagnosed at the initial consultation and examination, however, a firm diagnosis can be made when the endometriosis is actually seen, using a surgical procedure known as a laparoscopy. This enables the doctor to view the ovaries, fallopian tubes, uterus and other pelvic organs.

TREATMENT

Options for treatment may include no treatment at all (if the symptoms are tolerable), drug therapy or surgery.

Drug Therapy

Drug therapy is used to suppress ovulation and, therefore, menstruation. Some of the drugs used are the oral contraceptive pill, progesterones (which cause a pseudo-pregnancy), Duphaston (which causes a pseudo-menopause), Decapeptyl, Luprolide, Danazol, Synarel and Zoladex. There is also a new three monthly injectable drug. These drugs are not always effective.

These medications are usually taken for 6 months, depending on the severity of the condition. These synthetic hormones suppress the function of the ovaries by acting on the pituitary so that hormones necessary for ovulation are not produced.

By keeping a woman free of menstruation (“pseudo-menopause”) the endometrial tissue does not have a chance to bleed, thus enabling the inflamed areas to heal.

Possible side effects include weight gain of 1-4kgs, some decrease in breast size, a tendency towards acne, occasional increase in body hair, oily skin and symptoms of the menopause such as hot flushes and nausea. Symptoms should be reversible after the drug is discontinued. Normal ovulation and ovarian functions should return to normal following cessation of medication.

This treatment gives some women immediate and substantial relief from symptoms. Not every woman suffers from these side effects but for others the side effects can be worse than the original symptoms.

2. Surgery

Where more severe forms of endometriosis exit, particularly where “chocolate cyst” formation in the ovary and tubal adhesions prevent normal egg transportation, surgery is indicated to restore normal anatomy as far as possible.

Surgical procedures may range from simple cautery of endometriosis spots to extensive removal of scar tissue and microsurgery. Surgical use of laser technology is also becoming more frequent.

A combination of surgical treatment and medication has been used with impressive results – up to 79% pregnancy rate in reported series

FACT: There is rarely a quick or simple answer to infertility problems. Assessment and treatment procedures usually take considerable time.

FEELINGS: You can help by not forcing the issue with questions such as “When are you going to have a baby?” The person/s may not know if they can have a child, much less when it will be. You can help by allowing the person/s to decide if and when they want to talk about it.

FACT: There is a huge range of factors that can contribute to infertility, and treatments vary accordingly.

FEELINGS: Each couple’s experience of infertility is very real for them and cannot be compared with others as being more or less serious. The wish to have a baby, and the fear that it might not be possible, is of paramount importance. You can help by acknowledging the person/s” feelings for what they are, without comparing them with other situations you may know about.

FACT: 90% of infertility has a known medical cause.

FEELINGS: It is not helpful or medically sound to offer advice such as “relax”, “take a holiday”, etc. You can help by not giving misguided, albeit well intended, advice, and by helping to break down the myths that surround fertility difficulties.

FACT: Some people consider infertility to be a private concern. Yet others find comfort in being able to share it with close friends and family members. It is normal for people to feel sad, angry or depressed at times.

FEELINGS: You can help by respecting their need for privacy or, by offering support if there is a need to talk about it. Be prepared to accept the expression of feelings such as anger, sadness and depression.

FACT: Those experiencing infertility often feel inadequate because they have no control over their reproductive system.

FEELINGS: You can provide support by recognising and helping the person/s to see the strengths, qualities and achievements in other areas of their lives.

FACT: Some people experience fertility problems after having one child. This is devastating and frustrating for those who feel their families are incomplete.

FEELINGS: You can offer support by understanding what this means to them. Avoid comments such as “You’re lucky to have a child at all”.

FACT: Some women experience recurrent miscarriage.

FEELINGS: You can help by understanding the mixed feelings of hope, anxiety, guilt and despair. Do not offer false hope or be unduly pessimistic. The woman has enough feelings of her own to cope with, and miscarriage always represents a very real loss. Don’t forget, too, that the father has also experienced this loss. He also needs your support and understanding.

Your encouragement, understanding and support for your infertile friend or relative can help to guide them on their long road to resolving their infertility. This support is crucial to their emotional healing. Should you require any further information please feel free to contact our staff at CAREPL and if necessary visit and talk to us.

Large research studies have been undertaken in Europe and the USA to ascertain whether coffee consumption is related to infertility. The results however are conflicting and difficult to interpret.

The authors of one study concluded that a high level of coffee consumption is associated with an increased risk of delayed conception. One study found that as little as one cup of coffee per day was enough to increase the time taken to get pregnant.

Another study of nearly 3000 women found that coffee consumption was not associated with infertility. Other studies have shown 2-3 cups of coffee per day is associated with an increased risk of miscarriage during early pregnancy.

Very little is known about the impact of coffee consumption on semen quality, although in vitro studies have demonstrated that caffeine can enhance sperm motility. There is little evidence that coffee can improve the fertilizing capacity of sperm. In men who drink coffee and smoke, deleterious effects on sperm motility and vitality have been observed.

Recreational Drugs

Use of recreational drugs such as cocaine and marijuana may cause fertility problems. Research studies suggest that cocaine use within 2 years of an initial semen analysis is associated with low sperm counts. The use of cocaine for 5 or more years was found to be much more common in men with poor sperm motility. The authors of this report conclude that cocaine should now be considered a risk factor in male sub-fertility.

Cocaine use by men has also been linked to abnormal development in subsequent offspring. The cocaine is thought to bind to sperm and penetrate the egg at fertilization, resulting in abnormalities in the embryo. Cocaine use by women has been associated with infertility due to abnormalities of the fallopian tubes.

Animal studies have shown that moderate marijuana use stops ovulation by having a toxic effect on the developing egg. A study exploring marijuana usage and the time taken to conceive found that women who smoked marijuana had a slightly elevated risk of infertility due to ovulation problems.

Excessive Exercise

Proper exercise is important to maintain a desired weight and general level of fitness. Excessive exercise however, can lead to reduced fertility in both males and females. In men, excessive exercise has been associated with reduced sperm production.

In women, too much high intensity exercise can lead to the cessation of ovulation. It should be noted that to cause a reduction in fertility the exercise must be extensive. For most couples moderate exercise will not affect their fertility.

How exercise affects fertility is not clear. Is it due to the physical exercise itself, or the energy deficit that occurs when energy expenditure (exercise) is greater than supply (food intake)? To answer this question a comprehensive research study was undertaken by researchers from the department of Anthropology at Harvard University.

These researchers investigated 20 fertile women in Poland who worked hard but had an adequate food supply. The conclusion drawn from this study was that exercise induced ovulation problems are likely to be due to energy expended during physical work or exercise itself rather than a deficit in energy supplies.

Reproductive disorders that result from excessive exercise can usually be reversed by making adjustments to the amount and type of exercise undertaken.

Occupational Risks

The idea that certain occupations may put workers at risk of reproductive disorders is not new. In 1860 a French scientist noted that wives of lead workers were less likely to become pregnant, and if they were pregnant, more likely to miscarry. The general health effects of lead exposure are now well documented and it has been shown to decrease sperm production in both animals and humans.

Other occupational sources that can reduce sperm quality include heat, pesticides, hydrocarbons, ionizing radiation and estrogens. A study from Australia identified occupations at risk to include transport workers, building industry workers, motor mechanics, farmers and miners.

Women are also at increased risk of infertility from occupation exposures. A study from the USA examined occupational exposures and risk of female infertility and found that women who were exposed in the workplace to chemical dusts, volatile organic solvents, pesticides and video display terminals had an increased risk of infertility.

Interestingly, these authors found that video display terminal exposure was more likely to occur in women diagnosed with endometriosis and cervical problems.

Alcohol

Alcohol consumption is widespread and believed to be increasing in many countries throughout the world. Research on animals has shown that alcohol can decrease steroid hormone production, inhibit ovulation, and disrupt sperm transport through the fallopian tubes.

Does alcohol have similar affects in humans? High and frequent alcohol consumption can contribute to menstrual disorders and an increase in the percentage of abnormal sperm. Pregnant women with excessive alcohol intake have a higher incidence of spontaneous abortion, placental abruptions, pre-term delivery, stillbirth and fetal alcohol syndrome.

Whether moderate alcohol consumption has such detrimental effects on reproductive health is less clear. A recent research paper published in the British Medical Journal suggests that it does. The researchers reported that the probability of conceiving decreased with increasing alcohol consumption, even among women who were drinking less than five alcoholic drinks in a week.

In another study moderate alcohol intake had no effect on the sperm count or percentage of normal sperm. A study by Professor Robert Winston from Hammersmith Hospital in the United Kingdom found that a glass of wine given to patients at the time of embryo transfer improved the chances of pregnancy. Interestingly, the authors observed that red wine was more effective.

These latter studies suggest that low alcohol intake is not likely to adversely effect fertility. However, for couples trying to conceive and pregnant women, avoiding high and consistent alcohol intake is recommended. Couples with a high alcohol intake who are considering assisted reproduction are advised to seek counselling before commencing treatment.

Smoking

The World Health Organization estimates that approximately one-third of the world population over 15 years of age smokes, even though it is well known that the constituents of cigarettes can cause considerable side effects that are detrimental to general health. Smoking can also adversely affect reproductive health. Recent research suggests that smoking can have harmful effects on both male and female fertility.

These studies have shown that smoking can reduce the number of sperm in an ejaculate and cause DNA damage to developing sperm cells. In one study, smokers were reported to have a reduction in sperm count of 13 to 17% when compared to non-smokers.

A small study tracking the sperm count of three smokers 5 to 15 months after they had stopped smoking reported that sperm counts increased by at least 50%, suggesting that any reduction in sperm count is potentially reversible. A recent study showed that germinal cells in the testes are vulnerable to genetic damage. It is also evident that smoking induced sperm DNA damage can be transmitted to the embryo and subsequent offspring.

When examining pre-implantation embryos, researchers found that the altered DNA from the sperm was present in the embryo. Altered sperm DNA from smoking fathers was also associated with an increased risk of childhood cancers.

The evidence that smoking can be detrimental to female fertility is controversial. One study showed that smokers were 3-4 times more likely to take longer than a year to conceive than non-smokers. The chemical components of cigarettes have been isolated in the fluid surrounding developing oocytes (eggs) and smoking has been shown to cause DNA damage during oocyte cell division.

However, unlike sperm, oocytes have the capacity to repair DNA damage before fertilization occurs.

Can smoking influence the clinical outcomes of assisted reproductive technologies such as IVF? It has been estimated that approximately 55% of couples undergoing IVF-embryo transfer are smokers, suggesting that smoking is common among couples seeking treatment for infertility.

A number of studies have examined female smoking and clinical outcome after IVF-embryo transfer but the results are not conclusive. They do suggest however, that women who smoke during treatment produce fewer oocytes and have increased rates of abortion. It was reported in one study that 11-30 cigarettes per day resulted in a 17% reduction in oocyte number.

It should be noted that this result has not been consistently demonstrated. The relationship between smoking and spontaneous abortion has been examined by several researchers. The evidence presented by these researchers suggests that there is a small dose related increase in the rate of spontaneous abortion in women who smoke.

Whether paternal smoking effects the success of IVF-embryo transfer is also controversial. Researchers report that reduced pregnancy rates are associated with male smoking and with increased age of the smoking male.

Although the research to date is inconclusive, the evidence presented suggests that not smoking during IVF-embryo transfer procedures may be beneficial to achieve the desired outcome.

‘A healthy diet is not only a good way of avoiding illness, but improves the quality of semen’ said Professor Jaime Mendiola, the leading researcher. ‘We saw that, among couples with fertility problems coming to the [fertility] clinics, men with good semen quality ate more vegetables and fruit, which means more vitamins, folic acid and fibre, and fewer proteins and fats.’

The study, undertaken at the University of Murcia in Spain, was prompted by the gradual decline in sperm counts across Europe in the last few decades. Male patients at two Spanish fertility clinics took part, and scientists concentrated on the possibility that exposure to contaminants in the workplace and diet might be reducing chances of successful conception. They hypothesised that antioxidants could potentially improve sperm concentration and motility by reducing or slowing the oxidation of other molecules which harms sperm.

Sixty-one men with fertility problems were enrolled into the study, 30 of whom had problems specifically with sperm count. Interviews with the participants showed that those with good sperm quality ate significantly more fruit and vegetables than those whose diets were rich in meat and full-fat dairy products.

‘People who eat more fruits and vegetables are ingesting more antioxidants, and this is the important point’ said Professor Mendiola. In his next study, he will investigate whether there is a difference in sperm count between men who get their antioxidants via food or from vitamin supplements.

1. DISAPPOINTMENT

Infertility itself creates a feeling of intense hurt and disappointment. The opportunity of an ART treatment and thus the possibility of a pregnancy offers hope. However, the intensity of effort put in undergoing ART procedures is more than likely to be unrewarded in each cycle (otherwise the pregnancy rate would be more than 50%).

Success is achievable for most couples, as long as a number of attempts are tried. It is also likely that your parents, relations or friends will not appreciate what you have been through. They cannot really know. You may feel lonely yet become irritated by sympathy; angry, but not sure who or what with or why.

Do not be afraid or ashamed to ask for help. The CAREPL Counsellor is available for everyone to talk to.

2. MULTIPLE PREGNANCY

There is an increased pregnancy rate with an increase in the number of oocytes or embryos replaced but there is also an increased risk of multiple pregnancies.

One or two oocytes or embryos are currently replaced but, depending upon age, cause of infertility and previous outcomes three may be replaced.

This will be discussed with you before the oocytes or embryos are replaced.

With two embryos or two oocytes replaced the chances of twins are about one in five.
There are some possible disadvantages in multiple pregnancies.

• Medical (Maternal)

Obstetrically, carrying two babies places greater pressures on the pregnant women. There is an increased risk of miscarriage, obstetrical complications, premature deliveries and birth complications. Please discuss these with your gynaecologist.

• Medical (Babies)

Babies born as one of multiple birth have a greater risk of prematurity which may or may not then require neonatal intensive care. These babies are also at greater risk of cerebral palsy although delivery methods may contribute to this. Please discuss this further with your obstetrician.

• Social (Babies)

Babies born as one of a multiple need to compete for the attention and care provided by the parents. This may cause greater social problems in due course. Please discuss this with your gynaecologist.

3. ECTOPIC PREGNANCY

(i.e. implanting, and growing in the Fallopian tube and not in the uterus.)

It is easy to understand that this can happen in GIFT procedures but it may not be realised that placing embryos into the uterine cavity can also result in this situation. The embryo may frequently transfer to the Fallopian tubes: in the great majority returning normally to the uterus. Some embryos, however, may stay and implant “ectopically”.

A tubal pregnancy can grow, rupture and lead to a surgical emergency. If recognised early measures can be taken to avoid such emergency situations. It is important that Concept’s screening procedures be followed to ensure that no patient suffer from an unrecognised ectopic pregnancy.

• A patient diagnosed as pregnant following IVF or GIFT should have an ultrasound carried out at such time that an intra-uterine pregnancy can be identified. This is possible from three weeks after ovulation or when the QHCG level reaches 3000 units or more.

• That patients assumed “not pregnant” have this confirmed by a negative QHCG at two weeks (14 days) after ovulation. A “period” can occur with an ectopic pregnancy and is not sufficient reasurrance.

D) LABORATORY MATERIALS

1. SPERM TREATMENTS

In some cases where reduced sperm motility or numbers indicate that normal fertilisation rates might not be attainable, the use of a stimulant on the sperm will be recommended.

This stimulant will be Pentoxyfilline. Both these agents act by removing some of the excess oxygen compounds from the sperm and eliminating some of the damaging effects of these compounds.

The result is that sperm are more capable of swimming faster and have an increased fertilizing potential. Some other chemical agents are used to improve the sperm recruitment procedures. These include Percoll, Nycodens and Isolate.

These agents have been in use routinely, to improve the fertilizing capacity of sperm, for a number of years.
While there has been no evidence, to date, that these agents have any damaging effect on the developing embryo or baby, there is no proof that this cannot occur.

None of these agents were developed or registered for these specific uses but have been used in these ART treatments since the early 1980’s.

If you have any concerns over the use of any of these agents please discuss these with our Embryologist.

2. CULTURE MEDIUM

The Earles and T6 culture fluids for A.R.T. procedures utilise inert salt solutions.

A number of other materials including but not limited to such products as Propylene Glycol, Hepes and D.M.S.O. are also used in the culture and in the freezing of sperm and embryos. None of these agents were developed or registered for the specific uses but have been used in ART culture treatments since the early 1980’s.

Penicillin and Streptomycin are also included in the culture medium but in such minute quantities that even women who have penicillin allergies have not noticed any effects at CAREPL in the past seventeen years. Some other human blood products may be used and although they are made from plasma which has been screened or tested for known transmissible agents such as HIV (AIDS), hepatitis B and hepatitis C, there may be possible contamination with these or other unknown agents.

Chemical processing and virus inactivation stages included in the manufacture of these products are believed to render them safe from the risk of infection. Nevertheless the possibility of transmitting these agents must always be considered.

If you have any concerns over the use of any of these agents please discuss these with our embryologist.

It is neither possible nor useful to list all the possible reactions to medication. All drugs produce some side effects. These can be one or more of the following;

• Allergic reactions: These are bizarre responses peculiar to some individuals and not to others (eg. Penicillin can produce lumpy rashes or sudden fluid retention and, if this occurs within the larynx, some obstruction to breathing is possible).

• Exaggerated side effects: These are the effects of medication which in some degree are common to many patients taking drugs but some people have an exaggerated reaction (eg. Pethidine produces relief of pain but commonly “queasiness” or light headed feelings).

The specific medications which are used in ART are as follows:

1) LUCRIN/SYNAREL

This medication is used to suppress the natural menstrual cycle to allow greater control over the response by the ovaries to gonadotrophins eg. Menogon/Puregon and Gonal F.

It will produce similar effects to the menopause. It does not produce an early menopause. The main side effects are hot flushes and mood swings.

Stopping the drug will allow the pituitary to recover (similar to the effect of oral contraceptives). Hence the normal menstrual cycle may be delayed.

2) GONADOTROPHIN (PUREGON/GONAL F/HUMEGON)

These are the injectable drugs which directly stimulate the ovaries to produce more oocytes (eggs). The side effects are very similar to the menopause since these medications are exactly the same hormones as menopausal women have in their own bodies.

Patients may notice weariness, mood changes, hot flushes, nausea and headaches. These are temporary and cease as soon as the medications are stopped.

As the ovaries will swell to accommodate the follicles, some patients may notice an increased pelvic pressure. If the ovaries are bound down by adhesions the pressure may be felt as pain.

This pressure may continue into the second half of the cycle (luteal phase) and if pregnant, for up to three (3) months.

Very rarely, the ovary may rotate and twist or may bleed. These may produce severe pelvic pain and lead to a requirement for further surgery.

3) HUMAN CHORIONIC GONADOTROPHIN (HCG/PROFASI/PREGNYL).

This medication causes the final maturing of the oocyte before aspiration. It may be a slightly more uncomfortable injection than the others.

4) CLOMIPHENE (CLOMID/SEROPHENE)

This oral drug is used to stimulate the pituitary to stimulate the production of extra oocytes.
Occasionally side effects like headache, weariness, occasional visual disturbance and hot flushes may be noticed after a few days on this drug. These cease as soon as patients stop taking it.

Some patients who have used Clomid have suffered breast and ovarian cancers in later life but there is no proven association between the use of Clomid and cancer. (*NOTE: women who delay child bearing until later in life or those who do not have children also have a higher incidence of breast and ovarian cancer in later life and Clomid users are in these groups).

5) FOLIC ACID

A deficiency of this vitamin may be responsible for neural tube defects (eg. spina bifida). All CAREPL patients are advised to supplement their diet with folic acid before ART treatment.

6) DOXYCYCLINE

CAREPL believes that the use of the tetracycline drug, doxycycline will be of benefit in the following situations:

a) In reducing the chance of pelvic infection during oocyte aspiration.

b) Protecting the embryo from cervical or vaginal bacteria after embryo transfer.

c) Protecting the embryo from bacteria in the semen sample during fertilisation.

The side effects of doxycycline may occasionally be:

a) nausea, vomiting or diarrhoea

b) skin rashes, including photo sensitivity to sunlight, ie. making some areas of skin more sensitive to sunlight.

c) Increased chances of vaginal thrush

Women who are susceptible to thrush should use anti-thrush medication at the same time. Patients with side effects should stop the drug and contact the Co-ordinator and their doctor.

OVARIAN HYPERSTIMULATION SYNDROME (OHSS)

What is it?

This is a specific problem which occurs in about 1% – 2% of patients who undergo super-ovulation induction. It is impossible to predict which patients may suffer from it before Assisted Reproductive Technology treatments commence.

During the treatment it is more likely to occur in those producing large numbers of follicles and high hormone levels. It does NOT occur if the final HCG injection is not given.

Essentially, fluid from the blood stream leaks into the abdominal cavity causing it to swell noticeably and leaving the blood more concentrated and more viscous. Mild cases of OHSS may pass unnoticed.
The consequences of severe OHSS can be breathing difficulties, temporary kidney “shut-down”, and some arterial and venous thrombosis.

Rarely extensive thrombosis could cause interference with blood supply to parts of the brain or to other organs. Death due to OHSS whilst very rare, is possible.

Patients who suffer severe OHSS must be hospitalised and treated. This treatment would involve the infusion of intravenous fluids and the fluid in the abdomen may need draining off.

OHSS always disappears in a few days unless a pregnancy occurs. In early pregnancy the problem may last weeks and require prolonged hospitalisation.

PREVENTION OF OHSS

All patients using HMG or Puregon will require close monitoring using blood tests and ultrasound scanning of the ovaries to ensure the ovaries do not over- respond to the drugs.

Patients are generally monitored daily and those who have oestradiol (E2) levels approaching 12,000pm/L are considered to be getting close to the risk level. If this occurs, the options are as follows:

1) To cancel the cycle
2) To collect and fertilise the oocytes and then freeze the embryos (ie. avoiding pregnancy in that cycle).

These will be discussed with you should this situation arise.