Fertility Treatment Guide

Fertility treatment, or assisted conception, are the medical terms for several different procedures which can help a patient become pregnant. If patients are struggling to conceive naturally, having fertility treatment can increase their chance of becoming pregnant.

The exact type of treatment that is most suitable for patients depends on several factors, including why they are struggling to conceive. Some of the most common causes of sub-fertility and infertility are listed below. Each procedure has different risks and success rates, so it is important that patients fully understand their options before making a decision.

What causes infertility?

Infertility has a range of different causes depending on the patient and their biological sex. However, the root of infertility helps the surgeon decide which treatment is best for each patient.

Female causes of infertility include:

• Ovulation problems (e.g. polycystic ovary syndrome or premature ovarian failure).
• Internal scarring from previous pelvic surgery or pelvic inflammatory disease.
• Fibroids, which can prevent implantation or block the fallopian tubes.
• Problems with cervical mucus.
• Medical conditions such as endometriosis, thyroid problems or eating disorders.
• A previous sterilisation procedure – if you have had your “tubes tied”.
• Certain medications.

Male causes of infertility include:

• Low sperm count
• Unusually shaped or slow-moving sperm
• Infections of the testicles
• Previous testicular surgery
• Congenital problems with the testicles
• Undescended testicles
• A previous sterilisation procedure (vasectomy)
• Low testosterone levels
• Ejaculation problems
• Certain medications

If an identifiable cause is present, steps to cure or improve are the initial steps taken for fertility treatment. However, in some people struggling to conceive, there is no apparent cause. If this is the case, the doctor may write that the patient has infertility for an unknown reason. For these people, in vitro fertilisation (IVF) is generally the best type of fertility treatment.

What types of fertility treatment are available?

Fertility Medications

Medications to improve fertility are usually suitable for women who have problems ovulating, including those with conditions such as Polycystic Ovary Syndrome (PCOS).

The common medications are:

• Clomifene
• Metformin
• Gonadotrophins
• Bromocriptine
• Cabergoline
• Gonadotrophin-releasing hormone agonists

Usually, these medications are prescribed to female patients. Sometimes, males also take medication to help to make them more fertile.

Female Surgery

If patients have scarred or blocked fallopian tubes, it may be possible to perform surgery to restore their normal function. It is also possible to have surgery to remove fibroids which can help with fertility issues. In people with PCOS, a procedure called ovarian drilling can increase the likelihood of pregnancy.

Finally, patients with endometriosis may be suitable for surgery to remove some abnormal tissue or any cysts that have developed. Surgeons frequently perform this treatment with keyhole surgery.

If patients have other medical problems or suffer from severe endometriosis, the keyhole approach may not be possible.

Male Surgery

Some males are born with a blockage in a part of the testicle, which affects the passage of sperm. This blockage stops the release of sperm.

If this is the case, surgery to correct this may be a suitable option.

If patients have had this surgery in the past and it did not work, or if the problem is instead of how the testicle produces sperm, then a procedure such as surgical sperm extraction may be suitable. This involves the direct collection of sperm via the testicle under an anaesthetic.

In Vitro Fertilisation (IVF)

IVF is probably the most famous type of fertility treatment. It requires a female patient to take fertility medication to stimulate ovulation, followed by collecting their eggs.

Sperm is collected from the male partner or sperm donor. The eggs are then manually fertilised in a lab., After successful fertilisation, patients must wait for 2 to 6 days before the fertilised egg (known as the embryo) is implanted into the uterus. After this, the pregnancy ideally continues in the same way as it would if conceived naturally. Intracytoplasmic sperm injection (ICSI) is a specific part of IVF in cases of male infertility.

It involves surgical sperm extraction from the testes directly (as mentioned above). The sperm then undergoes analysis to identify the best quality sperm for insertion. Then, a single sperm is injected directly into a single egg taken from the female patient. The resulting embryo is then replaced into the female patient's uterus. Generally, the IVF process results in the production of several embryos. Usually, patients should only replace one embryo at a time. Therefore, the doctor may suggest freezing the other embryos to use if patients have a second round of IVF or wish to have another baby later on.

Intrauterine Insemination (IUI)

Another name for this type of fertility treatment is artificial insemination. It is most often, but not always, suitable for people who are using donated sperm. The IUI process also requires sperm collection or a sample of donated sperm. The sperm is then introduced into the uterus with the help of a small injection type tube. The fertilisation process then occurs in the same way as it would naturally. As a result, IUI is a cheaper but less effective treatment in comparison to IVF.

Why choose to have fertility treatment?

A large proportion of people have problems with conceiving a baby naturally. Consequently, these people may need treatment to help increase their chances of becoming pregnant. Furthermore, some people may not have a partner or need help to have a child. In all of these cases, fertility treatments have the potential to overcome these difficulties.

Who are the ideal candidates for fertility treatment?

As it is a biological process, infertility can only be diagnosed after a year of trying to conceive naturally. However, as fertility declines with age, it is important to seek help earlier if you are a woman over 36. In addition, there is a wide range of reasons that may make it difficult to conceive, and these can also affect your treatment options.

Below is a list of general features for the ideal candidate. However, the precise type of treatment that may suit patients best also depends on their circumstances and a known cause for infertility. Therefore, the best approach is to arrange a consultation to see if you are a candidate for fertility treatment.

An ideal candidate includes those who:

• Have been trying to conceive naturally for over 1 year, or females over 36 years old.
• Are aware or suspect that they have fertility problems.
• Are in relatively good health.
• Have a healthy BMI.
• Have a positive outlook on their fertility journey.
• Are aware that the treatment may not work.
• Have support available from family and/or friends.
• Appreciate the possible risks and complications of fertility treatment.
• Have considered and decided against surrogacy or adoption.
• Have a referral from a specialist health professional.

How is fertility treatment performed?

There are several different ways a fertility treatment procedure can be carried out. Therefore, the different steps of your specific procedure will vary. First, the medical team will discuss the available options and explain which option they think is the most appropriate. This means the procedure time will vary from treatment to treatment. Then, the doctor or surgeon will provide more specific information once the patient decides which fertility treatment they wish to try.

Medication

If patients choose to take medication, the first step is a consultation with a fertility specialist. They will discuss the problems patients have been experiencing and take a full medical history. Next, they may run some blood tests before deciding which medication is the right one. Once everyone is happy with the plan to start a particular medication, the doctor will write up a prescription.

The course of medical treatment for infertility depends on which medication the doctor prescribes. In most cases, the medication will be taken for at least 3 menstrual cycles to ensure the best chance of ovulation.
Additionally, there is some variation in when patients take the medication. For example, some medications such as Metformin are taken every day, whereas others like Clomifene may only be taken for a few days per cycle. Therefore, the doctor will ensure that patients have clear instructions on when they should take their medication.

As with all fertility treatments, patients may not get pregnant immediately. Unfortunately, there is no way of predicting how long it will take to conceive on fertility medication.

Surgery

1. Consent

Before you have any fertility treatment, patients will have to consent to treatment in writing. They should read the consent form carefully to understand the procedure they are about to have fully and the risks that come with it. These are different depending on the procedure that they are having.

2. Anaesthesia

If patients opt for surgical treatment, they will be given an anaesthetic before the procedure.

For a surgical sperm extraction, the surgeon will usually inject a local anaesthetic to numb the testicle and surrounding area. Patients will, therefore, be awake for the procedure, but they will not feel any pain. It will take a few hours after the surgery for the numbness to wear off.

For more extensive surgery, a general anaesthetic may be more appropriate. In this case, patients will meet with the anaesthetist, and they will explain how the anaesthetic agent will work. Patients will be asleep for the surgery and will wake up slowly when it is over.

Patients may feel groggy for a few hours after waking up, but this will wear off. It may also affect memory and concentration for 1 to 2 days but this will also resolve.

3. Surgical technique

The actual surgical technique used will vary depending on the cause of infertility and the chosen procedure. The surgeon will discuss this before patients make their decision about undergoing the surgery.

If patients are undergoing keyhole surgery, the surgeon will make several small incisions around the areas they want to access to insert surgical tools. If patients have more extensive surgery using an open technique, the surgeon will make a larger incision over the area to be operated on.

Generally, treatments like surgical sperm extraction are quicker to perform than those for blockages in patients of both sexes and operations for fibroids and endometriosis.

As the time taken is specific to the patient and their operation, the best person to indicate operation time is the surgeon.

4. Return home

In many cases, patients will be able to return home soon after the procedure. The treatment area may remain numb for a few hours, but the anaesthetic effects will wear off with time.

If patients have more extensive surgery, they may have to stay in hospital overnight. Again, the surgeon will discuss this before the operation and together come up with a recovery plan.

IVF

This differs depending on a patient's needs and preferences and so the following information is a rough guide only.

Male

If you are male, the IVF treatment involves providing a sperm sample.

This undergoes analysis to identify the most healthy sperm to use in the fertilisation process.

Female

After deciding to go ahead with the treatment, the doctor or surgeon will prescribe some medications which first override the natural menstrual cycle and then stimulates it to produce eggs. Patients usually take these medications for around two weeks each, one after the other.

During the IVF process, patients can expect to have at least one ultrasound scan and blood tests to monitor their progress. This allows the fertility specialists to be sure that the medication is working and plan to collect the eggs.

Egg collection

Egg collection is a minor surgical procedure and requires local anaesthetic with sedation to keep you as comfortable as possible.

This part of the treatment involves using a fine needle to collect the eggs via the vagina.
After egg collection, the next step is fertilisation.

In IVF, this means that the egg and sperm sample mix and after one day the fertility specialist returns to assess them and see if there has been any fertilisation. If this is successful, these embryos grow for two to six days in the lab before embryo transfer, the act of replacing them into the uterus.

During this time, patients can expect to take medication to help the uterus to prepare to accept the embryo.

Egg transfer

The transfer part of the IVF treatment procedure is less invasive than the egg collection and often does not require sedation.

The specialist will use a thin tube to pass into the vagina and deliver the embryo to the uterus. The specialist may suggest waiting two weeks before taking a pregnancy test to see if the treatment has been successful.

What to expect from a fertility treatment consultation?

The fertility treatment consultation will involve meeting a specialist doctor to discuss potential treatment options. During the fertility treatment consultation, the fertility specialist will talk through treatment options. They can run through the procedures and discuss any risks or complications. Additionally, they may ask to see a referral from a GP and a copy of any test results, so make sure to take these along to the appointment.

During the consultation, the fertility specialist may ask a number of things including:

• Current health status
• Medical conditions
• Previous pregnancies or children
• Regular medications use (Including prescription, over-the-counter or herbal medications)
• Smoke, drink alcohol or use recreational drugs
• How long have you been trying to conceive?

It is important that patients answer these questions as honestly as possible so that the doctor can help to direct the patient towards the best choice of fertility treatment. Therefore, the more details a patient can provide, the better the doctor’s understanding of the struggle with infertility.

Questions to ask during the fertility treatment consultation

This consultation is also an excellent time to ask any questions about the treatment options. These may include more specific details on a procedure or the chances of a successful pregnancy after each sort of treatment. It is important that patients have a good understanding of what their chosen treatment involves, the risks and complications that may arise, and what their recovery will be like.

Some questions that you may like to ask include:

• Which treatment do you think will work best for me?
• Will the procedure be painful?
• How long does it usually take for the type of treatment I have chosen to be successful?
• Is there anything else I can do to increase my chances of conceiving?

What are the main fertility treatment risks and complications?

As with any treatment, there are some fertility treatment risks and complications to be aware of. These vary depending on the type of treatment that patients opt for. Patients must be aware of all the risks and complications that could occur during and after the treatment. The one risk of every type of fertility treatment is the chance that the patient may not become pregnant. How likely this depends on their individual circumstances, and the fertility specialist will be able to give you a better indication. Overall, fertility treatments are considered safe and effective. Having said this, it is still important to understand what could happen if things do not go to plan.

Medication

If patients opt for fertility medications, the possible risks and complications include:

Medication side effects

All medications have the potential to cause side effects. Not everyone that takes fertility medications will suffer from side effects, and even if they do, they are usually mild. Some of the common side effects include:

• Headache
• Bloating
• Breast tenderness
• Nausea
• Hot flushes
• Mood swings.

Ovarian hyper-stimulation syndrome

Most fertility medications stimulate the ovaries to produce more eggs than they usually would. Sometimes, this is excessive and results in ovarian hyper-stimulation syndrome. In this condition, there is dangerous over-stimulation of the ovaries. This can also occur during IVF treatment because of the similar medications used. Most cases are not serious, but they can rarely lead to blood clots, kidney failure, and potentially life-threatening. Patients must recognise the symptoms and receive early treatment if needed. The symptoms of this include:

• Fast weight gain
• Severe abdominal pain
• Bloating
• Severe nausea
• Dizziness
• Problems passing urine
• Shortness of breath
• Rapid heartbeat
• Palpitations.

Multiple pregnancies

Because of the stimulatory effect of fertility medications, patients are much more likely to conceive more than one baby whilst undergoing treatment than they would by conceiving naturally. Although some people may welcome this, others may not. Occasionally, more than three eggs are fertilised, which as the pregnancy progresses is detrimental to both the mother’s health and that of the developing babies. The doctor will explain this risk and their options if they found themselves with multiple pregnancies.

Ectopic pregnancy

Fertility medications can lead to a small increase in the risk of an ectopic pregnancy. This is when the embryo implants in the fallopian tubes rather than in the womb. This is dangerous as it can cause the fallopian tube to rupture and can require emergency treatment. The symptoms of an ectopic pregnancy are:

• Severe abdominal pain
• Vaginal bleeding and/or dark discharge
• Dizziness

If patients have any of these symptoms after having a positive pregnancy test following fertility treatment, they must seek immediate medical attention.

Surgery

If the fertility treatment involves any surgery, the potential surgical risks include the following:

Infection

Every type of surgery carries a risk of infection. The surgeon will do their best to prevent any infections from occurring. If patients develop an infection, the medical team will usually treat it with a course of antibiotics. Infections should not be left without treatment as they can spread and become more severe. Therefore, patients must be aware of the signs of infection to know when to seek medical help. These include:

• Redness around the wound that gets worse over time
• Redness that is beginning to spread away from the incision
• Foul-smelling discharge or pus from the wound
• A temperature of over 38° C
• Pain that is not relieved by painkillers

Bleeding & bruising

There may be some minor bleeding from your wounds and bruising of the skin. This is common and can be expected in most cases. However, more rarely, a collection of blood can gather beneath the skin – the medical name for this is a haematoma. These can occur in the first few days after surgery and require further treatment by the surgeon.

General surgical complications

There are general risks that come with all surgeries. These include nausea and vomiting, risks of anaesthesia, post-operative pain and blood clots. To reduce the risks of their occurrence, it's advised that patients take their time choosing a qualified, experienced surgeon that they can trust.

Damage to surrounding structures

There is the risk that the surgery may cause damage to structures surrounding the treatment area. For example, nerve damage or damage to other structures such as the womb or testicles. Rarely, the operation becomes difficult, and the surgeon must perform a more extensive surgery than initially planned.

Scarring

Surgical techniques will leave scarring on the treatment area. In the first few months after surgery, the scars will be lighter than the skin and quite obvious. However, with time and a good scar care regimen, the scars will fade. To minimise scars, ask the surgeon for any scar care recommendations that they may have. Frequently, fertility operations can be done with a keyhole technique, meaning that they will have much smaller scars than those from traditional surgical incisions.

Failure

Unfortunately, there is always a risk that the surgery may not be successful. Patients must be aware of this and understand that having the operation does not guarantee that they will conceive. Ask the surgeon about the likelihood of this and the next steps if they did not fall pregnant after the surgery. It is also important that patients attend any follow-up appointments.

Finally, there are also possible risks and complications with IVF treatment. These include those listed under the medication and surgery sections and so are not outlined specifically here. If patients would like more information, please ask a fertility doctor for advice.

How to prepare for fertility treatment?

Fertility treatment preparation is key to give patients the best chance of successfully becoming pregnant after undergoing fertility treatment. Below are some suggestions of things patients can do to improve their health and lifestyle before they begin their journey.

Maintain a healthy weight

People who are underweight or overweight can both struggle to conceive. Therefore, the fertility specialist must assess patients in the lead up to starting fertility treatment. First, they will be able to see if weight may be affecting fertility. Then, the best thing that patients can do is lose or gain weight so that their body mass index (BMI) lies in the healthy range of 18.5 – 24.9. If patients think that their weight may be contributing to the problem, please discuss this during the consultation.

Eat healthily

Regardless of weight, a healthy diet is vital to ensuring that the body is in its best condition. To nourish a baby, the body needs to be well-nourished in itself. A healthy diet consists of plenty of fruits and vegetables alongside some meat, fish, dairy, or vegetarian protein sources. In addition, try to eat less sugar and saturated fats and avoid processed foods when possible.

Cut out alcohol and caffeine.

Alcohol consumption indeed has a negative impact on fertility for both men and women. Therefore, the surgeon may recommend that patients completely cut out alcohol if they struggle to conceive or want to undergo fertility treatment. Also, the surgeon may suggest cutting out caffeinated drinks such as tea, coffee and energy drinks. The best way of staying hydrated is to drink lots of water. Patients can put mint, lemon or cucumber in the water to change the flavour if patients struggle to drink plain water.

Reduce stress

Stress has a huge impact on fertility and won’t help the chances of becoming pregnant. Although easier said than done, patients should try to reduce stress levels as much as possible. Think about the things that cause the most stress and how to change this. For example, if patients have a stressful job, consider talking to a colleague or boss about how it affects stress. Patients could come up with some suggestions that would make work less stressful. Try to stay organised, but allow some time to relax. Getting a good night’s sleep will be beneficial in many ways, not just in helping to lower stress and prime the body for fertility treatment.

Supplements

The fertility specialist will tell patients if they need to take any medication or supplements before beginning the fertility treatment process. There is a huge range of supplements claiming to help with fertility, but these often have little effect. However, folic acid is recommended for all women trying to become pregnant, so this would be a sensible choice. The fertility specialist will give more information about this and answer any questions.

What to expect after fertility treatment?

Knowing what to expect after treatment is an important part of understanding the process of the fertility procedure. The specialist doctor will be able to give specific fertility treatment aftercare advice. After patients have their treatment, they will organise a follow-up appointment to check up and to see if the treatment has been successful. They will ensure that patients feel well and understand what is happening. They will also talk through the next steps.

After the treatment

This will depend on what kind of treatment the patient has had. If patients have a local anaesthetic, they will be awake for the procedure but unable to feel anything. After surgery using a general anaesthetic, patients will wake up gradually when the operation is complete and feel slightly groggy as the anaesthetic wears off.  Patients may feel some numbness in the pelvis and groin. This should wear off within a few hours. The treatment area may begin to feel painful as the numbness wears off. Patients may notice that memory and concentration are affected for a day or two after surgery. Again, these side-effects will wear off with time.

For other types of fertility treatment, patients may not feel any different. However, if patients are prescribed a medication, they may notice some side effects. If patients opt for an IVF type procedure, they may have some crampy stomach pains and possibly a small amount of bleeding after egg retrieval.

Returning home

This again depends on the type of treatment. For simple procedures, patients will likely be able to go home the same day. However, if the surgeon has to do a more complex operation, such as for fibroids, they may have to stay in hospital overnight. For procedures with several steps like IVF, patients will come into the hospital fairly regularly but usually will not need to stay overnight.

Getting home

Patients should arrange for a family member or friend to drive home if the treatment involves surgery. This is to ensure that the patient is safe if they have an anaesthetic and make sure they have someone there to look after them.

Returning to work

The majority of people undergoing fertility treatments do not need to take any time off of work. However, if patients have a surgical procedure, then it is likely that they will need some time to recover. Most people are able to return to office work within one to two days of their surgical fertility treatment. However, this may vary if patients have a more physically demanding job. The fertility specialist will be able to give more specific advice on this. Of course, it is up to the patient to decide how much time to take off, particularly as these treatments can be emotionally draining.

Exercise and physical activity

Patients will be able to return to return to light activities five to seven days after surgical fertility treatment. The doctor will give a more exact timeframe as this depends on the type of treatment the patient has. Patients should avoid strenuous physical activity throughout treatment, but it's encouraged patients to keep fit with regular exercise.

Taking a pregnancy test

Once again, this depends on the type of treatment. After IVF, patients should wait for a minimum of two weeks before taking the test to avoid false positives. For medications to be effective, they need to be taken for several cycles, so patients may wish to test as they were doing before the fertility treatment. There is no set time to test after surgical procedures.