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Genea experts answer your IVF and fertility questions

Man and woman sitting on couchDo you have questions on the subject of fertility, infertility and IVF? You’re not the only one…

We asked our Bub Hub forum members to tell us their fertility questions. Here a group of fertility experts from Genea offer their responses …

Can I do a natural FET if I’m still breastfeeding? Specifically is there any evidence, what are the chances, does prolactin level make a difference?

There may be a reduced chance of pregnancy while breastfeeding therefore I advise my patients not to have an embryo transfer until they have stopped breastfeeding for two months, even if their prolactin level is normal. – Dr Mark Livingstone

 

I have chronically elevated prolactin. Have had an MRI – not a tumour. IVF daughter born June 2014, stopped breastfeeding August 2015 – cycle still hasn’t returned (no cycle at all while breastfeeding). Nobody seems to be able to tell me what’s causing my elevated prolactin and what its effects on my fertility are. Could it be why my cycle hasn’t returned?

It is difficult to give an opinion on this situation as there can be many causes and therefore I strongly suggest you have a review with your treating doctor. Usually tablets such as dostinex can be used to reduce prolactin levels with the aim of ovulation resuming. It is possible that a raised prolactin may be the reason your cycle has not returned. – Dr Mark Livingstone

 

I want to have a FET in the next 6 months, is it better to wait for a natural cycle or should I just get cracking with meds?

I suggest a natural cycle is easier and may have a slightly higher success rate, however, it all depends on your particular circumstances. I would suggest discussing the approach that’s best for you with your Fertility Specialist. – Dr Mark Livingstone

 

I’m 42 and doing IVF with PGD testing. I have no fertility issues apart from age and previously have had children in my late 30s all of which were conceived in a short time with no miscarriages in between. On my first round of IVF I got 17 mature eggs but only 2 were still going on day 5. To be biopsed they had to grow to day 6 so they were sufficiently hatched even though they were blastocysts on day 5. One of those day 6 tested was chromosomally abnormal. The other day 6 was suitable to freeze but wasn’t tested as it wasn’t hatched enough. My fertility specialist has told me not to place any hope on the day 6 frozen untested embryo as it is probably ‘no good’ because it wasn’t fully hatched by day 6. My question is should I rule out transferring this untested day 6 embryo because it wasn’t hatched enough to be biopsied on day 6?

I would never rule out using a day 6 frozen embryo, otherwise why was it frozen in the first place. Although it was not technically “pushing out”enough cells to be tested this does not mean it is incapable of forming a viable pregnancy. If you want only one more child then it is easier to use a frozen embryo than embark on a new stimulated cycle. – Dr Mark Livingstone

 

I’m currently in the process of a FET cycle and I have three frozen – two day 4s and a day 5 – however I have been told they are putting back a day 4. Any idea why this would be?

My recommendation would be to thaw a Day 4 embryo and grow it for an extra day to take it to Day 5. If it does not continue to divide to blastocyst stage then the Day 5 embryo can be thawed and transferred instead. This could help to reduce the number of frozen transfer cycles and give better quality embryos for transfer. In the future it may be best to grow all embryos to Day 5 before freezing. There will be less frozen embryos and it makes the process more efficient. Our policy at Genea is to grow embryos to Day 5 and only freeze at that point in time. –  Dr Mark Livingstone

 

As an average – what are the success rates for women over 40? and for women 35-40? I mean the “live birth rate” not the “pregnancy rate” please.

At Genea, women aged between 40 and 44 years old have a 15.6 per cent chance of a live birth per each embryo transfer and women aged 35 to 39 years have a 30.8 per cent chance of a live birth per each embryo transfer. These are the figures officially verified by the Australian and New Zealand Assisted Reproduction Database. They are based on data from 2013, released in September 2015. – Dr Mark Livingstone

 

Can adenomyosis affect success rates of IVF? Are there any different steps involved in the IVF process for women with adenomyosis?

Significant adenomyosis with uterine enlargement creates a hostile environment for embryo implantation to occur. The best investigation is an MRI of the uterus. This will define whether there is a focal mass of adenomyosis or whether it is diffusely spread throughout the uterine wall. If there is a focal mass of adenomyosis, this can be surgically removed. If there is diffuse adenomyosis, suppression with medication is recommended. The most commonly used medication is a GnRH analogue (Zoladex) given for three months before commencing IVF. Both of these strategies are designed to improve embryo implantation. – Dr Geoff Reid

 

After five rounds of IVF/ICSI and two miscarriages we have still had no success. Egg pick up is good with between 9-19 eggs each time and initial fertilisation rate is good also. At day 3 everything is good BUT between day 3 and 4 things slow right down and we only ever get 1-2 embryos to transfer on day 5 with none to freeze and none good enough for PGD. Any advice on how/why we can’t get them past that day 3-5 day hurdle?

The process of forming a blastocyst is extremely complicated for an embryo. For the first few days of life the division of the embryo is supported by the egg but after Day 3, the embryo needs to switch on its own genes to continue to develop. This Day 3-5 development is therefore a common hurdle for embryos. In a laboratory with a good quality blastocyst culture system we expect around 30% of fertilised embryos to form blastocysts and they need to be good quality blastocysts to survive PGD biopsy or freezing. When Day 3-5 development is less than expected this can be due to a range of problems that need to be looked into on an invidualized basis. Common causes are poor egg quality, older female age, poor sperm quality, or lifestyle issues. If a particular factor is found there may be steps that can improve the situation. It is also important to check the amount of experience the laboratory has with blastocyst culture as conditions such as the quality of the media used, consistencies in temperature, oxygen saturation etc, can also make a difference. – Dr Katrina Rowan

 

Will antisperm antibodies ever improve? Are there any new developments in this?

The immune system will produce more antibodies when challenged, and in the case of sperm antibodies, when the sperm antigens get in contact with the immune system. This occurs when the testis-blood barriers are affected, for example through infection, trauma, surgery, or in the case of vasectomy, from the epididymal “blow-out”. Treating those conditions which expose sperm antigens to the immune system will help to lower the antibodies’ titre. – Dr Derek Lok

 

What is the cost of a normal IVF cycle, an FET cycle – and how have the medicare changes affected the costs?

The cost of IVF varies between clinics in Australia. Premium IVF clinics tend to have a couple of different components to their cost. At Genea, IVF treatment costs contain two hospital procedures (both in-patient) and a cycle cost (out-patient). Private health insurance generally covers the in-patient hospital procedures such as the egg collection and embryo transfer (based on individual cover and personal circumstances). Medicare will rebate some of the cost of the cycle. When we talk about a cycle in billing terms it is from first day of period or first day of FSH medication depending on the type of cycle and includes:

  • Ultrasounds and blood tests (including first pregnancy test)
  • Lab, scientist and administration costs
  • Genea Specialist fees for day surgery procedures
  • Coordination of your cycle by your allocated nursing team
  • Planning and management of your cycle
  • Counselling (except for donor cycles)
  • Local anaesthetic (where applicable)

There can be additional costs such as anaesthetist fees, medications, freezing fees and PGD depending on your Fertility Specialist’s tailored treatment plan. If you have full cover with Medicare and your private health fund will cover all of the in-patient costs you are looking at a out of pocket range of $3204 – $3760 for an IVF cycle and $1811 – $2465.72 on a frozen cycle in 2015 (indicative amounts only – your treatment type, Medicare status and personal circumstances will determine final out of pocket). The Medicare rebate in 2015 was made up of two components: a Standard rebate and extended Medicare safety net rebate which offered an additional rebate based around spending over the $2000 threshold. – Genea

 

What are the expected costs of IVF under the new medicare rules in 2016?

The 2016 proposed Medicare Safety net changes reduce the amount of eligible out of pocket costs that can be put towards the safety net threshold of $1000 (for couples) as well as limiting the maximum benefit you could receive for the service to 150% of the MBS fee. Essentially, these changes will reduce the amount of rebate you will be able to receive from Medicare on your cycle and therefore increase the out of pocket on all ART cycles that privately bill above 150% of the MBS fee. Please see Medicare for more information. – Genea

 

What is your stand on NK cell relevance to fertility?

Immune issues in the uterus lining – a popular discussion point among patients – probably exist but are in reality probably not very common. Additionally, the tests undertaken to diagnose an immune problem (Natural Killer or NK cell testing) are not perfect – there is a risk of a false positive diagnosis. In other words, the Natural Killer Cells test suggests the woman has a problem but in reality she doesn’t actually have the problem. Also, not only has the immune treatment for this condition (often prednisone or equivalent immunosuppressant drugs) not been shown in properly conducted studies to assist implantation, but these drugs can have serious side effects – albeit rare – to both the woman and the foetus. Many fertility specialists worldwide are also concerned about this issue. [1] Assoc. Prof. Mark Bowman

 

What does your current research say about the benefits of use of melatonin, saizen and COQ10 (ubiquinol) to improve egg quality particularly for those over 40.

There is no evidence that CoQ10 or melatonin make any difference, in our Genea clinics or anywhere in the world. There was some limited evidence from some small studies as to the benefit from growth hormone (saizen), in women with low egg reserve. However, a larger Australian study finished recently did not demonstrate any benefit. – Assoc. Prof. Mark Bowman

 

With 100% antisperm antibodies is there any chance that IUI could work or is IVF the only way? Are there specific methods of washing sperm that can reduce/remove antibodies?

There is a wide range of sperm antibodies attaching to different sperm antigens, lots of which would have no impact on sperm functions. That’s why studies on the impact of sperm antibodies and treatment to lower sperm antibodies on fertility produce conflicting results. Different sperm washing methods may remove less competent sperm (whether affected by antibodies or not) but will not totally remove the sperm antibodies when they are bound to sperm. If the types of sperm antibodies bound and levels are deemed significant on fertilisation/fertility as assessed by laboratory testing and history, then IVF treatment with sperm microinjection will be the only effective way for the fertility treatment to succeed. – Dr Derek Lok

 

How do HLA matches between parents affect embryo formation and growth?

HLA is a very controversial area in fertility and miscarriage. There is no definite medical evidence to justify HLA testing in fertility patients. –  Dr Mark Livingstone

 

Do embryos look different (vastly different) after thawing, compared to the original images we might have been shown?

Cryopreservation (AKA freezing) of embryos is a good thing. It maximises the fertility potential from a single oocyte (egg) collection procedure (OPU) – some couples will have more than one child out of one OPU. Cryopreservation is also safer as it reduces the need for multiple embryo transfers thereby reducing the rate of multiple pregnancies. Recently, some studies have also demonstrated a higher implantation and clinical pregnancy rates with frozen embryos compared to fresh embryo transfers. They concluded that the detrimental effect of ovarian hyperstimulation on the endometrium was thought to be responsible. Uncontrolled cryopreservation damages cells. There are two methods of cryopreservation – slow freezing and vitrification (rapid freezing). Both methods remove water from the cells that make up the embryo and replace it with a chemical (cryoprotectant) for protection. The embryo is then frozen. When an embryo is thawed, the reverse occurs – the final step being the accumulation of water back within the cells. This final process, which is known as re-expansion, can take 2 – 4 hours on average. It is perfectly reasonable to transfer an embryo that has not re-expanded as long as the percentage of cell survival is OK. This embryo will look different to a fresh embryo. The embryo will appear smaller and collapsed. – Dr Anthony Marren

 

I am 32 years old and have low AMH (3) and endometriosis cysts of (3+cm) on both ovaries. I have decided to do IVF before having a lap as I’ve heard this can reduce my AMH even more and even push me into menopause. I have two questions; 1. How much does a laparoscopy increase your chances of getting pregnant; both naturally and through IVF? 2. The clinic I’m with put me on a long down regulation; is this the right option for me? What’s the difference in success between long and short? Thank you

This is my favourite topic. We did pre-operative and post-operative AMH levels on 30 women having ovarian endometriomas removed. The average fall with unilateral disease was 50%, and with bilateral disease it was almost 70%. You should therefore avoid surgery as your AMH is already severely compromised. My advice would be to try and bank some embryos first, then have your endometriosis removed to improve embryo implantation. With your low AMH it may take a number of cycles to get a number of embryos frozen. The best data about spontaneous pregnancy after removal of ovarian endometriomas shows 50% of women will achieve a pregnancy over 12 months. Another study followed 169 women with endometriomas who refused any form of treatment. Only 12% achieved a pregnancy over 8 years. I believe that removal of endometriosis improves embryo implantation, so this effect should be seen with IVF. Most studies show no difference in pregnancy rate between short and long cycles. Some show a tendency to slightly higher egg numbers with long cycles. This would have been my choice in your situation. – Dr Geoff Reid

 

Young frozen sperm or fresh old sperm? Which is better?

It is by far more important to consider the qualities of the sperm (semen analysis parameters and sperm DNA integrity), the health of the man at the time of sperm collection and how the sperm were processed and frozen, than how long the sperm have been frozen for. – Dr Derek Lok

 

Why would one FS advise me to take 412mg Gonal-F when another advised me to take 200mg Puregon? It’s frustrating that we are not privy to the data behind these sorts of decisions – e.g. what results each clinic has got using what methods. Why would they advise such different protocols?

It’s not appropriate to address specific management issues in a forum such as this. Responding to a question of this level of detail requires a formal medical consultation and full patient history. – Genea

 

I have tubal damage and a heart-shaped uterus (33% smaller than normal) what are my chances with IUI?

When trying to work out success rates, it is important to try to break things down. Firstly, the monthly probability of pregnancy is determined by female age – 23% at 25; 21% at 30; 16% at 35; 8% at 40; and 3% at 45. Secondly, you need to look at the number and severity of various ‘infertility factors’. Tubal damage will significantly reduce the success rate of IUI. Fertilisation of the egg by a single sperm occurs within the fallopian tube. The fertilised embryo is then transported to the uterus where it will implant. Tubal damage may reduce the ability of the tube to capture the egg, transport the sperm to the egg, and finally transport the embryo to the uterus. The risk of ectopic pregnancy (pregnancy within the tube) will also be increased. The reason for IUI is also important. If the IUI is with donor sperm then this will not negatively affect success rates. If the IUI is because of male factor infertility then this will negatively affect success rates – the impact will be proportional to the severity. Finally, the ‘heart-shaped’ uterus is important. One has to differentiate between a uterine septum and a bicornuate uterus. The uterus forms by the fusion of two tubes. With a uterine septum, fusion occurs but a piece of tissue fails to reabsorb and therefore divides the cavity into two. With a bicornuate uterus, the two tubes fail to fuse. Both are associated with a reduction in fertility and an increase in pregnancy loss. Importantly, a septum can be surgically treated – the bicornuate uterus cannot. – Dr Anthony Marren

 

NOTE: Genea welcomes questions about infertility treatment and fertility issues but caution that the best source of information about your specific circumstances is always your Fertility Specialist.

1. Natural killer cells and fertility: unwarranted treatments flourish amid misinformation and poor regulation, BioNews 827, 2015

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This blog post is sponsored by Genea.

Genea has almost 30 years’ experience helping people achieve their dreams of a healthy baby and has sponsored this post to answer some of your fertility questions.

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