Frequently Asked Questions
What is the general progression of infertility treatment?
A variety of procedures can be used to diagnose the cause of infertility
in a couple; these range from simple blood tests to more complicated
analytical methods. In any case, diagnosis is a crucial first step
to determine the appropriate therapeutic path that should be followed.
In addition to the cause itself, other factors, such as the age of
the woman, or problems shared by both partners, might also influence
the choice of treatment.
2. What treatment options do infertile couples
Several options are offered to couples depending on the type of infertility
that has been diagnosed. The vast majority of female patients are
successfully treated with the administration of drugs such as Clomiphene
Citrate, Bromocriptine or Gonadotrophins. Surgery can also be a means
to repair damage to the reproductive organs, such as those caused
by endometriosis and infectious diseases. Treatment options for male
infertility also include the administration of drugs, surgery and
assisted reproductive technologies, such as Intracytoplasmic Sperm
Injection (ICSI). Drug therapy and surgery have proved very successful
for specific types of male infertility. However, in a great number
of cases, the reason why men have fertility problems remains unexplained
and the treatment methods applied are empirical. Some patients nevertheless
require more complex medical intervention.
Assisted reproductive technologies (ART) refer to several different
methods designed to overcome barriers to natural fertilization such
as anatomical problems (e.g. blocked fallopian tubes). One of these
techniques, in-vitro fertilization (IVF), has now been practiced for
more than 15 years. Overall, the estimated number of infertile patients
currently treated by ART is around 20%.
3. How successful is infertility treatment?
When talking of success rates for any type of infertility treatment,
one should bear in mind that the average chance to conceive for a
normally fertile couple having regular unprotected intercourse is
around 25% during each menstrual cycle. It is estimated that 10% of
normally fertile couples fail to conceive within their first year
of attempt and 5% after two years. Comparable to normal fertility
rates, effective treatments can be expected to have, on average, up
to a 25% success rate per cycle of treatment, and may therefore need
to be repeated several times before a pregnancy is achieved.
Simple ovulation induction to compensate for hormonal imbalances has
a very high success rate; more than 80% of women suffering from such
disorders are likely to conceive after 6 to 12 cycles of treatment
with drugs such as Clomiphene Citrate or Gonadotrophins. The pregnancy
rates may be increased if this is combined with Intrauterine Insemination
4. Are there particular factors influencing
the success of a treatment?
In any type of infertility treatment, important factors need to be
taken into account when referring to success rates. The age of the
woman and the duration of the couple's infertility are likely to influence
the success of treatment. In women, fecundity decreases as age increases,
particularly after 40 years of age. When the woman is being treated,
her chances of conceiving can be lessened if her partner also has
infertility problems (e.g. poor quality sperm).
5. Are there particular health risks for
women undergoing infertility treatment?
Along with their intended benefits, drugs used to treat infertility
may on occasion cause side effects. In ovulation induction, close
monitoring of follicular growth is crucial to ensuring successful
Monitoring techniques (such as ultrasound scan and blood tests) and
adequate use of treatment protocols help the physician to avoid ovarian
hyperstimulation syndrome (OHSS) and minimize the risk of multiple
pregnancy. Current treatment protocols have been designed to reduce
the risk of multiple births and OHSS.
Ovarian Hyperstimulation Syndrome (OHSS) is a side-effect that can
occur during infertility treatment with ovulation inducing drugs.
Symptoms of this syndrome may include ovarian enlargement, accumulation
of fluid in the abdomen and gastrointestinal disorders (nausea, vomiting,
diarrhea). Severe cases of OHSS are however very rare (1-2% of cases).
One may have to admit the patients in an Intensive Care unit. Rarely,
she may need to undergo abdominal tap procedure, to remove fluid from
her abdomen. Very rarely, she may need more intensive therapies such
as dialysis, or respirator. In order to prevent or reduce the severity
of OHSS, intravenous albumin may be given at the time of egg pickup
during IVF/ICSI procedure.
7. Multiple births
Multiple births occur more frequently after infertility treatment
than in the normal population. About 80% of pregnancies achieved following
simple ovulation induction with Gonadotrophins result in single births,
the remaining 20% being multiple pregnancies, mostly twin pregnancies.
New treatment regimens carefully adapted to the patient's response
help to decrease the risk of a multiple pregnancy.
After IVF, one pregnancy out of four is multiple (20% twin pregnancies
and 3-4% triplets. In IVF centers, physicians now frequently choose
to replace a maximum of three embryos after fertilization, to further
reduce the chance of multiple births. Alternatively, many units are
going in for blastocyst culture, especially if there are 3 or more
8 cell embryos available for transfer on day 3.
In case of triplets or more, one can offer the procedure of Fetal
Reduction, to the patient. In this, with the help of sonography, a
thin needle is passed into the fetus , and drugs are injected to stop
the fetal heart. Care is taken to see that at least two intact fetuses
are left behind. This is a relatively simple technique, with minimal
side effects. However some patients may avoid this technique for religious
or personal reasons.
8. Local side effects
Common local side effects experienced by patients who receive Gonadotrophins
by intramuscular injection include skin redness, swelling and bruising.
Pain and discomfort sometimes reported after intramuscular injections
are now likely to be lessened with the availability of a highly purified
follicle stimulating hormone preparation which can be administered
subcutaneously. Nowadays Gonadotrophins produced by recombinant DNA
- or genetic engineering - techniques are available for administration
by subcutaneous injection.
9. Can ovulation induction increase the risk
of ovarian cancer?
Ovarian cancer is a rare disease; the chance of a young woman developing
an ovarian malignancy during her lifetime is lower than 1.5%. A number
of factors have been found to increase the risk of ovarian cancer,
including genetic predisposition and dietary habits. Scientific studies
carried out in the last few decades have demonstrated that infertility
itself is a risk factor for ovarian cancer.
There is evidence that each pregnancy reduces the risk of a woman
contracting ovarian cancer (this risk could be reduced by more than
25% by a first pregnancy). No epidemiological study has ever established
a causal link between ovulation promoting drugs and ovarian cancer.
An extensive study on this issue, reporting on more than 2,600 women
treated between 1964 and 1974 and followed for an average of twelve
years, found no association between ovulation inducing drugs and ovarian
10. What about the health risks for children
born following infertility treatment?
born following treatment with ovulation promoting drugs, the incidence
of birth defects has never been found to be higher than that in the
normal population. The same goes for babies conceived after IVF. The
incidence of malformations is around 2%, which is comparable to that
of babies born naturally, without any treatment.
In patients undergoing ICSI the incidence of malformation is around
2.7%. If the father has a low count, there is a chance that the male
child, born following ICSI may also inherit the defect.
11. How important is counseling to the patient
undergoing infertility treatment?
The physician helps the infertile couple find the most appropriate
therapeutic path to overcome barriers to conception, but before a
treatment is started, patients need to be aware of all its aspects,
including its constraints. Beyond the medical expertise, infertile
couples are also looking for counseling and support. From a psychological
point of view, infertility is often a hard condition to cope with.
During treatment and before a pregnancy is achieved, feelings of frustration
or loss of control usually experienced by the infertile couple are
likely to be exacerbated. Management of infertility includes both
the physical and emotional care of the couple. Therefore, support
from physicians, nurses and all people involved in treating the infertile
couple is essential to help them cope with the various aspects of
their condition. Offering counseling and contact with other infertile
couples and patient associations can provide help outside the medical
12. What is timed sexual intercourse?
To increase the chance on getting pregnant spontaneously, timed sexual
intercourse is recommended. This means that sexual intercourse, or
coitus, has to take place around the time of ovulation, which is the
most fertile period of a woman. To detect the approximate time of
ovulation a temperature curve of several menstrual cycles can be made.
The woman takes her body temperature each morning before getting out
of bed, starting on the first day of the menstruation until the start
of a new period. The body temperature rises around 0.5 degrease Celsius
after the ovulation. This is mostly about 14 days after the first
day of the period and when no pregnancy occurs the temperature drops
to normal again, with pregnancy the temperature stays high. One can
also use urine or saliva tests to detect the ovulation.
Alternatively, one can use a serial ultrasound monitoring to follow
the development of the follicle and subsequent rupture which indicates
ovulation. The time of ovulation can sometimes vary a few days each
month, even in a regular menstrual cycle. Also, if the circumstances
are right, sperm can live inside the women for a few days and sperm
quality can decrease with high sexual activity. Therefore, it is best
to have intercourse 3-4 days before the expected ovulation and every
other day until 2-3 days after the expected ovulation with no necessity
for higher frequency.
When tests are used to detect ovulation it is advised to have sexual
intercourse on the day of a positive test.
13. What is embryo reduction?
Assisted Reproductive Therapy (ART) has caused an increase in multiple
pregnancies. Especially in ovulation induction and Intra Uterine Insemination,
this situation is encountered frequently. In order to prevent the
risk of severe premature birth and handicaps as well as risks for
the mother, embryo reduction is sometimes performed: The amount of
embryos in the uterus are reduced and the remaining pregnancy has
more chance of normal development and delivery. Of course this is
not an easy decision for both patient and doctor. With careful guidance
of the patient during treatment and good counseling when the patient
is at risk for a large multiple pregnancy, many triplets or higher
pregnancies are already avoided.
14. What is reproductive surgery?
Reproductive surgery is a subspecialty that treats anatomical abnormalities
interfering with normal reproductive function. Advanced reproductive
surgery requires meticulous surgical technique for optimal results,
including rapid patient recovery and avoiding the need for routine
hospitalization. Reproductive surgeons treat tubal obstruction, endometriosis,
uterine fibroids, scarring of the ovaries or other pelvic structures
resulting from pelvic inflammatory disease (PID) in the female, and
varicocele and vas obstruction in the male as well as other abnormalities.
1. Is Intra Uterine Insemination suitable
for every infertile couple?
No. In Intra Uterine Insemination (IUI) semen is directly put into
the uterus. It is a technique used for couples with fertility problems
based on specific causes. These causes are:
Cervical hostility: This means that the cervix is not permeable
for semen shown after the Post Coitum Test.
Idiopathic subfertility: No cause has been found for the inability
Male subfertility: The sperm quality is decreased. Clinics
use different ranges for sperm count in which they perform IUI.
Sperm Antibodies: Inability for vaginal ejaculation with decreased
sperm quality, for example in men with retrograde ejaculation or spinal
IUI can be performed either in a spontaneous ovulatory cycle (cervical
hostility) or in a cycle with ovarian stimulating hormones (idiopathic
sub-fertility and male sub-fertility/sperm antibodies). The stimulation
is mostly done with Clomiphenecitrate or Gonadotrophines.
Nowadays, the indication may be relaxed to include all cases where
routine treatments have failed. These patients can be given 3-6 cycles
with Gonadotrophin stimulation with Intrauterine Insemination, before
they opt for IVF/ICSI.
1. What about success rates of IVF?
Overall, success rates for IVF have steadily improved over the last
ten years. Birth rates for IVF vary according to the expertise of
the centers practicing this technique. However, centers in Europe
have reported pregnancy rates after one cycle of IVF equal or superior
to 25%. In 1993, the French IVF registry (FIVNAT) reported a pregnancy
rate of 25.4% per embryo transfer on a total of 23,025 oocytes retrieved.
Based on such results, after three to four cycles of IVF, a woman
under 40 whose partner does not have any fertility problems could
reasonably expect to give birth. Again, in general, success rates
may vary from one center to another, since they are influenced not
only by the level of expertise of the medical team but also by the
characteristics of the patients treated. A clinic treating a large
number of women over 40 is likely to report lower success rates than
a clinic having a majority of patients under 35. This is because the
success rates are better in women who are less than 35 years of age.
2. What is the duration of one IVF or ICSI cycle?
One complete IVF or ICSI cycle takes approximately six to eight weeks.
First, the normal menstruation cycle of the woman is down regulated
by injection or nasal application of specific hormones each day. This
part of the cycle can vary from a few days to several weeks. When
the ovaries have become inactive, shown on ultrasound control and
laboratory findings, the stimulation of the ovaries start by muscular
or subcutaneous injections of hormones. The mean stimulation period
is 12 days, depending on the reaction of the ovaries. The ovum pick
up takes place within two days after stopping the stimulation. Now
the real IVF or ICSI follows in the laboratory. When fertilization
occurs, embryos are transferred into the uterus after two to four
days and drugs supporting the uterus are given. After approximately
15 days a pregnancy test will show whether the IVF treatment has been
successful or not.
3.What is Egg-donation?
Women with no, or not properly working ovaries can, in some cases,
get pregnant through egg donation. In this procedure another woman,
mostly a relative or good friend, will be the egg donor. This woman
will have an IVF stimulation and ovum pick up. After the ovum pick
up the collected eggs will be fertilized with sperm of the partner
of the recipient woman i.e. donor acceptor. The embryos are then transferred
in uterus of the donor acceptor. If a pregnancy occurs, the donor
acceptor and her partner will have a child which is only biologically,
half their own.
In recent times, another concept called egg sharing , has also become
4. What is Cryopreservation?
Cryopreservation means preserving in a frozen situation. The best-known
Cryopreservation is of semen. This is mostly done in case of cancer
of the testicles before treatment of the cancer. Furthermore Cryopreserved
semen is used in donor insemination. It is also possible to freeze
fertilized eggs after IVF or ICSI. If more embryos are left after
an IVF or ICSI procedure they can be frozen and transferred another
time. In this way there is a larger chance on a pregnancy while only
one IVF or ICSI cycle is performed. For human oocytes Cryopreservation
is much more difficult. Only in very few experiments this is done
successfully. The attention of researchers now is on developing a
way to freeze ovarian tissue and after thawing, to obtain the oocytes
in it. This procedure is not yet fully refined but when it is, it
can offer great opportunities in the future. We at the Babies And
Us Fertility center have started doing preliminary research work in
5. What is TESE or PESA?
TESE: Testicular Sperm Extraction Sperm collected out of the
testicles after operation. PESA: Percutaneous Epididymal Sperm
Aspiration Sperm collected out of the epididymis by simple aspiration,
without opening the skin
TESE or PESA is a technique developed for patients with no sperm cells
in their sperm due to an undeveloped or obstructed spermatic cord.
The cause of obstruction can be a former sterilization, an infection
of the epididymis or congenital absence of vas deferens. When the
testicles make no sperm cells at all, of course TESE or MESA is not
possible. If sperm cells are obtained, an ICSI procedure (Intra Cytoplasmatic
Sperm Injection) will follow.
6. What does sperm preparation mean?
Spermatozoa are ejaculated in the seminal fluid during intercourse
or masturbation. During assisted reproduction the spermatozoa are
extracted from the semen by a series of processes - centrifugation
and washing, layering (to select the active sperm and leave the immotile
or dead sperm behind) or selecting the best sperm by making them swim
through a denser medium (Nidacon Puresperm or Spermgrad) and using
those that succeed.
7. How and why are embryos frozen?
Human embryos can be stored very successfully by being frozen and
stored in liquid nitrogen. An estimated 15-20,000 babies have been
born as a result of the freezing technology. Drug-induced stimulation
of the ovaries, resulting in super ovulation, leads to an excess of
embryos being created that can't all be transferred to the uterus
at the same time. The good quality excess embryos can therefore be
stored by freezing for transfer to the uterus at a later date. It
should be noted that poor quality embryos do not withstand the freezing
process that well, and hence are not generally frozen. This technique
allows couples to have more attempts at IVF without the need for the
woman to have to undergo another stimulatory cycle of IVF for egg
The success rates following transfer of frozen thaw embryos is in
the region of 10-15 % - not as good as the fresh cycle success rates.
In some countries freezing of embryos is restricted or banned (e.g.
Germany and Switzerland will only allow freezing of the zygote - i.e.
before the first cell division of the fertilized egg).
8. What is assisted hatching?
Assisted hatching (AH) may help couples who have had many attempts
at assisted reproductive procedures without success. It is a technique
which helps the embryo implant in the endometrium. Embryo implantation
is one of the greatest barriers to success in In Vitro Fertilization
(IVF) cycles. When embryos are replaced into the woman's uterus, they
are covered by an outer coating called the Zona Pellucida. Once the
embryo is in the uterus, this "shell" must dissolve in order for the
embryo to be able to "hatch", a necessary step for implantation. In
certain situations, this step is less likely to naturally occur: in
women 38 years and older, women with elevated serum FSH levels, and
women who have failed to achieve a pregnancy in a prior IVF cycle)
and in patients with AH, a microscopic glass tube is used to make
a small defect in the zona using a very small amount of acid solution
to dissolve the outer coating of the embryo. Nowadays this hole is
created with the use of a laser beam.
Babies and Us has already performed more than 300 cycles of Laser
Hatching with very good results. Assisted hatching is done on the
third day after egg retrieval, and embryos are immediately replaced
into the uterus. It has been suggested that treating women with steroids
(to suppress the mother's immune system) and antibiotics (to counteract
any infections in the uterus) may be beneficial when carrying out
assisted hatching. These medications are only given for four days,
starting on the first day the eggs are collected.
9. Why do not all embryos implant in the
After IVF, as after spontaneous conception embryos are susceptible
to chromosome abnormalities. The egg or the sperm may have born the
anomaly to start with, but at each cleavage division, mistakes may
happen that lead to abnormal daughter cells in the embryo. These abnormal
cells may fragment and get lost to the embryo. In case the embryo
loses too much cells, its abilities to progress until the blastocyst
stage and to implant may seriously be hampered and no pregnancy will
follow. Actually the relatively low implantation potential of human
embryos is an example of natural selection, which is very efficient
in eliminating abnormal concept uses.
10. How can we improve the implantation rates
of human embryos in human IVF?
We cannot. All we can do is try to select the better ones so that
the transfer will lead to a higher pregnancy rate. Some centers are
experimenting with embryo biopsy and Aneuploidy screening to select
the genetically soundest embryos. Other centers choose to culture
the embryos to a later stage (the blastocyst stage) to select the
best ones, and indeed both strategies seem to lead to higher implantation
rates. These strategies, however, work only if a sufficient number
of embryos are available. The major problem are still couples in whom
only a low number of embryos can be obtained, since no selection can
be performed there and the pregnancy rates will still remain low.
11. What about the transfer of only one embryo to reduce the incidence
of multiple pregnancies?
It seems to work, at least in a selected group of good prognosis patients.
In this group (about one quarter of all couples) where the female
partner is young (<35 yrs), possibly has been pregnant before and
who are undergoing their first IVF attempts and where good quality
embryos are available, the elective transfer of a single embryo leads
to very acceptable pregnancy rates, similar to the ones in control
patients undergoing double embryo transfer. However, no twin pregnancies
are occurring, which is a major advantage in terms of neonatal outcome.
Unfortunately, not all patients are good candidates to this approach
and more clinical trials have to be carried out to investigate the
possible wider use of elective single embryo transfer.