When to seek help
More than 8 in 10 couples where the woman is under 40 conceive within a year of regular unprotected sex. If you have not conceived after a year, see your GP or a fertility specialist. If you are 36 or over, or already know of something that may affect your fertility, such as irregular or absent periods, endometriosis, previous pelvic infection or surgery, or a problem with sperm, it is sensible to seek advice sooner.[1]
Where I see you
My fertility clinic runs at the CRP Clinic in Epsom, which is a satellite clinic of King’s Fertility in London. I am an honorary consultant at King’s Fertility. You have your consultations, scans and blood tests close to home in Epsom, and the steps that need a licensed laboratory, egg collection, fertilisation and embryo transfer, take place at King’s Fertility.
Finding the cause
Fertility depends on both partners, so we assess you both from the start.
For you, I take a full history and, with your permission, do an internal (vaginal) ultrasound scan at the first appointment. The scan shows the womb, its lining and the ovaries, including the number of small fluid sacs (follicles) in the ovaries, each holding an egg, which gives an idea of your egg reserve. Blood tests check hormone levels and ovulation.
A test of whether the tubes are open, usually a HyFoSy (an ultrasound scan while a small amount of foam is passed through the neck of the womb, the cervix), shows whether eggs and sperm can meet. A saline scan or a hysteroscopy (looking inside the womb with a slim telescope) helps if the cavity needs a closer look.
For your partner, a semen analysis measures the number, movement and shape of the sperm. The CRP Clinic works with a urologist when a male cause needs specialist assessment. After miscarriages or failed treatments, a separate test of DNA damage in the sperm is sometimes offered, although the evidence that it improves the chance of having a baby is limited.[2]
Sometimes no cause is found. That is called unexplained infertility, and treatment is still possible.
When the results are back, we go through the options together, from no treatment for now, if your chance of conceiving naturally is still good, to IVF, and decide together what suits you.
Ovulation induction
If you do not ovulate regularly, for example because of polycystic ovary syndrome (PCOS), tablets taken early in the cycle can stimulate the ovaries to release an egg; the CRP Clinic calls this superovulation. Scans track the growing follicles, so that the dose for the next cycle can be adjusted and the chance of releasing several eggs at once, and so of twins or triplets, is kept low.
An injection can be used to set off the release of the egg at the right time, and you then try to conceive naturally. Most of the chance of success with this treatment comes in the first few cycles.
Intrauterine insemination (IUI)
In IUI, the sperm are prepared in the laboratory to concentrate the healthiest ones and then placed directly in the womb through a fine, soft tube at the time of ovulation. It feels similar to a smear test and takes a few minutes. It is often combined with gentle stimulation of the ovaries and monitoring scans, and it needs at least one open tube.
IUI is mainly used when intercourse is difficult. It is sometimes considered for a mild sperm problem or unexplained infertility, although national guidance does not recommend it routinely for these,[4] and I will discuss with you whether IUI or IVF suits you better. Stimulating the ovaries for IUI carries a chance of twins or triplets, which is why the scans matter.
When the DNA test shows a high level of damage, the CRP Clinic can use a sperm selection method called microfluidic separation, which selects sperm with less DNA damage before IUI. It has not yet been shown to increase the chance of having a baby.
IVF
IVF is the main treatment for many causes of infertility, including blocked tubes, more significant sperm problems, more advanced endometriosis and infertility that has not responded to simpler treatment. In outline:
- Stimulation and monitoring. Daily hormone injections, usually for about ten days, help several eggs to mature. Scans and blood tests at the CRP Clinic track the follicles and adjust the dose. A small number of women over-respond and develop ovarian hyperstimulation syndrome (OHSS), with swelling and discomfort in the abdomen; the monitoring is designed to keep that risk low, and we will tell you what to look out for.
- Egg collection. At King’s Fertility, the eggs are collected with a fine needle guided by ultrasound, through the vagina, under sedation (you are drowsy and comfortable, though not fully asleep).
- Fertilisation. In the laboratory, the eggs are mixed with sperm, or, when the sperm need help, a single sperm is injected into each egg (intracytoplasmic sperm injection, or ICSI). The embryos are watched as they grow over two to five days.
- Embryo transfer. Usually one embryo, the one most likely to implant, is placed in the womb through a fine tube, a short procedure similar to a smear test. Transferring one embryo at a time avoids the higher risks of a twin pregnancy for mother and babies. Any other good embryos can be frozen for later.
- Pregnancy test. About two weeks after the transfer.
The chance of a baby from IVF depends most on the age of the woman whose eggs are used, and also on the cause of infertility and the number and quality of the embryos. I will give you a realistic estimate for your own situation. The Human Fertilisation and Embryology Authority (HFEA), which licenses fertility clinics, publishes the results of every licensed clinic.
King’s Fertility can also freeze eggs or embryos for the future. Fertility treatment can be emotionally demanding, and counselling is offered to everyone having licensed treatment, before, during and after it.
A treatment planned for you
IVF should be planned around the individual woman. I scan you myself at your consultations, so I can relate the response of your ovaries and the lining of your womb directly to the plan.
The lining matters. In a large study from one centre in China of more than 29,000 frozen embryo transfers, the chance of a live birth ranged from about 1 in 6 when the lining was thinner than 7 mm and lacked a three-layered pattern (three distinct lines on the scan), to more than 4 in 10 when it was 14 mm or more with that pattern.[3]
Most of the gain came as the lining thickened to about 9 or 10 mm, and the three-layered pattern made the most difference when the lining was thinner. A study of this kind is observational: it shows a link, rather than proof that changing the plan improves the result, but it is one reason I look carefully at the lining before a transfer.
Many extra treatments (“add-ons”) are offered alongside IVF. Most have not been shown to increase the chance of having a baby, and the HFEA rates each one by the strength of its evidence.[2] I recommend an add-on only when there is a good reason for it in your case, and I will explain what the evidence does and does not show.
Fees and booking
The CRP Clinic publishes its fees for IUI and IVF cycles on its own website, where you can also read more about its fertility services. Medication, consultations and tests before treatment are charged separately, and the clinic can tell you what a full cycle is likely to cost. Most insurers do not pay for fertility treatment; the CRP Clinic sees Bupa and self-pay patients. You may be eligible for NHS-funded treatment, and your GP can advise you about this. To book, contact my secretary, Helen, or the CRP Clinic.
