By: Mr Edward Coats | 12th June 2023
Mr Coats is a Consultant Gynaecologist and Specialist in Reproductive Medicine and Surgery with 18 years medical experience. He is Medical Director at a West London fertility clinic. He is a member of The Royal College of Obstetricians and Gynaecologists, The British Fertility Society and The British Menopause Society. Ed tailors treatment according to the needs of his patients using an evidence-based but holistic approach.
Seeing new fertility patients every day, I meet a range of people in different situations with different requirements. From those investigating their fertility for the first time, perhaps with the intent of having children later down the road, to others who have undergone fertility treatment before both successfully and unsuccessfully. As a result of these years of consultations in clinic, I have found these are the 10 most common questions asked at a fertility consultation by patients and the answers that I typically give for each one:
1. Do I qualify for NHS funded treatment?
NHS funding of fertility treatment in the UK can be complex to understand. The distribution of money for funding fertility services in the NHS is overseen by Clinical Commissioning Groups (CCG’s) and there are more than 200 of these in England. Each CCG is responsible for allocating money to different healthcare services. The result of this is that each infertile patient falls under the remit of a different CCG based on where their GP surgery is located. The criteria that each CCG sets for patient to access NHS funded fertility treatments is well known to vary across England. This is sometimes referred to as the ‘Postcode Lottery’, which means where you are located in the UK may affect your entitlement to fertility treatments such as IVF. In general across the UK the CCG’s create health policy based on guidance.
The National Institute for Clinical Excellence (NICE) produce guidance around how healthcare should be optimised and delivered in each area of medicine. The fertility guidance last issued by NICE in 2013 states that women under the age of 40 should be offered 3 full cycles of IVF if you have been trying to get pregnant after 2 years of regular sexual intercourse. The reality is that not all CCG’s offer this level of NHS treatment and many fall short of this due to arbitrary criteria set by the CCG’s. The rationing of services like this means that patients with infertility have to meet several criteria to determine if they are eligible for NHS funding. Unfortunately only around 10% of CCG’s offer the full three cycles of IVF to patients and around 40% of CCG’s offer just one fresh cycle of IVF to patients.
The Fertility Fairness campaign group run a website with more detailed information about whether you qualify for IVF treatments.
2. What does my BMI need to be to have treatment?
Body Mass Index (BMI) is a measure calculated from your height and weight and is used in medicine to determine if you are of a healthy weight. BMI has health consequences and is also important for fertility success. It can take longer to get pregnant if your BMI is low (BMI less than 19) or if you are obese (BMI greater than 30). Men also may find their sperm parameters are affected with increased BMI. Therefore having a BMI that falls in the healthy range may improve fertility chances and the outcome of a successful pregnancy. NHS funded IVF treatments are not offered to patients with an BMI above 30 or if it is very low. Many fertility clinics will allow patients to self-fund treatment with a BMI 30-35 but this will depend on the clinic policy. Check with your clinic if they have a higher threshold for treating patients with a raised BMI.
3. What does my AMH level mean?
Anti-Mullerian Hormone (AMH) is a blood test commonly measured by fertility clinics. It is produced form the early developing follicles in the ovary. It is a blood test that can be taken at any point in the menstrual cycle. The AMH level is a marker used by fertility specialists to understand a woman’s egg reserve. All women are born with a number of early follicles and this number of follicles falls through their lifetime up to the menopause. The AMH level is a blood marker of how good the reserve of eggs is in the ovaries. AMH is a not a predictor of whether you will fall pregnant naturally or a reflection of egg quality. It is measured in the blood by fertility specialists to assist in predicting how the ovaries may respond in an IVF cycle and to help choose the correct medication dose and IVF protocol.
4. How does the IVF cycle work?
Fertility clinics all use variations of different IVF treatment protocols and regimens. There is not one single approach used in all clinics to do IVF. In general the ovarian drive to release eggs must be blocked to allow controlled stimulation and growth of the resting ovarian follicles in preparation for an egg collection procedure. The main two types of protocol used are short and long protocols. In a Long protocol the patient switches off the ovarian drive to grow eggs by injecting of sniffing a medication. This take 2-3 weeks and is followed by a period of 2 weeks of stimulation medication, before reaching egg collection. In a short protocol the resting follicles in the ovary are stimulated from the very start of the menstrual cycle over a 2 week period but at the same time a blocking medication is given to ensure the eggs are not released. The final step in both these treatment protocols is to artificially trigger ovulation in the body so that the follicles are ready to release mature eggs before a timed egg collection procedure under anaesthetic.
5. What can I do to optimise my chances of IVF success?
IVF success is intrinsically linked to maternal age at the time of treatment. Good quality eggs and sperm are more likely to lead to good quality embryos ultimately. The morphological appearance of an embryo in the laboratory is not always a directly correlated to success. The best looking embryos in other words do not always make babies. However, patients who achieve the highest quality embryos do tend to have better chances of their IVF treatment working. The chromosomes of the cells of the embryo tend to determine if that embryo will have a chance of normal implantation and development. If the cells of the embryo are abnormal with chance chromosomal errors predominating during initial development, then those embryos are less likely to implant and lead onto a healthy pregnancy. Failed implantation and miscarriage is in many cases explained by chance errors that occur in the development of the embryo following fertilisation of the egg.
So ultimately having healthy sperm and eggs is a great starting point to optimising your success. There are many dietary, lifestyle and nutritional factors to consider here. There has been many studies looking at how to improve egg and sperm quality and some research studies are more convincing than others. This has led to an enormous amount of information available to patients to wade through to work out what they can do to influence success. To find out more about diet, lifestyle and nutritional and its impact on IVF success take a look at one of our courses (coming soon).
6. What supplements should I take to help my IVF work?
The fertility supplements market can be quite a challenge for patients with many different suggestions and recommendation coming from nutritionists, fertility specialists, patients and forums. It may seem like a daunting topic to understand and this is because the information and list of supplements can be endless (Arginine, DHEA, Coenzyme Q10, Folic acid, Myo-inositol, Melatonin, Omega 3, Vitamin D, Vitamin E…). Research this topic carefully and used trusted resources to learn more about the benefits of supplements to both male and female fertility. In general a male and female pre-conception multivitamin supplement will contain many of the important ingredients that are required to optimise fertility health. Speak to your specialist doctor or nutritionist to understand which supplements may benefit you and always check a few things first. You need to understand what the supplement is used for and how does to improve success. You need to understand when you need to start and stop taking the supplement and importantly are there any side effects to consider.
We have covered some of the commonly discussed fertility supplements here on Total Fertility before and our course on Diet, Lifestyle and Nutrition may help you understand this topic better.
7. What does my partner need to do to optimise his sperm?
Spermatogenesis is the term used to describe the biological process in the body to make mature sperm. It takes 80-90 days for the body to make a mature sperm, so men trying to optimise their sperm need to make a sustained effort over several months to influence a positive chance in sperm parameters.
Diet, lifestyle and nutritional factors can all influence the quality of sperm. Maintaining a healthy diet by eating foods that contain more of the ‘good’ unsaturated fats is preferable to foods high in the ‘bad’ trans fats. Eating whole foods such as fruits, vegetables, whole grains, beans, lean meats, fish, nuts, and lean poultry are all examples of foods that do not contain the saturated fats. Saturated fats are bad for sperm quality and can be found in a lot of different processed foods. There are the so called ‘super foods’ such as blueberries, broccoli and dark chocolate (100% cocoa), which all seem to help sperm. Eating a balanced diet with foods that contain high levels of anti-oxidants help prevent sperm damage and so Vitamins C and E and Omega 3 are all examples of essential nutritional factors to boost. Zinc and Selenium are important too and in fact all of these can be obtained by purchasing a good multivitamin supplement.
Avoiding heat is an absolute necessity as excess heat can damage the mature sperm stored in the epididymis. The testes hang outside of the body to maintain a lower temperature, so hot baths, saunas, hot tubs or very tight lycras and underwear may harm your sperm. There are a number of absolute forbidden toxins that will damage sperm and long term male sperm health, such as smoking, marijuana, excessive alcohol and anabolic steroids. Read more on our blog on “Optimising Sperm for IVF“.
8. What does IVF treatment cost?
IVF treatment is expensive and in most UK clinics a fresh IVF cycle will cost between £6,000 and £9000. There are a number of different elements that are essential to IVF cycle and clinics chose to display their prices in different ways. We make it easier to understand with our clinic finder tool where you can compare the prices between clinics based on whether all the essential elements of IVF treatment are included in the headline price (as a package) or whether there may be extras to consider. This makes it very challenging to compare the price of IVF between clinics as they all display their prices differently. We have undertaken a podcast on this exact topic with Dr Raj Mathur on what treatment costs and what questions to ask.
9. How may embryos do you put back in the womb?
Since IVF started over 40 years ago the trend has been towards reducing the numbers of embryos replaced in the womb. At the very start multiple embryos were replaced often with disastrous consequences as multiple birth is a much higher risk complex pregnancy. The Human Fertilisation and Embryology Authority (HFEA) restricted triple embryo transfers in 2003 and introduced the ‘one at a time’ campaign in 2007 which resulted in a significant culture shift leading to more single embryo transfer cycles. The result was that by 2019 around 75% of IVF cycles are single embryo transfer cycles, compared to just 13% of IVF cycles in 1991. The effect of this is that the numbers of multiple births has dropped significantly but interestingly this has not meant a drop in success rates. In 1991 the chances of a live birth from IVF was around 8% (under 35 years) and today this is now closer to 30% despite the significant reduction in double and triple embryo transfers.
Reference – Fertility treatment 2019: trends and figures (published May 2021) – HFEA
10. How long until we can start treatment?
This is a such an important question to check with your clinic. Some clinics may not have the capacity to start patients as quickly as they would like. In some cases there may be waiting lists as the number of IVF cycles that can be performed each month are capped. The larger clinics tend to have larger capacity to accommodate patients but this should not be assumed. When you meet with your doctor or specialist for an initial consultation a number of natural steps will follow involving blood tests, consent, medication training and ultrasound scans. Most patients should be able to start treatment in an efficient clinic within weeks of their doctors consultations. However, this is an important question to ask.
So if you’re considering booking an initial fertility consultation, bear in mind these questions and answers and be prepared before attending to ensure you get the most from your appointment with a fertility specialist.