Below is the event summary and some additional content that we hoped help give more context on some of the ideas covered in the talks. The information has been fact checked by Venessa Smith, the Embryologist who spoke at the event. A few definitions (e.g. IVF) have been repeated in more than one section where it provides context.
- Fertility definition: Fertility relates to the ability to conceive. Most women are only “fertile” for 2-3 days a month. It is sometimes difficult to predict these days without the aid of an ovulation kit because often individuals do not ovulate mid-cycle as is assumed.
- Relationship between fertility and age:
- Both the chances of natural pregnancy and success rates with IVF (assisted fertility technique - see below for more details) decline with age. Fertility declines with age in women for a number of reasons but predominantly due to decreasing egg quality (i.e. risk of the egg having too few or too many chromosomes). These chromosomal changes increase the risk of miscarriage and the chances of having a child with a genetic issue.
- It is commonly cited that 35 is the average age at which the pace of fertility decline increases. However, Venessa shared that recent research in clinics indicates a more significant decrease in success in IVF in women over the age of 37 which is leading to professionals to explore if the increased pace of decline happens after 37.
- But the experts made clear that these “rates” are based on averages and everyone’s own body and chances of success are different.
- Egg freezing: or oocyte cryopreservation, is the process of stimulating the ovaries to produce eggs (stimulation), extracting those eggs (egg collection) and then cryopreserving (freezing) them prior to storing them in liquid nitrogen. When you decide to use the eggs, they would be thawed and can then be used in IVF/ICSI treatment (see below). When the eggs are used, the chance of success is reflective of the age at which they are stored rather than the age of the woman at the time of this treatment (more detail in egg freezing section).
- In Vitro Fertilisation (IVF): refers to fertilisation outside of the body. It is commonly referred to as the process of stimulating your ovaries (stimulation) to produce a number of eggs which are then collected and fertilised in the laboratory. These fertilised eggs are then left to develop to create embryos prior to transfer into the womb. The transfer of the embryos usually occurs after 3 or 5 days of embryo development.
- Intra-cytoplasmic sperm injection (ICSI): differs from conventional IVF in that the embryologist selects a single sperm to be injected directly into an egg, instead of fertilisation taking place in a dish where many sperm are placed near an egg. This process is more commonly used in assisted fertility treatments using thawed (from frozen) eggs rather than IVF incase the freezing process causes the outside of the egg to harden and reduce the chance of fertilisation.
- Menopause: is the cessation of menstruation. The average age for menopause is 51 years old although it is not uncommon to occur between mid 40s to early 50s. Early menopause is defined as menopause occurring before the age of 40. There is no proven link between the age at which you start your period and the age you experience menopause. A good predictor for when you might experience menopause is when your female relatives experienced it – it is thought to have a genetic element.
- Infertility prevalence: 1 in 7 couples have trouble conceiving, around 3.5 million people in the UK.
- Reasons for infertility: There are a range of reasons why people have trouble conceiving - these include female factors, e.g., endometriosis, ovulation problems, poor egg quality, Polycystic Ovarian Syndrome (PCOS), tubal blockages, and male factor relating to the production or maturation of sperm. In around 25% of cases infertility is defined as “unexplained”.
- Identifying issues: Fertility testing can help identify some of these problems and allow you to investigate some of these issues prior to conceiving (e.g. cysts can be removed, tubal blockages can be addressed). The most common proactive testing for women is an Anti-Müllerian hormone (AMH) blood test and a trans-vaginal ultrasound scan.
- Preparing for future conception: There are a range of healthy lifestyle suggestions that can help get you in shape for future fertility e.g., addressing sexually transmitted inflections (STIs), maintaining a healthy weight (Body Mass Index or BMI), stopping smoking and recreational drugs.
- Lag effect of the pill: A question was left on the board on the lag effect of getting your cycle “back to normal” after coming off the pill in order to get pregnant. The “lag effect” of getting your cycle back to its natural pattern can vary depending on type and dose of contraception used, but more importantly it depends on individuals. Some people find no lag period at all and are able to get pregnant in their first natural cycle after stopping, while others take a few months to settle back into their natural cycle routine. You can discuss this with your GP, when deciding what contraceptive method you plan to use or are currently using.
- Fertility testing can help identify some problems and allow you to investigate some issues prior to conceiving (e.g. cysts can be removed, tubal blockages can be addressed). The most common proactive testing is an Anti-Müllerian hormone (AMH) blood test and a trans-vaginal ultrasound scan.
- The AMH level gives an indication of "ovarian reserve" i.e. the quantity of eggs left as benchmarked against women in your age group. The benefits of the AMH test as compared to the more traditional hormone profile is that it is not dependent on the time in your cycle that you take the test and also does not change month by month. It also may indicate, in the event you decide to have treatment, the level of response you may expect from stimulatory drugs.
- A basic trans-vaginal pelvic ultrasound, is used to look at the ovarian reserve and the condition of the reproductive organs (ovaries, fallopian tubes and uterus). It can also identify the presence blockages, polyps, and fibroids. All of which will require further investigation.
- We discussed the limitations of testing. That AMH is not the perfect test but it’s the best possible indicator of the range of ovarian reserve we have.
- Articles/studies we found interesting:
- More details of the fertility testing offer mentioned at the event: http://www.smartegghq.com/fertility-mot
Egg freezing: or oocyte cryopreservation, is the process of stimulating the ovaries to produce eggs (stimulation), extracting those eggs (egg collection) and then cryopreserving (freezing) them prior to storing them in liquid nitrogen. When you decide to use the eggs, they would be thawed and can then be used in IVF/ICSI treatment (see below). When the eggs are used, the chance of success is reflective of the age at which they are stored rather than the age of the woman at the time of this treatment.
- Ovarian stimulation: Typically, stimulation medicine is taken for 10-15 days to increase the production of eggs. Eggs grow in follicles and it is easy to count the number of follicles present through an ultra-sound scan however not every follicle will contain an egg. Once a suitable number of follicles have grown an injection is given to mature the eggs. Eggs are collected 36 hours later by ultrasound guided/ laparoscopic aspiration before being vitrified ("frozen") and stored in liquid nitrogen. This collection ("egg retrieval") is usually done under sedation.
- Number of eggs collected: A clinic will aim to retrieve between 8 to 12 eggs per cycle but individual results may vary. Experts recommend the storage of 15 to 20 eggs therefore multiple cycles may be required. This study examines the relationship between the number of eggs frozen and the chances of success: http://www.fertstert.org/article/S0015-0282(15)02111-1/abstract
- Long-term effects: Research suggests that the long-term impact of ovarian stimulation in the majority of people is minimal. However, all medication does have the potential to lead to minor side effects and this is something that should be discussed with the doctor when you plan any treatment.
- Impact of egg freezing on menopause: there is no scientific evidence that links the timing of menopause on previous use of stimulatory drugs.
- Success rates: In the UK, egg freezing is a relatively new procedure and therefore the available data set for live births is small and may not be considered to be statistically significant. However, US data suggests that the age at which you freeze your eggs is strongly related to your chance of a subsequent pregnancy with those eggs you have frozen. Concerns regarding the survival of eggs following vitrification and thawing have been found to be unwarranted. However, eggs that were frozen more than 2 years ago may have been “slow frozen” and therefore the % survival rate is not as good as with vitrified eggs. The use of ICSI also increases chances of fertilisation if suitable sperm is used. You should confirm with your chosen clinic what their method of storage is, prior to embarking on the freezing process. We found the following study useful: Comparing frozen eggs with fresh eggs in IVF/ICSI treatment in US http://bit.ly/29vFJ14
- Length of storage: The law states that eggs can be frozen for a maximum period of ten years (extension can be requested by a doctor if for a medical reason) but this is currently under review.
- Using the eggs in the future: If you want to use your frozen eggs (through an IVF/ICSI i.e. assisted fertility process) you need to decide which clinic you want to have treatment. It is straightforward for laboratories to move stored eggs without risk to other appropriately licensed facilities both in the UK and abroad. It is worth discussing with your clinic how eggs might be transported and any rules and regulations of the particular geographic jurisdiction. Fees will apply, so don't forget to enquire about the cost.
- Is there any correlation between egg freezing and having twins?: The higher number of multiple pregnancies (i.e. having twins, triplets) through IVF/ICSI is mostly attributed to replacing several embryos into the womb in one treatment cycle. However, in the UK focus is given to encouraging clinics to replace only one embryo at a time. This reduces the risk of multiple pregancy and miscarriage. Multiple pregnancies also increase risks during pregnancy to both the mother and the babies. It has been statistically proven that the transfer of more than one embryo during an IVF cycle does not significantly increase your chances of pregnancy but does significantly increase your chance of a multiple pregnancy. It is good to ask clinics about their rates of multiple pregnancies when you’re researching where to have treatment. More on this here: http://www.oneatatime.org.uk/96.htm
- Effect of freezing and thawing on the egg: Venessa told us that there have been extensive international studies comparing outcomes for naturally conceived children, children created through IVF/ICSI and/or using frozen embryos. A significant increase in risk of genetic abnormalities was not documented. However, it should be noted that the average age of conception using assisted reproductive techniques is significantly higher than natural conception and this carries its risks. A study looking at differences between frozen and fresh eggs: http://www.ncbi.nlm.nih.gov/pubmed/25064408
Picking a Clinic
There is limited support from the NHS for proactive fertility (i.e., fertility testing if you’re not trying for a baby right now). If you are trying to conceive naturally without success, your GP can help with some tests and potentially fund IVF. However, this is dependent on where you live. For proactive fertility and egg freezing (for non medical related reasons) you will need to access private services
- There is a range of clinics in UK offering fertility testing (80+) and egg freezing (50+). All are listed on the HFEA website along with data on success rates (mainly of IVF)
- HFEA website: http://guide.hfea.gov.uk/guide/AdvancedSearch.aspx
- For fertility testing: the tests are probably delivered in a similar way, the reputation of the fertility doctor is a good indicator of the credibility and success of a clinic.
When picking a clinic for egg freezing you should consider: customer service, proximity from work/home (as you have to go in a lot) and success rates. There is limited information publicly available on success rates and costs. Ask to speak to the embryology team and understand their experience. From interviews with embryologists we have heard that the success rates in the egg freezing process is down to the skill and competency of the embryology team.
Therefore when picking a clinic for egg freezing it is worth asking:
- Clinic's experience and success in egg freezing:
- How long has your clinic been using the vitrification rather than slow freezing method?
- How many egg freezing cycles has your clinic performed? (for own and donor use)
- How many women have come back to use their frozen eggs?
- What is the clinic’s egg thaw survival rate? (for own and donor use)
- What is your clinic’s live birth rate using frozen eggs? (own and donor use)
- What is the live-birth rate per frozen embryo transferred?
- Clinic's perspective on your situation and expectations:
- At my age, how many eggs do I need to bank to have a “good chance” of having one live birth from my frozen eggs?
- Based on my AMH and ultrasound, how many eggs do you think I will produce? At this stage should I consider more than one cycle?
- Costs: vary from clinic to clinic and country to country. In the UK a single egg freezing cycle may cost around £5K plus an annual storage fee (£100-300 per year). Check what the clinic includes in its fees - eedication, investigations and theatre costs may be additional to cycle costs.
- Questions to explore if proactive fertility testing is for you:
- What will knowing the results bring me?
- What will I do if the results identify issues?
- What support do I have in place if the results are not what I was hoping for?
- Questions to explore if egg freezing is for you:
- How important is having children to me?
- Why am I considering this? What will egg freezing bring to my life?
- Do I understand the process, and possible side effects?
- Do I understand the expected success rates? Do I understand that this is increasing my chances of having my own genetic child one day but is not a guarantee or “insurance policy”?
- Am I comfortable with the fact it is unclear how many eggs one round/cycle of egg freezing may produce?
- On balance, do I think the process is “worth it” for me?
- Do I have the support structure in place to aide me through the process?
- How do I feel about the fact that I may never need to use the frozen eggs? Do I have a sense of what I will do with them?