Do you really need ICSI?

ICSI (intracytoplasmic sperm injection) is a successful treatment when there are male fertility problems, but it is often used more widely in fertility clinics – and some offer ICSI to many patients where there is no male factor problem at all. Now, new research presented at ESHRE (the European Society of Human Reproduction and Embryology) shows that there is no benefit to offering ICSI unless there is a male fertility issue.

ICSI was developed in the 1990s as a breakthrough treatment for men who would otherwise have had to use donor sperm to become a parent, but now it is used so often that twice as many ICSI cycles are carried out around the world as IVF cycles. In some countries all assisted conception cycles are ICSI.

This large study of almost 5000 patients in Belgium and Spain being treated with ICSI or IVF found there was no benefit to using ICSI where there was no male fertility problem. The results of the study were presented by Dr Panagiotis Drakapoulos from UZ Brussels, the Belgian centre where ICSI was developed more than 25 years ago. The study was a collaboration between the Brussels centre and 14 clinics in Spain.

The reason given for using ICSI is often that it is thought it results in a higher chance of fertilisation and more embryos, but this large study showed no overall difference in outcome using IVF or ICSI regardless of whether the female patients had large numbers of eggs (more than 15) or not so many (1-3) – so there is no rationale for using it to try to improve outcomes in cycles where there are just a few eggs.

The use of ICSI varies around the world, with the highest rates in many countries of Eastern and Mediterranean Europe. There is a slightly lower use in some Nordic countries, the UK and France. In its latest review of treatment trends in the UK, the HFEA reported that ICSI use ‘continued to increase until 2014, but it is now in decline, possibly due to clinical opinion that it’s not needed in all contexts of IVF’. 

This reflects the message from this study, which, according to Dr Drakapoulos, found ‘no justification for the use of ICSI in non-male factor infertility’. He added that the number of eggs retrieved ‘should not play any role in selecting the insemination method’. Dr Drakapoulos also highlighted the extra financial cost of ICSI over IVF.

Men have a biological clock too

We’re all very aware of the female biological clock, but what we don’t hear so so much about is the fact that male sperm counts decline and DNA damage in sperm cells may increase as men get over. The fact that some high-profile men have become fathers when they are pensioners perpetuates the myth that male fertility lasts forever.

In fact, evidence shows men do have a biological clock with a decline in natural male fertility and an increase in the miscarriage rate as men get older. New evidence at ESHRE from one London fertility clinic shows that IVF/ICSI is less likely to succeed if a male partner is over 51 too.

Dr Guy Morris from the Centre for Reproductive and Genetic Health (CRGH) in London presented results at the ESHRE (European Society of Human Reproduction and Embryology) conference of an analysis of more than 5000 IVF/ICSI cycles which found that although there was no difference in miscarriage rates, there was a significant reduction in the chances of success

The results showed that that clinical pregnancy rate declined as men got older – from 49.9% when men were under 35, to 42.5% for men aged 36-40, 35.2% for those aged 41-45, 32.8% for those aged 46-50, and 30.5% in the over 51s.

The researchers also noted that 80% of couples where the male partners were over 51 were treated with ICSI, a treatment developed for male infertility. Dr Morris said: ‘There may well be a public perception that male fertility is independent of age. Stories of celebrity men fathering children into their 60s may give a skewed perspective on the potential risks of delaying fatherhood. Indeed, in natural conception and pregnancy it is only recently that evidence of risks associated with later fatherhood has become available. These more recent studies contrast with decades of evidence of the impact that maternal age has on fertility outcomes. In the context of this emerging evidence for the deleterious effect of increasing paternal age, our data certainly support the importance of educating men about their fertility and the risks of delaying fatherhood.’ 

Fertility information research

Researchers are looking at patient information currently available about fertility treatment and are keen to talk to anyone who either has had treatment in the past or is thinking about it as an option. The study is called the Empowering Patient Informed Choices (EPIC) study and it is about developing better patient-centred information. The research team wants to know what helps when it comes to making decisions, particularly related to additional treatments. 

You can take part here – it takes about ten minutes to complete the survey https://lse.eu.qualtrics.com/jfe/form/SV_bdAnfkKd2YGp5qd

When IVF doesn’t work…

You may have heard in the news recently about the latest statistics on IVF success for women in their forties, and seen that Sally Cheshire, Chair of the fertility regulator the Human Fertilisation and Embryology Authority (HFEA), has spoken out about the need for fertility clinics to be more honest and open with patients about their chances of IVF success.

The latest figures show that the number of women in their forties having IVF has doubled since 2004, but only 75 women aged 42 and 43 will get pregnant using their own eggs, and once you reach the age of 44, just two women a year are successful. To put that into context, approaching 11,000 women who were over 40 had IVF in 2017.

Some clinicians say that women are entering into IVF with their eyes open, well aware of the chances of a successful outcome, but you don’t have to talk to many women who have had IVF to know that is often far from the case. When you are longing for a baby, you tend to hear the positives rather than the negatives, and when there’s a 5% chance of success, it’s the 5% you focus on rather than the 95% chance of your treatment not working.

It is difficult as sometimes women feel that although they may be 44 or 45 and know it is unlikely that treatment will work, they still want some kind of closure and need to know they’ve done everything they possibly could.

Sally Cheshire talks in her interview about being approached by clinics at the Fertility Show in Manchester and being given unrealistic suggestions of her chances of having successful IVF treatment. It is vital for clinics to be honest about this – and it doesn’t take much searching to find clinics publishing clinical pregnancy rates for women in their mid-forties which many will see as their chance of having a baby – when in fact, miscarriage rates are high for women of this age and these clinics know only too well that the live birth rate is very different from the clinical pregnancy rate.

You can read more about Sally Cheshire’s interview with the Telegraph here

To The Moon and Back

At last year’s Fertility Fest I was lucky to be in a session with mother and daughter, Anna Furse and Nina Klaff, who gave an amazing performance about their experiences of IVF as a parent and as someone born through IVF. It was incredibly moving, and I was delighted to hear that Anna and Nina will be back performing at this year’s Fertility Fest at the Barbican where they will be joined in discussion afterwards with Channel Four News Health and Social Care Correspondent, Victoria MacDonald and Ann Daniels, a polar explorer and mother of IVF triplets.

The performance takes place on Friday 26 April at 7pm and you can book tickets here

Emotional support

When you’re thinking about having fertility treatment, it’s probably the Injections, drugs and egg collection which sound challenging, but if you ask people who’ve had IVF what makes it so hard, most will say it’s dealing with your emotions which is the really tough part. It’s often described as an “emotional rollercoaster” and although that’s become rather a cliche, it’s true that it’s the ups and downs of treatment that are so hard to handle. IVF can feel like a series of hurdles and no sooner are do you get past one, than you find yourself facing the next along the way.

All fertility clinics offering IVF have to provide people with the opportunity to see a counsellor but it doesn’t have to be included in the cost of treatment. Some people are keen to have counselling support from the start, but others may feel they don’t want or need to see a counsellor, and it’s worth bearing in mind that it is fine to change your mind if you feel you want to access support further down the line.

It may be that part of your concern about counselling is that you aren’t quite sure what it might involve and you may have visions of yourself lying on a couch talking about childhood traumas. If you want to know more about fertility counselling and how it might help, Angela Pericleous-Smith, chair of the British Infertility Counselling Association (BICA) will be speaking on the subject at the Fertility Forum in London on March 30. BICA trains the counsellors who work in the UK’s fertility clinics and offers a “find a counsellor” service to help you to ensure that you can access specialist support no matter where you live. Angela will be talking about  the pressures on yourself, your relationships and your friendships. She will explore coping strategies and explain how to manage anxieties.

The Fertility Forum is a non-commercial evidence-based day which has been organised by patients and all the professional bodies in the field working together, and aims to help those who have been trying to make sense of the overwhelming mass of information on offer.

Tickets for the Fertility Forum are on sale here – and you can see more details of the day including a full programme here.

When IVF doesn’t work…

It’s something no one wants to think about when they are just starting out on fertility tests and treatment, but we know that IVF doesn’t always work. Even in the best case scenario, an individual treatment cycle is more likely to end with a negative pregnancy test than a positive one, although cumulative success rates are much more heartening. Perhaps if we didn’t shy away from the statistics, it would make unsuccessful IVF easier to cope with.

At fertility information events, there is often a reluctance to include any mention of IVF not working, and that doesn’t help fertility patients. We wanted to include a session on this, and on living without children at the Fertility Forum in London on March 30. We wanted to give an opportunity to hear some of the strong and powerful voices of women who are living without children, and how they have found peace and happiness. This session isn’t exclusively for people who are approaching the end of their treatment – it’s just as important for those who are still going through tests and fertility treatments to allow them to see that treatment not working doesn’t have to be the end of happiness.

In a session chaired by Fertility Fest founder Jessica Hepburn, we have four inspiring women who are helping others change the way we think about living without children. There’s Jody Day, founder of Gateway Women, Yvonne John, author of Dreaming of a life unlived, Kelly Da Silva of the Dovecote and Lesley Pyne, author of Finding Joy Beyond Childlessness.

I’ve met all of them and they are a pretty fabulous bunch – don’t be afraid to come and hear what they have to say, no matter where you are on your fertility journey. Organised by patients and bodies representing all the professionals in the field, the Fertility Forum also includes talks on a huge range of other fertility-related topics with many of the UK’s leading experts. Come and join us in London on March 30 for a day of accurate, unbiased information in a non-commercial setting with no promotions or sales pitches. The Fertility Forum is all about evidence – and you can get tickets here.

Fertility funding restored in South Norfolk

Usually when we hear about changes to fertility funding, it means one thing – cuts to services. In South Norfolk, however, local commissioners who cut all funding for fertility treatment two years ago have now reviewed their decision and will offer two cycles to women under 39 and one cycle to eligible women aged 40-42.

It’s great news to see such a positive step for fertility patients and will bring hope to people in other areas of the country where funding for fertility treatment has been reduced or removed.

You can read local media coverage of this development here

Fertility Forum – bringing professionals and the public together

If you’ve ever wanted access to clear, reliable information about fertility problems and treatment, the Fertility Forum on 30 March is for you. Set up by patients working with all the professional bodies in the field, the Fertility Forum aims to be a day of pure evidence about fertility with no promotion for particular clinics or treatments, and no one selling anything. It’s all about evidence.

The Fertility Forum will take place at the Royal College of Obstetricians and Gynaecologists (RCOG) in London, and many of the UK’s leading fertility specialists will be speaking at the day, and there will be three strands of talks. They will cover everything from nutrition and lifestyle advice to the latest developments in fertility treatment. There will be talks on specific fertility issues such as endometriosis and polycystic ovary syndrome (PCOS), on donor treatments and surrogacy, on recurrent miscarriage, on stress and fertility support, on male fertility problems and how men deal with infertility. The HFEA will give advice on how to choose a fertility clinic and there will be a talk on deciding whether to opt for treatment abroad. How embryos develop and why IVF does and doesn’t work will also be discussed along with an assessment of the evidence on additional treatments like endometrial scratch or embryo glue, and there will be a session on accessing NHS funding. You will be able to choose which talks you attend when you get your tickets. There is a charge for the tickets (£25) to cover the cost of putting on the day, but there are no additional charges.

The day has been organised by the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Fertility Society working in partnership with the Human Fertilisation and Embryology Authority (HFEA) and Fertility Network UK alongside the Association of British Andrologists, British Andrology Society, Association of Clinical Embryologists, British Infertility Counselling Association, Royal College of Nursing and the Senior Infertility Nurses Group. The Donor Conception Network will be taking part in the event along with other patient groups including the Miscarriage Association. The day will be opened by the RCOG President, Professor Lesley Regan, and the Chair of the HFEA, Sally Cheshire CBE.

To find out more and to buy your tickets go to http://bit.ly/FertilityForum

The impact of IVF

You may have heard that having IVF brings a slightly increased risk of giving birth early and having a premature baby, but new research suggests that this may not be to do with the IVF itself. This large study was the first time researchers had used information from Finland about children conceived using IVF who had siblings who’d been conceived naturally – and found that the naturally-conceived siblings had just as great a risk of being born prematurely. It’s really interesting research as there are often questions about whether adverse effects which appear to be related to IVF are actually to do with the treatment itself or whether the underlying causes of infertility may be the real link.

You can read more about the study, which was published in the Lancet, here and here