Why one embryo may be better than two

Embryo,_8_cellsWhen it comes to embryo transfer, some people still worry that putting one back will reduce their chances of success. In fact, for those who have good quality embryos putting them both back will just increase your chances of having a multiple pregnancy – and although twins or triplets may sound like a wonderful idea when you are trying to conceive, it is the biggest health risk from fertility treatment. Now, some interesting new research suggests that perhaps it isn’t just those who have good embryos who should be having one embryo transferred.

A study by scientists at Nurture in Nottingham found that putting back one low quality embryo alongside a high quality one reduced the chance of becoming pregnant by more than a quarter. It was only when neither of the embryos were good quality that putting back two actually increased rather than decreased the chances of a successful pregnancy. You can read more about the research here.

This does back up the idea that single embryo transfer is the best option for many – but not all – fertility patients. It should always be something you discuss with the team treating you but it is really important to be aware that putting back more than one embryo may not increase the chances of success.

Other people’s fertility treatment

laptop-computers-1446068-mThe Internet can be a fantastic resource when it comes to finding out more about fertility and treatment, and many people gain important insights by reading other people’s fertility stories online. This can, however, have a less helpful side. Although it may be useful to get practical tips, to read about what happens during a cycle and to feel that you are more prepared for what is about to happen, it is also vital to remember that everyone’s treatment is different. The tests carried out, the protocols used, the drugs prescribed can all vary depending on your own individual situation.

Recently I’ve been contacted by a few people asking about their treatment who have become worried that something might not be right because they’ve come across other people who have had different tests or treatments – or who have been prescribed different drugs at different doses. Just because your treatment is not exactly the same as someone else’s, that doesn’t mean it is wrong or less likely to work. If you have concerns, you should never worry about asking at your clinic, but remember that fertility treatment is always tailored to an individual to some degree and that clinics may not all do everything exactly the same way.

Expert opinion on treatment add-ons

If you’ve been unsure who to believe about fertility proline_level_measurement_in_eurasian_national_universitytreatment add-ons, you may be interested in some impartial and expert advice in two new scientific opinion papers published by the Royal College of Obstetricians and Gynaecologists (RCOG). They call for more high quality research into the role of natural killer cells in fertility and the effect of endometrial scratching on pregnancy outcomes.

Scientific Impact Papers (SIP), are up-to-date reviews of emerging or controversial scientific issues. The first paper looks at the role of uterine natural killer (uNK) cells, how they are measured, the role of testing and the evidence behind any links to improving implantation rates and early placental development. The paper clarifies that uNK cells are completely different from peripheral blood natural killer cells (which you would be testing in the blood tests some fertility clinics currently offer).

The paper makes it clear that there is no evidence to offer routine tests for NK cells as part of fertility treatment or testing, and that there is uncertainty about how NK cells are measured and reported. The paper says that treatment for raised levels with intravenous immunoglobulin (IVIg)  is not supported by the current evidence and, since it may have serious adverse effects, should not be used..

The second opinion paper explores the effect of endometrial scratch on pregnancy outcomes in women who have experienced recurrent miscarriage and recurrent implantation failure.

Endometrial scratch is a procedure which is hypothesised to help embryos implant more successfully after IVF/ICSI and involves scratching the lining of the womb.

Several studies have examined the impact of endometrial scratch in the cycle preceding an IVF treatment cycle in women with recurrent implantation failure, which appear to provide convincing evidence of benefit of superficial endometrial scratch in improving the implantation rate in this group of women. However, the effect of this treatment on pregnancy outcomes in women who have experienced recurrent miscarriage or those undergoing their first IVF cycle is uncertain.

Professor Adam Balen, Chair of the British Fertility Society (BFS) and spokesperson for the RCOG, said: “These two papers look at the current available evidence which exists and give much-needed guidance to both healthcare professionals and the public on these two topics. It is important that patients receive full information about treatments, the current evidence for benefit and whether there are any side effects or risks associated with it.”

Mr Mostafa Metwally, Vice Chair of the RCOG’s Scientific Advisory Committee added: “There is currently no convincing evidence that uterine natural killer cells are the cause of reproductive failure. Despite this, a number of women are requesting and being offered analysis of either peripheral blood or uterine killer cells and the value of these measurements remains controversial. Current evidence suggests that endometrial scratch may benefit women with recurrent implantation failure and therefore defining the optimal number of previously failed embryo transfer cycles needs to be evaluated in large cohort randomised prospective clinical trials.We still do not understand the mechanism by which endometrial trauma may lead to improvements in IVF outcomes in women and further studies are needed looking specifically at its success among women undergoing their first IVF cycle.”

The papers are available here:

The Role of Natural Killer Cells in Human Fertility

Local Endometrial Trauma (Endometrial Scratch): A Treatment Strategy to Improve Implantation Rates

Left confused about intralipids?

lipidemulsionIf you watched Panorama yesterday and were left worried or confused about intralipids, there are sources of accurate and sensible information.

Looking at some of the comments from fertility patients after the programme, it seems that many people were actually surprisingly unconcerned by the lack of evidence for many of the treatments discussed because they felt if there was any chance at all of something making a difference, they would still be happy to try it.

What the programme didn’t make clear was that there are some potential health risks from using intralipids. These are clearly explained on the current HFEA website which has excellent information on reproductive immunology and covers intralipids. There is also a basic information sheet on add-ons from the British Fertility Society.

Will my IVF work?

ivf_science-300x168You may have heard about the new predictor tool for IVF/ICSI which has been developed recently which is available through the University of Aberdeen website.

It uses data from the Human Fertilisation and Embryology Authority which keeps records of all cycles of treatment carried out in the UK, to aim to give a picture of your individual chances of having a baby after IVF/ICSI treatment,

The reporting of this has been analysed by NHS Choices which points out that there are some gaps in the data which the researchers themselves have acknowledged as it doesn’t account for the woman’s body mass index (BMI), whether she smokes and how much alcohol she drinks.

Despite these limitations, it is certainly a very useful tool and one which may help many couples get some kind of realistic idea of the chances of an IVF cycle working. Of course, the experience of each individual couple is always different and this doesn’t allow you to include any detailed medical data either, but it does give a broad picture view which may prove very helpful.

Should you pay for add-ons when having IVF?

proline_level_measurement_in_eurasian_national_universityWhether you are at the point of considering IVF or have already had some treatment, you will be aware of the wide range of additional treatments which some fertility clinics offer on top of the standard treatment cycle. The idea is that these will improve your chances of success, and as people inevitably want to do all they can to boost the likelihood of a positive outcome, it can be very tempting to pay for at least some of these.

It is clear that they will certainly add to the cost of your treatment, but whether they will add any benefits in terms of outcomes is still very much up for debate. Few of these add-ons have a reliable base of scientific evidence to prove that they are likely to work, yet patients are often paying for them believing that without them there is a lower chance of a successful cycle.

Yacoub Khalaf who is Director of the Assisted Conception Unit a Guy’s and St Thomas’ in London, spoke on the subject at The Fertility Show at the weekend. If you missed it, you may be interested in his article on the Huffington Post about this.

Choosing a fertility clinic

800px-Woman-typing-on-laptopOn Saturday, I’ll be speaking at the Fertility Show at London’s Olympia about what you need to think about if you are choosing a fertility clinic. If you are fortunate enough to have NHS-funded treatment, you may not have a wide range of clinics to choose from, and in some parts of the country there are fewer clinics than in others – but if you live in London or the South East and you are paying for your treatment, the choice can be overwhelming.

I’ll be explaining how to make sense of what can seem an overwhelming array of different clinics all claiming to be the best, and what factors you should take into consideration when making your choice. I’ll cover treatment outcomes – how to make sense of the IVF success rates published by the HFEA and why they may not be the only thing you want to look at when making a decision – and will look at a number of other issues that can affect which clinic might be right for you.

If you’re at the Show on Saturday, I look forward to meeting you – make sure you come and say hello!

Taking part in clinical trials

proline_level_measurement_in_eurasian_national_universityPeople often email asking about clinical trials, and there are a couple of big multi-centre trials taking place at the moment which may be of interest. Taking part in a trial can be a really positive thing to do as you will be helping to improve understanding of techniques which may help make IVF more successful in future.
The first trial is called EFreeze and is investigating whether using frozen thawed embryos rather than fresh ones may lead to improved success rates in IVF. The theory behind this is that if the embryos are frozen rather than replaced straight away, the delay in embryo transfer means that any effects of the hormones used to stimulate the ovaries have worn off and the womb has time to return to its natural state.

Couples taking part in the study will be randomised to either have embryo transfer straight away as usual in IVF, or to have their embryos frozen and replaced later to see if this does improve outcomes. There is a lot of information for anyone considering taking part, including a list of participating centres, and a video to explain more on the trial web pages. You need to be under the age of 42 to take part in the trial which is being conducted across England and in Scotland.

The other trial is looking at endometrial scratch – a process which involves scratching the womb lining in the month before IVF treatment. There has been some research looking at this in women who’ve had repeated unsuccessful IVF cycles which suggest it may improve outcomes, but this new trial is looking at those who are having their first cycle. The study is based in Sheffield, but will be taking place at clinics around the country. It involves placing a small tube about the size of a drinking straw through the neck of the womb and gently scratching the womb’s lining.

Those taking part will be randomised to receive the scratch or not. If you want to find out more you can look at the information on the University of Sheffield website and there is a video to explain more about what is involved,

Can people without fertility problems be infertile?

flag_of_who-svgWhen a story about the World Health Organisation apparently deciding to revise their definition of infertility to include single men and women without fertility problems who wanted to become parents, there was an inevitable media flurry of stories about the NHS having to offer them fertility treatment.

The Daily Mail heralded the story with a headline shouting “Single, childless but want a baby? You could be labelled infertile“, while The Telegraph told us that “Single men will get the right to start a family under new definition of infertility” and The Sun went one better with “Gay couples and single men who want kids will be branded ‘INFERTILE’ – to make accessing IVF easier“…

In reality, the chances of this happening in the UK in our current fertility funding climate is very slim. It is already hard for couples with proven fertility problems to access treatment in many parts of the country, let alone those without them. We have seen cuts to fertility services in recent months and fewer and fewer fertility patients are now being offered the treatment that NICE recommends – which is three full cycles of IVF for those who are 39 and under. So the idea that commissioners are going to rush to start offering treatment to single men and women is far from likely…

Men speaking out

Sex_educationWhen you read about fertility problems, it’s nearly always women who are speaking out and telling their stories, but I’ve been really heartened to see that more and more men are opening up about their experiences of fertility tests and treatment. This article by Dan Rookwood in the Evening Standard is a great example.

Dan makes it clear that it isn’t just women who find it difficult when other people announce their pregnancies, that it isn’t just women who feel the disappointment when every period comes, that it isn’t just women who come to dread that question about when they are going to get around to having children… And anyone who has struggled with a diagnosis of unexplained infertility and who has been told that being less stressed might help will know exactly where Dan is coming from when he says that “nothing stresses you out more than someone who can’t give you any definitive answers telling you not to stress out“.

It’s a great article and well worth a read – it’s really important that we start to realise that fertility problems affect men just as much as they affect women.

One small quibble though – Dan says that he and his partner opted to transfer two embryos in order to “double our chances of success“. It is very important to be aware that although it may feel that way in fact putting back two embryos most definitely doesn’t double your chances of success – it just increases your chance of having twins. Dan explains that he and his partner began their treatment in the US, and if that’s where they had their IVF, it would explain this entirely as not all clinics in the States are as concerned as we are here in the UK with reducing multiple pregnancy. Here, a team would usually recommend single embryo transfer for a first IVF cycle if the embryos were good quality. Although we all know twins who are fine, many others are not – and multiple pregnancy is the biggest health risk from IVF, which is why it is so important to choose a fertility clinic which has a good success rate combined with a low multiple rate.