Estelle Matthews: In today's society, couples tend to have children much later in life. This can lead to an increasing number of difficulties when trying to conceive, so much so that it's lead to a growth in demand for treatment of sub-fertility.
Dr. Alison Taylor is a fertility consultant at the Lister Hospital. Welcome! Thanks for joining us Alison. First of all, can you remind us about the main reasons why couples have difficulties having a baby.
Dr. Alison Taylor: Sure. We can really think of them as reasons from the male partner's point of view, from the female partner's point of vie and the couple together. If you think about that male partner, then it really comes down to problems with the semen sample or sperm count, and that can be, either there are small numbers of sperm there, they are not moving very well or there's a high number of abnormally shaped sperm. And there are number of reasons for that. It might be that the man has been born with a problem like the testes didn't come down probably at birth or there might be genetic reason why the testes aren't producing sperm properly. Or there might have been something that's happened since he has been born, perhaps some infection that has caused some damage or he might have had to go through some medical treatment for cancer, probably just radiotherapy or chemotherapy that has caused some damage.
But in the majority of cases where there is a sperm problem. Actually we don't often know what the underlying problem is. On the female side of things and then there could be problems where the woman is not producing an egg regularly, not copulating, or she might have a problem with her fallopian tube, and they might have become damaged perhaps by infection in the past and become blocked, so they are not collecting and picking up the egg properly when it is released each month.
Estelle Matthews: And how will you find that out? I mean how would you detect the problem in the fallopian tubes?
Dr. Alison Taylor: You would have to investigate that with a test to see whether the tubes are open, which can either be an X-ray based technique or Ultra Sound based technique or an operation called laparoscopy. But in all of them, you put some dye through the tubes and watch what's coming out of the ends of the tubes,
There are some other female reasons why partners maybe -- why couples maybe having difficulty getting pregnant. They also include problems with the uterus. So women who have significant fibroids in the wall of the uterus can have difficulty getting pregnant. And there's also a condition called endometriosis which can cause damage and scarring in the pelvis and that also can make it difficult for couples to conceive.
And then there can be problems between the couple themselves when they are trying to have sex. It may not be happening very often or it may be happening, but not appropriately timed within the cycle of woman's most fertile time in her menstrual cycle. And then theirs a group which is about 20% of couples when no obvious cause is found and we sometimes call that unexplained sub-fertility.
Estelle Matthews: So what would you do? What's the next step if you cannot explain the fertility problem?
Dr. Alison Taylor: Well, it depends a little bit on the age of the couple and how long they have been trying. If they haven't been trying for more than 3 years, then, actually there's a really good chance that they could get pregnant naturally and it can be up to 70% of couples will get pregnant without any particular intervention at all.
But many couples have been waiting longer than that or have reached the point, where they feel time is running out, perhaps because the woman is a little bit older. And in those situations, usually, we will advise moving on to some form of assisted conception treatment, which might be one of the simpler treatments by intrauterine insemination, where we are taking a sperm sample from the male partner concentrating the best sperm together and then placing it through the cervix into the uterus at the time the woman releases eggs from the ovaries.
Estelle Matthews: And at that state there are no drugs involved?
Dr. Alison Taylor: Yeah. We can either do it without drug in the woman's own natural cycle and the recent national guidelines recommended doing insemination in natural cycles. But there is no doubt that actually if you use some drugs to stimulate the ovaries, the success rates are a little better than if you do it in natural cycles without stimulation.
Estelle Matthews: Now, there's been a lot of press about the dangers of using fertility drugs. What do you say to people who have obviously been quite desperately trying for a baby for many years? Could you give us your version of how safe are they?
Dr. Alison Taylor: Sure, sure. I think its varying proportion because it is very commonly in the press these scary stories about risks of cancer following treatment, and no one wants to think that they are going to put themselves at significantly increased risk of major problems like cancer.
What I can say is that most of studies that have been done to date are generally reassuring that there aren't suddenly big increases in risks of breast or a variant cancer following fertility treatment. What's difficult is that patients, who have never achieved themselves, have a slightly higher risk of having breast and ovarian cancer anyway, and having a pregnancy seems to be protective.
So actually if we can give some treatment that results in a pregnancy, their risk may in fact go down. With some of the simple oral tablets, something called clomiphene, there has been a study that has suggested that very long-term use, beyond a year, or more than twelve cycles of treatment, might be associated with a small increase in the risk of ovarian cancer. So we tend to now be perhaps a little more cautious than we were in the past and recommend a more limited number of treatment cycles and then moving onto other treatment, if it hasn't worked, for example, after 6-9 months of treatment.
But we are flexible and we'll look at each couple individually.
Estelle Matthews: Now, are there any other ways of treating ovulation problems, we have talked about the drugs. But could you go some more specifically into what can be done without the invasive introduction of drugs?
Dr. Alison Taylor: Well, the simplest place to start usually actually is looking at a woman's weight. For some women, if they are significantly overweight or significantly underweight, just simply getting their weight near the correct range for their height can be enough to get them ovulating naturally which is obviously always the best way, because then they can just go off and try and conceive without any more medical intervention.
So a woman who is significantly overweight, we always stop with trying to get them to loose weight. Obviously that's easier said than done often. But with encouragement, some women can be very successful if they are motivated enough and can have very good results without needing drugs at all.
Estelle Matthews: And of course, being underweight is a problem as well. Isn't it?
Dr. Alison Taylor: It can be.
Estelle Matthews: Because periods can cease and --
Dr. Alison Taylor: Absolutely right.
Estelle Matthews: A woman's body isn't at the right state to conceive.
Dr. Alison Taylor: Yes. Even if the periods stop altogether there can be there aren't quite enough of the hormones around to really stimulate ovulation to occur effectively each month. So yes, again, if someone is underweight, who is perhaps exercising very markedly then we might advice them to try and gain weight.
Apart from using the simple clomiphene tablets that we were mentioning, which actually are a very effective way of treating ovulatary problems, the next step along the line is to consider using injections of hormone called Follicle Stimulating Hormone which directly acts on the ovary to produce the eggs or encourage the eggs to develop. But it has to be very carefully monitored with Ultra Sound scan, because apart of the potential risk we were talking about earlier with the worry about possible cancer, although that's probably extremely small. The more worrying risk actually is of causing multiple pregnancies and that is a definite risk with ovulation induction.
So we have to be careful to monitor with Ultra Sound scan to make sure there aren't too many eggs developing in the ovaries.
Estelle Matthews: What are the minor side effects that women will have to be prepared to go through for this?
Dr. Alison Taylor: Well, with simple ovulation induction actually, there's often very little in the way of side effects, because you're often just correcting something that's not happening naturally. And some women with clomiphene will get a few hot flushes. But generally, it's extremely well-tolerated, and with the injections, some women who over-respond and are very sensitive to the drugs might get a problem called a ovarian hyperstimulation, where the ovaries become very enlarged with way too many eggs developing. And the tummy can feel quite swollen and they can be bloated.
And if they are really severely affected then they may need admission to hospital. But that's extremely uncommon with simple ovulation induction. It's a bit more common after IVF treatment where you are pushing the ovaries a little harder to try -- deliberately trying to get several eggs to develop at the same time.
Estelle Matthews: Just as if you would talk us through the success rates, first of all, of ovulation induction.
Dr. Alison Taylor: Well, I think if you -- the important thing is to compare it to the chances of achieving a pregnancy naturally. The good thing about having a problem with ovulation is if you correct it and can get a woman ovulating each month, in the same way that another one is doing naturally then you put that woman's chance of conceiving back to exactly the same as if she had no problem at all.
So after a year of ovulatory cycles, you would expect about 85% of couples to have achieved a pregnancy.
Estelle Matthews: That's very high, isn't it? And what about, the IVF route?
Dr. Alison Taylor: Well, the IVF depends a lot on the age of the patient. The success of the IVF depends a lot on the age of the patient undergoing treatment. But you would expect around overall one in three patients to take home a baby after one IVF treatment cycle.
Estelle Matthews: Okay. Now, you mentioned earlier, we talked about the male problems. Can we just go back to that for a moment? I don't think many people will know, well, I certainly didn't before I met you too, that a sperm test would actually or could produce no sperm at all. In fact, that the semen could show that there was no sperm within that test. Could you explain why, there would be no sperm present?
Dr. Alison Taylor: Yeah. That's absolutely right, thankfully it's not common. But and it can be quite a devastating blow when a man is given the results of a semen test which shows no sperm present.
Occasionally, it's because there's been perhaps a febrile illness like a bad bout of flu a few weeks before and it just knocks sperm production on the head temporarily and then if you wait for a few weeks, it'll start to be produced again, as the man recovers. But more commonly there is another reason underlying it and the first thing to do is always to repeat the sample to make sure that is genuinely the case that there are no sperm present.
And then the reason why there might not be is there could be -- the testes are producing plenty of sperm quite normally responding to all the normal hormonal signals, but the sperm can't get out of the testes because there's a blockage in some of the pipes or tubes coming out of the testes.
Estelle Matthews: So what do you do with that?
Dr. Alison Taylor: Well, you can either -- sometimes it might be possible to refer them for specialist surgery to try and unblock the blockage and then allow the couple again a chance of conceiving naturally which is always preferable. But if you can't undo the damage or the blockage, then it's actually relatively simple to take sperm directly from the testes or the little tubules called the epididymis, which are close to the testis, with a fine needle and then use the sperm that you collect in that way to inject eggs in IVF or what's more commonly known as ICSI treatment where you are injecting sperm into eggs.
So that's the way you have a blockage of the sperm. Sometimes there are some men, who have normal testes there that would be capable of responding, but they are not getting the correct hormone signal from the brain and then they are relatively easy to treat because you can replace the hormones that are missing to stimulate the testes to produce the sperm.
So in those two groups, it's quite easy to help those couples to achieve pregnancies which is good news. The more difficult group to help are those where the testes themselves are either inherently not able to produce sperm or have been damaged in the past perhaps by radiotherapy or chemotherapy or infection, and are no longer to produce any sperm at all or perhaps only in very, very small numbers.
But even in that group, it's worth taking a little bit of tissue from the testis with small biopsy, because in about a third of cases, we can find some sperm there. There's not enough to have got out into the semen sample, but it's still -- you can find an occasional sperm within the testes and then you can use those sperm in the ICSI treatment.
Estelle Matthews: It sounds to me you would rather have a problem with the man than the woman, it seems easier to solve. Would you say that's right?
Dr. Alison Taylor: No, I wouldn't and I will.
Estelle Matthews: So weigh out the problems.
Dr. Alison Taylor: Because I think it was -- what the problem is in the woman. If the problem is -- one of the easiest problems to sort out is often an ovulation problem in the woman, because that ---
Estelle Matthew: Especially, if it's linked with weight. So that's easy to solve.
Dr. Alison Taylor: That you can sort that out more easily. You can get around some of the problems in the male partner. But it's very difficult to actually fundamentally change an abnormal sperm counts or sperms that aren't moving very well. There's very little we can do about that. So people often want us to try and prescribe drugs. But actually there aren't any drugs that make a difference, in that situation. So sometimes couple find that frustrating.
So I would say, although we can now get around a number of male sides of problems, it often involves quite hi-tech assisted conception treatment which couples naturally would prefer often to avoid. On the female side of things, there are other problems that we can treat but again not always with great success.
Tubule problems in women can sometimes be treated by surgery. The first thing you would do is if you thought that on the initial testing there might be tubule problem would be to generally we recommend doing a laparoscopy, if that haven't been done already to have a look at the tubes in a bit more detail and assess where the damage is and how severe the damage is.
If the tubes are just mildly damaged, it can sometimes be possible to open them up, and surgically remove the scar tissue. If the tubes are very severely damaged though, it may not be possible to open them up. But even if you can open them, they may not work or function properly, because the lining of the tube is very, very specialized. And it's very important for the tube to be able to move the sperm and egg along in the tube; it has a very specialized transport function.
So even if you can get some dye coming through the tube after surgery, it doesn't always mean it will work properly.
Estelle Matthew: Alison, this is a very long list of ifs, what if you can't identify, you have gone through the male, you have gone through the female, there's nothing that you can really identify as the source of the problem. You've touched on it earlier, but really, as a short answer, what would you do with a couple like that?
Dr. Alison Taylor: With unexplained sub-fertility you tend to start recommending assisted conception treatment and we mentioned a little bit about intrauterine insemination earlier. But couples will often end up in that situation moving on towards IVF treatment, which has the advantage, that not only does it give a high success rate than intrauterine insemination treatments, but it also gives more diagnostic information, because it's really the only way that we have of seeing how the woman's eggs will interact with the man's sperm in the laboratory where the fertilization can happen. That's all, because until you see that you don't necessarily know unless they have had a pregnancy previously.
It also gives information about, what happens to the eggs once they fertilize. So do they go on and divide and become rather simply normal looking embryos or are they embryos that are rather slow in development or are perhaps rather fragmented and tending to breakdown as they are trying to divide. And some of those things maybe happening naturally. So it maybe, but it will reveal some other reasons why a couple perhaps hasn't achieved a pregnancy up to that point.
Estelle Matthew: This is all very enlightening. Thank you so much for talking to us, and I am sure things will develop even further in the future.
Dr. Alison Taylor: Thank you.
Estelle Matthew: Thank you very much Alison.
Dr. Alison Taylor: Thank you.
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