Delaying Parenthood- Wake Up Call Needed in UK

Many women in the UK are delaying conception...the average age that married women have their first child is now above thirty. And while infertility treatments can be very successful they are not a miracle cure, especially in cases of advanced maternal age. Experts are calling for educational efforts through schools on fertility in conjunction with sex education. Mark Hamilton, MD, former chair of the British Fertility Society, believes that the public is uninformed about fertility, even those who are well-educated. Adding to the issue is the demographic profile in the UK. Much of the population consists of older people who are retired or near retirement and there is a shortage of young people. While keeping older people in the workforce longer would be helpful, educating young people about the risks of waiting to start of family would also be beneficial.

Susan Seenan of Infertility UK agrees that more education is needed for the general public. She states the only emphasis currently for younger women is contraception. "We spend our twenties trying not to get pregnant and our thirties trying very hard to get pregnant," she said. If women choose to put off having a family it should be with a full understanding of the risks, she added.

Male Infertility: The Other Half Of The Equation

By: Sunita Kulshrestha MD, FACOG Reproductive Endocrinologist

When a couple has trouble getting pregnant, there is about a 50% chance that there is a male factor causing or contributing to their infertility. In order to achieve pregnancy, a man must deliver into the vagina healthy sperm that are able to reach, penetrate and fertilize the egg.

The first test to assess male fertility potential typically is a semen analysis. Semen is the fluid that contains both the sperm and the secretions from glands that nourish and protect the sperm. A normal ejaculate contains more than 40 million sperm! A semen analysis measures several factors, including: the amount of semen produced (volume); the total number of sperm in each milliliter of semen (concentration); the percentage of sperm moving (motility), and the percentage of sperm that are normally shaped (morphology). Abnormalities seen in the analysis may include too few sperm (oligospermia), sperm that are not motile and do not move the way they should (asthenospermia), abnormally shaped sperm (teratozospermia) or a combination of all of the above. The number of sperm and the percentage of those sperm that are motile influence how many sperm are able to reach the vicinity of the egg. Sperm motility and morphology determine the ability of the sperm to penetrate the egg.

Historical risk factors for infertility and abnormal semen analysis include a history of sexual/erectile dysfunction, history of sexually transmitted diseases, exposure to environmental toxins including tobacco, drug use, and alcohol, prolonged exposure of the testes to high heat, history of undescended testes, history of mumps, chronic medical conditions such as diabetes, a family history of cystic fibrosis, urological procedures including inguinal hernia repair, history of cancer treatment, use of anabolic steroids, and the use of certain types of medications.

If a semen analysis is abnormal, another test should be performed at least three weeks later to confirm the findings. For any given man, semen quality can be quite variable and simple environmental effects (such as a fever, excess alcohol use, medications) can temporarily decrease the quality of the semen. If an abnormality persists, a urological evaluation can be informative. A physical exam can evaluate the size and location of the testes and the presence of a varicocele. A varicocele is a dilated testicular vein that can compromise fertility. The physical exam can also determine the presence of a patent vas deferens, the duct through which sperm flow from the testes to the penis.

Additional testing for the male may include a blood hormonal profile. Total testosterone and FSH (follicle stimulating hormone) are both indicators of testicular function. A prolactin excess or thyroid abnormality can also be evaluated with blood tests and can affect fertility. If the sperm concentration is less than 5 million/ml, genetic blood testing such as a chromosomal analysis (karyotype) and testing for missing segments of the Y chromosome (Y deletion) is recommended. A karyotypic abnormality can not only cause infertility, it can increase the risk of miscarriage and an abnormal pregnancy.

The treatment for male infertility is based on the suggested cause. Some causes of infertility can be accurately defined and effectively treated. Lifestyle changes such as avoiding smoking, excess alcohol, and heat to the scrotum can improve semen quality. Medication can help men with erectile or sexual dysfunction. Varicoceles can be treated through outpatient procedures. Hormone treatment can be instituted if there is a hormonal insufficiency of the thyroid gland or the signals from the brain that control sperm production (FSH, LH). Antibiotics can be given for prostatitis or other infection.

Most causes of male infertility, however, do not have an identifiable cause. For mild to moderate abnormalities in sperm numbers, sperm motility or morphology, an intrauterine insemination (IUI) can improve fertility. An IUI delivers a higher concentration of sperm closer to the egg and improves the efficiency of the process.

For moderate to severe abnormalities, in vitro fertilization with ICSI (intracytoplasmic sperm injection) can be performed with great success. IVF involves the female partner taking hormones to stimulate the ovaries, collecting eggs through an office procedure called an egg retrieval, and then injecting a single sperm directly into each egg (ICSI) to create embryos. These embryos then grow in the lab and are transferred back into the female's uterus. IVF with ICSI has revolutionized the treatment of male infertility because the vast majority of problems that lead to male infertility can be completely bypassed, as long as just a small amount of normal sperm is present (rather than the normal millions).

Sperm can be obtained for IVF/ICSI from an ejaculate or directly from the testes/epididymides using the techniques of testicular biopsy, epididymal sperm aspiration and non-surgical sperm aspiration (NSA). An NSA can be performed in a simple medicated procedure in the office at the time of the egg retrieval. This procedure can also be used to obtain sperm from men who have had vasectomies.

For men who are azoospermic (no sperm produced at all), the use of donor sperm offers an option for achieving pregnancy. Donor sperm can be obtained from either a known donor or an anonymous donor (or both) and can be used with both IUI and IVF.

Book Review- Navigating the Land of IF

By: Kathleen

Navigating the Land of IF by Melissa Ford has a refreshing take on the experience of dealing with infertility. The “IF” in the title is named after the online abbreviation for infertility, but also plays on the many “ifs” involved in infertility. The Land of IF is a place no one really wants to visit but many women find themselves isolated there. Melissa Ford writes “There are the what ifs and if onlys and if this, then that…being here is all about living in uncertainty and doubt and wonder and hope”. The author goes one step further than most books on this subject, intimately sharing with the reader what it actually feels like to go through infertility, rather than a more clinical overview of the process. Through her witty and honest writing the reader feels like they are talking to a close friend on the subject of infertility.

She offers hard earned advice on how to survive and stay sane during infertility. Do you have to attend your cousin’s baby shower? If you do, how do you cope? Other sticky situations such as deciding who to tell (or not tell) about your infertility treatment are also discussed. Dealing with all the unsolicited advice you might get from friends or family is a topic most books on infertility do not address. Throughout the book, the author weaves in content about the large online infertility community. The internet is one place patients can discuss their situations and pose questions of other infertiles while still remaining anonymous. The book also serves as a field guide to diagnostic testing, infertility treatments, adoption, third-party reproduction, and living child free.

Melissa Ford is a mother of twins conceived via fertility treatments and runs an award winning blog called Stirrup Queens.

What Is Diminished Ovarian Reserve?

By: Ervin E. Jones, MD, PhD, FACOG Reproductive Endocrinologist

Diminished ovarian reserve is a term used to describe a woman's potential for successful pregnancy--the desired end-point of all fertility investigation and treatment. In order for a pregnancy to occur, a normal egg must be available. The presumed ability of a woman to produce normal eggs underlies all so-called tests of ovarian reserve. There is no single test or group of tests capable of answering this question directly. All tests of ovarian reserve are indirect nonnumeric estimates of a woman's ability to produce normal eggs and of how many normal eggs remain in her ovaries. Such endocrine tests include, but are not limited to, cycle day 3 follicle-stimulating hormone and estradiol levels, the clomiphene citrate challenge test and measurements of other endocrine substances such as Inhibin-B and anti Müllerian hormone. These tests are often combined with what is referred to as the antral follicle count, i.e., the number of small follicles that can be seen on ultrasound during the early follicular phase.

Tests of ovarian reserve should be viewed as global estimates of ovarian competence. No test of ovarian reserve is completely predictive of a woman's ability to have a child. Instead, tests of ovarian reserve are used for counseling, decision making with respect to choice of treatment, and for inclusion and exclusion criteria. A normal test of ovarian reserve does not insure a woman's ability to produce normal eggs and embryos and an abnormal test of ovarian reserve does not always predict for failure. If they do not achieve pregnancy with their own eggs, women with significant diminished ovarian reserve often find that donor egg is a great option for achieving pregnancy.

When Staying Pregnant Is The Problem: Recurrent Pregnancy Loss

By: Harvey J. Stern MD, PhD

The loss of a pregnancy is a very unsettling experience for couples, but when multiple miscarriages occur, the effect is even more devastating. The American Society of Reproductive Medicine (ASRM) defines recurrent pregnancy loss (RPL) as a condition, distinct from infertility, characterized by 2 or more failed pregnancies. Some experts consider 3 or more losses in a woman less than 35 years of age as warranting evaluation. Although about 15% of all clinically identified pregnancies end in miscarriage, less than 5% of women experience 2 consecutive losses and only 1%experience 3 or more. In women who have a history of 2 miscarriages, the subsequent risk of pregnancy loss rises to 25%, while 3 losses raises the risk of a fourth to 33%.

Often, the patient's obstetrician will initiate an evaluation of couples with recurrent pregnancy loss, but frequently, experts in reproductive medicine and medical genetics are also asked to provide consultation to these patients. At GIVF, we offer our experience in reproductive medicine and genetics to couples with RPL and work with their obstetricians to devise an appropriate evaluation and treatment plan.

There are many causes of RPL, and in at least 50% of couples who undergo evaluation, no explanation for RPL is identified. Possible reasons for RPL include:

1. Chromosomal abnormalities in embryos from egg or sperm, particularly in women over 40 years of age


2. Endocrine (hormonal) abnormalities


3. Diabetes and other metabolic disorders


4. Anatomical abnormalities of the uterus


5. Autoimmune disorders


6. Thrombophilias (clotting disorders)


7. Sperm chromatin abnormalities


8. Possibly some infections, lifestyle factors, or exposure to toxins

The typical evaluation will include a comprehensive medical and family history, physical exam, blood tests for chromosome analysis, measurement of hormone concentrations, autoimmune and thrombophilia testing, semen analysis and bacterial culture of the male and female reproductive tracts. For women, the anatomy of the uterus is evaluated with transvaginal ultrasonography, hysterosaplingography or saline hysterosonography. Any findings in the male can be further evaluated by a urologic specialist.

Testing can take several weeks to complete and, when results are available, the couple returns for a detailed discussion with their physician. All reproductive options are discussed, including assisted reproduction by IUI, IVF or donor gamete where appropriate. A comprehensive medical summary and treatment recommendations are forwarded to the patient's obstetrician.

Most patients do not need IVF and, in many cases, couples can be successful with natural conception. For patients identified with structural rearrangements of the chromosomes, IVF with preimplantation genetic diagnosis has been shown to be very effective. Patients with thrombophilia are often treated with anticoagulation, and surgical correction of structural uterine anomalies is generally possible.

The chance of having a successful full-term pregnancy is dependent to some extent on the number of miscarriages and whether any previous conceptions ended in a live-born child. Other significant prognostic factors include the maternal and paternal ages, presence of polycystic ovaries or other hormonal defects, maternal BMI and lifestyle choices such as smoking and alcohol consumption. In women with RPL without an identifiable cause, approximately 70-75% of women are able to have a successful pregnancy.

Disclosing Fertility Treatments To Others

Couples frequently struggle with disclosing their infertility problems with friends, family and co- workers. An article on The American Fertility Association website titled Pros and Cons of Disclosing Fertility Treatment to Others discusses the stressful decision of deciding if and who to tell about your reproductive treatment. It is important to make the decision jointly with your partner. You will need to decide which "groups" of people you are going to include if you decide to disclose- immediate family and friends, extended family, or work colleagues. The author decribes some issues on disclosing:

Reasons to share:

Support- having a support system during the emotional rollar coaster of infertility treatments can be very beneficial.

Understanding- compassion from those whom you confide in can give you peace of mind but be prepared to also educate people about the physical and emotional demands of treatment.

Honesty- keeping secrets from family and friends can be a heavy burden to bear and can add an extra level of stress during a difficult time.

Reasons not to share:

Fear of censure- you may find that people do not agree with the path of treatment you have chosen and can be critical based on physical, emotional/spiritual, or financial concerns.

Fear of failing- with the emotional ups and downs of infertility treatment you may not feel like talking about cycle failures.


Fear of career interruption- some people worry that revealing infertility treatment to work colleagues may mean they are passed up for promotions or projects.

Some patients find that talking to a mental health professional who has experience in the area of infertility can be extremely helpful. Therapists can teach couples coping techniques and help them agree on choices that confront them.

Clinic Offers PGD Discount

In celebration of GIVF's 25th anniversary they are offering a 25% discount off the cost of PGD for procedures performed between August 1 and December 31, 2009. To learn more about Preimplantation Genetic Diagnosis (PGD) at GIVF please click here.

Surrogacy In The News

Surrogacy is in the news again as another celebrity opens up about infertility. In June Sarah Jessica Parker and Matthew Broderick welcomed twin girls via a surragate. Other parents in this article talk about their stuggles to conceive and have shared birth stories with their children. A new children’s book was recently published that is tailored to the story of birth through surrogacy- “Hope & Will Have a Baby: The Gift of Surrogacy” by Irene Celcer.

The American Society for Reproductive Medicine (ASRM) estimates 400 to 600 births per year from 2003 to 2007 from gestational surrogate births. Advocacy groups believe the actual number is much higher. A traditional surrogate is inseminated with sperm for the purpose of conceiving for a recipient and has a biological link to the fetus. In contrast a gestational surrogate (also called a gestational carrier or uterine carrier) is an individual who has no genetic link to the fetus she is carrying- embryos created by the intended parents are transferred into the surrogate's uterus.