Who can help if we’re not getting pregnant?

Written by Dr Julie Whitehead
05 May

If you’re struggling to conceive, it may give you some hope to know that Australians have good access to medical advice and assistance in relation to fertility. With 1 in 6 couples experiencing some difficulties when trying to fall pregnant, it helps to understand who you can turn to and how they are likely to approach your situation.
 
As you consider your next step, the most important factor to take into account is a woman’s age. As more women and couples delay parenthood until later in life, medical professionals recommend that if you are nearing your late 30’s or in your early 40’s, you should consider getting advice sooner rather than later.

Couple seeing Fertility Doctor

First, talk to your GP

Each year, Australian GPs consult with almost 90% of the population. They are often the first point of contact for anyone wishing to conceive as they will carry out many of your pre-pregnancy screening tests, recommended three months before you start trying for a baby. These tests include ensuring your vaccinations and pap smear are up to date, and screening tests for infectious diseases.
 
GPs also play an important role in the preliminary investigations if you’re struggling to get pregnant, and in particular, if you have been trying for over 12 months (or after just six months if you’re 35+). For example, your GP will typically make an initial assessment based on how long you’ve been trying to conceive, the length of your menstrual cycle, pregnancy history, determine ovulation and order a semen analysis for your partner.  GPs may even recommend some lifestyle changes, such as dietary changes and exercising, in particular if your BMI exceeds the recommended range.
 
If your GP determines that your situation warrants further investigation, they will suggest a referral to a specialist.

Seeing your gynaecologist

By their 30’s many women have already seen a gynaecologist for a range of issues, so it’s natural that if you are experiencing a delay in conception, you may feel most comfortable talking to your gynaecologist about this.
 
In relation to fertility, gynaecologists most commonly help with investigations and simple assisted reproductive treatments such as Ovulation Induction (e.g. Clomid). However, if you have been trying unsuccessfully for over a year or for any of the more advanced assisted reproductive treatment options, a referral to a fertility specialist may be advised.

When to see a Fertility Specialist

A fertility specialist has specialist training in gynaecology and obstetrics followed by further study in reproductive endocrinology and infertility. This typically takes another three years of training, making them experts in understanding infertility and fertility treatments including IVF.
 
Fertility specialists can offer a complete range of fertility tests and treatments – for both men and women. Your GP is likely to refer you to a fertility specialist for most fertility concerns including if there is no obvious reason for the delay in conception, if the female partner is in her mid-30’s or older, if the female partner has experienced a reproductive issue previously (such as PCOS or blocked fallopian tubes), and if there is a genetic condition in the family that you are wishing to avoid passing on.

What to expect at your first fertility specialist appointment?

At your first appointment with a fertility specialist, he or she will review your medical history, the results of any previous tests you’ve had done, and arrange more advanced investigations for you and your partner. It is helpful for both the female and male partners to attend this first appointment so that you can be assessed together, ask questions and both understand the options available.

For women, extra tests may include a vaginal ultrasound, a test to check your fallopian tubes are not blocked (ultrasound assessment of tubal patency) or a laparoscopy to look for conditions such as endometriosis. For men, this will likely involve a semen analysis.

Your fertility specialist will discuss the tests that are appropriate to your situation.

A tailored pathway to pregnancy

The results of all these tests will help guide your fertility specialist to develop a recommended plan of action. These options may range from ovulation cycle tracking, ovulation induction and intrauterine insemination (IUI) to IVF and ICSI. Most major fertility clinics can also provide access to pre-implantation genetic screening (PGS) as well as comprehensive donor programs. Your fertility specialist will be able to co-ordinate the most appropriate treatment for you and you will see them regularly throughout your treatment.

The important thing to remember is that your fertility specialist is best placed to provide you with answers and options, and support you on your path to parenthood.

Find out more:Fertility Specialists in QLD, Fertility Specialists in NSW, Fertility Specialists in VIC, Fertility Specialists in TAS, Fertility Specialists in Singapore

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Post mortem sperm retrieval – a matter of life and death

Further to his interview on Channel 9’s 60 minutes programme, Dr Ben Kroon of Queensland Fertility Group discusses the topic of post mortem sperm retrieval.

Thankfully for the vast majority of people, post mortem sperm retrieval will never become a reality.

It is an extremely complex and challenging area of reproductive medicine, involving retrieval of sperm after a man’s death so that it can be used by his surviving partner.

While new assisted reproductive technologies are allowing more people than ever to fall pregnant and start the family they desire, the law, at times, does not keep pace with these developments.

In Australia, the law does not specifically address the issue of retrieval and use of sperm after a man’s death. So, while a partner may be sure she knows what her partner ‘would have wanted’, without supporting legal documents explicitly stating those wishes, the question of retrieval and use of sperm is not clear.

In most cases, an urgent court order is needed to retrieve sperm. This is a problem because while the judge is coming to a decision, every hour that the sperm lies in the body after death decreases the chance of finding live sperm.

While 24 hours is the accepted time period for successful retrieval, there may still be a small chance up to 36 hours after death.  However, while retrieval might be medically successful, the court may never permit a woman to use the sperm.

I co-authored a paper, published in the Australian and New Zealand Journal of Obstetrics and Gynaecology, in which we surveyed 28 IVF clinics across Australasia to test attitudes towards posthumous sperm retrieval and use.

It appears that directors of IVF units are generally supportive of the practice, given the right circumstances, but that the lack of clear laws makes the response to requests for sperm retrieval very difficult.

Myself, and the papers co-authors, believe that ‘clear, accessible and consistent law in this area would benefit everyone involved, including the medical, legal and societal stakeholders’.

It is not only the law that needs to catch up. In the same way that people discuss organ donation, I believe that couples should discuss post mortem sperm use.

Men should consider and discuss with their partners whether they would want to father a child after their death, bearing in mind that they could not raise the child, and that the child could conceivably be raised by another man.

I need to be clear that I am not suggesting that more people should have their sperm collected and used after their death.

Personally, I wouldn’t want my sperm to be retrieved and used if I died suddenly, and my wife knows this. But, if couples don’t have the discussion and document their wishes, it is seldom clear what one would have wanted if one dies.

Have you considered discussing post mortem sperm retrieval with your partner?

Dr Julie Whitehead
05 May

Children of IVF parents as healthy as those conceived spontaneously

In 2007 a local Melbourne paediatrician approached me curious about whether girls conceived through In-Vitro Fertilisation (IVF) and other Assisted Reproductive Treatments (ART) enter puberty earlier than those conceived spontaneously. With the first babies born through IVF now reaching their mid-30s, this query was my early motivation and the catalyst to initiate a study on the effects of IVF and ART on the health and wellbeing of children conceived through these technologies.

How healthy are IVF children?

This project was the largest of its kind ever attempted, worldwide.

We found that children conceived by IVF grew into healthy, normal adults when compared to children conceived spontaneously.

The collaborative study initially funded by Melbourne IVF prior to a National Health and Medical Research Council (NHMRC) grant involved researchers from Murdoch Children’s Research Institute, Monash IVF, the University of Melbourne and Monash University. Interviewing 656 mothers who used ART and their 547 young adult offspring aged between 18 and 29 years, and compared this to reports from 868 mothers and their 549 young adult offspring who were conceived spontaneously.

Self-report of their health and wellbeing for the first 18 years of life found the ART children had a normal body mass index and similar history of pubertal development to those spontaneously conceived. Educational outcomes, including tertiary admission ranked scores and completion of tertiary education, were also similar.

Were there differences in the health of IVF-conceived children?

Mothers did report a higher rate of hospitalisation, as well as a higher rate of asthma and hay fever in ART children. We found this to be in line with what we already know as a common mild condition in the whole community. The rate is not much higher at 23% of spontaneously conceived children experiencing allergies, compared to 30% of ART children.

These problems are more common in premature babies and we know a higher proportion of ART babies are born prematurely for reasons still largely unknown. Premature births may be because of the age of IVF mothers, as having a baby in your early 40s is generally harder than having a baby in your late 20s or early 30s.

ART parents might take their children to the GP more often and consequently they are diagnosed at a higher rate. We found ourselves speculating if parents of IVF-conceived children are more protective reducing their baby’s exposure to dust and dirt in turn increasing their risk factor for later allergies.

The finding of increased hospitalisations, including in the secondary school years, has not been examined in other studies to date and the reasons for hospitalisation varied, with no consistent set of conditions. Again, we wonder if this is due to parental vigilance.

What will be done to investigate further?

This study fills an important gap in our knowledge about the long term health outcomes of children conceived via IVF and ART. Our results indicate that the perceived physical, mental health, social and environmental quality of life reported by the 547 ART-conceived adults is very similar to that of their non-ART conceived peers.

We have a responsibility to continue this research and gather further clinical review in long term follow up of those conceived through IVF and other ART. Further research will evaluate their health status and follow up to determine if there are any important lifelong medical or other legacies of IVF.

What does this mean for those considering IVF?

This study provides reassurance to those requiring IVF that there are no apparent substantial negative long term health and wellbeing effects on young adults compared to those spontaneously conceived.

This study is published in Fertility and Sterility. 

Learn more about IVF in Queensland, Victoria and New South Wales.



 

Dr Julie Whitehead
05 May

15 years of IVF patients – how have women changed?

The media is increasingly full of stories showcasing the latest 50 year old mum, or the celebrity who has undergone IVF. Even women who have used donor eggs are increasingly more comfortable discussing their medical history.

But, do these sensationalised stories really reflect the changing face of the IVF patient we see every day at our fertility clinic?

At Queensland Fertility Group Toowoomba we decided to assess the reality of these changes. In order to do this we conducted a retrospective study of 1587 women who had undergone IVF between 1998 and 2013 at our clinic in Toowoomba (based in the Darling Downs, west of Brisbane). We know that during this time there has been considerable social change, and we were interested to see how our patients may correspondingly have changed during this 15 year period.

Older women

Studies carried out by the Australian Institute of Health and Welfare informs us that the average age of women receiving treatment using their own eggs or embryos, is 36 years. We know too that over the last 20 years the average age of women giving birth has increased by 7.5%.

What did our study of 1,587 women show? The average age of women undergoing IVF treatment in Toowoomba has significantly increased by 6% - from 33 years in 1998 to 35 years in 2013.  Interestingly, the major shift has been the marked increase in the number of women aged over 39 completing treatment - which 15 years ago was just 3% and by 2013 had grown to 18%.

Rising obesity

The number of overweight and obese Australians has been gradually increasing for the past 30 years across all demographics – from wealthy, metropolitan suburbs to rural and disadvantaged communities.

An Australian Bureau of Statistics Australian Health Survey identified that between 1995 and 2011/12 the average adult woman’s weight had increased by 4kgs. The report likewise stated that in 2011/12 27% of all females aged 18 and over were overweight with a Body Mass Index (BMI) of 25 to 30.

Toowoomba is no exception to this trend. It’s therefore not surprising that the average IVF patient has become heavier. Women undergoing IVF treatment in 1998 at QFG Toowoomba had an average weight of 66kgs, and this had increased up to 77kgs by 2013. More significantly, their BMI (which also takes into account their height) moved from normal at 24 to overweight at 28 in 2013.

Single Women and Same-sex Couples

Shifts have occurred in the structure of families and as a result, we have seen a considerable increase over the past five years in single and same-sex couples accessing donor sperm to start their families.

Looking at the subset of patients where female cause was the sole reason for them having treatment, the proportion of single women and same-sex couples undergoing IVF increased from 2% in 2008 to 22% in 2013.

15 years later

Women attending our fertility clinic in 2013 are significantly older, heavier and have an increased BMI than they did in 1998. However, as women delay child bearing, by choice or circumstance, we need to ensure that there isn’t an unrealistic expectation that medical science can undo the effects of age.

What would you advise?

Unfortunately, we still cannot reverse the aging process, but we can ensure women are given the correct information to help them make informed decisions earlier. For example, the increasing use of the Anti-Mullerian Hormone (AMH) test or as it's more widely known, the egg timer test, can help a Fertility Specialist better assess a woman’s fertility and guide the direction of her fertility treatment.

Many women still remain unaware of the effect of weight on their fertility. We advise weight loss with simple lifestyle changes and, if necessary, dietician support. In addition to boosting a woman’s natural fertility, this can also have a beneficial impact on pregnancy and the health of the child.

This data was presented by Leita Fien, Fertility Nurse, Toowoomba at the 5th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2014) in conjunction with the Fertility Society of Australia Annual Conference held in Brisbane April 4-6, 2014.  Leita would like to acknowledge and thank her co-authors and colleagues Susan Lax, Julie Logan, Jeremy Osborn, and Dr John Esler, Clinical Director QFG Toowoomba.

Dr Julie Whitehead
05 May

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