Menopause and Sleep

Menopause and Sleep

One of the main issues that I come across is sleep issues.  Falling asleep, staying asleep and having a restful nights’ sleep is a complex issue – there is a great deal involved.

Sleep problems are quite common amongst menopausal women and I would expect most of my patients to have some sort of sleep issue (6 out of every 10 menopausal women).

Sometimes it is quite straight forward to pin point the cause such as hot-flushes and night sweats.  Hot flushes are normally preceded by the body temperature rising causing awakening.  Obviously being drenched in sweat at night and requiring changes of nightwear is quite disturbing. Waking up to change nightwear is very disruptive but there are often more esoteric induced sleep problems such as relationship hiccups and concerns about children and work.

There are lots of reasons that contribute to poor sleeping and so it’s important to have a good diet but essential to follow a good bedtime routine.  We all tend to use our smart phones and screens late into the day. Try switching off a few hours before bed time and engaging in reading a book or meditation will slow the body down.  We all know that a dark room with no distractions is ideal to initiate good sleep, but like many people, I find this difficult to do.

It’s not only the in hormonal levels that will affect sleep quality in menopausal women (and relatively straightforward to remedy by replacement therapy), but the additional stresses of life which suddenly manifest at this life stage; notably children leaving home as well as re-appraising partner/ parent/ personal relationships. Sadly, these are often much more difficult to address than hormone levels

How can hormone replacement help?

From a hormonal point of view, the presence of hot flushes, night sweats (called vasomotor symptoms) and irritability will cause sleep problems and these can be addressed with low dose oestrogen

Progesterones (e.g. Utrogestan) are good at helping a woman drift off to sleep. Even comparatively low doses of progesterone cream can be beneficial.  Here is the medical bit…. When progesterone is metabolised (broken down) a new hormone is produced called Allopregnanolone. This new hormone affects a different hormone framework in the brain called the GABA system.  Mild stimulation of the GABA system results in relaxation, decrease in anxiety and sedation.

There are many facets to improving sleep issues and low dose hormonal replacement has an important role.

Bio-identical HRT

It is an inevitable part of life that as we age, our bodies change, and for the most part, we do the best we can to feel ourselves at each stage of the journey. For women, starting the menopause can test this to the limit, with the appearance of physical and emotional symptoms that are wide-ranging and often difficult to handle.

The menopause usually occurs in your 50s, but early onset menopause can affect women as young as 30 when falling levels of the hormones progesterone and estrogen can lead to a range of symptoms, including:

Mood change

Irritability

Hot flushes

Night sweats

Vaginal dryness

Change in body shape

Although the physical changes can be hard to cope with, it’s often the emotional changes that can have the most impact on day to day life. Some women decide that the symptoms are manageable, but others find that they need some help, maybe because mood swings are affecting family life or disrupted sleep is having an impact on their work day.

Traditionally, there are some natural remedies that have been used to help with the symptoms of the menopause. Black cohosh for example for the emotional symptoms and evening primrose oil for relieving breast pain and helping with mood swings. A diet high in plant-based phytoestrogens can also have positive effects, and I recommend introducing soy products as well as increasing intake of whole grains, dried beans, peas and fruits. These natural remedies can help, but often symptoms are having such a negative impact on a woman’s well-being that another solution needs to be found.

The symptoms of the menopause are caused by a natural drop in oestrogen and progesterone and Hormone Replacement Therapy (HRT) does just what it says on the tin to address this imbalance and restore the levels of female hormones. HRT also protects bones from premature aging, which is particularly important if you’re experiencing early onset menopause or have a family history of osteoporosis. The decision as to whether you want to pursue HRT is a personal one based on whether the symptoms are enough of a problem in your day to day life.

There are very few genuine contraindications for HRT, but if you have previously suffered from a blood clot, heart disease or stroke, have a family history of cancer or suffer from bad migraines on the contraceptive pill then traditional HRT may not be for you and you should discuss your options with your doctor. There have been many studies into the effects of HRT and it has been shown to slightly raise the risk of breast and ovarian cancer, which is why it is not recommended for those with a family history of these diseases. Despite these risks, the proven benefits of the treatment mean that it is an effective hormone treatment and when used on a short-term basis (during the menopause), the minimal risks are judged to be outweighed by the positive results.

When you look into HRT options online, there are many aspects to consider. HRT can be taken in pill form or in a patch or gel that is applied directly to the skin and absorbed more quickly into the bloodstream. Usually HRT in tablet form contains a compound that is broken down by the body into the female hormones whereas the patches and gels introduce compounds that are very similar to natural progesterone directly into the body.

Alongside these considerations, ‘bio-identical’ hormones have entered the market, billed as a safer alternative to traditional hormone replacement therapy, using natural ingredients in personally tailored quantities. Conventional HRT uses synthetic or animal-derived compounds that are therefore slightly different to the hormones occurring naturally in the body, whereas bio-identical hormones are biochemically the same as those produced by the body. The appeal of this ‘natural’ treatment is clear, but despite the elevated treatment cost, there is currently little evidence available to show that bio-identical hormones are any more effective and there are significant concerns about their safety.

Where conventional HRT is strictly regulated and subject to purity and production controls, with set levels prescribed, bio-identicalhormones are not subject to the same controls, as the levels prescribed are often determined by salivary hormone levels. In fact, the National Institute for Health and Care Excellence (NICE) guidelines on the diagnosis and management of the menopause state that the effectiveness and safety of bio-identical hormones is unknown and neither the American Congress of Obstetricians and Gynecologists or the British Menopause Society recommend them.

With this in mind, I would recommend conventional HRT, over ‘bio-identicall’ HRT to any woman considering hormone treatment for menopausal symptoms, based on the current research and legislation. There are a range of HRT options available, and it’s important to discuss these thoroughly before making any decisions.

To discuss the menopause and HRT, contact Yvonne on liebermanpa@gmail.com

Polycystic ovaries (PCOS)

Polycystic Ovary Syndrome (PCOS) is thought to affect 1 in 5 women in the UK, but awareness of the condition is still relatively low. As with many conditions that affect fertility, a lot of women will not be diagnosed with PCOS until they are trying to conceive and find that they are having difficulties, especially if their symptoms are mild, so education about the syndrome is important for early diagnosis.

What are polycystic ovaries?

If your ovaries are polycystic, they become enlarged and develop fluid-filled bubbles just below the surface. These bubbles or follicles contain eggs that have not fully developed. Most women with polycystic ovaries will not have any problems other than irregular periods. As well as having polycystic ovaries, to be diagnosed with PCOS you will also be experiencing one or more symptom from the list below.

What is PCOS?

Polycystic ovarian syndrome is a name given to a group of problems. In order to have PCOS you should have two of the following three – polycystic ovaries, an irregular menstrual cycle or an excess of male hormone.

The symptoms of PCOS can vary greatly between women and include:

  • Irregular periods
  • Unwanted facial/body hair (hirsutism)
  • Oily skin/acne
  • Thinning hair/hair loss
  • Weight gain
  • Reduced fertility

What causes PCOS?

Polycystic ovary syndrome is associated with hormonal imbalances in the body, although the exact cause is unknown. Its likely that there is a genetic link as it often (but not always) runs in families. One of the main issues is that PCOS women will have higher than normal levels of the hormone Insulin. Insulin helps to control the level of sugar in the blood by moving glucose from the bloodstream into the body’s cells to be used for energy. PCOS women will be more likely to be resistant to Insulin, so the body produces high amounts of it to overcome this resistance.

The high Insulin levels then lead to other hormone problems including high LH and Testosterone. High levels of LH through the cycle is why ovulation sticks are often falsely positive in women with PCOS.

Although typically thought of as a male hormone, all women produce a small amount of Testosterone in their ovaries and the majority of it is usually converted to Oestrogen. For women with PCOS, the amount of Testosterone produced tends to be higher and even a small rise in Testosterone in a woman’s body can affect menstruation and ovulation.

Who suffers from PCOS?

About 1 in every 4 young women will have polycystic ovaries on ultrasound, but only some of these women will go onto have other problems associated with PCOS. Symptoms usually begin in adolescence but can also appear later in life, usually in a woman’s early or mid-twenties. PCOS often runs in families, so if there is a history of the condition in your family tree you should be aware of the symptoms in case you start to display them.

How do I know if I have PCOS?

If you are experiencing any of the symptoms of PCOS, the first step is to make an appointment with your doctor to discuss it and to rule out any alternative causes. Your doctor will look at your symptoms, arrange for tests to check your levels of certain hormones and possibly arrange for an ultrasound to confirm diagnosis.

What treatment is available for PCOS?

If you have had a diagnosis of PCO or PCOS then the most important thing is not to worry. Although PCOS cannot be “cured’ most of the symptoms can be helped.

The first of the suggested treatment plans is usually lifestyle changes, especially if you are carrying excess weight. Excess fat in the body causes an increase in Insulin production, which can worsen the symptoms of PCOS, so losing weight can lead to a significant improvement in quality of life.

I can’t stress enough how important it is to try and get to a healthy weight. Remember that there are many women who are on the too “light side”.  Being a healthy weight may not completely treat your symptoms, but certainly will be beneficial if you need medical treatment as you will respond much better.

Crash and fad diets should be avoided and healthy eating is far to be preferred. I often hear how PCOS patients have been advised to avoid certain types of food at all cost. Forget about this and concentrate on having a healthy. balanced diet whilst being very careful about how much energy (Calories) you consume. I love exercise and it is very important, but its probably more important to the average person to be strict and consistent with what they eat than anything else when it comes to weight control.

There are many medical interventions depending on your specific symptoms and your views on how you would like to be treated. No two PCOS women are alike.

Many of my patients who have irregular cycles with their PCOS have worked with acupuncture practitioners to regulate their cycles. It’s not a treatment for everyone – and I don’t really understand how it would work – but certainly anecdotal evidence is that it seems to work for some.

How does PCOS affect fertility?

I see many women with PCOS who are struggling to conceive. The biggest issue with PCOS and sub-fertility is irregular or even totally absent ovulation. There’s often a lot of confusion, because as I mentioned before, urinary ovulation sticks can be falsely positive.  The good news is that with treatment, most women with PCOS will go on to have healthy pregnancies and there are many treatment options depending on your specific requirements.

To discuss PCOS and fertility options, contact Yvonne on liebermanpa@gmail.com

Does my lifestyle really affect my fertility?

Does my lifestyle really affect my fertility?

 

In the world of fertililty, all people are not made equal and although it can seem unfair to see mothers who who have had no problems conceiving despite their weight and smoking, everyone’s situation is different.  As a fertility clinic, it is our job to do everything we can to optimise your fertility and so when we advise lifestyle changes, it is with this goal in mind. Making changes now will only help to increase your chance of having a baby and we need to work together to put you in the best position to build your family,

 

Smoking

We all know the negative effects that smoking has on health in general, but it’s not so widely known that smoking can also significantly affect fertility. As well as the damage caused elsewhere in the body, cigarette smoke causes damage to your reproductive organs and directly to your eggs. All of this means that smokers are much more likely to have problems conceiving and are likely to take longer to conceive than non-smokers.

But it’s not just the female partner who can make changes, your male partner smoking can also decrease your chances of conceiving. Research shows that passive smoking also negatively impacts fertility and second-hand smoke can be almost as harmful as smoking yourself. Smoking can also damage men’s reproductive systems, lowering sperm count and sperm motility and causing fertility problems.

While the damage caused by smoking is not reversible, both partners quitting smoking will increase your chances of conceiving. When exploring fertility treatment options, smoking can also play a large part. For NHS IVF referrals, most centres require both partners to be non-smokers and many private clinics also set the same conditions.

Weight

When it comes to weight, the closer your BMI (Body Mass Index) is to being within the normal range, the higher your fertility is likely to be. Your BMI is one way of working out whether you are a healthy weight for your height and a healthy range is 20-25 (you can check yours here). As with smoking, most NHS centres require a woman’s BMI to be within a healthy range before starting IVF treatment.

While we know that this can be frustrating to hear, because weight management can be a difficult and emotionally loaded topic, bringing your BMI to within a healthy range is one thing you can do to significantly increase your chances of conceiving. But it’s not just being overweight that can limit fertility, being significantly underweight can be just as damaging. If your BMI is significantly below the normal range, your ovulation is likely to be affected, making your periods irregular and decreasing your fertility. If you do conceive, there is also a risk that the baby may not be able to get all of the nutrients they need from you if you are underweight.

Weight is one area where there is an imbalance between the sexes, as while male fertility also improves with a normal BMI, the female partner’s weight has a much greater impact. However, both partners should be equally invested in improving fertility and therefore it is in your interest as a couple for both of you to bring your BMI to within a healthy range – you’re in this together!

Eating & Drinking

I speak to women all the time who are anxious to know what supplements they need to be taking to boost their chances of conceiving and it’s hardly surprising, especially when the adverts for vitamins targeted at women trying to conceive can be so overwhelming. My advice is that a healthy and well-balanced diet is all that’s required to improve your chances of falling pregnant. No supplements are required unless you’re on any medication that could cause a specific deficiency, in which case you would need to seek further advice from your GP. During pregnancy, the only supplement I would recommend is folic acid as low levels can increase the chance of congenital back problems and cleft palate.

Drinking can also be a controversial topic when talking about conception. While there is evidence that drinking during pregnancy can be harmful to the baby, there is little to support that drinking in moderation when trying to conceive will have any impact at all. While drinking more than 3 units in one sitting is not advised, having a glass of wine during the week is not going to cause problems.The same goes for caffeine: fifteen double espressos is not a sensible option (for your fertility or your sleep!) but a couple of cups of coffee a day will not impact your chances of conceiving.

Exercise

All exercise is good, as long as it’s not taken to unhealthy levels. Exercise improves health, calms the mind and aids relaxation, all things that are highly recommended for women trying to conceive. The common fear is that exercise could disrupt an early pregnancy, but it’s important to remember that the uterus is a super muscle! Even a microscopic early pregnancy is surrounded by a tough wall of muscle and exercise or even a fall will not dislodge it if that pregnancy is set to progress normally, so you do not need to wrap yourself in cotton wool. As with any advice, this should not be taken to extremes and if the exercise you’re doing is negatively impacting your health or putting you at risk then you should discuss this with your doctor – it’s still important to look after yourself.

And that is probably the single most important thing to remember thinking about how lifestyle affects fertility: you need to look after yourself to give yourself the best possible chance of conceiving. Your life doesn’t need to be put on hold and your friday glass of wine, morning latte and occasional biscuit are not evil habits that need to be entirely removed from your new, saintly existence. However, stopping smoking, making a concerted effort to bring your BMI to a normal level, eating well and exercising regularly are all positive steps you can take and are changes you can make as a couple to both increase fertility and prepare for a healthy family life.


To discuss what might be right for you please contact Yvonne on liebermanpa@gmail.com

I’m sure its me…..

“I don’t really know what the problem is… but I’m sure it’s me”

Over the years, I’ve heard lots of versions of this statement, normally based on something that has happened in the past or an offhand comment from a friend or relative. As certain as you are that you’re the problem, it’s not until your particular history has been heard and investigations undertaken that you really know where there may be an issue and how it can be addressed. It’s only then that a treatment plan can be made to fit your unique situation.

There are lots of reasons why it’s usually the female partner who books the initial appointment. Generally women are in touch with their bodies in a different way to men and as a woman’s reproductive setup is more complex, it’s easy to jump to the conclusion that fertility issues always lie with the female partner, even though that’s often far from the truth.

I’m sure its me because…

“I’ve been on the pill for 10 years without conceiving and now I’ve stopped, I’m going to have problems”

The contraceptive pill is designed to prevent pregnancy… and it does so very effectively! It’s important to remember that while the pill may have prevented pregnancy for the last ten years it does not have any negative impact on your long term fertility. After stopping the pill, you may find that your periods are irregular, but it may just be that your cycle is returning to how it was before taking the pill and you’ve forgotten what that looked like.

“I had unprotected sex for years in a previous relationship and never fell pregnant”

This may be the case, but it’s only part of the picture. We can never be sure that your previous partner did not have an issue and we need to look at both partners in the current relationship to try and find out where there maybe an issue and make a treatment plan that is right for both of you.

“my partner has children from a previous relationship”

This seems like a logical conclusion but sperm count and motility can vary a great deal from month to month, so your partner may have been more fertile in the past. There’s also a chance that your partner may not be the biological father of any children from his previous relationships!

“I tried unsuccessfully with my previous partner too”

In this scenario, there are many possible explanations. Surprisingly often, it later transpires that a previous partner had fertility issues. There’s no way we can be sure why you didn’t conceive in previous relationships, but perhaps there was a male factor, perhaps timing, it’s difficult to know. What’s important to remember is that it’s the fertility of you and your partner right at this moment that’s important. It’s helpful to know what has happened in the past but your previous fertility history is just one of many factors that we need to take into consideration.

“I’ve had abortion(s) in the past”

This can be a difficult topic to discuss, as abortions are often a source of mixed emotions and need to be treated sensitively. The crucial element here is that as long as the abortion was medically uncomplicated, with no infection or problems following the termination, it’s unlikely to affect your fertility. Be reassured that subfertility would be a lot more common if it were directly linked to abortions and it’s unlikely to be the cause in your case.

“I drank, partied and had too much unprotected sex in my twenties”

Running the risk of sounding like a magazine advice column, each stage of life is different. You spent your twenties living your life; there’s is no use regretting those decisions today. The good news is that only very significant drinking over a prolonged period would have a negative impact on fertility, and if this is not the case, a wild youth is probably not a factor. In regards to unprotected sex, STIs do not usually impact fertility as long as they are treated quickly and correctly. Particularly bad pelvic infections, such as syphilis and gonorrhoea have been linked to sub-fertility, so if this features in your medical history it would be worth investigating.

“his penis is the wrong size/ doesn’t produce enough ejaculate/ all the ejaculate leaks out after sex”

While all of these are entirely understandable concerns, you’ll be relieved to hear that none of them translate into fertility issues. For the last on that list, it’s entirely normal for a mixture of semen and vaginal fluid to leak out of the vagina after sex, which doesn’t affect the chance of conception. On that topic, while a woman lying with her legs in the air after sex may seem sensible, it doesn’t actually improve the chances of pregnancy… but I think everyone has tried it!

What these questions show us is that people are quick to point the finger of blame when it comes to fertility issues, but generally problems conceiving are much more complex than that. To get a clear picture of a couple’s fertility we need to look at both partners’ fertility independently and combine it to give us all of the information. Every couple’s level of fertility is different. For example a woman in her 20s may have no problem conceiving with a man with a lower sperm count, but the same couple may struggle for another child when she is in her late 30s as her fertility will have decreased.

To offer the best level of care, it’s important for us to get the full story, to really listen to both partners and understand both your medical histories and your current problems in context. People are more than just numbers and to put together a personalised treatment plan, a wider view is needed than just the results of the tests we conduct. When we use all of the information available to us, we’re then in the best position to look at the problems you’re facing as a couple and start working towards a solution together.

Treatment plans differ according to your specific circumstances, and must be tailored to your individual needs.
To discuss what might be right for you please contact Yvonne on liebermanpa@gmail.com

How much of a security blanket is egg freezing?

 

How much of a security blanket is egg freezing?

More and more of my consultations are about egg freezing. The more women I see the more I wonder how effective it is going to be as far as a realistic hope in producing a baby in the future.

The women that tend to come and see me about egg freezing are often in their mid to late thirties (sometimes older) wanting to have a “fertility snap-shot”, an accurate portrayal of their current fertility to be re-opened at a later time. On the face of it this sounds very sensible and pro-active in terms of reproductive autonomy. It is certainly a very exciting prospect to have the peace of mind and security to know that some of your eggs will be safe from the much-discussed decline with age.

As a clinician, egg freezing seems to be a constructive and positive treatment option, as patients are often quite excited at the prospect of taking control over their future fertility.

This hope is based the acceptance of technological advances. Many women will put a great deal of faith and life planning on the belief that this snap shot will offer a reliable security blanket for the future.

What’s the inevitable but?

My main ‘but’ is around the chances of having a baby at this distant and delayed time in the future? It’s so important to really be clear that what you are freezing may not be not much more than a just a slim hope of success… a far cry from the belief that there will be a good prospect of being able to have a baby in the years to come after treatment.

Of course all women undergoing treatment are counselled that the final outcome cannot be guaranteed but what exactly is the probability of actually having a baby when the eggs are finally thawed, fertilised and transferred? I am sure all clinics will have in their paperwork that the outcome is unknown and patients will sign consent forms along these lines.

But in reality we really do not know what happens to the eggs, embryos and pregnancies in the years to come.

What do we know?

We know that the technology works. We are advised by the professional organisations that egg freezing (using vitrification) is no longer in the research stages and can be used for treatment.

We know that babies have been born using frozen eggs, and certainly there are clinics that publish their frozen egg data.

We know that many clinics widely publicise their egg freezing programs without publishing their data.

We know that frozen eggs are sold to patients for use in egg donation cycles, but without a robust reporting mechanism.

What don’t we know?

This is going to be a longer bit. In the UK there is not an externally verified and published data set concerning frozen eggs. In the fertility field we rely heavily on the HFEA for our data to advise patients but unfortunately the number of patients having egg freezing and their outcomes are not publicly available.

This is because numbers are simply not yet available for us to analyse. The numbers are so important in order for appropriate counselling and advice to be given. We can’t answer the common questions of how many eggs does a women need to freeze with each cycle at a certain age and fertility level (AMH and antral follicle count) ? … and what are the thaw, fertilisation, pregnancy, miscarriage and live birth rates?

One of the biggest and most tricky questions is “how many cycles of egg freezing would I recommend?” Such a difficult question to answer! Every woman will produce a different number of eggs, how they will fertilise is unknown and the number of good embryos that they will produce is even more unknown.

I normally start by describing the pregnancy rates of a fresh cycle of treatment based on age and ovarian reserve and work from there. IVF outcomes from a single cycle in women in their late 30s are good but hardly a certainty of success, and we will need to further reduce the estimate by making the assumption that frozen egg pregnancies are less likely.

There is lots of data available on clinic success rates available on the HFEA website. How useful this data is when choosing a clinic is a wider discussion, but there is no data available on egg freezing outcomes. So how do patients know where they should go?

I’ve read and heard lots of doctors say that there is not that much to egg freezing. This may be the case, but successful freezing that produces eggs that will thaw and ultimately produces a pregnancy is going to be a very specialised and skilled task.

From a prospective patients’ point of view you really want to go to a clinic that has a large amount of experience with successful egg freezing (blogs and articles generally refer to clinics in Spain). As I’ve not worked in Spain I’m unable to comment on this. I do think it is completely justified to ask clinics how many patients they have dealt with for egg freezing and how many have returned to use their eggs. Most importantly, how many babies have been born as a result of treatment? I know that this is a relative new treatment option and rates of thawing, fertilisation and pregnancy are very interesting but it’s really the number of babies born per eggs collected that is most important. For instance if its takes 15 or even 20 eggs to produce a baby then a women may think of alternatives if their predicted egg number is much lower than this.

How valid a treatment is it?

Process “validity” is much used term by the HFEA and other quality assurers, and this generally means that a method is proven to be based on existing or accepted observation and practice. But I question whether egg freezing is a “valid treatment” until we really are confident that there is a realistic chance of pregnancy in the future rather than just an optimistic hope.

What do I do?

I do offer egg freezing but I try to counsel women very clearly that although it appears to be an empowering and exciting option, the outcomes are still unknown.

In a nutshell it’s a long shot and you should consider all options.

Want to know more?

Have a look at these pages on the HFEA website http://www.hfea.gov.uk/8597.html. This is an interesting read on the Times magazine website http://time.com/3959487/egg-freezing-need-to-know/

A number is not everything

A number is not everything

I was thinking about this when I was walking through the park today, lots of joggers and cyclists out and about in the spring sunshine. Nothing surprising about that, winter is gone for a while and we can enjoy the outdoors. Lovely.

What I noticed was that just about everyone exercising was wearing some sort of technology. The runners with their heart rate monitors and music players, the cyclists measuring their wheel speed, turns per second, tyre pressure and so on all while talking into their phones.

This made me think about two main things. Firstly how little they are focusing on what they are actually doing, how much can you enjoy the lovely weather and outdoor environment if you are concentrating on an electronic monitor? How much of the freedom of cycling do you lose if you are measuring how many times your feet go round. I may be wrong but I think you probably get more relaxation and health benefits out of cycling if you just pedal and enjoy the weightlessness and freedom rather than examine every bodily and bicycle function.

The other issue is what on earth do people do with all the information? How many go home and spend time comparing their heart rates, maximum speeds and cadence rates week by week and month by month. I am sure Victoria Pendleton and Mo Farah do, but the rest of us? Did Daley Thompson wear a heart rate monitor and obsess over his max V02. I doubt it.

 What’s this got to do with fertility? Test results.

The fertility industry measures just about every reproductive output imaginable. It is easy to test, just tick a box on a piece of paper and measure everything, hormone levels, organ sizes, follicle numbers, number of sperm etc. I was reading the excellent sperm factsheet on the infertilitynetworkuk website, where there are very interesting questions about actually what it is we hope to gather from a semen analysis. Depending on your laboratory, a healthy semen analysis may have 2-5% normal sperm, this means that up to 98% are abnormal. It is very difficult to persuade a couple that this is ok.

Everyone is (thankfully) different and test results will vary between people. Results will change and fluctuate for an individual. Semen analysis, as a good example, is extremely variable over time. Female hormone levels will fluctuate even if taken on the same day each cycle.

You made be very upset by some results other will be reassuring. If test results are not as positive you were expecting, remember that they are just a number to help plan your treatment options. Try not to focus on the number, its just the part of the journey that you need to go through before you start treatment.

But you cannot take test results in isolation. It is wrong to make treatment plans purely and simply on a number printed on a piece of paper. Your situation, symptoms, needs and wants are unique to you and are the deciding factors. Test results can help to indicate which options are best and the chances of them working.

Who knows what were the heart rate measurements of the gold medal-winning athletes from years ago, perhaps if they had been measured then they would never have been allowed to compete at the highest levels.

 You are much more than a test result.

There’s more to an embryo than its appearance

There’s more to an embryo than its appearance

Over the passed few years there have been rapid tech developments in improving embryo selection and so increasing the chance of success of fertility treatment.

Patients often ask about the grade of their eggs directly after egg collection. The egg’s colour, shape and texture will be helpful, but it’s not until the fertilised egg (now called an embryo) has been allowed to grow for a few days can you really give any meaningful information about the quality of the embryo.

In the laboratory the embryologists keep a close watch on the embryos and are highly skilled in selecting the best embryos and advising the best day for transfer. The role of the embryologist cannot be underestimated. Although you may only meet them briefly, they are the key individuals in your treatment.

Traditionally embryologists select embryos based on the speed of how their cells divide, the number of cells, how much cell breakdown (fragmentation) there is and other more subtle markers of quality. Different labs use different grading schemes often using a combination of numbers and letters.  Grading systems have changed over the years so it’s important to be careful when comparing embryos created in different clinics or even in the same clinic at different times.

Embryos that reach five days after fertilisation are called Blastocysts and may have a different grading system to those embryos that have not reached this stage.

Until very recently the daily routine in a laboratory is for the embryos to be removed from the incubator, moved to under a microscope where their appearance is checked before being returned to the incubator. It’s acknowledged that embryos prefer not to be moved around too much, so we try to avoid checking embryos too frequently. The majority of laboratories will still use this tried and tested approach.

There is obvious advantage to being able to continually monitor the embryos without disturbing them by moving them from one place to another and with the advent of faster computers and improved optics it is now possible to continually look at embryos in their incubator. Increasingly clinics are using time-lapse photography. This means that the embryo can be continually assessed but crucially without disturbing the embryo by taking it out of the incubator. There is a good YouTube video by the manufacturers of “Embryoscope” that is the most widely used time-lapse system in the UK. On top of this, precise embryo selection is improved using software that analyses the rate of progress from one developmental stage to the next.

But the real heart of the matter is not what the embryo looks like but being able to predict which embryo will go to produce a healthy on-going pregnancy.

It’s a huge disappointment for patients to have an unsuccessful cycle after they have been told that they have very high quality embryos based on their appearance, with or without the use of time-lapse techniques.

Time lapse is very helpful in identifying those embryos that look and develop in an expected way, but even top quality looking embryos will not always produce healthy pregnancies. In fact, some babies are born from embryos that don’t on inspection look top quality.

This means that an embryo’s appearance is not the whole story, or rather it’s not possible to completely judge an embryo by its appearance.  An embryo that looks good on the outside may not be functioning well on the inside. For example. it may not have the normal amount of genetic information.

Pre-implantation Genetic Screening (PGS) technology is now a rapidly developing method of testing the embryos genetic information. PGS involves taking a cell from an embryo (biopsy) and assessing the genetic material. This allows selection to be made on the embryo genetics rather than embryo appearance.

It’s very much like reading through a few chapters of a book before buying, rather than deciding on how good it will be by looking at the front cover.

So if it’s such a good idea, why does everyone not use this technology? Large studies have still to show that it actually improves pregnancy rates. There is concern that embryo biopsy may damage the embryo affecting the outcome.  The cost of biopsy continues to fall and is now less than a quarter of the cost of a total IVF cycle. Here is another good YouTube video to look at.

If you would like to discuss the different methods of embryo selection then please contact my PA Yvonne Baillie on 0207 125 0547 liebermanpa@gmail.com to arrange an appointment.

Ovulation Monitors

Using Ovulation Monitors

There are electronic gadgets used to measure all sorts things, heart rate, steps taken…calories burned 🙁 …..the list goes on and on.

So why not use a gadget to monitor ovulation? And are they useful? Points of view differ.

Many (if not most) of the women that come to see me use a cycle monitoring app. I think they are really helpful when trying to work out how regular the cycle is and can be useful in trying to time the fertile window. These apps are a modern take on the age old approach of counting days…..remember your fertility window is BEFORE ovulation..which tends to occur 14 days BEFORE  your period starts..

But measuring ovulation surges in urine….I am not so sure it is really that helpful if you have a regular cycle and you are not in a treatment program. Lots and lot of couples find that they add to the tension of trying to conceive and are a source of friction between partners. If you are going to use them then try NOT to use them EVERY month, perhaps spending the money on a little treat for yourself!

The best way to confirm that you have ovulated is a progesterone blood test taken 7 days before your expected start of your period.

Egg Freezing

Egg freezing

This week I went to a very interesting debate about “social” egg freezing. Social egg freezing is a term used to describe freezing of eggs because a women wants to delay conceiving for social not medical reasons.
Until a few years ago, egg freezing was still in the research stages and could not be used as a treatment. With the development of a more successful freezing method called Vitrification, the process is now considered a realistic and practical treatment option.

Why egg freeze?

There is no question that female fertility declines with age. Going on the pill or being pregnant will not slow the decrease in quality or number of eggs. The fall in egg quantity happens at a different rate in individual women. Egg freezing allows a group of eggs to be frozen so preserving a small bit of a women’s fertility at that age.
At the debate I attended there was a point of view concerning the pressures that women find themselves in trying to balance career development (and so delaying pregnancy) against the lowering of chances of success of conceiving with increasing age. The cost and difficulty of accessing quality child care is also a reason that some may wish to delay.  A very interesting point of view was that the delay in conceiving is a problem that is caused by the expectations of society and the answer (egg freezing) is now placed with the individual. So really shouldn’t we look to change society and people’s expectations?

Is egg freezing going to be very disruptive to my work schedule?

There will normally be one or two pre-treatment consultations where treatment plans will be discussed along with some tests and the signing of consent forms. There will then be between 3 and 4 visits during the stimulation where you will have ultrasounds and blood tests. A further visit will be needed on the day of egg collection. In reality the consultations and treatment ultrasound appointments can normally be scheduled around work. You will however need to take a day off on the day of egg collection.

How successful is it?

It is really difficult to give precise success rates. Pregnancy data is not demonstrated on the HFEA website for frozen eggs. Non-HFEA data that clinics present on their websites are not always externally validated and may not represent the whole picture. Nevertheless it is likely that pregnancy rates will be similar or just slightly lower to those of other women having IVF/ICSI in the same age range with fresh eggs.

Is egg freezing safe?

Egg freezing needs the ovaries to be stimulated so encouraging a good number of follicles to grow. This requires daily injections (up to about 14 days), ultrasounds and blood tests. At the end of the stimulation phase the egg collection procedure is performed to retrieve the eggs. The main concern is the over production of eggs which is called ovarian hyperstimulation syndrome which is uncommon and treatable. The long-term safety to a child is unknown as the technology has not been around long enough to give a clear answer. But there is no reason to think that a child would be at any more risk than any other child born as a result of IVF/ICSI.

All eggs have to be fertilised by ICSI

Before eggs are frozen the embryologists first need to prepare them. One of the important steps is called egg stripping. This is where the supporting cells around the egg are removed. These supporting cells (called the Cummulus) are necessary for normal fertilisation as in IVF. With normal IVF about 100 thousand sperm are mixed with the egg and Cummulus. If the Cummulus is removed then the only way to fertilise the egg is to artificially inject one sperm into the egg.

Costs

When you are trying to work out how much it is all going to cost then you need to think about all the steps involved. These include the costs of pre-treatment investigations, medication, treatment scans and blood tests. The cost of freezing for one or two years is normally included in the treatment price, with additional charges for extending the storage period.
If you would like to know more then please contact my PA Yvonne Baillie on 0207 125 0547 or liebermanpa@gmail.com