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FERTILITY 360

FERTILITY CLINICS: The Good, The Bad And The Ugly

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My first experience of a fertility clinic was disastrous. I was forced to undergo invasive treatment in a hospital corridor and ended up refusing to go through with it and walking out. The clinic never contacted us again and we never went back. Let’s just say it wasn’t an auspicious start.

Since then I have been through the multiple rounds of IVF and over a dozen clinics. I’ve become a fertility veteran and had every test known to woman and doctor in a bid to diagnose and cure my infertility. Here are my top tips for choosing a clinic and how to separate the good, the bad and the ugly.

I think the first shock about fertility clinics is that most of them don’t look like the sort of place you’d go to create a baby. Over the years I’ve come to expect the unexpected – from the clinic that looked like it was straight out of a Dickens novel to the one that doubled for some sort of New York contemporary art gallery.

One thing, however, I have never got used to is the fertility clinic waiting room. Most places don’t think about the privacy and anonymity that many patients want and need. In the worst offenders, couples are crammed together, chairs facing each other so there’s nowhere else to look, with maybe a pile of children’s toys in the corner to remind you of what you haven’t got.

Three months later it turned out that I was pregnant but the** foetus was ectopic and had implanted in my stomach**. This was a life-threatening situation that could have been avoided if a more accurate pregnancy test had been done at the end of our treatment.

The best waiting room I ever attended had clearly taken the patient experience into consideration in its design. The walls were curved so that each couple got to sit in their own private space. Given that there is always a lot of waiting involved, it made it so much nicer.

Sooner or later in your fertility journey, your partner (or you) are going to experience the horror of the ‘Producing Room’ – the place where men and magazines convene to produce a sperm sample. Most rooms are tiny, often doubling as a toilet or a cupboard. The one at our first clinic had a bucket and mop in the corner, boxes of surgical gloves piled from floor to ceiling, the obligatory well-leafed top shelf magazine and a very uncomfortable looking plastic chair.

It has always disappointed me that couples are not routinely asked if they would like to be together for this part of the process so that, as a mother, you can say to your child: “I was there.” Whenever we’ve been bold enough to request this, the clinic staff have treated us as if we were weird, despite the fact that generally speaking it does take two to make a baby.

Perhaps if producing rooms were designed more like bedrooms with soft lighting and maybe an iPod with a selection of music then couples, if they wanted to, could choose to start the assisted conception process together in a more natural way.

Nowadays most fertility clinics allow partners to be present for the embryo transfer procedure and that’s definitely a positive thing. But one of the best clinics we ever went to also allowed us to watch the ICSI process when the embryologist injected sperm into the egg. The thought that we might be able to say to our child in years to come that we had witnessed that moment was such a privilege.

In addition, new technology such as the Embryoscope – which takes continuous film footage of your embryos during their first few days in the laboratory – is amazing. Of course, given the choice, all of us going through fertility treatment would rather conceive a baby naturally but these opportunities are unique and special and do offer some compensation for having to confront what is, let’s face it, an artificial and difficult process.

If you are being treated privately (and most women who are going through fertility treatment are) then taking time to choose the right environment and quality of care is really important. In the busiest clinics it can sometimes feel akin to being a cow in a cattle market with a number printed on your backside. I went to one clinic where not only the waiting room was full but you’d regularly find people sitting on the stairs. I also recently spoke to a woman who said that her clinic was so busy that they never answered the phone so if she had a question, however small, she had to get on the train from Brighton and come up to London.

The best fertility clinics have time for you and make you feel like an individual. You are given the opportunity to develop a relationship with one doctor who makes the effort to understand your story and, rather like a detective, attempts to work out what the problem is and what should be done. Ideally, that same doctor will be the person who sets your stimulation drug dose and does your scans, egg collection and embryo transfer.

I have been to only two clinics that took this approach – at most clinics, you see different people at different stages and sometimes you never see the same person twice. But at those two clinics, the doctor/patient familiarity and care made a huge difference to how I felt about my treatment.

Sadly even the best clinics have to face failure. One of the things I strongly advocate is that all IVF patients be given a blood test at the end of their treatment to measure the levels of the pregnancy hormone, hCG. No-one likes that trip to the clinic when you’ve started spotting or even bleeding to take a test which you know in your heart is going to be negative. No-one likes the pain of waiting for that dreaded call to give you the result.

But, and I say this from personal experience, you should never be allowed to simply take a urine test at home. I went to one clinic that only offered their patients this option and because the home test looked negative and I was bleeding, I assumed it was. Three months later it turned out that I was pregnant but the foetus was ectopic and had implanted in my stomach. This was a life-threatening situation that could have been avoided if a more accurate pregnancy test had been done at the end of our treatment.

I do feel for the staff who regularly have to make that terrible call to tell you that your test is negative – current statistics indicate that only a third of cycles succeed. At the same time, I have to say that most clinics don’t handle the management of failed cycles well. When a close friend of mine had her first negative result after NHS treatment, she asked if she could see a counsellor and was told that there wasn’t an appointment available for the next three months.

I also heard another story recently where a woman was distraught when she found out her blood test was negative but wasn’t allowed to leave the clinic before going into Accounts to settle up for the test. (Why not at least ensure that all patients pay for their hCG in advance?)

Moreover, there hasn’t been a clinic I’ve attended and moved on from, not a single one, that has contacted me at a later date to find out how I am or where I’m going next on my fertility journey. It has always made me feel as if I’m the black sheep of the clinic, the one who bought their live birth statistics down and, thankfully, eventually disappeared.

One of the disadvantages of the whole process is that even though fertility is big business these days – just spend a weekend at the annual Fertility Show at Olympia to see – patients are still way too powerless in the face of doctors who hold our happiness in their hands. We don’t want to make a fuss; we want all the clinic staff to ‘like us’ so that they will do their best to deliver us the baby we long for. This means that many people are prepared to put up with the ‘bad’ and even the ‘ugly’.

I have done it myself over and over again. So choose your clinic carefully. Success rates are important but so are other things. Think about the sort of environment, involvement and care you want in your treatment. And when it’s not good enough or there’s something that could make it better, let’s shout about it so things will eventually change. If as customers we start to demand better clinics and a more personalised approach to our treatment, it will eventually happen, and I have no doubt that results will improve.

The Pursuit of Motherhood is published on February 1, by Matador, priced £8.99. For more information, visit thepursuitofmotherhood.com

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FERTILITY 360

What Is Polycystic Ovary Syndrome (PCOS)?

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Polycystic Ovary Syndrome

Polycystic Ovary Syndrome or PCOS is a hormonal imbalance that affects 5 to 10 percent of women of reproductive age across the world, and results in irregular or absent periods, acne, excess body hair and weight gain. It is also a major cause of infertility and yet is frequently misdiagnosed and often missed completely.

PCOS gets its name because under an ultrasound scan, the ovaries can look like a bunch of grapes, each one covered in what look like multiple cysts. In fact, these aren’t cysts at all, but are small, undeveloped follicles.

Symptoms

Not every woman with PCOS will get the same symptoms, but common signs to look out for include:

  • Few or no periods
  • Excess hair on the face or breasts or inside of the legs or around the nipples
  • Acne
  • Oily skin
  • Scalp hair thinning or loss (male pattern baldness)
  • Skin tags (known as acrochordons)
  • Skin discolouration (known as acanthosis nigricans) where the skin looks ‘dirty’ on the arms, around the neck and under the breasts
  • Mood swings
  • Depression
  • Lack of sex drive
  • Weight gain especially around the middle of the body
  • Difficulty in losing weight
  • Cravings and binges
  • Irregular or no ovulation
  • Difficulty in becoming pregnant
  • Recurrent miscarriages

PCOS creates a vicious cycle of hormone imbalances, which has huge knock-on effects throughout the rest of your body. With PCOS, the problem often starts with the ovaries, which are unable to produce the hormones they should, and in the correct proportions. But linked to this is the very common problem of insulin resistance. Women with PCOS very often have difficulties with blood sugar levels which can cause weight gain and the excess insulin can stimulate your ovaries to produce yet more testosterone. Half of all women with PCOS do not have any problems with their weight, yet they can still have higher insulin levels than normal.

How is Polycystic Ovary Syndrome diagnosed?

The most widely accepted criteria for the diagnosis of PCOS says that you should have two out of these three problems:

  • Infrequent or no ovulation
  • Signs (either physical appearance – hirsutism or acne – or blood tests) of high levels of male hormones
  • Polycystic ovaries as seen on an ultrasound scan

The Seven Nutritional Steps to beat Polycystic Ovary Syndrome

Good nutrition is the foundation of your health and you should never underestimate how powerful it can be.  It is the fuel that provides you with the energy to live your life and it gives your body the nutrients it needs to produce your hormones in the correct balance.  The better the supply of those nutrients, the more healthily your body will function.

The fundamental aim of my nutritional approach to PCOS is to target a number of areas simultaneously so that you get the maximum effect in the minimum amount of time.  

Here’s how:

  1. Switch to unrefined carbohydrates (eaten with protein) and never go more than 3 hours without food to keep your blood sugar levels balanced
  1. Eat oily fish and foods rich in Omega 3s to help your body to become more sensitive to insulin so it can overcome insulin resistance
  2. Cut out all dairy products for 3 months to bring levels of male hormones under control
  3. Eat more vegetables and pulses to which helps control male hormones
  4. Cut right back on or cut out alcohol for 12 weeks to allow your liver function to improve
  5. Cut down on caffeine to give your adrenal glands a rest
  6. Cut down on saturated fats and eliminate trans fats to help control the potentially damaging inflammatory processes PCOS causes in the body
Polycystic Ovary Syndrome

Best Supplements for PCOS

The use of certain vitamins and minerals can be extremely useful in helping to correct Polycystic Ovary Syndrome, along with a good diet.

Chromium

Chromium helps to encourage the formation of glucose tolerance factor (GTF), which is required to make insulin more efficient. A deficiency of chromium can lead to insulin resistance.  It also helps to control cravings and reduces hunger. Can help to reduce insulin resistance associated with PCOS

B vitamins

The B vitamins are very important in helping to control the symptoms of PCOS. Vitamin B2 helps to turn fat, sugar and protein into energy. B3 is a component of GTF which is released every time blood sugar rises, and vitamin B3 helps to keep the levels in balance. Vitamin B5 has been shown to helps with weight loss and B6 is also important for maintaining hormone balance and, together with B2 and B3, is necessary for normal thyroid function.

Zinc

Zinc helps with PCOS as it plays a crucial role in the production of your reproductive hormones and also regulates your blood sugar.

Magnesium

Magnesium is an important mineral for dealing with PCOS because there is a strong link between magnesium levels and insulin resistance – the higher your magnesium levels the more sensitive you are likely to be to insulin.

Co-Enzyme Q10

Co-Q10 is a substance that your body produces in nearly every cell.  It helps to balance your blood sugar and lowering both glucose and insulin.

Alpha lipoic acid

This powerful antioxidant helps to regulate your blood sugar levels because it releases energy by burning glucose and it also helps to make you more insulin sensitive. It also has an effect on weight loss because if the glucose is being used for energy, your body releases less insulin and you then store less fat.   

Omega 3 fatty acids

Omega 3 fatty acids taken in supplement form have been found to reduce testosterone levels in women with Polycystic Ovary Syndrome.

Amino Acids

Certain amino acids can be very helpful for PCOS as they can improve your insulin sensitivity and also can have an effect on weight loss.

N-Acetyl cysteine

In women with PCOS this amino acid helps reduce insulin levels and makes your body more sensitive to insulin. Study using NAC in women who were clomiphene resistant and had ovarian drilling.  After ovarian drilling, the women given NAC compared to a placebo showed a significantly higher increase in both ovulation and pregnancy rates and lower incidence of miscarriage.

Arginine

Arginine can be helpful in reversing insulin resistance. In one study, a combination of both arginine and N-acetyl cysteine were given to women with Polycystic Ovary Syndrome.  The two amino acids help to improve blood sugar and insulin control and also increased the number of menstrual cycles and ovulation with one women becoming pregnant on the second month.

Carnitine

Carnitine helps your body break down fat to release energy and can help improve insulin sensitivity.

Tyrosine

Tyrosine is helpful for women with PCOS who are overweight as it helps to suppress the appetite and burn off fat.

Glutamine

This amino acid is useful for helping with sugar cravings as it can be converted to sugar for energy and so takes away the need to eat something sweet.  It also helps to build and maintain muscle which is important for fat burning.

Branched Chain Amino Acids (BCAAs)

BCAAs include three amino acids leucine, isoleucine and valine. They are important in PCOS because they help to balance blood sugar and having good levels of these BCAAs can have a beneficial effect on your body weight

Inositol

A study used inositol (2,000mg) in combination with NAC (600mg), significant increase in ovulation rates.

Having a good diet, regular exercise, controlling stress and taking key nutrients will help in getting your hormones back in balance and reducing the negative symptoms associated with PCOS.

More information can be found on www.naturalhealthpractice.com

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EGG DONATION

IVF Spain Update Us on Claire & David and Laura & Ian Progress

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Claire & David IVF Spain

During the first week of August, Claire (42) and David (35), the winners of this year’s Fertility Journey, visited our clinic for their first embryo transfer.

They were pleased to share with us the emotion and joy created by their short stay in Spain;   

“We have spent some time in Alicante ahead of the transfer, relaxing in the area and preparing for our next visit to IVF Spain. Our experience with previous treatments with UK clinics has been very stressful but in Alicante, we have spent most of our time preparing for treatment by relaxing on the beach!”

Claire and David arrives at IVF Spain after having been trying to get pregnant for 7 long years and experienced 3 failed ICSI treatments with their own eggs. IVF Spain discovered that the quality of the embryos was poor and that they had always been transferred on day 3 of their development with a bad morphology. In order to increase their chances of getting pregnant the clinic recommended an egg donation treatment – a fertility treatment which that greatly depends on matching the perfect donor to the patient.

To protect both patients and donors Spanish law requires that the donation process must be completely anonymous.  In addition, donors must be in good condition and younger than 35. Moreover, both donor and patient must share a phenotypical resemblance: hair colour, BMI, eye colour, and so on.

Dr Herea

Claire and David were grateful that so many women in Spain were willing to donate their own eggs, enabling others less fortunate, the chance of forming a family.

“We are really grateful that there are people willing to donate eggs. If we are being honest, it has taken a while for us to understand the Spanish anonymity rules for egg donors, but we have taken the time to consider this. It’s hard not having control or letting another person being in charge for something related to your baby. However, we even think now it is better that way, because the more you know, the more you want to know and we do prefer knowing nothing and leaving it in the clinic’s hands.”

There are other factors, however, that are crucial to achieving a successful pregnancy: the quality of the embryo and the microenvironment of the endometrial lining. This means that a successful pregnancy also depends on the successful communication between the embryo and the endometrial lining.

When we discovered that Claire didn’t have a single positive pregnancy test, we suggested to perform an endometrial biopsy to analyse the retrieved sample by means of the ER Map® test (Endometrial Receptivity Map) and accurately determine the receptivity of Claire’s endometrium during the window of implantation (the moment when the endometrial lining is receptive).

”The test results showed that Claire’s endometrium was post-receptive, meaning that a transfer performed on day 5.5 of progesterone (like in 70% of cases) would not end up in a successful pregnancy” explains Dr Natalia Szlarb.

“Before coming to IVF Spain, we had never heard of an endometrial study or ER Map. The fact that the endometrial study analyses the best time to transfer the embryo could make a big difference to our treatment. We were really impressed with the accuracy of the test. Our ER Map test result was post-receptive and although this was initially a concern, we later came around to the view that knowing the best time to transfer the embryo would increase the chances of success, and this might have been the reason our other treatments in the UK had failed” – Claire and David.

There are other key factors, however, to achieve a pregnancy such as the male factor. David suffers from teratospermia which implies that 96% of the ejaculate sperm cells have an abnormal morphology. Luckily, we were able to improve David’s sperm quality and fertilize the retrieved eggs.

We now wish them the best of luck!

Although it will not be until mid-September when Laura (41) and Ian (44), the 2018 runners-up visit us in Alicante for their embryo transfer, they already talked about the differences between IVF Spain and former clinics. They were impressed at how extensively their case had been studied by our fertility specialists.

Laura and Ian IVF Spain

“I think the longer you have treatment the more difficult it becomes. When you begin there’s a naivety along the lines of, ‘we’ll have one, maybe two goes at IVF and have a baby in our arms’. After 7 treatments (and lots of add-ons) the feelings completely change. You feel terrified that it won’t work, and you’ll never become parents. You’re scared it will work and you’ll lose the baby again (Laura and Ian have experienced 5 losses). You’re scared of physically going through the treatment as you’ve had so much. Each test and treatment creates fear – fear that it will hurt, be traumatizing, that it will give you more bad news. Then there’s the impact on your own mental health and emotional well-being. Can I handle this? What if the results say something’s wrong with me? Will I blame myself? It starts to really damage your mental health and well-being. Financially you start to feel that you’re risking everything, and it may not pay off.

For us we have renewed hope with IVF Spain. We have undergone tests that we’ve never had before (ERA, NK biopsy and KIR). We have paid for lots of very expensive blood tests and drugs but never received this kind of analysis. So, we feel as though the treatment is now specifically for us.

This creates more positivity, a feeling of being cared for and that maybe, just maybe, we’ll get to be parents.

Plus, we’re now using donor eggs. The hope starts to soar and with that comes excitement. Hope is the only thing that keeps you going and overcoming the fears I mentioned. This opportunity with IVF Spain has given us hope that we thought we’d lost.”

Laura is 41 years old and has already been through traumatic losses including an ectopic pregnancy. Due to this and to the fact that Laura suffers from trisomy 22 syndrome, our medical team at IVF Spain recommended an egg donation treatment to increase their chances.

The couple is thankful for the egg donation process being anonymous, as otherwise it would be really difficult to find a donor:

“For us, it’s taken some of the pressure away. I can’t imagine how difficult it would be to choose a donor ourselves. But putting your complete trust into someone else’s hands is hard.

We’ve explored whether it would be better for our future child to know the donor. I think that’s something we’ll never know. But we hope that he/she will understand our decision to choose an anonymous donor. It would be good to know a little more about the heritage of the donor but then we also know that we often don’t even know our own heritage. We’ll make sure Spain is a key part of their story.

It’s also really odd to not know who this person is. What they look like and personality. What’s motivating them to help us. One of the things I’ve been really consumed with is the gratitude you have for this person. I’d like to thank them but can’t.

Anonymity means we have a chance to become parents. Without it there’d be a shortage of donors like there is in the UK. For us, this makes it a wonderful gift – a chance to hopefully find a donor that is perfectly matched to us genetically (due to the KIR tests) as well as in physical looks.

I can’t stop thinking about what our future child will look like – but I think that’s quite normal” says Laura.

Immunologically speaking, finding a matching donor for Laura is certainly a challenging task, which is why IVF Spain suggested that we find out her KIR via a blood test. Ian was also tested for his HLA-C in order to determine whether the maternal – foetal interaction will be optimal or not.

Thanks to the KIR-HLA-C genotyping test it is possible to determine if the uterine KIR and the embryonic HLA-C will both be compatible. If so, the pregnancy will carry on successfully; if not, then the most probable outcome will be an unviable pregnancy and subsequent miscarriage.

“We carried out the KIR-HLA-C genotyping and concluded that the patient had a KIR AA. It is known that KIR expressed by the natural killer cells present in the maternal part and the HLA presented by the trophoblastic cells together will influence the outcome of the pregnancy. With Laura’s KIR AA variant, the sperm would have to be HLA C1 C1 and the HLA of the donor should be as well HLA C1 C1; as her husband has a HLA C1 C2 variant, we will treat her with a medication that reduces her immune-genetic reaction. We believe that not paying attention to this issue in the past is what may have caused the implantation to fail” suspects fertility specialist Dr Isabel Herrera.

We tend to recommend a single embryo transfer, as it has been proven that on patients with an immunological profile such as Laura’s, a double embryo transfers would increase the immunogenetic reaction, hindering the achievement of a pregnancy” says Dr. Herrera.

It is also known that these cases tend to have a higher risk of pre-eclampsia, late spontaneous abortion or miscarriage.

Until their transfer day the couple will try to enjoy summer just as any other couple would;

“I’ve tried to just carry on as normal. Remain healthy, take pre-conception vitamins. Reach out and get support through the Donor Conception Network in the UK and connect with other people going down the DE route via online forums. It’s quite isolating and scary so it’s important to reach out and not feel so alone.

I’m trying to relax a little – not so easy with work but it’s a work in progress. I need to get that bit sorted now treatment is on the horizon.”


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FERTILITY 360

Egg Freezing: Is It An Fertility Insurance Policy

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Egg Freezing

‘Should I freeze my eggs’ is a question many women consider and for many different reasons. Perhaps they have not found the right partner or they are at a particular stage in their life when they are simply not ready for a child, but at the same time, do not wish to miss the opportunity of producing and storing eggs before their biological clock gets the best of them, or before the quality of their eggs degrade making it harder to become pregnant in the future.

With many fertility clinics offering egg freezing to their patients, the procedure has transformed from one only undertaken if there is a medical need (perhaps before embarking on a course of treatment which is likely to affect fertility) to what has been termed by some as a fertility ‘insurance policy’ allowing women the opportunity to take steps now in an attempt to preserve their fertility just in case they are unable to produce viable eggs in the future. However, the value of that ‘insurance policy’ continues to be a matter for debate with wildly varying quoted success rates, which remain relatively low, and at a not unsubstantial cost. Yet many take the view that a backup plan is better than nothing at all, even if it offers no guarantees.

However the decision to freeze is only the first of many decisions to be taken which can have significant consequences in the future. For example, should the egg be frozen on its own, or should it be frozen as a fertilised embryo? The embryo is thought to be more robust than the egg increasing the prospects that it would survive the freezing process but comes with less flexibility to meet changes in the woman’s circumstances. The genetic makeup of an embryo is set by the choice of sperm used to create it (whether known or through anonymous donor sperm) and cannot be changed if, for example, the woman meets a new partner before she is ready to have children. Furthermore, if a woman and her partner separate before the embryo is implanted and the partner withdraws his consent for the embryo to be stored or used, it may have to be destroyed.

The decision of when to freeze the eggs is also an important one. From a medical perspective, the advice seems to be to freeze early on rather than waiting till you are in your mid to late 30s and 40s and using egg freezing as a last ditch attempt to preserve fertility. Whilst this may well be sound medical advice, there can be legal ramifications. That is because in the UK, it is only possible to store eggs for a maximum of 10 years after which they must be destroyed. The only exception to that rule is if the woman, or in the case of freezing embryos, her partner, are or are likely to become prematurely infertile. In that case, if the correct steps are taken before the 10 year time limit expires, the time for storage can be extended.

The choices that freezing offers are undoubtedly beneficial – but in making decisions about what and when to freeze guidance should be taken from both your medical and legal team.  As with all forms of insurance, a full assessment of the risks and the possible future consequences is needed to ensure the choice you finally make is the one most likely to provide you with the best outcome in your particular circumstances in the future.

Liz Bottrill is a Partner in the Family Law Team at Laytons Solicitors with over 25 years’ experience in the field. She has a particular interest in the law relating to children and fertility.

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