The Fertility Show 2015: Navigating the fertility journey, IVF and understanding diminished ovarian reserve
The Fertility Show 2015
Why attend the Fertility Show?
I had the privilege of visiting the Fertility Show in London’s Kensington Olympia in November and given the obvious interest in this event from a number of my fertility patients, I wanted to share information from some of the talks I had attended from a practitioner’s perspective.
My fertility patients had talked about their reasons for attending the show before – for some, they wanted to be as proactive as possible in finding out what they could do to support themselves either whilst trying naturally or whilst going through in vitro fertilisation (IVF). Some were considering IVF treatment at a number of clinics in London or Hertfordshire and found it convenient to book in to meet several consultants in one place and on a single day. Others were looking for specific information and advice about egg or sperm donation, or about IVF treatment abroad. From the hubbub that I saw throughout the Saturday that I attended, these were certainly reasons that were shared by many other singles and couples looking to start, or continue building, their families.
But the Fertility Show is not attended just by those seeking fertility options. For practitioners like me who work closely with fertility patients, the show provides a unique opportunity to hear about emerging new technologies or changes to specific advice or recommendations so that we can actively stay informed. Granted this information can be accessed in a number of other ways such as reading research papers and which would certainly be far less time-consuming than attending a 7-hour event. But having just completed a number of years in research, I was especially interested in finding out how evidence was being translated into clinical recommendations – how this was informing the way that consultants were making decisions not only about IVF in general, but also in personalising recommendations for different patient groups. For me this was the really exciting part of the day and I hope that the snippets of the talks that I’ve provided in this blogpost will give an idea of what you can expect if you’re thinking of attending a Fertility Show in the future.
Themes of the presentations
As I attended only a proportion of the talks and only on the Saturday, it’s obvious that my main take-home messages from the show are limited to the content from these sessions. However, when reflecting on the day to prepare this blogpost, a number of common themes emerged and I’ll summarise the key points under these subheadings:
- Starting your fertility journey and managing expectations
- Preparing for IVF treatment and estimates of ovarian reserve
- Diminished ovarian reserve
Starting your fertility journey and managing expectations
Do you remember when you first decided you would start a family of your own? Imagine if somebody had told you at the time that it is quite normal for it to take up to 2 years for couples with normal fertility to get pregnant. Two years! For most of us, getting pregnant is much harder than we think and it’s important to bear this in mind in order that we can put our experiences into context and make informed decisions moving ahead.
Mr Stuart Lavery from IVF Hammersmith highlighted that couples with normal fertility have an 18-20% chance of falling pregnant per menstrual cycle. At first these don’t sound like particularly good odds. But what it does do is help explain why for so many of us, our expectations simply don’t match up to the reality that 90% of couples without any fertility problems will be pregnant within 2 years. When it comes to deciding the right time to see your GP however, current UK NICE guidelines recommend fertility investigations after a couple have been trying for a baby for 1 year and if there are no known existing problems such as endometriosis or polycystic ovary syndrome (PCOS). However, where the female partner is over 35 years old or where there is a previous history of fertility issues for either the male or female partner, an earlier referral is normally advised. In these circumstances, Mr Lavery recommended that this ought to be after 6 months of trying to conceive.
Preparing for IVF treatment and estimates for ovarian reserve
Couples who have decided to look into IVF treatment will be asked to undergo a number of checks before starting a treatment cycle. Besides a sperm test, a fertility clinic will also ask for markers of ovarian reserve such as Follicle Stimulating Hormone (FSH), Anti-Müllerian Hormone (AMH) and possibly antral follicle count (AFC) (ACOG, 2015).
Tests for ovarian reserve provide information regarding the quantity of eggs that are remaining in a woman’s ovaries. When girls are first born, research suggests that their ovaries can contain an impressive 7 million eggs. However, with age this rapidly declines and by a woman’s first period, there will be just 0.5 million eggs and this will continue to decline until the menopause when no eggs remain. FSH, AMH, AFC as well as a woman’s age will give a rough idea of a woman’s likely response to IVF drugs. This allows consultants to advise on success rates, to choose correct dose of medications and to offer advice on alternative routes such as donor eggs in order to boost chances of success.
Ovarian reserve tests give an estimate of the number of eggs remaining in a woman’s ovaries but these tests don’t provide specific information regarding the quality of eggs. It’s normal practice to use age as an estimate since the proportion of poor quality embryos rises with age (Ata et al., 2012). Whilst ovarian response to IVF relies on both the number as well as quality of eggs, according to Mr Tarek El-Toukhy of Guy’s and St Thomas’ Assisted Conception Unit, the best test for ovarian response is ultimately to undergo a stimulated cycle and to monitor each stage of the treatment. If the first treatment cycle is unsuccessful - though undoubtedly disappointing - this does provide the fertility clinic with useful information which allows them to better understand your ovarian response. Should you and your partner decide to continue with another cycle of treatment, your clinic is better informed for this next treatment cycle and likely to recommend various changes such as increasing dosages, introducing additional drugs or perhaps considering other techniques such as assisted hatching or pre-implantation genetic screening (PGS).
Diminished ovarian reserve
The view that Mr Hossam Abdalla of the Lister Clinic holds on reduced ovarian reserve is that it’s unethical to treat when the chances of conception are zero – such as when there are no sperm, or no fallopian tubes - or where there is a significant risk to the child, to the mother or to society. Although women with diminished ovarian reserve have a reduced chance of success, the chances of conception are certainly not zero and according to a French study, a woman aged 40 has a 44% chance of having a baby naturally within 1 year of trying, and a 64% chance within 4 years of trying (Leridon, 2004). The recommendation according to Mr Abdalla has always been to continue trying naturally - especially where a woman is experiencing regular menstrual cycles and which is likely to point to regular ovulation.
He also highlighted the importance of considering cumulative success rates when making decisions about whether or not IVF is right for a couple - that is, the success rate over a number of treatment cycles rather than per cycle or per embryo transfer which has been the traditional method of reporting. For example, according to a 2009 publication on cumulative live birth rates in IVF, a woman aged over 40 has a 9% chance of having a baby using her own fresh eggs (Malizia et al., 2009). Although this might sound like a low chance of success, it can be helpful to approach these figures by seeing that after three IVF attempts, this woman will have had the same chances of having a baby (31%) as someone aged less than 35 but on their first IVF attempt (27%) (Witsenburg et al., 2005). One has to bear in mind obvious factors such as the financial cost of numerous IVF attempts as well as the emotional burden of undergoing fertility treatments. But this information can be valuable in helping many of my own patients have constructive discussions with their partner and their consultants as well as setting more realistic and optimistic expectations regarding an upcoming IVF cycle.
Mr Abdalla also makes a fascinating case for pushing the boundaries when it comes to offering fertility treatment to those with diminished ovarian reserve. Research carried out in 2008 by US doctors suggests that women with FSH levels above 18 are highly unlikely to succeed with IVF using their own eggs and this, alongside many other factors, results in most consultants strongly recommending the use of donor eggs. Though this viewpoint remains commonplace, Mr Abdalla notes that he had had the privilege of seeing a number of success stories, including one woman in her early thirties presenting with an FSH reading of 35. Clearly these stories are anecdotal and in themselves are unlikely to dramatically change clinical practice recommendations, but what it has done is facilitated a more inclusive approach with some consultants now being more open to prescribing treatment despite diminished ovarian reserve - as long as expectations have been responsibly set.
What can I do now?
For more information on navigating the fertility journey, I’d highly recommend accessing the NICE guidelines on fertility management which can be accessed here. GPs and fertility consultants refer to these guidelines when making recommendations and it’s a good idea to check out the most up-to-date evidence-based recommendations so that you can feel more prepared and more involved in the decisions that are being made about your treatment. Being guidelines, they’re not designed as a tickbox exercise for doctors to follow robotically, but rather to guide decisions about your care and making recommendations bearing in mind your and your partner’s needs and wishes. It’s a good idea to be prepared for your appointment by discussing in advance with your partner what views or concerns you both have about various treatment options. This will allow you both to communicate to your consultant what you are - and are not - looking for and ensure that all parties make the most use of usually very little time during a fertility consultation to have a meaningful discussion about upcoming treatment.
Acupuncture and other complementary approaches can have a valuable role to play at various points of the fertility journey and I’ve supported many patients at these different stages including:
- Those who have just decided to start a family and wish to start preparing by regulating their cycles or boosting their wellbeing;
- Those who will be starting their IVF treatments in the coming months and wish to prepare for their upcoming cycle the best they can;
- Those who have failed a number of IVF cycles and are looking for a complementary approach which can provide support on the run up and during the treatment cycle;
- Those who have decided that IVF is not – or no longer – a route they wish to go down, and would like to continue trying for a baby naturally.
Acupuncture can lead to incredible results for some (more about this in another blog in the new year!), but it needs to be the right approach for you. During the show, when Zita West was talking about recommending acupuncture as part of her practice, a member of the audience called out ‘Can reflexology help if I don’t like needles?’ to which she responded with a resounding ‘Yes! Why use acupuncture if you’re afraid of needles?’. Nowadays there are numerous sources of support besides acupuncture that one can choose from but it’s important to remember to engage with everything critically, to be pragmatic and to not allow the ‘shoulds' and 'should-nots’ take over – picking what’s right for you and your partner is the most empowering action you can take.
If you do decide that acupuncture is the right approach for you, ask around and see if anybody you know can recommend an acupuncturist in the local area. You can also look up practitioners via registers such as the Association of Traditional Chinese Medicine and Acupuncture or the British Acupuncture Council. Practitioners named on these registers will be vetted to ensure that they are appropriately trained, hold insurance and adhere to standards of professional and ethical codes of conduct. Once you have the names of two or three practitioners, get in touch with each of them (most registered practitioners will offer a free 15-minute consultation). Use this opportunity to ask about their experience, how they think they can help you and to get a feel for whether their approach feels right for you. Acupuncture – like any other healthcare treatment – is an investment in you and your health, and it’s important that you feel confident in the practitioner you’ve chosen, and that you trust that their expertise and clinical know-how give you the best chances of getting you where you want to be.
Thanks for reading - I hope this has been informative and that it’s provided a useful synopsis of what you can expect to find at next year’s Fertility Show if you’re thinking of attending!
ACOG 2015. Ovarian Reserve Testing: Committee Opinion No. 618. Obstet Gynecol, 268-73.
ATA, B., KAPLAN, B., DANZER, H., GLASSNER, M., OPSAHL, M., TAN, S. L. & MUNNE, S. 2012. Array CGH analysis shows that aneuploidy is not related to the number of embryos generated. Reprod Biomed Online, 24, 614-20.
LERIDON, H. 2004. Can assisted reproduction technology compensate for the natural decline in fertility with age? A model assessment. Hum Reprod, 19, 1548-53.
MALIZIA, B. A., HACKER, M. R. & PENZIAS, A. S. 2009. Cumulative live-birth rates after in vitro fertilization. N Engl J Med, 360, 236-43.
WITSENBURG, C., DIEBEN, S., VAN DER WESTERLAKEN, L., VERBURG, H. & NAAKTGEBOREN, N. 2005. Cumulative live birth rates in cohorts of patients treated with in vitro fertilization or intracytoplasmic sperm injection. Fertil Steril, 84, 99-107.