Medically assisted pregnancies

With a little help from science

Thousands of babies born in Australia every year are conceived with some form of medical assistance. Here's the latest on what's on offer and how it all works.

Generations ago, if you weren't able to fall pregnant the natural way, you had very few options available: adoption or a life without children were basically it.

But these days it's a different story. Thanks to the startling and miraculous developments in reproductive technology, there's an extensive range of medically-assisted techniques that can help couples become parents. In Australia, we're fortunate that they're all relatively affordable and accessible and that the quality of medical expertise to carry them out is world-leading.

Most women go through life never imagining they may one day have trouble falling pregnant, so the world of infertility and possible treatments is a foreign and emotionally frightening place, both for women and men. That's why it's essential to be fully informed and educated about everything involved before you talk to your doctor.

Fertility drugs
For women who rarely or never ovulate, one option to help boost their chances of pregnancy is the use of fertility drugs. The drugs, made from hormones that stimulate ovulation, are most suited to women who have normal fallopian tubes and whose partner has a normal semen analysis.

The main two types of drugs used are tablets of clomiphene citrate (branded Clomid or Serophene) or injections of a follicle stimulating hormone, or FSH (Gonal-F or Puregon).

With the clomiphene tablets, doses range from half a tablet to three tablets a day, depending on the severity of the ovulation problem and the woman's size. For FSH, you need to inject yourself with a pen-like device that injects the drug under the skin.

Most importantly, what kind of success rates do these drugs have? These range widely, with about a 40-50 percent success rate over a six-month course of treatment for women under 38.

"Clomid really works and is a very good drug for people who don't ovulate," says Dr Mark Bowman, clinical director of Sydney IVF. "But it's a pretty lousy drug for women with unexplained infertility, when the GP just shrugs their shoulders and says 'let's give it a go'."

Both clomiphene and FSH have some minor physical side effects, especially with higher doses. These can include mild ovarian swelling, breast discomfort, irritability, thickening of the cervical mucous and nausea. But the largest risk from using fertility drugs — and the most well known — is having a multiple birth.

"With stimulating drugs, the most common side effect is having a multiple pregnancy, with a 20-25 percent twin rate," explains Dr Bowman, adding that more twins get into trouble during pregnancy and birth than single babies.

Assisted conception
It's the oldest and least invasive of all the medically-assisted conception options and assisted insemination, or intrauterine insemination (IUI), still remains a good option for some couples.

It can work for many male-related fertility problems, like impotence, poor semen quality or retrograde ejaculation or if the woman has any cervical abnormalities. It's also used if there's a sperm donor, but does require the woman's fallopian tubes to be in good shape.

IUI is a quick and simple procedure, much like having a Pap smear. The sperm are inserted into the cervix or uterus with a soft, thin plastic tube around the time of ovulation. To ensure the timing is spot-on, your cycle will be closely monitored with blood tests and ultrasounds beforehand.

Sometimes assisted conception is combined with fertility drugs to boost the number of eggs available, but that brings a high risk of multiple pregnancies.

How successful IUI is depends largely on the woman's age. In general, the pregnancy rates aren't higher than those for a healthy couple having regular sex. In many cases, the streamlined and more controlled procedure of IVF will offer a greater likelihood of pregnancy in less time.

"It's a valid treatment, but IUI success rates are about 15 percent per cycle, which is significantly less than IVF," says infertility specialist Dr Kelton Tremellen, of Repromed, in Adelaide. "Ten years ago they were almost on a par but now success rates in IVF have improved considerably."

All about IVF
If you're facing the prospect of IVF treatment to try and conceive, there are plenty of reasons to feel positive. The rate of IVF babies born in Australia is soaring, at around 5000 a year and growing. The technology is also advancing rapidly, with success rates increasing as the procedures get more streamlined.

"IVF today is so much more user-friendly [that it once was]," says Dr Tremellen. "There are shorter drug protocols and it's getting more easy and affordable."

As a result, IVF remains the preferred treatment option for a growing number of conditions. But it is still a time-consuming emotional journey, with no guarantees of having a baby at the end. Here's what's involved.

Ovarian stimulation. A series of daily injections of the hormone FSH is used to stimulate the ovaries to make more eggs than they normally would. This is done with a pen-like device into the tummy fat and your IVF clinic will closely monitor the results with blood tests and ultrasounds to see if the dosage needs to be adjusted.

Egg and sperm retrieval. When a good number of follicles is produced, you'll have a trigger injection that matures the follicles and eggs, getting them ready for collection. The egg retrieval is done using local anaesthetic or sedation and a vaginal ultrasound to guide the procedure. The sperm is collected at this time and they're all transferred to the lab.

Culturing embryos. The eggs and sperm are placed in a culture dish to fertilise for up to five days. They're transferred back into the woman's body any time after two days, though increasingly they're transferred at five days, also called blastocyst stage, when doctors have a better idea of the quality of the embryo. "There's an increasing push towards a day-five transfer," says Dr Bowman. "To grow them that long without harming them, you know there's a good chance of success." Any remaining embryos can be frozen to be thawed and used at a later date if needed.

Embryo transfer. This is a quick, painless procedure in which one or two embryos are transferred straight into the uterus via a fine plastic catheter placed in the cervix. The biggest question most couples face is whether to use one or two embryos, but the Australian trend is to transfer only one to try to avoid the risk of multiple pregnancy.

How successful is it? The success rate depends largely on the age of the woman and can range from five-to-50 percent in one cycle. "There are no guarantees and you can't talk about success rates with just one go," says Dr Tremellen. "When you embark on IVF you've got to give it a decent go and that can mean at least three cycles."

Success rates drop drastically with a woman's age. "Someone in their thirties could have a 40-50 percent chance per go, but for a woman in her forties, that drops to 10-20 percent and less."

What are the possible side effects? The main side effects relate to the drugs you'll be given to stimulate the ovaries. These can include physical symptoms, like a tender abdomen and headaches, through to more emotional symptoms, such as the ones you may get with PMT.

How much does it cost? The good news is that the cost of IVF in Australia has been dropping and it's cheaper here than in most other western countries. "It's more affordable now because of the Medicare Safety Net," says Dr Bowman. "Out-of-pocket costs might be somewhere between $1000 and $2000 for a fresh cycle." It can cost more for procedures like ICSI or using frozen embryos. But before proceeding, check with your clinic to see exactly what the cost includes.

Sperm intervention What is ICSI? ICSI stands for intracytoplasmic sperm injection and is an extra level of intervention in the IVF process. It's been embraced as a breakthrough in treating male problems of poor sperm quality. It involves injecting the sperm directly into the egg when it's first placed in the culture.

Gift no more One infertility treatment that's been on offer for years, with some success, is now on the verge of extinction. Gamete intrafallopian transfer, more commonly known as GIFT, sits halfway between IUI and IVF in terms of what's involved. Fertility drugs are used to stimulate the ovaries and retrieve extra eggs, in the same way used in IVF. Then the gametes (the egg and sperm) are transferred into one of the fallopian tubes, usually via laparoscopy, and left on their own to fertilise.

For this to work, the fallopian tubes must be normal and the sperm count good. But for a decent chance of success, usually three or four eggs are transferred, which also leaves open the very high risk of multiple births. While it's a good option for people who may have religious or moral objections to the embryo being fertilised outside the body, GIFT is also more costly due to the need for anaesthesia and laparoscopy.

"GIFT is hardly ever used today," says Dr Mark Bowman of Sydney IVF. "It was a fantastic option when we couldn't grow embryos in the lab very well, but now the results of IVF are better and the transfer's simple, while GIFT is more invasive."

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