So it hasn't happened – what's next? An overview of medical intervention and assistance options

If you have been trying to conceive for a while, and it hasn’t happened, it’s a good idea to seek medical help. In our last blog we talked about when to get help. And in this blog, we want to explain the types of medical intervention and assistance that are available.

How many people access fertility treatment?

Since the first IVF baby in 1978, the number of people conceived by reproductive technology has grown much faster than expected, reaching several million today and rapidly approaching 0.1% of the total world population. According to HFEA, about 54,000 patients had 68,724 fresh and frozen in-vitro fertilisation (IVF) cycles and 5,651 donor insemination (DI) cycles at HFEA licensed fertility clinics in the UK in 2018.

Types of fertility treatment

Once you decide to seek medical help, the doctor will request several exams to assess your fertility as a couple. The treatment recommended should be directed at addressing the cause of infertility, as far as possible. For example, some people may just require medication to stimulate ovulation or medication to support the uterus lining. In other cases, surgery may be required, to remove endometriosis, remove a uterine septum or correct a varicocele, for instance. In these cases, it may still be possible to conceive naturally once the cause of infertility has been addressed.

However, in certain circumstances, more invasive treatment may be appropriate. There are two main types of fertility treatment: intrauterine insemination (IUI) and in vitro fertilisation, which can be standard or with Intracytoplasmic Sperm Injection (ICSI). When having IVF, it is possible to have treatment with own eggs and sperm, or with donor eggs and sperm.

Intrauterine Insemination (IUI)

Intrauterine insemination (IUI) is a fertility treatment that involves placing sperm inside a woman’s uterus to facilitate fertilisation. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilisation.

IUI provides the sperm an advantage by giving it a head start, but still requires a sperm to reach and fertilise the egg on its own. It is a less invasive and less expensive option compared to IVF.

Before intrauterine insemination, ovulation stimulating medications may be used, in which case careful monitoring will be necessary to determine when the eggs are mature. The IUI procedure will then be performed around the time of ovulation, typically about 24-36 hours after the surge in LH hormone that indicates ovulation will occur soon. You can use Mylo to identify your LH surge.  A semen sample will be washed by the lab to separate the semen from the seminal fluid. A catheter will then be used to insert the sperm directly into the uterus. This process maximises the number of sperm cells that are placed in the uterus, thus increasing the possibility of conception.

Standard In Vitro Fertilisation (IVF)

In vitro fertilisation (IVF) is a fertility treatment that involves stimulating the ovaries to produce several eggs in the same cycle, fertilise them with sperm in the lab, let them develop over a few days and then transfer them into the uterus. There are 8 stages to IVF:

Step 1: suppressing the menstrual cycle. Medication will suppress the natural menstrual cycle. It can be given as a daily injection or as a nasal spray. Not all IVF cycles need suppression of the natural cycle.

Step 2: ovarian stimulation. Medication is given to stimulate the ovaries to produce more eggs. Ultrasound scans are used to monitor the response of the ovaries to the stimulation.

Step 3: trigger injection. When there’s a good amount of follicles, of the right size, the ovarian stimulation ends. The doctor will tell you when to take the trigger injection that helps the egg’s final maturation and loosen it from the follicle wall.

Step 4: egg and sperm collection. About 34-36 hours after the trigger injection, the eggs need to be collected. This is a procedure done under sedation. The doctor will place a needle through the vagina and into each ovary under ultrasound, to collect the eggs. In couples, the partner will be asked to produce his semen sample. In sperm donation, this sample will have been chosen previously.

Step 5: fertilisation. The collected eggs are mixed with the sperm in a laboratory. After 16 to 20 hours, they're checked to see if any have been fertilised. The fertilised eggs (embryos) continue to grow in the laboratory for up to 6 days before being transferred into the uterus. Whilst the embryos are developing, women take medication to prepare the uterus lining for transfer.

Step 6: embryo transfer. A few days after the eggs are collected, the embryos are transferred into the uterus. This is done using a catheter that's passed into the vagina, through the cervix and into the uterus.

Step 7: two week wait. The two-week wait is the period between the embryo transfer and the pregnancy test. It can be one of the most challenging times of fertility treatment.

Step 8: pregnancy test. It measures the level of hCG hormone which is produced by the embryo once it has implanted in the uterus.

In Vitro Fertilisation with Intracytoplasmic Sperm Injection (ICSI)

In standard IVF, the egg will naturally be fertilised by the sperm in the lab (step 5 above). However, sometimes, despite being mixed together in a petri dish, the sperm still fails to fertilise the egg. In these circumstances, the embryologist may perform intracytoplasmic sperm injection which involves placing a sperm inside the egg. Once fertilisation has occurred, the development of the fertilised egg still needs to occur naturally over the next few days.

ICSI is used in the following circumstances:

• Where there is a severe problem with sperm quality, such as very low numbers, a high percentage of abnormally shaped sperm or a low percentage of mobile sperm)
• Where in previous IVF treatment(s) none or few of the eggs fertilised
• Where sperm was obtained surgically, directly from the testicle (TESE) or epididymis (PESA)
• Where sperm quality on the day of egg collection is insufficient for IVF, most likely due to natural variation in semen samples. In this procedure, the embryologist places the sperm inside the egg (instead of allowing them to fertilise naturally in the petri dish).

In Vitro Fertilisation with egg, sperm or embryo donation 

People choosing donation as a route to parenthood has increased significantly over the years. Donation can involve egg, sperm or embryo donation. Egg donation is most common in situations of poor egg quality, early menopause, or when standard treatment with own eggs hasn’t been successful. Sperm donation is more common when there is poor sperm quality, when having treatment as a single woman or as a female same sex couple.