Fertility treatment

Fertility treatment explained

Understanding fertility treatment

There are many types of fertility treatments available, ranging from simple interventions such as medication to help a woman ovulate, through to more complicated procedures known as assisted reproductive treatment (ART). ART, also known as assisted reproductive technology, refers to medical and scientific methods used to help people conceive.

Fertility treatments are used:

• to treat infertility
• for people who can’t become pregnant, carry a pregnancy or give birth
• to reduce the chance of a baby inheriting a genetic disease or abnormality
• to preserve fertility.

Types of treatment

Depending on the cause of infertility, the following types of treatment may be recommended by your fertility specialist. This information provides a general overview of techniques available. Speak to your fertility clinic for more information.

Ovulation induction (OI)

Ovulation induction (OI) can be used if a woman is not ovulating or not ovulating regularly. It involves taking a hormone medication (tablets or injections) to stimulate ovulation. The response to the hormones is monitored with ultrasound and when the time is right, an injection is given to trigger ovulation (the release of the egg). Timing intercourse to coincide with ovulation offers the chance of pregnancy.

Artificial insemination or IUI

Artificial insemination, which is sometimes called intrauterine insemination (IUI), involves insertion of the male partner’s (or a donor’s) sperm into a woman’s uterus at or just before the time of ovulation. IUI can help couples with so called unexplained infertility or couples where the male partner has minor sperm abnormalities. You can use the Unexplained infertility - exploring your options guide to better understand if IUI is a suitable option for you.

IUI can be performed during a natural menstrual cycle, or in combination with ovulation induction (OI) if the woman has irregular menstrual cycles. If a pregnancy is not achieved after a few IUI attempts, IVF or intracytoplasmic sperm injection (ICSI) may be needed.

In-vitro fertilisation (IVF)

During IVF, the woman has hormone injections to stimulate her ovaries to produce multiple eggs. When the eggs are mature, they are retrieved in an ultrasound-guided procedure under light anaesthetic. The eggs and sperm from the male partner or a donor are placed in a culture dish in the laboratory to allow the eggs to hopefully fertilise, so embryos can develop. Three to five days later, if embryos have formed, one is placed into the woman's uterus in a procedure called embryo transfer. If there is more than one embryo, they can be frozen and used later.

The IVF process:

Is IVF safe?

IVF is a safe procedure and medical complications are rare. But as with all medical procedures, there are some possible health effects for women and men undergoing treatment and for children born as a result of treatment. Read more about the possible health effects of IVF here.

Understanding IVF success rates

Clinics report success rates in different ways, so when comparing clinics’ success rates make sure you compare like with like or ’apples with apples’. Most importantly, you need to consider your own personal circumstances and medical history when you estimate your chance of having a baby with IVF. You can read more about interpreting success rates here.

The chance of a live birth following IVF depends on many factors including the woman’s age, the man’s age and the cause of infertility. Research using the Australian and New Zealand Assisted Reproduction Database calculated the chance of a woman having a baby from her first cycle of IVF according to her age. The results below apply to women who used their own eggs, and it includes the use of frozen embryos produced by one cycle of IVF:

• Under 34: 44 per cent chance of a live birth
• 35-39: 31 per cent chance of a live birth
• 40-44: 11 per cent chance of a live birth
• 44 and above: one per cent chance of a live birth.

Costs of IVF

In Australia, Medicare and private health insurers cover some of the costs associated with IVF and ICSI but there are also substantial out-of-pocket costs.

The difference between the Medicare contribution and the amount charged by the clinic is the ‘out-of-pocket cost’. These costs vary, depending on the treatment, the fertility clinic and whether a patient has reached the Medicare Safety Net threshold. You can read more about costs here.  

Intracytoplasmic sperm injection (ICSI)

ICSI (intracytoplasmic sperm injection) is used for the same reasons as IVF, but especially to overcome sperm problems. ICSI follows the same process as IVF, except ICSI involves the direct injection of a single sperm into each egg to hopefully achieve fertilisation.

Because it requires technically advanced equipment, there are additional costs for ICSI. For couples with male factor infertility, ICSI is needed to fertilise the eggs and give them a chance of having a baby. But for couples who don’t have male factor infertility, ICSI offers no advantage over IVF in terms of the chance of having a baby. You can read more about what’s involved in ICSI and its possible health effects here.

Intracytoplasmic morphologically selected sperm injection (IMSI)

Intracytoplasmic morphologically selected sperm injection (IMSI) is a method used in IVF to select a sperm so it can be injected into an egg. This is a variation of ICSI or intracytoplasmic sperm injection which has been used for about 30 years to help couples overcome male factor problems. ICSI has greatly improved birth rates for this group.

ICSI involves a scientist viewing sperm under a microscope with 200 times magnification and selecting one to inject into the egg. The IMSI technique is a variation of ICSI where a microscope with even higher magnification is used (6,000 times). The reasoning for this is that it allows scientists to view more detailed images of the sperm which may help them choose the ‘strongest’. 

What does the research say about IMSI?

In 2019, researchers working for the independent Cochrane group reviewed 13 randomised controlled trials comparing IMSI and standard ICSI in 2,775 couples to see what the combined results showed. This type of ‘systematic review’ produces the highest quality evidence to help patients and health professionals make informed decisions about medical interventions. The systematic review found that taken together, the 13 studies produced ‘very low quality evidence’ about whether IMSI was better than ICSI in terms of improving the chance of a live birth or reducing the risk of miscarriage. This means that IMSI could be beneficial, harmful, or have no effect on the probability of getting pregnant and having a baby – we just don’t know.  

What are the benefits and risks of IMSI?

Because the evidence is very low-quality, it’s not possible to know whether IMSI improves the chance of having a baby compared to ICSI. It is also not possible to know whether there are any risks or harms from using IMSI instead of ICSI.

What does it cost?

In Australia, the average cost of IMSI is approximately $300 (this is on top of the cost of standard ICSI). It is not covered by Medicare.

What else do I need to know?

• IMSI can only be used when ICSI is already being used, which is normally only for certain groups of patients
• You can read more about the risks and benefits of ICSI here
• IMSI cannot be used for cases where the sperm has been taken directly from the testis.

Donor conception

There are many reasons why donor sperm, eggs or embryos may be needed.

Donor sperm

Donor insemination (DI) may be used when:

• a male partner does not produce any sperm
• a male partner does not produce normal sperm, or
• there is a high risk of a man passing on a genetic disease or abnormality to a child.

Donor insemination can also be used by single women and women in same-sex relationships. The process of donor insemination is the same as IUI.

If the woman also has an infertility problem, donor sperm can be used in IVF treatment.

Donor eggs

Treatment with donor eggs may be needed when:

• a woman doesn’t produce eggs or her eggs are of low quality. This may be due to age or premature menopause (ovarian failure)
• a woman has experienced several miscarriages, or
• there is a high risk of the woman passing on a genetic disease or abnormality to a child.

In these cases, the egg donor has hormone injections to produce several eggs. When the eggs are mature, they are retrieved and sperm from the recipient's partner or a donor is added to the eggs. Two to five days later, when embryos have formed, one is inserted into the recipient woman’s uterus. In the two to three weeks leading up to the embryo transfer, the recipient woman takes hormones to make sure the lining in the uterus is ready for an embryo to implant. If a pregnancy is confirmed, the hormone treatment continues for another eight to 10 weeks.

Donor embryos

Donor embryos can be used if a person or couple requires both donor sperm and donor eggs to achieve a pregnancy. Although rare, some people who have frozen embryos that they don’t need, choose to donate them for someone else to use. The recipient woman takes hormones in preparation for the embryo transfer and when she is ready, embryos are thawed and transferred to her uterus.

You can find out more about donor conception here.

Preimplantation genetic testing (PGT)

There are two types of PGT:

PGT for monogenic/single gene defects (PGT-M) is used to identify embryos that are not affected by a ‘faulty’ gene that can lead to disease.

PGT for chromosomal structural rearrangements (PGT-SR) is used to identify embryos that have an incorrect amount of genetic material.

PGT-M and PGT-SR are also known as preimplantation genetic diagnosis (PGD).

In PGT, embryos are generated through the process of IVF or ICSI and then a few cells are removed from the embryo and screened for the genetic condition. Embryos that are not affected by the genetic condition are then selected for transfer to the woman's uterus.

Fertility clinics in Victoria perform PGT to avoid a range of conditions. If there is a disorder that you are particularly concerned about, speak to your fertility specialist.

Clinics may also offer PGT for aneuploidy (PGT-A) to check that embryos have the right number of chromosomes. This is to avoid transferring embryos that have too few or too many chromosomes. While this may seem useful, the test is not a perfect tool and there are risks associated with PGT-A.

You can find more information about PGT here, and you can read more about the pros and cons of preimplantation genetic testing for aneuploidy here.

Surrogacy

Surrogacy involves a woman (the surrogate) carrying a child for another person or couple with the intention of giving the child to that person or couple after birth. VARTA has a range of resources to assist people considering surrogacy.

Treatment ‘add-ons’

Fertility specialists are constantly looking for ways to improve your chance of getting pregnant through IVF or other fertility treatments. In the last few years an increasing number of so called ‘add-ons’, or ‘adjuvants’ have been offered by fertility clinics. They are tests, procedures or medications that are added to IVF to try to improve the chance of success. Examples include endometrial scratching, time lapse imaging, genetic testing of embryos, sperm selection methods, and the prescription of steroids, testosterone and growth hormones.

But many of these add-ons are experimental or have not been properly tested, so it’s not known if they actually make a difference to the chance of having a baby. They may also cause negative side effects and cost more money with no Medicare refund available. VARTA is looking at what the research says about the potential benefits and risks of add-ons offered by fertility clinics. Here is a summary of what is known about some of them. We will publish information about others as it becomes available.

To make sure you have all the facts, ask your doctor questions about the pros and cons of any add-ons offered. Here are five questions you can ask your doctor to help you decide if an add-on is right for you:

Source: www.choosingwisely.org.au

You can find more helpful information about add-ons on the UK-based Human Fertilisation and Embryology Authority (HFEA) website.