Information for Patients

Fertility Unit

James Paget University HospitalsNHS Foundation Trust

James Paget University Hospitals Fertility Unit

Index Introduction 4

The Fertility Team 4

Referral to the Fertility Unit 5

Your First Appointment 5

Subfertility Investigations and Treatment 6

Consent to Treatment 7

Counselling 8

Welfare of the Child 8

Confidentiality 9

Complaints 9

General Information on Fertility and Subfertility 9

Causes of Subfertility 11

Subfertility Tests and Investigations 11

Problems Causing Subfertility 13

Preparation for Pregnancy 16

In-Vitro Fertilisation – IVF 17

Intra-Cytoplasmic Sperm Injection IVF 17

Drugs Used in Subfertility Treatment andtheir Side-Effects 18

Useful Reading 20

National Subfertility Support Groups 20

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Welcome to the James Paget University Hospitals Fertility UnitWe are located within the Waveney Clinic which is on the ground floor of the hospital. There is an external entrance at the front right side of the hospital before you get to the Department of Medicine. If you are coming through the main door of the hospital ask at the reception desk and they will direct you through the ENT and Ophthalmology Clinics to the Waveney Clinic. There are also signs in the hospital to direct you.The contact number is 01493 452366 or 01493 452686

Mission StatementThe aim of the fertility unit is to provide the best possible treatment for each individual couple and give them the best chance of achieving a pregnancy. We also aim to give as much support as possible to couples where the treatment proves unsuccessful. We welcome any suggestions that you may have to improve the care we provide - especially to reduce the inevitable stress that all couples feel during treatment.

The Fertility TeamConsultant Gynaecologist Peter GreenwoodConsultant Gynaecologist Ali El FaraRegistrar in Gynaecology Rotational postMatron Angela WakeleySub-fertility Sisters Ellis Leadley and Nicky EadeFertility Nurses Beverley Brady and Ann HobbsSenior laboratory technicians Steve Nicholls Elaine Osben Christopher MyhillMedical Secretary Lisa Walker and Gaynor HannonClinic Receptionist Sandra WillimottOutpatient Assistant Lorraine Prizeman

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Referral to the Fertility UnitReferrals are accepted from your GP. Your GP will request some initial investigations and will need to complete what is called a primary to secondary care proforma. Once this referral proforma has been received and checked to be fully completed you will be sent your first appointment. There are criteria that need to be met for you to be eligible for fertility treatment. This may be discussed with your consultant, fertility sister and/or GP.

Your First AppointmentYou will be given an appointment within four weeks of your referral. Ideally both partners should attend the first appointment and you will be seen together. The appointment will take between 30 and 40 minutes. During the appointment you may be examined. Occasionally it will be necessary for your partner to be examined too. A Trans-vaginal Ultrasound scan is often carried out at the time of the first appointment to assess the uterus and ovaries but the Consultant will discuss this with you and you may decline this if you wish. Further tests and investigations may be necessary including a repeat semen analysis if the first sample has shown an abnormality.

Further AppointmentsFurther appointments are arranged depending on the findings of the first appointment. It is often important to plan a test to see if the woman’s Fallopian tubes are open. This may be done either by arranging an X-Ray called an hysterosalpingogram or by an operation called a laparoscopy and dye test. Any test that is arranged will be discussed with you and all couples are encouraged to ask questions about their investigations, results and plans for treatment

A range of investigations and treatments are offered at the James Paget University Hospital Fertility Unit. If it is necessary for you to have more advanced treatments these may involve the help Bourn Hall IVF Clinic near Cambridge. The Trust has a contract with Bourn Hall Clinic to plan and provide a treatment

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called Transport IVF. Much of the treatment will happen at the James Paget University Hospital but the replacement of the embryo is performed at Bourn Hall Clinic. Your options and choice of unit will be fully discussed with you.

This booklet provides information regarding fertility investigations and treatments at the James Paget University Hospital. It also provides information regarding other more advanced treatment options. Please ask if you require any additional information.

Subfertility investigation and treatmentThe following investigations may be necessary:- Hormone profiles - male and female.Full semen analysis and sperm survival tests.Tests for anti-sperm antibodies - seminal and serum.Trans-vaginal ultrasound scan.Hystero salpingography.Hysteroscopy.Laparoscopy and dye test.Further details are available later in this booklet.

Treatment options available at the James Paget University Hospital

Induction of ovulation with clomiphene.•Laparoscopic tubal surgery.•Laparoscopic ablation of endometriosis.•Freezing and storage of sperm e.g. before vasectomy or •chemotherapy for cancer.Laparoscopic bilateral ovarian diathermy for polycystic •ovarian disease.Reversal of female sterilisation • (not funded by the NHS).

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More Advanced Treatments involving other hospitals

Transport In-vitro Fertilisation (IVF).•Transport IVF with Intra-cytoplasmic Sperm Injection (ICSI).•Transport ICSI IVF following Percutaneous Epididymal Sperm •Aspiration (PESA).Freezing of spare embryos and later replacement (FET).•

Consent to treatmentBefore commencing any treatment you will both need to sign a consent form specific to that particular type of treatment. Consent forms should only be signed after full discussion with members of the clinical team, and when you have been given sufficient verbal and written information.

Starting Fertility TreatmentBefore you start fertility treatment the following points will be explained to you.

The limitations and possible outcomes of the proposed •treatments.The possible side-effects and risks of the treatment.•The techniques involved.•Alternative treatments.•The possible disruption to your life. •The availability of counselling.•The role of the Human Fertilisation and Embryology Authority •(HFEA).The Fertility Unit’s statutory duty to take into account the •welfare of any children resulting from the treatment and the effect on any existing children.The importance of telling the unit about any pregnancy and •its outcome.The advantages and disadvantages of continuing treatment •after a certain number of attempts.

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CounsellingYou may wish to have counselling before, after or during your treatment. Counselling sessions provide a ‘safe and confidential’ space with a qualified and experienced professional who understands the kind of experiences you are going through.

Counselling sessions enable you to:-explore your feelings about the past difficulties and current •options.gain a clear perspective on what your treatment needs are.•discuss and face any reservations or concerns you or your •partner may have about your treatment and consider any implications for the child that may result and your wider family.find an outlet for your feelings of frustration at being faced •with fertility problems.find ways of dealing with the situation of childlessness and •the additional stress of treatment.focus on yourself and what is positive in your life if you find •the quest for a baby has ‘taken you over’.look at how your relationship as a couple may be affected •and find ways of improving communication.

The Fertility Nurses are able to put you in touch with the independent counsellors used by Bourn Hall Clinic. This service is only funded by the NHS for couples on the IVF programme and men undergoing oncology treatment who are planning to have sperm frozen and stored for use in the future.

Welfare of the childThe Human Fertilisation and Embryology Authority (HFEA) requires all licensed Centre’s (The Waveney Clinic is HFEA Licensed Centre 0190) providing assisted conception treatments to take account of the welfare of the child born as a result of treatment and the welfare of any existing children.

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If you are referred for more advanced fertility treatment you will be asked to complete a short questionnaire and will be asked questions relating to the welfare of the child. You will also be asked for permission to request information from your GP.

ConfidentialityYour treatment at the Fertility Unit is completely confidential. We aim to care for all our patients with dignity and plan individualised care.

ComplaintsIf you have any concerns or complaints, please talk to a member of staff as soon as possible so these can be discussed with you. The Patient Advice and Liaison Service (PALS) are also available to help you and can be contacted on 01493 453240 or email at pals@jpaget.nhs.uk

General Information on Fertility and SubfertilityFertilityIn couples of proven normal fertility the chance of conception per monthly cycle is 20% (1 in 5) in the first month, then subsequently falling to about 5% (1 in 20). The average monthly conception rate is 15% (1 in 7). One in ten fertile couples take more than a year to conceive and 1 in 20 take more than two years. Therefore many couples that have been trying to conceive for only a year or two are normal, and will conceive without help. If conception has not occurred after 12 months a fertility referral is suggested.

About one couple in 6 will seek specialist advice about fertility issues. Either the man (30%) or woman (50%) has the main infertility problem and in about 20% there seem to be problems on both sides. Fortunately in the majority of cases the problem is minor and only time or occasionally simple treatment is required to get pregnant. In the minority a more serious problem is present that may require complicated treatment to achieve a pregnancy.

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AgeFertility, particularly in women, is known to decrease with age. Even if hormone levels are normal, a woman in her forties is much less fertile than earlier in life. This is reflected in success rates for fertility treatments, and may be a reason for your consultant to advise against embarking on treatment.

ConceptionSemen needs to be ejaculated close to the cervix. Sperm penetrates the cervical mucus, leaving the seminal fluid behind in the vagina (don’t be concerned that it runs away afterwards). The sperm are stored in the mucus in the cervical canal for a day or two and are released in a steady stream to swim up the Fallopian tubes to meet the egg.

Sexual intercourse is best timed when the cervical mucus is at its best and most receptive to sperm, a day or so before ovulation. In that way a constant supply of sperm is provided ready for the egg as soon as it is released. When the egg follicle in the ovary is fully grown it ruptures to release the egg. The egg is picked up by the finger-like fimbria of the tube and is wafted along the tube, between the folds of its lining which have microscopic hairs (cilia) that beat towards the uterus.

Fertilisation of the egg by the sperm occurs in the tube and the fertilised egg (now called an embryo) begins to divide into 2,4,8, cells etc. It remains in the tube for several days before reaching the uterus. There it begins to implant itself in the lining of the uterus (endometrium) about 6 days after ovulation, and after implantation begins to grow in size.

Soon after implantation the hormone HCG from the embryo can enter the woman’s bloodstream, and so stimulate the ovarian follicle (now called the corpus luteum) to keep producing the hormone progesterone. That in turn supports the endometrium and prevents menstruation occurring; normally the first sign of pregnancy. HCG can be detected in the woman’s blood and

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urine and is the basis of pregnancy tests. Later the pregnancy can be seen on Ultrasound.

Causes of SubfertilityMale factors Sperm defect - 25% Anti-sperm Antibodies - 5%Female factors Ovulation problem 25% Damaged Fallopian tubes 20% Endometriosis 5% All tests normal 20%

Subfertility testsSemen analysisIt is important for a reliable result that the instructions are followed carefully and the specimen examined in the laboratory as soon as possible after collection (an instruction sheet will be given to you in clinic). The laboratory currently performs sperm counts from Monday to Wednesday.

The seminal fluid is examined under the microscope and the number and the activity of the sperm counted. A normal man will ejaculate 2-6mls of fluid and there will be more than 20 million sperm/ml with at least 50% of them motile (swimming actively). A test for anti-sperm antibodies is also carried out.

Normally fertile men may from time to time have an abnormal test result, so if the first test is abnormal the sperm count will need to be repeated. An abnormal result does not necessarily mean infertility but indicates the need for further tests.

A normal test result is encouraging but does not necessarily mean that there is no sperm problem. Some men with normal counts make sperm that do not fertilize the egg. (defective sperm function).

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Progesterone blood testThis test checks on whether ovulation is occurring (making an egg). A level of over 25nmol/l, 5-10 days before the onset of your period is good evidence that you are ovulating normally. Healthy fertile women do not always ovulate every month so if the level is low the test will need repeating before coming to any definite conclusion.

Chlamydia cervical swabChlamydia is an infection which can be carried in the cervix and pelvis of the female. It can be detected by taking a cervical swab or carrying out a urine test. It is important to be sure that there is not an active infection present before carrying out assisted conception techniques. Such procedures may make the infection worse leading to pelvic inflammatory disease. The presence of Chlamydia may reduce the chances of successful outcome.

HIV and Hepatitis B and C blood testsCouples undergoing IVF procedures must have HIV, Hepatitis B and Hepatitis C blood tests in order to guard against the risk of cross-infection of embryos in long-term storage tanks. Couples are counselled before these tests. A positive result would also lead to appropriate implications counselling before any treatment was carried out. IVF treatment for couples where one or both partners is infected with Hepatitis B, C or HIV is offered by the other four IVF Units in the East of England NHS IVF programme – Leicester, Oxford, Hammersmith and St Bartholomews, Bourn Hall Clinic do not provide fertility treatment couples who have any of these infections.

Ultrasound ScanThis is a simple, painless way of getting a picture of the uterus and ovaries. These scans are normally carried out using a narrow vaginal probe and are performed in the Waveney Clinic. The procedure will be explained beforehand but it is important to have an empty bladder for an ultrasound scan.

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LaparoscopyThis is a telescope examination under a general anaesthetic to check on the uterus, fallopian tubes and ovaries. The examination is carried out between menstrual periods and before or after the expected date of releasing an egg (ovulation). If the examination is scheduled for after ovulation then it is important to take precautions against pregnancy in that cycle. (See Procedure Information Sheet for more details)

HysterosalpingographyThis is an outpatient examination in the X-ray Department at the James Paget University Hospital. It is used to check on whether or not the Fallopian tubes are open. It is normally carried out between the 6th and 12th day of a regular menstrual cycle which is after the period has finished and before ovulation occurs (an information sheet will be given to you in clinic and the details of the procedure will also be discussed with you by the Consultant).

Problems Causing SubfertilitySperm Defect (very low counts or poor sperm function)If the semen analysis shows a low count on repeat testing the man will need to be fully assessed by examination and blood tests to see if anything can be done to increase the number or activity of the sperm. Treatment of the man to improve the sperm count is often not possible. However, cutting down on alcohol consumption, stopping smoking completely and taking vitamin C and vitamin E can lead to an improvement in the sperm count.

Trials have shown that artificial insemination alone does not increase the chance of pregnancy. Effective treatments that may need to be considered are IVF or IVF with Intracytoplasmic sperm injection (ICSI).

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Male Anti-sperm AntibodiesThese antibodies act to prevent sperm fertilising the egg. Occasionally a spontaneous pregnancy may occur for a couple without any treatment. However, if treatment becomes necessary then most cases are best treated using IVF technology with possible ICSI (sperm injection into the egg). Treatment with steroids may reduce the amount of antibody in the semen but the medical risks outweigh the small increase in spontaneous pregnancy rate.

Ovulation ProblemsThe woman may have infrequent periods or even no periods at all. Occasionally the periods are regular but the progesterone blood test 5-10 days before the onset of menstruation will show that ovulation is not occurring properly. Further hormonal blood tests will be required to find the reason for the failure to ovulate properly. Treatment will often be with fertility drugs such as clomiphene (Clomid) or sometimes with FSH (follicle stimulating hormone) injections. Treatment for ovulation problems, if there are no other fertility problems, is normally very successful.

Damaged Fallopian tubesWhen a laparoscopy shows blocked or damaged Fallopian tubes there may be little chance of pregnancy without complicated treatment. The Fallopian tubes may also need to be examined by hysterosalpingography to check on the exact site of the blockage and the health of the inside lining of the Fallopian tube. If the damage is mild then it may be possible to carry out an operation that would provide a realistic chance of pregnancy without further treatment. However, often the only realistic chance of pregnancy would be through IVF treatment. Sometimes the Fallopian tubes are so badly damaged that it is best to remove them completely before IVF treatment in order to improve the success rate of IVF. This removal is called a bilateral salpingectomy and is considered if both Fallopian tubes are unhealthy and full of fluid (hydrosalpinges).

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EndometriosisIn this condition some of the tissue (endometrium) that is normally only found lining the uterus starts to grow outside the uterus. It is often found behind the uterus in the pelvis or on the ovaries. It is thought that 20% of all women before the menopause have a degree of this condition. It is not usually a serious condition but it can be associated with subfertility and sometimes causes pelvic pain. Laparoscopic treatment to destroy the endometriotic deposits seems to be beneficial in improving the chance of pregnancy but long courses of drug treatment (6 months) are not helpful.

Endometriosis UK is a national charity dedicated to helping women with this disease - the phone number is 0808 808 2227, open 7pm – 10pm 7 days a week.The website is www.endo.org.uk

Unexplained Infertility (all tests normal)In 20% of subfertile couples the basic tests are normal. Most are fertile and have just been unlucky so far and the outlook is good. In couples with 2 years unexplained subfertility over 50% will conceive in the following 2 years without treatment. Treatment with the mild fertility tablet clomiphene can slightly increase the chance of conception but should not be used long-term (see under Drugs and Side-effects) .

When a couple has been trying to conceive for 3 years, the chance of conception without treatment is decreasing and IVF may be considered. There may also be specific age concerns for individual couples as the chance of spontaneous pregnancy and of successful treatment decline significantly from the age of 35 in the female.

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Preparation for PregnancyAll women planning a pregnancy should take some precautions before they conceive.

Rubella (German measles) can cause serious damage to the baby in early pregnancy so it is important to check by a blood test that you are immune to Rubella and for you to be vaccinated if you are not already immune.

Cervical smears should be up to date.

Weight Women should aim to be near their ideal weight for their height. Women who are overweight for their height will be strongly encouraged to lose weight before starting treatment, as research has shown that overweight women conceive less easily, require higher doses of drugs to stimulate the ovaries and if they do conceive have a statistically higher rate of miscarriage and complications throughout pregnancy.

Diet A good mixed diet with plenty of iron and folic acid (in green leafy vegetables and breakfast cereals) is advisable. Coffee and alcohol intake should be low.

Smoking should be stopped completely as it reduces fertility, increases the miscarriage rate, causes low birthweight and increases the likelihood of premature delivery and stillbirth.

Folic Acid supplements are recommended for all women trying for a pregnancy as there is good evidence that it reduces the chances of spina bifida. The advised dose is 400 micrograms per day and it is available over the counter in all pharmacies.

Women with diabetes, epilepsy, high blood pressure, depression or other illness should seek advice about their treatment before trying to conceive.

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HFEA Licensed Infertility TreatmentsIn-Vitro Fertilisation (IVF)

IVF may be considered for:a couple where the woman has blocked Fallopian tubes.•male subfertility.•subfertility associated with endometriosis.•prolonged unexplained subfertility.•

Intra-cytoplasmic Sperm Injection IVF (ICSI)ICSI is a technique that has been developed to assist fertilisation when sperm quality is particularly poor. The technique involves injecting a single sperm into the centre of each egg. The treated eggs are checked the day after the ICSI procedure to see if fertilisation has occurred. The embryo will then be transferred into the uterus as in a normal IVF cycle and any suitable spare embryos will be frozen and stored for you, if that is your wish.

If you require IVF or ICSI this will be discussed with you and you will be given options of where you may receive this treatment. Most couples decide to undergo this treatment on the Transport IVF programme between James Paget University Hospital and Bourn Hall Clinic as success rates are good and the programme reduces travelling time for couples and loss of time at work.

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Drugs used in Subfertility treatments and their side-effectsClomipheneThis drug is used to stimulate the ovaries to ovulate. It is taken from day 2-6 of the menstrual cycle. There is uncertainty regarding the long term effect of the drug on the ovaries but there is no good evidence that it increases the risk of ovarian tumours in later life in women who have taken this drug for more than a year. Currently it is not felt that this treatment should be continued beyond 12 months (just to be on the safe side) and if pregnancy has not been achieved by that stage then different treatments should be tried.

Synarel Nasal Spray or InjectionsUsed twice daily (once daily for injections) to reduce hormone levels before stimulating injections are started.Side-effects:- Irritation at the injection site, Hot flushes, Sleep disturbance, Mood swings including depressive effects. Vaginal dryness.Nasal irritation may occur with the nasal spray.

Follicle Stimulating Hormone FSHA substance which is essentially the same as FSH produced by the human pituitary gland. It stimulates the growth of egg follicles in the ovary.

Side-effects: Injection site irritation, Abdominal and pelvic discomfort, Tiredness, Symptoms of OHSS - see OHSS information leaflet.

Human Chorionic Gonadotrophin - HCGThe hormone which is naturally produced by early pregnancy which is purified and used by injection to mature the developing eggs in the ovary.

Side-effects: Injection site reactions, Symptoms of OHSS – see OHSS information leaflet.

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Crinone Gel or Cyclogest SuppositoriesA progesterone type drug which helps maintain a receptive lining to the uterus ready for embryo transfer. It is given either rectally or vaginally and is continued as long as there is a chance of pregnancy becoming established or until the end of the 12th week of an ongoing pregnancy following IVF treatment.

Side-effects: Soreness, diarrhoea and flatulence with rectal administration. Leakage of the pessary base with vaginal use.

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Useful Reading Getting PregnantProfessor Robert Winston. Publishers: Pan, 2/95, ISBN 0330327666

Overcoming InfertilityGoldfarb. Publishers: Wiley, 3/95, ISBN 0471557064

The Gift of a ChildRobert and Elizabeth Snowden. University of Exeter Press, 3/96, ISBN 085989407 X.A Guide to Donor Insemination.

Male Infertility - Men TalkingMary-Claire Mason, Publisher: Routledge, 9/93, ISBN 0415 072891.

MiscarriageAnn Oakley, Dr. Ann McPherson and Helen Roberts. Publisher: Penguin, 1/96, ISBN 01401202446.

The Human Fertilisation and Embryology Authority produce a wide range of pamphlets, patient guides to IVF and Donor Insemination Clinics and also an Annual Report. These are available from the HFEA website www.hfea.gov.uk

The British Agencies for Adoption and Fostering produce a range of literature. BAAF, 11 Southwark Street, London, SE1 1RQ.

National Subfertility Support Groups

CHILD, Charter House, 43 St. Leonards Road, Bexhill-on-sea, TN40 1JA. Tel: 01424 732361Provides fact sheets, a quarterly magazine, publications, medical advice and emotional support including helplines, local groups and local and national meetings.

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Miscarriage Association, c/o Clayton Hospital, Northgate, Wakefield, W. Yorks. WF1 3JS.Tel: 01924 200799 Website: www.miscarriageassociation.org.ukProvides support and information on the subject of pregnancy loss.

D.I. Network, P.O. Box 265, Sheffield S3 7YX. Tel: 0181 2454369Provides contact and support for those who have children, or plan family creation, conceived using donated gametes through donor insemination (DI) and IVF with donor sperm of eggs.

National Infertility Awareness Campaign (NIAC), P.O. Box 2106, London W1A 3DZ.Tel: 0800 716345A lobbying organization campaigning for NHS funding for all infertility treatment on an equal basis across the UK. Gives advice on the current situation with regard to NHS funding and on campaigning/lobbying activities.

British Infertility Counselling Association (BICA)BICA aims to promote high quality, accessible counseling services for those with fertility problems. It offers information to patients seeking details of counsellors specializing in infertility.Tel: 01744 750 660 Website: www.bica.net

Infertility Network UK (I N UK)I N UK provides practical and emotional support to those experiencing difficulties in conceiving whatever stage of their journey they are at. There is a regional network and local support groups, and the charity also produces factsheets and other information, including a video. They have a telephone advice line, medical advisers and a website with news, forums and information.Tel: 0870 118 8088 Website: www.infertilitynetworkuk.com

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Multiple Births Foundation, Queen Charlotte’s & Chelsea Hospital, Goldhawk Road, London W6 0XG. Tel: 0208 383 3519.Provides professional support and information about all aspects of multiple births.

Useful Websites

There are many websites that provide information about infertility and opportunities to ask questions and exchange personal experiences with others.

www.hfea.gov.uk www.fertilityfriends.co.ukwww.may-b-baby.co.uk www.gettingpregnant.co.ukwww.ivf-infertility.com www.ivfworld.com

www.singlemother.typepad.com

If you have unresolved questions please raise these with the Fertility Clinic Staff. It is important that you do not

undergo investigations or treatment unless you are fully informed of the indications and possible outcome.

The contact number is 01493 452366 or 01493 452686

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The hospital is able to arrange for an interpreter to assist you in communicating effectively with staff through INTRAN. If you need an interpreter or a person to sign, please let us know.

If you require a large print version of this booklet, please contact PALS on

01493 453240

Author:Peter Greenwood, Person Responsible HFEA Licensed Unit 190

© July 2011

James Paget University Hospitals NHSFoundation TrustReview Date: July 2014GY 24 version 6