First comes love
Then comes marriage
Then comes a baby in a golden carriage
So the old rhyme goes. However, nowadays we know things do not necessarily happen in that order and for some, they do not happen at all. While most couples assume they will be able to get pregnant when they want to, the reality is that at least 10% will have problems conceiving a child. Many of these will opt to seek fertility treatment in an attempt to realise their dream of becoming a parent.
There are many different types of fertility treatment available, from the use of fertility drugs to procedures such as ICSI (intracytoplasmic sperm injection), but IVF remains one of the best known types of treatment.
With IVF, a woman's eggs are fertilised with sperm outside the body in a test tube and then placed back inside her womb. The first IVF baby was born in the UK in 1978 and since then, more than four million children have been conceived worldwide using this treatment.
But what is the situation in Ireland? Who needs this treatment and what does it involve?
The advice for couples attempting to become pregnant used to be straightforward - try for a baby for one year and if nothing happens, go to your GP to get the ball rolling.
However this advice has changed in recent years, partially due to the fact that women are tending to wait longer to have children.
Age is a factor
According to Dr David Walsh, consultant gynaecologist and medical director of the SIMS Clinic in Dublin, if a woman is over the age of 35 and has been trying for at least six months, she should consider seeking help.
This is echoed by Donal Buggy, business manager at the Merrion Fertility Clinic in Dublin, who believes early referral, within six months, should be considered in a number of scenarios, including if the woman is over the age of 35, if she has endometriosis or another pelvic disease, if she has had recurrent miscarriages, or if the man has reduced semen quality or has had genital surgery carried out.
Padraig Kelly, quality manager of the HARI Unit in Dublin's Rotunda Hospital, goes a step further.
"In general, our clinic advises that when a couple believe or have any concerns over fertility, they should go to their GP and not wait."
All three clinics acknowledge that while you do not have to attend a GP or consultant, most couples are referred by a doctor and this is the preferable route.
But how do couples choose which clinic to attend? This can be based on a number of factors, from location to recommendations to price.
"Probably the most important factor is the advice of the patient's GP or consultant. Specific clinics may also have specialisations for certain diagnosis types," explains Mr Buggy.
Mr Kelly and Dr Walsh agree. According to Mr Kelly, many couples ‘follow the recommendations of their referring doctor', while Dr Walsh emphasises the importance of ‘word of mouth'.
HARI was the first clinic in Ireland to offer IVF and it currently receives up to 800 enquiries a year specifically about the procedure. It carries out over 1,350 cycles of IVF treatment annually and over 3,500 babies have been born as a result.
The Merrion Clinic carries out up to 500 cycles of IVF per year, while last year, SIMS carried out 1,063 cycles.
According to Dr Walsh, the SIMS Clinic receives around 25 new enquiries from people every single week and ‘at least half of these are candidates for IVF'.
He points out that the clinic does not know for sure how many babies have been born as a direct result of IVF because as soon as a pregnancy is detected, the woman moves on to the maternity hospital system. While some will let the clinic know if the pregnancy has resulted in a live birth, some will not.
The Merrion Clinic says that over 1,000 live births have been recorded as a result of treatment carried out there, however it emphasises that this is due to fertility treatment in general, including IVF, rather than just IVF.
Tests
When a couple initially attend a clinic, a number of investigations will be carried out on both the male and female. According to Dr Walsh, these are ‘basic, easy tests', and include blood tests which determine levels of prolactin and anti-Müllerian hormone (AMH).
AMH is produced by ovarian follicles containing eggs. It can be an accurate predictor of whether a woman is still fertile and how many eggs she has left in her ovaries. Prolactin is a stress hormone that is released by the pituitary gland. High levels of prolactin can prevent the release of FSH (follicle stimulating hormone) and LH (luteinizing hormone), two important pregnancy hormones.
Investigations involving the male include a semen analysis.
Following these investigations, there are a number of reasons why IVF may be recommended as the best treatment option. These include sperm problems in the male, such as a low sperm count, and anovulation in the female. This is when ovulation fails to take place.
Other reasons include any tubal disease, i.e. any condition that impedes or blocks egg transport through the fallopian tubes and endometriosis, which is when the lining of the womb (the endometrium) grows outside of the womb.
According to Dr Walsh, if a couple experiences unexplained infertility for at least 24 months, IVF will also generally be recommended.
There are four general steps involved in an IVF cycle:
-Stimulation of the ovaries to encourage development and maturation of the eggs
-Retrieval of the eggs
-Fertilisation of the eggs and culture of the embryos
-Transfer of the embryos back into the uterus.
Different couples will have different protocols and depending on the protocol, the actual treatment can take anything between two week and two months, but for most couples, it takes between four and eight weeks.
Unfortunately, IVF may not be successful for everybody and couples must then decide whether to attempt another cycle. But is there a limit to how many times you can undergo IVF?
"Technically not," says Dr Walsh.
However in reality, he points out, most couples attending SIMS undergo an average of two to three cycles. While for some, particularly in the current economic climate, finances may play a role, emotions play a much bigger one, Dr Walsh notes.
"This is an incredibly difficult process for couples and society doesn't tend to empathise with them," he says.
According to Mr Kelly, while each case is different, in general, the HARI Unit recommends stopping treatment after three unsuccessful attempts.
While again it depends on protocols, a couple generally have to wait two to three months before attempting another round of IVF.
With such an emotionally demanding process, are there supports available to the affected couples?
Support
According to the HARI Unit, it offers a free counseling service for people pre-, during and post-treatment.
The Merrion Clinic also offers access to counseling and Chinese therapies, while SIMS offers counseling as well a Mind/Body Programme, which involves one day retreats aimed at providing couples with relaxation strategies, stress management skills and information on lifestyle habits.
The cost of one round of IVF is dependent on the couple's protocol, but it generally costs €4,100-€5,000. A couple can avail of 20% tax relief on this expenditure.
According to Mr Buggy of the Merrion Clinic, money is a big issue for couples today.
"Access to funding is an issue as personal loans for treatment from banking institutions are severely reduced. Thankfully credit unions are very supportive of many of our patients. Where previously, patients might have had funding in place for up to three cycles in advance, many patients now might only have funding in place for one cycle. This obviously puts additional stresses on patients, which might affect the eventual outcome," he explains.
According to Mr Kelly of the HARI Unit, ‘the desire for a family is still very strong and we feel that patients are prioritising their expenditure in favour of IVF treatment'.
However, irrespective of the financial cost of treatment, it can be the emotional cost that determines whether couples seek further treatment.
Dr Walsh of SIMS points to a study carried out in the US, which found that the number of IVF cycles couples underwent did not change, even when some were subsidised for the cost. The study found that the emotional impact of IVF was a major factor in the decision to stop treatment.
"When I have a couple sitting in front of me who have had a long history of infertility, I think it is a remarkable feat and an incredible achievement that they are still together, as this is such a difficult process.
"I believe couples need three things to get through this - they need to be emotionally coherent, they need to be determined and they need to be flexible," Dr Walsh says.
He acknowledges that there is an air of secrecy around infertility in general, with couples often choosing to keep their problems to themselves.
"Internet discussion forums are brilliant for that. Couples who are isolated can ‘talk' to each other and give each other support," he notes.
There are currently two active discussions on Irishhealth.com on this subject. Click here or here.
Dr Walsh also recommends a UK site, www.ivfpredict.com, which uses information based on 144,000 couples to predict a person's chances of success following IVF.
For more information on the HARI Unit, click here
For more information on the SIMS Clinic, click here
For more information on the Merrion Fertility Clinic, click here
Information on fertility clinics in Ireland and on infertility in general is available on the National Infertility Support and Information Group website here
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