10 Commonly Asked Questions about IVF and Insemination

I recently was invited as a guest speaker for an ‘Ask a Consultant’ session at a patient support group meeting in London. It was such an interesting and interactive session.

I decided to share some of the questions that are often asked by the patients related to Fertility treatments such as IVF or Insemination.We are committed towards the empowerment of our patients. I think this information would be useful for anyone seeking fertility treatments.

1. How long should I wait after failed treatment before starting the next cycle?

This is a question that I get asked every time I see a patient for a follow-up fertility consultation.

  • It is recommended that patients wait at least 2-3 months before starting the next treatment cycle. This varies from one fertility specialist to another. This time allows you to not only recover, but also prepare again for the future IVF treatment. Once you go through the treatment, most of the hormones and the drugs will flush out of your system within a week of the adverse outcome.

    It takes much longer for ovaries to return to their normal size. During stimulation, the ovary in most women may be two to three times of its standard size. So, waiting few months allows the ovaries to return to their normal size.

  • If you are starting a frozen embryo replacement cycle following a failed stimulated IVF treatment, then you may be able to start the frozen embryo replacement treatment in two months time. The reason is that in frozen embryo replacement, your ovaries are not stimulated.
  • If you are thinking of starting a natural IVF and have just completed an unsuccessful natural IVF cycle, then you can start the treatment in the next cycle or later. This is one of the major advantages of Natural IVF, unlike stimulated IVF.
  • If you had an IUI or Insemination, then you can start the treatment next month, provided there are no significant ovarian cysts from the just completed Insemination or IUI treatment.
  • If you have had a miscarriage following a successful fertility treatment either IVF or other treatments such as insemination, then most fertility specialists would recommend waiting at least three months before starting the next IVF treat

These are some standard practices within the UK. You may see some variations both within the UK, but more so if having treatment abroad.

2. Can I exercise when going through fertility treatment?

This is another common question women ask when starting any fertility treatment. As we all know exercise is good for health. But, there are certain points when you should avoid certain forms of exercise.

If you are going through an IVF treatment or are about to start an IVF treatment, then you can continue with most training until the start of stimulation. During stimulation, you should either stop running or replace with power walking.

The same holds true if you engage in any activity that causes repeated up and down movement of the ovaries in the pelvis, such as running, mountain biking and certain advanced yoga postures.

The reason is that the ovary is attached to the pelvis with a soft attachment or pedicle. As ovary gets bigger with stimulation or in the presence of an ovarian cyst, the attachment may not be able to hold the ovary stable.

In such a situation, the ovary may twist its pedicle causing torsion of the ovary.

A majority of times the torsion is reversible and corrects itself. But, occasionally it may not be able to reverse, and the ovary may then get deprived of the blood supply.

This usually requires an operation, and there is a chance you may end up losing your ovary. The risk of torsion for the stimulated ovary is almost 10-12 fold higher than an unstimulated ovary without any cyst.

The same holds true if you are going through superovulation, either on its own or with insemination, using gonadotropins such as Menopur® or Gonal F®.

After embryo transfer and until you take pregnancy tests, you should avoid lifting heavy weights or vigorous exercise. If the pregnancy test is positive, then you should continue to refrain from the strenuous exercise or heavy lifting.

3. Should I have the immune tests?

Many patients who have been through an unsuccessful IVF treatment are aware of the immune tests. This may be either through patient forums, friends/family suggestions or recommendation by your fertility specialist.

The immune tests are now becoming a common practice. They are considered controversial, and their exact role is still debated. Immune tests check for certain markers, such as

  • thyroid antibodies
  • a range of other antibodies
  • natural killer cells
  • cytokines
  • KIR
  • leucocyte antibody detection
  • Th1:Th2 ratios

Most of these are blood tests. Some tests may need an endometrial biopsy (biopsy of the lining of the womb). This information will shed some light on any immune-related causes that may be contributing to the failure of implantation or the rejection of the embryo. They are also called Chicago tests, reproductive immunology tests, NK test, level 1 and level 2 tests.

We recommend these tests to patients who may have experienced two or more failed IVF treatments. It is assumed that at least two or three good quality embryos may have been transferred in these IVF treatment cycles.

A healthy womb and a healthy embryo are required for successful implantation and ongoing pregnancy.

If your specialist is confident about the health of the embryos, then it may be the womb or other factors that are resulting in failed implantation or miscarriage. Of course, this varies from condition to condition and also the severity of the illness.

As there is a lack of clear evidence, these tests are not offered by the NHS Fertility clinics.

4. Can I return to work after embryo transfer?

Every patient considering IVF or ICSI treatment wishes to give themselves the best chance of getting pregnant. Hence, they are worried about not doing anything that can affect their chances of IVF treatment success.

There is no evidence that strict bed rest improves IVF success rates. So, the standard recommendation regarding return to work depends on the nature of the work.

  • If your job is manual and involves lifting heavy weights, then you should speak to your GP and your employer before starting treatment regarding taking time off or modifying the job role.
  • But, if your work is psychologically or emotionally stressful for a variety of reasons, then again you should consider taking time off or discuss with your employer or line manager to review the job profile.
  • If neither of the above holds true, then there is no reason why you cannot return to work. You can consider working from home for some of the days if you have such an arrangement.

After embryo transfer, it is important, that you are reasonable and avoid strenuous activities such as lifting heavy things, vigorous activities such as climbing multiple flights of stairs, running, cycling and adventure sports. This is not an exhaustive list of activities, but only a guidance.

5. Do I need to take time off during treatment? / How much time off do I need to take when going through treatment?

This is a common question from patients starting their first treatment. During an IVF treatment, you have to attend around 5-7 clinic appointments besides the initial consultation.

After the initial consultation and before starting IVF, you would attend an IVF co-ordination or injection training appointment. During stimulation phase, you have at the least three or more follicular tracking or monitoring appointments.

These appointments are either daily or on alternate days until the egg collection. Most patients can manage these without having to take time off. Yet, if your employer is not so considerate, then you may have to explore your options.

You will need to take time off on the day of egg collection and for at least the next 48 hours. Between day 2 – 6 of the egg collection, you will come for the embryo transfer.

Sometimes, it may be best to take a week off from the egg collection. This may give you a few days to recover. Prepare yourself for the embryo transfer and take a day or two off after embryo transfer.

This is a general suggestion for most patients going through an IVF or ICSI or PGS treatment cycle. It also depends on the nature of work, work schedule and how supportive your employer might be.

Patients going through artificial Insemination or IUI also have to come for follicular tracking appointments, just like IVF patients. Most patients do not have to take time off.

Patients going through frozen embryo replacement cycle have fewer monitoring appointments. Hence, less disruption to your other commitments.

6. I am over 40 and have a good ovarian reserve. Can my age still affect my chance of getting pregnant with IVF?

Most women are aware that fertility decreases with age. Thus, it is less likely that they will get pregnant either naturally or the following treatment. Many are under the impression that if their ovarian reserve tests such as FSH or AMH are normal, then there should not be any compromise in them getting pregnant at least after treatment.

Despite having normal FSH and AMH, the chances of successful fertility treatment is lower in women over 38 when compared to someone less than 35. This happens because the quality of the remaining eggs is not as good. This leads to mistakes in the splitting of the genetic material during cell division and fertilisation.

So, some embryos may end up having too much genetic material or too little. Both of these situations may lead to a genetically abnormal embryo. The embryo is unlikely to implant after embryo transfer or even if it implants it is more likely to miscarry. In summary, the chances of getting pregnant are lower in women over forty even with good ovarian reserve.

7. My gynaecologist said I had mild endometriosis. Will it affect my chances of conceiving with IVF?

Many patients are aware of having endometriosis, but they don’t know what is best for them and whether this may affect their treatment. The facts are that 10% of women in the general population may have endometriosis. But, in women experiencing infertility, the incidence of endometriosis can be as high as 24 to 50%.

The chance of women with mild endometriosis conceiving each month is as low as 2.5 to 5% compared to 15 to 20% for women with no fertility problems. This further decreases for women with moderate to severe endometriosis to around 2.5%. Endometriosis is a condition where the lining of the womb is present outside in the pelvis or bowel.

How does endometriosis affect fertility?

Endometriosis changes the pelvic environment in subtle but important ways. We do not understand how it exactly affects fertility, but there are different theories. Some of these propose that it may cause blockage of fallopian tubes from scarring, an inability of the fallopian tube to pick up the egg by changing the structure and function of the tube.

While other potential reasons are that it may cause inflammation and this may lead to changes in an immune environment. This can affect the egg quality, embryo quality and the implantation in a negative way.

Those women who had mild endometriosis and had been surgically treated may have a small period where their natural fertility has been restored. They should try to conceive naturally in the following 6-12 month period. Mild endometriosis does not affect the success rates of most fertility treatments including IVF.

Those women who have moderate to severe endometriosis will need a proper assessment whether the endometriosis should be cleared by surgery before starting IVF treatment. Your fertility specialist or gynaecologist will make a decision. It also may be a joint decision between both.

8. I have a small fibroid. Should I get it removed before starting fertility treatment?

The fibroid is a benign or harmless lump in the muscle of the womb. Almost 5-10% of women with fertility problems may have a fibroid within the uterus or womb. Many women conceive with fibroids.

Fibroids may affect fertility in different ways. For example, by blocking fallopian tube. It is possible that a cervical fibroid may distort the cervical canal and prevent the sperms from entering the womb cavity.

In others, it may distort the womb cavity and make the womb less favourable for embryo implantation. In some, especially with fibroids over 6-8 cm, it may redistribute the blood flow. Thus, it may reduce the chance of implantation and pregnancy.

So, the mere presence of fibroid in the womb does not mean you need to have surgery to remove it before starting any fertility treatment. If the fibroid

  • is blocking the fallopian tubes
  • or is pushing into the cavity of the womb
  • or is more than 6-8 cm in size
  • or is in the cervix
  • or is in the neck of womb such that it may obstruct the entry of the sperms into the womb.

In these cases, one should consider removing fibroids to restore fertility or to improve the IVF or other fertility treatment success rate.

9. This is my second failed infertility treatment cycle. Are there any tests that my husband should consider besides the initial semen analysis?

It is a difficult situation to experience repeated IVF treatment failure. There are many tests that may be recommended by your specialist. As far as men are concerned, the basic semen analysis gives us a lot of information, including:

  • sperm count
  • motility
  • sperm appearance
  • morphology and clumping
  • agglutination

It does not provide a full picture of the sperm function e.g. fertilisation, genetic normality, etc. Almost 10% of men with normal semen analysis may experience fertility problems. But, there are tests that may provide more information about the sperms:

  • Sperm DNA Fragmentation Index (sperm DFI)
  • ROS test
  • Sperm Aneuploidy

The ROS and Sperm DFI look into the degree of damage to the genetic material of the sperms from the various lifestyle factors. Sperm aneuploidy provides information regarding the prevalence of five common chromosomal problems in the sperms. This information may help your fertility specialist in advising your partner.

Possibilities are lifestyle interventions or a different kind of assisted fertility treatment or other appropriate intervention. It may not guarantee IVF treatment success, but it may maximise your chances of successful treatment. Some may decide to explore alternative options or even decide against further treatment.

10. If I am using donor eggs, do I have to tell the child?

This is a common question I get asked each time when I see a patient who is thinking of using donor eggs. The law around the egg and sperm donors in the UK changed in 2005.

Until 2005, the donors remained anonymous. But after 2005, they can no longer remain anonymous. All egg donors have to register as donors with the HFEA. Children who are born after the use of donated eggs in the UK can seek identifying information about their donor at the age of 18. This will include the name, address, contact details and half siblings. At no point will any fertility clinic will ever provide the identifying information about the donors directly to recipients.

With regards to telling the child about their egg donors, it is a good practice that the parents inform the child at an early age. The child grows with the idea. This is preferred to disclosing much later when they are in late teens or 20’s. The law does not mandate or stipulate that the parents of donor conceived children have to tell the child. So, it is the parent’s decision whether to inform the child or not. Most child psychologists will recommend telling the child at an early age.

Understandably, parents are anxious when thinking of disclosing egg donation to children. They can seek help from a Donor Conception Network or DCN. The Donor Conception Network is a charity. It supports patients using donated eggs or sperms or embryos for their treatment.