The little details 2015

inspiring modern families I ohbaby.co.nz

brought to you by Fertility Associates

get ready, get set how to prime your body for pregnancy

conceiving medical miracles: IVF explained

caring about conception things to think about changing before trying to conceive

age before baby is there a right age to get pregnant?

the little details your journey to parenthood

conception * FERTILITY * infertility * IVF

welcome I have really enjoyed writing my articles for OHbaby! It has given me an opportunity to spread the word about fertility and infertility and the issues that they raise for many.

Fertility issues vary from the very simple to the extraordinarily complex. No matter how simple or complex, however, for the couple or person involved with the issue, it is always a significant problem. We have put together this compilation of articles as a ready source of information to help you along the way.

There is nothing fair about infertility and most commonly there is nothing that the affected couple can personally do to change the situation other than to wait or to have treatment. Having said that, we all want to give our children the best start in life by providing them with healthy eggs and healthy sperm as the initial building blocks of their future life.

I hope you find this in-depth booklet, with articles written by Dr Richard Fisher and myself, useful and encouraging. You can find more information on our website and updates on our Facebook page. All the best with your own fertility journey.

DR ANDREW MURRAY

Chair of Fertility Associates Dr Mary Birdsall Medical Directors Dr Simon Kelly Dr VP Singh Dr Andrew Murray Dr Sarah Wakeman Fertility Specialists Dr Michelle Bailey Dr Anna Bashford Dr Mary Birdsall Dr Neil Buddicom Dr Catherine Conway Dr Elizabeth Curr Dr Richard Fisher Dr Kirsty Gendall Dr Freddie Graham Dr Simon Kelly Dr Phil McChesney Dr Simon McDowell Publisher Angela Pedersen angela@ohbaby.co.nz

Dr Stella Milsom Dr Digby Ngan Kee Dr Megan Ogilvie Dr Greg Phillipson Dr Sunil Pillay Dr Susannah O’Sullivan Dr Lakshmi Ravikanti Dr Mark Stegmann Dr Olivia Stuart Dr Helen Wemyss Contact details Website: fertilityassociates.co.nz P: 0800 255 522 E: info@fertilityassociates.co.nz Facebook.com/fertility.associates Clinics Auckland: Lvl 3, 7 Ellerslie Racecourse Dr, Remuera P: 09 520 9520 E: faa@fertilityassociates.co.nz Photography Shutterstock

North Shore: Lvl 1, Apollo Centre for Health and Wellness, 119 Apollo Dr, Albany P: 09 475 0310 E: fas@fertilityassociates.co.nz Hamilton: Lvl 2, 62 Tristram St P: 07 839 2603 Email fah@fertilityassociates.co.nz Wellington: Lvl 2, 205 Victoria St P: 04 384 8401 E: faw@fertilityassociates.co.nz Christchurch: Hiatt Chambers, Level 1, 249 Papanui Road P: 03 375 4000 E: fac@fertilityassociates.co.nz We also hold clinics in Whangarei, East Auckland, West Auckland, Tauranga, Gisborne, Hawke's Bay, New Plymouth, Whanganui, Palmerston North, Lower Hutt, Nelson and Queenstown with more clinics coming in the lower South Island.

Published by OHbaby! Limited, PO Box 80081, Green Bay, Auckland 0643 Phone (09) 376 1778 Fax (09) 817 6729 Website www.ohbaby.co.nz Email magazine@ohbaby.co.nz 0508 OHBABY (0508 64 22 29)

Copyright © 2015 OHbaby! Limited. OHbaby! Magazine is registered with the National Library (ISSN 1178-6515). OHbaby! Magazine and www.ohbaby.co.nz are wholly owned by OHbaby! Limited. No other parties or individuals have any financial interest in the company or in OHbaby! Magazine or www.ohbaby.co.nz. OHbaby! Magazine contains general information only and does not purport to be a substitute for health and parenting advice. All reasonable care is taken in the preparation of this magazine and its contents but the publisher, editor, and authors cannot be held legally responsible for errors in the content of this magazine or any loss arising from such errors. Readers are advised to seek a doctor or health professional for all medical or health matters. The publisher, editor, and authors do not accept any liability whatsoever in respect of action taken by readers in reliance on the recommendations set out in this magazine. Opinions expressed or information given in this magazine should never replace medical advice. This magazine intends to provide general information on a subject or particular subjects and is not an exhaustive treatment of such subject(s). Accordingly, the information in this magazine is not intended to constitute any legal, consultative, or other professional advice, service, or contract in any way. OHbaby! Magazine is subject to copyright in its entirety. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopiers and information retrieval systems.

All rights are reserved in material accepted for publication, unless initially specified otherwise. All letters and other material forwarded to this magazine will be assumed for publication unless clearly labelled “NOT FOR PUBLICATION”. No responsibility is accepted for unsolicited material. All reasonable efforts have been made to trace copyright holders. Published by OHbaby! Limited.

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contents 4

get ready, get set what you can do to prime your body for pregnancy

6

age before baby is there a ‘right age’ to get pregnant?

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making baby-making fun taking a lighter look at conception

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10 caring about conception

things to think about changing before trying to conceive 14 the amazing race

when it takes three to a make a baby 16 male infertility

the miracle of conception 18 conceiving medical miracles

the process of IVF 20 the gene factor

exploring the ethics of gamete donation 24 can you choose your baby’s gender?

the truth in the old wives’ tales 26 the future of fertility treatment

what's new and what to expect 29 your questions answered

answers to your frequently asked questions

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GET READY, GET SET Getting pregnant is something that most of us take for granted, but conceiving isn’t always easy. However, there are things you and your partner can do to ‘prime’ yourselves for pregnancy as Dr Richard Fisher explains.

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aving children is something our society places a high value on. Although some people will reject this option, for the vast majority of people, having children is both a biological and social imperative.

Despite this, it is often one of the things we prepare least well for.

Contraception has given women an opportunity to choose the time they might ideally conceive, but only a small number actually plan before conceiving to ensure the best outcome for themselves and their babies.

Doctors like myself tend to focus on those who have difficulty getting pregnant, rather than those who do it with ease. For most couples, conception occurs without problems. Conception is very much about chance, and some people are just luckier than others.

Being lucky but unprepared, however, is not of benefit to either the mother or the baby.

Getting pregnant is not meant to be a military exercise. The aim should be to maximise the chance of a healthy pregnancy while still retaining the concepts of love and passion. If pregnancy takes a while to achieve, even this aim becomes more difficult.

Few couples make major life decisions without some discussion with close friends and family, but this discussion seems very limited when it comes to planning to conceive. That arm’s-length relationship is satisfactory as long as pregnancy happens quickly, but if it does not, then relationships become complicated by the lack of knowledge of those close to you about your desires, and the frustrations that occur when they are not met. Those to whom you might turn for support in good times and empathy in bad simply don’t know what to do. The ratio of what appear to be stupid or unsympathetic comments to expressions of real care will only change when knowledge of the goal is shared.

Timing is everything, and the right time will be different for everybody. There are aspects one cannot change, such as the age you are when you meet your partner, and it seems only sensible not to attempt to conceive too early in a relationship. However, understanding the effect of age on conception, so that you can be realistic about the chances of getting pregnant each month, is very important in managing your expectations, never mind anyone else’s.

Knowing when ovulation occurs and, consequently, the best time for conception, is also important. One can, of course, try the

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'random chance' technique of getting pregnant, which tends to lead to a regularity of intercourse — which, although superficially attractive, is not particularly focused. The fantasy of persistent, regular sex seems to wear thin if conception does not occur quickly.

In women with regular cycles, ovulation occurs around 14 days before the onset of her period, and intercourse on every second day through this time should be sufficient to give you as good a chance as anybody else.

For most people, it is unnecessary to take temperature charts, test saliva or urine for hormone changes, or learn to detect pre-ovulatory mucous changes for conception to occur.

Getting pregnant is not meant to be a military exercise. The aim should be to maximise the chance of a healthy pregnancy while still retaining the concepts of love and passion. If pregnancy takes a while to achieve, even this aim becomes more difficult.

If you must focus on a particular day, then the day before ovulation is the best time to try to conceive, when cervical mucus is at its most receptive. Sperm, like vegetables, are best used fresh.

Saving up for a week to let loose a neutron bomb’s worth of sperm at ovulation is unhelpful, as the sperm is aged and, consequently, subject to DNA degradation and reduced function.

So, how might one prepare best for pregnancy? A visit to your GP or fertility specialist is a great place to start. Besides being able to confirm that you are immune to rubella (and consequently at no risk of contracting rubella in early pregnancy and damaging your baby),

he or she will be able to take your blood pressure and some routine blood tests to make sure you have no unexpected underlying health issues. He will also be able to help you assess when ovulation is occurring, or is likely to do so, and is a good point of contact if things don’t happen quickly. As part of that assessment visit, he will also talk about the sort of issues I discuss below, which are becoming increasingly important.

There are some things about which we have a degree of confidence. Weight, the use of drugs, be they recreational or prescribed, and the use of alcohol are known to have an effect both on conception and the growth and development of a baby.

use of supplements Whether the use of supplements prior to conception is of any help remains an unanswered question. There is clear evidence that the use of folic acid pre-conceptionally reduces the incidence of some congenital abnormalities, in particular spina bifida, but currently there is no definitive evidence that other vitamin or mineral supplements, in otherwise healthy women, improve the chance of conception or the outcome for their children. One needs to be careful about extrapolating from single pieces of information into a generalisation that creates a need for the “worried well” to change their lifestyle or supplement their diets unnecessarily.

weight Weight is clearly important. Being too big or too small can affect the chance of conception, the chance of miscarriage, and the outcome for the child. Both calorie restriction and calorie excess in early pregnancy are known in animals to alter the long-term health outcomes for offspring, and confirmation of the same effects in humans is beginning to appear.

smoking Smoking negatively impacts nearly every aspect of fertility. The chance of getting pregnant per month is only 60% of your sameaged non-smoking sister; miscarriage rate increases significantly, as does the rate of ectopic pregnancies. In women who smoke and undergo IVF, fewer eggs are obtained, more failures of treatment occur, and more miscarriages tend to occur.

caffeine There is an increasing body of literature which shows that caffeine is potentially harmful, both in terms of trying to conceive and in increasing the risk of miscarriage. The data suggests that limiting caffeine intake would be wise, although having a single coffee a day in our coffee-socialised society does not seem likely to adversely impact on the average woman.

alcohol It is easy to be supercilious about alcohol. It’s probably true that more children are conceived following consumption of alcohol than without it, and it is ever-present in our society. It is clear, however, that any amount of alcohol is unsafe in pregnancy. The risks to the foetus are idiosyncratic, and everyone knows someone who has consumed alcohol in early pregnancy or throughout the pregnancy and their children have come to no harm.

Sadly, this is not universally true. Drinking in pregnancy carries

unwarranted risks and should be avoided. Pre-conceptionally, the only truly accessible data comes from IVF programmes, where it has been shown that both the chances of conception were diminished and the risk of miscarriage was increased in women in proportion to the number of units of alcohol consumed in the time leading up to treatment.

for men In men, one additional drink per day increased the risk of failure of treatment by two to eight times, depending on the time period. It is always difficult to extrapolate findings from a specific treatment like IVF into natural conception, but it is reasonable to assume there must be some effect, even though it might be quite small.

Increasingly, men are asking what they can do to help improve their partner’s chance of conception. Finding relevant data is particularly difficult in men, as the only outcome really worth measuring is whether a live birth occurs. Measuring sperm counts is not particularly useful, as it is so enormously variable, and within that variation there are so many potential outcomes.

Clearly, however, cigarettes (be they tobacco or marijuana), alcohol, and excess weight all appear to be detrimental and appear to increase the risk of long-term health effects on their children.

Smoking more than 10 cigarettes per day in men increases the risk of childhood cancer in their offspring four-fold. Men need to be aware that what they do now may well affect the quality of life of their children. Producing healthy sperm at conception is among the greatest gifts a man will ever give his children. ●

OHbaby! Fertility Associates Exclusive | 5

AGE BEFORE BABY...

What is the best age to get pregnant? With the average age of New Zealand women having a child now at an all-time high of 30, it seems obvious that with the age of first parenthood increasing, women’s fertility is decreasing.

Dr Richard Fisher looks at the research surrounding how age impacts on fertility, for both men and women.

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S

ocial change is always fascinating. Changes in the way we behave often lead to unintended consequences.

One of the most significant adverse consequences arising from the change to older parenthood (long held to be consequentially 'good for society') is that the incidence of subfertility is increasing for many couples. For many, conception is easy; but for an increasing number, it is becoming more difficult.

This is not because there is a fundamental change in the human ability to reproduce, it is simply a side effect of beginning one’s reproductive life later than in the past.

The average age of first birth in New Zealand has climbed steadily since the 1970s. The situation now in 2008 is that it has reached 28.

The average age of all New Zealand women giving birth is around 30 years. Clearly this is only an average, but what it does mean is that a significant number of people are trying to have their first baby later than they used to.

Human fecundity (the chance of conception per month) changes quite dramatically over time, with good evidence that it begins to decline in the late 20s and it falls more rapidly from the mid-30s.

At age 30, the average chance of conception per month is around 20%, and by age 35, it has fallen to around 17% or 18%. By 40 it is down to 10% per month. At 43, most women have only around a 4% to 5% chance of conceiving each month.

Fecundity is a biological variable, and involves two people rather than one, but the primary determinant is usually the woman’s age.

That some women do conceive at 43 is certainly true, but also means that a significant number will not conceive, through no fault of their own, and with no underlying cause other than chance.

As women age, the likelihood of the egg that is released each month being normal decreases, and by age 40, around 85% to 90% of eggs are chromosomally abnormal.

At a time when couples would most like to conceive quickly, nature determines that conception will, more likely than not, occur slowly. To compound this, the incidence of miscarriage and later foetal loss increases as age increases. The risk of miscarriage increases from around 10-15% at age 30 to 35-40% at 40.

We have known for many years that there is an increase in chromosomal abnormalities in the children of reproductively older women, but recently, more interest has been shown in men’s age as an independent variable in reproductive outcomes.

Lately, there has been some publicity about the chance of foetal death increasing as the male age increases, but this just confirms data known for some time that a paternal age of greater than 50 doubles the chance of foetal death at any time in pregnancy, and paternal age of more than 40 leads to an increased rate of miscarriage independent of maternal age.

More recent data has shown that as men age, the chance of their partner conceiving reduces as well, and a man older than 40 may halve the chances per month of his partner conceiving.

Young sperm seems to have a significant biological advantage, just as young eggs do.

Just as in women, paternal age can affect children’s outcome, although more recognised in non-chromosome abnormalities such as schizophrenia, autism, and achondroplasia (dwarfism). The data about schizophrenia seems particularly robust, with the chance of a 45-year-old male having a child with schizophrenia being three times greater than one under 30. Similarly, as men age there is an increased risk of the child having autism.

These are all relative risks, however, and the absolute levels remain small. Men, however, clearly shoulder some of the burden of risk factors with the changing reproductive age.

I am often surprised how many couples are unaware of the significant effect of female age on reproduction. Despite 20 years of my constantly talking about maternal age and its effect on fertility, the information is still not widely disseminated, or, if it is, not widely absorbed. Most people are brought up to think about 'when' they have children, rather than 'if', and hold firmly to the belief that such an 'if' could not happen to them.

As always, there are competing messages in the media, which make an assessment of likelihood difficult. News that yet another celebrity has conceived in their 40s (and often with twins) often lacks added information that their conception was assisted, and often with the use of donor eggs. Hollywood must have the highest incidence of spontaneous twin pregnancies in the world!

A consequence of this delay in attempting to conceive is that more people present to infertility clinics for assistance than ever before.

Often there is no definable cause other than age, and with luck, time alone will allow conception to occur. The average normal 37-year-old will take around seven to eight months to conceive, and the average 40-year-old will take up to 15 months.

Clearly the underlying emotional pressures of such delay are significant. The insecurity about conception leads to interventions such as the use of drugs and even IVF, which, if more time was available, might prove unnecessary.

Since 1990, there has been a four-fold increase in the use of IVF in women over 40. Approximately 20% of all couples having IVF at Fertility Associates Auckland are now over the age of 40.

There is little question IVF is the most effective treatment in any individual month for these couples, although it is a complex treatment, which most couples would rather have avoided. Just as in natural conception, the success rates in IVF are also limited by the underlying biology. IVF is a highly successful treatment in younger women and a relatively effective one in older women, but the incidence of failure increases with age.

It has been widely stated (without any factual basis) that the reasons for delaying conception were primarily around women deciding to become educationally, professionally and financially more secure, quite apart from the independence that the emancipation of women has brought. Two recent surveys, however, in Australia and New Zealand, both of infertile couples, strongly suggest that the lack of a suitable partner may well be the prime determinant. Whether women are getting more fussy, men are becoming less ready to commit or there are just are not enough suitable men to go around, it is a fertile topic for further research.

For most couples, conception should occur without too much difficulty. Intercourse should not need to be planned like a military exercise, but having an awareness of the time of ovulation is important and having an awareness of the importance of age is critical.

If there is anything in your, or your partner’s, history which is suggestive of a reduction in your chances of conception, such as pelvic infection, endometriosis, or surgery to the testis, then you should present early for assessment. The more irregular your cycles, the less predictable the time of ovulation is.

With social changes come unintended consequences. How we deal with these particular consequences will shape the future for both individuals and society as a whole. ●

OHbaby! Fertility Associates Exclusive | 7

having fun making babies We understand the basics of conception, but how much of the process is guesswork or a gamble? Dr Richard Fisher offers some tips to enhance your chances of conception.

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ormally, I write about trying to conceive for those who are having difficulty in doing so, but fortunately, for most people, conception proves to be not too much of a problem. Despite this, everyone is an expert on ways in which you can improve your chances, and will willingly offer advice without being asked or without any evidence that their advice has any validity. For most couples, normal biological chance and time are all that is required.

Unplanned, unexpected, and surprising pregnancies are commonly in the news. Women’s magazines are full of stories of Hollywood actresses conceiving in their 40s without mentioning that donor eggs are commonly used among this group.

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One of the consequences of this is often an unrealistic expectation of success when couples start to try themselves.

So, for 85% of couples conception will occur without difficulty.

The remaining 15% will end up taking longer than a year, although these percentages will vary significantly according to the age of the woman. The traditional definition of infertility — not being able to conceive after a year of trying — is a definition really only suitable for the textbook, as opposed to real life. A 25-year-old woman not pregnant after six months is much more likely to have an underlying problem than the 37-year-old who has been trying for a year; for at a time when women would like to conceive the quickest is the time that nature demands it to be the slowest. At 25, the chance is about 25% per month, whereas at 37 it is about

14%. When one takes into account the risk of miscarriage at each age, then the chance of having a baby is 20% and 10% respectively.

Unfair, isn’t it?

So how long should a couple wait before they consider seeking help, and are there particular things one could do to optimise the chance of pregnancy?

Being as fit and healthy as you can be, avoiding smoking absolutely, and drinking alcohol with care is all sound advice, but it is not the advice most commonly sought. That advice is usually about when, how, and how often.

Ovulation is a singular event in time. Fortunately, sperm usually has the capacity to hang around for a while, and uses the mucus in the cervix, as well as the rest of the female reproductive tract, as a place to hide, so that fertilisation can occur with intercourse up to four or five days before ovulation. Although this may give some men a great sense of pride in the longevity of their sperm, most commonly conception occurs when intercourse happens the day before ovulation, followed by the day of ovulation, and then back from two days before ovulation. Intercourse after ovulation very rarely results in success.

For most women, the detection of ovulation, sufficient in its accuracy to conceive, is an uncomplicated process. About 90% of the time, ovulation occurs between 12 and 15 days before the first day of the next period, so that if the menstrual cycle is regular, no great skill is required to understand the most likely days. And the ability of normal sperm to survive for a few days makes absolute accuracy unnecessary. Even women with irregular cycles that occur within a window of a week or so, can simply count the days and focus intercourse around the most likely time. Those who want, or need, more accuracy can learn to detect the changes that occur in cervical mucus around ovulation, when the mucus changes from a sticky white substance to something increasingly like egg white at the pre-ovulatory day. Mucus detection is usually easy, and certainly cheap and vastly superior to temperature chart recording, which many women seem to spend months trying to master.

The basal body temperature rises after ovulation, and can be helpful to confirm that ovulation has occurred, or as part of teaching the change in cervical mucus, but by itself I think it is almost always useless. By the time the temperature rise has occurred, so has ovulation, and sadly it is not possible to conceive retrospectively.

If ovulation detection is proving difficult and confirmation is required, then using urine tests each day leading up to ovulation is a very accurate way of defining the best day for intercourse. These urine test sticks detect the rise in the luteinising hormone (LH) that begins to occur some 36 hours before ovulation and so can be helpful when there is indecision. In some couples, particularly when conception is taking some time, intercourse on cue has become a chore, and sex is a “have to” rather than a “want to”, then using LH kits ensures that “have to” is only once, and “want to” is left for other occasions. If the menstrual cycle is very irregular, then medical advice should be sought, as trying to use LH kits can become difficult and expensive if tracking goes on over many days.

An alternative way of detecting ovulation is to use salivary tests, which look at pattern changes in saliva structure but most people find these difficult to interpret, and although attractive because of the apparent simplicity of the method, most people find them difficult to use in practice.

Frequency of intercourse is always a question I am asked. Given the information I have outlined above, most couples do not need to turn getting pregnant into a military exercise, and normally

fertile couples should not have to. Intercourse on every second day through the likely time of ovulation is all that should be necessary (and sex for conception is a bit like marketing expenditure, you never know which part of the expenditure was successful). Sperm are like vegetables, they are best used fresh. Saving up to provide an attack of nuclear proportions is not a helpful plan. Old sperm function much less well than fresh ones and ejaculation should not be delayed on the grounds that quantity is better than quality. It is rarely true in any aspect of life, and in particular, this one.

A Google search for sexual positions for conception will lead you to a vast number of entries, and although these may add interest to the occasion, there is no evidence that any one is better than another for conception. Sperm behave like men, they seldom ask for directions, and the fact that they ultimately find themselves in the cervical mucus, and on their way to seeking out an egg, is as much by chance as good planning. There is some evidence that the process of initial sperm transport is an active rather than a passive one and occurs during intercourse. Lying with your feet in the air, or up the bedhead, or in the knee-chest position after sex, favourites on the web, appear to create no advantage except perhaps for wry amusement.

If conception is taking a long time, seek help when you begin to feel worried about it. Most couples require no intervention, but the stresses of intercourse on demand can profoundly change the sexual relationship for couples, and early assessment and reassurance can be very helpful in alleviating the building tensions.

If conception is taking a long time, seek help when you begin to feel worried about it. Most couples require no intervention, but the stresses of intercourse on demand can profoundly change the sexual relationship for couples, and early assessment and reassurance can be very helpful in alleviating the building tensions.

Couples often ask about the use of lubricants and their effect on outcome. It is true that many lubricants commonly used kill sperm, but I doubt that this is ever really a practical problem, unless the volume of lubricants used is large and intravaginal. There is now a lubricant made especially for use around ovulation, which sperm is happy to live in, but I have seen no data that the chance of pregnancy is better using this in preference to any other.

Trying to conceive should be fun, but it is not always quick or easy. A realistic idea of the likely time to conceive is in itself helpful in reducing the concerns that can arise, and a little bit of knowledge in planning can improve your chances. Follow some basic rules as outlined above, and then mostly the rest is up to chance.

Just like finding the right partner to begin with, life seems more about chance than we would like to admit. ●

OHbaby! Fertility Associates Exclusive | 9

CARING ABOUT CONCEPTION If you’re trying to get pregnant, you’ve likely been inundated with advice on what you should be doing to increase your chances of conception.

Dr Richard Fisher looks at the options.

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ost of us plan for events of significance in our lives. Such relatively uncomplicated things as birthday parties and holidays often consume the most planning effort. Buying a house takes a degree of financial planning, but it always surprises me how spontaneous the decision to buy a particular house can be. Getting pregnant, likewise, should be a planned event, but the vagaries of biology often make the particular timing difficult, even if the intent is clear.

Unplanned and unwanted conceptions are clearly a social tragedy, with significant risks to children conceived and brought up in an environment full of physical risk factors.

Planned pregnancies, however, are now coming under more scrutiny as well, as medicine moves towards a further clinical and research sub-speciality of pre-conceptional medicine.

There is increasing recognition that parents’ behaviour and habits around the time of conception can have significant short and long-term effects on their foetus and child.

There is no greater gift parents could give their children than healthy sperm and healthy eggs, and to reach this goal, you have to understand the environment in which those gametes grow and in which a resultant embryo will also be nurtured.

It is commonly stated that we live in a child-centred society, and I dare say that most of us think we do. We can always point at the exceptions as if they are not our problem.

The vulnerable in our society are so often children, and we as a community owe them all a duty of care.

folate supplements The recent debate about folate supplementation in bread to help prevent neural tube defects such as spina bifida points to our ambivalence about this. Middle-class opposition to such fortification was based around an argument about individual choice and our ability to protect our own children by taking the supplements we choose. It is so often not the children of the middle class who are at major risk, however, for, with some exceptions, those most at risk are born to parents who have poor nutritional status, quite apart from

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OHbaby! Fertility Associates Exclusive | 11

a genetic predisposition. If we are to protect those children, then we should bear some community responsibility for this by accepting that supplementation of bread with folate is a way in which we might significantly reduce the risk for someone else’s children, rather than care about our own alone.

Institute in Auckland has shown that mothers fed a high-fat diet at the time of conception had babies who went through puberty earlier and had higher levels of total body fat and altered levels of sex hormones. How well they were looked after or fed after birth had little effect on those parameters.

weight

supplements

Recent studies from the University of Adelaide have shown that couples having IVF had clinical pregnancy rates which were significantly reduced, as both maternal and paternal body mass index increased quite independently of each other. Of particular interest in one of these studies was that approximately 80% of all men in this unselected group were overweight or obese, and this posed the question about what effect paternal weight might have on the chance of natural conception. For overweight and obese women, not only did they have a smaller chance of being pregnant, but the pregnancies which resulted had more complications as well as more adverse effects on the newborn in terms of growth, development and the rate of congenital abnormality.

Neural tube defects, heart abnormalities, and complex abnormalities are significantly increased in the children of obese and overweight women. If a medication had the same adverse effect on foetal abnormality as obesity does, we would certainly ban its use.

Animal studies have shown that weight alone is not the only determinant of outcome, but also the type of food consumed at the time of conception is important. Animal work at the Liggins

Our concern about healthy eating, however, often leads us to irrational behaviour. Around 50% of couples presenting at Fertility Associates are already taking supplements of some sort. In the world of complementary medicine, marketing seems to trump science on all occasions. With the exception of folic acid, there is little evidence that supplementation of vitamins in someone ingesting an otherwise healthy diet does little more than make expensive urine. The concern that not taking supplements might be harmful is seldom balanced by the question as to whether taking them is actually harmful. There is evidence that high supplementary levels of vitamin A in pregnant women is potentially harmful, and vitamin A has been shown to be associated with an increased risk of congenital heart defects.

A question has been raised about the use of vitamin E for the same reasons, although the evidence is much less clear. The fact that a vitamin occurs naturally and that in some specific people replacement of inadequate levels of particular vitamins have positive health outcomes does not mean that supplementing all diets is necessarily beneficial. Developing a concept that both food and vitamin supplements are drugs will be, I think, a significant

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advance in ensuring that the environment in which conception occurs is as healthy as possible. While we have printed warnings about the health effects of adverse factors such as cigarette smoking; perhaps it is time to issue a warning on supplements that says, “There is no evidence that taking this supplement will do you any good.�

sperm and sperm function Over the past decade, a considerable amount of data has become available about sperm and sperm function.

Recent data looking at the fragmentation of DNA in sperm and its association with a decrease in function has led to a search for effective treatments in men whose sperm exhibit such abnormalities.

The presence of DNA fragmentation is correlated with oxidative stress, and the finding that the use of some antioxidants can reduce the presence of reactive oxygen species, which cause this stress, has led to considerable research effort.

The extrapolation of findings in a small study, which showed men who had poor sperm counts and motility in IVF cycles being treated with micro-injection led to better pregnancy rates, has led to a marketing explosion supporting the use of antioxidants in all men trying to conceive. Although there is no data suggesting these might be harmful, the people whom we think will benefit from the use of antioxidants are those with a defined problem, and we have no knowledge about whether otherwise normal men will be similarly advantaged or disadvantaged.

The fear of 'missing out', together with sophisticated marketing, makes the use of supplements for 'support' and 'assistance' in conception a fertile ground for exploitation. For some time it has been known that vitamins C and E (both antioxidants) can alter sperm function.

There is limited data as to whether it makes a difference to the chance of conception. There is no data at all as to whether cheap products are any worse than an expensive product with the designated use for supporting male sperm health.

The whole area of sperm function is very important and, more than ever, focus is being placed on the male to see what we can do about improving pregnancy outcomes. The production of reactive oxygen species in abnormal environments may be the key to deterioration in sperm function, and the use of antioxidants may prove helpful in mopping these up. Antioxidants are found in foods, particularly in highly coloured vegetables and fruits, but the effect of improved nutrition in men, either in humans or in the animal species, has not been subject to the same scrutiny as in women.

Oxidative stress, however, is known to be associated with smoking and some dietary deficiencies, excessive alcohol consumption and extremes of exercise. The way to resolve these problems is certainly to remove the stressors rather than treat the subsequent problem.

Age and chronic disease also cause oxidative stress, and although the latter may be alleviated, the former is a terminal disease.

smoking and alcohol Smoking cigarettes has long been suspected as a cause of decreased fertility, and the increased incidence of problems in offspring. There is now clear evidence. Not only does male smoking decrease the chance of conception, it also increases the risk of miscarriage in the partners of men who smoke. More recent

evidence also shows that women living in a smoking environment take longer to conceive due to the effect of passive smoking, and that there is an increased incidence of birth defects in their children.

Alcohol consumption in men also shows a correlation between the amount ingested and the chance of conception in both men and women, quite apart from its recognised effects in pregnancy.

So where does all this evidence leave us? Clearly, external influences such as smoking and alcohol are risk factors to avoid.

Being either overweight or underweight is undesirable and may affect the offspring, and certainly being overweight in men will reduce the chance of conception, and is probably associated with an increase in congenital abnormalities in their children.

The influence of particular types of diet is likely to become much clearer in the next few years.

Our desire to do our best will probably mean that we continue to consume large amounts of unnecessary supplements, but it may take some time until we are sure they are really safe.

The goal of healthy sperm and healthy eggs is one which we are still some way away from achieving. We should change those factors we can, steer away from dietary extremes and eat as healthily as possible. We should not allow ourselves to overmedicate with unproven supplements until we can be more certain that they are truly beneficial, but embrace those such as folic acid which we are sure can be.

Getting pregnant need not be a military exercise, but careful planning is likely to lead to the best outcome for our children. â—?

OHbaby! Fertility Associates Exclusive | 13

the amazing race Heroic distances, daunting obstacles and fierce competition — the conception journey defies the odds. In fact, as Dr Andrew Murray explains, it’s a miracle any of us are here at all.

In my role as a fertility specialist, I suppose I get quite a skewed view of the world when it comes to conception and pregnancy.

From the moment we are taught about the birds and the bees, then especially around subsequent first brushes with sexuality, we are often made to feel terrified about the possibility of an unwanted pregnancy. It all seems so risky!

By the time couples come to see me they are often startled by the statistics relating to fertility. One in five couples experience infertility (no conception after 12 months of unprotected intercourse) and the well-worn phrase ‘biological clock’ is at the forefront of their minds. Even so, knowledge of the odds of successful conception is not high. The chance of conceiving a baby per month at age 35 is about 15%, by 40 it’s around 5%, and by 45 only 1%.

man versus wild When you examine on a microscopic level what actually has to go right, it amazes me any of us are here at all! The following is

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a description of the incredible journey that is conception.

To tell this story, imagine that instead of sperm we have millions of tiny Bear Grylls. If we could enlarge a sperm to the actual life size of Bear Grylls, the distance he would have to swim is roughly equivalent to the width of the Atlantic Ocean. Not only that, but he’d only have 12 to 24 hours to find his prize, the egg, as that is how long the egg will survive unless it is fertilised.

The journey is not only a matter of distance. There are many obstacles to overcome. Sperm like an alkaline environment, so ejaculatory fluid has a high pH. From the moment of ejaculation they are being dropped off into hostile territory. The vagina is acidic, so almost immediately a fair number of our adventurers are taken out of the equation by low vaginal pH. Most of the time the cervix is not particularly receptive to any invaders including sperm, so the cervical secretions are often thick and tacky and act as a barrier. However, as oestrogen levels start to rise, and during the middle of her cycle when a woman ovulates (releases her egg), the cervical secretions become

thinner and stretchy. It is almost like they send down little mucous ropes for the sperm to swim up. For a brief period of time, the doors to the cervix are open.

wipeout So perhaps, out of the initial several million Bear Gryllses who set out on this race, a few thousand make their way into the cervical canal. The cervical canal is a formidable place. There are blind alleys and crypts all the way along and it is lined by white blood cells ready to repel any invaders. I imagine it must be a little like one of those initiation ceremonies at American universities, where the bullies form a line with the newbies running through the gauntlet.

Those sperm that make it through the cervical canal and into the uterus now number in the hundreds. Within the uterus itself are further white blood cells to dodge. Most women have two ‘exits’ for the sperm, a left and right tubal ostium – that is where the fallopian tubes join the uterus. So it’s now a 50/50 chance, does he go left or right? Which one might the egg be in? Half of the survivors so far are doomed to find no egg.

Once in the fallopian tube we are now talking about tens of sperm. In the meantime, what is happening at the other end of the ‘reproductive gauntlet’?

If we could enlarge a sperm to the actual life size of Bear Grylls, the distance he would have to swim is roughly equivalent to the width of the Atlantic Ocean.

the numbers game In the ovaries, from even before a female is born, are all the eggs she will ever have. There are about eight million when an unborn baby girl is at 28 weeks gestation, but by the time she is born, there are about one to two million. By puberty – 400,000 and by age 35 around 25,000 eggs remain. This loss of eggs is due to a normal process called apoptosis. Without it cells become immortal and keep dividing and eggs just happen to be very good at apoptosis.

Of the surviving eggs, each month just before a woman’s period, the next wave of eggs are called up for duty. On average 10-12 are recruited. The message to get ready is by no means a simple one. Like a CEO sending out memos to the staff, the pituitary gland residing in the brain sends out messages in the form of the hormone FSH (follicle stimulating hormone), which makes its way to the ovaries. Within the ovaries are tiny containers called follicles each containing an egg, along with some support cells. The follicles have receptors on their surface for FSH, and start to grow in response to this signal.

Think of the follicles, all lined up like athletes at the beginning of the 110 metre hurdles; they all start off running hard, but only one can cross first. It’s the same way inside the ovary, one of the

follicles establishes dominance, and provided there is a normal hormonal balance, will go on to release its egg.

Once released, the egg will hopefully be swept up by the ends of the fallopian tube. These are quite pretty structures, the ends look a lot like a sea anemone. The egg is transported along the fallopian tube wall on tiny structures called cillia. These are like little bristles that move the egg along on what is really a fantastically organised biological escalator.

Now, the egg is not sitting there in the nude. It is surrounded by a cloak of cells called the cumulus that provide important chemical signals for the sperm and egg. Once the egg is found by the sperm they all race to get through the cloak to their prize underneath. Several try, but only one can win.

line honours Once the ‘winner’ has penetrated the outer layer of the egg shell a unique reaction occurs hardening the egg shell so that no other sperm can get through. In the meantime the sperm releases its genetic information to subsequently be combined with that of the egg.

This is the part that amazes me. When you think of the millions of pieces of genetic code that combine to form the genes which in turn give instructions for the cells in our bodies, it is incredible that two distinctly separate individuals can have these combined and the information not get scrambled up. Of course, quite often critical pieces of information are either copied incorrectly, inappropriately duplicated, or missed out altogether.

This is why even though fertility treatment might assist in getting the egg and sperm together, what happens next is still up to nature. If the information is bad, the subsequent embryo will either fail to implant, or more commonly miscarry. As women get older the number of eggs in the ovaries with pre-existing genetic abnormalities is increasing, which is why it gets harder to conceive as the years pass.

The fertilised egg then starts to divide roughly 20 hours later, initially two cells, then four, then eight by day three, and so on. By day five it will hold over 250 cells, and is now known as a blastocyst.

Whilst all this is going on the uterus itself has been busy. In the first half of the menstrual cycle, the lining of the uterus (endometrium) has been thickening up – basically making a nice soft bed for the embryo to implant on to. After ovulation, during the time the egg and sperm are hopefully finding each other in the fallopian tube, the ovary produces progesterone. This stops the lining getting too thick, but also encourages changes within the lining in preparation for the embryo. The endometrium becomes enriched with nutrients and also forms welcoming receptors on its surface for the embryo to attach to. These receptors act like anchors, and are only on show for about 18 hours, so it’s critical they’re displayed at the correct time when the blastocyst finally makes it to the uterus. Once attached the blastocyst establishes a blood supply with the endometrium and begins developing into a foetus. The next 40 weeks are another story…

It is amazing that all of this happens in just five days. It really is a beautifully intricate system and it’s awe inspiring to be involved in an area of medicine where we get to observe some of these processes outside of the body. ●

OHbaby! Fertility Associates Exclusive | 15

MALE INFERTILITY Infertility isn’t only a female problem – men are affected as well as Dr Richard Fisher explains

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or many years, a lack of scientific information and some cultural factors in our society led to the assumption that almost all infertility is likely to be associated with a female problem. In some societies today, this assumption is still the norm, but it is an assumption made on the culture of men’s dominant roles, rather than the facts and the available science.

To be fair, even in western societies now considered to be more enlightened about the roles of various factors in infertility, it has only been in the past 10-20 years or so that a better understanding of the subtleties of sperm production and function has provided a more scientific basis to the acceptance that 'male factors' are now involved in the cause of infertility in at least 50% of couples presenting with infertility.

The absence of sperm in some men’s ejaculate (known as azoospermia) has been recognised for 150 years.

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The treatment of male-based infertility by the use of donor insemination was first described in medical literature in the 1880s. Although this was initially greeted with much moral outrage, the use of donor insemination became established in the middle part of the 20th century. It is an integral part of the treatment of infertility, and, by the late 1970s, was practised widely throughout the world.

Initially, donors were anonymous, and, sadly at times, no records were kept of whom the men were, much to the regret of many of the consequent children who would now dearly like to know their biological background.

Careful, identifiable record-keeping began in New Zealand in the early 1980s and has now become the norm in most countries in the western world. The initial decision to use anonymous donors was made at the time, in what was thought to be the best interests of all concerned.

Today, there are very few men who cannot at least attempt to conceive using IVF or ICSI.

But, like anonymous adoption, it has proved to be a major frustration to many families and children. The move from anonymity to identification has changed the environment in which donor insemination is practised. Donors are now more often men with families of their own, and the use of personally recruited donors, with the formal process of insemination within an infertility clinic, is much more common.

Sperm counts (concentration) have been diminishing steadily over the past 30 years. At Fertility Associates, the concentration of sperm and its activity (motility) have steadily declined over the past 20 years. Whether this reduction in total numbers of sperm has yet reached a point where it is affecting fertility rates in the general population is not yet clear. Certainly anecdotally, there appears to be an increasing number of partnerships in which male-factor infertility is playing a significant role.

The use of intra-uterine insemination to make up for the reduced number of sperm in the original ejaculate is now a common approach to enhancing a couple’s fertility. Roughly 20,000,000 sperm/ml is needed to be deposited in the vagina at intercourse for conception to occur.

If however, we can recruit 1,000,000 motile sperm from the ejaculate and place it in the uterus, then the chance of conception each month is greatly enhanced, if the initial specimen was of low concentration or motility. The introduction of this technique, especially in the presence of additional eggs (stimulated from the woman’s ovaries), has allowed many couples to conceive who otherwise would not have.

The greatest change for couples with male-based infertility came about in the early 1990s. A serendipitous finding during experimental treatment in Belgium led to the introduction of intracytoplasmic sperm injection (ICSI), where individual sperm can now be injected into an individual mature egg retrieved after ovarian stimulation during the process of IVF and embryo transfer.

Instead of relying on natural fertilisation by lying the eggs and sperm next to each other, ICSI ensures that if there are only a few sperm present, the chance of fertilisation can be maximised.

Using ICSI, then, one only needs as many sperm as eggs present — though, like all relationships, it is nice to have a few to choose from.

For many couples, IVF and ICSI has proved a very successful method of conception using their own gametes (eggs or sperm) and, even in men where there are no sperm in the ejaculate at all, a mature sperm can be found in the testicular tissue or the collecting ducts around the testes (not as difficult or as painful as it sounds to nearly all men).

Today, there are very few men who cannot at least attempt to conceive using IVF or ICSI. One of the groups in men for whom IVF and ICSI is now proving helpful, is in men with failed vasectomy

reversals or when vasectomy reversal is not possible or chosen.

In the not-too-distant future, it may well be possible to produce sperm-type cells from ordinary human cells. Consequently, all men may have the possibility of conception using their own genetic material.

At present, there is no clearly proven drug treatment for the vast majority of men who present with infertility. Some men with hormone (endocrine) problems can be treated with injections of artificial hormones. This is only a small number.

Recently, there has been renewed interest in the use of oral antioxidants, in specific groups of men with diminished sperm count or function.

In a small study from Australia, a group of men who required ICSI for fertilisation had better pregnancy rates following ingestion of a specific antioxidant rather than the group who did not.

Further studies are awaited to confirm this finding and to see if a wider use of antioxidants might make a difference to the underlying fertility of men with reduced, but not necessarily markedly reduced, sperm counts or motility.

Sperm take around 90 days for their journey from their earliest form to maturity, so any treatment is likely to have to be taken for much of the time of this process.

Antioxidants such as vitamins A, C and E are found in many fruits and vegetables, including prunes, raisins, berries, oranges and kiwifruit. Spinach, sprouts and beets are also well endowed with them. Whether taking antioxidants in tablet forms is as effective in food is not yet known, although antioxidants are becoming more widely used in other aspects of disease such as arthritis, heart disease and prostate health. Micro-nutrients such as zinc, copper and selenium are also powerful antioxidants.

Emergence of male factors as being important in fertility is probably due to an increased ability of science to detect subtle abnormalities previously unrecognised rather than the emergence of a new problem. Evidence from animal models about the effect of environmental influences, such as oestrogen and evidence in humans of an increase of genital-tract abnormalities, suggest, however, that there may well be an increasing environmental influence on sperm production and function.

The next few years will be interesting in the diagnosis and treatment of male-based infertility as this sort of information becomes clearer. ●

FACT FILE DID YOU KNOW? Sperm: Normal values in 1.5-5ml Concentration: 15,000,000/ml Motility: >40% Morphology: >5% Values differ between laboratories and in general, laboratories associated with infertility clinics have much stricter criteria about normality.

Most men produce around 80,000,000 sperm per day.

This is around 1200 sperm per heartbeat. No wonder men feel tired and watch lots of TV!

OHbaby! Fertility Associates Exclusive | 17

conceiving medical miracles In vitro fertilisation (IVF) has been changing lives for 30 years, and the process itself has changed too. What was once rare and complicated is now mainstream practice. Dr Richard Fisher explains how medical developments over the past three decades now mean even more couples are seeing their dream of parenthood fulfilled.

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his year marks the 33rd anniversary of the first child being born as a result of in vitro fertilisation (IVF) and embryo transfer. It is also 28 years since IVF began in New Zealand. Approximately 1% of all children born in New Zealand this year will be conceived by the process of IVF, and in some parts of the world, such as Denmark, the statistic will be around 5%. What was 30 years ago an extraordinary marriage of professional commitment and technical skill is now a much more mainstream process, comfortably integrated into modern healthcare.

history of IVF Initially, IVF was seen as a method of bypassing damaged Fallopian tubes. Women who could not conceive because their Fallopian tubes were blocked or severely damaged could use the technology to create embryos outside the body and to reimplant them inside the uterus without using the Fallopian tubes. Today, IVF has much wider uses than this, and nearly all forms of sub-fertility can potentially be treated by using IVF and embryo transfer.

In the early days, a 5% chance of having a baby was considered an exciting prospect for many couples, but, fortunately, these rates have improved significantly and now only those in their mid-40s remain with

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such a low success rate. Women under 35 have as good a chance as 50% of having a baby from a single cycle of IVF. In the past 30 years, the process of IVF has simplified greatly, both for those having the treatment and those involved in delivering it. New drugs are now available which can control when ovulation occurs, so it is no longer necessary to do egg retrievals very late at night. Also, current protocols for stimulating the ovaries allow us to obtain more eggs than we used to. It was not uncommon in the early 1980s to obtain only one or two eggs and, consequently, have no embryos to replace. The use of newer and different drugs has made the process of ovarian stimulation much more controllable and more successful.

the process The process of IVF and embryo transfer initially involves the stimulation of the ovaries to make more eggs than usual. In a normal menstrual cycle, only one egg is produced from a single mature follicle (a fluid-filled cystic structure which develops around the egg). Using injections of a follicle-stimulating hormone (FSH), the ovary can be stimulated to produce multiple follicles from which eggs can be obtained.

To ensure that the eggs are mature and available for retrieval at a reasonable time, two other drugs are used. One, which controls the pituitary gland’s ability to produce its own FSH and LH (luteinising hormone which triggers ovulation), and hCG, which is used to trigger ovulation in this artificial cycle. There are a myriad of different stimulation protocols available, none of which have proved significantly superior to any other, although in individuals a different protocol might be chosen because of that individual’s previous history.

What was 30 years ago an extraordinary marriage of professional commitment and technical skill is now a much more mainstream process, comfortably integrated into modern healthcare.

In the early 1980s, eggs were retrieved laproscopically, a procedure requiring general anaesthesia and what is now commonly known as keyhole surgery. With the advent of ultrasound and the development of transvaginal ultrasound probes, egg retrieval is now invariably done under sedation and ultrasound control by passing a needle through the top of the vagina into the developing follicles and aspirating the fluid from within them.

Eggs can be obtained from around 60-70% of follicles.

Most of these eggs will be mature, but some will be immature and not suitable for fertilisation.

fertilisation and transfer Once eggs are available, they will be fertilised in one of two ways.

In circumstances where sperm quality appears satisfactory, then the eggs and sperm are laid next to each other in small dishes in the laboratory and fertilisation occurs as it does in nature. Where sperm quality is doubtful, sperm injection occurs, with individual sperm being picked up and injected into the cytoplasm of the egg.

Around 70% of eggs become fertilised, although this does vary from couple to couple. Initially, fertilisation is seen as the presence of two nuclei inside a single cell and, over the next two days, these embryos will divide into two, four, and eight cells. Embryos that have divided into eight cells are most commonly replaced into the uterus.

Whereas multiple embryos were transferred in the past, with the improvement in implantation rates (that is, the chance of a single embryo implanting on replacement), there has been a move towards single embryo transfer in younger women.

As a consequence of this, other embryos that are considered to have good potential for implantation themselves are available for freezing. The embryo, or embryos, being replaced are placed within the uterus, through the cervix, in a fine catheter under ultrasound control. Although embryo quality is likely to be the prime determinate of success, new techniques such as ultrasoundguided replacement have improved pregnancy rates further.

On occasion, embryos are replaced five days after fertilisation as blastocysts. If an embryo can get to the blastocyst stage in culture, this is further proof of its high chance of implantation. It doesn’t make embryos previously seen at eight cells any better, but just helps us select which are the best. Consequently, when there are a large number of embryos available on Day Three with a seemingly good chance of success, embryos can be grown on to Day Five so we can be even more selective about which embryos to replace. In

good laboratories, there is little risk in growing embryos these extra two days. Embryos can also be frozen at this stage.

Technology such as Time Lapse Imaging TiMI takes video footage from fertilisation to the 5th day of embryo development, identifying embryos with the best prognosis to then be transferred.

risks and side effects IVF, like all medical treatments, is not without risk and side effects.

The drugs used can cause mood swings and commonly a feeling of tiredness. Even though egg collection is normally done under sedation, some pain can be felt at the time of the egg collection, but most people find this quite acceptable.

After egg collection, there are risks of infection and bleeding, although both are very rare. The most significant risk is the development of a problem called ovarian hyperstimulation syndrome, which occurs in about 2-3% of women having treatment.

Untreated, severe OHSS can cause blood clots, stroke and even death. While these risks are small, it is important to recognise that they exist. Mostly ovarian hyperstimulation syndrome can be managed as an outpatient, although around 1% of women may need to be admitted to hospital.

Children born following IVF are being followed up in a number of centres around the world. The chance of congenital abnormalities in children is about a third higher than that for children conceived naturally. This means a chance of around four per 100 births instead of three per 100 births. There might be a slightly higher rate of chromosomal abnormality in children conceived using ICSI. The chance of abnormalities such as Down’s Syndrome is the same in IVF and ICSI pregnancies as it is in the general population. No one is sure as to whether this increase in congenital abnormality is associated with the process of IVF, or with an underlying cause of infertility. There are a few very rare diseases that seem to occur more commonly following IVF and Intracytoplasmic Sperm Injection (ICSI). The incidence following IVF is still around one in 2000.

For many couples, using IVF as their primary treatment is a much more sensible option than serial treatments with procedures that have a low chance of success. In the end, individual couples need to make their own decisions about what treatment is suitable for them or not. However, not conceiving following simple treatment feels every bit as bad as not conceiving after more complex ones.

In New Zealand, access to publicly funded IVF is limited. Couples who have a very poor chance of success by themselves are eligible for treatment earlier than those who appear to have a higher chance. Most people will be eligible in time, providing they meet criteria that are also based around age, weight and smoking status.

Although initially these criteria can sometimes appear unfair, they are based on maximising positive outcomes. Women who smoke, or who have a BMI of more than 32, have a significantly smaller chance of success than those who don‘t smoke or those carrying less weight. Waiting lists vary in different parts of the country, but providing the eligibility criteria are met, treatment can usually be started within one year. ● To work out your chance of conceiving monthly visit our online biological clock at fertilityassociates.co.nz.

OHbaby! Fertility Associates Exclusive | 19

THE GENE FACTOR In the world of assisted reproduction, nothing is black-and-white. Dr Richard Fisher explores the grey areas surrounding the ethics of egg and sperm donation.

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hat is it about our own genes that we find so important? Why is it that we value passing on our genes so highly? I am sure there is a myriad of sociological research which gives us some ideas, but I doubt that there is any real clarity about it.

Maybe it is just that we have been socialised to believe it is important, or that it really is important for us to pass on some traits that allow us to better relate to our children.

Somehow I doubt this too. Ask most people what they would do if they found out that one of their children was not genetically theirs, and the usual response is that it would make no difference to the way they viewed them as individuals, even though it might raise some other more distinctly uncomfortable questions.

The power of being the nurturer to one’s children or grandchildren appears at first glance to be much greater than the power of the genetic attachment. Or is it?

It is certainly difficult to disentangle the emotions involved with disputed paternity and its effect on relationships between the involved adults, or the abject confusion that occurs after the rare but recognised 'swapped at birth' scenario. I cannot for one moment imagine that my feelings about my children would in any way be altered given the emotional investment I have in them and them in me. There is, however, no denying that where there has been a considered choice for procreation, the genetic investment is important as well.

I cannot remember a 'swapped at birth' scenario where enormous emotional stress did not occur for all the participants.

In my experience at Fertility Associates, the commitment to procreate seems to be stronger universally than the necessity of a genetic attachment, and the genetic attachment is only as strong as the original wish to procreate at all.

The issue that raises these questions in my mind is my involvement with couples who use donor eggs and sperm in treatment. The use of donor eggs and sperm in a formalised arrangement, supported by good counselling services and a well-informed family, is an increasingly common — and successful — resolution of the desire to have a child whom one can conceive, grow, deliver, and nurture, and, consequently, confront all the challenges that parents universally face.

The use of donor sperm has, of course, been around for more than a century; donor eggs have been available only since the advent of IVF and the development of techniques by which menstrual cycles could be synchronised for embryo replacement. As in all sociological phenomena, it has been a significant learning curve.

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If you would like to consider being a donor, start by looking at the information on the Fertility Associates website www.fertilityassociates.co.nz or call 0800 255 522 and talk to either the Donor Sperm or Donor Egg Co-ordinator at any of our clinics.

Fortunately, the long history of donor insemination has made the introduction of the use of donor eggs much more comfortable.

The socialisation of gamete donation, with increasing openness between the participants, has been in response to a difficult prior century in which secrecy with the use of donor sperm was dominant. Up until the early 1980s in New Zealand, the use of anonymous donors met the needs of the recipient couples to have a source of sperm, though little thought was given to the long term interests of the child or the donor.

Today, children conceived from the use of donor eggs or sperm have a right of access to genetic information about their biological parents. Donors also have a say as to whom they might donate their sperm. An increasing number of donors of both eggs and sperm are personal donors recruited by the recipient couple.

Two pieces of legislation have brought New Zealand towards a position to lead the world in ensuring that subsequent children’s rights are protected. The Status of Children Amendment Act in 1987 defined quite clearly who the parents of children were, and ensured that any donor was not legally liable for support, providing that appropriate consent had been obtained. The Human Assisted Reproductive Technology Act (HART) 2004 legislates for information about biological parenthood to be available to children conceived from donor gametes. This legal clarity has led to more comfort rather than less comfort with the use of donor gametes, even though potential identification of donors may have limited the donor pool.

One could argue that never disclosing their genetic origin to children might equally be protective, given my previous

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comments about nurturing and the emotional comfort of families. However, the issue of secrets in families was well learned in earlier adoption practices, and the harm that these secrets caused is well recognised.

Various studies worldwide over the last 30 years have suggested that as many as 3-15% of children may not be of the parentage that they think they are (and they are usually pretty sure who their mother is). The data from which this information is gathered is still hotly debated, but even if one takes the least estimate of 3%, it still equates to around 1,800 children per year in New Zealand. We should be careful not to unnecessarily legislate for infertile couples and their children what we do not insist upon for those fortunate enough (or silly enough) to be able to conceive by themselves.

Who, then, gets to use donor gametes? About 5% of men have sperm counts or function which will severely limit their chances of fathering a child. Given time, some will succeed, but a significant number will attend an infertility clinic with their partners for help.

With the advent of advanced techniques in reproductive technology involving the injection of single sperm into eggs, very few of these men will not be able to attempt conception in combination with IVF with their own sperm, and as a group, 'male factor' IVF couples do very well.

In the small group of men with no sperm, donor insemination is a clear option. The chance of success with donor insemination in an otherwise normally fertile woman is only a little reduced from natural conception. The requirement to store sperm in its frozen state prior to use hardly diminishes its ability to fertilise in vitro.

It is unusual today for couples to proceed to donor insemination

as an initial choice where sperm is present, although for some other groups it is their only option. Single women and lesbian couples now make up around 70% of women being treated with donor insemination. Although using donor insemination for conception in this circumstance sometimes generates quite a lot of heated discussion, it is seldom heat based on objective evidence.

Donor-conceived children brought up in lesbian relationships develop socially very similarly to those brought up in heterosexual ones. A major advantage for single women and lesbian couples is that they have to choose to conceive rather than do so accidentally, so a child is planned for in an environment in which its needs and long-term care are carefully considered. It is common in both of these groups of women for plans to be made for men to play a significant role in their children’s upbringing.

The use of donor eggs for the treatment of infertility in women has shown a significant increase over the last decade. About 3% of women will have menopause prior to age 37 and their fertility is reduced in the decade prior to this. For them, there is a clear medical indication.

Although the risks of physical injury are small, as are the side effects, an egg donor does have to undergo an IVF cycle. It says much for the altruism of women that finding egg donors is currently easier than finding sperm donors.

The larger group of women now using donor eggs, however, are women who, through various circumstances, have found themselves later in their reproductive life cycle than they would choose before trying to conceive, and then finding out that they have only limited numbers of eggs or eggs that no longer function normally. Most of these women are in their late thirties and early forties where, if nature had been kinder to them, they might have reasonably expected to be able to conceive naturally. They are unlucky enough, however, to find themselves in a position where their reproductive capacity is foreshortened by either a physiological accident and/or social circumstances.

Recent research in both Australia and New Zealand has shown that one of the major causes of delay in women attempting to conceive is not an underlying desire to delay because of financial or professional reasons, but simply because a desirable partner did not appear until later.

By this time, although their brain and body are willing, their ovaries are less so. Reproduction is not very different from anything else in biology. Not everyone has the same reproductive lifespan, just like not everyone is the same height or weight.

Discussions about the use of donor gametes are often

characterised by initial feelings of discomfort, but when this debate is personalised, about someone you know and care about, then many peoples’ views change quite quickly. The desire to have children seems to be a powerful biological one and although a few couples choose to be child-free, this remains very much a minority position.

Having made the choice to conceive, the denial of that choice, regardless of the cause, is a devastating experience. The use of donor gametes is part of the armamentarium available to overcome that denial of choice.

So who are donors and how are they recruited? Traditionally, worldwide donors of sperm were anonymous donors, often young and usually uninformed. Today they are more likely to be between 25 and 40 and have children of their own. They also often have contact with other couples troubled by infertility and understand both the difficulties faced by them, and the joys they themselves have in having children.

The move from anonymous donors has also led to more personal or known donors who are recruited from among family or friends.

Our advice to couples seeking to recruit in this way is always to seek advice from our counsellors first. One does not want to fundamentally change the basis of one’s relationship with friends or relatives by asking for their help in a way which leads to discomfort and the subsequent break down of that relationship.

Some men respond to advertisements, either placed by recipient couples through one of the Reproductive Medicine Clinics, or by the Clinics themselves to endeavour to increase the number of men available as donors. Once again, these men are usually motivated by the desire to be of help to someone else in need. As donors, they can write clear guidelines as to what sort of couple or people they want their donor sperm used for and those for which they would not.

Sperm donors are currently more difficult to find than egg donors, despite the fact that it is difficult to injure yourself collecting sperm!

Although the risks of physical injury are small, as are the side effects, an egg donor does have to undergo an IVF cycle. It says much for the altruism of women that finding egg donors is currently easier than finding sperm donors.

To return to my discussion in my first paragraph about whether genes really matter, it does seem that we all like to pass on our genes. What I am not so sure about, however, is why? My experience with couples using donor gametes, and their subsequent children, gives me confidence that although it may be desirable, it is by no means essential. For couples using donor sperm or donor eggs, they matter in that they cannot provide some of their own, but they diminish not one jot the love and affection they provide to their subsequent children. Being a donor of eggs or sperm makes you a special person indeed.

The demands for donor eggs and sperm remain high, with significant waiting lists for both procedures currently. Donations in New Zealand are all altruistic. No payment is made for either eggs or sperm. The view expressed by New Zealand legislation is that there are some things in life that are too precious to charge for, and the rewards are too great to quantify. In the US and some European jurisdictions, payment for donations is the norm, and little evidence is available so far that this will prove harmful.

What donors mean to recipients is seen weekly in our clinics with the arrival of new life, new love and new happiness. ●

OHbaby! Fertility Associates Exclusive | 23

can you choose your baby’s gender?

The miracle of conception can be quite well organised, thanks to an increase in knowledge since our parents’ generation. We can attempt to organise birth dates and times, but what influence can parents have over gender? Dr Richard Fisher explains the practical and ethical minefield surrounding gender selection.

T

he ability humans have to reproduce is often as much a product of chance as of planning. The desire to plan conception has led to an increased knowledge about the best times in the menstrual cycle for intercourse to occur. Like all human endeavours, however, we often seek to influence not just the absolutes such as conception, and for many people, trying to influence the gender of their potential baby becomes an important goal as well. Despite the fact that giving advice to enable someone to do this, or to perform a procedure that would ensure it, is illegal in New Zealand, it remains a common query from patients attending reproductive medicine clinics.

The 2004 Human Assisted Reproductive Technologies Act states that “it is illegal for reproductive purposes to select an in vitro embryo on the basis of sex or to perform any procedure, or provide, prescribe or administer anything in order to increase the probability, that a human embryo will be of a particular sex”.

There is a defence to a charge under this section, however, and that is that if the gender selection is performed to prevent or treat a genetic disorder or disease. There are some genetic diseases which occur only in males and consequently this may be a rational approach to limiting the likelihood of the presence of this disease in a particular family, although in time, as technology improves, the particular mutation will more commonly be able to be assessed and the rather blunt instrument of gender won’t be needed.

Ethical viewpoints and standards vary between communities so it is probably no surprise that this prohibition of gender selection is not universal. Although the United Kingdom and most of the rest of Europe prohibit gender selection, it is an acceptable use of technology in countries such as the United States, Russia, Thailand and a number of other Asian countries. Israel allows the use of gender selection for family balancing where couples may already have a number of children of a particular gender and wish for a further child of a different gender. Clearly there is no single ethical answer to the issue and New Zealand has fallen back on a legal one.

The arguments for and against gender selection have become more polarised since our ability to attain the goal has improved. It seems that our community (through its representatives in Parliament) is tolerant of attempts to choose a child of one gender or the other when the likelihood is not certain.

There has been no objection to couples attempting to influence the gender of their child in many ways for centuries. It is an interesting

24 | OHbaby! Fertility Associates Exclusive

philosophical point as to when any particular community might decide to move to proscribe gender selection in the continuum of random chance to 100% certainty. The basic underlying ethical issue, to seek to alter the gender, has not changed. Only our ability to do so with accuracy has.

The penalty for breaking the law in New Zealand is imprisonment of up to one year or a fine not exceeding $100,000, or both. The law is carefully written as "no person may" rather than “no doctor or clinic”, so one might presume that even passing on information in the form of a book might place one at risk.

The history of attempts at gender selection is long. The ancient Greeks apparently advised that men who wanted a boy should lie on their right side. In 18th century France, it was suggested that men tied off their left testis, as this was thought to be the source of femalebearing sperm, if one wished to create a baby boy. More recently, American folk history suggested that for men to have a son they should wear their work boots to bed; also that they should get drunk before intercourse, or that they should take an axe to bed. Hanging one’s pants on the right bedpost was also thought to alter the gender balance to boys. I’m not sure whether each of these things were to be done separately or together but either way, they all sound unlikely to be tolerated by a modern woman.

Advice to women seeking a son was that they should eat red meat, they too should lie on their right side (the ancient Greeks might have found this complicated), or alternatively pinch their husband’s right testis. Although all the above suggestions can be dismissed as having no scientific basis, nor evidence of success, it did not stop a surge of activity in the quest for natural gender selection late in the 20th century.

There exists a Chinese gender chart, touted to have been found in a tomb 700 years ago and now available for a small fee, which purports to give you up to a 90% chance of conceiving the desired gender based on the days of the month and the status of the moon, but sadly once again there is no evidence at all that this is effective.

The best known name in natural gender selection methods is Landrum Shettles, a scientist turned doctor who published a book How to Choose the Sex of Your Baby in the 1970s. This book sold well over a million copies and was bedtime reading for thousands of couples. Shettles turned some plausible biology about the size, longevity, and speed of X- and Y-bearing sperm into practical advice about how to change the gender balance.

Shettles noticed that male sperm were smaller, moved faster, and were less long-lived than X-bearing sperm, which were also larger and slower. He believed that by having intercourse at the time of ovulation, the male sperm would get to the egg quicker and that fertilisation with a Y-bearing sperm was more likely to occur.

He dressed up the basic concept with further pseudo-science, which included that women should have an orgasm at the same time as their partner as this increased the amount of alkaline secretion present, supposedly also favourable to the Y-chromosome. He thought that if you could deliver the sperm closer to the egg then that would also enhance the conception of a male child and so advised deep penetration at intercourse as well.

Shettles’ book continues to sell internationally. Whether in the misguided belief that the theory is true, or whether it adds interest to an otherwise recreational pursuit, one cannot tell — but there have now been numerous studies which have refuted this theory.

Among those is a study carried out at National Women’s Hospital by my colleague Dr Freddie Graham and his colleague Dr John France. Their data clearly refuted Shettles, and in their study, most conceptions that occurred early turned out to be boys.

A woman reading this paper further went on to interpret that the pregnancies that appeared to occur after ovulation were girls, and so grew another internet group, which went under the name of “O+12” (ovulation plus 12 hours). Once again, there is no statistical significance in this information, and the original paper and the perceived outcome became yet another myth about gender selection.

It is of interest that a natural family planning study, of which New Zealand was a participant in the late 1990s, showed that almost no conceptions occurred when intercourse took place after ovulation and that all these previous studies are limited in their statistical significance by the difficulty in accurately determining when ovulation occurred. Shettles went on to be part of a major ethical scandal in the United States regarding early research around IVF without ethical consent and with little scientific rigour.

A Dr Ericisson described a technique for separating X and Y bearing sperm by centrifuging sperm through various gradients to enrich concentrations of each. A number of clinics sprung up worldwide which exploited his initial claims to success until such time as a number of other authors failed to confirm his findings. It is quite clear that this technique alters only fractionally the gender balance.

More recently, a more scientific and now patented technique of sperm separation has been developed in the United States. It is marketed under the name of Microsort. Sperm is passed through a cell sorting system after having been labelled with a luminescent dye, which then separates it into X-enriched and Y-enriched pools using a laser beam that recognises volume differences.

The technique is still being evaluated in a research protocol but current results after inseminating this enriched sperm show that it is about 90% successful for girls and 75% for boys. This technique requires normal sperm concentrations and is both complex and expensive. It is, of course, possible that success rates for both genders will improve in time as the technology improves, although it is unlikely to be 100%.

Gender selection using the technique of preimplantation genetics in combination with IVF has made it possible to be almost certain of the embryo’s gender. This means that in people with sex-linked disorders, only embryos of the desired gender can be replaced and future disability avoided. It also means, however, that the social use of this technology has become available in some countries.

The process of IVF, of course, requires the injection of drugs,

development of more eggs than usual, the physical collection of these eggs and fertilisation in the laboratory. It is possible to use microsorted sperm to increase the number of embryos of the desired gender but the step beyond this occurs when a single cell is removed from the embryo on the third day of development (when there are about eight cells present) and this cell is tested to determine the gender.

This can be done with minimal effect on the embryo. Embryos of the desired sex are then replaced inside the uterus.

Like all IVF, this is not a risk-free process, and neither is it a guarantee of conception, although if conception occurs, the gender is almost certain. IVF success rates vary from around 50% in younger women to less than 10% in women 43 or older.

The decision to do IVF for social reasons surely requires a couple to have not only robust emotional resources but also a fervent desire to have a child of one gender or the other, given its cost. The use of IVF for such a purpose is hotly debated.

Along with the enthusiasm for Shettles and Ericsson came a number of theories about diet and dietary supplements. Stolkowski proferred the view that a diet high in potassium and sodium would more likely lead to having a boy, whereas supplements with calcium and magnesium would help the conception of girl. No clinical evidence is available to support this.

Douching with a lemon (I suspect in diluted form) was said to increase the likelihood of having a girl because of the change towards acidity in the vaginal secretions, and a number of books then followed looking at dietary supplements.

Some of the authors became wealthy; most of the couples were disappointed. The great advantage of gender as an outcome is that every suggestion has at least a 50% chance of being right and if you charge enough, even offering a money back guarantee if you are wrong is likely to lead to financial success.

There are some biological factors that are thought to increase the incidence of one gender over the other. The best example is in post-war Holland where, after the starvation and deprivation in the Second World War, there was a significant increase in males born in the immediate post-war period.

Whether this is evolutionary adaptation or one associated with underlying nutrition directly is currently not possible to discern. With increasing knowledge about the effect of nutrition in the time around conception, it may be that some rational scientific data will become available which will alter the gender balance.

Sex ratio — that is, the number of live males divided by the total number of births in a given period of time — is variable under many conditions. There remains a poor understanding of factors that alter this ratio, but there is evidence that external influences can be associated with such change.

Older mothers and fathers having IVF have been shown to produce more girls than boys. Currently there is no explanation available for this. In Holland in the 1980s there were more daughters born to men who worked with pesticides. Anaesthetists of both genders appeared to have more girls. There is certainly lots yet to be gleaned as to the causation of these changes.

Most people are uncomfortable about the primary use of gender selection for social reasons. Many of us can think of couples for whom having a child of a particular gender at a particular time of their reproductive career would have been nice. Whether “it would have been nice” is a good enough justification to embrace the technology is an international debate that will continue long into the future. ●

OHbaby! Fertility Associates Exclusive | 25

THE FUTURE OF FERTILITY TREATMENT A lot has happened in the world of fertility treatment since the first IVF baby was born 35 years ago. Dr Andrew Murray investigates what’s new and what to expect in the future.

O

ne of the exciting things about working in this particular area of medicine is the rapid pace in which technology evolves. It is amazing to think how far fertility medicine has advanced since the birth of the first IVF baby, Louise Brown, back in 1978.

The core ingredients to make a healthy baby have remained unchanged over time — eggs, sperm (which together make an embryo) and a womb (uterus) for the embryo to develop into a healthy baby.

Any advances in fertility treatment focus on these core ingredients in order to optimize the chances of success. Some of the latest developments are already here, whilst others will continue to be trialled and improved until they become mainstream. Here are some that we are seeing in our practice.

IMSI IMSI stands for Intra-cytoplasmic Morphologically Selected Sperm Injection. It is an advancement on the conventional ICSI, or Intracytoplasmic Sperm Injection. In ICSI sperm are selected at 200x magnification, which allows the embryologist to select sperm for egg injection based on the sperm’s movement and the shape of the sperm’s head.

IMSI is designed around recent advances in optics and computer enhancement of digital images. It’s similar to the difference in picture quality from traditional to high definition televisions. Newly designed lenses and microscope condensers allow 600x magnification, and then digital imaging boosts the effective magnification to 6000x.

This means embryologists can see the sperm head in a lot more detail and, in particular, features inside the sperm head which are thought to be associated with incorrect packaging of DNA. Poor packaging can make the sperm’s DNA more susceptible to oxidation damage, which in turn may be associated with lower pregnancy rates and possibly higher miscarriage rates.

time lapse photography During IVF embryos are normally cultured in an incubator for three to five days. Until recently the embryologist selected the best embryo to replace based on how it looked each day after fertilisation. This has a number of disadvantages.

First of all, to look at the embryo the incubator has to be opened, and the embryo disturbed at this very delicate time. Even subtle changes in the local environment (temperature, gas concentrations, pH, ultraviolet light) may have an impact on the quality of the embryo. Daily examination also only provides a snapshot of what the embryo is doing at that point in time.

Time lapse photography during IVF is when a camera is installed inside the incubator and takes a photo every few minutes. The images are run together to make a “movie” of the embryos as they develop.

New insights can be gained from watching the embryos develop.

For example, embryos that are slow to divide may have a higher rate of genetic abnormalities. Two embryos that may look the same on day five may have had very different pathways to get there. One may have a higher chance of making a baby based on how the cells were dividing in the preceding days.

Typically, using time lapse photography can reduce disturbance to the embryos, as the incubator lid can be kept shut whilst the cameras are rolling providing the very first 'home movies' of the

developing embryos. We can then observe the differences in development; these observations can then be used to select which embryo should be replaced.

pre-implantation genetic screening (PGS) In pre-implantation genetic screening, embryos created through IVF can be tested for either single gene problems such as cystic fibrosis, or screened for chromosomal abnormalities that may make miscarriage more likely. This isn’t new technology, but the costs are coming down and the reliability is improving to the point where one day PGS is likely to be applied whenever IVF is used.

The women most likely to benefit from this are those with recurrent miscarriages, and those trying to start their families later in life. As women get older the proportion of eggs with preexisting chromosomal abnormalities increases. Consequently for women over 35 at least 50% of the embryos created from their own eggs are likely to have chromosomal abnormalities. PGS means those embryos free of abnormalities can be selected.

Another group of women we are seeing more of are those who have found they are carriers of the breast cancer gene BRACA. Depending on the sub-type, the lifetime risk of those women developing breast cancer can be up to 80% and ovarian cancer 40%. These women have a 50% chance of passing the gene on to their children, so many choose to undergo PGS, even if they haven’t developed cancer themselves.

social egg freezing A topic we have been talking about lately is the biological clock and the need for couples to not 'leave it too late'. Women today are having babies later than ever before due to a number of factors, such as travel and education as well as busy careers or simply not yet finding the right partner.

Social egg freezing offers women the opportunity to lock in their potential for a baby. Clearly the younger you are when you freeze the eggs, the better. For example, the chances of having a baby naturally at age 30 is about 20% per month, but reduces to 5% per month by age 40. Some women do manage to conceive naturally, however we see many people in this age group who need fertility assistance.

How is it done? The same fertility drugs used in IVF are given (normally 10 days of daily injections) followed by an outpatient procedure, where the eggs are retrieved from the ovaries under sedation. The eggs can then be frozen for up to 10 years (the legal time limit for egg storage in New Zealand) and subsequently thawed when needed.

The earlier women can preserve their fertility the better their chances of pregnancy later in life. We suggest that women have the conversation with their GP and find out their fertility options, even if they are not ready to have a baby just yet.

What may have seemed pure fantasy in the past is already now reality. As with any new techniques in medicine it is important their safety is established before they are widely adopted. Incremental improvements add up over time. There have certainly been massive improvements in what can be done for fertility in the last three decades. ●

OHbaby! Fertility Associates Exclusive | 27

Have you checked your Biological Clock?

If your plans for the year ahead include starting a family, it’s best not to take your fertility for granted, because it doesn’t last forever.

But we can help you find out exactly where you stand, and right now might be the best time to do it.

It’s quick and simple to check. You can: • Pick up a paper version from our receptionists • Go online to www.biologicalclock.co.nz, or • Download the applet on your iPhone (search Fertility Associates)

When it comes to fertility, we understand CALL FOR A FREE NURSE CONSULATION 0800 255 522 www.biologicalclock.co.nz

FAQ Fertility Associates have been helping New Zealand parents for more than two decades. But many of the questions about fertility and treatment have not changed.

Q: Do I need a referral to see a fertility doctor?

A: I think it is important that your general practitioner is aware of what is happening in your healthcare. Having a referral often means your first consultation with some initial results will be more useful than it might otherwise have been. However many couples initially like to make an enquiry without involving their GP and self-refer, this can be done on our website or by phone. You should come armed with as much information about your health status as you can. At Fertility Associates it is our practice to seek your consent to send a copy of the letter we would normally write at the end of the consultation to your GP, to keep him or her informed.

Although couples often wish to keep fertility issues private, there may well come a time when the involvement of your GP is important.

Q: I would like twins. Can you help?

A: Fortunately, most women who conceive twins have normal outcomes. The incidence of miscarriage and premature labour, however, is considerably increased. The incidence of congenital abnormalities and the potential for long-term ill health is also increased. Conceiving twins by accident is an unavoidable risk which can usually be managed successfully. Conceiving twins by design is not something you should ever plan to do.

Q: I am 42 and have been trying to have a baby for two years. What are the options available to me?

A: As you get older, your chance of conception year by year, and month by month, declines significantly. At 42, your chance of having a baby is around 4% each

month. Although it is entirely possible you have not conceived yet by chance alone, it certainly is time you hadyour fertility assessed. You should ask your GP to refer you to a reproductive medicine specialist, where you will be given an assessment of your chance of conception as well as some suggestions about potential treatments.

With regard to age, my view is you should try to conceive as soon as you are able and certainly no later than your mid-thirties, if possible. If, however, you cannot start trying until much later, then you should present early for an assessment of your fertility and a discussion about options for potential treatments. Many women will still be able to achieve pregnancies in their early 40s, but you don’t want to leave it to chance.

This doesn’t mean you necessarily will need treatment, but a clear understanding about

OHbaby! Fertility Associates Exclusive | 29

options and when they might be appropriate would seem wise.

Traditionally, it was said that the definition of infertility was not conceiving after a year of unprotected intercourse.

I think this is a particularly stupid definition in a practical sense, because if you are young, then you should have conceived well before a year if everything was normal, and if you are older, you don’t have time to wait that long. If you want to look more closely at the effect of age on fertility, check out the Biological Clock at www.fertilityassociates. co.nz. This device tells you your chances of having a baby each month at any particular age, and our opinion about when you should seek advice about options in the future.

Q: I have a three-year-old and have been trying to get pregnant again for the past 18 months, without success.

What should I do?

A: Getting pregnant easily the first time sets you up for real disappointment and anxiety if it doesn’t happen quickly again.

Your previous pregnancy doesn’t really change the rules about when you should seek advice, as many things might limit your chance of conception (a man with a low sperm count is perhaps the most common).

If this is the case it is possible to have achieved conception by very good luck the first time and still not be pregnant after a long time of trying after that.

The decision about when to seek help or intervention shouldn’t really be different if you have already been pregnant. Fertility is all about chance. It’s important to understand how long 'normal' is because quick conception the first time doesn’t prove that you are very fertile. On average, it takes a 27-year-old about four to five months to conceive but a 37-year-old will take around eight to nine months. At age 40, only 60% of women will have conceived by the end of the year, and sadly, around 40% of these cases will miscarry.

Q: I am 42 and have had a vasectomy.

I now have a new partner who would like to have a child. What can I do?

A: Unfortunately, in the rush to become world leaders in vasectomy as permanent contraception, we in New Zealand seem to have forgotten that reproduction in second relationships is a very common desire. For 20 years, gynaecologists have taken great care in their counselling and advice to

30 | OHbaby! Fertility Associates Exclusive

women seeking permanent contraception, and the incidence of tubal ligation has declined markedly.

Sadly, it seems little thought goes into the counselling of men seeking vasectomy.

Neither tubal ligation nor vasectomy should be viewed as potentially reversible procedures, as outcomes are unpredictable.

It is very important that discussion on vasectomy reversal looks at the likely fertility of the new partner. It saddens me greatly to find couples coming to see me where a man has had a vasectomy reversal and his new partner has significant fertility issues which should have been recognised before the decision for reversal was made. Vasectomy reversal is not just an issue of plumbing. The length of time between vasectomy and reversal is an important factor in outcome, as is the method of original vasectomy. In my view, vasectomy should never be a 'walk in, walk out' procedure without consultation with both partners, and an enquiry as to the stability of that relationship. Fortunately, there is good non-permanent contraception available to most couples now, which means that permanent contraception should never take place under any sort of duress.

For many couples, IVF might be a better treatment, with a better chance of success in a shorter period of time, than vasectomy reversal. If a vasectomy reversal is chosen, an arrangement should be made to store sperm collected at the same time, just in case the reversal fails and IVF is necessary later.

A request for vasectomy reversal is a good example of how reproductive medicine often requires the skills of more than one person to make an assessment and to treat infertility, and why, in most circumstances, a fertility clinic is the best place for this to occur. Clinics have the resources of clinicians with a particular interest in this area, scientists who can assess sperm function and store it, and the availability of counsellors for those difficult decisions that need to be made.

Q: I am single and in my mid-thirties. Is there a way to assess my future fertility?

A: There are good tests to assess the number of eggs you have, but without more complex investigations, it is difficult to know what your chance of pregnancy would be.

The Anti-Mullerian Hormone (AMH) test can predict whether you are likely to continue

to ovulate for as long as most other women, and therefore be in with a chance at least.

This test is currently not funded and is available only in main centres.

It’s a useful test, however, for younger women who are thinking of deferring conception for some time. If the AMH is low (fewer eggs than you would expect), then it can perhaps alter the time in which you might think getting pregnant is sensible. It is not much use getting your life organised both professionally and socially, and then finding that you are in the unfortunate position of having many fewer eggs than you would expect. The prospect of freezing eggs in younger women is now a real option, but I don’t think it should be undertaken lightly on the off-chance that there might be a problem in the future. However it can certainly give some comfort to single women whose reproductive clocks are ticking faster than they would wish.

Q: I am overweight and can’t get pregnant. I realise I need to lose weight, but would really like to get pregnant now.

A: The issue of weight and conception is now a real problem in reproductive medicine. As women become more overweight, their fertility declines. If you are overweight or obese, your risk of miscarriage increases. If you are bigger when you conceive, the risk to your child of later developing metabolic illnesses, such as diabetes, also increases. Having a body weight which is as near to the normal range for your age and height as possible is a really important goal before conception.

Even losing a little weight can make women who don’t ovulate produce eggs, and those who do ovulate but can’t conceive become pregnant. For many years, the focus in reproductive medicine has been on women who are underweight. The effect of obesity on conception, miscarriage and child health is now front and centre of research and treatment in the field. Perhaps the most important developing information is around the potential long-term health effects on children born to overweight women. You owe it to your children to be as fit and healthy as you can be at the time of conception.

Q: Is sex selection available at your clinic?

A: The Human Assisted Reproductive Technologies Act in New Zealand makes it illegal to offer sex selection in this country. l

Be Sure with Fertility Cover Fertility Cover gives you three chances to have a baby and the comfort of knowing in advance what the cost of your treatment will be. If treatment should prove to be unsuccessful after 3 cycles of IVF, we will refund 70% of the cost of the programme.

How does Fertility Cover work?

Payment upfront

70% refund

Success

Upfront payment for IVF cycles.

If you are not successful in taking a baby home after three cycles, we will refund 70% of the cost of the programme.

With the use of frozen embryos included in the cost, some people will have more than one child through this programme.

3

Criteria for eligibility can be found at: fertilityassociates.co.nz

At Fertility Associates, we understand that having a baby is what it’s all about.

OHbaby! Fertility Associates Exclusive | 31

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