Fertility Center

Delayed conception is a challenge potentially threatening every aspect of couples life and happiness. It eats deep into the couple's relationship and could destabilize their self-esteem. The social stigma associated with delayed conception, affects their relationship with parents, friends and neighbours due to prolonged frustration from endless search for solutions or remedy. It breeds loneliness, apathy and sometimes separation and divorce. It is a great threat to one's dream. These few but overwhelming challenges of emotional stress, crises and implications can only be best described by the ones so afflicted by this delay.

"Counselling is the friend with a listening ear, a patient guide, a reliable comforter, a motivator to carry on and a supporter for all weathers. It affords you the opportunity to explore yourselves, thoughts, feelings and beliefs in order to come to a greater understanding of the emerging situation".

Incidentally, fertility consultation with focus on IVF treatment differs significantly from other medical consultation in obstetrics and gynaecology clinics. It involves a series of tests and intrusion into the couple's intimacy with a view to determining the cause and appropriate treatment plan.

Emotional support is a vital aspect of fertility management; to this effect we provide both formal and emotional support by trained counsellors and informal counselling by all the staff and most importantly by other clients who have gone through the treatment or still undergoing treatment and wish to support other couples (mum to mum support system).

Counselling is a service you need to make the difference in your care! Let me introduce to you our fertility DVD titled 'Moments of Fruitfulness'. Pick a copy, listen carefully to the teaching and be blessed.

- Make enquiries and receive enquiry pack.
- Read contents of enquiry pack.
- Make appointment for Preliminary assessment.

The Preliminary assessment is essential for everyone coming to Life Fertility Centre and allows us to have some results before your appointment with the Doctor.

Please note that it is not important to see a doctor before the preliminary assessment is carried out. The nurse coordinators are well trained and perfectly able to organize this.

- Come to the clinic between 1st and 3rd day of the woman's period.
- You pay for Preliminary Assessment.
- You will receive and complete the client's information questionnaire.
- Blood is taken from the wife and the husband.
- The man is asked to produce a semen sample.
- An appointment is made for both of you to return for the doctor's consultation when the results of the tests carried out will be available.

If you are from out of Anambra state, it is important that you phone the nurse coordinators to schedule your doctor's appointment for the same day.

- It is essential that both of you attend this appointment.
- The wife will have a transvaginal scan carried out.
- The wife will be examined. The husband will also be examined if necessary.
- You will discuss your results, sign the agreement forms and be scheduled for appropriate treatment.

You will be given an information pack, which will contain:
- The time schedule for your treatment.
- The list of drugs you will require and cost implications.
- Instruction on self-administration of your drugs.
- Record sheets to record your injections.
- A billing form.
- Discussion with the Accounts Officer

This will take place immediately after the doctor's consultation. You will be able to discuss your bill and payment terms.

This section is an introduction to the treatment with this technique at life and should answer many of the questions that you may have. Please read it through carefully before your first consultation/treatment cycle.

Consent forms
Before your first treatment cycle, you will be asked to attend the hospital to complete some forms consenting to use of your eggs and sperm for treatment and also to tell us what you would like to be done with spare eggs, sperm and embryos. You will be given some information sheets by the doctor when you have been accepted for treatment. These sheets detail the options open to you. You will be given a copy of the consent forms to keep for your own information.

Confidentiality
We understand the private nature of your treatment and every effort is made to maintain your privacy. All communications with you are made via telephone and if we need to send you urgent letters then we use non-identifiable stationery. We will communicate with your referring doctor unless you expressly inform us not to. All our staff are trained on confidentiality issues to protect your interests.

There may be some information that you want to give to us in private without your partner knowing. If this is the case, you can ring the Unit and ask to see the doctor alone either before you register for treatment or afterwards.

Parental Responsibility
We attend to married couples seeking for solution to their fertility challenge. Unmarried couples will produce legal evidence to empower us to offer them this procedure.

General Health for IVF
A recent paper suggests that the chance of pregnancy on the first IVF treatment cycle is halved if the woman smokes. All women who are trying to get pregnant are advised to take FOLIC ACID 400 mg once a day to reduce the risk of a baby born with spina bifida. You will receive a prescription for this.

If you would like more information about sickle cell or you would like to be tested for it, please see the patient co-coordinators.

Sexually transmitted diseases caught at any time may create further problems with trying to conceive. It is also possible that vaginal infections at the time of embryo transfer reduce the chance of IVF working. If you are worried about this at any time, we encourage you to ask your doctor to screen you for these infections. We routinely screen for this at the beginning of you treatment cycle.

We encourage couples undergoing fertility investigations and treatment to have a blood test to screen for HIV, Hepatitis, Syphilis and Chlamydia infections.

Who is at risk of HIV?
Anyone who is sexually active is potentially at risk of HIV infection. Especially if you have multiple sexual partners or engage in casual sex.

Why is it important to be tested before pregnancy?
If one or both partners were HIV positive, this would affect your future as a family, and possibly your plans for conceiving.

It is important to know your HIV status as it may affect your unborn child. The virus may be transmitted to the baby during pregnancy or delivery. If this happened, the baby could go on to develop AIDS. There are a number of ways that treatment and modified management during pregnancy and delivery can reduce the chance of mother to child transmission of HIV.

What does the test show?
The blood test shows the presence or absence of antibodies against HIV. If antibodies are present, you are HIV positive. You may later go on to develop the AIDS disease. A negative test indicates that no HIV antibodies were detectable on that occasion. However, in some cases antibodies can take up to three months to develop after exposure to the virus. You may wish to repeat the test after three months.

How do I get the test done?
Testing, together with additional counselling can be arranged by the client coordinator at our laboratory.

What happens if the test is positive?
In any case, the test result will be given to you personally. Results will not be given over the phone.

If you test positive, the result is confidential to you. However, in the context of fertility treatment, we encourage you to share this information with your partner.

Fertility treatment of any individual who is HIV positive is controversial. We are obligated to consider the welfare of any child conceived as a result of treatment and each case would be considered individually.

Superovulation
To increase the chance of success and to make management of the treatment cycle easier for both you and us, we use a combination of drugs: Follicle Stimulating Hormone (FSH) to stimulate the ovaries to mature more eggs than in your natural menstrual cycle. Either Gonadotrophion Releasing Hormone Agonist (Buserelin/Nafarelin) or Gonadotrophin Releasing Hormone Antagonist (Cetrorelix) to control the timing of egg maturation and egg collection.

Human Chronic Gonadotrophin (HCG) which ripens the eggs so that they are capable of being fertilized.

Supply of Drugs
We have our preferred brand of drugs in the hospital pharmacy that supplies all our patients with their drugs. The pharmacy is located within the hospital premises and is open 24 hours from Monday to Sunday.

Please ensure you pay and obtain your drugs in time, before your treatment commences. During the treatment cycle, some women may need more drugs in addition to those prescribed before treatment starts.

Administration of drugs
You can choose to receive your injections in the hospital or we teach you to self administer the injections. This is a simple technique to learn and much easier than having to visit the hospital every day. If you choose not to administer your own injections and wish to go to a clinic near to you, you must make arrangements for this yourself, remembering that some injections have to be given at weekends or late at night. We are happy to teach whoever you wish such as a relative or a friend the injection technique. We will also supply you with the needles and syringes you need.

Care of Drugs
Your drugs must be stored in the fridge or at room temperature away from direct sunlight. Many of the drugs will last several months or more. Before using any of the drugs, you should check their expiry date printed on the label. You should not use any ampoules/bottles that have past their expiry date. Open bottles of Buserelin injection should be disposed of at the end of your treatment cycle and not be kept for subsequent treatment cycle.

If you have any questions about the use or storage of your drugs please contact the nurses.

Cycle Control Drugs
There are two ways we can control your ovaries during stimulation. We can either use gonadotrophin releasing hormone agonists (Buserelin or Nafarelin) or antagonists (Cetrorelix).

Agonists: e.g. Buserelin (Trade name Suprefact), Guserelin (Trade name Zoladex)

These drugs work by "switching off" the woman's ovaries, giving us complete control over the menstrual cycle. Usually you will start your drugs on the 1st day or the 21st day of your period and continue all through the treatment cycle until you have had the HCG injection.

Buserelin is taken as a subcutaneous injection. You must take 0.5mls/50iu subcutaneously once a day. Goserelin is also taken subcutaneously once in 4 weeks (3.6mg dose). It is a slow release (depot) preparation and avoids the burden of daily injection.

Side Effects
Once the ovaries start to "switch off" and the woman's own hormones are suppressed, menopausal symptoms may be experienced such as hot flushes, headaches, forgetfulness and feeling slightly depressed. These are normal, and you should not be concerned if you experience any of these. For headaches, Paracetamol or similar drugs may be taken.

Some women may notice their period is different from normal, or may notice further bleeding after their period is finished. Again this is not a cause for concern and will not affect the treatment.

There are, as yet, no known long-term side effects after Buserelin or Gosereline use. If the IVF treatment is not successful, you may find your periods are irregular for a couple of months before returning to normal.

Antagonists: e.g. Cetrorelix (Trade name Cetrotide)

The main advantage of Cetrorelix is that it will shorten the length of your treatment cycle. Instead of the priming two weeks of Buserelin needed with IVF cycles now, the Cetrorelix is started after the Follicle Stimulating Hormone (FSH, Menogon or Puregon) and then continued until the time of the hCG (Profasi, Pregnyl) injection. This means that the whole cycle is likely to be completed within 28-30 days. It also means less injections (if you were using Buserelin injections before) but is unlikely to mean that you will need less FSH.

At Life Fertility Centre, the initial scan is arranged to be on Saturday. When using Cetrorelix, treatment must start on either Day 2 or Day 3 of a menstrual cycle, and this means the previous cycle must be controlled using the oral contraceptive pill. This means that you cannot conceive on the preceding cycle.

The other consideration is cost: Antagonists (Cetrorelix) are more expensive than agonists (Buserelin).

As with all treatments there can be no guarantee that it will result in the production of healthy eggs or pregnancy. Cetrorelix is given by injection under the skin. This can sometimes cause redness and itching around the injection site.

Your first visit to the Centre after commencing Buserelin will be 2-3 weeks after you start the injections. At this appointment, which is usually done on Saturdays we will perform a trans-vaginal scan. The vaginal probe is introduced into the vagina covered by a sterile condom. It is slightly larger than a finger and should not cause any real discomfort. The probe then transmits a picture onto a small screen which you will be able to see yourself.

If the ovaries still show signs of activity and the endometrium (lining of the womb) is still thick, you will continue on Buserelin. If the scan shows the ovaries to be inactive and the endometrium is thin, we will tell you when to start the FSH injections; this will be within the subsequent 2 weeks. All women on a particular batch will start this injection same day. We will show you how to perform the injections if necessary, so please prepare to pay for the FSH injection if you have not done this.

If you have had treatment to your cervix we may perform a "mock" embryo transfer. A speculum would be inserted into your vagina and a fine catheter passed into your womb to confirm that this can be done easily. If we have difficulty in passing the catheter in, we will repeat the procedure using different catheters, if necessary.

Also at this appointment if we are running any research trials we will give you information sheets for you to take away and read then discuss with your partner.

Semen Sample
We like to see a semen sample for assessment during every treatment cycle. Ideally, a semen sample should be produced before this first appointment, so that the results are ready in notes for discussion.

However, if you live some distance from the centre, you produce the sample on the same day, but you will need to wait for the assessment result so that we can discuss it with you.

Occasionally, if there is a problem with the semen sample, it is advisable to defer the treatment (see below) for both partners to receive antibiotic treatment.

For the best results, intercourse or masturbation should be refrained from 36-72 hours before producing a sample. We have a special room that may be used, but if you or your partner foresee any problem in producing semen samples, please talk to a member of staff as soon as possible, so that we can discuss the ways in which we can help.

(Note that you may not start your FSH injections until we have seen a semen sample for assessment).

Follicle Stimulating Hormone (FSH)
This is the drug that should stimulate your ovaries to produce follicle. It is administered by a daily subcutaneous or intramuscular injection. Follicles are tiny fluid filled sacs that grow on the ovary and contain the eggs. In your normal monthly cycle, only one egg is produced. To increase the chances of pregnancy with IVF treatment, we need several eggs (ideally ten).

There are several types of FSH available. These can be broadly divided into 2 groups – urinary FSH and recombinant FSH. Urinary FSH comes from the urine of postmenopausal women, and is purified in a laboratory. Recombinant FSH is made solely in a laboratory, using DNA technology.

Examples of urinary FSH are: Menogon, Menopur, Meional Diclair-HMG (Human Menoposal Gonadotrophin).

Examples of recombinant FSH are: Gonal –F and Puregon.

Some studies have suggested that IVF cycles using recombinant FSG may have a slightly better pregnancy rate when compared to cycles using urinary FSH, but this probable increase in pregnancy rate has to be balanced against the cost of recombinant FSH which is about three times the cost of urinary FSH.

This is performed to assess your response to ovarian stimulation with FSH (gonadotrophins). We will count the number of follicles developing on the ovaries, and then measure them. When the follicles reach about 16-20mm in size, we would expect the egg inside to be mature. Occasionally it will be necessary to continue your FSH injections and come for a third or even a fourth scan. Please do not take your FSH injections on the days you are having a scan, until after it has been performed.

Remember that you must continue with Buserelin as instructed whilst taking FSH injections.

HCG injection: Trade names: (Diclair HP-HCG/Profasi/Pregnyl)
When the follicles are large enough, we will tell you to stop the FSH injections and have the HCG injection. This drug prepares the eggs for collection. We will tell you the time to have the injection. This is often late in the day or at night, which is another reason why it is convenient for you to be having your injections at home.

Your partner will need to ejaculate just before this injection, and then refrain from intercourse or masturbation until the day of egg collection, when he will need to produce a semen sample for the insemination of the eggs.

Please stop Buserelin, Nafarelin or Cetrorelix when you have had the HCG injection.

Under response
Sometimes the ovaries respond inadequately to the drugs and produce very few, if any, follicles. If the woman is already on the maximum dose of FSH (450 units) per day then a decision will be made as to whether the treatment cycle is to be continued, in spite of the very poor chance of success or cancelled. If the latter option is chosen, the couple will be offered a consultation to see the doctor during which other treatment options (if there are any) will be discussed.

If the woman is not on the maximum dose of FSH, the cycle may be cancelled and a further attempt arranged with an increased dose of FSH. Alternatively, the woman may be "down regulated" (where FSH is stopped but Buserelin or Nafarelin is carried on for another two to three weeks). She may then start FSH again.

Over response
Severe ovarian hyperstimulation syndrome (OHSS) is a rare but serious complication of the use of FSH. Usually it only occurs if large numbers of follicles (i.e more than 20) have developed in the ovaries. We try to avoid OHSS by choosing the lowest dose of FSH that will produce adequate numbers of eggs. However, the response of different women to these drugs is very unpredictable, particularly in those women with polycystic ovaries. We will be able to tell if you have polycystic ovaries by blood tests and scans.

When a large number of follicles develop, we have three options:

1. We may decide to abandon the cycle before the HCG injection and start again at a later date with lower dose of FSH.
2. Alternatively, we may, having reminded you of the risks, continue the cycle taking particular care to empty all follicles at egg collection. It does seem that if great care is taken during egg collection to drain all the follicles; the severity of OHSS is reduced.
3. The final option is to continue with the cycle but to freeze all embryos and not perform embryo transfer. This is because OHSS is much prolonged and therefore more serious if pregnancy occurs. The embryos can then be transferred at a later date when the woman is well again.

However, problems may still arise despite all our care. Symptoms usually commence around 4-5days after HCG injection, and usually start with pain and swelling of the abdomen. The ovaries become very large and surrounded by fluid, and the woman may start to vomit. Loss of fluid in this way may lead to dehydration, which can lead to concentration of the blood and to the formation of clots. This can be serious and women have been known to have a stroke or even die as a result of these complication. It must be stressed that this is very rare, and the following precautions will be taken:

1. Women who have developed large numbers of follicles will be made aware that there is a risk of them developing this syndrome (OHSS), and given the option to abandon the cycle before HCG.
2. Where a decision to proceed has been made, but prior to embryo transfer it becomes clear that the risk of severe OHSS is very significant, we may insist that all embryos are frozen for later transfer in an unstimulated cycle.
3. Any woman having abdominal pain that increases rather than settles a day or two after egg collection should please contact the clinic (see contact information sheet for details). If you are unable to contact any of the doctors please report to the hospital. It is particularly important to let us know of the development of any nausea and vomiting.
4. If the situation is not too severe, we will probably ask the woman to return in a day or two for further assessment.
5. If the condition is severe, the woman will be admitted to hospital and have a drip to reduce the dehydration. It may also be necessary to insert a tube into the abdomen to drain the fluid that causes the swelling.

By carrying out these precautions, we hope that a dangerous situation will be averted. It should be added that OHSS does not mean that the treatment has not worked – it is not uncommon for women with these symptoms to be pregnant, and once the symptoms have subsided, the pregnancy should proceed normally.

When you are ready to have your egg collection arranged, you will be given an instruction sheet telling you exactly what you need to do.

Egg collections are preformed in the unit's theatre on schedule by specially trained doctors. Your partner, or another relative or friend, are welcome to be with you during the procedure to give you moral support. You will need to take the day off work.

Firstly, a needle will be inserted into a vein in the back of your hand, and you will be given an intravenous injection of a strong painkiller and tranquillizer. The ultrasound probe is inserted, to which is attached the needle guide and needle. The clinician will guide the needle through the vaginal wall and into the ovary and you will experience short sharp discomfort or pain as this is done. Once in the ovary, the clinician will puncture and drain every follicle. The degree of discomfort during the procedure varies from patient to patient. Most women experience a moderate degree of pain that they can bear without much difficulty.

The embryologist will then examine the fluid under the microscope to detect and collect the eggs. Depending on the number of follicles there are on each ovary, the procedure time can range from 5 to 20 minutes. The clinician will puncture and drain every follicle possible, but not every follicle contains an egg. We expect to obtain eggs from approximately 75% of the follicles.

Very occasionally, it is not possible to reach the ovaries vaginally, so we may need to fill the bladder and use the abdominal scanner. In this instance, after injecting some local anaesthetic, the needle will be inserted through the abdomen into the ovaries.

After egg collection, we will be able to tell you the number of eggs that have been collected. The eggs are placed in culture medium in labelled and individually numbered dishes and kept in the incubator. Very occasionally we do not collect any eggs. This is usually due to poor ovarian response, but sometimes there are many follicles, none of which yield eggs.

Side Effects and Complications of Egg Collection
It is common to have some crampy period – like pain for approximately 24-48 hours after egg collection. You may take Paracetamol for this discomfort if you wish. It is also common to have some spotting, due to bleeding from the puncture site of the needle.

However, egg collection does carry some risk of infection and of puncturing a blood vessel or loop of bowel. Such complications are extremely rare, and we aim to keep them to a minimum by using sterile equipment and ultrasound guidance, but should you feel particularly unwell with a fever or severe sharp pain, please contact the hospital immediately (see contact information sheet for details).

Sperm Preparation
If you are not using donor sperm, your partner will need to produce semen just before collection. The embryologist then prepares the sperm in the laboratory ready for insemination.

Approximately 200,000 healthy sperm are added to each drop containing 5 eggs about 40 hours after HCG injection. Fertilisation takes about 12 to 18 hours. The eggs are looked at under the microscope the next day, and characteristic changes can be seen if fertilization takes place.

The morning after egg collection you will be instructed to call the embryologist to enquire about the progress of your egg(s) and their fertilization. If certified okay and embryos(s) suitable for transfer to your uterus are obtained, we will discuss with you the time the transfer will be carried out.

Failed Fertilization
If fertilization does not occur, it is obviously very disappointing for both you and us. Occasionally, this does happen even when both sperm and eggs appear normal, but mostly failed fertilization is due to poor quality sperm. If you are known to have poor quality sperm we will have warned you of this danger. Occasionally, a man produces poor sample unexpectedly. We will make you an appointment to see an appropriate member of staff to discuss the situation and further treatment options.

If you have had a "mock" embryo transfer you will have been told whether you need a full or empty bladder. If you haven't had a mock embryo transfer you should attend with a full bladder. Immediately before your procedure, the scientist will tell you about your embryos, and then show them to you on the microscope. Two or three embryos will then be transferred into the womb. The procedure usually takes a few minutes and is usually quick and painless. We advice that you rest for about an hour or go home straight afterwards (resting or lying down does not particularly improve the success rate). You may also empty your bladder if necessary!

However, the procedure is not always straight forward;
- There may be unexpected difficulty in passing the catheter into the womb. The doctor or nurse may have to give the catheter containing the embryos back to the embryologist while he or she passes an "introducer" into the womb to make passing the catheter easier.
- Very rarely, the embryos may be lost during a difficult transfer. This probably happens if mucus gets into the end of the catheter when the embryos, which are close to the tip, may be sucked out as the catheter is withdrawn down the neck of the womb. If there are more embryos available they are transferred in lieu of the lost embryos but they may not be of such good quality. There may be no alternative embryos available.
- After all embryo transfer procedure the catheter is checked to confirm that the embryos have gone. Occasionally one or more may be stuck inside the catheter and the procedure has to be repeated.