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Allison Coote, MLA/T, Laboratory Manager, Northern Reproductive Therapies, Newmarket, ON and mom of twins born via IVF Feature Fertility and Infertility W hat is Infertility? Infertility is the inability to become pregnant after 12 months of unprotected intercourse. 1 in 5 couples are infertile. There are 3 basic categories of infertility: Female Factor, Male Factor, and Unexplained/Combined. Female Factor Infertility can be any of the following: tubal obstruction, mullerian defects such as bicornuate, unicornuate uterus, adhesions due to endometriosis, polycystic ovarian syndrome, hypothalamic amenorrhea, advanced maternal age, abnormal karyotypes, such as balanced and unbal- fertility. Smoking plays a major role for both males and females. Nicotine (and the other toxic chemicals in cigarette smoke) is known to damage DNA in sperm and nicotine can also be found in follicular fluid surrounding the egg. Marijuana use also affects sperm quality over time, decreasing motility, increasing abnormal forms, and decreasing total sperm counts. Excessive use of alcohol and other recreational drugs can also affect fertility in both the male and female partner. Sexually transmitted diseases, such as Chlamydia, can cause infertility by scarring and blocking fallopian tubes. These are all preventable causes of infertility. The impact of infertility is enormous and touches every part of an individual’s life. Marriages are strained, sex lives are on-demand, and family relationships are stressed. anced translocations, or other genetic conditions such as Turner’s syndrome. Male Factor Infertility can be any of the following: azoospermia, oligospermia, asthenospermia, Sperm DNA fragmentation, abnormal karyotypes, such as balanced and unbalanced translocations, and other genetic conditions such as cystic fibrosis or Klienfelter’s syndrome. Unexplained Infertility can be described when both partners have normal investigations and no distinct reason can be found for their infertility. Combined infertility is when both partners have conditions that impair fertility. The impact of infertility is enormous and touches every part of an individual’s life. Marriages are strained, sex lives are on-demand, and family relationships are stressed. Work relationships may be strained due to time missed from work for treatment and the secrecy a patient may feel. There is also a strong correlation between stress and the outcome of fertility treatment. Many alternative treatments are now being utilized by patients to reduce stress and help improve treatment outcome. These treatments can include yoga, meditation, acupuncture, biofeedback, and counselling. There are many lifestyle choices that affect 16 Basic Causes of Infertility 20% 40% 40% Male Factor Female Factor Unexplained/Combined Some of the fertility treatments available are: Ovulation induction and Intrauterine Insemination - With the use of oral or injectable fertility medications, cycles are monitored using bloodwork and ultrasound until an acceptable amount of mature follicles develop. Ovulation will be induced with HCG or occur naturally. A sperm wash will be done and an IUI performed. This treatment overcomes hormonal issues, cervical issues, and moderate male factor issues. In-Vitro Fertilization with or without Intracytoplasmic Sperm Injection – With the use of injectable fertility medications, cycles are monitored using bloodwork and ultrasound until an acceptable amount of mature follicles develop, the number of mature follicles will be higher in IVF. Ovulation will be induced, but instead of it occurring naturally, eggs are then retrieved by the physician and fertilized in the lab. Traditional IVF means to put the egg and sperm in a dish together and let them fertilize on their own. ICSI is taking a single sperm and injecting it directly into an egg. ICSI has made it possible for men with extremely poor sperm counts to become fathers. Egg donor – Egg donors are needed by patients wanting to have a child that are either advanced in age, have poor egg quality, or suffer from premature ovarian failure. Since 2004 in Canada, it has no longer been legal to pay for donor eggs. Patients may find a family member, friend, or someone else that is willing to donate their eggs without being reimbursed. Unfortunately many Canadian women seek treatment with donor eggs outside of Canada and will travel to Europe, Mexico, and the United States. Sperm Donor – Sperm donors are used by single women, lesbian couples, and couples who have severe male factor infertility. Again, since 2004, it is no longer legal to pay a sperm donor in Canada. The existing sperm banks in Canada import semen from Europe and the United States. Patients may choose from on-line catalogues and have access to donor profiles and photos. Open Identity sperm donors are also readily available. The children born to these donors will have access to the donor’s information when they turn 18 if they so choose. Surrogacy – Once again, since 2004 you may not pay a surrogate in Canada. Family, friends, or travelling abroad to obtain a surrogate is the only option. Costs of fertility treatment will depend on the treatment required. Ovulation Induction with Intrauterine Insemination is Continued on page 17 ADVOCATE Feature Continued from page 16 approximately $1,000 per cycle (OHIP will cover the bloodwork and ultrasounds), IVF/ ICSI is approximately $10,000-$12,000 per treatment cycle. Donor egg cycles can run up to $30,000 per treatment cycle. OHIP does not cover the majority of treatment and the cost must be covered by the individual. Quebec has started to cover IVF treatment and although it has only been approximately a year, the system seems to be working well. Cost can be the main obstacle for patient treatment. Only 50% of couples that require treatment to conceive are able to afford the services. Multiple Pregnancies have become a hot topic in the news. Many people relate fertility treatment to multiple pregnancies and births. Multiple pregnancies have a much higher incidence of premature birth than singleton pregnancies, this in turn increases the healthcare costs by a huge amount. With careful cycle monitoring and conservative medication doses, most higher order multiple births (triplets or more) can be avoided. During IVF treatment, transferring a conservative number of embryos is a good way to avoid higher order multiple pregnancies. The newest trend in Europe, and it is slowly being adopted into North American practice, is a SET or Single Embryo Transfer. This does decrease the pregnancy rate slightly, but the multiples birth rate dropped. These countries also have subsidized fertility treatment, which changes the attitude of the patient; they know if one cycle fails the government will continue to pay for the treatment. In conclusion, the good news is that the field of fertility treatment is ever undergoing change. New research is being conducted on previously neglected areas, such as male factor infertility and other areas such as fertility preservation (egg freezing). ❖ Preliminary results were reported for a combined total of 10390 IVF/ICSI treatment cycles undertaken in all 28 IVF centres in Canada in 2009: • The overall pregnancy rate was 37% per cycle started, 40% per egg retrieval procedure, and 43% per embryo transfer procedure. • 69% of pregnancies were singletons, 29% were twins, and 2% were triplets or more. • A singleton pregnancy occurred following 24% of cycles started, 26% of cycles having egg retrieval, and 27% of cycles having embryo transfer. • The pregnancy rates per cycle started, by age of the mother, were: • 46% for women under 35 years old • 37% for women aged 35-39 years • 20% for women 40 years old and over. • The singleton pregnancy rates per cycle started, by age of the mother, were: • 29% for women under 35 years old • 24% for women aged 35-39 years • 14% for women 40 years old and over. • Complications occurred in fewer than 2% of treatment cycles. IVF Success Rates as taken from CFAS Press Release on September 29, 2010 (www.cfas.ca) Image courtesy of Todd Bowen 17 Volume 18/Issue 2 Summer 2011 17 ADVOCATE