The Fertility team at Ballarat IVF would like to congratulate Dr Kristin Cornell on the establishment of South West Fertility, in Warrnambool. South West Fertility is regional Victoria’s new Fertility service, complementing existing local Women’s Health Services. Working closely with Russell and the Ballarat IVF team, Dr Cornell provides comprehensive, expert assessment of fertility issues in a supportive and respectful setting.
Kristin is able to provide a range of fertility treatment options in a convenient location for the people of Warrnambool, and surrounding areas.
South West Fertility will significantly reduce the need for travel to Ballarat for straight forward fertility treatments and provide an easy option for people preparing for IVF and other fertility treatments provided by Ballarat IVF.
We look forward to seeing Dr Cornell’s service grow as she shares the fertility journey with the women and couples of South West Victoria.
Well done Kristin!
From the Ballarat IVF team
The best reference points to use are age related break downs of success rates, and to “overlay” this information with your fertility specialist’s experience with your circumstances. When an IVF unit, or group of units report, or publish results, the information presented can often be difficult to apply to you, as the patient/couple.
Most comparisons between IVF services refer to Clinical Pregnancy Rates. A “clinical pregnancy” is defined as, a pregnancy sac in the uterus, a miscarriage, an ectopic pregnancy, or, an ongoing viable pregnancy. Hence, whilst an IVF service may have a particular clinical pregnancy rate, and generally, higher is better (as there SHOULD be more ongoing viable pregnancies leading to the birth of a baby), the clinical pregnancy rate does not equal the Live Birth Rates.
In 2016, Ballarat IVF had a clinical pregnancy rate of just over 40% per embryo transfer, which is excellent, and the highest rate in Victoria in 2016. Whilst we are proud of this “comparative figure”, a more useful piece of information to couples using our service is the likelihood of a LIVE BIRTH of a baby from a stimulation cycle, or the Cumulative Live Birth rate from a single stimulation cycle. The latter means the likelihood of a live birth when a woman undergoes a stimulation cycle, embryos are formed, and embryos are transferred, one at a time until a pregnancy and live birth occurs.
By providing cumulative Live Birth Data we are answering the question, “Okay, I’m planning an IVF cycle, what’s the chances of me getting a live birth of a baby from the embryos formed from that cycle?”
For more information regarding age related break downs of outcomes, please visit the Ballarat IVF website results section. (Click Here) We are proud to report that the cumulative live birth rates after one stimulation cycle at Ballarat IVF between 2013 and 2016, was around 40%, and if a woman has a second IVF stimulation cycle, 70% of women will achieve a live birth. Besides having a live birth, many of these women still have frozen embryos stored for their next pregnancy
If you have any questions, please feel free to contact Russell, or your Ballarat IVF fertility nurse on 03 53398200, or via email email@example.com.
All the best
Planning the time of embryo transfer - easy stuff ? Not really!
Some people think that planning and performing embryo transfer during a thawed embryo transfer is a piece of cake. Well - not really.
Ballarat IVF has very high pregnancy rates for the transfer of frozen embryos. This generates significant benefits, especially for couples who have had a number of previous attempts at pregnancy. Whilst we don’t necessarily like to share ALL of our secrets, our main focus is working hard on determining the time of embryo transfer, taking advantage of the narrow timing of endometrial receptivity. This is the brief period of time in which the endometrium is ready for implantation of the embryo.
In order for an embryo to implant and develop, the stage of development of the uterine lining must align with the age of the embryo.
This timing of development can vary between cycles, and certainly, between women.
If we look at the timing and synchrony of the development of the endometrium in relation to the age of embryos, it has been shown that, whilst most “luteal phases” are 14 days in length, 15 % are shorter, and 15% are longer. This raises the likelihood that the period of receptivity can vary between patients, and, in the same patient, between cycles. The lack of “synchrony“ between age of the embryo, and stage of development of the endometrium is likely to be a contributor to implantation failure of normal embryos.
Our approach, at Ballarat IVF, is carefully assess factors such as previous results, a women’s hormone levels, the thickness of the endometrium, and a visual impression of the endometrium on ultrasound, which is often performed by Russell, or a woman’s own fertility specialist.
Some times, we completely replace hormones in an artificial cycle, and alter the day of transfer. This detailed assessment, and careful planning with our fertility nurses ensures that we give our patients’ frozen embryos the very best chance to develop into a baby.
We know how hard women and couples work to get frozen embryos, so we do everything we can to avoid wasting them. Occasionally, we have patients requesting transfer of their frozen embryos to cheaper clinics, which are run by non-specialists with very little experience. We always worry about the woman and her embryos in that situation.
Russell attended the SEED (Sharing expertise, experience and data) in Sydney on 4-5 March. The list of speakers included world experts, a number of whom are Australians, who presented evidence based information on a number of important areas of fertility treatment.
The meeting was a great opportunity to share ideas with colleagues from other centres about current, and new, treatments. As is usually the case, I was pleased to have the treatment processes provided at Ballarat IVF supported by further data and opinion, and to hear about future treatments which may provide benefits for patients.
Over the next couple of weeks, we will provide information regarding the topics covered.
The first topic - Male Sperm Health
A number of speakers presented topics relating to sperm health.
It was highlighted that measuring semen parameters in the usual “sperm test” is a fairly crude assessment of the quality of an individual sperm. Sperm are highly sensitive to environmental influences due to the way in which their DNA is packaged. This means that increased levels of DNA fragmentation can occur in situations such as smoking, obesity, poor diet, and exposure to environmental toxins.
Some men, despite best efforts just happen to have high levels of DNA fragmentation, and these people are over represented in couples who have poor embryo development despite a relatively young female partner.
The best treatment to improve sperm health is to correct the obvious things mentioned above, but to also move to a diet focused on fruit and vegetables, with a Mediterranean style.
From a medical perspective, there was support for the collection of sperm by testicular biopsy in couples with repeated poor outcomes, as this tends to have lower levels of DNA Fragmentation.
One speaker elegantly presented data looking at proteomic profiles of sperm in infertile men, and showed a lack of crucial protein in some men, which is intimately responsible for the binding of sperm to the oocyte, explaining why some couples need ICSI. It was highlighted that the area of proteomics of sperm is an evolving science, and more explanations regarding the causes of male factor infertility will be derived from this in the future.
Should we put off performing a Frozen embryo transfer after a fresh stimulation cycle?
It has been traditionally thought that it is better to let a woman’s body “settle down” after a fresh embryo transfer, if she doesn’t conceive, before having a frozen embryo transfer.
The reasoning was that hormonal changes immediately after a fresh cycle might decrease the pregnancy rates with frozen embryo transfers.
In fact, there is very little published evidence to support, or refute, this view.
A recent, multi centre, multi national study, published recently in Fertility & Sterility Journal, looking at almost 1200 frozen cycles in over 1000 women has provided excellent information regarding this. This study looked at women having Antagonist protocol Fresh cycles (as most Ballarat IVF women do), and looked at the pregnancy rates for those who had a frozen embryo transfer performed from their very first period after a stimulation cycle, compared to those who waited more than this before having a frozen embryo transfer.
The pregnancy rates in each group was exactly the same, at 32.5%, suggesting strongly that there is no benefit to be gained from waiting before frozen embryo transfer is planned.
Obviously, there are a variety of reasons why a woman or couple may choose to delay having a frozen embryo transfer, but improving her chances of conceiving is no longer one of them.
What is new to help women who are “Poor Responders”, or produce very few eggs?
The term “ Poor Responder” is used widely in the Fertility Treatment Specialty, and is one, which we really don’t like.
All women or couples who consult Fertility Specialists at Ballarat IVF have a problem, and a proportion have low Ovarian reserve. This may be due to their age, or other reasons, for example genetic issues, or previous complex ovarian surgery.
The challenge when looking after a woman with low ovarian reserve is that, despite best efforts, she may only develop one or two eggs per IVF stimulation cycle. Those eggs may, or may not develop into an embryo, and with all the delays between cycles, there can be months between attempts at egg collections, and subsequent embryo transfers.
The Fertility Specialists at Ballarat IVF have recently been offering an innovative regimen, based on high quality, multicentre research published in Fertility & Sterility in September 2016.
This Regimen, called DUOSTIM, involves having two stimulation cycles in a very short space of time, with a gap of only five days from the end of the first cycle to the start of the second cycle.
This regimen takes advantage of the normal process of follicular development, where a group of immature oocytes start development as the follicles in the first cycle mature.
The results of published data suggest that, on average, a woman will develop one or two more follicles with the second part of DUOSTIM compared with the first, and that embryo quality is comparable between both steps on the cycle.
DUOSTIM may be performed for any woman, except over responders, and we offer it during fertility preservation treatments, such as oocyte freezing, or pre chemo IVF.
Important matters to consider if you are thinking about whether DUOSTIM is a treatment for you is that all embryos must be frozen, and that if you have had low egg numbers, or poor embryo development, despite all our collective efforts, you may still not have any embryos to freeze.
If you wish to have further information about this new treatment option, please email or call our Fertility Nurses for a free consultation.
On +61 3 53398100 firstname.lastname@example.org
All the best.
During a recent review of IVF laws it has been proposed that parents be allowed to select the gender of their third child when undergoing IVF treatment.
The argument for the proposal was, according to Professor Michael Chapman about "dealing with the patient's desires [and] their needs to fulfill what they see as their ideal situation”. “We're in the 21st century," he said.
Currently selection of embryos based on gender for non-medical reasons is not allowed. Does it happen? Probably. Should it happen? Well that’s the ethical question the Health Department needs to answer when reviewing these laws.
There are two ways to select the gender of a child. The first is to become pregnant (either naturally or through assisted reproductive technology) and determine the gender on a maternal blood test at around 9-10 weeks. Then terminate the pregnancy if the gender is not as desired. This is an ethical minefield but as testing allows gender determination earlier and earlier (previously it was not until the 20 week ultrasound that couples were able to know the gender) it will become more of an issue.
The second way is in the laboratory when performing pre-implantation genetic diagnosis (PGD) on embryos created through IVF. This is usually performed to screen for specific genetic conditions and chromosomal abnormalities that are medically indicated. When testing the chromosomes the gender of each embryo is known. For some sex-linked conditions this is relevant but most PGD screening it is not. Patients can request PGD be performed due to maternal age alone as the risk of chromosomal abnormalities increases with the mother’s age. A quiet request can then be made for an embryo of a certain gender.
After an IVF cycle and PGD screening, you have 3 healthy embryos available to your patient for implantation. They already have two daughters and request if you could please put a male embryo in, they would really like a son. Is this really wrong?
From an anthropological and social view point we should be careful when “fixing” our gender preferences. Our society is based on a male 102 to female 100 ratio to allow for a slightly higher early male death rate and then our, in general, monogamous approach to mating. The social discord evident in countries where legal, or mainly illegal, gender selection has lead to an imbalance of up to 120 males for 100 females should be a warning.
Chromosomes do not reflect a person’s character or general attributes. A set of XX chromosomes (female genetics) does not dictate that a person will love tea parties, shoe shopping and be guaranteed to take care of you in your dotage. Just as a set of XY chromosomes (male) does not guarantee a person to watch the football with or to take over the running of the family farm.
Currently IVF is partly funded by Medicare, and thus our tax dollars, as I think it should be, to help people struggling with infertility. When you start to try and “fulfill peoples ideal situation” in terms of their child’s gender this, in my opinion becomes a harder sell. Should those three embryos I mentioned earlier all be female, do we, as a society need to contribute to that family undergoing another round of treatment to produce male embryos? Could this money be better spent to better society in another way?
As an IVF specialist, nothing gives me a greater buzz than a positive pregnancy test, a heartbeat on ultrasound and then several months later the birth notification letting me know a baby was born. Do I care what the gender was? No. Do my patient’s care what the gender was? No. The resounding comment is always “as long as it’s healthy”.
Don’t get me wrong, I don’t think there is anything wrong with wanting a child of a specific gender, but saying you need it is different. When you conceive a baby, in my opinion, the aim is to love and nurture that person no matter what their interests, abilities or gender. If you start putting clauses on this, then perhaps you should re-evaluate why you are having this child.
Dr Katrina Guerin
A large component of the female partner’s contribution to a couple’s fertility relates to her egg quality. Other issues, such as her general health, lifestyle factors, and the presence or otherwise of endometriosis are important, but one of the most difficult problems to improve is poor egg quality, or when the number of eggs collected are low, despite maximal doses of drugs.
There are a range of treatments which have been tried to improve egg quality or number of eggs obtained, but virtually none have been shown, in proper trials, to be effective. This is not to say that a particular, novel treatment MAY be helpful in certain individuals, but, it is more likely that a good outcome, when followed by an unproven intervention, was going to happen anyway. Many women, and couples are faced with the harsh reality of poor egg quality or low egg numbers during fertility treatment.
There are two ways of looking at this problem; the first is how to treat the problem, and secondly, how to prevent it happening in the first place.
For many women with poor egg quality and an experience of unsuccessful IVF with their own eggs, utilizing donor eggs can improve the chances of conceiving from somewhere around 1-3% to 25% or more. This represents an 800% to 1200% increase in success rates!
Most egg donors are friends or relatives of the recipient, but a number of women needing egg donation find it difficult to access a donor. This tends to be due to a person’s friends often being of similar age, and not everyone has a younger sister who is able to help out.
Some women approach Ballarat IVF to donate eggs, and they are allocated to a recipient on the waiting list. Because very few women decide to donate eggs, the waiting list at Ballarat IVF is considerable.
The best method of preventing poor egg quality is for a woman to look after her health in her earlier years of life. Maintaining a healthy diet, controlling her BMI, and avoiding smoking and excessive alcohol consumption are important contributors.
A number of women are now storing embryos, (if they have a long term partner), or oocytes if they, or their partner do not wish to commit to forming embryos together.
The success rates for conception from the use of donor eggs are continually improving.
Eggs can stay frozen, for a very long period of time, and the success rates for conception relate to the age of the woman when they were frozen, not the age at which they are being used. Storing oocytes provides a realistic method of preserving fertility for women who are not yet ready to have a baby, and is a good way to reduce the risk of having poor oocyte quality in the future.
If you are interested in storing eggs, donating eggs for another woman, or simply would like more information, please contact the fertility nurses at Ballarat IVF by calling 03 5339 8200 or emailing email@example.com
Laparoscopic Ovarian Drilling (LOD), is a treatment aimed at increasing the chance of ovulation in women with PCOS.
Essentially, it involves causing localized damage to the ovarian stroma (which is the outer part of the ovary). In the process of recovering from the damage, the receptors in the ovary become more sensitive to FSH, and hence, ovulation is more likely to occur.
The exact mechanism of the increase in ovarian sensitivity to FSH is not known, but is thought to involve changing levels of hormones such as Inhibin, and other “intra” ovarian molecules called Insulin-like growth factors (IGF).
The idea of ovarian damage leading to subsequent ovulation in PCOS women arose from the olden days, where women with PCOS were diagnosed by taking a piece of tissue out of the ovary. The operation involved opening the woman’s abdomen, and was called “wedge resection”.
The Gynaecologists of the day noted that a lot of these women subsequently ovulated and conceived, and so “wedge resection” became a treatment for lack of ovulation. Yes, times have certainly changed!
In the late ‘80s when I started training in Obstetrics & Gynaecology, a French Laparoscopic Surgery Unit showed that similar results in improving ovulation rates could be achieved by performing Laparoscopic Ovarian Drilling (LOD). The Laparoscopic procedure involves inserting a diathermy (electrically activated) needle into the ovary, making between four and eight holes in each ovary.
This caused great excitement, and we performed a lot of these procedures in the mid to late ‘90s with reasonable results in terms of achieving pregnancies for the women treated.
As is the case with many treatments, concerns evolved about ovarian drilling. The risks of the procedure, in addition to those of having a laparoscopy, were shown to be causing adhesions around the ovary, damage to the blood supply of the ovary, and damage to the ovary from the surgeon making too many punctures with the needle. Some Surgeons thought, incorrectly, that if 4 punctures is good, 12 is better.
Within the field of fertility treatment, there are some doctors who advocate LOD enthusiastically, and, I think there is a majority (of whom I am one), who think it is NOT bad treatment, but has a limited place in the treatment of women with PCOS and are trying to conceive.
If you look at the results of comparisons between LOD and ovulation induction with Letrozole and/or FSH, the pregnancy rates are the same. There is a higher rate of multiple pregnancy if you use Letrozole and FSH, which is important, but at Ballarat IVF our multiple birth rate is less than 5%.
At Ballarat IVF, we may speak to our patients regarding LOD if they have had a number of unsuccessful ovulation induction cycles, either with poor, or uncontrolled over response, AND they are not interested in making the transition to IVF with single embryo transfer.
If LOD is to be performed, it must be discussed carefully with the woman before the operation and definitely not a procedure that our Specilaist’s will add in randomly at the time of surgery.
LOD should be performed by a Specialist who has been trained properly, and include the use of surgical equipment specifically designed for the operation.
At Ballarat IVF, we provide more than 500 ovulation induction treatment cycles per year, yet perform one or two LOD treatments for our patients. So, most of the time, if you have PCOS, ovulation induction is all that is required.
~ Dr Russell Dalton
A number of Ballarat IVF patients will have had the experience of having an Egg Collection, and then having all of the healthy embryos formed frozen, rather than having a fresh embryo transfer. There are a number of possible reasons for having this treatment step, all of which are based on maintaining the health of the mother to be, and maximising the likelihood of a pregnancy with a healthy baby.
The first reason to" freeze all" is when the woman is at risk of hyperstimulation.
In this situation, most women will have been given a syneral trigger, and provided they don’t conceive the risk of hyperstimulation is very small.
The second reason to "freeze all" is if a woman's progesterone level is elevated at the time of triggering in preparation for egg collection. In general, the lower the progesterone level is prior to egg collection the better, but the younger you are, and the better you respond to FSH, the less important it is. Your fertility nurse and your Ballarat IVF specialists will discuss your progesterone level & advice regarding the need or otherwise to "freeze all".
Finally, there are some women who require maximal dose FSH, and despite all efforts they don’t conceive. These women may also benefit from a freeze all cycle and planned frozen embryo transfer.
The disadvantage of a freeze all cycle is the delay in conceiving. Ballarat IVF data shows that on average it takes 3 extra months to get to the same cumulative pregnancy rate from a cycle compared to having a fresh transfer. However, after 4 months, the cumulative pregnancy rates are the same. The reason for the lag is that women often take a couple of months' break before coming back for their frozen Embryo transfer.
It is important to note that the Ballarat IVF fresh and frozen embryo transfer pregnancy rates are essentially identical, so apart from the delay in getting pregnant, the pregnancy rates with frozen embryos are excellent. A further benefit from frozen embryo transfer is that the likelihood of having a healthy baby is exactly the same as naturally conceived babies.
Ballarat IVF Specialists share the vision that in the not too distant future, the majority of IVF stimulation cycles will have all embryos frozen, and a single, high quality thawed embryo will be transferred shortly afterwards. This will generate high pregnancy rates in women at no risk of hyperstimulation, and result in greater numbers of healthy babies being born.
~Dr Russell Dalton