Your decision to go abroad for fertility treatment is a big one. That's why Your IVF Journey supports you every step of the way. Run by and for IVF patients, we work exclusively with one of the most respected IVF clinics in mainland Europe.We write new posts regularly on a variety of IVF treatment topics.
The ERA test, or endometrial receptivity array test, is a new way to address implantation issues. But is it any good? A number of our fertility patients have had it. Some have then had successful treatment, perhaps thanks to the ERA test’s recommendations. So let’s have a closer look.
The ERA test examines a sample of endometrial tissue to try to pinpoint the optimal moment for your embryo transfer. The makers of the test call this the ‘window of implantation’. The test is primarily aimed at patients having fertility treatment. It’s quite expensive (around £850), but a number of clinics now offer it.
The test claims to work out how receptive your endometrium is by assessing, at the genetic level, its readiness for implantation. If you’re a fertility patient with recurrent implantation failure, particularly after transferring good-quality embryos, it might be worth considering. The ERA test claims a 73% pregnancy rate.
What does the ERA test actually quantify? In essence, it seeks to measures the ‘receptive profile’ of your endometrium five days after starting your progesterone support. You’ll take HRT medication (estrogen and progesterone) up to your ERA test biopsy day – when a blastocyst (day 5) embryo transfer normally takes place. That’s usually when your endometrial tissue is priming itself for implantation.
You’ll get a written report one or two weeks after your ERA test biopsy. The key recommendation is the timing of your embryo transfer in relation to when, precisely, you start your progesterone. A typical conclusion might be: have your embryo transfer 126 hours, plus or minus three hours, after the start of your progesterone application. So if you start your progesterone on your main cycle at 8 am, you should have your blastocyst transfer five days later, between 11 am and 5 pm, and ideally at 2 pm.
One thing your ERA test report might also say is that it’s only applicable on ‘the same type of cycle treatment’ on your main cycle as for the biopsy (mock) cycle. So if you’re having an FET, a donor-egg or donor-embryo cycle and are therefore on an HRT protocol, that’s okay. For a patient on a natural cycle, the ERA test is carried out seven days after the LH surge. But would IVF patients optimally have to do the biopsy after taking the same (expensive) FSH medication they planned for their main cycle, on their mock cycle, and would the biopsy be done seven days after the trigger shot? Not sure.
An ERA test can’t guarantee a future pregnancy. Other factors, such as poor embryo quality or blood disorders, can cause implantation failure. So it’s an objective test, an extra tool for guiding clinics towards possible success.
The key findings come from a 2013 study, which found that patients with repeat implantation failure are around 25% more likely to have a ‘displaced’ window of implantation. Hence why a personalised test that strategically times your embryo transfer may help. Another study in 2015 was also supportive. But a 2018 study found that, for FET patients, the ERA test didn’t seem to improve the pregnancy rate for good-prognosis patients. It concluded, like the 2015 study, that a large-scale trial was needed to really prove the benefits of the test.
So should you have the ERA test? The best person to ask is your fertility doctor. The cost is pricey and it can be an uncomfortable procedure. Our verdict? The ERA test’s genetic approach is certainly a step in the right direction. It may well improve outcomes for certain patients. But it’s not revolutionary – yet.
Why did we choose Reprofit for our fertility treatment? In short: quality and price. But it came out top for other reasons too. Here’s why we feel it was the best decision we ever made.
1. Affordable treatment cost.
Reprofit charges under 2,000 euros for an IVF cycle, which is pretty remarkable. But low prices still mean high-quality treatment. As we found out, it’s the same equipment, techniques and medical expertise as UK clinics. (Better expertise, actually.) Salaries are lower in the Czech Republic: one reason why treatment costs are less.
We eventually decided on donor eggs. The price at Reprofit was at least 30% cheaper than most UK clinics we looked at, even factoring in flights and accommodation costs. The treatment price included many items that were an additional cost in the UK, e.g. ICSI and extended embryo cultivation. For extras not part of the Reprofit package price, these were still very reasonable. For example, embryo freezing was 300 euros for one year at Reprofit. At a well-known London clinic (we won’t mention names!) we were quoted almost £1,000.
2. Amazing standard of care.
After our experience at clinics in Nottingham and London, we were desperate for a more caring and personal service. We did lots of research and saw that Reprofit was getting consistently good reviews on the fertility forums. We look back today with real gratitude at the way we were cared for by Reprofit. We weren’t rushed. They listened to us. And they directed us towards donor eggs sensitively and compassionately. Our treatment plan was spot-on. We were offered an amazing donor. We honestly couldn’t fault the service we received.
3. Great success rates.
Obviously we wanted to find a clinic with good success rates. Reprofit’s were excellent – and certainly higher than the UK clinics we considered. We focused on clinical pregnancy rates and the cumulative success rates for donor-egg treatment. The latter reassured us that our chances of success after more than one cycle went up quite a bit. As it happened, we needed a couple of follow-on FETs to succeed with our second daughter, Coral. So three cycles – one fresh and two frozen – gave us our two gorgeous girls! The key thing was that the results at Reprofit were clearly explained and consistent. There were no wild claims, just honest and solid figures that we actually believed.
4. Incredible donors.
Once we decided on the donor-egg route, treatment abroad was our only option. Donor supply in the UK was pretty poor n 2013, and it still is. At Reprofit, it was a totally different story. We were offered an excellent match and a proven donor. She produced a good number of top-quality eggs. There was no egg sharing, as sometimes happens in the UK (a questionable practice in our opinion). All the eggs from our donor were ours. Those eggs developed into seven amazing embryos, which led to the births of Ida and Coral.
Altruistic donation is far more common in the Czech Republic than in the UK, and there are other reasons for the excellent choice of donors at Reprofit. We felt comfortable and in good hands, since Reprofit is the most established clinic for donor eggs in the Czech Republic. The online reviews from other donor-egg patients were uniformly good. That really put us at ease.
5. It’s a holiday!
If there’s one thing we’ve learnt from our personal struggle with infertility, it’s that stress is bad. Very bad. So going abroad and spending a week relaxing while having our treatment helped. We were definitely less anxious. No mad dashes on motorways and trains to the clinic, as we did in the UK. The Reprofit experience meant we took it easy. We’re convinced it made a difference. On our two successful cycles, we even extended our stay in Brno by four days after our embryo transfer (implantation time). Did that help? Who knows, but we were certainly relaxed and happy. Leaving our stresses at home and having a ‘treatment holiday’ made sense to us.
In summary, choosing Reprofit for our fertility treatment was the right decision for us. Sure, the treatment worked – twice. But the whole experience was a supremely positive one. We now take our children to Brno whenever we can, and it’s comforting to know that we will always have a bond with this beautiful town and the wonderful Reprofit clinic. Five years later, we still count our lucky stars.
It’s a question we’re asked all the time. Should I transfer one or two embryos? Fertility patients often think transferring two embryos during IVF treatment boosts their chances. Are they right? Here’s our five-tip explainer.
1. One is best – most of the time.
Research continues to show that transferring one embryo per cycle is the safest option. Transferring two increases the chance of a multiple pregnancy and associated complications. (Not by a huge margin, but the risk is still significant.) These include pre-eclampsia, gestational diabetes and premature birth. From a purely medical angle, single embryo transfer is generally the way to go. At our clinic, the stats show that putting in two marginally boosts life birth rates. So the question boils down to this: why risk complications, particularly if you’ve got, or are likely to have, stored embryos? Back-up FET options are worth their weight in gold. Freeze and repeat is better than putting all your embryos is one basket.
2. A poor embryo can scupper your chances.
Interesting fact this, and not well-known. Transferring two embryos, when one embryo is poorer quality than the other, may lead to both embryos failing. A recent study found that, in around 25% of cases, putting in two embryos of contrasting quality led to less pregnancies than putting in one. Perhaps surprisingly, putting in two poor embryos did boost pregnancy chances. What can we take from this? The body likes consistency – and quality over quantity. Another argument for putting in one.
3. Think frozen, not fresh.
Clearly, the type of fertility treatment you have is relevant to the one-or-two debate. This is when a steer from your clinic is needed. A patient aged 40 having IVF treatment generally has a poorer prognosis than a 30-year old. Putting in two viable but medium-grade embryos during a fresh cycle may be wiser for the 40-year-old than putting in one. But consider this: FET pregnancy rates at our clinic for IVF patients are often higher than for the previous fresh transfer. Why? Because FET cycles don’t concern themselves with the heavy-duty FSH hormone medication taken in fresh cycles. So in an FET cycle after IVF, the body has a cleaner run at it. Freezing embryos after an IVF cycle may, in the end, be a better bet than transferring two in a fresh cycle – at whatever age.
4. Some bodies need single transfers.
There are other medical reasons why transferring one embryo in an IVF, donor-egg or FET cycle is sensible. A donor patient in her late 40s may well be advised to transfer one embryo to reduce strain on her uterus and placenta. Some patients who’ve had c-sections may also be better off putting one in. If a patient has a fibroid, polyp or sub-optimal endometrial lining – sometimes only spotted at the last minute – transferring one embryo and freezing the rest could be a good plan. Frozen transfers are almost as successful as fresh transfers these days. It may be inconvenient to return for an FET. But seeing your treatment as a two or three-cycle affair is better for your stress levels, not just your prospects. Repeat cycles also allow clinics to adjust and fine-tune your protocol. So an unsuccessful first cycle is simply a first step, not a disaster. Single embryo transfer is part of this new approach.
5. Don’t fall for anti-foreign-clinic clichés.
It’s a myth than non-UK clinics don’t do single embryo transfers. But read comments online and the myth persists, in the UK at least, that clinics abroad push multiple-embryo transfers on patients. Nonsense – they don’t. In the early days of IVF, clinics across the world (including the UK) more routinely transferred two or more embryos. That figure had dropped across the board. So trust in overseas clinics – particularly in the EU. The same strict European fertility regulations apply to all EU member states. And the quality and safety of treatment at EU clinics, post-Brexit, will continue.
To summarise, single embryo transfers are now routine. On balance, putting in one embryo per fertility cycle is the best option for most patients – medically, tactically and financially. The mantra really is: one at a time.
IVF treatment is tough – and the best people to tell you that are fertility patients themselves. The simple truth is, unless you’ve had IVF treatment, you can’t fully understand the emotional upheaval patients go through. It’s very real and very hard. Life-changing. Friends and family are generally well-meaning, but they can still say the wrong thing at the wrong time. So based on our experience, and that of our patients, here are five things NOT to say to IVF patients.
1. How’s the treatment going?
Sounds like a fair question, right? Wrong, though it does depend on your relationship with that person. That question from a close friend or family member could be fine. But generally, IVF patients don’t want to provide a running commentary and won’t appreciate being asked for a progress report. If a treatment cycle works, they’ll tell you. But probably not till the 12-week mark. Or maybe after the 20-week scan. So until you’re told, bite your tongue and just be patient.
2. Keep trying – you’ll get there in the end.
That’s not for you to say. You mean well, but no. First, it’s the doctor or clinic, based on medical opinion and prognosis, who should say this. Second, asking fertility patients to keep trying shows a lack of empathy in what they’re going through. Third, saying they’ll get there eventually may offer false hope. Not all fertility patients succeed. Don’t give hope instead of support. There’s a big difference.
3. Why don’t you adopt?
It’s so easy to ask this. But IVF patients already know their options. They’ll resent you for asking this deeply intrusive question. Adoption may be something they’re considering but they don’t need you to point it out. It’s a solution in your mind, not theirs, so be wary of recommending parental choices. Suggesting adoption also shows a lack of understanding of other options open to IVF patients, including embryo adoption, donor eggs or surrogacy. The point is, try to avoid giving parenting advice or opinion. It could backfire.
4. Not having kids is okay.
Best not to say this to patients knee-deep in IVF cycles – particularly if you’ve got kids yourself. It also implies you already think they’ve failed or decided to stop having treatment. It’s not your call to suggest a child-free life is fine. It may well be, but it may also be the last thing a couple struggling with infertility wants to hear. Actually, they may never want to hear it. So be careful about looking into their future – they’re doing this themselves. On a daily basis.
5. You’re using a donor – really?
Many infertile couples consider donor eggs or donor embryos if IVF using their own eggs fails, or is unviable. Sadly, despite donor treatment becoming mainstream today, some people disapprove. Don’t be one of them. Show support, not surprise. Donor eggs and embryos are a wonderful way to start a family and, for thousands of couples, including us, the end of a long and painful fertility journey. Besides, how people choose to conceive is their business, not yours. Love their donor-conceived child as much as they do and you’ll remain firm friends.
To summarise, choosing the right words to say to couples going through IVF is a challenge. Personally, we think gestures are best. The best support we received was actually not from family and friends at all. We’ll never forget the kindly neighbour who asked us round for supper the night before we had to terminate our first pregnancy at 14.5 weeks gestation for medical reasons. (This contrasts with a family member who said “it was only an embryo” after that termination.) Or the female taxi driver who waived her fee after driving us back from hospital. Or the school friend who asked if he could call us every so often to check how we were.
Kind gestures matter the most. And if you’re not sure what to say, silence is not an option either. It’s a tricky juggling act. But whatever you do or say, think first and offer support when you can. Be kind and you can’t go wrong.
What is ICSI? Most fertility patients know the basics. Fertilisation of an egg cell using ICSI means injecting a sperm cell directly into it. The aim? Better IVF fertilisation rates. But there’s more to ICSI than that. Here are five key things to think about.
1. Donor sperm, anyone? Not anymore.
Since the first ICSI (intracytoplasmic sperm injection) procedure in 1992, the use of donor sperm has dropped dramatically. More than 95% of men can now be birth fathers thanks to ICSI. It’s often overlooked just how much ICSI has helped with male infertility. It was the second IVF revolution.
2. ICSI is cheap to do – so don’t get fleeced.
ICSI only takes a skilled embryologist a few minutes to do. Yet some clinics charge hundreds, even thousands of pounds to carry it out. That’s pretty outrageous in our book. Look for clinics who include ICSI as part of their IVF treatment packages. Many overseas clinics do. Most UK clinics do not.
3. ICSI’s not just for men.
Back in the 90s, medics thought ICSI would only help couples with a male-infertility issue. While it undoubtedly helps isolate the best sperm in a sub-optimal sperm sample, ICSI pregnancy rates are sometimes better than standard IVF fertilisation methods. More stats are needed, but ICSI has developed a lot in 25 years. Micro-manipulation techniques and equipment have improved. More clinics do it and expertise has sharpened. Patients who produce fewer eggs, or who have a history of poor fertilisation, may also need ICSI to ensure fertilisation happens. So male-factor issue or not, it’s worth considering ICSI as part of your IVF cycle.
4. Men: here’s when you need it.
First, have a semen analysis. And have a proper one that looks at the five key parameters: volume, concentration, motility, progressive motility and morphology. It’s amazing how often we see test results that don’t cover all five bases. If sperm concentration is below 15 million/ml, ICSI will help. Same goes for a progressive motility score of less than 32%. And if morphology is less than 4%, ICSI may, arguably, help things along too.
5. Successful ICSI is down to several things, not just one.
IVF cycles using ICSI rely on many factors along the way. This makes quantifying the benefits of ICSI tricky. If the female patient is fertile and the male patient has a sperm issue, the ICSI cycle is more likely to succeed. So that’s more to do with the female prognosis than the male problem. An ICSI cycle is also only as good as the embryologist doing it, the quality of the lab and the skills of the doctor performing the embryo transfer. So ask your clinic about all of these before having it.
So what is ICSI all about? It’s about pinpointing the best sperm, improving fertilisation rates, potentially boosting pregnancy rates and addressing certain egg-related problems. More importantly, ICSI is a technique that’s got better over the years. It has focussed attention of ways to improve sperm selection and thus improve IVF outcomes. So it’s a stepping stone to more live births. Talk to your clinic to see if ICSI is right for you.
Norethisterone is sometimes prescribed prior to an IVF treatment cycle, whether that’s using your own eggs, donor eggs or an FET. An alternative to birth control pills, Norethisterone controls your cycle before your stimulating medication. Here’s how and why the drug is used.
Norethisterone is a synthetic form of progesterone, the vital pregnancy hormone that optimises your uterine environment and sustains your pregnancy. In your natural menstrual cycle, the body is producing progesterone in spades midway through your cycle. But fertility patients sometimes have irregular bleeds, making a medicated fertility cycle hard to plan. Patients with regular cycles may still want to time their fertility treatment, particularly if they’re travelling abroad for their treatment and need to book flights and time off work. Norethisterone makes this possible.
Birth control pills (BCPs) normally regulate a cycle before the stimulation phase to address these concerns. But BCPs don’t agree with everyone. Those over 40, with high blood pressure or with a history of aura migraines are the first to get a ‘no’ from their GPs. Why? Because BCPs are less natural than Norethisterone. Containing an equal dose of estrogen and progesterone, combined BCPs trick the body and don’t mimic the natural cycle. No wonder some women react badly to them. Norethisterone is just one hormone (progesterone) and fools the body in a much gentler way.
By taking Norethisterone from roughly mid cycle (typically 10mg daily) fertility patients can extend their menstrual cycle, delaying their bleed. Typically you can extend it by up to 10 days – sometimes less, sometimes more. Or you can use it to bring it on in the first place, if your bleeds are unpredictable. This bleed control gives fertility clinics the means to get you to bleed when it wants you to. Progesterone levels drop towards the end of a natural cycle. It’s this hormone drop that precipitates the bleed. Taking Norethisterone keeps your progesterone levels high. When you stop taking the pills, the hormone crash brings on your bleed three to four days later.
Timing the bleed that marks the start of your medicated cycle offers less flexibility than BCPs. The latter can regulate your cycle if started on day 1 to 4 of your bleed. But you can’t take Norethisterone for too long. So your bleed window is shorter. Very roughly, you need to start Norethisterone about six weeks before your estimated egg retrieval or transfer. You may need to adjust your treatment date if your bleed pattern is not quite aligned to this.
In summary, Norethisterone is medically safer than BCPs for controlling your bleed prior to your fertility treatment cycle. But it’s more complicated to time than BCPs. Talk to your clinic to see which route will work best for you.
Been prescribed birth control pills before your fertility treatment? It may seem counter-intuitive, but an initial course of birth control pills (or BCPs) is common for many fertility patients. Here’s why.
Birth control pills prevent pregnancy – we all know that. But BCPs before a fertility cycle allow the clinic to control your cycle and your subsequent, pre-stimulation bleed. For fertility patients travelling to another country for treatment, they allow you to book your treatment and trip well in advance, saving you money on costly last-minute flights. Once your bleed is controlled by the birth control pills, the clinic then tells you exactly when to stop them. Your bleed arrives three or four days after that. And you then start your stimulating medication, often on day 2 of that bleed.
Only the combined birth control pill will do. These contain an even dose of synthetic estrogen and progesterone. Progesterone-only BCPs don’t work so well. You’ll need to take the birth control pills for a minimum amount of time – usually 18 days. This means you must start them at least six weeks before a frozen embryo cycle or at least five weeks before an IVF cycle using your own eggs. For donor-egg cycles, five weeks will also do. Any less and the clinic needs to organise your treatment in a different way.
Birth control pills aren’t suitable for all fertility patients. If you’ve got high blood pressure or a history of aura migraines, BCPs may not agree with you. Other medical conditions may also preclude their use. Doctors are sometimes wary of prescribing birth control pills to fertility patients over 40. But as the BCPs are for short-term use only the risk to older patients is often not that great. But speak to your doctor about this.
Since donor-egg fertility patients are often in their 40s, there’s also a non-BCP option you can take. The timing of your bleed pattern in relation to your donor’s estimated egg-retrieval day might allow the clinic to avoid the use of BCPs altogether. Instead, your down-regulation injection (if needed) may be used to start off your treatment cycle. Usually, though, donor-egg recipients will be on BCPs and the timing of that injection in relation to the end date of the BCPs helps brings on the bleed just before you start stimulation. That’s the optimal way to synchronise your cycle with your donor’s cycle.
It’s slightly – very slightly – optimal not to take birth control pills before fertility treatment. A body without made-made hormones is more ‘natural’ than one with them in. But the advantages of using BCPs prior to treatment, particularly those planning IVF trips to other countries in advance, outweigh this.
If you’ve had unsuccessful fertility cycles, there’s a stronger argument for planning follow-up cycles without using BCPs at the start. That applies to IVF and FET cycles, but it’s not so relevant to donor-egg cycles. If birth control pills don’t agree with you, an alternative approach to controlling your cycle before a fertility cycle is to use Norethisterone. This progesterone-only medication works in a different way to BCPs, prolonging your bleed from mid cycle. Since these pills can’t be taken for too long, they are less flexible than birth control pills in terms of planning your treatment well in advance. But they can have less side effects than BCPs.
For fertility patients travelling abroad for treatment, your clinic will advise on the use of birth control pills. Most of the time they are indispensable. Occasionally, they should be treated with caution.
Is mild IVF, or minimal stimulation IVF, worth considering? For some patients, this lower cost alternative to a standard IVF cycle means lower success rates, so why bother? But a growing number of clinics are seeing good results from mini IVF cycles. Let’s look at the facts.
In brief, mild stimulation IVF is a treatment cycle that often uses a lower daily dose of injectable FSH medication, combined with clomiphene (Clomid) pills. The FSH medication is the same as for high-dose cycles (Menopur, Gonal-F, Puregon). In traditional IVF cycles, a patient may inject between 125 and 450 daily units. In a mild IVF cycle, the FSH dose drops to between 75 and 150 units daily, depending on your personalised protocol. Typically a minimal-stimulation cycle adds in 150 to 200 mg of Clomid pills each day. Clomid stimulates follicle growth in a slightly different way to FSH injections.
So what’s the aim of a mild stimulation IVF cycle? Generally, to grow fewer but better-quality follicles. If you’re in your forties and/or have an AMH level below 10 pmol/l, a mild IVF cycle may produce more viable eggs. Blasting your ovaries with 475 daily units of Menupur may do more harm than good. Think of blowing bubbles. Blowing gently can lead to bigger and better bubbles. With mild IVF, the approach is the same: keep it light and gentle.
This approach, using lower levels of ovarian stimulation, is catching on. It’s less aggressive than a standard IVF cycle. It’s kinder on the body. It’s cheaper, because FSH medication is very expensive. Although producing fewer eggs generally leads to poorer outcomes, mild IVF may work better for those patients who respond badly to high-dose cycles.
Looking at the success rates at our clinic for mild stimulation IVF cycles, there are encouraging signs. Mini IVF cycles produced, on average, around 3 eggs at egg retrieval. Standard IVF cycles averaged around 9 eggs. Fertilisation rates were just as good for both approaches (around 75%). But despite producing a third of the number of eggs as standard IVF cycles, mild IVF cycles had a pregnancy rate of 36.1%, compared to 51.7% for standard cycles. So lower, but not by that much.
For the right patient, a mild stimulation cycle may be worth considering. Clinics may make more money with traditional IVF cycles. But clinics with integrity, skilled at judging what is truly best for patients, are carrying out more mild IVF cycles than 10 years ago. After all, the interest of the patient is paramount.
Some causes get it absolutely right, and National Fertility Awareness Week is one of them. It runs from 30 October to 5 November, the weekend of the Fertility Show. We encourage anyone interested in fertility to donate. This scheme is doing incredible work, highlighting how infertility affects 1 in 6 couples and raising money to help them.
Whether you’re one of our patients or not, please give something. The money you give in National Fertility Awareness Week helps the charity Fertility Network UK provide free support to anyone struggling with infertility. It’s recognised as a medical condition by the WHO, and rightly so. The anguish caused by infertility is very real – we know that as past fertility patients ourselves.
Whatever you donate, it all helps to bring support and solutions to singles and couples facing fertility problems. Many infertile people don’t realise that infertility is a condition they can overcome. National Fertility Awareness Week can shine a light on how. Fertility Network UK tirelessly campaigns for better access to NHS fertility services, provides local support to people with fertility issues and coordinates a network of volunteers and advisors.
We like this year’s #Talk Fertility initiative – getting people to talk about their infertility. Only by talking can we change attitudes to infertility. It’s no longer a silent disease. Friends and family of those with infertility need to know, and understand, what sufferers are going through. Only then can they really help and say the right thing, not the wrong thing! Male patients often find it harder to talk, and the #FertilityFellas campaign is a great idea to get them talking too.
It is 40 years since IVF was invented. It has transformed millions of lives and brought hope and help to a very personal kind of suffering. If you’d like to donate to this very worthy cause, here’s the webpage to do it. Thank you for your support – and see you at The Fertility Show!
Female fertility is a hot topic. So why is male infertility never really talked about? In a fertility industry geared towards women, medical help for men also exists. Obviously. 1 in 50 men produce no sperm in their ejaculate, even though healthy sperm is stored in their testes. Since IVF requires a sperm sample via masturbation, this statistic is relevant. Surgical sperm retrieval (SSR) is an option for men with serious fertility issues. Read on to discover 10 facts you should know about surgical sperm retrieval.
1. SSR – what exactly is it?
Before an IVF cycle, the first step for male partners is to provide a semen analysis. Depending on the results, and in quite rare cases, surgical sperm retrieval may be needed prior to egg retrieval. Some men may have a very low sperm count (azoospermia) or no sperm in their semen. SSR is an impressive technique for collecting sperm directly from a man’s testicles, epididymis or vas deferens. Many men don’t know about it. But it can be a successful solution for male-factor infertility.
2. Obstruction or not?
There are several ways to obtain sperm by medical intervention. The exact method of surgical sperm retrieval depends on why sperm aren’t in the semen. For men who produce no sperm in their ejaculate, there’s a 50% chance it’s due to a blockage in one of the tubes that carry sperm from the testes. When obstruction is the problem, which can occasionally be caused by conditions such as testicular cancer, TESA, PESA, Perc Biopsy or MESA are suitable. These can generally retrieve large numbers of sperm.
If there’s no obstruction and still no sperm, it’s likely there’s a problem with sperm production. A more invasive retrieval method may be needed, such as TESE or Micro-TESE.
3. Surgical sperm retrieval – the full list.
The six main SSR treatments all work a little differently. Here’s a breakdown.
PESA (percutaneous epididymal sperm aspiration). This is perhaps the simplest and least invasive SSR procedure. Sperm is collected through a fine needle directly from the epididymis – the tube connected to the testicle. It’s performed under local anaesthetic). If PESA doesn’t work, then NAB (needle aspiration biopsy) can be tried.
TESE (testicular sperm extraction). If both PESA and NAB fail, this technique can be used. TESE is a more invasive procedure. Biopsies are taken from a larger area of testicular tissue, not the epididymis. These are examined under a microscope to find small numbers of usable sperm. It’s perhaps the most popular surgical sperm retrieval method.
Micro-dissection TESE. This is slowly replacing TESE as a more optimal form of retrieval for men with no sperm in their semen. Very similar to the TESE technique, micro-TESE uses a micro-dissecting microscope to pinpoint the tissue to be removed. Much smaller biopsies are taken. Less damage is caused to the structure inside the testicle.
TESA (testicular sperm aspiration). A needle is inserted in the testicle using a biopsy ‘gun’. This obtains samples of sperm and tissue using gentle suction. These are then carefully dissected under a microscope. Like the other techniques, any sperm found are cultured and/or frozen for future use in an IVF cycle – typically using ICSI.
Percutaneous biopsy. This is similar to TESA, but a different needle is used. It’s sometimes called a fine needle biopsy. A biopsy is taken from the testicular tissue and it usually retrieves a larger number of sperm.
MESA (microsurgical epididymal sperm aspiration). This procedure usually requires a general anaesthetic, as a microscope is used. It’s carried out when PESA is not possible and may also allow an attempt to surgically correct any obstruction. There’s a 70% success rate.
4. Surgical sperm retrieval loves vasectomies.
Many men have a vasectomy as a means of contraception, then later regret it when they want more children. SSR removes sperm surgically. So for men who’ve had a vasectomy, a failed vasectomy or perhaps have no vas deferens, SSR is a godsend. PESA and MESA are often considered the optimal SSR procedures for post-vasectomy patients. The chances of collecting usable sperm are pretty high.
5. SSR is low risk.
Surgical sperm retrieval is a relatively low-risk procedure. But, as with all operations, there can be complications – including bleeding, infection and haematoma (blood clot) in the testicle. There’s also a very small risk of testicular damage and chronic testicular pain.
6. Success rates look promising – so far.
Surprising, the jury is still out on the precise success rates of surgical sperm retrieval. Like so many infertility treatments, large-scale randomised trials are sorely needed. One clinic we spoke to said that men with obstructive azoospermia have a very high chance of recovering sperm via SSR (over 90%). For men with non-obstructive azoospermia, another clinic said the chances of recovering sperm is approximately 40%. If any clinics or practitioners are reading this post, please leave a comment with your stats.
7. Okay – but it is really always needed?
One argument is that surgical sperm retrieval is not necessarily always needed. The American Society of Reproductive Medicine says that SSR has revolutionised the treatment of azoospermia. But because of how easily it is performed it’s now perhaps being over-used. And they say in no way should it be done without counselling first. Like ICSI, SSR has become mainstream. But routine treatments are not always right.
8. It’s all about… price.
Let’s talk money. Surgical sperm retrieval can be pretty costly, with prices ranging from £500 to £3,000. But the average UK price, including a pre-op assessment, seems to be around £1,500. (At the Czech clinic we work with, it’s £500. Enough said.)
9. After all that, it’s over to ICSI.
Once sperm has been successfully retrieved, intracytoplasmic sperm injection (ICSI) can be used to inseminate the collected eggs. Success rates for ICSI, post-SSR, are very similar to those using ICSI and ejaculated sperm. Or to put it another way, once SSR is carried out, the chance of creating viable embryos is very good.
10. Donor sperm as backup? You may need it.
Is surgical sperm retrieval fails, what happens? The short answer is that a sperm donor may be your next option. It’s not for everyone, but if your objective is a baby and a repeat SSR also fails, it may be your only route. You may also have just had your eggs collected, so no back-up means a wasted cycle. The good news? Plenty of clinics abroad, and third-party providers, can help. Don’t assume you need to use a UK sperm donor if you live in the UK. Clinics in mainland Europe far exceed the UK in terms of supply and recruitment of sperm donors. Do your research and you’ll find an option to suit you.