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“During my undergraduate degree in biochemistry at the University of Birmingham I realised that embryology was the career for me, so when I was offered the chance to undertake an internship at Bath Fertility I jumped at the opportunity.

Now having spent 3 months in the lab I have gained invaluable experience and a real insight into the vital roles embryologists play in a patient’s IVF journey.

During my internship I have received hands-on experience and training in lab work including semen analysis, a really important step to identify male factor infertility. Since being trained I have performed the daily semen analyses where I have learnt that patients are suitable for different treatments depending on sample parameters such as motility, morphology and concentration.

It has been great to have been given this responsibility and already receive training on skills that will be part of the day to day life of an embryologist. Along with this I have learnt so much about the different stages of treatment including the cryopreservation of gametes and embryos as well as embryo grading and the identification of top quality embryos for transfer.

I have also learnt about recent technologies that have been introduced into laboratories such as time-lapse imaging of embryos to minimise disturbances during culture.

Along with the lab work I have been lucky to spend time in other departments, observing egg collections and scans with the nurses, and with the admin department who have important roles as the first point of contact for patient treatment as well as answering and directing patient queries. I have seen how well the departments at Bath Fertility work together to deliver patient-focused care and help patients realise their hopes and dreams of a family.

In a few weeks’ time I am moving to London to begin an MSc in Reproductive Sciences and Women’s Health at University College London. After this I will apply to the NHS Scientist Training Programme to try to gain a place as a trainee embryologist.

The practical skills I have learnt and knowledge I have gained about fertility treatment as well as advice on applications and interviews from the embryology team will help so much with my future endeavours and I can’t thank Bath Fertility enough for giving me this amazing opportunity!”

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Our Counsellor, Gill Aldridge, says she often hear patients comment that walking through the doors of Bath Fertility feels like handing over control of their lives to the medical team.

Frequently, patients tell her they feel powerless in their fertility journey, as there is no certainty and no guarantee of success.

“You are working with science and statistics where you feel creating a baby should be about emotion and intimacy”, says Gill.

People who come to Bath Fertility naturally don’t have expert knowledge and have to rely on others. Your body is not doing what it “should”, and often, there are no real explanations. “The internet tells you everything and nothing. This powerlessness and uncertainty can gradually creep into all areas of life. For many if feels no longer possible to plan, to change job, to move, to go on holiday”, she says.

From an evolutionary standpoint, if we are in control of our environment, then we have a far better chance of survival. Control is consequently of vital significance to our wellbeing. It is in reality the sense of control, rather than actual control which seems to be important. That sense of control is supported by a number of key factors:

  • A sense of certainty
  • Understanding how things wok
  • Being able to predict what will happen
  • That people (including ourselves) and things are consistent

Gill says “Patients often tell me that they struggle with all of these”. It might be helpful to consider how you could bring a level of control back into your life.

“Make time to talk, structure space to look after yourselves and have fun. If you have questions about your treatment, ring the Patient Advisors and make sure we have explained clearly what you need to know”.

“Ask yourself why you have given up planning, why your life is on hold. Does it really need to be? One area of your life is certainly in flux, but does it have to drag the rest of your world along too?” she says.

At this time of the year, some don’t want to book a holiday because they think they might be in treatment, or pregnant, on the 2 weeks wait, which is normal and common, but is it necessary? The benefits of relaxation, escape and time together could bring a sense of control back into your relationship, give you time to remember why you are together and build resilience. “Whether it’s a staycation, a tent or a palace, take control and look after yourselves” Gill says.

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In natural conception, the open end of the fallopian tube moves towards the ovary. At ovulation the egg is released when the surface of the follicle gently tears open.

The open end of the fallopian tube is fringed with little tentacles (a bit like a sea anemone) and these little fronds, called fimbriae, gently catch the egg as it is released and waft it into the open end of the tube. Microscopic hairs create gentle waves of current, moving the egg slowly deeper into the tube, and there it waits to be fertilised. If it’s the lucky egg, sperm will be making their way towards it. Only the fittest sperm will reach the egg, as they will have had to swim from the vagina, into the cervix up into the uterine cavity, across the cavity and into the tubal opening, then along the length of the tube. The first sperm to reach the egg will penetrate it, and the egg responds by locking out any other sperm which might reach it.

The day after this fertilisation process, the egg and sperm join their genes together and the embryo then starts to grow by cell division, first two cells, then four, then eight and so on as each cell splits into two. During this process of cell division the tube continues to gently waft the embryo towards the uterus, where it arrives about five days after fertilisation. By this time the embryo has a few hundred cells, and is called a blastocyst.

When IVF was first developed embryos were transferred at the early cleavage stages (between two and eight cells) as it was not possible to culture embryos successfully in the laboratory beyond this stage. Eventually the Embryology Scientists discovered the secrets of culturing embryos up to blastocyst stage (Day five), as the very exacting requirements of embryo growth were revealed. It was then possible to mimic nature more precisely by putting blastocysts into the uterine cavity, which is when they would normally be expected by the endometrium awaiting their implantation. This is one of the reasons why blastocyst transfer allows a higher pregnancy rate. The other important reason is that an embryo which can achieve blastocyst status is a very fit and active embryo, and has a higher implantation potential.

What is a blastocyst?

A blastocyst is an embryo that has been allowed to develop for five days or more after egg collection. By day five it has developed a small cavity which contains a clump of cells that will grow to form the baby. This clump of cells is called the inner cell mass. The outer cells form the placenta and membranes.

Why doesn’t everybody have blastocyst transfer?

Only a proportion of cultured embryos reach blastocyst development stage, and many of the early embryos may falter and fail to grow further. Blastocyst culture therefore is a more selective process, enabling the embryologists to select the “cream of the crop” to give the very best chance of a successful pregnancy. If it becomes evident which is the best embryo at an earlier stage, or if there are only one or two embryos, they will be transferred at that point.

At Bath Fertility the majority of our patients have embryos transferred at the blastocyst stage.

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Bath Fertility was one of the UK centres involved in the PIP-study, an international randomised controlled trial looking into the effects of endometrial scratching on IVF treatment outcomes.

The results were presented at the 2018 ESHRE annual conference and caused quite a stir because the research showed there was no difference in pregnancy rates between women who had the scratch compared with those who did not. A brief overview of the results can be found here.

Our Senior Embryologist, Emma Votteler, was responsible for coordinating Bath Fertility’s involvement in the study. Following the release of the results people have been saying to her “You must be really disappointed with the results since you put so much time and effort into recruiting patients?” But Emma says, “I am delighted that we could make a contribution to this important research. The whole purpose of conducting clinical studies is to ensure that we are offering safe, effective treatments to our patients. We can only provide answers to these questions through this kind of research. The last thing we would want to do is recommend treatments that potentially have little benefit for our patients, which is why Bath Fertility are now no longer recommending endometrial scratch for our patients.”

Here Emma describes her experience of recruiting and monitoring patients for the PIP study.

“Before I could begin recruiting patients for the study in July 2016 I had several meetings with the Lead Study Coordinator Dr Sarah Lensen, and Dr Sarah Armstrong, the Local Study Investigator. I also had to attend a Good Clinical Practice (GCP) course which is mandatory for those involved with clinical research – the purpose of which was to give me all the information I needed to know about clinical research to ensure the rights, safety and dignity of research participants. It also helped ensure I was collecting the best quality of research data that I could.

My task was to seek out candidates and to give them all the information they needed to decide whether they would like to participate or not. This involved me checking a lot of medical records, reading all the clinical details and checking whether the woman met the eligibility criteria. If she did, I would indicate to the doctor seeing them for their appointment that the patient may be suitable for recruitment into the study. All in all I must have looked at well over 400 sets of medical records, and 240 patients were approached. Of those I spoke to I had make sure they fully understood what they were signing up for, as consent to a study is key and this was only completed after all information had been given and understood. Overall I managed to recruit 48 women.

I added patient data to a secure online database where the patient was randomly selected to have the procedure or not. There was a 50/50 chance for either outcome. Patients were often disappointed when I told them they had been randomised into the ‘no scratch’ group but were still understanding and were still happy to be contributing to the study as a whole. We stopped recruiting new patients at the end of May 2017, and to recruit 48 patients in under a year was a massive achievement for a clinic of our size which was recognised by the study coordinators.

Many people think that once you have randomly allocated a person into a study and they go on to have their procedure (or not) that’s where it stops. But in actual fact a study coordinator has to report on several things right up to a live birth. There began my endless phone calls and emails to our kind patients, from me asking if they could give me the results of their scans and then information on babies born as a result of treatment. This is also why it takes so long for results of a study looking into an IVF treatment to be published. Everyone was so patient and helpful and that made my job a lot easier. I am so grateful to all the women who participated.”

The written report of this study is due to be published in a peer-reviewed scientific journal in autumn 2018.

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The Human Fertilisation and Embryology Authority (HFEA) – our regulatory authority – requires all clinics to provide information about treatment outcomes which are then verified and published on the HFEA website. These are available to anyone who wants to check a clinic’s performance.

In the past pregnancy rates were published annually in a handbook, which was eagerly pounced on by the Press who would then produce “League Tables” of the ‘Top Ten’ IVF clinics for the next days’ papers. Unfortunately, it proved to be possible to manage the data deliberately to enhance rankings, and the handbook was scrapped in favour of regularly updated digital postings; annual League Tables have now disappeared. It is however, still possible to research individual clinic results site by site here https://www.hfea.gov.uk/choose-a-clinic/

The HFEA now report “births per embryo transferred” because they consider it the best measure of a clinic’s success and say it allows people to make a fair comparison between clinics.

Q: Do “pregnancy rates” accurately reflect a clinic’s performance?

A: By and large the answer is yes, but outcome measures can still be affected by clinic practices.

Q: How?

A: A simple way to do this is to replace multiple embryos: more embryos = more implantations = more pregnancies. The problem with this practice is that the pregnancy rate is only increased a bit, but the multiple birth rate is increased a lot, and this is associated with an increase in risks of prematurity, low birth weight and perinatal mortality.

The HFEA has tried to overcome this tendency by setting targets for reduced multiple births. The current target is 10% for multiple pregnancy rate (MPR) and has been for a few years now.

We have had an MPR less than 10% for the last five years, but many clinics have still failed to achieve this.

As Obstetricians we often look after the patients we have treated, and so we are very aware that multiple pregnancies are not always easy – we therefore feel it is more ethical to promote single embryo transfer to avoid the unnecessary risks that multiple pregnancies can have.

Each clinic has to provide the MPR, and it can be found in any clinics’ data if looked for. Improvements in embryo freezing, resulting in good pregnancy rates means that there is less need to transfer multiple fresh embryos, and our ethos is “One healthy baby at a time”. We think this is the best practice.

Q: Are there other things that affect pregnancy rate?

A: Yes – ovarian reserve has an effect: Patients with lower ovarian reserve produce fewer eggs, which can reduce the pregnancy rate. It is possible to use strategies to avoid inclusion of this group in a clinic’s data. We believe everyone has a chance of a pregnancy, as long as they have some eggs left in their ovaries. We won’t give false hope, but we will be ‘up front’ if chances are low. We do however discourage women over 43 years old from attempting IVF, as the pregnancy rate is virtually zero by this time, and whilst eggs may be recovered and fertilised, unfortunately pregnancies rarely follow in this older age group.

Q: So, how can I be sure that my clinic is giving me a good chance of having a healthy baby?

A: Look at the pregnancy rate for your age group and compare to the national norm, as well as other clinics that interest you. Look at the multiple birth rate, is it as low as it should be, remember healthy babies, one at a time, is best.

Look at the frozen embryo pregnancy rate for your age group – if it’s good, then your frozen embryos will be safe for future use if needed, and your clinic will look after them well. Remember that pregnancy rate is only one measure of a clinic’s treatment, and your health and especially your baby’s health with a safe pregnancy is what really counts.

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By N.C Sharp, Senior Director at Bath Fertility

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There has been a lot of attention in the press lately around endometrial scratching, a procedure that was thought to help embryos implant by improving the endometrial receptivity.

Endometrial scratching involves creating a small area of injury to the endometrium by passing a sterile catheter through the cervix and into the uterus. The endometrium (lining of the uterus) is then gently “scratched”. Early research appeared to show that the procedure could be beneficial for some patients, however these studies had significant limitations which may have led to bias in the results. This meant it was not possible to say with confidence whether endometrial scratching could increase the chances of pregnancy.

We recently participated in an international research program (PIP study) assessing the benefit or not of endometrial scratch on pregnancy rates following IVF treatment. The PIP study recruited more than 1300 patients and the results were presented at the annual ESHRE Conference held in Barcelona earlier this month.

Overall, the results of this important study showed that there was no benefit from this procedure and we will therefore no longer be recommending this procedure in IVF treatment.

A brief outline of the results from the PIP study can be found here: https://www.focusonreproduction.eu/article/barcelona-adjuvant-treatments/1791AF8A-AD05-4C42-B42D-52C989925E5C

There are ongoing studies assessing the use of endometrial scratch in women with Polycystic Ovary Syndrome (PCOS, a common condition which affects how a woman’s ovaries work) and in couples with unexplained infertility.

If you have any questions regarding endometrial scratch, please contact us on 01761 434464.

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During fetal development, the female baby develops her own store of eggs – approximately 4 million in fact.

By the time the girl has reached puberty, many of these have disappeared – though we don’t know why. At puberty there are about 400,000 eggs in the ovaries, and these will gradually be used up over the next 40 years, until the menopause is reached – on average around the age of 52.

Unlike males, who produce sperm continuously throughout life, women cannot make eggs after birth, and simply use up their egg stock bit by bit. One would think that nearly half a million eggs would be enough to last a couple of centuries at least – unfortunately though, they are used up in batches, not one at a time, and for some women this seemingly wasteful use of their eggs can leave them short, just when they need them.

One day we may understand why so many eggs are just wasted, but at the moment we do not know the reason. Unfortunately, the programmed wastage cannot be stopped – even with going on the pill to suppress ovulation, the menopause will still arrive at its allocated time – pre-ordained at birth by the girl’s genes. At present the only mechanism that seems to prolong fertility slightly is pregnancy itself, which is why some older women with children seem able to become pregnant at an age when another woman trying to conceive for the first time finds it impossible.

We hope one day to understand how suppression of ovulation by natural pregnancy may spare fertility in a way that drugs can’t, but for the moment we have to look to artificial means in the form of egg freezing.

Q: What exactly is egg freezing?

A: Currently the term is applied to eggs produced by an IVF process. This involves a course of injections of fertility hormones – usually for 10 to 14 days. One or two ultrasound scans are needed to monitor growth of the follicles containing the eggs, which are then collected under sedation using ultrasound guidance. Instead of being fertilised with sperm, the eggs are frozen using a technique called vitrification. Once vitrified, the eggs theoretically can be stored indefinitely, although there are regulations regarding storage periods (usually a maximum of 10 years).

Q: Why would anyone want to freeze their eggs?

A: Egg freezing (or oocyte cryopreservation as it is technically known) was initially developed to preserve the fertility of women about to undergo treatment for cancer, which in many cases will kill the eggs as well as the cancer cells leaving them infertile. The technology has developed rapidly in recent years and it has become fairly reliable as a form of treatment, which has led to an extension of its use for other reasons.

The other main reason is so called “social” egg freezing. Increasingly, modern lifestyles have led to deferment of childbearing such that having a family is preferred at a more mature age. Whilst this can have undoubted benefits, the ovaries remain unaware of the changed priority and continue to carve their way through the reserve egg stock, so the eggs may not be there when they’re really wanted. Egg freezing means that some eggs can be reserved and protected from the passage of time. The other main reason for egg freezing is when early menopause might be expected because:

  1. it’s a family trait, or
  2. a woman has had ovarian tissue removed for disease

More recently a third group has started to emerge – these women who have requested testing, and found to be heading for an early menopause, often unexpectedly.

Q: Should I get tested?

A: You should definitely get tested if early menopause is known in your family. In some families it comes earlier with subsequent generations, so early testing is advised if you want the chance to have children. Anyone having ovarian surgery should also consider testing, if they are yet to have children. The test measures AMH (anti-mullerian hormone) and can be taken at any time in your menstrual cycle. It is an easy check to have for anyone who has a concern or feels time might be running out for any reason. It may be possible to obtain this blood test from your GP – there may well be a charge for it (typically £60-80).

Q: Can I freeze my eggs at any age?

A: No. Unfortunately, the usefulness of egg freezing diminishes with age. It is best undertaken before the age of 38, and preferably 36 or younger. There are two reasons for this – quality and quantity. Older eggs are less likely to produce a successful embryo, and also they are less likely to freeze well. Older women generally produce fewer eggs per cycle of stimulations, and not all eggs collected will be suitable for freezing.

To stand a realistic chance of having a baby from frozen eggs, quite a few need to be stored – some studies suggest as many as forty! From smaller numbers, good luck may also be needed. At Bath Fertility we have had lucky patients, confirming that egg freezing really does work in practise.

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Here at Bath Fertility we support our employees continued professional development, so we are delighted that our team member, Hannah Long, has moved from the Business Team to become a Health Care Assistant in the Nursing Team.

Hannah has always been passionate about health care and became increasingly interested in fertility when working as a Patient Advisor.

We believe organisational transfer helps our employees gain new and broader skills, which will make them an even greater asset to the centre. Additionally, it can also benefit employees’ different aspect of the workplace and organisation.

“I am very grateful for the opportunities that Bath Fertility have given me. I am really enjoying my new role as Healthcare Assistant working with the Nurses. I hope to continue offering compassionate care and support to patients, which the team at Bath Fertility are so well known for. I would also like to thank Lucy George especially for the support and guidance throughout my training” says Hannah.

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If you are interested in donating your eggs, or need donor eggs as a part of your fertility treatment, you will meet our friendly Donation Coordinators.

Our team are experts in understanding the circumstances of women who would like to donate their eggs, and also women who need donor eggs in their treatment.

The first step towards egg donation is to book you in for a counselling session with our Counsellor, Gill Aldridge. This appointment will be for about an hour, and if you are in a relationship, your partner should also attend. If you have any questions prior to booking, feel free to contact our Donor Administrator, Jenny Cross, who will be happy to help.

Why do potential donors need counselling?

Counselling is an integral part of the egg donation process. We do find it extremely important that all potential donors understand what their donation will mean. Our Counsellor, Gill, will discuss the donation process, answer any questions you may have, and explore the implications of the decisions being made – for you and for any future children created as a result of your donation.

At Bath Fertility, we want to be sure that we give you all the information you need and also that we will support you throughout the process. Once you have had a session with our counsellor, you may decide that donation is not for you and your journey will then end here. If you decide you would like to go ahead and become an egg donor, you could be giving someone else something they never thought they would have – a family of their own.

I have made my decision and would like to donate, what’s next?

Following your session with our counsellor, you will be booked in for an appointment to have an AMH blood test to check how your ovaries may respond to the fertility drugs. Occasionally this result indicates you would not be able to donate.

Once we have the results of your blood test, we will book you in to see one of our Donation Coordinators: Clare Williams or Helen Miller. You will also have a vaginal ultra sound scan and some additional blood tests at this appointment.

When the results of blood tests are available (about 8 weeks later), your egg donation cycle can begin.

What is the treatment for donating eggs?

The treatment for egg donation is similar to IVF, except that you will not have an embryo transfer. You will also be officially registered with the HFEA Human Fertilisation and Embryology Authority as an egg donor.

We want you to feel supported and cared for during this time. Should you have any questions or concerns, do not hesitate to contact our friendly Donation Coordinators. For more information, please call us on 01761 434464, or email us on enquiries@bathfertility.com.

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