How to play the ‘Fertility Waiting Game’ and win
For many IVF patients the HFEA’s decision to call for an almost immediate halt to fertility treatment in early April in the UK because of the coronavirus pandemic came as a bitter blow. Many were only days away from starting stimulation or having an embryo transfer and had possibly spent months or even years either sitting on a waiting list for funded treatment or saving up as private patients.
However we were allowed to start up treatments again quite soon and it is certain that storage times, qualifying ages and access to funding will be adjusted to allow for the delay caused by the pandemic. But that may have been little comfort to people dreaming of becoming parents but either constrained by working from home or stressed by their courageous decision to work supporting the community in vital ‘frontline’ jobs.
So what can be done to help cope with the waiting AND increase the chance of the treatment working when the ‘lockdown’ is lifted?
All IVF patients are well aware how the skills of the doctors who make the diagnoses and decide the treatment options, the nurses who teach, support, care and scan and the embryologists who work with the infinitesimally tiny little dots of protoplasm that have the potential to become our patients’ babies are crucial to the success of the procedure. But what is important to know is that the IVF patients too have a significant role to play in optimising the outcome.
Those of you who’ve read my blog on Nutrition will know how important I believe a low carbohydrate ‘Mediterranean’ diet is for improving IVF outcomes. A low carb, lean protein, leafy vegetable diet not only aids weight loss (which is very important for the 1 in 5 IVF patients who are on the Polycystic ovary spectrum), but has been shown to reduce miscarriage and gestational diabetes. The eggs that we collect during an IVF cycle actually started developing 3 months earlier in tiny pre-antral follicles around the edge of the ovary. The ‘antral follicles’ that are counted as part of Ovarian Reserve Testing are what they develop into a few weeks later and it is these follicles that get recruited when stimulation with gonadotrophins start. So the quality of the eggs we collect is influenced by what happened two to three months before. This may explain why women having an egg collection when they have been ill in the last few months sometimes have an unexpectedly disappointing result.
So now is the perfect time to commit to the weight loss and fitness programme that will move your BMI closer to 25 than 30. See my blog ‘Why BMI is such a weighty problem’ for all the evidence about weight and fertility treatment outcomes.
The same 2-3 months rule applies to sperm production as well. The sperm cycle is about 70 days as the sperm develop from tiny round cells to spermatids with stumpy tails into fully mature sperm with long swishy tails.
Any lifestyle changes that are made such as stopping smoking, losing weight, taking supplements and staying out of hot baths and saunas will take 2-3 months to show the benefit. The closure of gyms during the lockdown means that many men will be doing their workouts at home or restricting them to their daily hour of exercise. It is important to remember that testicular cooling (by wearing loose boxers rather than tight pants) was the only intervention shown to positively influence sperm parameters in a large cross-sectional study carried out in America. This matches research undertaken by Prof Allan Pacey from Sheffield University here in the UK. So fast cycling in tight Lycra may not be so good for sperm production!
We are increasingly seeing young men seeking fertility treatment with poor sperm who have been taking steroids or steroid mimics such as soya as part of their ‘body building’ programme. Androgens and steroids can certainly build muscles but they can have a devastating effect on sperm production and are to be avoided. The clearest evidence for this was the development of a male contraceptive that was testosterone based. Sperm counts dropped to practically zero, but the chaps kept forgetting to take the tablets!
Stress is clearly a factor for fertility patients in Coronavirus times and the work of Prof Jacky Boivin from Cardiff has shown there is clear evidence that negative psychological traits and mood states are associated with reduced conception rates in women. These effects have been found in women who are trying to conceive naturally and in women undergoing fertility treatment—mainly IVF but also donor insemination. The association has been shown with diverse psychological measures such as anxiety and depression and especially where a couple have different attitudes to starting or continuing treatment. Telling people not to get stressed is not very helpful! However, stress management is vital and recent research has shown that interacting with Nature; just spending time in green spaces, walking through woods and planting seeds can be just as effective as medication. There are lots of resources on-line to help so this might be the time to try yoga, meditation or Mindfulness.
Many patients have a diagnosis of ‘low ovarian reserve’ based on a low AMH level or poor response to stimulation in a previous cycle. They are understandably worried that any delay in starting or restarting treatment could seriously affect their chances of success. This isn’t how biology works fortunately. The same dose of the same stimulation drug for the same woman just two months apart can produce a different result in either direction. And the same dose and drug for two different women at the same time with the same age, AMH and BMI can produce quite different responses. Mother Nature doesn’t know it was your 35th or 40th birthday, so try not to worry about a little delay.
An interesting retrospective study just published in the journal ‘Human Reproduction’ gives further reassurance to women worried about delay. The American authors reviewed nearly 1800 cycles of treatment for women having a first fresh IVF cycle at their clinic who had been diagnosed with low ovarian reserve (an AMH level of less than 8 )and divided them into 2 groups: 2/3 had started their IVF stimulation within 3 months of first attending the clinic and the other 1/3 started between 3 and 6 months later. The average age of the women was 39 years. 90% of the women in both groups got an embryo transfer and there was no difference in the live birth rates between the two groups (23.9% for the ‘immediate’ group and 25.6% for the ‘delayed’ group. When they looked at women with very low ovarian reserve (AMH less than 3.5) there was still no difference between the two groups with live birth rates of 18.8% and 19.1% respectively.
These results suggest that a delay of several months will make no difference to the outcome and so for patients who need to have further investigations, treatment for polyps or fibroids or who are waiting for the HFEA to allow us to restart offering CARE’s special Immune Therapies, there is no need for anxiety.
Now we’re back, we want to help you make your dreams of parenthood come true as soon as possible, but in the meantime, help yourselves to the best outcome possible.