Fertility, IVF and the microbiome - Part 1

Fertility is a wide-reaching topic, and each facet is just as important - and interesting - as the other. Whether you’re looking to find out about how to address issues regarding conceiving, the microbiome and its relation to improved fertility or IVF, this four-part series can assist. Furthermore, the ethical and moral issues surrounding genetic ‘editing’ are significant talking points.

Mr Stuart Lavery, consultant gynaecologist and specialist in reproductive medicine and surgery, goes into expert detail about conception and the assistance that’s available for women and couples in part one.

What's the first port of call if a couple or person is having difficulty in conceiving?

For the vast majority of couples, it would start with a trip to the GP. That's still the first point of access. They are well placed in not just giving initial advice in terms of maximising your chances of actually doing things naturally and hopefully avoiding going to the fertility clinic, but also setting up the first baseline series of tests to find out if everything is in working order.

The vast majority of patients these days will also be surfing the Internet, of course, and looking for alternative sources of advice. There are all sorts of kinds of advice out there; some great quality and some perhaps possibly more commercially messaged and less good quality. Sometimes to find your way down that path, we would still recommend a GP visit to start the journey.

If you are looking online, what are the recommended resources?

In the UK, the British Fertility Society (BFS) runs a great website with lots of patient information. There’s the European Society of Human Reproduction and Embryology called ESHRE, which again has some fabulous patient information. We also often recommend the American Society of Reproductive Medicine (ASRM). It's more of an American slant on things, but nevertheless, there's still lots of valuable resources.

Patients can be reassured that when they access these websites, they get an unbiased message. Whereas many of the clinics that are out there, although they have excellent pieces of information, they may tell you - or they may suggest - that there might only be one way of doing things right.

How long on average does it take to get pregnant?

For most couples trying after 12 months, about 80 per cent of couples will be pregnant. We will suggest it might be worthwhile doing some tests if you've been trying regularly, having lots of sex at the right time for about 12 months and nothing's happened. If you look at the population data, actually trying for two years is entirely within normal limits.

It can be easier to have that conversation with a couple who are 23, saying, ‘Go away, try a little bit longer’. If the couple are 38 or 39, time becomes more sensitive, and I think we would always give that advice in an individualised context.

What sort of initial tests could you expect to have then?

There are a couple of basic things that most of our patients go through, that we recommend. The first one is an assessment of ovarian reserve in the woman. This is a combination of:

• A blood test, usually called an AMH;
• An ultrasound scan to look for Antrel Follicles.

These give you an idea what your personalised ovarian reserve is and how many eggs you’ve got left. If you’ve lots of eggs left, you might be able to take a more relaxed, staged approach to things. That's important to understand.

Are women born with different numbers of eggs?

There’s a huge difference, in terms of the number of eggs that women are born with, which is about 450,000. Most people don't realise that you actually lose hundreds of eggs each month. In assessment of; if you’re 32 years old, are you the average 32-year-old? Or are your eggs on the 90th percentile and your ovaries think you're chronologically younger than you are? It helps us guide women on the timeline.

We would then also do an assessment of the pelvic anatomy. This is an ultrasound scan that looks at the uterus, the ovaries, and if there anything there that's making it more difficult to conceive. Are there cysts, polyps or fibroids? We'd usually do a test of their fallopian tube patency as well, with a little bit of dye. This used to be done by an X-ray, but now it can be done at the same time as the scan very accurately.

If women are having a regular period, most of them will be ovulating. A high progesterone level can confirm that, which can be helpful. Of course, you mustn't forget the male partner. You would do a basic semen analysis, and this would tell us a little bit about the quality and the quantity of the sperm.

Most men, when they're given the report, there's no one box that gets ticked which says it’s a great sperm test or poor sperm test. There's a variety of different parameters, usually about 12 on each report. It can be difficult to navigate that as a layperson.

The most important things we look at are:

• The concentration of the sperm: How many are there? Are they wriggling?
• Progressive motility: Are they wriggling in a straight line?
• And finally, morphology, which is their appearance under the microscope. Do they look as if they've been drawn by Leonardo da Vinci with a beautiful oval head and a nice, squiggly tail?

Are there natural things that can be tried first? Can you make a difference with things like diet and lifestyle?

It depends how much faith you can put in these things and how much movement they can give in terms of your expectation of results. Diet can be important, and there are certain supplements that may be helpful. For women, folic acid supplementation is absolutely essential. In terms of encouraging conception, there's some interesting research on vitamin D and Omega-3 fatty acids.

Find out more about supplements that can assist in conception in part two of Mr Lavery’s series of articles, coming soon.

Arrange an appointment with Mr Lavery to address any of your fertility and conception concerns, via his Top Doctors profile.