What is Infertility?

Inducing ovulation using medication (ovulation induction) allows an egg to mature and be released by the ovary. The cycle is tracked with blood tests and ultrasound, to confirm the best time to conceive.

There are two types of medication used to induce ovulation: tablets (oral medication) or daily injections of Follicle Stimulating Hormone (FSH). If you are having ovulation induction at the same time as IUI treatment, either type of medication is suitable.

Oral medications
The most common oral medication is Clomiphene Citrate, known as Clomid or Serophene. Clomiphene blocks oestrogen receptors in the body. This tricks the brain into increasing hormone production to stimulate development of one or more follicles on the ovary. Follicles are the small fluid filled sacs on the ovary which contain an egg. If they develop, and

Monash IVF tip: Clomiphene may have some side effects which usually pass within a few days of stopping the medication. They include hot flushes, thickening of cervical mucus, mood changes and irritability.

FSH injections Follicle Stimulating Hormone (FSH) is a pure hormone injected daily in the first half of your menstrual cycle. It is injected just under the skin with a very fine needle (usually as a pen-device). It is easy to inject yourself with the needle, and our fertility nurses are on hand to show you how to do it and offer support.

Ovulation induction may be the best choice if you:

• don’t have a regular cycle
• don’t have periods at all (in premenopausal patients)
• have healthy tubes
• have unexplained infertility

Multiple pregnancies
Ovulation induction medications can lead to multiple follicles developing and maturing in one cycle – more than one egg may be released in ovulation. This means there’s a higher chance of multiple pregnancy. This can be a risk to mother and babies. Your fertility specialist will use blood tests and ultrasound to track ovulation and check on how many follicles mature.

If ovulation induction is unsuccessful, we’ll talk about other treatment options like Intrauterine Insemination (IUI) or In Vitro Fertilisation (IVF)

Intrauterine Insemination (IUI) Couples who experiencing difficulty trying to conceive.
IUI might be the first step in your fertility treatment journey if you:

• Have been diagnosed with unexplained infertility
• Have been diagnosed with mild male factor infertility
• Have scarring of the cervix or other concerns that prevent sperm penetration
• Have irregular or absent ovulation
• Cannot have regular or penetrative sexual intercourse
• Need to use donor sperm

IUI treatment would generally not be recommended to patients who have severe male factor infertility or blocked fallopian tubes or severe endometriosis.
The purpose of IUI treatment is to increase the number of sperm that reach the fallopian tube which therefore increases the chance of fertilisation. The technique provides sperm with an advantage by giving it a head start with where it needs to go, but it still needs to reach and fertilise the egg on its own.
After you’ve consulted with your fertility specialist and completed some preliminary fertility testing, you will have a better idea as to whether IUI is a suitable treatment option for you.

The IUI treatment process
For this procedure, the fertility specialist will insert a speculum into your vagina in order to better visualise your cervix.
They will then pass a soft, thin catheter through the opening of your cervix and into the uterus. The pre-prepared sperm will then be introduced to the uterus via the catheter. The procedure will only take a few minutes to complete and can be likened to a pap smear.
You will be able to return to your daily activities as soon as the IUI is completed. You will not require anaesthesia unless you do not tolerate speculum examinations. There is an option to complete the procedure under light sedation if required and this is something you should discuss with your fertility specialist.

Important components to IUI treatment

Different IUI treatment types
If your fertility specialist recommends IUI treatment for you, there are three different methods of treatment that you may undertake. They are:

• Natural Insemination Cycle – This option allows patients to complete IUI without being required to take any medication. This cycle will follow your natural menstrual cycle and is commonly used for individuals or couples who are unable to have intercourse.
• Medication Cycle – This treatment options involves using a drug to help stimulate the ovaries. The is pill taken orally and is commonly used to assist women with ovulation disorders as reflected by infrequent or irregular menstrual cycles.
• FSH Ovulation Induction Cycle – Follicle stimulating hormone (FSH) injections can also be used in an IUI treatment cycle to help stimulate the ovaries. FSH stimulates the production of eggs in the ovaries from the pituitary gland in the brain.

Sperm Washing
Our specialised team of scientists prepare each sperm sample with a procedure commonly known as “sperm washing” in our laboratory. Sperm washing involves placing the sperm sample in a test tube. A centrifuge spins the sample at high speed, resulting in the sperm collecting in a “pellet” at the bottom of the test tube. The scientist removes the seminal fluid and places the fluid (media) above the sperm pellet. The most active sperm will then swim up into the media. The final sample consists of the most active sperm concentrated in a small volume of media taken from the top of the test tube.

Timing the Insemination
IUI treatment procedures will be timed around your time of ovulation. However the exact timing of insemination is not critical to the exact time of ovulation. Both the sperm and the egg remain viable in the female genital tract for many hours, so your fertility specialist may time the insemination within a window of several hours around the time of ovulation.
If you have taken hormones, you may need to take daily supplemental progesterone—usually in the form of a capsule inserted into your vagina twice a day— or injections, to support the endometrial lining of the uterus and implantation of the embryo.

IVF is about taking eggs and sperm, putting them together in a lab and letting the natural process happen. If they fertilise, an embryo will form. The tiny embryo (0.1 mm) is then inserted into the uterus. If it grows and develops, you’ll take your baby home 9 months later. So, how do we get there?

• We stimulate your ovaries to help your body to produce eggs it has created naturally. This might involve a series of injections which are easy to manage
• We remove those eggs in a day procedure called the egg collection or egg retrieval
• Within the same day, your partner will provide us a sample of his sperm, or we prepare the donor sample in the laboratory
• Our expert scientists mix the eggs and sperm in the lab. We try to create as many embryos as we can to give you the best chance of healthy embryos
• If the embryo/s fertilise, you will be back about 5 days later to have the embryo/s transferred into your uterus
• Any extra little embryos are frozen and can be used for another cycle
• You’ll have a 2-week wait while we see if the embryo takes
• We do a blood test to see if you’re pregnant

Your fertility specialist gets to know your medical history and your individual circumstances. There’s lots of reasons they may recommend IVF, and create the best treatment plan for your body.
Some common reasons why IVF may be required include:

• blocked fallopian tubes
• fallopian tube damage/tubal factor/tubal ligation
• male infertility relating to sperm quality or quantity
• endometriosis
• uterine fibroids
• polycystic ovarian syndrome (PCOS)
• increased difficulty of conceiving naturally as women age
• unexplained infertility
• recurring miscarriage
• potential genetic issues where embryo screening may help

Step 1: Day 1 of your period
The first official day of your IVF treatment cycle is day 1 of your period. Everyone’s body is different, and your fertility nurse will help you understand how to identify day 1.

Step 2: Stimulating your ovaries
The stimulation phase starts from day 1. In a natural monthly cycle, your ovaries normally produce 1 egg. You’ll take medication for 8-14 days to encourage the follicles in your ovaries (where the eggs live) to produce more eggs.
Your specialist prescribes medication specific to your body and treatment plan. It’s usually in the form of injections, which can vary from 1-2 for the cycle, or 1-2 per day. It can be daunting, but your fertility nurse will be there to show you exactly how and where to give the injections. You can get your partner involved too and watch and learn together to get it right. It quickly becomes a habit and you’ll be an expert in no time.
The most common hormones in the medications used to stimulate the follicles are:

• follicle-stimulating hormone (FSH)
• luteinizing hormone (LH)

Both hormones are produced naturally in the body. The eggs are already there; the medication boosts the natural levels to encourage more eggs to develop.
We keep an eye on your ovaries and how the follicles are developing with blood tests and ultrasounds. Your medication will be adjusted if needed. You will have some transvaginal ultrasounds (a probe is inserted internally). Our team will support you through these processes and make you as comfortable as we can.
We’ll track you more frequently towards the end of the stimulation phase to time the ‘trigger injection’ perfectly.
The trigger injection gets the eggs ready for ovulation – the natural process where eggs are released and you have your period. Your fertility nurse tells you exactly when to do the trigger injection. Your fertility specialist will schedule the egg retrieval before you ovulate.

Step 3: Egg retrieval
Egg retrieval, or egg ‘pick up’, is a hospital day procedure where the eggs are collected from your ovaries. An anaesthetist will get you ready for a general anaesthetic. You’ll be asleep and the procedure takes about 20-30 minutes.
Your fertility specialist uses the latest ultrasound technology to guide a needle into each ovary. It’s delicate work where every millimetre counts, and this is where the experience of our specialists pays off. You can’t see an egg with the naked eye; they’re contained in the fluid within the follicles in your ovaries. The specialist removes fluid from the follicles that look like they’ve grown enough to have an egg inside.
Your fertility specialist should have a fair idea from your ultrasounds how many eggs there are before retrieval. The average number of eggs collected is 8-15.
Recovery takes about 30 minutes and you’ll be able to walk out on your own. It’s a good idea to have a support person with you as you won’t be able to drive after the procedure.

Step 4: The sperm
If you’re a couple planning on using fresh sperm, the male will produce a sample the morning of the egg retrieval. If you are using frozen or donor sperm, our scientists will have it ready in the lab.
The sperm is graded using 4 different levels of quality. It’s washed in a special mixture to slow it down so our scientists can spot the best ones under the microscope. A perfect, healthy sperm is not too fat or thin, with a tail that’s not too long or short. The best sperm are selected, and they’re ready and waiting in the lab to be introduced to the eggs.

Step 5: Fertilisation
Your fertility specialist gives our scientists the eggs they have retrieved, still in the fluid from the follicles of the ovaries. The scientists use powerful microscopes to find the eggs in the fluid so they can be removed.
It’s important the eggs are fertilised quickly. The eggs and some sperm and placed in a dish. They have the chance to find each other and fertilise like they would naturally within your body.

Step 6: Embryo development
If the sperm fertilises the egg, it becomes an embryo. Our scientists put the embryo into a special incubator where the conditions for growth and development are perfect.
We create the perfect growing conditions using a mix of amino acids, just like your body would use to nurture the embryo.
Our scientists keep an eye on the embryos over 5-6 days. What we want is:

• a two- to four-cell embryo on day 2 and a six- to eight-cell embryo on day 3 (called the cleavage stage)

We know implanting embryos at the blastocyst stage into the uterus boosts your chances of a successful pregnancy.
Unfortunately, not all eggs will fertilise and reach embryo stage. The eggs might not be mature or the sperm not be strong enough. We know you’ll be waiting on news, so we’ll keep you up to date with the progress of your egg, sperm and embryo development.

Stage 7: Embryo transfer
If your embryo develops in the lab, you’re ready for it to be transferred into your uterus.
Your fertility nurses will explain the process. You’ll need to drink water before the transfer so you have a full bladder. We use ultrasound technology to get the embryo in the perfect spot, and it helps to see the lining of the uterus.
The embryo transfer is a very simple process, like a pap smear. It takes about 5 minutes, you’ll be awake, there’s no anaesthetic, and you can get up straight away. You can continue with your day, the embryo can’t fall out if you stand up or go to the toilet. A scientist talks to you about your embryoprepares it by placing it in a catheter. Its critical this is done by an expert to disturb the embryo as little as possible.
Your fertility specialist places the catheter through your cervix and into your uterus. They use ultrasound guidance to pinpoint exactly where to place the embryo. An embryo is only 0.1 millimetre, and the specialist has a target area of approximately 1 millimetre to play with. If it’s placed in the wrong spot, the embryo may not ‘stick’ and there is risk it’ll find a home outside the uterus.

Step 8: The final blood test
Two weeks after your embryo transfer, you’ll have a blood test to measure your levels of the hormone hCG (human chorionic gonadotropin). hCG in your bloodstream usually means a positive pregnancy test.
The time between the embryo transfer and the blood test is often called the ‘two week wait’ (2WW). It can be tough not to be anxious about the result. If you need some help to cope or someone to talk to, our counsellors are ready to answer your doubts.

Intracytoplasmic Sperm Injection (ICSI) is a technique where a single sperm is given a helping hand to ‘enter’ the egg. Since it only takes one single sperm to fertilise the egg, the embryologist catches a single sperm and injects it directly into the centre of the egg. This method is far more successful when there is male infertility problems. ICSI sounds pretty simple but is one of the most technically challenging roles for an embryologist.

ICSI can be an option for patients who have:

• an abnormally low sperm count or poor motility
• a high percentage of abnormal sperm or few healthy sperm
• sperm obtained via testicular biopsy or micro TESE
• previously low fertilization rates with standard IVF

It is important to note that there is growing evidence that IVF success rates are actually better when standard insemination techniques are used instead of ICSI in couples who don’t fit the above categories.
ICSI can be used with fresh or frozen/thawed sperm. Our Embryologist will choose the best sperm from the sample, based on it being a normal shape, size and motility Movement

The healthiest sperm cells tend to have a certain shape and size, particularly an oval head and a long tail which they use to push themselves along as they swim. Infertile men often make fewer such sperm so that sperm selection for ICSI is important.
Next consideration is sperm motility – a sperm cell’s motility is its ability to move itself around and penetrate an egg. This depends on the length and size of its tail. Tails that are curly or doubled up aren’t as efficient when it comes to swimming.
Routinely in ICSI, a small amount of washed and prepared sperm is placed into thick viscous media that slows the sperm down so that they can be selected according to their shape, motility and trajectory.
The most “normal” looking and vigorous sperm are selected and then immobilized by squashing their tails with a glass injection needle. One these sperm are sucked into the needle tail-first ready to be

The egg is placed in customized dishes under a microscope and moved using a leading micro-manipulator. A holding pipette secures the mature egg and then a thin, sharp glass micropipette, loaded with a single sperm, pushes first through the zona pellucida (outer egg casing) and then the oolemma (the cell membrane of the egg) to enter the centre (cytoplasm). The sperm is most delicately deposited into the centre of the egg.
In other words, we do all of the work for the sperm – no swimming or penetration of the egg involved. The only thing left for the sperm to do is make the ‘spark’ of fertilisation happen.

If you experience cancer or premature menopause, we can offer choices to preserve your fertility so you can have a child later in the life.
Female fertility can be protected and preserved through different options depending on your medical issue, including:

• egg freezing
• embryo freezing

Egg freezing
Egg freezing allows a woman to store eggs to preserve fertility. When you’re ready to use your eggs, they are thawed and fertilised before being implanted into your uterus. The process generally takes a couple of weeks, and can be fast-tracked for patients who need urgent medical treatment.

Embryo freezing
If you have a partner, you may wish to freeze embryos (fertilised eggs) for future use. This process can also be fast-tracked for patients who need urgent medical treatment.

Freezing sperm is an option for men who want to preserve their fertility. Sperm can be stored for long periods of time and then thawed for an insemination or IVF technique.
Freezing sperm might be an option if:

• you’re about to start chemotherapy or radiotherapy that may impair fertility*
• you have a very low sperm count that might fall to zero over time
• you’re about to have a surgery or a vasectomy