In a normal and healthy menstrual cycle, the ovaries make the egg that is ovulated (released) each month. Because of the hormonal imbalance, the egg may not develop or ovulate during ovulation as it should, causing irregular or missed cycles. 

Bottom line, if you don’t ovulate a healthy egg, or at all, it means you can’t get pregnant. 

Most women won’t know they have PCOS until they begin and fail at trying to conceive.

Some of the symptoms of PCOS include:

• Irregular menstrual cycle. Women with PCOS may miss periods or have fewer periods (fewer than eight in a year). Or, their periods may come every 21 days or more often. Some women with PCOS stop having menstrual periods all together.
• Development of cysts (small fluid-filled sacs) in the ovaries.
• Too much hair on the face, chin, or parts of the body where men usually have hair. This is called “hirsutism.” Hirsutism affects up to 70% of women with PCOS.
• Acne on the face, chest, and upper back
• Thinning hair or hair loss on the scalp; male-pattern baldness
• Weight gain or difficulty losing weight
• Darkening of skin, particularly along neck creases, in the groin, and underneath breasts
• Skin tags, which are small excess flaps of skin in the armpits or neck area

What causes PCOS?

The exact cause of PCOS is not known. Most experts think that several factors, including genetics, play a role with the most common two being a high level of androgens or insulin.

Androgens are sometimes called “male hormones,” although all women make small amounts of androgens. Higher than normal androgen levels in women can prevent the ovaries from releasing an egg (ovulation) during each menstrual cycle, and can cause extra hair growth and acne, two signs of PCOS.

Insulin is a hormone that controls how the food you eat is changed into energy. Insulin resistance is when the body’s cells do not respond normally to insulin. Many women with PCOS have insulin resistance,  which over time can lead to type 2 diabetes.

How is PCOS diagnosed?

There is no single test to diagnose PCOS. PCOS is diagnosed by a mix of tests and exams that may include: 

• Ultrasound to look for a high AFC, enlarged or swollen ovaries, and multiple cysts.
• Blood tests for your hormonal panel, androgens levels, AMH (higher than normal AMH can indicate PCOS), and diabetes.
• Physical exam will look at your skin for extra hair on your face, chest or back, acne, or skin discoloration. Your doctor may look for any hair loss or signs of other health conditions (such as an enlarged thyroid gland).

What are my treatment options for PCOS if I’d like to get pregnant? 

After ruling out other causes of infertility in you and your partner, the most commonly prescribed treatment is medication such as Clomid or Letrozole to help you ovulate. Fertility medication is often used in conjunction with Metformin, to reduce insulin levels.

IVF may be an option if medicated cycles do not work. Compared to medicine alone, IVF has higher pregnancy rates and better control over your risk of having twins and triplets (by allowing your doctor to transfer a single fertilized egg into your uterus), as those diagnosed with PCOS are more likely to produce multiple eggs with medicated cycles.

The great news for those with PCOS who do choose to undergo IVF treatment, is that you are likely to have more eggs retrieved than average. The question will always be the quality of your eggs, which lifestyle and diet changes can help. 

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If a normal monthly follicle keeps growing, it’s known as a functional cyst. There are two types of functional cysts…

What Is A Simple Ovarian Cyst?

A simple cyst is basically a big follicle that didn’t realise it was time to stop growing and got bigger becoming a simple cyst. They usually disappear on their own in a few months or with down regulation drugs if you’re doing fertility treatments.

Your Fertility treatment cycle may get delayed due to a simple cysts. That’s because it can produce excess estrogen which won’t allow your protocol to have control over your cycle. 

What Is A Corpus Luteum Cyst?

The corpus luteum is the ‘shell’ of the egg that gets left behind and pumps out progesterone. It normally dissolves away if you don’t get pregnant in that cycle. If it doesn’t, it can fill with fluid and form a cyst. 

They can bleed into themselves which can be painful and is described as a ‘haemorrhagic corpus luteum cyst’. his is not the same thing as an endometrioma (see below) and does not mean you have endometriosis.

Your fertility treatment cycle may get delayed due to a Corpus Luteum Cysts because the progesterone it produces can delay your menstrual cycle from starting, or not allow for your protocol to have control over your cycle.

What are some other types of common benign (non-cancerous) ovarian cysts?

• Dermoid cysts, Also called teratomas, these can contain tissue, such as hair, skin or teeth, because they form from embryonic cells. They are rarely cancerous.
  
• Cystadenomas develop on the surface of an ovary and might be filled with a watery or a mucous material.
  
• Endometriomas, aka chocolate cysts can develop as a result of endometriosis. Some of the tissue can attach to your ovary and form a growth of old blood.
  
• Polycystic ovaries, is when you have over 12 small follicles – tiny developing eggs – on a single ovary. The cysts are caused by a hormonal imbalance, where the egg may not develop or ovulate as it should, causing irregular or missed cycles.

Dermoid cysts and cystadenomas can become large, causing the ovary to move out of position. This increases the chance of painful twisting of your ovary, called ovarian torsion. Ovarian torsion may also result in decreasing or stopping blood flow to the ovary.

What Are My Treatment Options For Ovarian Cysts?

Not all cysts need removing and most functional cysts will go away on their own. Your doctor will explain depending on the type, size and  your symptoms.

Treatment options may include down regulation drugs such as birth control pills or lupron, draining of a fluid filled cyst, or in severe cases, laparoscopic surgery. 

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Sperm quality refers to the sperm’s ability to fertilise an egg. This ability is determined by two interconnected factors: sperm motility and sperm morphology. The health of the DNA carried by the sperm is also extremely important.

The sperm analysis test explained:

When performing a sperm analysis we look at the following key parameters to determine the quality of the sperm: 

1. Volume: 1.5ml to 4.5ml
2. Count: minimum 15million/ml 
3. Concentration: minimum 39 million/ml
4. Motility: ideally 40-50% (minimum 32%)
5. Morphology: minimum 4% normal

What is Sperm motility?

Sperm motility refers to the ability of the sperm to “swim” to an egg. Progressive motility is the best type of movement noted during a semen analysis and means that the sperm are moving forward in straight lines, as opposed to in small tight circles or along highly erratic paths.

The lower limit for sperm motility is 40% of both progressive + non-progressive aka “twitching” sperm.

What is Sperm morphology?

Sperm morphology refers to the way the sperm looks – it’s appearance. A morphologically normal sperm should have:

• A long tail: made of protein fibers that contract to propel the sperm through the seminal fluid. Up until very recently it was thought that sperm moved forward due to the lashing movement of their tail. Last year a breakthrough study revealed that the tail of a sperm actually only flagellates on one side, causing a rotating “corkscrew” pattern, so sperm  actually “spin” towards the egg!  
• A mid-piece: which contains mitochondria (energy producing organelles) to power the sperm’s movement.
• A nicely shaped head: made of a fatty acid membrane which stores the nucleus (which contains the sperm’s genetic information (DNA)) & cytoplasm: a thick solution that fills cells and is made of water, salts & protein. At the tip of the head is the “acrosome”: a structure bound to the sperm membrane in its own fatty acid layer, which contains digesting enzymes that enable the sperm to break down the zona pellucida (outer glycoprotein layer) in order to enter the egg for fertilisation. 

The lower limit for normal sperm morphology is 4% according to WHO statistics, though some clinics use 2% as their barometer – if your clinic does use the latter and dismisses these results as problematic, seek the second opinion of a urologist specializing in fertility. 

What should my Total sperm count be?

The total number of sperm is considered the total number of sperm in a particular quantity of semen, the fluid that carries sperm out of the penis. 

A high sperm count isn’t helpful to fertility if most of the sperm have abnormal morphology or can’t swim properly. Similarly sperm with textbook morphology may carry abnormal DNA.

The lower limit for total sperm count is 39million per ejaculation.

What is Sperm Concentration?

Sperm concentration refers to the total number of sperm per milliliter (ml) of ejaculate.

The lower limit for sperm concentration is 15 million per ml.

Sperm count and sperm quality (morphology and motility) can be tested with a semen analysis. A routine semen analysis however cannot assess the genetic health of sperm. 

What is Sperm DNA Fragmentation?

The sperm DNA carries all the instructions for the development of the embryo. Any damage to this DNA may interfere with the sperm’s ability to fertilise an egg correctly or develop into a healthy developing embryo. Genetic integrity is thought to be one of the most important factors for male fertility. Our DNA is contained in structures called chromosomes. Our cells usually contain 46 chromosomes but sex cells or gametes, i.e., the sperm and egg, contain just 23. When the egg and sperm combine, they produce an embryo with 46 chromosomes in each cell. 

Sperm DNA fragmentation happens when there is a change in the strands of DNA contained within the nucleus of the sperm. This could be a deletion, a break or a separation in the DNA strands and can occur at any point during the sperm’s life: whilst its being made in the testis (during spermatogenesis), during its time stored in the epididymis before ejaculation or even after ejaculation. 

A specialist test is required to assess the level of DNA fragmentation within a sperm sample. The following tests can be offered:

• sperm chromatin structure assay (SCSA) – the most commonly used test (industry standard)
• sperm chromatin dispersion test (SCD)
• transferase-mediated terminal uridine nick-end labelling (TUNEL)
• Comet Assay test

Risk factors for sperm DNA fragmentation: 

• Paternal age
• Smoking
• Illness or infection (e.g., covid-19)
• Cancer treatment (e.g., chemotherapy)
• Chemical, radiation or toxin exposure

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Why is my Egg Fertilization Rate Low? 

And more importantly, is there anything that can be done about it?

Understanding the exact cause of TFF is extremely difficult. Some of the most common causes are:

Poor Egg Quality:

Once injected, an egg needs to go through certain processes in order to become ‘activated’. ‘Oocyte activation’ renders the egg capable of becoming fertilised. Failure of oocyte activation is one of the most common reasons for failed fertilisation after ICSI, accounting for over 50% of TFF cases.

Egg Maturation Issues:

An egg can degenerate following ICSI if it is post-mature or if the egg matured immediately prior to injection. Eggs falling to achieve good maturation may be due to hormonal stimulation methods which did not suit you.

Sperm Issues:

Failed fertilisation due to sperm factors has been linked to sperm morphology, sperm nuclear morphology, acrosomal factor and sperm chromatin status. Issues with sperm head decondensation can lead to the sperm’s DNA remaining ‘locked’ inside the sperm head and not being released into the egg. This inevitably leads to failed or abnormal fertilisation.

Technical Issues:

A rare cause of TFF after ICSI can indicate poor technical skill of the embryologist – as it is possible for an egg to be damaged by the injection process.

How can my egg fertilization rate be improved?

The life cycle of an egg is long, complicated & prone to errors. By improving your lifestyle & nutrition and supplementing with the correct antioxidants, egg health may be improved. 

The human egg starts its final developmental cycle about 90 days before ovulation, so it’s important for these adjustments to take place during as much of these 90 days as possible.

A change in treatment protocol and/or stimulation medication may also improve your results.

In cases with persistent failed fertilization (after different meds and protocols were used), using assisted oocyte activation (AOA) is currently the only available method to improve fertilization rates. 

Activation can be induced with the use of electrical, mechanical, or chemical stimuli that elevate intracellular concentrations of calcium ions (driving force behind activation). However, these methods work by flooding an egg’s ooplasm (the inside of the egg) with calcium ions that don’t follow the physiological cascade. 

This practice raises concerns, as these chemicals may affect embryo viability and future offspring due to their potential cytotoxic, mutagenic and teratogenic effects.

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Here are some of the most common reasons your IVF Cycle Failed…

Implantation Failure

When good quality embryos do not implant there may be issues with:

• Uterine anatomical abnormalities can include Fibroids, polyps and septums which may interfere with the embryo’s ability to implant and grow. 
• Lack of luteal support is when your progesterone levels are too low or additional estrogen support is required.
• Immune issues or an increase in NK cells could mean that your body is attacking your embryo. Immune testing is not a routine fertility test and not conducted by all fertility clinics. Make sure to speak to your doctor about this or see a reproductive immunologist for additional testing to rule out immune issues. 
• Thrombophilia and blood clotting issues include conditions in which there’s an imbalance in naturally occurring blood-clotting proteins, or clotting factors that could keep blood from flowing properly to your uterus or create clots that interfere with implantation.
• Receptivity issues / endometrial thickness may not be achieved if your lining is under 8mm at the time of your trigger shot. This may mean that you need additional estrogen and progesterone support. Your receptivity can be measured using an ERA test during a mock transfer. 
• Genetic issues (aneuploid embryo) for non tested embryos.
• Zona pellucida issues: embryo hatching abnormalities
• Poor choice of transfer day if your clinic doesn’t operate every day.

Arrested Embryonic Development

When embryos stop growing in the embryology lab before embryo transfer the causes may be because of…

• Egg Quality issues are usually suspected if an embryo arrests during the cleavage stage of embryonic development (days 1-3) as the maternal genome is in charge of cell divisions during this time. Failure of embryonic genome activation is suspected if the embryo does not progress beyond 8 cells. On day 3 of embryonic development, the embryo has to switch its genome on and take over cell divisions – if this doesn’t happen the embryo cannot continue to develop.
• Poor Sperm Quality or sperm DNA fragmentation
• Genetic Reasons (aneuploidy)
• Poor embryology lab quality is usually down to poor culture environment/embryo handling. Ask your clinic for their Key Performance Indicators (KPIs). What is their overall fertilisation rate for your age group? What are their cleavage and blastocyst formation rates? Compare these to international benchmarks.

Ask your embryologist for your personal statistics and compare these to the benchmarks for your age group. In some cases small adjustments to a future cycle can make a difference between an IVF cycle fail and success.

Sometimes, however, the only option is to gather the strength to try again and remember that IVF is a treatment with cumulative chances of success.

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You’re finding yourself in this awkward phase of your journey where you are both a mom and still infertile. While some may throw insensitive comments your way about how “your body knows what to do now” or “your infertility is probably corrected,” they would be wrong.

Infertility is not cured by a pregnancy and, for that reason, patients commonly return to IVF treatment after the birth of their first IVF-conceived child.

What are the real chances of success for women returning to fertility treatment in the hopes of having a second child with IVF? 

One of the few studies addressing this followed 35,290 women who started fertility treatment using their own eggs between January 2009 and December 2013 and successfully delivered their first baby from treatment performed during this period. These women were then followed up for a further 2 years of treatment to December 2015, providing a minimum of 2 years and a maximum of 7 years of treatment follow-up.

The results showed the cumulative live birth rate (LBR) for women returning to fertility treatment was between 50% and 88% after six cycles depending on whether women had a frozen embryo transfer or a new ovarian stimulation cycle. 

The results were higher for the women who had a frozen embryo transfer, likely due to the age of the egg at the time the embryo was created and frozen.

What does this mean if you have yet to conceive your first child via IVF?

Embryo banking, which may require multiple rounds of stimulation and egg retrievals. should be discussed with your clinic prior to embryo transfer.

Hopefully these age-specific success rates will facilitate individualised counselling and clinical decision-making for the large number of patients hoping to achieve a second ART-conceived child. 

The post What Are The Chances Of Conceiving A Second Child With IVF? appeared first on Embie | IVF, IUI ; Egg Freezing Tracking App!.

We are born with a certain number of eggs in our ovaries – this is our ovarian reserve. If you are told you have a low or diminished ovarian reserve (DOR), this means that your egg number is lower than what is expected for your age. 

This is completely different to premature ovarian failure, which is the loss of function of your ovaries before the age of 40.

How is DOR diagnosed?

Diminished ovarian reserve is diagnosed through blood tests that measure follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) levels. It is completely natural for FSH levels to increase and AMH levels to drop as you age, so it is important to assess these hormone levels against a baseline for your age. 

Those with diminished ovarian reserve will have higher FSH levels and lower AMH levels compared to others of their age range.

What Is The Average Egg Count For My Age?

The “average” number of eggs in our ovarian reserve depends on age. All the eggs we will ever have were formed before we were born, while in our mother’s womb! From there, our egg reserve decreases over time.

According to the American College of Obstetricians and Gynecologists, these are the average number of eggs at each age:

• 20 weeks of gestation: 6 to 7 million oocytes
• Birth: 1 to 2 million oocytes
• Puberty: 300,000 to 500,000 oocytes
• Around age 37: roughly 25,000 oocytes

51 is considered the average age of menopause, but when you have DOR, menopause is likely to arrive at an earlier age.

How does DOR impact my fertility?

If you don’t have the expected amount of eggs for your age, pregnancy is still possible, but keep two things in mind; 

• Heightened FSH can mean that egg quality is lower.
• Lower egg count may mean your fertile period is shortened, and you may not be able to achieve pregnancy as you get older.

What Fertility Treatments Are Recommended If You Have Diminished Ovarian Reserve?

The key is to take action to improve egg quality right away, as you may be able to get pregnant naturally.

Various treatments can be offered to patients with DOR which include high gonadotropins (stimulation drugs), natural and modified natural cycles, estrogen priming, supplementation with LH, luteal antagonists, etc. Co-treatment with adjuncts like androgens (DHEA), growth hormone (GH), melatonin, aspirin, etc.

In cases where DOR is accompanied by additional diagnosis, such as recurring miscarriages or endometriosis, IUI or IVF may be recommended.

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Endometriosis is a disease in which cells similar to those that line the uterus may grow elsewhere in the body, such as the ovaries and fallopian tubes, resulting in extremely painful periods and sometimes causing infertility. 

Endometriosis causes distortion of the pelvis and the release of inflammatory markers: macrophages and cytokines. But the impact of endometriosis goes beyond this.

How Is Endometriosis Diagnosed?

Endometriosis can be very difficult to diagnose. As a part of diagnosis an ultrasound, followed by an MRI and CA-125 blood tests which may be performed, though Endometriosis can only be definitively determined by laparoscopic surgery.

Advances have been made for non-invasive testing.  The ReceptivaDx test, is a first of its kind test for the detection of inflammation of the uterine lining most commonly associated with endometriosis. 

How Does Endometriosis Impact My Fertility?

Endometriosis can affect your Ovarian reserve and normal egg development by…

• The mitochondrial content of eggs can be distorted causing cytoplasmic granulation: breakdown of the cytoplasm.
• Abnormal spindle formation in the egg.
• Hardening of the zona pellucida: the outer shell of the egg.

All of these factors can impact the result of fertilisation, embryonic development and ultimately implantation.

Endometriosis can affect your implantation and carrying a pregnancy to term by…

• Raising Inflammatory markers in your uterine cavity which cause an inhospitable environment for your healthy embryos.  

Endometriosis can affect the DNA structure of the cells that line your uterus…

A recent study has shown that women with endometriosis may have epigenetic differences compared to women without the disease. Genomes of endometrium cells in women with and without endometriosis were assessed and differences in the patterns of DNA methylation were identified. Methylation is a chemical change to the DNA that influences which genes are turned on and off. These changes could play a role in the infertility that often accompanies endometriosis.

The DNA methylation patterns of endometrial stromal fibroblast cells were compared in women with early (stage I) or late (stage IV) endometriosis and women without endometriosis. The data showed that these patterns were different in each of these conditions, indicating that there may be two disease subtypes, rather than progressive stages of the disease!

What Fertility Treatments Are Recommended If You Have Endometriosis?

The severity of your endometriosis will ultimately decide the level of treatment. Those suffering from stage 3 or 4 (Severe) endometriosis, will be advised that IVF is the first choice of treatment. 

If you have been diagnosed with endometriosis and are not yet ready to have a baby, it would be a good idea to consider egg freezing (before the disorder progresses). 

Some studies have shown that antioxidants may mitigate the damage to our eggs. N-acetyl cystein (NAC) and other antioxidants may decrease the chance of chromosome and spindle misalignments in eggs and embryos.

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