The lab environment aims to mimic the conditions your embryos would experience if they were growing in your reproductive tract. This includes the right oxygen pressure, temperature and nutrients, as required for all the different stages of development. In addition, we continuously monitor the growth of your embryos using time-lapse imaging. However, despite these efforts, some embryos may not progress to the blastocyst stage.

In this video, fertility specialist Dr Nicole Hope details some of the changes that take place when a fertilised egg develops into a blastocyst embryo.

Embryo arrest

Approximately 60% of fertilised eggs become blastocysts. This means that around 40% of embryos stop growing before becoming a day 5–6 embryo. This is known as embryo arrest and occurs when an embryo stops dividing for 24 hours.

Not all embryos that reach the blastocyst stage are suitable for embryo transfer or freezing, as they may not have all the components necessary to result in a healthy pregnancy. Generally, around 40–50% of fertilised eggs become blastocysts that we can transfer or freeze. However, this varies greatly depending on your age and medical history. There is also a small group of individuals who have poor embryo development, which may be due to developmental-specific events or a pattern of embryo progression. Most IVF patients experience embryo arrest in some form, and it is usually a protective mechanism for stopping the development of abnormal or poor-quality embryos.

Causes of embryo arrest

There are many reasons why an embryo might stop developing. The embryo could have reduced metabolic activity or slow development and as a result, degenerate. In addition, embryos can stop growing during different stages of development. They may fail to reach the blastocyst stage for several reasons discussed below.

Chromosomal errors

Around 70% of arrested embryos display chromosomal errors.¹ Chromosomes are rope-like structures inside your cells that contain DNA – i.e. the instruction manual that makes you unique. When sperm and egg come together, the mother and father pass on 23 chromosomes each, so that the resulting embryo has a total of 46 chromosomes.

Sometimes, chromosomes can fail to combine correctly leading to chromosomal errors. This may include having:

• an abnormal number of chromosomes (called aneuploidy)
• more than one full set of chromosomes (called polyploidy)
• a combination of both normal and abnormal numbers of chromosomes (called mosaicism).

In addition, chromosomal errors can develop during the replication and division of the cells in the embryo. If an embryo divides abnormally during the early stages of its development (also known as the cleavage stage), this can lead to an abnormal distribution of chromosomes between cells and result in embryo arrest. Cells within the embryo can also have abnormal DNA replication and/or damaged DNA leading to embryo arrest.

Some chromosomal errors do not stop the embryo from growing, which is why preimplantation genetic screening (PGT) may be recommended.

Cell division errors

Usually, a cell within an embryo divides from one cell into two and distributes its chromosomes evenly. However, in some instances, a cell within an embryo divides from one cell to three. This is called Direct Uneven Cleavage (DUC). When DUC occurs in the first cell division, there is a higher chance of embryo arrest occurring.

The chances of embryo arrest occurring also depend on how much the cells are affected. Sometimes, an embryo may divide very quickly from one cell to two and three cells, and this rapid division can be difficult to differentiate from DUC. Under these circumstances, the rapidly dividing embryo has a greater chance of becoming a blastocyst.

Another cell division error can occur if the cell fails to divide but the nucleus (the information centre of all cells which contains your chromosomes and DNA) continues to replicate. This can lead to there being more than one complete set of chromosomes inside a single cell. If this occurs in several cells, the embryo will arrest; however, if this phenomenon is present only in a few cells, the embryo still has the potential to reach the blastocyst stage.

Poor embryo development

Early cleavage within the embryo relies on special products inside the egg to drive development. Sometimes, defects in the development of an embryo reflect the quality of the egg and can cause the embryo to stop dividing.

Embryos can also undergo instructed cell death (known as apoptosis). Apoptosis is a biological mechanism that aims to remove any unwanted or damaged cells from the embryo in its early stages of development. If enough apoptosis occurs, the embryo can fail to develop further.

Mitochondrial function

Mitochondria are like little organs inside a cell that act as a power supply. Specifically, they produce an energy-carrying molecule called ATP (short for adenosine triphosphate). Inherited only from the mother’s egg, mitochondria produce the energy that eggs and embryos need to function properly. During the early growth stages of an embryo, mitochondria undergo structural and positional changes that allow them to provide energy to the embryo and regulate their environment. These events are a key part of the development of an embryo before implantation takes place inside the womb.

As a woman ages, the quality of her eggs declines. Increasing maternal age can result in mitochondrial dysfunction due to changes or damage to the mitochondrial DNA – yes, mitochondria have DNA just like the nucleus of a cell. If the mitochondrial DNA is damaged, this can result in inadequate amounts of ATP or energy, as well as the loss of other important mitochondrial functions required following fertilisation. In addition, low mitochondrial DNA content is also associated with fertilisation failure and abnormal embryo development. Basically, if an egg or embryo does not have enough of a power supply, developmental processes will stop.

Between days two and three of embryo development, i.e. from the four-cell to the eight-cell stage, an embryo’s genome is activated. A genome refers to the genetic material (chromosomes containing DNA) inside a cell. When an embryo’s genome is activated, the embryo no longer relies on the egg to continue growing; rather, it uses its own cellular machinery. This change in embryonic genome activity is regulated by special products that mitochondria produce. Around 10% of embryos do not make the switch from maternal egg control to embryonic genome control. This means that an embryo on day two may be at the four-cell stage but fail to progress further if the genome switch does not occur.

Looking for more information?

There are many reasons why an embryo may not progress beyond a certain developmental stage. Throughout your cycle, our embryologists will phone you to keep you updated on the progress of your embryos. We know this can be an anxious time as you wait to hear how many of your eggs have been fertilised and then how many of these have developed into quality embryos suitable for transfer or freezing. If you have any concerns throughout this time, we encourage you to call us on (03) 8080 8933 for the extra support and information you need.

References

Accessing donor sperm

There are several ways you can obtain donor sperm from both clinic-recruited and known donors.

Clinic-recruited donors

Most fertility clinics have access to a sperm bank with stored donated samples. Although these used to be known as ‘anonymous’ donors, it’s important to note that children conceived from these samples can request the identity of their donor after they turn 18. At Newlife IVF, our dedicated on-site sperm bank contains samples from local donors. We also offer the option to select donor sperm from an international sperm bank.

Known donors

Alternatively, you may choose to use a sperm sample from someone you know, such as a friend or acquaintance. Some couples wish for their baby to be genetically connected to them. In these circumstances, you may decide to approach a family member. It’s important to note that the sperm donor must not be related to the partner who will provide the egg.

So, how do I choose?

There are many factors to take on board when choosing a sperm donor. These will depend greatly on your situation and can be discussed with your fertility counsellor.

Sperm quality and medical screening

One of the benefits of accessing donor sperm from a fertility clinic such as Newlife IVF is that all sperm samples and donors undergo thorough testing. This includes a quality assessment of the sperm, as well as testing of the donor for any infectious diseases (such as HIV or hepatitis) and genetic conditions. Samples are then frozen and quarantined for at least three months before donors are retested for infectious diseases. This ensures that the sperm is safe for use. If you elect to use a sample from a known donor, we recommend contacting a fertility clinic. We can perform the same screening we normally would for clinic-recruited donors on known donors, as well as freezing the sperm for a similar quarantine process.

Legal considerations

An advantage of using a clinic-recruited donor is that they are fully aware of their obligations and rights. Typically, the donor will attend one or more counselling sessions informing them of the various legal boundaries in place to protect them, the recipient and the donor-conceived child. For instance, the donor has no legal relation to your child and cannot seek custody. In addition, clinic-recruited donors cannot donate to more than 10 women (including their own partners). Fertility clinics also keep specific information about the donor, such as their name and date of birth, as well as medical and genetic test results. Whilst the donor’s identity remains undisclosed to recipients, your child can request the donor’s identity when they turn 18. All donor-conceived births are reported to the Donor Conception Registrar (DCR), a statutory authority that assists donors and donor-conceived individuals.

If you obtain donor sperm from someone you know, it’s important to create firm social and legal boundaries. You may choose to seek legal advice to assist with this process. As the level of donor involvement can vary greatly from situation to situation, it’s important to discuss expectations from all members involved (including any partners) before trying to conceive. For example, in co-parenting arrangements the donor may maintain an ongoing relationship with the child, whereas for other families the donor may have a limited level of involvement (or no involvement at all).

Personal preferences

Donor characteristics may also help guide your selection process. For example, some patients will want to choose a donor with a similar physical appearance. If you decide to go down the known-donor route, you will have a good understanding of their appearance, personality and perhaps why they are donating to you. Clinic-recruited donors are also asked to provide general information about their appearance, characteristics and personality. You may also take into consideration why they have chosen to donate. All clinic-recruited donors provide a donor statement as a part of their donor profile.

Newlife IVF deliberately recruits sperm donors from a wide range of backgrounds and ethnicities, with the aim of providing donor recipients with adequate choice and cultural representation.

The route to receiving donor sperm

Before you can select and obtain donor sperm, there are several appointments you will need to attend. At your initial consultation, your fertility specialist will explain in-depth the process of receiving donor sperm, including particular legal considerations such as using an identity release donor (i.e. donors who consent to releasing identifying information about themselves). Your fertility specialist may also request the person providing the egg and carrying the pregnancy to complete a medical evaluation with blood tests if they haven’t been done previously. This helps us develop an appropriate fertility treatment plan for you.

During your donor counselling appointment, you (and your partner if applicable) will meet with one of our fertility counsellors. The purpose of this session is to talk about common issues that can arise following the decision to use donor sperm. For instance, you may discuss topics like:

• How to select a donor
• The level of donor involvement during your pregnancy and child’s life
• Handling conversations with a child conceived from donor sperm
• Communicating about your fertility treatment with your inner circle and acquaintances.

Following this appointment, our donor profiles will be made available for you to access online (if you choose to use this service as opposed to known-donor sperm). If you select a donor from our sperm bank, a second counselling appointment and a consultation with a fertility nurse will be arranged to organise the various consents. For instance, donor consent is required to release identifying information upon your child’s request. During this session we will also arrange the details of your fertility treatment.

Further advice

If you are ready to begin your fertility journey or want to find out more about donor sperm, book a consultation with a Newlife IVF fertility specialist. We can recommend the most appropriate options for you based on your personal circumstances and preferences. To book an appointment, call (03) 8080 8933 or book online.

Sometimes, however, embryos fail to implant. If this happens during three or more IVF cycles, we use the term ‘repeated implantation failure’. While this can be a frustrating hurdle for women and couples undergoing IVF treatment, there are ways to improve embryo transfer success depending on the likely cause of implantation failure.

Common causes of repeated implantation failure

Factors relating to either one or both parents can contribute to repeated embryo implantation failure, so we will typically use a range of tests to help investigate and determine the cause.

The quality of the egg or sperm

A high-quality egg and sperm are essential ingredients for a healthy embryo. Bearing in mind that healthy embryos have the best chance of implanting in the womb, it is important to use eggs and sperm of the highest quality possible during IVF. Unfortunately, numerous factors can reduce egg and sperm quality.

Age plays a major role in egg quality (and quantity). Once a woman reaches the age of 35, egg quality typically declines. This means that eggs collected from older women are less likely to successfully implant in the wall of the womb.

Sperm defects can also contribute to recurrent implantation failure. For instance, damage to the sperm’s genetic material – also known as DNA fragmentation – can affect the development of an embryo and, therefore, the likelihood of implantation. Aging and lifestyle factors like smoking, alcohol consumption and being overweight, as well as some underlying medical conditions and prescription medications, can damage the DNA in both sperm and eggs.

While there isn’t a test to assess egg quality, we can look for higher-than-normal levels of sperm DNA fragmentation when performing a semen analysis.

Chromosomal anomalies in the embryo

Variations to the chromosomes inside the embryo are a major cause of recurrent implantation failure. Chromosomes are special structures within cells that contain DNA, and are crucial for a healthy embryo transfer during the IVF process. Normally, each egg and sperm contains 23 DNA-housing chromosomes, and during fertilisation all 23 are passed on from each parent (giving the embryo a total of 46 chromosomes).

However, chromosomal errors can sometimes arise during the generation of an embryo. This includes abnormalities in the number of chromosomes present (known as aneuploidy) and structural changes affecting the size of chromosomes or how the DNA is organised within them. There can also be an increase in the amount of genetic material present in the embryo. No matter the type of error, chromosomal anomalies within the embryo are much less likely to result in an ongoing pregnancy.

Female age is the biggest contributing factor to chromosomal anomalies in the embryo. However, rarely a person can be born with a structural rearrangement in their own chromosomes, which can predispose them to producing mostly abnormal eggs or sperm. This can be detected by performing a karyotype test on the individuals providing the egg and sperm.

If we suspect chromosomal error, we can use pre-implantation genetic testing (PGT-A or PGT-SR) before transfer to assess an embryo’s chromosomal arrangement.

The environment of the uterus

For an embryo to successfully implant in the uterus, the endometrium (the tissue that grows on the internal lining of the uterus) must undergo biological changes. In preparation for a healthy embryo, the endometrium thickens and becomes responsive to potential implantation by the embryo.

A number of conditions that cause inflammation and scarring, such as fibroids, polyps, adenomyosis, hydrosalpinges and endometriosis, can impact the structure of the uterine environment. Sometimes, the presence of these conditions can make it more difficult for the embryo to implant in the wall of the uterus, affecting the chances of a successful embryo transfer.

Imaging studies and surgical tests can help us determine if an inflammatory condition is affecting the uterine environment. These include pelvic ultrasound, as well as the insertion of a camera via hysteroscopy or laparoscopy.

Lifestyle factors and medical conditions

Health and lifestyle factors relating to one or both parents can impact the success of embryo transfer. In the mother, underlying health conditions, such as diabetes, thyroid disease and other endocrine disorders, as well as autoimmune disorders and clotting disorders (e.g. thrombophilia), can block the interaction between the embryo and the endometrium. In addition, alcohol consumption, smoking and other modifiable lifestyle factors in both parents (including poor diet, exercise and being overweight) may also contribute to recurrent implantation failure by affecting egg/sperm quality and the health of the uterine environment.

Simple lifestyle tweaks

Making small diet and lifestyle changes that optimise your overall health may also improve your reproductive function, which can support implantation and early pregnancy following an embryo transfer. These include:

• Quitting smoking and avoiding second-hand smoke, which can damage egg and sperm quality
• Limiting your alcohol and caffeine intake (consuming no more than one standard coffee a day)
• Opting for a Mediterranean-style diet with plenty of fruit, vegetables, whole grains and healthy fats
• Maintaining a healthy weight, with a body mass index (BMI) between 18.5–25 kg/m². Even a modest weight loss of 5–10% body weight has been shown to improve fertility
• Engaging in moderate-intensity, routine exercise. Vigorous activity should be limited to four hours per week
• Avoiding recreational drugs, which can disrupt hormone production and increase miscarriage risk
• Adopting regular sleep patterns and minimising night-shift work to protect your body’s hormone rhythms.

Focusing on these lifestyle factors and nurturing your overall health can increase your likelihood of conceiving and carrying a healthy pregnancy.

Improving the success of embryo transfer

To improve the chances of the embryo implanting in the wall of the uterus, our embryo transfer method is designed to both protect the embryo and help it reach its destination. A gentle tube called a catheter provides a pathway for the embryo from the incubator to the uterus. Along the way, we use ultrasound imaging to make sure that the placement of the embryo is precise.

Before transfer, we also put the embryo in a special substance called EmbryoGlue to boost the chances of it implanting in the uterus. EmbryoGlue contains a compound normally found in the uterus called hyaluronan that may help the embryo attach to the wall of the uterus.

If embryo transfer fails several times, we typically recommend testing for some of the common causes discussed above and may also recommend some additional treatments, described below.

IMSI and HA ICSI

IMSI (short for Intracytoplasmic Morphologically selected Sperm Injection) is a technique we sometimes use to help select a sperm for ICSI (or IntraCytoplasmic Sperm Injection). ICSI may be used during IVF to aid fertilisation. During ICSI, we isolate a single sperm and inject it into the centre of a mature egg, helping to overcome any barriers to natural fertilisation. In the case of IMSI, we first look at all the available sperm under a powerful microscope, then pick the sperm with the healthiest-looking shape and structure to introduce into the egg via ICSI.

Hyaluronic acid (HA) ICSI, also known as PICSI (Physiological Intracytoplasmic Sperm Injection) is another technique we sometimes use to help select the best sperm for the ICSI procedure. Sperm that can bind to hyaluronic acid (a substance found naturally in your body) have low levels of DNA fragmentation. Choosing the best sperm increases the chances of a healthy embryo, which in turn, has a higher chance of implanting.

PGT

Before transfer, we can also assess your embryos for chromosomal or specific genetic defects using pre-implantation genetic testing (PGT). This may include PGT-A to screen for random chromosomal anomalies (e.g. due to age), or PGT-SR to detect structural rearrangements in the chromosomes inherited from the sperm or eggs. This assists us in choosing embryos for transfer that have the best chance of implanting and resulting in an ongoing pregnancy.

Treating inflammation

As mentioned above, a favourable uterine environment helps implantation to take place. Depending on the cause, location and severity of the inflammation, surgical treatments targeting conditions that impact the structure of the uterus may be useful. For example, laparoscopic surgery is frequently used in women with endometriosis and can help remove scar tissue and/or growths.

What to expect when receiving an IVF embryo transfer

An embryo transfer is a straightforward procedure where an embryo is placed into the uterus using ultrasound guidance to achieve pregnancy. Typically, only one embryo is transferred at a time. During this process, a long, thin instrument is used to gently insert the embryo through the vagina and cervix, and into the uterus. The experience is comparable to having a pap test, and no anaesthetic is required. After the procedure, the woman can return to her normal activities right away.

Looking for more information?

Newlife IVF employs a range of advanced tools and techniques to improve the success of embryo transfer during an IVF cycle. If you would like to learn more about the options available for overcoming recurrent implantation failure or discuss your fertility needs with a specialist, call Newlife IVF on (03) 8080 8933 or book online.

In this video, fertility specialist Dr Lauren Hicks discusses the impact of blocked or damaged tubes on fertility, along with how this condition is diagnosed.

 

So, what causes blocked tubes?

Blockages can occur for a number of reasons. However, typically they are associated with conditions that cause inflammation and scarring.

Pelvic inflammatory disease

One common cause of inflammation is pelvic inflammatory disease (or PID for short). PID is an infection that can affect a woman’s reproductive organs, including the fallopian tubes. The inflammation resulting from PID can affect both the inside and outside of the fallopian tubes. Often internal inflammation is caused by infections that travel from the vagina and uterus into the fallopian tubes. These include infections due to the bacteria normally found in the vagina, as well as at times from sexually transmitted bacteria (like chlamydia and gonorrhea). On the other hand, external inflammation may arise due to trauma or infection inside the abdomen, as might happen following a burst appendix or recent bowel infection. Repeated bouts of PID have been shown to increase the risk of infertility in women.¹ Therefore, it’s important to see a doctor if you have signs of a possible infection like fever or lower abdominal pain, although sometimes symptoms can be mild and go undetected. If an infection is detected, antibiotics will usually be prescribed.

Endometriosis

The endometrium is the tissue that grows on the internal lining of the uterus. In endometriosis, tissue similar to the endometrium grows on tissues and organs outside the uterus such as the fallopian tubes. Over time (particularly in advanced or late-stage endometriosis), tissue that has grown in and around the fallopian tubes can cause inflammation and subsequent scarring, resulting in blockages.

Congenital tubal disease

In extremely rare cases, an obstruction of one or both fallopian tubes may be present at birth. Many women with this condition are not aware that they have a blockage until they try to fall pregnant.

Scar tissue after surgery

Sometimes, excessive tubal scarring can follow abdominal or pelvic surgery, e.g. caesarean section, bowel surgery. This scarring also has the potential to block your fallopian tubes.

Are there any symptoms of blocked tubes?

Tubal obstructions can often slip under the radar – i.e. you may not notice any symptoms at all. In fact, many women do not know they have a blockage until they experience trouble falling pregnant. Some conditions that cause tubal blockages do have their own tell-tale signs. For example, women with PID may experience lower abdominal pain, pain upon urination and intercourse, as well as abnormal vaginal bleeding and/or discharge. For many women with endometriosis, the primary symptoms are pelvic pain at the time of their period and pain with intercourse. In addition, a hydrosalpinx (a collection of watery fluid which may complicate a tubal obstruction) can cause ongoing and mild discomfort on the affected side of the abdomen in some women. If you are experiencing any of these symptoms, it’s important to make an appointment with your doctor.

How can you tell if my tubes are blocked?

There are imaging and surgical tests that we can use to determine whether your tubes are blocked. However, the test that is most appropriate for you will depend on individual factors such as any underlying conditions you may have.

Pelvic ultrasound with contrast

The first port of call is usually a special type of ultrasound called a tubal patency ultrasound. During this imaging test, a fluid which shows up on ultrasound is injected through a thin catheter placed in the cervix. The fluid then runs through the uterus and if no obstruction is present, it will continue to run out the ends of the fallopian tubes (after the test is complete, the fluid is gradually absorbed by the body). At the same time, an ultrasound of your pelvic area is taken so we can see where the fluid travels. This provides a detailed view of your uterus and fallopian tubes, which helps us determine if an obstruction is present.

Hysterosalpingogram (HSG)

Similar to a tubal patency ultrasound, a HSG also involves inserting a special fluid into your uterus and fallopian tubes. However, instead of using ultrasound, x-rays are taken instead.

Laparoscopy with dye

A laparoscopy is a type of keyhole surgery enabling us to look at your uterus, fallopian tubes and ovaries. Following a general anaesthetic, a camera is inserted through some small incisions made in the lower abdomen. A fine catheter is also inserted into the cervix and then a blue dye is injected. It passes up through the uterine cavity and along the tubes, then comes out the ends of the tubes where the blue colour can be seen. If we notice any abnormalities during this procedure, we may be able to treat these at the same time, e.g. remove endometrial growths.

Getting pregnant with blocked tubes

Depending on the cause, location and severity of the obstruction, there are a couple of different treatments that can boost your chances of falling pregnant.

Surgical removal

As mentioned above, laparoscopic surgery can be used to both identify, then remove any growths and/or scar tissue that are blocking your fallopian tubes. This technique is frequently used in women with endometriosis and can improve natural fertility in the months following surgery. It can also increase your chances of pregnancy with IVF. Surgically removing a tube that is full of watery fluid or pus (known as a hydrosalpinx and pyosalpinx, respectively) can also lead to an improvement in IVF treatment success. A hydrosalpinx can be caused by endometriosis, infections within your pelvis or prior surgery, whereas as a pyosalpinx occurs when your fallopian tube becomes severely inflamed and pus is produced, usually as a complication of PID.

In vitro fertilisation (IVF)

Most times, removing a tubal blockage is not possible or the best option for our patients. In these instances, we may recommend IVF if you are trying to conceive. IVF can help you fall pregnant by bringing the egg and sperm together inside a laboratory dish, completely bypassing your fallopian tubes. If fertilisation is successful and an embryo forms, it can be transferred into your uterus. If the embryo is able to successfully implant in the wall of the uterus, a pregnancy results.

What about tubal flushing with oil?

Tubal flushing involves placing a tube through the cervix and flushing an oil-based solution into your uterus and fallopian tubes. It’s not used when a proven tubal blockage is present, e.g. it can’t break down scar tissue or reopen a blocked tube. However, a recent review found that oil-based tubal flushing in women with subfertility (those experiencing an unexplained delay in falling pregnant) may increase their chances of falling pregnant compared to women who do not have a flush.² It’s not really understood how tubal flushing may improve the chances of pregnancy but presumably it works by helping to remove any stray mucus and cellular fragments out of the fallopian tubes. Tubal flushing may sometimes be performed together with diagnostic imaging studies and/or surgical procedures as an ancillary option when no obvious obstruction is detected.

Understanding your options

If you are struggling to conceive, blocked tubes is one of the first things your fertility specialist will want to rule out. To book an appointment with one of our specialists, call (03) 8080 8933 or book online via our appointments page.

References

What is endometriosis?

In endometriosis, tissue similar to the lining of the uterus (known as the endometrium) grows on organs and tissues outside the uterus. It typically affects the ovaries, fallopian tubes and the tissue lining the pelvis. However, it can grow anywhere in the pelvis.

Just like the lining of your uterus, this abnormal tissue builds up, breaks down and bleeds each month in response to changing hormone levels. However, unlike your period, there is no way for this blood and debris to leave the body. This leads to inflammation (irritation and swelling of the affected areas) and the formation of scar tissue known as ‘adhesions’. Over time, these fibrous bands of scar tissue may cause tissues and organs to stick together. In more advanced disease, this knitting together of structures can interfere with an organ’s normal function.

Recognising the symptoms of endometriosis

About 20 to 25% of women with endometriosis do not experience any symptoms at all.² In fact, some women only find out they have it when they experience trouble falling pregnant.

For other women, pain is the predominant symptom. Pain is typically worse during a woman’s period, but can occur at any time throughout the month. Endometriosis is also usually associated with heavy periods, longer periods (greater than five days), and spotting or bleeding between periods.

Depending on the structures involved, endometriosis may also cause bladder or bowel irritation. This can lead to pain, urinary frequency and difficulty with bowel movements. Some women may also experience pain during intercourse.

How endometriosis affects fertility and pregnancy

Between 30% to 50% of women with endometriosis will experience trouble conceiving.² There are a few different ways endometriosis may cause fertility issues.

In advanced or late-stage disease, endometriosis can interfere with the function of reproductive structures like the fallopian tubes and ovaries. For example, one or both fallopian tubes may become inflamed, and the ovaries may develop cysts, known as endometriomas. The tubes may become blocked, making it difficult for eggs to enter or travel along the tubes towards the uterus. These blockages can also hinder sperm from entering the fallopian tubes, making it harder for sperm to meet and fertilise an egg.³

When endometriosis affects the ovaries, cysts and scar tissue can also prevent ovulation (the release of an egg from the ovary each month), particularly if the ovary has become stuck to the wall of the pelvis. In this case, there is no egg available for fertilisation, even if sperm is able to gain access to the fallopian tubes. Inflammation and its related toxins may also reduce egg quality and ovarian reserve (the number of good-quality eggs remaining in the ovaries), reducing the chances of a successful pregnancy.

Additionally, pain associated with endometriosis may make it difficult to conceive naturally, as chronic pain and pain during intercourse may make sex very difficult.

We don’t fully understand how endometriosis leads to fertility issues in women with milder disease. In this case, the reproductive organs are not severely affected. However, the inflammation associated with endometriosis may be toxic to the egg, sperm and/or embryo. It may also reduce the ability of an embryo to implant in the lining of the uterus,⁴ an important step in conception.

It is important to note that endometriosis does not always affect fertility. If you have endometriosis and are experiencing difficulty conceiving, it’s important to undergo a thorough assessment by a fertility specialist to help determine if it is your endometriosis and/or other issues that are affecting your ability to conceive. An assessment of the male partner (where relevant) is also important for identifying any male-factor infertility that may be contributing to a delay in falling pregnant.

Fertility treatments for endometriosis

There is a range of fertility treatments that can help women with endometriosis conceive. These include assisted reproductive techniques (ART), as well as options that increase your chances of falling pregnant naturally. Studies show that ART cycles offer higher pregnancy rates (22%) than natural conception (11%) for women with moderate to severe endometriosis.⁵ The most appropriate treatment for you will depend on your medical history, the severity of your endometriosis, and whether your fertility specialist believes that this is the primary cause of your fertility issues.

Intrauterine insemination (IUI)

IUI is a procedure where a very large number of sperm are introduced into your uterus to increase the chances of egg and sperm meeting. In this procedure, a sperm sample from a partner or donor is concentrated in the lab to contain a very high number of sperm. The concentrated sample is then injected into your uterus soon after you have ovulated.

Your fertility specialist may also prescribe medication to help your body release more than one mature egg from the ovary before you undergo IUI, as there is evidence that this increases the chances of success in endometriosis.⁴ IUI is most likely to be suitable for women with mild to moderate endometriosis who have no blockages in their fallopian tubes.

Laparoscopic surgery

Laparoscopic (keyhole) surgery is a minimally invasive procedure that can identify and treat endometriosis. In this procedure, a small incision is made near the belly button, and a thin and flexible telescope is used to look inside the abdomen. Any growths that are found are then treated. Removing endometriosis that is blocking or ‘distorting’ reproductive organs may improve their function and improve fertility.³

In the months following surgery, natural fertility may increase. Laparoscopic surgery can also give you a better chance of a successful pregnancy after ART, such as in vitro fertilisation.

In vitro fertilisation (IVF)

IVF is most likely to be recommended as a first-line treatment when there are other factors also impacting your fertility. This may include older age (fertility naturally declines with age), advanced endometriosis, or low sperm quality in the male partner.

In IVF, several of your eggs are extracted from your ovaries and mixed with sperm in laboratory dishes. If the sperm are of good quality and swim well, they are left to enter the eggs on their own, much like they would in natural conception (this is called ‘standard insemination’). In cases where the sperm sample is lower quality or doesn’t move well, the best sperm can be selected and injected directly into each egg, making it much easier for them to unite and form an embryo. This process is called intracytoplasmic sperm injection (ICSI). The highest-quality embryo will then be placed in your uterus, where it will hopefully embed and develop into a successful pregnancy. Any remaining embryos can be frozen and stored for later use, if needed.

Depending on your medical history and circumstances, your doctor may prescribe medication to reduce your oestrogen levels for three to six months before IVF. Oestrogen is the main female sex hormone and promotes the growth of the endometrium in the first half of your menstrual cycle. Remember that endometriosis responds to hormones in the same way your uterus does; reducing oestrogen levels can therefore help to reduce the volume of abnormal growth prior to IVF. As a result, these medications may improve IVF success rates in women with endometriosis.³

Tubal flushing with oil

Tubal flushing is commonly used as a diagnostic technique to check for blockages in the fallopian tubes. However, tubal flushing with oil can also increase your chances of conceiving naturally in the months following the procedure. In tubal flushing, an oil-based liquid is introduced into the uterus through a tube placed in your cervix. The solution then makes its way through your fallopian tubes, ‘flushing’ them out and potentially removing blockages.

Freezing your eggs

In many women, endometriosis progresses with time. In addition, natural fertility declines with age. This means it may be harder to have a baby when you are older. If you’re not ready for parenthood but are concerned about how endometriosis may impact fertility later, egg freezing is a proactive step. This will ensure you have some high-quality eggs available should you find you need the assistance of IVF in the future.

Get help to have a baby with endometriosis

If you have endometriosis and have been struggling to conceive, book a consultation with one of our fertility specialists for expert advice specific to you. Call (03) 8080 8933 or book online today.

In women with regular menstrual cycles, an egg is usually released from the ovaries every month (‘ovulation’). However, in some women, the small fluid-filled sacs inside the ovaries (follicles) don’t always mature and ovulate (this typically affects women with polycystic ovarian syndrome). In this case, the release of eggs from the ovaries is unreliable – it either doesn’t occur at all, or only happens every now and again, leading to difficulty in falling pregnant.

If absent or irregular ovulation is contributing to your fertility issues, hormones and other special medications may be used to help your ovaries develop and release mature eggs. These medications may be used on their own to simply induce ovulation (‘ovulation induction’), with sexual intercourse then timed accordingly. However, these medications may also be used in combination with other fertility treatments if there are other factors contributing to your fertility issues. For example, if the quality and/or quantity of your partner’s sperm is also an issue (male-factor infertility), then simply getting the ovaries to release mature eggs is unlikely to be successful on its own. You may also need the help of artificial insemination (to insert a concentrated dose of sperm into the reproductive tract) or IVF (to collect the eggs for fertilisation outside the body).

How do we stimulate the ovaries to produce mature eggs?

The process we use to stimulate your ovaries to produce and release eggs is as follows:

1. Stimulation

Your fertility specialist will prescribe medication for you to take orally or by injection. There are a few different types of medications that may be used but they all work to increase the amount of follicle-stimulating hormone (FSH) in your body. Although your body naturally produces this hormone, the medication provides you with much more of it than what you would naturally produce on your own. The increased level of FSH is what causes the follicles inside your ovaries to develop and mature. At the start of puberty, you have around 400,000 follicles in your ovaries with the potential to develop into mature eggs. The number of follicles decreases year-on-year thereafter, with the greatest decline occurring after the age of 35.

2. Control

We will monitor you closely with blood tests and ultrasounds to see how your follicles are responding to the medication and to monitor for any side-effects. The aim is to allow the follicles time to mature while preventing the premature release of any eggs (‘ovulation’).

3. Egg release (ovulation)

You will usually be given an injection of human chorionic hormone (hCG) to trigger the release of eggs when the follicles are a good size. This is timed with sexual intercourse or artificial insemination to ensure there is sperm ready to meet the egg your ovaries release, in the hope that the egg and sperm will come together and develop into an embryo. Alternately, if ovarian stimulation is being used as part of the IVF process, then we won’t just ‘let nature take its course’. Instead, we will use ultrasound to help us physically retrieve the eggs your ovaries have produced. After we have collected your eggs, we will place them with your partner’s sperm in a special laboratory dish to fertilise. One fertilised egg (embryo) is then placed in your womb where it will hopefully ‘stick’ to the wall of the uterus and develop into a pregnancy.

Do all ovaries respond to stimulation?

Every woman responds differently to these medications. Thus, the dose of medication is tailored to each woman and closely monitored. However, even with this fine-tuning, sometimes the ovaries don’t respond well, in which case there may be no eggs or only a few eggs released. This is more likely to occur in older women (>37 years), women with elevated hormone levels, and women with reduced ovarian reserve (a low number of follicles to start with).

The type and dose of medication given will also depend on the type of fertility treatment you are having. If these medications are being used to facilitate the success of timed intercourse or artificial insemination, then we may use a more gentle mode of stimulation (e.g. oral tablets), as we are simply trying to mimic what would happen during your normal menstrual cycle – that is, have one egg lying in wait for your partner’s sperm to arrive.

However, if you are having this medication as part of the IVF process, then we would typically use injectable hormones at a dose that’s adequate for producing multiple eggs. Even if IVF circumstances are at their very best, not every egg placed with the male’s sperm in the laboratory will fertilise to form an embryo – and not every embryo will survive or be suitable for implanting into the womb. Therefore, the more eggs we make available for fertilisation by sperm during IVF, the higher the likelihood of producing a good number of high-quality embryos, which increases the chances of IVF success.

If my ovaries release lots of eggs, won’t that increase my chances of a multiple pregnancy?

Yes, these medications do stimulate the development of multiple follicles, so the ovary may end up releasing more than one mature egg. While this is desirable for IVF where the aim is to collect as many eggs as possible, it’s not ideal when these medications are used with timed intercourse or artificial insemination, as there is then an increased chance of having twins (or more). Although twins may sound like a lovely idea, multiple pregnancies do come with risks, both for the mother and babies. Thus, your fertility specialist will watch out for this via ultrasound monitoring – if too many eggs are developing, we may recommend abstaining from intercourse or adjusting the dose of your medication.

Multiple pregnancy is not an issue if ovarian stimulation is being used as part of the IVF process, as the eggs are being collected for fertilisation outside the body (in a laboratory dish) and we only implant one embryo into the womb at a time.

What are the potential side effects of these medications?

You may have heard that one of the more unpleasant aspects of fertility treatment is the side-effects of the medications used to stimulate the ovaries. Unfortunately, these medications do make you feel ‘hormonal’ and you may find yourself experiencing exaggerated PMS symptoms. The most common symptoms are temporary physical side effects, such as nausea, vomiting, headaches, cramps and breast tenderness. Mood changes, including mood swings, anxiety and depression, are also common. Bear in mind, however, that the emotional demands of infertility or IVF treatment can lead to similar feelings.

If you have injections, these may cause local skin irritations, but it is rare to have an allergic reaction to the medications.

The key risk associated with this type of treatment, particularly when higher doses are used as part of the IVF process, is ovarian hyper-stimulation syndrome (OHSS). This represents the body’s exaggerated response to the excess load of circulating hormones. It is characterised by enlarged ovaries and fluid accumulation in the abdomen. The chance of OHSS occurring is greater in women who become pregnant during the cycle in which the hormones are given and in women with polycystic ovary syndrome (PCOS). Close monitoring allows us to discontinue or adjust your medication if we start to see the signs or symptoms of OHSS. Be reassured that your fertility specialist will explain all the symptoms you should look out for, so you can let them know if you experience anything concerning.

Is ovarian stimulation right for me?

Ovarian stimulation plays a key role in many fertility treatments – from ovulation induction and timed intercourse to artificial insemination and IVF. For more information on how it could help you, make an appointment with one of our fertility specialists by calling Newlife IVF on (03) 8080 8933 or by booking online via our appointments page.

Further reading

• What influences your chance of IVF success?
• IVF success rates – what do the numbers really mean?
• Getting pregnant with polycystic ovarian syndrome