Fertility: the options laid bare

Ovulation-inducing drug therapy

WHAT IS IT?

Clomiphene citrate, marketed as Clomid, is probably the most widely used fertility drug. Taken as a pill, it tells the brain that not enough oestrogen is being produced, stimulating the ovaries into producing eggs containing follicles.

COST

Usually available on the NHS.

EFFECTIVENESS

For women who have irregular periods, or are not ovulating, it produces ovulation in 60 to 70 per cent of cases. About half of those will conceive, says Dr Gillian Lockwood, medical director of Midlands Fertility Services.

RISKS

Possible side effects include hot flushes, mood swings, breast tenderness, insomnia, heavy periods and weight gain. It is thought to increase the risk of ovarian cancer if taken for more than a year.

OTHER ISSUES

"We would urge patients to ask medics if they are being prescribed any drugs what the side effects are, how long they will be on them and, if they don't work, what is the next step," says Clare Brown, chief executive of Infertility Network UK.

Pituitary stimulation

WHAT IS IT?

For women with ovulation failure, a pulsed gonadotrophin-releasing hormone (GnRH), such as Gonadorelin, can kick-start the pituitary gland. A small, battery-operated pump, usually worn on the upper arm, pulses the drug directly into the bloodstream.

COST

Usually available on the NHS.

EFFECTIVENESS

"For those who have the stamina to wear the pump constantly for a couple of months, it is very effective," says Dr Lockwood.

RISKS

Side effects include stomach pains, sickness and nausea, heavy periods and headaches.

OTHER ISSUES

Unlike most fertility treatments, there is no increased risk of multiple pregnancy.

Ovary-stimulating hormones

WHAT IS IT?

Drugs containing follicle-stimulating hormone (FSH) and/or luteinising hormone (LH) stimulate the ovaries to produce eggs. These are used for infertility caused by pituitary gland failure and male infertility; for patients with polycystic ovary syndrome who are not responding to Clomid; and to stimulate ovulation before IVF cycles.

COST

Usually available on the NHS. Privately, Puregon/Gonalf FSH or Merional/ Menopur HMG injections cost around £500 to £900 for each treatment cycle.

EFFECTIVENESS

"Very effective, but it needs to be closely monitored because the risk of multiple pregnancies is very high," says Dr Lockwood.

RISKS

Over-stimulation of the ovaries, known as ovarian hyper-stimulation syndrome (OHSS); increased risk of multiple pregnancy when used for ovulation induction; allergic reactions.

OTHER ISSUES

Drugs form a huge part of the cost of IVF. Patients should ask why their doctor is prescribing a brand and check that they are being supplied at the lowest possible cost.

Surgery

WHAT IS IT?

Used in some cases of blocked tubes, caused by inflammation and scarring as a result of infections such as chlamydia.

COST

Available on the NHS in some cases. Privately, between £2,000 and £3,000.

EFFECTIVENESS

Where the tubal damage is minor, it can be very effective. In cases of more serious damage, it does not work as well, and is not recommended because of the risk of ectopic pregnancy.

RISKS

As with any surgery, there are general risks involved.

OTHER ISSUES

"Women should ask, 'Is this surgery going to give me a better chance of conceiving than IVF?' Its suitability is dependent on the type of blockage," says Brown.

Intrauterine Insemination (IUI)

WHAT IS IT?

This involves inserting sperm into the womb to coincide with ovulation. This can be used where there is unexplained infertility or ovulation problems. It is also used if the sperm count is low.

COST

Around £800 (excluding drugs).

EFFECTIVENESS

The success rate for IUI using fertility drugs is around 15 per cent per cycle of treatment, provided the sperm and the tubes are both healthy.

RISKS

Women may experience mild cramps, like period pains.

OTHER ISSUES

"I would ask why it's being recommended, and how many attempts I should have before moving onto the hi-tech treatment if it's unsuccessful," says Brown.

In Vitro Fertilisation (IVF)

WHAT IS IT?

Eggs are removed from the ovaries and fertilised with sperm in a laboratory dish before being placed in the womb. It may be recommended for older women; those with unexplained fertility; women whose tubes are blocked or who have been unsuccessful with other techniques such as drugs or IUI.

COST

NHS-funded treatment varies across the UK, but it aims to offer women between the ages of 23 and 39 at least one free cycle, provided they meet the criteria. Privately, a cycle of IVF, including drugs and consultations, can cost between £4,000 and £8,000.

EFFECTIVENESS

The overall success rate is about the same as in nature, and sometimes better. One in four women under 30 have babies after IVF, but only one in 10 by the age of 40. IVF cannot surmount the decline in the number and quality of eggs that is part of the ageing process.

RISKS

Ovarian hyper-stimulation syndrome. Cysts develop on the ovaries and fluid collects in the pelvis. In 1 to 2 per cent of cases, the ovaries become engorged and the fluid interferes with breathing. An increase in red blood cells can lead to clots. It can be fatal. The risk of an ectopic pregnancy seems to be higher, especially if the woman has had problems with her tubes.

OTHER ISSUES

"The treatment goes on for several weeks. The emotional pressure is quite huge, physically and emotionally. I would recommend talking to someone to help you cope," says Brown.

Blastocyst transfer

WHAT IS IT?

This technique allows the embryos to develop to the blastocyst stage – five to six days after fertilisation – before they are put back in the womb.

COST

Around £400 on top of IVF treatment. Some clinics don't charge extra.

EFFECTIVENESS

"It gives a higher implantation rate than transferring day-two or day-three embryos," says Dr Lockwood. "The pregnancy rate in my clinic for blastocyst transfer is 50 per cent."

RISKS

Ovarian hyper-stimulation syndrome.

OTHER ISSUES

"We would urge more research to establish whether this truly affects success rates," says Brown.

Assisted hatching

WHAT IS IT?

Before an embryo can attach to the wall of the womb, it has to "hatch" from a gel-like shell. Some embryos have a tougher shell, so making a hole in the shell, or thinning it with acid, lasers or mechanical methods, may help the embryo to hatch.

COST

About £400, plus IVF.

EFFECTIVENESS

Some clinicians believe that assisted hatching results in better pregnancy rates. "We no longer recommend this treatment as we have found that it does not improve the chances of pregnancy," according to the London Fertility Clinic.

RISKS

The embryo may become damaged by the procedure and not suitable for transfer.

OTHER ISSUES

"I would ask for continued research to prove whether this is a good thing or not," says Brown.

Intra-Cytoplasmic Sperm Injection (ICSI)

WHAT IS IT?

This involves injecting a single sperm into the centre of an egg. The woman takes fertility drugs to stimulate the ovaries to produce more eggs, which are then fertilised with her partner's sperm and replaced in the womb.

COST

About £1,000, plus the cost of IVF.

EFFECTIVENESS

"ICSI has been successfully performed since 1991 and at least some eggs have been fertilised in more than 95 per cent of patients," says a spokeswoman for the London Fertility Clinic.

RISKS

There have been concerns that injecting the sperm into an egg could damage it, leading to birth defects. Another risk is that infertile men could pass on their infertility to their sons.

OTHER ISSUES

"Long-term follow-up of the children is a must," says Brown.

Gamete Intra-Fallopian Transfer (GIFT)

WHAT IS IT?

The eggs and sperm are collected in the same way as in IVF. The healthiest are chosen, mixed together and placed in one of the Fallopian tubes. Unlike IVF, fertilisation takes place inside the body. It can help in cases of unexplained fertility.

COST

About £5,500.

EFFECTIVENESS

Rates vary between clinics, but 25 to 30 per cent of women usually get pregnant in any one treatment cycle. Like most fertility treatments, it is more successful in younger women.

RISKS

It requires a general anaesthetic and a laparoscopy.

OTHER ISSUES

"The tubes must be open, or it's a waste of time," says Brown.

Donor Insemination (DI)

WHAT IS IT?

This is an option when a partner is producing little or no sperm; the sperm is unable to fertilise an egg; the man has had a vasectomy; or there is no male partner. The sperm are put into a tube, which is used to place them at the entrance to the cervix.

COST

A home-insemination kit costs around £20. In a clinic, around £110 per ampoule of sperm in addition to the cost of IVF.

EFFECTIVENESS

At home the success rate is similar to that of intercourse. In a clinic, for women under 35, the success rate is 14 per cent. This falls to 4 to 5 per cent for ages 40 to 42.

RISKS

If you use fresh donor sperm for home insemination, it cannot be guaranteed free from infection. Supplying sperm outside of a licensed clinic is illegal.

OTHER ISSUES

Children are entitled to know the donor's identity.

Egg donation

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WHAT IS IT?

Donated eggs are mixed with the partner's sperm. Alternatively, the sperm can be introduced directly into the eggs (ICSI). When the embryos begin to develop they are transferred to the womb.

COST

About £8,000.

EFFECTIVENESS

There is a 25 to 40 per cent success rate for each treatment. This is a slightly higher success rate than conventional IVF because donor eggs must come from women aged 35 or under.

RISKS

As with any form of assisted conception, pre-eclampsia, high blood-pressure and gestational diabetes are more common, but particularly so with donated eggs.

OTHER ISSUES

Identifying information is held on HFEA registers and may be given to any children once they are 18.

Embryo donation

WHAT IS IT?

IVF treatment using donated embryos.

COST

About £1,700, plus the cost of drugs.

EFFECTIVENESS

Success is dependent on the viability of the donated embryo.

RISKS

Same as egg donation.

OTHER ISSUES

Most donated embryos are those that are "left over'' from successful cycles. The child born from a donated embryo is likely to have "full" siblings, so counselling is vital.

Surrogacy

WHAT IS IT?

Another woman carries and gives birth to the baby. Sperm can come from the partner of the woman, using the surrogate's eggs. Fertilisation is done by artificial insemination, often by IUI.

COST

Slightly more than that of a straight IVF cycle as both intended mother and surrogate mother will need to be treated.

EFFECTIVENESS

One would expect the normal IVF success rate of between 25 to 40 per cent per cycle, says Dr Lockwood.

RISKS

The same as those associated with IVF.

OTHER ISSUES

The surrogate is the legal mother of the child and will be put on the birth certificate until the woman has applied through the courts for a parental order or adoption.

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