What is IVF?
In vitro fertilisation (IVF) is a fertility treatment that has helped millions of women to conceive. You may be offered it because of a fertility issue that makes conceiving naturally difficult or impossible, or because you have been trying for a baby without success for a long time and other methods of assisted conception have failed.
In vitro fertilisation simply means that the process of fertilisation takes place outside the womb. Eggs are taken from the mother (or a donor) and fertilised with sperm in a glass dish – “in vitro” literally means “in glass”. Once the egg is fertilised and has developed into a ball of cells, it's transferred to the uterus. Eggs and sperm can be from you and your partner, or either can come from a donor. The process was first used in 1978.
IVF cost in the UK
You may be eligible for treatment on the NHS, but if not, you can have it done privately. Costs will vary from one clinic to another but are usually somewhere in the region of £5,000 per cycle. You can find details of your local clinics on the Human Fertilisation and Embryology Authority's website.
IVF: NHS provision
You have to meet specific criteria to be offered treatment on the NHS. NICE guidelines recommend that:
- Women under 40 should be offered up to three cycles if they've been trying to conceive for more than two years without success or they have had 12 cycles of artificial insemination and this hasn't worked.
- Women trying to get pregnant at 40 to 42 years of age should be offered one cycle if, as above, they've had 12 cycles of unsuccessful insemination or have been trying for two years, they have never had the treatment before, they don't seem to have low ovarian reserves (very few eggs) and they've been informed of the risks of treatment at 40 years plus.
- Additionally if fertility testing has shown that in vitro fertilisation is likely to be the only method via which you will ever conceive you should be offered it straight away too.
Can I have IVF if I already have a child?
The provision of IVF treatment varies across the country, and often depends on local Clinical Commissioning Group (CCG) policies. CCGs may have additional criteria you need to meet before you can have IVF on the NHS, such as:
- not having any children already, from both your current and any previous relationships
- being a healthy weight
- not smoking
- falling into a certain age range (for example, some CCGs only fund treatment for women under 35)
In some cases, only one cycle of IVF may be routinely offered, instead of the three recommended by NICE.
Ask your GP or contact your local CCG to find out what the criteria for NHS-funded IVF treatment are in your area.
Can you be denied IVF treatment?
Women over 34 are being denied IVF treatment in some parts of England, it has been revealed.
The Victoria Derbyshire programme and campaign group Fertility Fairness have found that women over 34 are being automatically refused IVF treatment on the NHS in 12 areas of England. While NICE guidelines recommend that women under 40 should be offered up to three cycles of treatment if they've been trying to conceive unsuccessfully for more than two years, new figures show that CCGs in around 80% of areas are not doing this.
Fertility Fairness obtained data from 195 CCGs, finding that:
- seven have stopped providing treatment entirely
- 85 (43%) have cut treatment for women over 39
- 12 have stopped offering treatment to women over 34
A Department of Health and Social Care spokesperson said:
“All decisions on IVF treatment should be made by doctors based on a patient's individual clinical needs and in line with NICE guidelines. While provision of NHS infertility treatment is decided by local Clinical Commissioning Groups, we are clear that blanket restrictions on treatment are unacceptable.”
Professor Adam Balen, Professor of Reproductive Medicine and Surgery and Spokesperson for the Royal College of Obstetricians and Gynaecologists (RCOG) told Mumsnet:
“It is extremely disappointing to see that some clinical commissioning groups across the country are still failing to provide fully-funded IVF treatment for women and their partners, as recommended by the National Institute of Clinical Excellence (NICE).
“NICE guidance recommends that infertile women under the age of 40 should receive three cycles of IVF treatment. But inadequate government funding means that access to these services varies across Trusts and clinics, with many women receiving only one free cycle, and some not being offered any cycles at all. IVF treatment is cost effective and if couples are provided with three cycles the majority will have a realistic chance of conceiving.
“We are very concerned that women and their partners are turning to costly private clinics for treatment or to travel abroad to countries were services may be less well-regulated. Another concern is that with only one free cycle, women may opt for implantation of more than one embryo which can lead to a higher risk of a multiple birth and this, in turn, may increase the chances of developing harmful complications for both mother and her babies.
“The resulting health inequalities from inadequate IVF treatment are completely unacceptable. The RCOG is calling on all UK commissioners and healthcare providers to follow NICE guidance and to end the current postcode lottery for IVF treatment. Scotland is leading the way by offering all couples fully-funded three cycles of IVF treatment and England must follow suit as a matter of urgency.”
Speaking on the Victoria Derbyshire programme, one woman who had been denied treatment said: “I felt cheated, I felt really disappointed initially, I felt angry and I felt that it wasn't handled in the best possible way. It was all so matter of fact, this is how it is, kind of get on with it.”
Another said: “It's bad enough, going through the process, knowing you can't have a child anyway and then to be told that you're too old, I guess, it was just horrible.”
Matt Hancock, Secretary of State for Health and Social Care, said: “There shouldn't be a blanket ban. Of course, people should be treated according to their individual circumstances, and these decisions are made independently of ministers, but the point of having the national guidelines is so that that is the position people can expect across the country.”
What should the NHS be offering?
Here's what NICE guidelines recommend women should be entitled to, depending on their age:
The IVF process – how does IVF work?
The process happens in several stages and you'll need to go to the clinic or hospital to see your fertility specialist several times at various points. Before you begin you'll be advised to start taking folic acid and you and your partner may be given blood tests to check for things like HIV and hepatitis, just to ensure you both have a clean bill of health before you begin.
Suppressing your cycle
Also known as 'down-regulation' or 'down-reg', this is the start of the process where you're given drugs to essentially 'turn off' ovulation. On about day 21 of your cycle, you'll start taking medication to suppress your hormones – either as a nasal spray or a daily injection that you can do yourself at home. Down-regulation usually takes about two weeks.
Stimulating your ovaries
Once your natural hormones are “turned off” you'll start a course of injections that will encourage your ovaries to produce lots of eggs (as opposed to the usual one they cough up per month). This is to give the doctors lots of eggs to work with so they can create several embryos and pick the best to implant. Again, you can do this injection yourself. You usually have the injections for 10-12 days.
Monitoring the follicles
While the eggs are getting ready to be released from their follicles, you'll be carefully monitored with transvaginal ultrasounds to check on their progress. When they look ready to go, you'll be given an injection, which will release the eggs around 36 hours later.
Egg and sperm collection
Approximately 36 hours after the injection to release the eggs, you'll go to the clinic to have your eggs collected. This is the really clever bit. The doctor will use a very fine, hollow tube attached to an ultrasound probe to go in, through the vagina and up into each ovary. This is done using an ultrasound scan so they can see exactly what they're doing.
They usually manage to extract an egg from 80% of the ripe follicles. The number of eggs collected varies enormously. It can be as many as 30 but they would hope to get at least 15. You'll be awake during the procedure but sedated. It's not usually painful but can feel a bit strange and uncomfortable. You should be able to take painkillers later on at home if you need them.
At the same appointment, your partner will be asked to give a sample of sperm. Obviously, he has the less uncomfortable end of the deal, but understandably, lots of men feel a bit of pressure and performance anxiety, too.
Sometimes they can use frozen sperm and obviously if you are using donor sperm, at this point they will simply defrost the sample.
The sperm will be “washed” – this is nothing to do with Imperial Leather and Marigolds, don't worry. It's the process by which individual sperm cells are separated from the semen. They pick out the best looking specimens, leaving any ropey-looking ones behind.
The collected eggs and the lucky few sperm selected are combined in a glass dish and put in an incubator to, well… 'get it on'. The dish is checked 24 hours on and if any eggs have been fertilised, they're then incubated for two to five days. This allows the fertilised eggs to develop into blastocysts of four or eight cells each. Usually, between 60 and 70% of the eggs will be fertilised.
If you're having ICSI (intracytoplasmic sperm injection) then a single sperm is injected into a single egg at this point. ICSI is a type of in vitro fertilisation that is usually done if there's a male fertility problem, such as a very low count or the sperm being of poor quality. ICSI is also sometimes used if you've had treatment previously and fertilisation wasn't successful.
Transferring the embryo
While the embryos were developing, you'll have been given hormone medication (progesterone) to take to thicken the lining of the womb in preparation for the embryo to be implanted. This could be either a pessary, a gel or an injection.
The embryologists will keep in touch with you and let you know when the embryos are ready to be transferred. They’ll then pick the best looking embryo or embryos to implant.
Some clinics will offer chromosomal screening at this point to ensure the best embryos are used, which reduces the chances of miscarriage. The transfer is done with a thin tube, a bit like when you had the eggs collected, but this is a simpler process and less uncomfortable – more like having a smear test – so you shouldn't need sedation. They use the tube to place the embryo (or embryos) through the vagina and cervix into the womb.
Any embryos left over will be frozen so you can use them another time if you wish.
The two-week wait
This is the agonising bit – waiting to find out if the embryo has bedded in. You'll be advised to wait two weeks after embryo transfer to take a pregnancy test. Some clinics suggest you do a simple urine test at home, while others like you to come in for a blood test, which is more accurate.
"I need to get prepared by cutting out caffeine etc but I'm finding it hard. I also know lots of people announcing their pregnancies – I'm trying not to be jealous of how easy procreation is for some."
You don't need to do anything “special” during this time but keep yourself busy if possible, or it can seem like a very long wait indeed. Obviously, follow any instructions your medical team have given you though. You'll probably be advised to abstain from sex, cigarettes and alcohol and to avoid doing anything too strenuous. Don't forget to keep taking your medication, too.
Other than that, this is a time just to look after yourself both physically and mentally. Get early nights, eat well and relax as much as is possible. It's easier said than done but try to avoid agonising over every last sign and symptom and wondering if it means you're pregnant – it will only drive you mad.
You might like to speak to a counsellor during this time, which your clinic can usually help with. The stress of trying to conceive is bad enough when you aren't going the in vitro route, so don't feel silly if you need some extra support – everyone understands that it's a really anxious time.
Sadly, the treatment is quite often not successful so, while it's good to think positively, it's worth keeping that in the back of your mind so it's slightly less of a devastating blow if it isn't successful this time.
If your pregnancy test is positive, you're likely to have one or perhaps more ultrasounds over the following weeks just to check that the embryo has implanted in the womb and nowhere else. You'll then start the journey of standard antenatal care, midwife appointments and scans just like everyone else. It can feel weirdly like the end of a long journey, getting to this point, when it's really the start of a much bigger journey.
How many embryos are implanted?
The number of embryos transferred will depend on your age. NICE guidelines state that the maximum number of transfers should be two. There are also guidelines about how many embryos should be transferred, depending on your circumstances:
- If you're under 37 – in your first cycle, you should only have a single embryo transfer. On your second cycle, you should only have one if at least one top-quality embryo is available. If no top-quality embryos are available, they may implant two. In the third cycle, you should have up to two embryos.
- If you're aged 37-39 – for your first and second cycles, one embryo is recommended if there is at least one top-quality embryo, and two if there are no top-quality embryos. In the third cycle, you should have up to two.
- If you're aged 40-42 – you can have a double embryo transfer at any point.
What is the IVF success rate?
I'm currently in the middle of the two-week wait after having a frozen embryo transferred. I'm trying my hardest not to think about it – but I'm constantly checking for every/any sign.
The younger you are, the higher your chances of success with in vitro fertislisation. Data from 2010 on IVF treatment (including ICSI) shows the percentage of cycles that resulted in a live birth by mother's age:
- Under 35 years – 32.2%
- Age 35-37 – 27.7%
- Age 38-39 – 20.8%
- Age 40-42 – 13.6%
- Age 43-44 – 5%
- Over 44 – 1.9%
Unfortunately, your chances of success do statistically decrease with each cycle you undertake so if you've had several cycles with no success, it's worth bearing that in mind when considering whether to continue or not.
Can I improve my chances of it working?
For the most part, it's in the lap of the gods, but obviously, you will want to ensure you've done all you can to maximise your chances of success. Being a healthy weight, not smoking, limiting alcohol to a unit per day and keeping caffeine intake very low will all help. It might also help you to try things like positive visualisation or yoga to help stay in a good frame of mind and keep relaxed. There's no way of saying whether this will have any discernible impact on your chances of success but there's certainly nothing to be lost.
What is an endometrial scratch and will it improve your success rate?
An endometrial scratch is a procedure that has, until now, been thought to improve the chances of successful embryo implantation. The procedure, which can cost up to £350 and is not usually available on the NHS, involves scratching the tissue of the womb lining – a process that is rather like a smear test, but more painful and invasive. The scratching process has, until recent studies proved otherwise, been thought to help embryos implant.
A large-scale study involving 1,346 women across five countries has shown the endometrial scratch procedure to be ineffective at improving success rates.
Are there any risks?
It is a very safe and regularly used process but there are a few slightly increased risk factors to be aware of:
- You're more likely to have twins (if you have more than one egg transferred). Obviously, for many women, this would be a boon rather than a disappointment, but it's worth remembering that multiple pregnancies always carry greater risks than a single pregnancy.
- Slightly increased risk of ectopic pregnancy. For this reason, you’ll be given a scan once you get a positive pregnancy test to confirm that the embryo has implanted in the uterus and not the fallopian tubes.
- Rarely, women having the treatment develop Ovarian Hyperstimulation Syndrome in the week after egg collection. This is where the medication you have to encourage the production of more eggs sends your ovaries into overdrive and they become large and swollen. Symptoms include faintness, shortness of breath, sickness and pain and bloating low in your abdomen. This can be dangerous if severe, so if you experience any of these symptoms you should contact your clinic straight away.
What are the side effects?
The process has become easier and smoother over the years but you may experience a few problems along the way. None of them are anything you won't be able to cope with, however, and you'll get lots of support along the way from your clinic. You may experience some of the following during the process due to the fertility drugs you're taking:
- Feeling irritable
- Hot flushes
Is IVF painful?
The minor procedures you'll have as part of the treatment can be uncomfortable, but most women say they aren't painful – retrieving the eggs tends to be the worst bit. Putting the embryos back in is usually a simpler and smoother process.
Fertility clinics warned over costly IVF add-ons
Fertility bodies have agreed that clinics must be more honest about the success rates of costly treatment 'add-ons'
The Human Fertilisation and Embryology Authority (HFEA) and ten other leading fertility bodies have warned in an early 2019 statement that fertility clinics need to be more honest about treatment add-ons and the fact that they have not been proven to work.
The statement comes in response to growing evidence that patients are being offered expensive add-ons without being told that there is no conclusive evidence that any of them actually increase the chance of a pregnancy.
Sally Cheshire CBE, Chair of the HFEA, said, “It's crucial that clinics are transparent about the add-on treatments they offer, including the potential costs, to ensure patients know exactly whether they are likely to increase their chance of having a baby.”
Key principles of the statement are:
- Clinics should only offer treatment add-ons where more than one high quality study demonstrates a treatment add-on to be safe and effective.
- Clinics should stop offering the treatment add-on to patients if concerns are raised regarding safety or effectiveness.
- Patients must be clearly informed of the experimental nature of any treatment add-on which is offered, where there is no robust evidence of its safety and/or effectiveness.
- Patients should not be charged extra to take part in a clinical trial.
A recent HFEA national fertility patient survey has shown that, for those who had treatment in 2017 and 2018, three quarters (74%) had at least one type of treatment add-on, similar to 71% of those in the past five years.
The most commonly performed treatment add-ons for those who used a fertility clinic in the past two years were clinical techniques such as an endometrial scratch (a process during which the woman's endometrium is 'scratched' with the hope of increasing the chances of an embryo implanting), using embryo glue (a substance that is added to the solution in the dish in which embryos are held before being transferred to the woman) or an Embryoscope (a type of incubator that allows the embryologist to monitor embryo cell divisions).
I wouldn’t do the scratch – my consultant was one of the pioneers and he was disappointed that the early successes they had had didn’t seem to be replicated.
Jason Kasraie, Chair of the Association of Reproductive and Clinical Scientists, said: “We support greater transparency in the sector with regard to treatment add-ons. While it is important that we work to ensure patients always receive the latest treatments and have access to new technologies in order to maximise their chance of treatment success, it is also essential that we ensure patients are fully informed and that only procedures or technologies that are evidence-based are used.”
IVF, Michelle Obama and declining fertility rates
In her new memoir, Becoming, Michelle Obama talks about how a miscarriage prompted her to think seriously about fertility, and eventually conceive her two daughters via in vitro fertilisation.
Talking to ABC News about her memoir, and the miscarriage itself, she said: "I felt lost and alone, and I felt like I had failed. I didn't know how common miscarriages were because we don't talk about them. We sit in our own pain thinking that somehow we're broken.
“The biological clock is real because egg production is limited and I realised that, as I was 34 and 35, we had to do IVF. I think it's the worst thing that we do to each other as women, not share the truth about our bodies and how they work and how they don't work.”
She also spoke about the difficulties of balancing her husband's schedule with the realities of IVF treatment – such as having to manage the regular injections herself, often.
At the same time, a report has also found that fertility rates are falling dramatically across the world, with fewer and fewer babies being born every year.
Researchers say that the fall in fertility rate means more than half of all countries are facing a “baby bust” – this means there are not enough children are being born to maintain the population size.
While, in 1950, women were having an average of 4.7 children. The fertility rate almost halved to 2.4 children per woman by last year.
What Mumsnetters say about IVF:
"I think there is a really good chance of it working fairly quickly these days but, if you do have disappointments, make sure you find good support."
"I found the whole process quite therapeutic as we were given a timetable of what drugs to take on specific days and times, and it somehow felt we were back in control and actually taking charge of the situation. This is our first attempt but I am so much calmer than I was this time last year, trying naturally."
"I had my first IVF cycle at 37. I went for natural IVF, so only got one mature egg (the one I produced naturally). To my astonishment, I got pregnant first time. I miscarried, but it worked! We're starting again as soon as my period arrives (any time now)."
"Just don't waste time, as I did, cocking about with diets and herbs and manuka honey and positive thinking and self-styled fertility gurus on Harley Street. Cold hard science offers much better odds."