The Hewitt Fertility Centre Leaflets

The leaflet is detailed below, or you can download the 'Letrozole Treatment' leaflet in PDF.

Letrozole (Femara) is a medication approved for the treatment of breast cancer. It is an aromatase inhibitor and works by lowering the production of oestrogen. Letrozole has also been shown to be effective at inducing ovulation in infertility patients. Treatment may increase the chance of a twin pregnancy, although this is much less than with Clomiphene (Clomid), where the risk can be increased four-fold.

Benefits

The benefits of taking Letrozole tablets are to encourage or regulate ovulation to achieve a pregnancy. The half-life of Letrozole is very short (2 days) compared to Clomiphene. This means the medication is metabolized more rapidly and the side effects are less. Letrozole does not affect the cervical mucus or endometrial (womb) lining as much as Clomiphene. This is better for sperm transport in the cervix and a more favourable lining for implantation.

Alternatives

Alternatives to Letrozole tablets are:

• Clomiphene tablets
• Gonadotrophin injections

Risks

• Ovarian hyperstimulation (caused by producing too many eggs)
• Increased risk of multiple pregnancy (approximately doubled)

Possible Side Effects:

Hot flushes are most common. Other side effects are nausea, headaches, bloating, muscle aches, blurred vision and fatigue. They can occur in approximately 10 to 20% of patients and are limited to that cycle. If you experience problems with vision, pain or swelling in the abdomen or vomiting, the medication should be stopped and medical advice sought. Also should you have any other questions or worries, please feel free to ring your clinic and speak to a member of staff (see Useful contacts below).

How Do I Take The Medication?

The starting dose is usually 2.5mgs a day from day 2 to day 6 of your menstrual cycle (period), day 1 being the first full day of bleeding. You will be asked to either perform home urine ovulation tests or attend for a blood test on day 21 of that cycle to check your progesterone level. These hormone tests will inform us whether you have ovulated or not. Some patients with irregular periods may be asked to attend on different days of the cycle to try to determine whether ovulation has occurred. It may take several days for the progesterone result to be available. If ovulation has occurred and you are not pregnant, in the next cycle you should take the same dose of Letrozole.

Before starting Letrozole treatment the doctor or nurse will discuss the drugs with you. If you do not understand, or have any concerns, please contact your clinic for further advice. Most patients will ovulate following treatment with one or two tablets of the Letrozole a day. Some patients may require higher doses and others may not ovulate at all. Under these circumstances alternative treatments will be discussed. Once ovulation has been confirmed it is usual to continue on the same dose for up to six cycles. If a pregnancy has not occurred after six ovulatory cycles you will be asked to see the Consultant. 

Useful contacts 

If you are a patient of the Liverpool Hewitt Fertility Centre you can contact the nursing staff Monday to Friday 08.00 – 16.45 and Saturdays 08.15-13.15 via 0151 702 4123 Option 1

If you are a patient of the Knutsford Hewitt Fertility Centre you can contact the nursing staff Monday to Friday 08.00 – 16.30, Saturdays answer phone only via 0151 702 4078

If you are attending the Gynaecology out-patient department on the ground floor of Liverpool Women’s Hospital you can contact the nursing staff Monday – Friday 09.00 – 17.00 via 0151 708 9988

Please note that Liverpool Women’s NHS Foundation Trust is a smoke free site. Smoking is not allowed inside the hospital building or within the hospital grounds, car parks and gardens. Staff are available to give advice about stopping smoking, please ask about this.

The leaflet is detailed below, or you can download the 'Surgical Sperm Retrieval (SSR)' leaflet in PDF.

Why do I need surgical sperm retrieval?

Surgical sperm retrieval (SSR) is a treatment option for men who have no sperm (Azoospermia) in their ejaculate. Reasons for undertaking (SSR) could include:

Obstructive Azoospermia – An obstruction preventing sperm release from the testicle due to previous injury or infection, or Congenital Absence of the Vas Deferens (tube carrying sperm from testis) in men with Cystic Fibrosis, or Vasectomy.

Non-obstructive Azoospermia – Likely testicular failure where the testicles are producing low numbers of sperm which are not found in the ejaculate. This could be also associated with genetic conditions.

Other possible clinical indications may be for men with erectile dysfunction and retrograde ejaculation.

What are the different techniques of SSR?

There are different methods of SSR. The cause of your Azoospermia will determine the best way to retrieve sperm in your individual case.

• TESE (Testicular Sperm Extraction). This is often done under general anaesthetic. There is an 0.5cm skin incision. A small incision is made into the testis itself. A small sample of the testicular tissue is taken which is then examined for sperm. (Usually carried out if the male hormone levels and testicular size are normal).
• Micro- TESE (Microscopic Testicular Sperm Extraction). This requires a general anaesthetic and involves performing a 2-3 cm incision on the scrotal skin. The testis is opened and several biopsies are taken from each testicle in different areas and by using an operating microscope, some of the fine individual sperm producing tubes are removed for detailed assessment. The sample is then transported to the Andrology department by a responsible adult of patient’s choice to the Hewitt Fertility Centre for detailed examination, and storage of sperm if found.

How long will I be in hospital?

SSR is a day case procedure.  When done under general anaesthetic, it usually takes 3-4 hours to recover and then you are discharged home. The material collected will be examined on the same day – or cultured in medium and processed – by the embryology team to see if there is any sperm present. Any material with sperm will be frozen (cryopreserved) and placed in storage to be used in In Vitro-Fertilisation / Intra-Cytoplasmic Sperm Injection (IVF-ICSI) assisted reproduction treatment cycle(s) at a later stage. These specimens are then thawed and used to inject the eggs obtained during IVF treatment using the technique of ICSI.

What will happen after the procedure?

Potential side effects post procedure may be some testicular discomfort & mild bruising.

The sedation or anaesthetic will wear off following the procedure; however a responsible adult of patient’s choice will need to drive you home. You should try to have a relative stay with you for the first 24 hours after surgery.

You will need to rest until the effects of the anaesthetic/sedation have passed. Your scrotum will feel sore as the anaesthetic wears off and you may need painkillers.

You will be wearing supportive underwear from the day of procedure and scrotal support (jock strap) daily for a further 5-6 days to minimise discomfort and protect your scrotum and testes.

If you need pain relief, you can take over-the-counter painkillers such as Paracetamol or Ibuprofen.

Showering is advised; try to avoid hot baths to prevent infection. Dissolvable sutures take about 2 weeks to come away.

Avoid Alcohol for 48 hours post-surgery

Refrain from strenuous exercise/lifting for four weeks.

There are no stiches that need to be removed.

Sexual activity is not advised for a week after the procedure.

During the procedure you will be given antibiotics.

Are there any complications?

SSR is a relatively low risk procedure.

Most men do not experience side effects.

However, possible complications include bruising, haematoma (collection of blood in scrotum), minimal scarring and infection. Damage to blood vessels - this can cause permanent damage to one or both testicles (testicular atrophy - rare). Long-term testicular pain (5-10%) - this is caused by damaged nerves or scarring and may require long term pain medication.

Anaesthetic side effects

These include postoperative nausea and vomiting (usually lasts for 1-2 hours and can be controlled with anti-emetic medications). Very rarely anaphylaxis, a severe reaction, (risk is 1 in 10,000).

How effective is SSR?

Obstructive cases are usually more successful than Non-Obstructive.

The sperm which is successfully retrieved is frozen and this does not affect its ability to subsequently fertilise an egg. However the sperm retrieved is usually low in numbers and may not be mature therefore cannot successfully fertilise an egg using standard IVF. Because of this, the embryologist will pick out a single sperm to inject into each egg, (this procedure is called Intracytoplasmic Sperm Injection or ICSI).

References

British Association of Urological Surgeons (2017). BAUS: Surgical sperm retrieval patient information leaflet. Leaflet No: 16/045. Available online: 

https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Sperm%20retrieval.pdf

NHS England (2016).Clinical Commissioning Policy: Surgical sperm retrieval for male infertility. Available online: https://www.england.nhs.uk/wp-content/uploads/2018/07/Surgical-sperm-retrieval-for-male-infertility.pdf

Shah, R. and Gupta, C. (2018). Advances in sperm retrieval techniques in azoospermic men: a systematic review. Arab Journal of Urology. 16(1): P125-131.

The leaflet is detailed below, or you can download the 'HYCOSY Information - Hysterosalpingo Contrast Sonography' leaflet in PDF.

What is HYCOSY?

A Hycosy is a test using ultrasound and a special fluid called Sonovue to examine the uterus and fallopian tubes.

Why do we perform HYCOSY?

We use this test as an infertility investigation. If either the cavity of the uterus, or the tubes are damaged it can prevent conception taking place.  It is not possible to see the tubes with normal x-rays or ultrasound, so a specialist examination such as this is needed.

What does the examination entail?

The examination is performed in the ultrasound room.  You will be asked to empty your bladder and the procedure will be explained by the practitioner.

You will be asked to lie on the bed and a cover will be draped over your lower body.  A transvaginal ultrasound examination will then be performed.  This entails a thin ultrasound probe being introduced into the vagina.  This is a routine gynaecological examination, and should not hurt.  This allows us to visualise the uterus and ovaries prior to the Hycosy.

If this is satisfactory, the examination will then progress to Hycosy

A speculum will be put into the vagina; this allows us to see the entrance to the womb (cervix).  A small catheter will then be passed into the uterus.  A tiny balloon which is attached to the catheter will be inflated to keep the catheter in place during the examination.

The speculum is then removed and a small amount of fluid is injected into the cavity under ultrasound control.  The fluid shows up as a “bright white” on ultrasound and we can trace its course outlining the cavity of the womb and tubes if there is no blockage.

You may feel some discomfort similar to period pain. A recent audit performed at the Hewitt fertility Centre showed that 35% of the women have mild discomfort and 8-10 % of them have mild-severe pain during the procedure; immediately after the procedure, the same women refer no pain or discomfort in 55 % of the cases. Only less than 2% of them still report mild pain after the procedure. Usually this pain or discomfort is helped by the use of usual painkillers such as Paracetamol.  If you are worried about the discomfort you may take your usual painkiller half an hour before the examination.

How long does the test take?

The procedure takes about half an hour.

What happens after the examination?

You may wish to bring a panty liner to wear as the fluid used is sticky.  You may not feel able to return to work immediately after the examination.  If possible you should be accompanied by a partner or friend on your homeward journey, and you should not drive for an hour or so afterwards. Most women feel completely well after the procedure and can return to their normal activities shortly after. The examination will be reported by the practitioner and will be discussed in full at your next clinic visit.

Booking your appointment

The test cannot be performed if you are bleeding or there is a chance that you are pregnant.  You must use barrier methods of contraception during the cycle of the hycosy appointment, and we will ask you to sign a disclaimer that you are not pregnant.

Smears and screening swabs should have been performed prior to this procedure and the results must be available to view.

Should you have any queries regarding your appointment or procedure please contact the Hewitt Fertility Centre on 0151 7024123 – option 1.