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.

The leaflet is detailed below, or you can download the 'Endometrial Immunoprofiling' leaflet in PDF

Background

Infertility affects approximately 10-15% of couples in the UK (see reference 1), requiring them to proceed with assisted reproductive technology (ART). Despite the significant advances of these techniques, data published by the Human Fertilization and Embryology Authority (HFEA) for the United Kingdom indicate that around one-in-four attempted in vitro fertilization (IVF) cycles (25.6%) results in a baby and only 50% of women under the age of 35 years, who receive a blastocyst (a five days old embryo) transfer do achieve a pregnancy (see reference 2). Repeated implantation failure (RIF) indicates when transferred embryos fail to implant following several attempts. RIF can occur by chance, or because of underlying problems in the eggs or sperm, or in the embryos or in the lining of the uterus (endometrium) due to what we call reduced endometrial receptivity (see reference 3). Recent studies on mechanisms of miscarriage and RIF indicate a possible common pathway suggesting that these two conditions may represent a different face of the same coin. A number of tests have been use to try and understand why embryos do not implant. None are guaranteed to work and in the fullness of time might be shown to be ineffective in larger scale studies such as randomised controlled trials. One issue we struggled with is, if and when to offer these tests to our patients? Some couples want us to decide whereas others would like the opportunity to choose for themselves.

One such test which is being presented at medical conferences at the moment is endometrial immune-profiling. This test is being offered by an immunology research laboratory in Paris(France). They believe that different biomarkers, like the level and activity of the Natural killer cells (an important component of our immune-system), measured in an endometrial biopsy taken at the time of presumed implantation will guide us on whether the patient’s immune response is normal, low or high. Some studies have suggested that up to 78-81% of women with a lack of implantation will demonstrate an imbalance (4-5). Importantly, they have also derived treatments to normalise the immune response. According to the same studies, when these treatments were used in women with imbalances, both live birth rate and miscarriage rate were improved (5). Repeat testing after being on the suggested treatment is then possible to reassess.

They are conducting a randomised trial but the results are not expected by late 2019, early 2020.

As we must consider this ‘experimental’, we cover our costs but do not profit from offering this test.

What is required?

Once the decision has been made with your doctor to undertake this test, we will prepare your womb lining with a combination of oral oestrogen tablets and vaginal progesterone pessaries. A blood test for HIV, Hepatitis B &C is needed within the last year. An endometrial biopsy is then taken by passing a tube through the cervix. It works by suction to draw off some endometrial tissue. We then place it in a tube and arrange courier transport to France. Once the sample is in Paris, there is an initial analysis to check there is sufficient tissue taken at the right menstrual phase. At this point, payment by the patient to the French laboratory directly is required. They then undertake analysis and let us know the results in 3 to 4 weeks. A suggested management plan to correct any imbalance is also provided. Should you wish to repeat the test, adding in proposed treatments to see if the immune-profile is corrected, then there is a 20% reduction on the laboratory cost.

What is the cost?

Viral screen (within 1 year of test)                                                      £125

Liverpool Women’s cost (including meds, biopsy & courier) £100* 

Analysis (to laboratory directly in Euros)                €500    (€400 for repeat if required)      

* The cost may vary depending on the individual medication required. 

References

1. Evers JL. Female Subfertility. Lancet 2002 Jul; 360:151-9
2. Human Fertilisation and Embryology Authority, Fertility treatment 2014 – Trends and figures, HFEA website.
3. Das M, Holzer HE. Recurrent implantation failure: gamete and embryo factors. Fertil Steril 2012;97(5): 1021–7.
4. Lédée N, Petitbarat M et al. The Uterine Immune Profile May Help Women With Repeated Unexplained Embryo Implantation Failure After In Vitro Fertilization. Am J Reprod Immunol. 2016 Feb 11; 75(3): 388–401.
5. Lédée N, Prat-Ellenberg L et al. Uterine immune profiling for increasing live birth rate: A one-to-one matched cohort study. J Reprod Immunol. 2017 Feb;119:23-30. 

For further information and to arrange an appointment: 

0151 702 4121 (option 3)

www.thehewittfertilitycentre.org.uk     via “contact us”

Hewitt.Centre@lwh.nhs.uk 

This leaflet can be made available in difference formats on request. If you would like to make any suggestions or comments about the content of this leaflet, then please contact the Patient Experience Team on 0151 702 4353 or by email at pals@lwh.nhs.uk

Liverpool Women’s NHS Foundation Trust

Crown Street

Liverpool

L8 7SS

Tel: 0151 708 9988

Reference:

Issue Date: 09/2019

Review Date: 09/2022                                          © Liverpool Women’s NHS Foundation Trust

The leaflet is detailed below, or you can download the 'Endometrial Receptivity (ERA), Endometrial Microbiome (EMMA) and Analysis of Chronic Endometritis (ALICE)' leaflet in PDF

Background

Infertility affects approximately 10-15% of couples in the UK (see reference 1), requiring them to proceed with assisted reproductive technology (ART). Despite the significant advances of these techniques, data published by the Human Fertilization and Embryology Authority (HFEA) for the United Kingdom indicate that around one-in-four attempted in vitro fertilization (IVF) cycles (25.6%) results in a baby and only 50% of women under the age of 35 years, who receive a blastocyst (five days old embryo) transfer do achieve a pregnancy (see reference 2). Repeated implantation failure (RIF) indicates when transferred embryos fail to implant following several attempts. RIF can occur by chance, or because of underlying problems in the eggs or sperm, or in the embryos or in the lining of the uterus (endometrium) due to what we call reduced endometrial receptivity (see reference 3). Recent studies on mechanisms of miscarriage and RIF indicate a possible common pathway suggesting that these two conditions may represent a different face of the same coin. A number of tests have been use to try and understand why embryos do not implant. None are guaranteed to work and in the fullness of time might be shown to be ineffective in larger scale studies such as randomised controlled trials. One issue we struggled with is, if and when to offer these tests to our patients? Some couples want us to decide whereas others would like the opportunity to choose for themselves.

One series of tests which are being presented at the most recent medical conferences is the “endometrial health pack” by Igenomix, Spain. It consists of an endometrial biopsy being taken and sent for analysis. Three different tests can be carried out on the same sample:

• The ERA test of implantation receptivity challenges the notion that the implantation window is the same for all patients and that for some, replacing an embryo either a day earlier or later may be associated with better results. This would only be appropriate for IVF patients and not for those with recurrent miscarriages naturally conceived.
• The EMMA test looks at the endometrial microbiome and determines the healthy bacteria levels that may play a role in the implantation of an embryo. Probiotic treatment may be suggested to balance the endometrial flora with the aim of improving the pregnancy prospects.
• The ALICE test looks for 8 potentially harmful bacteria to an implanting embryo for which antibiotic intervention may be advised.

What is required?

Once the decision has been made with your doctor to undertake this test, we will either arrange an endometrial biopsy on day 21 of a regular 28 day cycle or else prepare your womb lining with a combination of oestrogen oral tablets and vaginal progesterone pessaries. An endometrial biopsy is then taken by passing a catheter through the cervix. It works by suction to draw off some endometrial tissue. We then place it in a tube and arrange courier transport to Igenomix. They then undertake analysis and let us know the results in 3 to 4 weeks. A suggested management plan to correct any imbalance is also provided. Should you wish to repeat the test, adding in proposed treatments to see if the intervention has worked, then repeat testing does not incur an additional cost from Igenomix but the Hewitt Fertility Centre cost still applies.

What is the cost?

Liverpool Women’s cost (including any meds, biopsy & courier) £100*

EndomeTrio (all three tests) £895

ERA endometrial receptivity £695

EMMA (microbiome) + ALICE (endometritis) £495

ALICE (endometritis) £295   

* The cost may vary depending on the individual medication required.

References

1. Evers JL. Female Subfertility. Lancet 2002 Jul; 360:151-9
2. Human Fertilisation and Embryology Authority, Fertility treatment 2014 – Trends and figures, HFEA website.
3. Das M, Holzer HE. Recurrent implantation failure: gamete and embryo factors. Fertil Steril 2012;97(5): 1021–7.

For further information and to arrange an appointment:

0151 702 4121 (option 3)

www.thehewittfertilitycentre.org.uk via “contact us”

Hewitt.Centre@lwh.nhs.uk

The leaflet is detailed below, or you can download the 'Catheter Test' leaflet in PDF

What is a catheter test?

The catheter test is a common procedure. It gives your doctor the opportunity to perfect the technique needed to do your actual transfer in cases where it is suspected to be difficult.

Why is a catheter test done?

Having a catheter test is a lot like having an embryo transfer. During embryo transfer we use a very soft catheter which contains your embryo and is performed as gently as possible. A difficult embryo transfer has been associated with lower pregnancy success rates. In cases where we think that difficulty might be anticipated during the actual embryo transfer in view of your history we may recommend you to have a catheter test beforehand.

What does the catheter test involve?

The catheter test is usually done before starting the IVF cycle. You will probably be told to come that day with a full bladder. This is because your full bladder pushes the uterus into a position which makes the procedure easier. A speculum will be used to help your clinical practitioner visualize the neck of your womb (cervix), more like having a smear test, and place the catheter into and through the cervix into your uterus.

You may feel cramping or a sharp but tolerable pain when the catheter is placed. Some women only feel slight discomfort like during a pap smear, and nothing more.

What is the aim of the procedure?

The aim of the procedure is to choose the best catheter to use with your particular anatomy, to make sure there is nothing to prevent the catheter from entering the cervix smoothly and figure out the best path from your cervix into your uterus, this may vary according to the position of the uterus.

How do I know that I might need a catheter test?

If you had any previous surgeries to your cervix, uterine abnormalities, cervical fibroids, or any other factor that can make the passage through your cervix into the uterine cavity difficult.

Do I need anaesthetic?

No, the procedure is performed whilst you are awake. The procedure should be as gentle as possible and painless similar to Embryo transfer. However, you may experience some discomfort especially if the passage through the cervix is difficult which may lead your doctor to offer you a further procedure. 

Are there any risks?

It is generally considered a very safe procedure. There is a very rare chance of developing an infection. If you develop a fever within a few days of the procedure, experience severe cramping, or unusual bleeding (not just spotting), or offensive vaginal discharge, or If you are concerned at any time, please contact the Hewitt Centre for further advice. There is also a small chance that the procedure gets abandoned due to difficult entry, hence a subsequent procedure would then be required.

How much does it cost?

Currently if your treatment is funded by the NHS, you may be eligible to have the procedure performed without cost. However, if you are paying for your treatment an additional will be incurred.

This leaflet can be made available in difference formats on request. If you would like to make any suggestions or comments about the content of this leaflet, then please contact the Patient Experience Team on 0151 702 4353 or by email at pals@lwh.nhs.uk   

Liverpool Women’s NHS Foundation Trust

Crown Street

Liverpool

L8 7SS

Tel: 0151 708 9988

Reference:

Issue Date: 01/04/2019

Review Date: 01/04/2022                                     © Liverpool Women’s NHS Foundation Trust

The leaflet is detailed below, or you can download the 'Recurrent Implantation Failure' leaflet in PDF

Recurrent Implantation Failure 

If you have repeated unsuccessful treatments it is a very difficult experience both physically and emotionally. This information leaflet looks at the reasons why embryos do not implant and the tests and treatment that you may be offered.

Why are my embryos not implanting or my pregnancies not continuing?

There are a number of different reasons why treatment may be unsuccessful. These may be related to the eggs, sperm, womb or embryos. After the loss of 2 or more pregnancies or the unsuccessful implantation of 3 high quality embryos you will be offered testing to try and discover why.

However in around 60% of cases we do not find a reason why but this doesn’t mean that future treatment won’t be successful.

What tests will you do?

You will be offered an appointment with an experienced clinician who will review your personal and family history and your treatment cycles to date.

Tests that you may be offered will include blood tests to look at your thyroid function, blood clotting, antibodies and genetics. If you haven’t already had a 3D ultrasound of your womb then we may also arrange this. There are also additional sperm tests that we may advise.

What happens after the tests?

If any results come back as abnormal then we will advise what treatment is necessary.

We would also consider an Endometrial Scratch in your next treatment cycle as this has been shown to increase success rates in case of recurrent implantation failure. This is a simple procedure, similar to having an embryo transfer.

What other treatment options are there?

Other treatment options include genetically screening the embryos with an aim of only putting back genetically normal embryos. Or we may carry out further tests on the womb lining to look for issues with receptivity, the microbiome or the immune system.

Unfortunately these tests are usually only available if you are self-funding.

What can I do?

We would advise you not to smoke, this includes vapes, and to limit your alcohol consumption to the recommended safe levels or avoid it altogether.

We would advise you wherever possible to ensure that your BMI (body mass index) is above 19 and below 25 or that you are working to achieve that and to have 5 portions of fruit or vegetables per day.

All women hoping to conceive should be taking 400mcg folic acid daily (5mg if at risk of neural tube defects, diabetic or epileptic or BMI greater than 30) and 10mcg of vitamin D. You can buy folic acid and vitamin D over the counter in supermarkets or pharmacies but if you require 5mg folic acid then we will prescribe that.

We recognise that this is a very difficult time for you and self-care is important.

Our counsellors are available to support you and can be contacted on 0151 702 4075.

Further information on additional treatments for recurrent implantation failure is available from the HFEA via https://www.hfea.gov.uk/treatments/explore-all-treatments/treatment-add-ons/

This leaflet can be made available in difference formats on request. If you would like to make any suggestions or comments about the content of this leaflet, then please contact the Patient Experience Team on 0151 702 4353 or by email at pals@lwh.nhs.uk 

Liverpool Women’s NHS Foundation Trust

Crown Street

Liverpool

L8 7SS

Tel: 0151 708 9988

Issue Date: 11/19

Reference:

Review Date: 11/22              © Liverpool Women’s NHS Foundation Trust