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The Hewitt Fertility Centre Leaflets

Each of The Hewitt Fertility Centre leaflets are detailed below, select the heading of the one you would like to view and the content will expand with an option for you to download the PDF version.

Leaflets can be made available in difference formats on request, to view in a different language select the language change in the bottom left of the screen.

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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.

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Please note that Google Translate is the tool that is used to translate information on our website to other languages. Google Translate is a global tool that is not under Liverpool Women’s control. Therefore whilst you may use Google Translate for useful simple translations, it should not be relied upon as a substitute for official translation services that are provided by the Trust. Please take particular notice of this when you are using the translation feature for patient information that contains detailed clinical information. Speak to a member of staff when you visit the Trust if you require any translation support.

  • Letrozole Treatment

    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.

     

  • Surgical Sperm Retrieval (SSR)

    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.

  • HYCOSY Information - Hysterosalpingo Contrast Sonography

    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.

  • Endometrial Immunoprofiling

    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, requiring them to proceed with assisted reproduction technology (ART). Despite recent advances, one in four attempted IVF cycles results in a baby and only 50% of women under 35 years old achieve a pregnancy after a blastocyst transfer.

    Repeated implantation failure (RIF) is determined 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 receptivity1.

    A number of tests have been used to understand why embryos do not implant. At present there is little evidence that these tests provide a clinical benefit. A lack of large randomised, controlled trials means that it is difficult to know when it is appropriate to offer patients certain tests.

    What tests are available?

    Endometrial immunoprofiling is a test that has recently been developed. This test is being offered by an immunology research laboratory in Paris, France. As an extrapolation of the Natural Killer cell test, they believe that different biomarkers measured in an endometrial biopsy taken at the time of presumed implantation will indicate whether a patient’s immune response is normal, low or high.

    How is the test performed?

    Once the decision has been made with your doctor to undertake this test, we will prepare your womb lining with a combination of oestrogen oral tablets and vaginal progesterone pessaries. A blood test for HIV, hepatitis B &C is required (sampled within the last 12 months). An endometrial biopsy is taken by passing a tube through the cervix and drawing off a sample of endometrial tissue using suction. The sample is placed in a tube and sent to France for analysis. The laboratory does an initial analysis on the sample to check there is sufficient tissue taken at the correct time during the menstrual cycle. At this point, payment by the patient directly to the French laboratory is required. The sample is fully analysed and the result is reported in approximately 3 weeks. A suggested management plan to correct any imbalance is also provided. Should you wish to repeat the test, there is a 20% reduction on the laboratory cost.

    Is there any evidence available on this test?

    Some studies have suggested that up to 78-81% of women with a lack of implantation will demonstrate an imbalance2,3. 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 improved3. Repeat testing after having any suggested treatments are possible for reassessment. Current randomised controlled trial results for these tests are expected in 2020.

    Immunoprofiling is viewed as an ‘add-on’ treatment as it is not considered routine clinical treatment. For more information on treatment add-ons please refer to the HFEA website:

    https://www.hfea.gov.uk/treatments/explore-all-treatments/treatment-add-ons/

    Please discuss the current HFEA traffic light status for this treatment with your fertility specialist.

    How much does the test cost?

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

    Viral screen (within 1 year of test)                              £175

    Medication                                                                  Up to £150

    Scan                                                                            £175

    Courier                                                                        £100

    Analysis (Laboratory based in Paris, France)            €500

    If you are unsure as to whether you should have endometrial immunoprofiling, please contact the Hewitt Fertility Centre to discuss further.

    References

    1. Das M, Holzer HE. Recurrent implantation failure: gamete and embryo factors. Fertil Steril 2012;97(5): 1021–7.
    2. 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.
    3. 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

    This leaflet can be made available in different 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

     

    The Hewitt Fertility Centre

    Liverpool Women's NHS Foundation Trust

    Crown Street

    Liverpool

    L8 7SS

    Tel: 0151 702 4142

     

    4 The Pavilions

    Knutsford Business Park
    Mobberley Road
    Knutsford
    WA16 8ZR

    Tel: 01565 653287

     

     

     

     

    Email: Hewitt.Centre@lwh.nhs.uk

                                               

    Issue Date: 12.06.2020

    Reference: Gyn/2020-259-v2

    Review Date: 12.06.2023                  Women’s NHS Foundation Trust

    © Liverpool Women’s NHS Foundation Trust

     

     

     

     

     

     

     

     

     

  • Endometrial Receptivity (ERA), Endometrial Microbiome (EMMA) and Analysis of Chronic Endometritis (ALICE)

    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

     

    Liverpool Women’s NHS Foundation Trust

    Crown Street

    Liverpool

    L8 7SS

    Tel: 0151 708 9988

    Reference: Gyn/2020-258-v1

    Issue Date: 24.01.2020

    Review Date: 24.01.2023                                     © Liverpool Women’s NHS Foundation Trust

  • Catheter Test

    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

     

  • Recurrent Implantation Failure

    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: 28.01.20

    Reference: Gyn/2020-256-v1

    Review Date: 28.01.2023              © Liverpool Women’s NHS Foundation Trust

     

  • Endometrial Scratch

    The leaflet is detailed below, or you can download the Endometrial Scratch leaflet in PDF.

    Endometrial Scratch Information Leaflet

     If you are unsure as to whether you should have endometrial scratch performed please contact the Hewitt Fertility Centre.

     How much does it cost?

     Currently, this treatment is not funded by the NHS. The endometrial scratch procedure costs £200.

     Add-on treatments

     Endometrial scratch is generally described to be an ‘add-on’ treatment. The HFEA website states that this treatment has a conflicting body of evidence and further research is required. For more information on treatment add-ons please refer to the HFEA website:

    https://www.hfea.gov.uk/treatments/explore-all-treatments/treatment-add-ons/

     What is an endometrial scratch?

    An endometrial scratch is a procedure that is performed to try to improve the chance of implantation when an embryo is transferred back in to your uterus.

     What does an endometrial scratch involve?

    Having an endometrial scratch 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. In contrast, an endometrial scratch involves using a firm catheter that is moved repeatedly inside your uterus and aiming to temporarily induce damage of the lining of the womb.

    Most people report the scratch as being more uncomfortable than an embryo transfer; however the discomfort is best described as mild. The procedure itself rarely takes more than 30 seconds to complete.

    It is important to use a barrier method of contraception (for example, a condom) during the treatment process.

     How does it work?

    We are not entirely sure. Some studies suggest that traumatising the lining of the uterus (endometrium) promotes an immune response that increases new blood vessel growth and an influx of certain chemicals and cells that play important roles in implantation. On the contrary, other studies have not reported any difference in live birth rate.

     How do I know if I would benefit from an endometrial scratch?

    To date, the evidence is contradictory. Your IVF specialist may talk to you about this procedure, however please ask if you feel you require more information.

    How do I arrange an endometrial scratch?

    In order for you to have an endometrial scratch, you will need to be seen by a clinician. It is normally performed between days 20 and 25 of your menstrual cycle and its effect can last up to 3 months. You will then be contacted the day before your procedure to confirm a specific time. Please arrive 15 minutes before your scheduled appointment and with a full bladder. You will be given a provisional date for the procedure based on your last period date and anticipated.

     Do I need an anaesthetic?

    No, the procedure is performed whilst you are awake. It is more uncomfortable than an embryo transfer, but we are able to offer you gas and air which is a mild inhaled anaesthetic if you prefer or find the procedure too uncomfortable. We also suggest taking a simple painkiller such as paracetamol or ibuprofen about an hour before the procedure. Please note we do not allow partners to accompany you whilst you have the procedure.

     Are there any risks?

    It is generally considered a very safe procedure. The procedure is uncomfortable and you may experience some discomfort and very mild vaginal bleeding after the procedure. There is a very rare chance of developing an infection. If you develop a high temperature 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.

    This leaflet can be made available in different 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 

    Hewitt Fertility Centre                              

    Crown Street

    Liverpool

    L8 7SS

    Tel: 0151 702 4142

    Email: Hewitt.Centre@lwh.nhs.uk

                                                                  

    4 The Pavilions

    Knutsford Business Park

    Mobberley Road

    Knutsford

    WA16 8ZR

    Tel: 01565 653287

    Issue Date: 29.05.2020

    Reference: Gyn/2020-274-v1

    Review Date: 29.05.2023

    © Liverpool Women’s NHS Foundation Trust

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

  • EmbryoscopeTM

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

    Patient Information

    During treatment by in-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI), your embryos are kept in strictly controlled and heated incubators. Over a period of 2 – 6 days your embryos are regularly examined to see which are developing normally and are most likely to result in a pregnancy.

    Historically, monitoring your embryo’s development involved removing the plastic dishes in which they are growing from the incubator to examine them under a heated microscope. They must then be returned to the incubators as quickly as possible to keep the temperature and surrounding conditions constant and to avoid any damage to your embryos. In order to reduce these disturbances, they are only checked once or twice a day, offering brief ‘snapshots’ of your embryos. During these checks the embryologist assesses your embryos to determine which will have the highest chance of implantation.

    By contrast, the EmbryoscopeTM offers continuous “live” surveillance of your embryos in a safe, undisturbed and controlled environment from which they do not have to be removed for examination. A large screen provides a continuous view of the embryos within the incubator.

    In addition, continuous time-lapse ‘moving’ images are stored automatically within the patient file for review at any time during the embryo’s development. If you wish, we can provide you with a video containing the images of your embryos after your transfer.

    In addition, the EmbryoScopeTM logs the embryos’ development at all times so that their progress can be reviewed. We can see things that we might have missed before because it didn’t happen at a time when we were examining them under the microscope. Also, in the fallopian tubes and womb, nature provides a very stable environment for embryos and we try to mimic this in the IVF lab – this new incubator is the best thing we have had so far to do that. It is possible to observe key development events in the EmbryoScopeTM, this helps us select which embryos are most likely to result in pregnancy and there is a growing body of evidence to suggest that its use increases the chance of treatment working.

    Embryos are dynamic, constantly changing as they grow and develop. Historically we used to only get a ‘snapshot’ view of the embryos. With the EmbryoscopeTM we can now see exactly how an embryo has developed for the entire time it has been in our care, without having to remove it from its optimal environment”

    Dr Gregoire, Scientific Director of The Hewitt Fertility Centres 

    PLEASE NOTE: EmbryoScopeTM Time lapse technology is used in all cycles at The Hewitt Fertility Centre as standard practice and will not be charged as an ‘add-on’ to your treatment.

    This leaflet can be made available in different 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

     

     

  • Intra-Cytoplasmic Morphologically selected sperm Injection (IMSI)

    The leaflet is detailed below, or you can download the Intra-Cytoplasmic Morphologically selected sperm Injection (IMSI) leaflet in PDF.

    Intra-Cytoplasmic Morphologically selected sperm Injection (IMSI)

    Background

    Intra-cytoplasmic sperm injection (ICSI) is a technique, introduced in 1992 to help certain types of infertility. Thousands of couples have become parents as a result of ICSI. It involves the injection of a single sperm directly into the centre of an egg to fertilise it. This procedure bypasses the natural process of the sperm travelling to the egg on its own.

     

    What is IMSI?

    Intra-cytoplasmic morphologically selected sperm injection (IMSI) is a more advanced form of ICSI. This technique uses a higher magnification (x6000) to select the sperm used for the injection into the egg. The sperm are carefully chosen by the embryologist, who assesses the sperm head, mid-piece and tail. The sperm are also investigated for structural defects. The best sperm are chosen for the injection based on their appearance.

    Are there any risks associated with ICSI or IMSI?

    Risks associated with ICSI include the potential for damage to a small number of eggs as they are prepared for the injection procedure.

    ICSI has also been associated with certain genetic and developmental defects in a very small number of children born using this treatment. However, it is difficult to determine whether this is a result of the ICSI procedure or the underlying cause of infertility. Follow up studies from children born using this technique are still on-going. Another issue to consider is the possibility that if your child conceived as a result of ICSI is a boy, he may inherit his father’s infertility. At this stage it is too early to know if this is the case.

    IMSI is a non-invasive test performed on a semen sample as an additional step to the ICSI process. The risks associated with the use of ICSI also apply to IMSI; there are no significant additional risks to the patient or embryo with IMSI. IMSI just allows the embryologist to take a closer look at the sperm prior to injection. IMSI does not give any information about the genetic content or internal quality of the chosen sperm.

    It is important that you discuss possible risks with your doctor before going ahead with treatment. You may also find it helpful to discuss your concerns with a counsellor.

    How likely is IMSI to work?

    The research that has been carried out generally does not support the use of IMSI over standard ICSI for infertile men. However, the latest Cochrane review stated that the evidence available on IMSI vs ICSI is of very low quality evidence and the benefit of IMSI over ICSI is uncertain due to the limitations of the studies compared1.

     IMSI may help the following patient groups:

    • Men who have a high number of abnormal sperm found in their semen
    • Recurrent miscarriage
    • Previous failed fertilisation with ICSI
    • Poor quality embryo formation in previous treatments

    The Human Fertilisation and Embryology Authority (HFEA) and IMSI:

    IMSI is regarded by the HFEA as a treatment ‘add on’. The HFEA status for the use of IMSI as a treatment add-on is red. This means that there is no evidence that this add-on is effective and safe at present.

    For up-to-date information and access to recent patient experiences using ICSI, please use the following link to access the HFEA website:

    For up-to-date information and access to recent patient experiences using ICSI, please use the following link to access the HFEA website:

    https://www.hfea.gov.uk/treatments/explore-all-treatments/intracytoplasmic-sperm-injection-icsi/

    This leaflet can be made available in different 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

     

  • Pre-Implantation Genetic Testing for Aneuploidy (PGT-A)

    The leaflet is detailed below, or you can download PGT-A leaflet in PDF 

    What is PGT-A?

    Embryos with an abnormal number of chromosomes (aneuploid embryos) are known to have a reduced chance of producing a successful pregnancy and may also result in a baby being born with a genetic condition. Until recently, the only way to determine whether or not an embryo was aneuploid was to wait until a pregnancy was established and then perform chronic villus sampling (CVS) or amniocentesis, to test the chromosomal material in the foetus. If an abnormal number of chromosomes are detected, parents face the difficult choice of whether to continue or terminate the pregnancy. PGT-A (formally known as PGS) is a new technology which helps to identify embryos that have an abnormal number of chromosomes at this very early stage, and as such, are not transferred. 

    How is PGT-A carried out?

    The technique of PGT-A involves carrying out a biopsy on suitable embryos (those that have developed to the correct stage) and testing for any abnormalities in the number of chromosomes, in the hope to identify and transfer an embryo with the correct number of chromosomes. The biopsy is performed on suitable blastocysts (at either the day 5 or day 6 stage). The embryos are frozen whilst we obtain the genetic result and then transferred in a future cycle.

    What is the evidence to support PGT-A?

    There is some evidence to show that IVF success rates can be improved if embryos are tested for aneuploidy, with only those found to have the correct number of chromosomes transferred to the womb. It has also been reported that PGT-A significantly reduces the chance of having a pregnancy affected by certain genetic conditions. However, PGT-A is not yet considered to be a standard technique and consequently we strongly recommend that patients who become pregnant through PGT-A undergo prenatal testing using CVS or amniocentesis, to confirm whether or not the foetus has a correct number of chromosomes.

     Is PGT-A for me?

    We may recommend PGT-A if:

    • You are over 35 and have a higher risk of having a baby with a chromosome problem (such as Down’s syndrome)
    • You have a family history of chromosome problems
    • You have a history of recurrent miscarriages
    • You have had several unsuccessful treatments where embryos have been transferred
    • Your sperm are known to be at high risk of having chromosome problems

    Please Note: You are not obliged to undergo PGT-A, even if your doctor recommends it.

    Are there any risks with PGT-A? 

    In some cases, it may be that embryos are too poor quality to undergo the biopsy and testing process. If embryos are suitable for biopsy, there is a risk of damage to the embryo through the biopsy procedure; however this risk is quoted to be less than 1%. Additionally, although current PGS techniques are mostly very accurate, the test may give the wrong result (i.e. it may miss an abnormality, or detect one that isn’t there).

    If both the procedure and testing are carried out successfully, research has shown that babies born after PGT-A show no increase in congenital abnormalities above the general rate for IVF children1.

    What is the cost of PGT-A?

    There will be an additional charge per treatment cycle for PGT-A so please discuss this with your doctor.

    The Human Fertilisation and Embryology Authority (HFEA) and PGT-A:

    PGT-A is regarded by the HFEA as a treatment ‘add on’. For more information on treatment add-ons please refer to the HFEA traffic-light system on their website:

    https://www.hfea.gov.uk/treatments/explore-all-treatments/treatment-add-ons/

    Please discuss the current HFEA traffic-light status for the use of PGT-A with your fertility specialist.

     


    1Kuiper, D., Bennema, A., la Bastide-van Gemert, S., Seggers, J., Schendelaar, P., Mastenbroek, S. et al. Developmental outcome of 9-year-old children born after PGS: follow-up of a randomized trial. Hum Reprod201833147–155

                                 

  • Sperm DNA Damage Testing

    The leaflet is detailed below, or you can download Sperm DNA Damage Testing  leaflet in PDF.

    What is sperm DNA damage?

    Half of the information to make a human is delivered by the sperm to the egg. Sperm production takes place inside the testicles and takes approximately two months to complete. During this time, there is a possibility that the sperm DNA can become damaged. The exact cause of sperm DNA damage is unknown but may be related to lifestyle and genetic factors.

     

    What evidence is available for sperm DNA fragmentation?

    A number of studies have indicated that high sperm DNA damage can be associated with infertility issues including disrupted embryo development, poor IVF fertilisation rates and higher rates of pregnancy loss after IVF/ICSI1. However, two systematic reviews on sperm DNA damage testing have been completed which resulted in conflicting opinions on the use of the sperm DNA damage test2,3. Unfortunately, the evidence available on sperm DNA damage is limited and there is currently no large clinical study available to justify regular use of this test. 

    What is the sperm DNA fragmentation test?

    A test called the COMET assay is used to detect sperm DNA damage. This test involves chemically breaking down the sperm sample to release the DNA and testing it. The COMET assay enables the DNA damage to be measured by examining the number of DNA breaks in the sample.

    How is this test performed?

    A semen sample is needed to perform the DNA test. The results of the DNA test aim to indicate the fertility potential of the sperm in the semen sample.

    When will my results be available?

    The sperm DNA damage test will take less than a day to process in the andrology laboratory. The sample is then sent away for further testing. The results can take up to two weeks to be processed.

    Is sperm DNA damage testing for me?

    The genetic integrity of the sperm is essential for normal embryo development. A high level of DNA fragmentation in sperm cells may represent a cause of male infertility that conventional examinations do not test for.

    Your doctor or embryologist may recommend you have the sperm DNA damage test if failed fertilisation has occurred and there is no known cause for this outcome. This test offers a possible further explanation for un-explained infertility. The results of a sperm DNA damage test may impact slightly on the management of your treatment but may identify why you are struggling to get pregnant.

    How much does the test cost?

    The sperm DNA damage test costs £550 (this price includes the courier fee).

    The Human Fertilisation and Embryology Authority (HFEA) and the test:

    Sperm DNA damage testing is an additional investigation that can be added to your treatment. Sperm DNA damage is viewed as an ‘add-on’ treatment. For more information on treatment add-ons please refer to the HFEA website:

    https://www.hfea.gov.uk/treatments/explore-all-treatments/treatment-add-ons/

    Please discuss the current HFEA traffic-light status of sperm DNA damage testing with your fertility specialist.

     

    1Simon et al (2010)  Clinical significance of sperm DNA damage in assisted reproduction outcome, Human Reproduction, 25, 7, pp1594-1608.

    2Cissen et al (2016) Measuring sperm DNA fragmentation and clinical outcomes of medically assisted reproduction: A systematic review and meta-analysis, PLoS One, 11, 11, e0165125, pp1-23.

    3Simon et al (2017) A systematic review and meta-analysis to determine the effect of sperm DNA damage on in vitro fertilisation and intracytoplasmic sperm injection outcome, Asian J Androl, 19, 1, pp80-90.

  • Laser Assisted Hatching

    The leaflet is detailed below, or you can download Laser Assisted Hatching leaflet in PDF.

    What is laser assisted hatching?

    A human embryo has a soft outer ‘shell’ called the zona pellucida (or zona for short). When an embryo is five or six days old and is at the stage known as a blastocyst, it needs to escape or hatch out of the zona. The picture below shows a blastocyst

    Once the embryo has hatched out of the zona, it is able to implant into the lining of the womb and a pregnancy hopefully results.

    If the embryo does not hatch a pregnancy cannot occur.

    hatching out of the zona.

    What is laser assisted hatching and how is it done?

    Laser assisted hatching is a technique whereby a small artificial hole is made in the zona of an embryo using a laser. It is thought that the embryo can then hatch more easily through this hole and hopefully increases the chance of the embryo implanting.

    This picture shows the hole made by the laser in the zona of an embryo (indicated by the arrow).

    Laser assisted hatching is usually performed just before the embryo transfer procedure.

    Laser assisted hatching can be performed on embryos at the early cleavage stages (that is two or three days after the egg collection) and at the blastocyst stage (five or six days after the egg collection).

    Is laser assisted hatching suitable for me?

    Some patients may produce embryos in which the zona is thickened or hardened making it difficult or impossible for the embryo to implant. Also, patients who have had several embryo transfers without success or patients who are older may wish to consider laser assisted hatching.

    What difference will laser assisted hatching make?

    It is difficult to say with certainty whether laser assisted hatching improves your chance of pregnancy as the available evidence about this remains controversial. The National Institute for Clinical Excellence (NICE) states “Assisted hatching is not recommended because it has not been shown to improve pregnancy rates.” The Human Fertilisation and Embryology Authority (HFEA) have a traffic light system to rate the clinical effectiveness of add-on treatments. Please discuss the current HFEA traffic light status for laser assisted hatching with your fertility specialist.

    Are there any risks with laser assisted hatching?

    There is always some risk of damaging embryos with these types of procedures; further research is needed to examine the consequences for children born as a result of this procedure.

    What is the cost of laser assisted hatching?

    There will be an additional charge per treatment cycle of £380 for laser assisted hatching.

    If you are unsure as to whether you should have laser assisted hatching, please do not hesitate to contact The Hewitt Fertility Centre. 

  • Intra-Cytoplasmic Sperm Injection (ICSI)

    The leaflet is detailed below, or you can download ICSI leaflet in PDF (opens in a new window)

    Background

    Intra-cytoplasmic sperm injection (ICSI) is a technique, introduced in 1992 to help certain types of infertility. Thousands of couples have become parents as a result of ICSI. It involves the injection of a single sperm directly into the centre of an egg to fertilise it. This procedure bypasses the natural process of the sperm travelling to the egg on its own.

     

     

    What is the difference between IVF and ICSI?

    ICSI is very similar to IVF, with the same process for egg collection. The difference is in the process of insemination. Instead of the sperm being mixed with the eggs as in IVF, with ICSI, a single sperm is injected directly into each egg, with a highly trained embryologist having selected the sperm that are most active and healthy. ICSI allows the use of sperm that may not otherwise have been able to fertilise an egg.

    Are there any risks associated with ICSI?

    Risks associated with ICSI include the potential for damage to a small number of eggs as they are prepared for the procedure, and also through the process of injection.

    ICSI has previously been linked with certain genetic and developmental defects in a very small number of children born using this treatment. However, it is difficult to determine whether this is a result of the ICSI procedure or the underlying cause of infertility. Follow up studies from children born using this technique are still on-going. Another issue to consider is the possibility that if your child conceived as a result of ICSI is a boy, he may inherit his father’s infertility. At this stage it is too early to know if this is the case.

    It is important that you discuss possible risks with your doctor before going ahead with treatment. You may also find it helpful to discuss your concerns with a counsellor.

    How could ICSI help me?

    ICSI could be helpful if the male has: 

    • Low sperm count (oligozoospermia).
    • Abnormal sperm shape (poor morphology).
    • Sperm have poor swimming ability (poor asthenozoospermia).
    • Sperm cannot bind or penetrate the eggs for an unknown reason.
    • Tubes carrying sperm from the testicles to the penis (vas deferens) are damaged or missing.
    • Previous failed or low fertilisation.
    • Immune system adverse reaction to sperm (anti-sperm antibodies).
    • Failed reversed vasectomy. Testicular sperm extraction (TESE) may be required to obtain sperm. For more information about TESE and what it involves, and whether these may be options for you, please speak to your doctor.
    • Difficulty obtaining an erection or achieving ejaculation. This particularly affects men who have spinal cord injuries, Hodgkin’s disease and numerous other disorders.

    What are my chances of having a baby with ICSI?

    The chances of having a baby using ICSI are similar to those for IVF. As with most fertility treatment, success depends on many factors including female age.

    For up-to-date information and access to recent patient experiences using ICSI, please use the following link to access the HFEA website:

    https://www.hfea.gov.uk/treatments/explore-all-treatments/intracytoplasmic-sperm-injection-icsi/

     

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