General Questions

Here we aim to answer common questions about undertaking fertility treatment in Australia.

Is there a cut off age for fertility treatment?

It is Melbourne IVF's approach to treat women up to 51 years of age, the natural age of menopause. For women aged 44 and over it is very difficult to achieve a pregnancy using her own eggs, and we do not normally recommend women begin IVF at this age.  However, every woman is different and we support an individualistic approach. Your fertility specialist will discuss your individual chance of success in detail.

How many treatment cycles are covered by Medicare?

There are currently no limits on the number of Medicare-funded treatment cycles a couple can undertake.

Am I eligible for the Medicare rebate?

To be eligible for Medicare funded fertility treatment you must hold a current Medicare card, and be deemed to be medically infertile. 

How many attempts at IVF will it take me to conceive?

As everybody is different, there is no one definitive answer. Some couples will conceive on their first attempt at IVF, while others will only conceive after many attempts. There are some couples that, unfortunately, may never have a successful pregnancy.  Read about Melbourne IVF's success rates.

We have two boys already, however we would really like a little girl.  If we have IVF, can we choose the sex of the baby?

The National Health Ethics Committee guidelines only allow sex seletction where there is a medical need and do not allow sex selection for family balancing purposes.

What is a blastocyst?

With this procedure the embryo is cultured in the laboratory for five days to observe its development before being transferred. At Melbourne IVF, embryos usually are replaced on day two, when they are at a 2-4 cell stage, whereas by day 4-5 those embryos which are capable of further development have gone on to form a structure known as a morula, which contains many compacted cells or developed further to form a blastocyst (a fluid filled structure with distinct layers of cells).

Embryos destined for blastocyst transfer are cultured in the same media as all other embryos up to day 3 when the embryos are transferred to a different culture medium which is designed to support their changing nurtitional requirements.

A number of research studies have demonstrated that many embryos stop developing after the first few days. Culturing embryos to day 5 allows identification of those embryos that will not continue to develop, and avoids their transfer. This potential advantage must be balanced against the extra time spent in the laboratory and the less predictable ability of any excess blastocysts to withstand freezing.

Success Rates Terminology

What do we mean by 'pregnancy'?

At first glance that may seem to be a silly statement but it is important to understand that IVF units have the potential to quote a number of different success rates figures.
Obviously, the only success that really counts is the birth of a live baby. It is the best statistic of all to publish but there are problems with this. It takes a very long time for us to obtain the birth information.

You will notice that IVF statistics quoting live birth rates are often 3 years “out of date” by the time they are published.  With success rates improving each year, quoting old birth data may not always be a good indicator of current expectations and it is important to remember that when you look at these figures.

Positive Pregnancy Test

The simplest way of measuring success in any infertility treatment might be to simply record a positive pregnancy test. It is not a very good measure of “success”, however. It is very important to remember that not every woman who has a positive pregnancy test will go on to have a successful pregnancy. Many very early pregnancies fail to develop. These are what we refer to as “biochemical pregnancies”.

Obviously, if we used a positive pregnancy test as a measure of success our results would look fantastic but this would be unfair. We know that a significant proportion of those pregnancies will not continue to develop.

The Foetal Heart Implantation Rate (F.H.I.R.)

The Foetal Heart Implantation Rate (F.H. I.R.) is a widely used measure of “success” amongst different IVF units around the world. This measures the number of live foetuses detected in the uterine cavity by ultrasound examination between 6 and 7 weeks gestation. It is measured as a percentage figure per 100 embryo transfer procedures. (see below for more detail)This should, therefore, disregard and not include failed intrauterine “biochemical pregnancies” and ectopic pregnancies. You need to be aware that some IVF units may include all pregnancies in their “clinical pregnancy rate”.

It is true that not every foetus, which has formed in the correct position inside the uterus, and whose heart beat we see on the scan, will grow into a baby. A small proportion of pregnancies will still fail after this time and this is the main weakness with using the F.H.I.R. as a measure of success. However, the F.H.I.R. is an immediate and accurate predictor of a forthcoming birth for the large majority of cases and is a statistic which is scientifically very important when we wish to compare different treatments.

The Foetal Heart Pregnancy Rate (F.H.P.R)

The foetal heart pregnancy rate is a similar but slightly different measure of success. Success by this measure would be the demonstration of at least one live foetus on ultrasound per embryo transfer procedure but does not take into account the number of embryos which have been transferred in that embryo transfer procedure. Some units may also call this a Clinical Pregnancy Rate (C.P.R.)

For example: 100 women each choose to have two embryos transferred at the time of their embryo transfer procedure. Subsequently, 50 women become pregnant, but in each case only one live foetus is seen on ultrasound. In this example, the Foetal Heart Pregnancy Rate (FH P.R) would be 50%, but the Foetal Heart Implantation Rate (FH I.R) would be 25%.

It is really important to understand these differences if you are going to try and compare results from different IVF units. A unit, for example, that was perfectly happy to transfer 4 or more embryos in each embryo transfer procedure would have a fantastically high Foetal Heart Pregnancy Rate and would appear to be an extremely successful unit. However, their multiple pregnancy rate would be unacceptably high. You must always look at a unit’s Multiple Pregnancy Rate when you are attempting to compare figures.
 

What Factors Determine Success Rates?
 

There are many factors affecting the chance of pregnancy:
 

• the age of the woman
• how many embryos are replaced
• whether the embryos are being used fresh or after freezing/thawing
• the stage of embryo development
• how many attempts there have already been
• the 'quality' of the embryo(s)
• smoking

Age of the woman

The age of the woman is a very important factor to consider when estimating the chance of success. Success rates drop dramatically as the woman’s age increases beyond 35 to 40.

As has been noted consistently around the world, the success starts dropping at about age 35 and drops ever more steeply after that. It is rare for women aged 45 or older to have a baby from IVF using her own eggs, so we do not offer that treatment to women beyond the age of 45 years.

The age effect is similar for frozen / thawed embryos (but it is the woman's age when they were frozen that counts). This is where our model of care really makes a difference. If a 42 year old woman uses frozen embryos which, for example, were created at the time of her first pregnancy when she was 38, her fertility chance will be that of a 38 year old woman, not a 42 year old.

How many embryos are replaced

The pregnancy rate is increased in an individual embryo transfer cycle by transferring more embryos. This has been a potential dilemma of IVF treatment since the very beginning. Whilst putting back more embryos at a single transfer gives more opportunities for at least one to successfully develop into a pregnancy, the disadvantage is clearly the risk of multiple pregnancy. Weighing up the pros and cons of one versus two embryos transferred is not a trivial matter. It is one of the most important decisions to be made during your IVF treatment.

If a couple choose to have two embryos transferred at each embryo transfer procedure they will, on average, achieve a pregnancy more quickly, when compared to single embryo transfers.

Does it matter if I have twins?

This is really the key question. Many couples with long histories of fertility problems might see the birth of twins as a blessing. There is no doubt that the birth of two healthy babies may be a great joy but it is important to remember that twins are at increased risk of a number of childbirth problems. They are more likely to be born premature, to have low birth weight, to have cerebral palsy, and suffer a greater risk of dying at, or close to, birth. Interestingly, IVF twins are not as prone to these problems as are non-IVF twins. This seems to be because identical (‘monozygotic’) twins dominate the poor-outcome statistics, and they are much less common in IVF conceived twins.

Our practice at MIVF has clearly changed over the years. Single embryo transfer now outnumbers double embryo transfer, especially in younger women.

How many embryos should be replaced?
The decision of how many embryos to replace at the time of the transfer procedure may be one of the more important decisions that you make in your life. To assist you in that decision we have tried to outline some of the important issues to consider before deciding on the number of embryos to transfer.

Why transfer two embryos?

1. Transferring two embryos increases the pregnancy rate for that attempt. Whilst there may be important qualifications with regard to embryo quality, in a practical sense, the greater the number of embryos transferred, the more likely you are to conceive. The biggest single advantage to transferring more than one embryo is to reduce the time to achieve a pregnancy.
2. In a fresh embryo transfer procedure, each extra embryo that is transferred does not have to go through a freeze/thaw cycle. We estimate that there is a 10-15% reduction in pregnancy potential for each embryo that goes through the freeze/thaw cycle. The reason for this reduction in pregnancy potential is related to either non or partial survival of embryos after thawing.

Why transfer one embryo?

The transfer of one embryo virtually eliminates the possibility of a twin pregnancy. It is still possible ,however, for that embryo to split and form a twin pregnancy. In this situation the twins are identical. This is rare but it does seem to be more common following IVF treatment than occurs with natural conception.

Some pregnancy complications are increased in multiple pregnancies:

• There is an increased risk of Maternal complications, which include pre-eclampsia, pregnancy diabetes, delivery by caesarean section, DVT (blood clot).
• There is certainly an increased risk of a number of baby (perinatal) problems, including: 
  • Perinatal mortality (fetal/newborn mortality)is the measure of babies which tragically die after 20 weeks pregnancy, and in the first 4 weeks following birth. The risk of perinatal mortality increases with increasing numbers of fetuses in the uterus
  • Intellectual or physical disability commonly referred to as cerebral palsy
  • Prematurity; the average duration of pregnancy, decreases with increasing number of fetuses
  • Range of pregnancy duration
  • Cerebral palsy is more common in multiple pregnancy and risk appears to increase with increasing number of foetuses
  • Behavioral problems; an increase in speech and weaning problems amongst toddler twins. Increased ADHD (attention deficit, hyperactivity disorder), hearing and visual problems

The accumulated benefit of using both “fresh” and frozen/thawed embryos for transfer

At Melbourne IVF about half our births, over many years, have come from the transfer of frozen/thawed embryos. A thaw transfer is a much less complex and much less costly procedure than an egg retrieval cycle, yet these relatively easy cycles boost the birth rate per egg collection cycle significantly. Techniques for the freezing and thawing of embryos have steadily improved in recent years and now close to 90% of embryos will survive the process. More importantly, success rates have also steadily improved.

We advise patients to use all their frozen embryos before considering another egg retrieval cycle. This is also the policy of The Reproductive Technology Accreditation Committee as described in its Code of Practice (2004). There are exceptions to this policy, however, which may be discussed with your doctor.

Factors that may affect Success Rates

The stage of embryo development

The success of our treatment to date has been based on transferring embryos at the 4 cell stage, on day 2 after egg collection, and freezing the remaining embryos for further use. We have been glad to observe, however, the increasing success in the laboratory of growing embryos to a later stage of development, usually known as extended culture, or blastocyst stage.

Transfer of blastocyst stage embryos does result in a slightly higher pregnancy rate, per embryo transfer, and some clinics are changing to this form of embryo culture, as a matter of routine for all patients. These clinics may claim a superior pregnancy rate, per embryo transferred, but it is very important to remember that many fewer blastocyst embryos will be available for transfer when compared to day 2 embryos. In some cases there will be none at all.  The use of this technique is more likely, therefore, to require the use of repeated egg collection (OPU) procedures. These clinics ignore all the embryos which did not survive to the blastocyst stage when presenting their data.

Blastocyst transfer is not a routine practice at MIVF but it is certainly used. Blastocyst transfer plays an important role in selected patients within our program and this is one of the areas where we would suggest you discuss pros and cons of different stages of embryo development and transfer with your doctor in your individual circumstances.

The quality of embryo
The quality of an embryo, measured by the number and the appearance of the cells in the embryo, plays a very important role in determining the likelihood of success. It is the policy of MIVF to replace the one or two embryos of highest quality at the time of the fresh embryo transfer.

We are likely to see exciting new developments in the next few years to further help us determine which embryo is most likely to be successful. These new developments might enable us to determine how the embryo is actually functioning, rather then just its’ appearance. These tests will look at how the embryo’s metabolism is working, which genes are switched on and off, and which proteins the embryo is secreting.

We know that some embryos may appear to be of high quality and yet have an abnormal chromosome count and have little or no chance of producing a successful pregnancy. It is possible to test the chromosome count of an individual cell from an embryo and thus greatly increase the chance of success. The technique is called pre-implantation genetic diagnosis (PGD).

How many treatments have been undertaken.
The statistical chance of success, per embryo transfer procedure, does not significantly change for a number of transfer procedures. In other words, your statistical chance of success at your third attempt at an embryo transfer procedure is much the same as it was at your first attempt. Not surprisingly, however, if a woman has had a large number of transfer procedures without success. Her subsequent chance of success is reduced.

Cigarette Smoking
Cigarette smoking appears to have a deleterious effect on a woman's ovaries and on her fertility. Women who smoke heavily tend to reach the menopause earlier than non-smokers. Even with a fertile couple, it has been shown that women who smoke heavily will take longer, on average, to achieve a pregnancy than non-smokers. Women who smoke have a reduced risk of success rates on the IVF program.