Health And Fertility

Hi I am Dr Robert (Bob) Miller

The more I see patients, and talk, I realise there is a need for an informal spot on the net for people to access some basic fertility information.

As Cairns Leading Fertility Specialist, I have been helping couples achieve that much sort after pregnancy for the last fourteen years.

When I started out as an Obstetrician/Gynaecologist over twenty five years ago, I never thought it would lead me down the infertility path other than the basic Ovulation monitoring or Intrauterine Insemination.

My love and interest for this has grown to the point, that I am one of the few doctors who have attained my Masters of Reproductive Medicine.

Along the way, I discovered that there are many factors that contribute to falling pregnant, or should I say NOT falling pregnant.

A few examples of this are the social aspects of people’s lifestyle, dietary issues, even people’s age.

Hopefully over time we can chat about all of these, and many other issues affecting infertile couples, but also I may enlighten you on my personal achievements as well.

How many times have I heard the emotional cry of anguish. “We want a baby and we want it now”?

Starting a family can be one of the easiest, or one of the most frustrating exercises known to man – and woman. Unfortunately, natural fertility is a very hit or miss affair. For about one in six couples, there is significant delay, if not failure to conceive at all.

When it doesn’t happen, one’s life is put on hold, as anxiety tends to crowd out all other priorities. So it’s important to maximise your chances as much as possible.

Couples trying to conceive naturally have a one in four chance of success per cycle. It really is a bit of a lottery. As the lucky couples go on their way, for those left behind, the chance per cycle steadily decreases – such that there is only a 1% chance pre cycle of conception after 18 months of trying.

The Fertility Society of Australia advises that couples should seek advise and help after 12 months of trying; or six months when a woman is more than 35 years of age. 

Of course, not everyone needs IVF.  Often, simpler techniques will achieve success, such as ovulation induction and intra-uterine insemination. 

A fertility assessment starts with the simple things – the birds and bees of reproduction.  Initially, your general practitioner can help you with such advice.  Then they would refer you on to a specialist gynaecologist if the going gets tough.

“When is the best time to make love, doctor?”  Funny how the guys never ask that question!  Ovulation  should occur around the middle of a normal cycle.  Sexual intercourse every second night is adequate; more often if you like!

Both short and long cycles tend to be anovulatory (cycle where no egg is released) and help is advised.  More about the next month. 

My best advice is to not leave it too late before starting to try.  Don’t leave it too long before seeking help… and practice makes perfect babies.

The above post will also appear in a new Cairns lifestyle magazine called PROFILE and will be one of a series of articles over the next six months.

The menstrual cycle is all about growing and releasing a mature egg.  Meanwhile, the lining of the uterus is prepared by the rising progesterone level to receive the embryo for implantation five days after fertilisation from sperm.  If an embryo does not implant, the lining “menses” (flow of blood and cellular debris) and another cycle starts.

You can track your ovulation cycle – firstly by symptoms and then if it does not appear to be happening – by some simple tests.  Funnily enough, pre-menstrual tension can be a good sign.  Equally good signs are a mid-cycle surge of watery, sticky cervical mucous (spinnbarkeit) and some crampy, mid-cycle pain.

Measuring your temperature for that little rise, post ovulation, is a bit tedious.  Certainly, only track two or three cycles that way.  The best home ovulation kit is the serial mid-cycle urine spot test that looks for the luteinising hormone surge that precedes ovulation by about 24 hours. 

Again, don’t do this until you start to get worried and then only for one to three consecutive cycles.  It becomes too stressful without further fertility advice.

Ideally, the ovulation cycle should take 28 to 32 days.  The second half of the cycle is more constant, once ovulation has occurred.  So in a 28 day cycle, ovulation occurs on day 14.  In a 32 days cycle, say 18.  Longer and shorter cycles tend to be less efficient and you may not be ovulating at all.

It’s best to line up your partner for regular sexual intercourse around the middle of your cycle.  Frequent intercourse keeps the sperm nice and fresh.  Intercourse every 48 hours, between day 11 to 15 is ideal, nightly even better, but don’t let it become a chore.  Keep the love in it, or he will be off to the pub, or gone fishing.

Now, don’t worry about the messy leakage after intercourse.  The “commando” sperm are well on their way by then.  The ovulation mucous is a holding medium for sperm, usually for 48 to 72 hours, so there is good overlap.

Human fertility is very hit or miss.  In reality, at the start of trying, there is only a 20% to 25% chance per cycle.  This chance falls off rapidly with time.  While 50% of couples are pregnant after 6 months; by 18 months, one in 6 couples are doing it tough and the chance for a natural pregnancy is down to 1% per cycle. 

It’s a numbers game.  Get the stats on your side and the sooner you start trying the better!

 The above post will also appear in a new Cairns lifestyle magazine called PROFILE and will be one of a series of articles over the next six months.

I consider myself very lucky to have an interesting job I am passionate about.  Helping couples conceive is very satisfying.  While it can be demanding. I have always believed that one gets out of something what one puts in.

No two days are the same – I never know what medical conundrum will come through the doors.  There’s always something new to read or research.  Obviously as a fertility specialist, successful treatment means a baby in the cot and a whole new meaning and role in life for those fortunate couples.

It’s great to share success with them and the team, but assisting and counselling an unsuccessful couple is in many ways more important.  Assisted reproduction treatment is a major life event for those concerned and they need support  We are now in the 21st century and infertility treatment such as IVF is very comprehensive, fairly streamlined and proven.  Our investigations can help pinpoint the most likely problem and treatment can be individualised in order to optimise the best chance of success.  Biological ageing is the biggest barrier to success.

It takes a team to be passionate.  There is the IVF scientist, clucking over those previous embryos in the incubator.  Then there are the IVF nurse co-ordinators.  Their roles are to explain and help you through the treatment.  They are always just a phone call away.  They are the first to give the good news and also to console.  In addition access to a psychologist is offered to support clients through what is often a very stressful time.

Few goals in life are sought more passionately than one’s desire for a baby.  You’ve achieved everything you wished and worked for .. now it’s time for another chapter in your life.  So why is there this major stumbling block preventing you from moving on to the next phase in your life?  Unfortunately, you can’t assume that it will just happen or wish the problem away.  The chance of a natural conception decreases rapidly as the months roll by.

Hopefully, you will  never need fertility services, but if you have been trying to conceive for more than 12 months, 6 months if you are over 35, see your doctor and he or she may recommend a referral to a fertility clinic.

A survey a few years ago explored people’s attitudes and expectations in regard to their fertility.  There were a few worrying   misconceptions.  Women knew their natural fertility declined with age, but thought that process commenced around 40, when it really begins around 30 to 32.                                      

 Only 3% of respondents felt that male factor infertility was important, and they were all women!  In fact, 5% of  males have varying degrees of sub-fertility.  In many couples there are sub-fertility issues on both sides, compounding their chance of success together.  Increasing female age is an ongoing compounder, complicating the initial cause of sub-fertility. 

In more than 40% of couples requiring IVF, there is a male factor that needs treating.  Micro-injection of the sperm has revolutionised the treatment of male sub-fertility, and is now a routine part of IVF treatment.

A semen analysis is an essential step in the initial work-up of a couple.  That is not to say a sub-optimal count always predicts infertility.  However, where there is failure to conceive after 18 months (12 months when the female is over 35), a sub-optimal sperm count and functional analysis is highly significant.

Why do so many men have impaired sperm function?

While the appropriate tests will identify genetic and known factors, the majority will be unknown.

What can be done to improve sperm function?

Certainly, lifestyle factors are important.  Smoking is the main scourge.  Whatever you do, don’t smoke, as Yul Brynner famously said on his deathbed.

Smoking affects the fertility and health of both men and women, and recent research finds that smoking could ultimately affect the health of your baby.  While anti-oxidants may help, generally IVF makes the best use of the fewer sperm available.

Marijuana may upset sperm motility, as it is an endocannabinoid compound.  Sperm is like a mini torpedo; the genes are packed tightly in the warhead.  Marijuana can cause the sperm to fire its after-burner too soon, before reaching the egg.

Is male sub-fertility a new phenomenon?  Are there environmental factors at work, affecting spermatogenesis?  Unfortunately, we don’t have historical records to compare.  I guess Henry VII must have had a normal sperm count.  Pity he didn’t know that the lack of sons was his fault, not his six wives!  “Off with her head!”

Ladies, you can’t judge a book by its cover … so get him checked out!

This is an article written by one of my Nurse Co-ordinators, Marg Schilling. 

Possible infertility can be very confronting.  No couple enjoys being in the consulting room telling the doctor or nurse about their private life, nor in the treatment room having procedures that are sometimes embarrassing.  We understand this.

The doctor has a more clinical approach, the counsellor a psychological approach and the scientist a specific clinical approach.  The fertility nurse co-ordinator is stuck right in the middle.  Our job is to carry through the instructions of your treatment, outlining your possible treatment in every detail.  This includes those dreaded injections if necessary, side effects of the hormones you may be taking, what to expect of the procedures, any many, many sometimes simple, sometimes complex pieces of information.

We never expect you to recall all the information we give you, but are always here to answer your questions at the clinic, or on the phone and please remember, no question is a silly one.

Often we are asked if there is anything more that you, as couples trying to start a family can do.  Lifestyle is important, but not always the reason that the much-wanted pregnancy is not happening.  Smoking is a big no-no.  Alcohol is not recommended and food and drinks high in caffeine are not good for you fertility.  Being overweight seems to be a modern day phenomenon – if you are carrying extra weight, often just losing 10% of your weight can help your ovaries to perform better – i.e. if you weigh 90kg and you can lose 9kg, it could make a difference.  Regular exercise and adequate water intake are also important – we all know what is good for us.

Having fertility treatment can threaten to interfere with personal and work commitments.  We understand this and try very hard to accommodate your schedules.  Often your treatment will require scans twice weekly or even second daily.  Always ask if a specific time is better for you.  You do not need to take long periods of time away from work, but having an understanding employer is a bonus.

Thankfully, we have a counsellor who is available if you need more than just a chat.  As nurses we get to know you quite well during your treatment and hope to make a good connection with you to help you through the highs and lows.  Please be aware that we are always there at the end of the phone.

A growing area of our work is the need for donor eggs, sperm and embryos.  This is a specialised area which we are very experienced in treating.

More on that at a later date.

This is an article written by one of my Nurse Co-ordinators, Joanna Sutton

Infertility treatment can be very stressful. Fortunately IVF treatment is more user- friendly than ever before. Improvements in the delivery of  drugs, and the ability for clinicians to manipulate the use of these drugs, allows for cycle appointments and procedure times to be booked well in advance, making it easier for patients to schedule their IVF treatment around work and other commitments.   

The world’s first IVF baby is now in her early 30s. Technological advancements have allowed dramatic improvement in infertility treatments since that time. Those of us that have been working in this field for a long time will remember back to the days when all injections had to be intra-muscular, so unless a patient was a nurse or a doctor, they had to attend the clinic daily for about 12 days to have their injections!  Now, only 2-3 visits are required prior to the egg collection operation. There were no vaginal scans, so blood tests were used to measure hormone levels in order to choose the best time for egg collections- which were occasionally performed in the middle of the night! Blood tests were done up to 3 times per day in the day or so prior to egg collection- with often less than 24 hours notice to patients for the egg collection. I remember having to go back to work at 9pm at night to collect blood from patients!

Because there were no vaginal probes, egg collections were done via  laparoscope, which resulted in a longer and often more painful recovery. Even though egg collections are still mostly performed under a general anaesthetic, the surgery is performed vaginally, so there are no skin wounds to heal.  Following embryo transfer, patients used to be admitted to the hospital ward, and were confined to bed for at least 3 hours- a bed pan was supplied if necessary! Now, it is a five minute procedure as an outpatient, usually in the Doctor’s rooms.

I supply this information as a former recipient of IVF treatment, as well as a staff member. My son is now 17 years old, and is the result of a successful frozen embryo transfer. Back then I was in my early 30s, and I had 3 embryos transferred- unheard of these days! Success rates have improved so much, that generally only one embryo is transferred back into a patient under 35 years of age.

Scientific advancements such as chromosome testing and screening of embryos, as well as improved laboratory conditions have all contributed to the improved success rates of infertility treatment.

Every staff member at QFG Cairns has at least 10 years experience in infertility. Our doctor, embryologist, counselor, nurses and administration staff are passionate and committed, and are happy to answer any questions you may have about any aspect of infertility.