ART: The Many Paths to Parenthood

“It’s very personalised - there’s absolutely no ‘one size fits all’. You have to look at the couple or person in front of you and take everything into account.”

In this episode, Dr Rangi is joined once again by fertility specialist Dr Sylvia Ross for an insightful conversation exploring Assisted Reproductive Technology (ART).

Dr Sylvia Ross is a highly experienced Women’s Health specialist who has spent more than a decade helping individuals and couples build families, while also managing complex gynaecological conditions. She is also the co-host of the popular Fertility Untamed Podcast.

In this episode, Rangi and Sylvia discuss:

•  What Assisted Reproductive Technology (ART) actually is 
•  The different methods of ART: 
  • Ovulation induction 
  • Intrauterine insemination
  • IVF (briefly introduced ahead of a dedicated episode later this season)
•  How long to try different treatment methods 
•  Navigating the emotional burden of fertility treatment 
•  The approximate costs of private fertility clinics versus the public system, and the differences in care and access 

Stay tuned for a later episode this season, where Rangi and Sylvia will take a deeper dive into IVF.

DISCLAIMER:
This episode discusses fertility struggles and pregnancy loss. If you require support or additional resources, please visit:

• Centre of Perinatal Excellence | COPE
  • COPE provides families and health professionals with evidence-based perinatal mental health screening, resources, education and pathways to care.
• Miscarriage Australia - Navigating miscarriage together
  • Through our research and consultations with individuals, families and healthcare providers, we understand your need for evidence-based information, acknowledgement, and advice regarding miscarriage. We’ve designed this website to help you today, including the myths and facts about miscarriage, treatment options, how to care for yourself and where to seek help and support.
• The Centre of Research Excellence in Stillbirth
  • Access support services, online resources, and information for parents and families in Australia whose baby has died. These links include services offering counselling, practical support, and information to assist you to make to decisions during this difficult time.

Transcript

SPEAKER_00 0:01

Welcome to Prepare, the Mercy Perinatal podcast dedicated to helping parents prepare for the journey of pregnancy, childbirth, and early parenthood. Mercy Perinatal would like to begin by acknowledging the Rawundri Wuiwarung people, traditional custodians of the land on which we gather today, and also the traditional custodians of the lands in which you're listening from today. We'd like to pay our respects to the elders past, present and emerging, and we extend that respect to Aboriginal and Torres Strait Islander peoples listening today.

SPEAKER_01 0:32

Hi everyone, welcome back to another episode of Prepare. My name is Rangy DeSilva, and I'm an obstetrician and gynecologist here at the Mercy Hospital for Women, and I'm so excited to be joined again by the lovely Dr. Sylvia Ross, who is, as we introduced in our last episode, a fertility specialist based here in Melbourne. And she's also the co-host of the podcast Fertility Untamed, which will give you even more information into all of the topics we're talking about. But welcome Sylvia. Thanks so much. It's great to be back. Thanks so much. Last episode we talked about fertility, what is infertility, when to see any fertility specialist, and what might you expect. So the next step, if you are one of those individuals who might need help getting pregnant with what we call assisted reproductive technology or ART for short, what does that actually mean? What are all the different options and when might you need that?

SPEAKER_02 1:30

Yeah, look, great question. And I and I think it's really important to cover because everyone just assumes that it's IVF and that's all, but also no one really knows what that means. Exactly.

SPEAKER_01 1:39

Which we'll have a whole nother episode about.

SPEAKER_02 1:41

Yes. Essentially, it's any time that you need to use some kind of medical intervention or assistance to help someone fall pregnant. So I like to think of there's sort of your three main treatments that you can have under ART. And you're we always start with the simplest where it's appropriate, so something like ovulation induction treatment. So this is where people don't ovulate on their own, they're not releasing an egg, so they can't fall pregnant month to month. And that's the simplest. And this is appropriate for people who are not ovulating. So that's important, isn't it? Very important and not always adhered to, but it doesn't improve your chances if you're already ovulating. But in people, for example, with polycystic ovarian syndrome who don't ovulate on their own month to month, we can help make that happen with medications. And that can be either tablets that you just take for five days at the beginning of your period, or through hormone injections as well, for some people who need it. And essentially, you would have the treatment, you would come in and have a scan where we would visualize the ovaries and the uterus and try and work out are you growing one of these beautiful follicles on your ovary, which is that little house for the egg that's looking like it might release that egg, at which time we would advise this is your fertile window, and you should be having intercourse, you know, a couple of times this week, for example. So that's your most natural method as such, given that it's still intercourse. We're just encouraging that egg to release. Yeah, great. Your next step up would be intrauterine insemination or IUI. Um, and this is the treatment which starts very much the same as ovulation induction, where we try and boost that ovulation. We may try and get someone to release two eggs, for example, to increase their chances. And just when we know ovulation is about to occur, we would have the couple come into the clinic, we'd have the partner with sperm produce a sample. The lab would process that down to get the very best sperm in a very small volume, and then that would be placed through a very narrow catheter directly inside the uterine cavity. So that's great for people, for example, who have problems with intercourse or they have mild male factor infertility, so sort of mild abnormalities in the semen analysis, but there's still a good number that swim. People with a timing, they just haven't quite got it right. Yeah. Or it's also really good for people with unexplained infertility, so where we haven't found a specific reason conception hasn't occurred, but we can help increase those chances through IUI.

SPEAKER_01 3:54

And then with both of those, I suppose, more with the medical assisted reproduction that you described. What are some of the things that we might worry about or some of the risks that people might hear about?

SPEAKER_02 4:07

Risks are exceptionally low with both of those treatments, to be honest. I think historically it had a very bad name for multiple pregnancy. Yes. And of course, our goal is to give you a healthy baby. Yeah. And one healthy baby. Yes. It's much less likely if you grow two or three. Yes. So we know that the risk from multiple pregnancy is significantly higher. I'm sure you've got an episode on this.

SPEAKER_01 4:28

We will have an episode on this.

SPEAKER_02 4:31

And we try and avoid multiple pregnancy. But look, even in unmonitored cycles where we don't even necessarily know how many follicles people have had, if we look at the data, the rate of twins is still under 5%. That's not that different, really, from baseline rate. So although although technically I always warn patients it can increase your chance, it's not so bad. It used to be higher because people used to be a little bit more rogue with the dosing, and they maybe would let people go ahead where they had three or four eggs released. I think for the most part, one or two would be the goal. And it would be rare circumstances where you would allow three, and that would usually be people who are sort of much older with a long-standing history of infertility where their chance of conception was so low, it would be reasonable to push it a bit further. So overall, very low risk. Pretty low risk if it's managed appropriately.

SPEAKER_01 5:18

Yeah, if it's managed appropriately by a fertility specialist. Exactly. Yeah, with the appropriate monitoring. Really good to know. On average, how long would you say you find people might need to be trying one of these methods before they can see?

SPEAKER_02 5:37

So if you think about ovulation induction, if someone's not ovulating and we get them to ovulate, we're really just giving them that baseline chance of conception that anyone else would have if there's no other risk factors. So, you know, you can't expect to be pregnant from one cycle. If you're if you're, you know, 25, you might be 25% chance per cycle. If you're 40 or 40 plus, it's going to be low single figures. So you have to be realistic and patient selection is important. I usually tell someone doing ovulation induction, we will do three cycles before review because we're not really expecting a miracle here. We're just trying to get your statistics up there. And at the time of review after three cycles, that's when I would start doing further investigation if not previously done. So if you haven't assessed tubal patency, which we talked about in the last episode, if you haven't done a semen analysis, that would be the time I'd be doing that. Just to say, let's just make sure we haven't missed something else.

SPEAKER_01 6:29

Yeah, and that's we keep going. Absolutely. So you're going down that treatment path, but you want to make sure you're not missing anything else.

SPEAKER_02 6:40

Yeah, that's right. And so that's very well accepted management to not necessarily start with everything and give them an opportunity first. And if at that point everything's still normal, they can carry on. It's totally reasonable. Intraudine insemination, it'll depend a bit on things like um why you're doing IUI, you know, what is the age of the patient, things like that. I again often tell people try three before we review the plan if you want to do this anyway, because based on age, you know, your chance of success per cycle is still going to be well under 50%. And so we have to be realistic about the number of opportunities we give it.

SPEAKER_01 7:14

Good to know. And how long do you, I suppose, recommend someone might keep going with something like their medication before you might think about something else?

SPEAKER_02 7:27

I think sometimes this is often patient-driven, and it depends, you know, how their patients are and how they're going. I think if they're a good candidate for ovulation induction, it it's not unreasonable to do that for up to a year if patients want to. Okay. And you've got to also consider family sizing.

SPEAKER_01 7:41

Yes.

SPEAKER_02 7:42

You know, and age. If you have a patient in front of you who is 25 and they want two kids, you're okay to continue if there's no other reason not to. Yeah. If you have a patient who is 38 and they want two kids, different kind of story. Because we know that there's such a significant fertility decline that we don't want to use too much time if something's not working, or we might want to consider moving on to something more active that may give them a higher chance in the future. For example, they may do IVF with embryo banking where they're kind of putting some embryos aside for subsequent child. And so we don't want to spend too long doing other things if we've got other goals in mind as well. Yeah, that's fair enough. And again, same with IUI. What is the reason that we're doing it? If the only reason we're doing it is their intercourse is too difficult for the couple or there's a problem there, there's no reason why you you can't continue for, you know, six plus times, that would be totally fine. Um, but it's very personalized. You know, there's absolutely no one size fits all. You have to look at the couple or the person in front of you and take everything into account. You know, for some people the treatment burden, even with simple treatment, can be really high. Yeah. And they don't have the appetite to continue and want to move on to something else more quickly.

SPEAKER_01 8:52

Yeah, that's important. It's all always individualized and personalized, depending on your no couple is the same.

SPEAKER_02 8:58

You know, you're never going to treat one couple the same as the one that just walked out of your door. There's so many factors to take into account.

SPEAKER_01 9:04

Really important. And you touched on this, the sort of emotional burden of these processes. How do you recommend people might deal with that and what is available to help them deal with that?

SPEAKER_02 9:36

So fertility clinics will have a really specific counsellor essential, essentially. So they will be available. And most places, you know, with each treatment cycle will offer a further session if needed, and people can always take up more if they want. Some people will use their GP to get a mental health plan to help them access that in a more financially viable way if they're needing more sessions. I think there's a lot to be said for partner support and making sure that you're going into it with the same goals and it can be very difficult because people manage things very differently in a partnership.

SPEAKER_01 10:06

Yes.

SPEAKER_02 10:06

And also having support from people around you. So I feel like it's one of the saddest things is there's so much stigma around infertility that often people don't want to tell anyone they know. Yeah. And I always think this is so crazy. If you had a heart problem, you would take heart medication, right? And you have a fertility problem, you take fertility medication. Exactly. People don't see it that way because it's so personal. Yes. And I think that it's important to have someone to talk to. Some people find even listening to podcasts and getting support from that, knowing that there are other people out there is useful. The kind of support that I think is probably not so useful would be things like joining Facebook groups where people who have all had a bad experience are talking about it. Yeah. Because you don't want to fill yourself with negativity. You've got to be in a good mind space to get through. Yeah. And looking after yourself on a really holistic level is important. So, you know, everyone we see, we talk about diet, exercise, what what things are you doing for yourself, how are you keeping your body healthy? Yeah. Because that will also help to keep your mind healthy.

SPEAKER_01 11:04

Yeah.

SPEAKER_02 11:05

What did you think? What helped you?

SPEAKER_01 11:07

Yeah, I mean, I found it really difficult that I was not conceiving when I wanted to. I also went through a period of of medical ART with a medication called letrazole for about six months. And I was ovulating in that time, but we just weren't conceiving, and then moved on to IBF after that. Mainly because I was 35 when we started the fertility process, and as you said, age was a factor. I knew I wanted more than one, so we didn't want to wait for too long. But I did really find that very stressful, and to be honest, particularly because of what I do as an obstetrician gynecologist, coming to work every day became really challenging because, as much as I I love my job, I was finding it really difficult to deal with pregnant patients and delivering babies and seeing gynecology patients, dealing with people having miscarriages, which I also had at one point. You know, all of those things were really stressful. So emotive, you know, emotional area.

SPEAKER_02 12:11

And you know, even if you're not experiencing it yourself, it's hard. So it's hard. It's like a whole nother level, isn't it? I mean, exactly. We did a whole episode on mental health in our first season, um Infertility Untamed, because the three of us in that podcast have also all had infertility, all for different reasons.

SPEAKER_01 12:27

And that's the other thing. It's so common. Yes. Like I mean, I s I know so many people that have suffered with it from one reason or another. Yeah. And that's the other reason to talk about it.

SPEAKER_02 12:38

Absolutely, that's right. And you know, often when people start to open up in their workplace or with their peers, they find out that actually half the people there have been through the same thing and they can become great supports for them.

SPEAKER_01 12:47

Yeah.

SPEAKER_02 12:48

And that can be great when you're trying to juggle working and coming in for scans and doing bits and pieces. If you have someone who's there to support you, it's actually really helpful. Definitely. I think COVID did great things for fertility because working from home became this huge option and now people can kind of sneak away to get things done without feeling like the stigma. That's true.

SPEAKER_01 13:04

Yeah, because I did also find that a challenge, trying to fit in the scans and the acute obstetrics.

SPEAKER_02 13:09

You know, the babies aren't gonna wait. You can't just niff off for a for a scan. It's really hard, isn't it? It was the same for me.

SPEAKER_01 13:14

Yeah, yeah, exactly. As you said, found it really helpful to talk to friends, talk to colleagues. Uh, I did see a psychologist at one point for a period of weeks, and that was really helpful. Yeah. She was fantastic and I think really helped me as an individual, helped us as a couple, because it was stressful for my partner as well.

SPEAKER_02 13:35

So I think it's really hard, and the way that you deal with the stress is often very different. There are not many partnerships where you both deal with stress in the same way. Yes. You know, there's usually the person who's like, oh, you know, it should be right, we'll just don't worry about it. You know, and that's their that's kind of the extent of it. Whereas then there's the other partner, not naming any genders, who's, you know, constantly thinking about it, googling, taking that emotional. The supplements, working out what's going wrong and blaming themselves, essentially.

SPEAKER_01 14:02

So it's a really hard time. It it can be, yeah. But I think it's important to know that there's lots of help out there, lots of people that are also dealing with it, and information is important.

SPEAKER_02 14:15

Absolutely. And correct information is really important. And I think something which I'm really very passionate about is realistic expectations of treatment. And it's really important going into treatment to know the likelihood of something working. Because and I always say to people, you know, I'm not trying to scare you with the numbers, but I want you to know that if this doesn't work, that's okay. That's not unexpected. We just keep going. There's lots of other things we can do, and not to take that on and take that as an additional burden on yourself.

unknown 14:43

Yeah.

SPEAKER_01 14:44

And I think blame is a common or guilt, I suppose I should say, is a common emotion that people might feel. So, as you said, it's important to set those expectations and reassure people that it's not their fault.

SPEAKER_02 14:57

That's right. And look, I think, you know, with a population where we're seeing people trying for pregnancy later, there's a lot of regret often around, you know, why didn't I try earlier? Or many people who have potentially had an unwanted pregnancy previously and decided not to continue. And the thing that's really important in those situations is that you made the right choice for you in that time. Yeah. And you have to accept that. You can't go back and worry about you should have done something earlier. That's not going to change anything. Exactly. You did what was right for you then, you do what's right for you now, and you just keep going.

SPEAKER_01 15:28

Yeah, that's really good advice for everything in life in general. Write that one down. Yeah. Have it stuck on my wall. Um in terms of the costs of ART, I suppose we'll talk about IVF as a separate topic altogether. But for some of these methods that we've just talked about in this episode, what might people expect to pay?

SPEAKER_02 15:52

So, you know, you've got your consult fees. So when you see a specialist, you would probably clinics vary quite a lot. There'd probably be a three or four hundred dollar type fee for a first consult. That's usually a really long consult with both partners. If you both attend, there's a rebate for both of you. That would be sort of a rough starting point for most first consults. Treatment, so something like an ovulation induction cycle. So a cycle means from, as we said in the previous episode, from first day period to next first day period, or each opportunity that would be for ovulation induction around $400 or something like that. Intrauterine insemination, you're probably looking at more around $2,500. And that's every time you get the lab involved, the cost is going to increase. There's so many people, you know. We all say it takes a village. You know, we have something like 30 people working at our clinic, which is quite small in boutique. That's just what it takes to run it and to have everything looked after really well.

SPEAKER_01 16:46

And have it be safe and thorough.

SPEAKER_02 16:48

That's right. And in Australia, we're really lucky that we have Medicare and there's so many rebates. The treatment here is just so much more affordable than in New Zealand where I'm from, and it's amazing, really. And the other thing which we should, of course, mention is that in Victoria we have public fertility now. Yeah. So people who are eligible can be referred to the Royal Women's. Yeah. We have satellite sites, so I work at the Women's, I also work out at Sunshine or the Western in the public fertility clinics. And essentially, if you're eligible for that, you can have treatment where all you pay is your prescription fee for medications and nothing else. So the accessibility is really increasing and it is available.

SPEAKER_01 17:24

It's so good, and that's a relatively new thing, isn't it? Yeah. Which is fantastic. Is there a limit to how many cycles or or how long someone can be with that public clinic for?

SPEAKER_02 17:36

So with the public clinic, ovulation induction essentially is you can keep going with that. It's not a huge cost to the unit for that, so you can keep going as long as necessary. Intraudriine insemination, if eligible for that medically, you could have two cycles of intrautine insemination, and IVF would be two cycles as well. You can't go backwards. So for example, you might be eligible for two cycles of IUI, and if they don't work, you can still move on to IVF, which is amazing. If you start with IVF, you can't go backwards. And usually if you start with the same. Yeah. The problem with that is that if you took a hundred couples and you wanted more than half of them to have a baby, everyone would be doing three cycles. So there'll be a lot of people who won't actually get a baby through that process. But we also see a lot of people who have done treatment elsewhere then come or that might move on to treatment elsewhere if they need to as well. Yeah. But it certainly gives people an opportunity who otherwise may not have had it, which is really incredible.

SPEAKER_01 18:33

Yeah, it is incredible. Yeah. Great. Awesome. Well, thank you so much, Sylvia. That was a really great summary of assisted reproductive techniques other than IVF, sort of before you get to that process. And we will of course talk about that in much more detail because there's lots to chat about there. But I really appreciate you sharing a bit of your own personal history as well, and obviously your expertise in this area. It's really reassuring and important information.

SPEAKER_00 18:59

So thank you so much. Thank you so much for having me again. It was great. Every pregnancy is unique. The information provided in today's podcast is for educational and general purposes only. It is not intended to be substitute for professional medical advice. It is important that you always seek the guidance of qualified health professionals with any questions you may have regarding your health, pregnancy, or any medical conditions.