Episode 158 Fertility

Today is a much awaited episode having been brewing for over three years since I started the podcast which seems apt given the subject. How does it feel to be pregnant after fertility treatment, what might be the issues maternity staff need to be aware of ? What maternity care do we need to provide to the increasing number of families in our care after assisted conception and a fertility journey. Join me in an episode ready for fertility week (30th Oct -4th Nov) hear my thoughts about pregnancy after fertility. This episode with special  thanks to Katie Eaves an inspirational midwife
https://www.all4maternity.com/support-for-midwives-with-infertility-and-having-fertility-treatments/
https://www.thefertilitypodcast.com/midwifeandinfertility/

Want to explore more?
https://www.hfea.gov.uk/about-us/publications/research-and-data/fertility-treatment-2021-preliminary-trends-and-figures/#footnotes-i
https://www.rcn.org.uk/Professional-Development/publications/transition-fertility-maternity-care-uk-pub-010-338
https://www.hfea.gov.uk/about-us/our-blog/new-guidance-published-to-support-women-transitioning-from-fertility-to-maternity-care/
https://www.thefertilitypodcast.com/
Finally pregnant podcast https://open.spotify.com/show/148o2wODSIMyMFtsbZdods

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...

Transcript

Speaker 1: 0:00

Hello, my name is Florence. Welcome to the ObsPod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the ObsPod is for you.

Speaker 1: 0:49

Episode 158 Fertility. Quite aptly, this episode of the podcast has been a long time coming. Fertility or fertility problems and treatments, including IVF, have been on my list of podcast topics since the very beginning of the podcast, not least because the inspiration for starting the ObsPod was listening to Natalie, who hosts the Fertility podcast, sharing how actually using podcasts as a medium to reach people and give them information about women's health was a great idea. So why has it taken me more than three years to record this episode? Well, part of it was because I wanted to have a guest. I wanted to have the wonderful Katie Eves chat to me about this topic, and I hope Katie will forgive me for going ahead without her. Katie is a wonderful midwife and for many years spent a lot of time teaching fellow midwives about pregnancy after a fertility journey. And indeed you can hear her on one of Natalie's episodes, episode 103 of the Fertility podcast if you want to know more. Events have kind of conspired against us and Katie and I have never quite managed to make things join up and record this episode. And because it's such an important topic, three years on I thought why not just go for it myself, and I can always record another episode with Katie if things finally come together. I wasn't even sure what to call this episode.

Speaker 1: 3:06

I initially started with the idea of doing an episode about IVF or in vitro fertilization, but actually fertility treatment is far more than IVF. There are all sorts of other possibilities, all sorts of other abbreviations, not, sorts of other reasons why one might have IVF that are not necessarily directly related to not falling pregnant. These days, parents in same sex relationships may be using IVF, or single parents who want to start their own family alone. So it's not quite as straightforward as just recording an episode on IVF, although I am going to include that in what I'm talking about today. Talking about fertility in a maternity podcast might seem a bit strange. After all, anyone that I'm seeing in the antenatal clinic has succeeded in becoming pregnant, but there definitely is something about the both physical and emotional well-being of parents that have struggled or taken some time to get pregnant in the first place.

Speaker 1: 4:36

In preparation for Katie coming on the podcast, I made some notes and so I'm going to refer to some of the things she discussed with me in her absence, as well as having a little think about what I see and what I think when I'm seeing a woman or a couple who've had a fertility journey. If we start at the beginning of that maternity journey, seeing the booking midwife, usually ideally somewhere between 8 and 10 weeks of pregnancy. If we extrapolate back from that, if a couple have had fertility issues, they have probably known they're pregnant from the very day of the missed period and they have been waiting to do that pregnancy test on that day for probably a couple of weeks before that, from an embryo transfer, if they happen to have had IVF, or from the previous period, if perhaps they were using chlomaphen to stimulate ovulation. Then add into that the fact that they may have had many months of trying to get pregnant and successfully doing many tests and being disappointed or potentially had previous cycles of ovulation induction or previous cycles of IVF or ICSI, which stands for intracellular plasmid sperm injection. Therefore, at that moment when they're seeing that booking midwife which for that midwife will be very, very early on in pregnancy and the very, very start of that journey to having a baby for that couple, they are already months or years into the process. At this booking appointment we have to decide are we going to label an IVF or fertility assisted pregnancy as inadverticom, as high risk or low risk?

Speaker 1: 7:16

And there doesn't seem to be any standardization. Different maternity units do different things and there's also variation over time. So during my career I have seen a shift from an IVF pregnancy, as an example, being deemed high risk, needing consultant input, needing certain treatments and recommendations, to being deemed low risk, being suitable for midwifery care, not needing obstetric or medical input or intervention. And I can't help but think that part of that is to do with the huge number of IVF or fertility induced pregnancies these days and the capacity to think whether we should be seeing these women and certainly, if we are seeing these women, to what end, with what benefit for the woman. Some women, it's true, find a consultant appointment reassuring, but other women, deemed inadverticom as high risk, find that actually distressing. This very cherished, very, very longed for pregnancy is now deemed risky, so we need to think carefully about how we describe that and how we tailor that woman's care to what is helpful to her.

Speaker 1: 9:00

Let's consider for a moment what sort of numbers we're talking about. Well, if you've had IVF, the numbers of cycles and treatment is very carefully regulated by the human fertilization and embryology authority, hfea, and if you go on their website, you can very easily look at the statistics. If you take 2021 as an example because that's where most of the latest data is and you look at the national statistics, in England and Wales there are 624,828 live births and if you then go to the HFEA website, you can see that around 55,000 patients had IVF or DI donor insemination treatment at HFEA licensed fertility centres in the UK in 2021. They talk about the fact there have been 76,000 cycles in 2021 and this being a 10% increase from 2019, and if you go back a little bit further, you can see that this is generally increasing. There were 67,000 cycles in 2013, when there was kind of a bit of a review of the IVF state of play in England and Wales.

Speaker 1: 10:45

Of course, not all these cycles result in pregnancy and when you look at the success rates, there are huge variations depending on age and the reason why one might be having fertility treatment, but the average birth rate from IVF with a fresh embryo transfer is 22%. So, looking back at those stats from 2013, which was the best one I could find in terms of numbers of actual babies born, 67,000 cycles of IVF resulted in 15,283 babies being born. In the same figures from 2021,. They also state that 90% of couples having fertility treatment were in a heterosexual relationship, and I find that quite astonishing because that seems like a very high number. And they do comment that there is the biggest increase in cycles for people in same-sex relationships, women with no partner or also surrogacy, but the numbers are much smaller 2200 people having IVF were in female same-sex relationships and 2800 people having treatment were single. So we have to bear in mind they're not only having sex relationships single. So we have to bear in mind there may be different reasons why people are accessing fertility treatment and that not all fertility treatment and not all IVF pregnancies are necessarily subject to the same sort of background reasons for having gone through that treatment, let alone sort of underlying causes for potentially not getting pregnant.

Speaker 1: 12:59

The final thing I want to say about the statistics from the HFEA is that, shockingly, the stats of NHS funded cycles in England is 24%. So that means if you're seeing a couple or a pregnancy resulting from IVF in your NHS maternity service, there is a very high chance that to achieve that pregnancy may have been the result of the ability to pay for it. That may not have been an easy journey. It may have been very difficult to obtain funding and that also means that potentially people that don't have access to funding are being excluded from being able to access treatment and get pregnant, so that financial burden and financial stress may also be on the people that we're seeing in early pregnancy in our maternity service.

Speaker 1: 14:18

A lot of things to think about and be aware of when being empathetic and helpful meeting that woman for the first time. So if we turn back to that booking appointment, one of the things staff can find a little bit confusing is the idea that if one has had a sister conception, particularly IVF or ICSI, the date is the date we actually know exactly when this baby was conceived. We know exactly when the embryo was fertilised. Therefore, the idea of changing dates with a dating scan, which would normally be recommended for many pregnancies, to do with the measurement of the crown lump length, the length of the baby at that first 12-week scan, is not the correct approach for an IVF or ICSI pregnancy. The date of embryo transfer and the due date given to a couple by their treatment centre is the due date. It should never change because it is accurate.

Speaker 1: 15:52

Sometimes women are distressed if we refer to the fact that they may or may not have had a donor egg used as part of their treatment, and obviously we need to be sensitive. If it's not their egg, then it isn't that we're starting to tell them it's not their baby, far from it. But we do need to think about the fact it's not their egg, because some of the risk factors and some of the screening tests will be different, particularly as in most cases the donor egg comes from a younger woman. A common reason to use a donor egg is if the woman herself has a low success rate of treatment or is unable to produce multiple eggs of good quality in a stimulated cycle. This has implications if a woman is then having screening for the common trisemies, such as Down syndrome, because the age of the egg donor becomes an important piece of information for us to feed into that screening process rather than the age of the woman herself. So we need to know this important information but we need to not be constantly reminding that woman about what may already be quite a difficult psychological decision she has made.

Speaker 1: 17:33

Then we have the difficulty when seeing women in the antenatal clinic. Do we mention it or not? Is it the elephant in the room? If we don't mention it at all, women can feel unacknowledged and that that part of their journey is dismissed, not considered. But if we're constantly harping on about it, that can also be unhelpful too. It's like many things in maternity care. We need to be led by the individual. I do usually mention it and I sometimes ask how long it's taken them to get pregnant. I think it's part of establishing some rapport and understanding, making it clear that I am aware that it may have taken them a very long time to reach that point when they're coming to see me and that that may play into how they feel about pregnancy, how anxious or nervous they're feeling, how confident they're feeling. So I will often ask, maybe, how long they've been trying or how many rounds of or cycles of treatment they'd had, so that I can gauge a little bit where they're at, open up the conversation and allow them to talk about it if they want to.

Speaker 1: 19:09

Katie talked to me a lot about people having lost trust in their bodies. Their body couldn't get pregnant the way it should and was supposed to. Sometimes, during my training, we used to refer to precious babies, a terminology that I hated and that really has gone out now. All babies are precious after all. She said that she preferred to talk about precious mums, mothers that need a little bit of extra care. That mum won't have confidence in her body If she couldn't even get pregnant naturally. How is she going to carry that pregnancy? How is she going to give birth? How is she going to cope as a mother?

Speaker 1: 20:06

She talked to me about the fact that every month with a failed pregnancy test, you feel your body has failed. You can end up programmed to believe your body failed and you can't just flip a switch when you're pregnant to suddenly believing that you're a success and you can't suddenly flip to feeling you fit into the maternity system. You have doubts. Can my body do what it's now supposed to do? And definitely I see this in my clinic, many of you will know. I see quite a number of women with mental health problems Alongside my more mixed population of women, and I definitely see women who have wanted for years and years to become pregnant and then when it actually happens and they are actually pregnant, instead of that relief and joy they're suddenly confronted by difficult feelings of doubt, sadness, fear, anxiety. And then that's very confusing because it's something they've wanted for so long and they're puzzled why they're not overjoyed and they find it difficult to admit they're not overjoyed. So to have conversations and explain to them that many couples going through a fertility journey will struggle, will not necessarily find it easy being pregnant, and that they may have lots of difficult feelings to process and this is not unusual and we are there to help them and be alongside them during that journey can be very beneficial.

Speaker 1: 22:03

One of the key differences between different units is whether or not one offers induction of labour as a standard to all women that have been through fertility treatment, or particularly IVF. The background to this is some evidence that suggests a slightly higher chance of stillbirth in IVF pregnancies. Where I work, we used to automatically offer induction of labour around 40 weeks for women who'd got pregnant through IVF, and then we stopped and focused on things like maternal age or underlying raised uterine artery Dopplers, so things particular to that individual woman, rather than a blanket policy relating to fertility treatment. But I know it can be confusing for women because some women will be on forums for fertility treatments or with other women who have had IVF and who are now pregnant and they find it confusing that at one hospital induction is being recommended and at another hospital it isn't. So I thought for today I'd have a quick look and see hang on a minute what is the evidence? I did find a helpful paper, which I'll put in the programme notes, which talked about the risk of stillbirth being possibly up to four times higher than in women that had not had fertility treatment, and it breaks down the risks or chances between IVF and XC. The paper's fairly old 2010 and it was done in a large cohort study of around 20,000 pregnancies in Denmark and it did say that they don't really understand why there is a difference and they did try and balance out for confounding variables. So there definitely is some data there which made me think perhaps I should be having more conversations, or certainly more in-depth conversations with women about what are the chances and what do they want to do.

Speaker 1: 24:51

As usual, for this episode, I did a little bit of reading and thinking about the topic before sitting down to record and I decided I couldn't possibly do a completely comprehensive episode on every aspect of fertility because there are so many different fertility treatments and there are so many reasons why one might be pregnant after a fertility journey. So hence the fact I decided to focus a bit on the more general. I'm hoping that recording this episode has piqued your interest and perhaps you'll go off and explore things a bit and, as usual, I'm going to attach some links that I think might be helpful. Last year, the Royal College of Nursing produced some new guidance on transitions from fertility to maternity care, and there's a nice article about it on the Human Fertilization and Embryology Authority HFEA website. It details the fact that the guidance came about as a result of concerns expressed about the journey between a positive pregnancy test following fertility treatment and the safe birth of a baby, and that this could be very complex when moving from fertility to maternity services.

Speaker 1: 26:24

I find it interesting that this has been produced by the Royal College of Nursing, and this is not the first time that I've come across some good information for pregnancy that's being produced by the College of Nursing, rather than that of midwifery, which would seem the obvious place. One of the reasons I think this document is very helpful is it not only talks about maternity services and midwifery, but it also talks about early pregnancy care, the possibility of miscarriage and, yes, termination of pregnancy. It does happen, even after a very longed for and lengthy fertility journey. So for my zesty bit, I would like you to maybe dip into that document and also just reflect on the next time you see a family who have come to maternity services through some form of fertility treatment, that you acknowledge that, that you listen to them, you ask how they're feeling about that and you realise that it may not be total relief and joy. It may be that the pregnancy itself continues to be a source of anxiety and Try and help them build that confidence. Build confidence that we're going to look after them, but also build confidence in their body and their ability to carry that baby, birth that baby and look after the baby at the end of it all. So it's a quick dip into fertility, which I hope has been helpful and I'll see you all again soon.

Speaker 1: 28:22

I very much hope you found this episode of the OBS pod interesting. If you have, it'd be fantastic If you could subscribe, rate and review, on whatever platform you find, your podcasts, as well as recommending the OBS pod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalog from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.

Speaker 1: 29:21

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes, where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at the OBS pod on Twitter and Instagram and you can email me theobspod at gmailcom. Finally, it's very important to me to keep the OBS pod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and, by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.