In this session, Andreia Trigo, multi-awarded nurse consultant, author, TEDx speaker and founder of Enhanced Fertility Programme has been talking about fertility assessment for men and women, what tests should be done and when should they be indicated.
Andreia Trigo welcomes the presentation by explaining that the topic came from her own experience working with several patients as a nurse. She often finds patients who have had some basic tests done and were recommended to do a fertility treatment that didn’t work, and then, after a while, doctors might request further tests, and it can be confusing for patients. According to Trigo, “They start asking themselves why, haven’t I had these tests done before? Why am I doing them after I’ve been through invasive fertility treatments?”
For this reason, Andreia Trigo provides some tools that help patients possibly assess every single aspect of their fertility and get the global picture to make an informed decision about what treatment to try and, ultimately, know about their risk factors or problems. This can also help in having a more informed decision about the chances of conception, whether it’s naturally, through treatment or treatment with different protocols.
Before starting with her explanation, she presents herself:
I’m a nurse, and I’m very passionate about doing what I do: helping people get pregnant, my mission came from my own experience with infertility because I was diagnosed with infertility when I was 17, and it was very challenging for me to cope with it at that time.
Due to this fact, Andreia’s mission is to give back to the community, combining her personal experience as well as her skills as a nurse and as a researcher and lecturer. She goes on by saying:
I participate in all these webinars and all the initiatives that are available to give back as much as possible.
Over the last few years, Trigo mentions she’s been trying to make fertility education support and care accessible to everyone as she believes that support should be an add-on, not difficult to find access to trustworthy information. However, in reality, it’s difficult to find information that people can rely on. For this reason, the Enhanced Fertility Programme App was born. The App was launched in November 2020. It’s a free app that people can download from the Google Store or App Store. There’s access to many things such as: an online fertility course with five modules (there are short videos about each topic and texts), research, mindfulness recording, CPT exercises and more that will help in the journey.
Moreover, what Andreia Trigo shows during the presentation can also complete the fertility self-assessment in the get-started button of the app. She also explains all the different factors that can affect people’s fertility and recommends checking fertility in the get-started button.
Andreia Trigo talks about basic concepts to try to understand what people’s fertility risk factors are before going deep into what might be wrong. She emphasizes the need to understand the basics of the normal process, “what needs to be right to make a baby? (…) reflect on what can potentially affect my fertility?” This way people can identify what tests need to be done.
Andreia goes on by showing an image of a safe sex education class which says “Don’t have sex because you’re going to get pregnant and die.” She states, “this is the experience that probably all of us have had in sex education when we were younger (…) that’s why most of us end up trying to avoid getting pregnant until one day we realize the problem is there, and we weren’t aware.” Andreia considers that there’s a narrative that needs to change and people need to start talking more about fertility, conception and what can people do to make the choices they want to make for themselves.
Andreia stated that:
Getting pregnant doesn’t happen very easily, human beings are really bad at reproducing.
According to the statistics of natural conception shown by Trigo, a woman of 25 years old has a 25% chance of getting pregnant in one cycle. Therefore, according to Andreia, “it’s bad. We’re not great, I know animals in the world who’re much better at reproducing, but humans are not at the top .”
For women who are 35, their chances of conceiving naturally in one cycle are only 15%. This is because conception is a complex process: a lot of things need to be right for conception to happen. For instance:
By explaining this, it can be imagined that this is a huge journey for the sperm and egg, and there are a lot of things that can be wrong from the sperm side, the egg side, the embryo (when they’re already combined) or even from the uterus side in the environment where the implantation takes place. These are several factors that could be contributing to potentially lowering the chances of conception even further.
What are the chances of conception with a fertility treatment?The graphic shown below was made by HFEA in the UK. The black line represents the average patient’s age, therefore, most of them who have one cycle are 34 years and a half. Nevertheless, the average age of patients who have, for example, four cycles, is already 36 and a half. So, the age increases.
The birth rate remains around 20 % per embryo transfer so, it’s slightly higher compared to natural conception. Andreia indicates that it remains around 20% or higher for the first three cycles, and that this is the main reason why it’s recommended three cycles for everyone. In the UK, to be funded by the NHS doesn’t apply, but it comes from the likelihood of patients having a 20% chance of the first three cycles.
Andreia emphasizes the need to reflect on the fact “Why do the chances of success per embryo transfer reduce when we have, for example, 7–10 cycles?”
The main reason for the decay of the success it’s because the female age starts increasing, therefore, by the time the woman reaches cycle number 7, they’re much older than when they started cycle number 1. Due to this, the female age is an important factor to consider.
Andreia Trigo first mentions the egg that grows in the ovaries that are connected to the fallopian tube. Women are already born with all the eggs that they’re going to have, between one and two million eggs, which is a huge amount of eggs. Nevertheless, by the time women reach puberty, they have around 300,000 eggs left in their ovaries.
In every cycle, hundreds of eggs are going to start maturing, but there’s only one that’s going to complete the final stages of maturation, and it’s going to be released from the follicle. Moreover, this egg is going to be available for 24 hours to be fertilized while the sperm needs to cross the vaginal canal through the cervix, into the uterus and come through the fallopian tubes to make the egg.
Actually, only 1% of sperm is ejaculated and crosses the cervix; this is a very small amount – says Andreia.
It involves 2 cycles: The uterine cycle and the ovarian cycle.
It refers to all the changes that are happening in a woman’s uterus, meaning menstruation (the shedding of the uterus lining).
After menstruation, the proliferative phase takes place when the uterine lining regenerates itself. Then, women have ovulation. Finally, the secretory phase is when the uterus lining is getting ready for implantation.
This cycle matches the stages of the uterine cycle as they need to happen at the same time, in synchrony.
At the same time, a woman is menstruating, her follicles are maturing those eggs inside the follicles and that’s called the follicular phase.
The ovulation happens in both cycles and after this stage, the follicle surrounding the egg is going to degenerate and start producing progesterone.
The progesterone produced in the ovary in the luteal phase is going to allow the uterine lining, in the secretory phase, to thicken enough to allow implantation. Andreia emphasizes the importance that these cycles need to have a certain duration and synchrony between them. This is an important factor that she looks at when assessing women’s fertility.
According to Andreia, it’s important to look at male fertility because it is less assessed and checked.
Men, unlike women, have sperm and only start producing it when they reach puberty. Therefore, while women are born with all the eggs, men don’t. They’re going to continue producing sperm every day of their lives, from puberty and, potentially, until they die (when they’re very old, like in their eighties or nineties).
Sperm, just like the egg, matures from very small cells until it divides itself and forms to its recognized shape, with the head and tail. This whole process of maturation, unlike women, lasts one cycle. In men, it takes around 74 days, around 3 months, to go from one cell to a fully mature sperm.
As men produce sperm every day, in the testicles it can be found different sperms at different stages of maturation. Andreia mentions its interesting how ‘testis’ produces around 200 to 300 million spermatozoa every day, something very different to what women go through. However, only 100 million of these will become viable. Andreia goes on by saying:
It’s good that it’s a lot because we know only 1% of the ejaculated sperm will be able to cross the vaginal cervix.
An important aspect of sperm is that it needs to be at a lower temperature than people’s bodies. For instance, women have their ovaries inside their bodies, they have their internal temperature which is much warmer. On the other hand, the testicles are outside the body; the sperm doesn’t like hot temperatures. For this reason, Andreia assesses men’s temperature and environmental factors that can affect that temperature because, with higher temperatures, spermatogenesis (the production of sperm cells) is not going to happen.
After giving a quick overall view of the basics, Andreia explains that both male and female processes are regulated by hormones which start in their brains.
It’s something that a lot of people might not be aware of, that our reproduction is regulated by our brain.
This starts through the HPG axis and it can be explained in the following way:
The hypothalamus will produce gonadotropin hormone which will trigger the pituitary gland to produce two very important hormones: LH and FSH (both produced in people’s brain).
Moreover, the ovaries are going to produce estrogen and progesterone. Andreia mentions a “feedback loop”, in the sense that as the women’s eggs are growing, the follicles are getting bigger and the bigger they are, the more estrogen will be produced.
When there’s a certain threshold of estrogen, a message is sent to the brain to say “We’re ready to be ovulated,” explains Andreia, and the brain sends that message to the pituitary gland. This gland will release LH, and when it reaches the ovaries, ovulation happens. After the ovulation, the follicle surrounding the egg degenerates and starts producing progesterone.
Therefore, there’s a constant feedback loop mechanism that’s very important; if all those hormones are unbalanced, they could be affecting fertility. This is another thing to look at in a fertility assessment.
Andreia Trigo mentions some common fertility assessments that couples need to undergo:
Even though these tests are very basic, Trigo believes that they fail to assess many things that could be wrong. For this reason, on many occasions, people are recommended to have fertility treatment and then, after the treatment, to have tests to look for further causes.
Some people are also labelled as “Unexplained infertility” before they’re given all the other tests of what could be wrong. Therefore, Andreia explains all the tests that people could potentially have and what to check to make sure they’re not given that label.
Furthermore, Andreia explains the test that can be done in the app she mentioned Enhanced Fertility App. This test has 50 questions about female fertility and 35 questions about male fertility; it’s very thorough and takes about 7 to 10 minutes to complete. It also categorizes, depending on the answers, in Low, Medium or High Risk of developing fertility problems.
The idea is that people have a global view of everything that’s possibly affecting fertility. Giving this global view to people and the doctor of all the problems, he will be in a better position to suggest what treatment is more likely to work. The questionnaire of the Fertility Risk Detection Tool is part of Andreia’s research project, it’s validated and it’s still in progress. Therefore, if people can complete it today, they can complete it at any time they feel that some of the risks have changed over time and want to do it again, six months down the line because they’ve adjusted some of the things after doing the first questionnaire.
One of the most important factors is age. Unlike many people believe, says Trigo, men do have a biological clock just like women do but it’s not as early as them.
The fertility peak of women happens in their 20s and will stay good until 35, but it will star deteriorating at that point.
For men it starts a bit later. They still have a biological clock and it’s important to know that because as men age the likelihood of chromosomal abnormalities in the sperm increases as well.
Andrea explains she’s going to look at how regular the cycle of a woman is. They are yes/no simple questions.
Another aspect is the length of the cycle.
The final aspect is ovulation.
This finding, according to Andreia, is one of the biggest and there are already 200 people that answered the survey. The vast majority of them didn’t know their AMH levels but they’ve been trying to conceive for more than a year. For Andreia this is concerning because AMH is an important test to have and it’s a marker of ovarian reserve; how many eggs left does a woman have in her ovaries?
This AMH level changes according to age and Trigo put different units because depending on the laboratory, where the tests have been done (UK, US or in Europe), it might come as nanograms or moles per litre. Therefore, a woman has to check the units if they had their AMH tested and if the value is normal per age.
For the test, Andreia states they want to know women’s AMH levels and to combine it with the Antral-follicle-count scan. This scan is important because it’ll allow the doctor to count how many follicles are in the woman’s ovaries. By having these two tests together, it can be possible to say what the woman’s ovarian reserve is. As it’s not 100% certain if a woman’s ovarian reserve is low or high with only the AMH test, it’s essential to have both tests.
So many people either haven’t had any test done or they’ve had AMH but not the scan, so just bear in mind that you have an accurate view of what is happening in your ovaries it’s important to have both tests.
Many times, this aspect is not looked at in clinics, but according to Andreia, the following are very important:
Andreia also mentions that she’ll look at women’s quality of life and their ability to cope with treatment. All of these are very important because fertility is more than just physical, fertility is a well-being that comes from physical, emotional, psychological, and social impact; this is the definition of the World Health Organization.
We want to look at all aspects. We know that if we’re more stressed, we’re more likely to have a diet rich in high-caloric foods, which we know is bad for fertility. So, all of these things tend to be interconnected in some way, so it’s important to have the global picture.
It’s just being mindful of the toxins we’re putting in our bodies because they can cause changes to the DNA in our eggs and sperm. Sperm tends to be a bit more fragile in that sense but it’s important that we’re aware of that.
The toxins can also be found in the air or through the water. For instance, pesticides are added to the food that is being planted and it goes from the water to the food people eat; therefore, it’s important to have a global view.
Andreia Trigo mentions that the following are the initial tests that most men will have done.
Andreia explains that some clinics may do a sperm analysis and include DNA fragmentation while others don’t.
Andrea emphasizes that:
Your sperm analysis might be good, but when you look at DNA it might be bad. So, it’s good to be aware of that.
Once again, Andreia states that men are very under-tested, and they’re not looked at properly. As they’re 50% of the equation, they must be assessed.
When men have surgery, it’s a possibility or a risk that they have damaged the canals that transport the sperm.
For example, wearing very tight underwear or trousers, sitting for longer periods, having their computer in their laps or going to a hot sauna. These increase the temperature of the testicles and it’s not good.
Andreia Trigo concludes with some key takeaways points and states that she doesn’t want to scare people but to share that there are lots of things people can look into that could potentially give them an insight into what could be wrong.
I am of the opinion that knowledge is power, so the more we know about our bodies, the more we will be able to make informed decisions about treatment.
This also applies to people’s doctors, nurses, and clinical teams; the more information is given, the better they’ll be able to help.
To summarize, Trigo explains the following:
Sometimes, that does happen that the follicles develop, but the eggs inside those follicles didn’t mature, and that is a risk that we take with ovarian stimulation. Doctors usually refer to patients who might have, for example, a good AMH and a good antral follicle count but then respond to ovarian stimulation in a way that is less than what would expect for their age or those AMH and follicle count levels and doctors usually call those a poor responder to ovarian stimulation, and it might be that the doctors could try a different ovarian stimulation drug to see if it makes a difference. I think it’s a matter of trying different things before giving up because you might respond differently to different medications. Progesterone is produced by the degenerated follicles, so if your progesterone levels are high, that means that ovulation has happened. However, if the progesterone levels are low, it could be that there was no ovulation. In a rare scenario, there’s also something called LUF, which is luteinized and unruptured follicle when there is stimulation, there is LH, the follicle is stimulated, but still, ovulation doesn’t happen. That happens in very rare cases but mostly in situations of an unspecified cause of infertility.
I’m not sure why they would have a problem getting the eggs out, so they typically would use a syringe to collect them. Is it a problem with accessing the ovaries? Sometimes, the ovaries are a bit hidden, and it might be difficult collecting them through the normal approach, which is through the vaginal wall, but if they can get to the ovaries, they wouldn’t have problems getting the eggs out. The only thing the medication does is stimulate the ovaries to produce more eggs in that cycle.
Yes, it is possible that the follicles grow but that they don’t have mature eggs, that is possible. That’s because we have millions of follicles with eggs at those very tiny stages, but then we are forcing them to grow in some of them the eggs do not mature in time, it is possible.
Yes, if you have a very low AMH, you are less likely to have a higher number of eggs. If you are going through ovarian stimulation that is the likelihood. AMH is produced by the follicles. The bigger the follicles and the more follicles you have, the higher your AMH is. I’d like to highlight here that, for example, women who have PCOS usually tend to have bigger follicles, but not necessarily very good quality eggs inside those follicles. You might usually have higher AMH levels because of big follicles if you have PCOS, but not necessarily great quality eggs inside, but the number of AMH is related to the f0llicle size and the number of them.
If it’s just diagnostic, it’s very unlikely that will cause scar tissue because what you do in the diagnostic laparoscopy is just put the camera in your tummy just to have a look around, and then they don’t do anything apart from that. Laparoscopy means just surgery that is done through keyholes in our abdomen, so if they end up doing any treatment through the laparoscopy, then they could cause scar tissue, for example, sometimes there can be surgery done in our bowels that is done through laparoscopy, and that could cause scar tissue. If it’s just diagnostic to have a look at, it would not cause scar tissue.
You would know, only if the doctor would look inside again, so it’s not a very feasible way to know, but the more invasive the surgery and the procedure, the more likely it will create scar tissue. I’ve spoken to several physiotherapists recently who do a lot of work in the abdomen to help release that scar tissue, so if you’ve had surgery in your bowels, for example, extensive surgery, it might be a good idea to speak with the physiotherapist. They could help assess your abdomen and see if they could do abdominal massage to release some of that scar tissue.
I think it would be important for the doctors to identify why is your prolactin levels high. I’m not sure if any supplements can address that, but it’s important to know that supplements are medicines that haven’t been researched, so they haven’t been through clinical trials like proper tablets, and medication has. Prolactin high levels are something serious, so I think you need to speak with your doctor to try and identify why it is high. Also, you need to ask what you can do because you need to address the cause.
There is no big consensus in different countries. I think it will depend on what your doctor recommends. In men, it tends to be more important to be between 20 and 50, but I would say there isn’t an absolute recommended level. If you have a test done, it will tell you a range, so I would go with that but just bear in mind that different countries are giving different recommendations of what the ideal value should be.
Not necessarily. I think it would be important to identify whether you are having an LH surge. If you have an LH search, so if you measure with those urine sticks, and you can see a peak, that means that the follicle was stimulated and that ovulation is going to happen. You need an LH that is 2.5 above your baseline levels for ovulation to happen, and then secondly, I would measure either your temperature after a few days after ovulation if the temperature is high, it means you have progesterone, it means that the follicle has degenerated after ovulation, so that could be a good confirmation that ovulation has already happened. Either that or I know in countries, you’re also able to test progesterone at home. The progesterone level could also confirm ovulation that has happened in the past. It’s always good to check if your hormone levels are being enough for ovulation to happen. Your LH needs to be high enough to 2.5 above your baseline.
Ovulation sticks will give you a smiley face or a sad face to tell you if you are ovulating depending on if your LH has reached a threshold of 40. The problem with that is that a lot of women have lower LH surges. You might have an LH surge that ends up not being detected by your ovulation stick, and some women particularly, with PCOS, end up having a higher LH level as well. They might have false positives saying that ovulation has happened when it hasn’t happened. If you are looking for a method to identify your LH, I would say that the method that tells the exact value of LH is called a quantitative ovulation test, which is better than just an ovulation stick that gives you a positive sign or a negative sign whether you’re ovulating or not.
I think if you go from 24 follicles, and you get 13 eggs, I think that is a great number. I think we need to look at the sperm. You need to look at the sperm quality, you need to do the sperm analysis and the DNA fragmentation test because if you’ve had 13 eggs that that is amazing. We know that when we look at sperm quality, we usually talk about DNA fragmentation to see if there are any DNA changes. When we talk about egg quality, there’s no way of testing the egg DNA itself. We only know if the egg is of good quality if it fertilizes, and it continues developing. The next step would be to check the sperm. If we know that the sperm is good and that there are no DNA problems, then we could go back to check the eggs, but I’m betting on the sperm. I think that would probably be the best next step.
