Dr John Waterstone is Medical Director of Waterstone Clinic and has dedicated his medical career to women’s health and fertility.
He is committed to leading innovation in Reproductive Medicine in Ireland. He is a graduate of both the Science Faculty (Genetics) and Medical School of Trinity College, and began his career at the Rotunda Hospital, Dublin before training in Obstetrics & Gynaecology in teaching hospitals in London. He is a Consultant Gynaecologist, specialising in fertility investigations and surgical interventions for resolving fertility issues.
Couples experiencing a delay in achieving a pregnancy may well talk to a pharmacist before seeing their GP or a gynaecologist. Pharmacists should be able to provide practical advice.
The following are some of the questions pharmacists may be asked and suggested answers:
When should we be trying?
o Every one or two days over the five days before ovulation.
How do I know when I’m ovulating?
o By the calendar, 14 days before the next period is due or using ovulation predictor kits (OPKs). These daily urine tests detect the LH surge, which precedes ovulation.
Are OPKs a ‘good’ idea?
o Yes, they are the best way to confirm that ovulation is occurring and to know when. They also concentrate minds and focus effort: couples shouldn’t waste any of the twelve opportunities per year to conceive.
Is it wise to get any other fertility test done after trying for a few months?
o A semen analysis is worth considering if it can be easily arranged. If semen quality is so poor that natural conception is extremely unlikely, the couple could be wasting valuable time.
At what point should I see a doctor?
o After 12 months is the accepted wisdom, but after 6 months if the woman is 37 or older, and straight away if she is 41 or more.
What doctor should I see?
o Medical practice has become very subspecialised and it is best to see a doctor who works all the time in a fertility clinic.
What tests will be carried out?
o A semen analysis; a set of hormone tests for the woman, some of which will assess egg numbers; a transvaginal (internal) ultrasound scan to assess the uterus and ovaries. A test of fallopian tube normality is also likely.
At what point should fertility treatment be recommended if our subfertility is ‘unexplained’ (i.e. all tests indicate natural conception can happen, but it isn’t)
o After 18 months of unprotected intercourse, but sooner for patients who are older and/or have low egg numbers.
What are the different fertility treatment options?
o Ovulation induction followed by intercourse (OII) is for patients who seem to not be ovulating. Usually, tablets are used (Clomid or Letrozole, but occasionally low-dose FSH injections). The patients most commonly have PCOS.
o Intrauterine Insemination (IUI) is for patients with unexplained subfertility or mildly suboptimal semen. Low-dose FSH injections are used.
o IVF/ICSI can be used for all types of subfertility, often when simpler treatments have failed. High-dose FSH injections are given together with LHRH analogue injections. Multiple eggs are generated and collected. Embryos are produced and transferred or frozen.
Pharmacists may wish to familiarise themselves with the protocols used for OII, UI and IVF/ICSI and the medications involved. Information leaflets provided to patients by fertility clinics are a helpful resource.
Pharmacists should be aware that the most vital injection of all in an IVF/ICSI treatment cycle with regard to timing is the ‘trigger’. Patients must take this injection at exactly the right time: the exact interval varies between clinics, but generally, it is 35.5-36.5 hours prior to the scheduled egg collection.
Subfertility is stressful, and patients are desperate to do all they can to improve their chances of a baby, through natural conception or treatment. They often take supplements (‘nutraceuticals’) in the hope that these will help. Those most likely to take nutraceuticals are women who have produced very low numbers of eggs with IVF (or had repeated failed cycles) and men with apparent suboptimal semen quality. Good evidence that any nutraceutical improves the chance of a baby is lacking; published studies tend to be of poor quality, too small, and too poorly controlled to allow firm conclusions.
Women may request or be recommended DHEA, Coenzyme Q-10 (CoQ-10), melatonin or growth hormone. One small randomised controlled study of CoQ-10 (200mg TDS for 60 days) versus placebo in IVF poor responders suggested an increased chance of a live birth.
There is speculation that ‘oxidative stress’ may be a causative factor when semen quality is suboptimal. Antioxidant treatment (i.e. with ‘Wellman’ type preparations) is often recommended. There is poor-quality evidence that such antioxidant treatment can improve success rates after IVF/ICSI. A number of antioxidants tend to be given together, including Vitamin E, Vitamin C, carnitine, M-acetylcysteine, CoQ-10, zinc, selenium, folic acid and lycopene.
Those with fertility problems are often stressed and emotional; they will both appreciate and benefit from the kindness they receive at their pharmacy.
Dr John Waterstone is Medical Director of Waterstone Clinic and has dedicated his medical career to women’s health and fertility.
He is committed to leading innovation in Reproductive Medicine in Ireland. He is a graduate of both the Science Faculty (Genetics) and Medical School of Trinity College, and began his career at the Rotunda Hospital, Dublin before training in Obstetrics & Gynaecology in teaching hospitals in London He is a Consultant Gynaecologist, specialising in fertility investigations and surgical interventions for resolving fertility issues.
