Information for Students

Infertility/Assisted Reproductive Technology (ART)

Most people are now able to plan their families as carefully as they do their education, career, lifestyle and finances. Australian families are smaller and often come later in life than in earlier generations.

However one in six Australian couples experience infertility.

For these people the choices are limited and different.  Infertility is usually defined as "the inability of a couple to achieve conception after a year of unprotected intercourse or the inability to carry a pregnancy to a live birth."

There are many causes of infertility; some are due to ‘male factor’ such as problems with sperm; some are ‘female factor’ such as obstructed tubes or endometriosis and a large number are ‘unexplained’. For other people, having their own child carries an unacceptable risk of transmitting a serious genetic abnormality and some are unable to carry a pregnancy to term.

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Reproductive Technology Legislation and Regulation

South Australia

The Reproductive Technology (Clinical Practices) Act regulates assisted reproductive technology in South Australia. The Act applies a fundamental principle: that the welfare of any child to be born in consequence of an artificial fertilisation procedure must be treated as of paramount importance.  The Act established the SA Council on Reproductive Technology which provides advice to the Minister and the clinics.

The Act requires a clinic that provides assisted reproductive technology services to be licensed by the Minister for Health and as a condition of that licence to abide by regulations issued under the Act (the Code of Ethical Clinical Practice) and guidelines issued by the National Health & Medical Research Council.  The clinics provide a variety of services including advice on fertility generally, invasive procedures such as IVF and ICSI and donor conception with either donated sperm or eggs.

Donor conception (artificial insemination) services using donated sperm (but not donated eggs) do not require any invasive procedures.  They can be provided outside of a licensed clinic by a registered medical practitioner who is registered for this purpose and agrees to abide by the Code of Ethical Clinical Practice or who provides the service for free.  No medical practitioners have ever registered with the Minister for Health to provide such services.

The Act prescribes who the licensed clinics can provide treatment to and under what circumstances.  It allows treatment in two circumstances:

• infertility – in a male or a female (or both in some couples)
• genetic abnormalities – where there is a risk that a genetic defect would be transmitted to a child conceived naturally, assisted reproductive technology can assist by screening out embryos that carry the gene in question.

The  SA Council on Reproductive Technology has determined that the Act intends treatment to be offered in cases of medical infertility (rather than social infertility) as described by the World Health Organisation: 12 months of unprotected heterosexual intercourse with no resulting pregnancy.  Infertile people need a referral from the local doctor to the clinic to this effect. 

The Act stipulates that only married couples or long term de facto couples can access treatment at a licensed clinic.  This was challenged in the South Australian Supreme Court in 1996 by a single woman, Gail Pearce, who claimed that the South Australian Reproductive Technology Act was inconsistent with the federal Sex Discrimination Act because it discriminated on the basis of marital status.  The Court agreed that since under the Australian Constitution federal Acts over-ride State Acts to the extent that they contradict, the marital status requirements were invalid and should not apply.  Since then, marital status has not been a criterion on which clinics determine eligibility for treatment.  However, infertility remains a criterion unless there are genetic problems.  Therefore, although the Act has never been changed, infertile women (whether single, married or de facto) can access reproductive technology treatment in South Australia, and have been able to since 1996.

Lesbian women have an interest in seeking access to reproductive technology in order to conceive artificially.  If a lesbian woman is medically infertile, she would be eligible for treatment the same as any other infertile woman.  Lesbian women who are fertile don’t require invasive treatments like IVF.  They need only donor conception treatment using donated sperm.  They can organise this themselves in their own homes or through a medical practitioner registered to provide such services. 

At present the stocks of donated sperm are held in the licensed clinics.  The sperm donors are counselled and the sperm are screened for genetic problems and diseases including hepatitis and HIV.  Lesbian women who are not medically infertile cannot access treatment through a clinic and therefore cannot access these screened sperm banks.  Lesbians can and do travel interstate to clinics that can legally provide services to fertile women.

An Eligibility Fact Sheet has been developed that provides information about eligibility for treatment and the Pearce decision, and is available on the Fact Sheets page of this site.

Legislation In Australia

Information about legislation in Australia is available on the Legislation page of this web site. 

Comparison of Australian Legislation

Please click here to access a table comparing ART legislation in Australia.

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Human Reproduction

The Female Reproductive System  

The female reproductive system is entirely internal.  The vagina is the passage that leads from the outside of the body to the cervix, which is the opening to the uterus.  The uterus is the muscular organ where a fertilized egg attaches and develops.  It is about the size and shape of a pear, and is lined with a rich and nourishing membrane called the endometrium.  From the top of the uterus extend the fallopian tubes, which lead backwards and downwards to the ovaries.  These are two small sacs that contain the eggs. 

Each month during her reproductive years, usually only a single egg matures.  At mid-cycle, the egg is released from the ovary in a process called ovulation.  The egg then enters and travels down one of the fallopian tubes towards the uterus.  While in the fallopian tube it is ready to be fertilized by the man’s sperm.  If fertilized it may implant in the lining of the uterus and create a pregnancy.  If a pregnancy doesn’t develop the lining of the uterus will break down and be shed during what is known as menstruation.

This sequence of events is controlled by monthly changes in a woman’s hormone levels and is known as the menstrual cycle.

The Male Reproductive System

The testes lie in the scrotal sac and produce the male hormone testosterone and sperm.  From the testes, sperm pass through the coiled channel of the epididymis where they undergo maturation.  The entire process of sperm formation and maturation takes about 72 days. Mature sperm then move into the vas deferens, a tubal structure that connects the epididymis with the seminal vesicle and provides for storage of the sperm.  Upon ejaculation, the sperm pass by the seminal vesicle which, together with the prostate gland supplies the fluid content of the semen to nourish the sperm.  Sperm can live 2-3 days when deposited in the vaginal tract of the woman.

The semen analysis is the single most important test in the evaluation of the male.  The test gives an accurate measurement in sperm count, motility (movement), morphology (shape & size of the sperm cells) as well as the volume of the ejaculate.  It is not unusual for semen analysis to vary significantly from time to time so often two tests some months apart are required.

Andrology Australia Newsletter: www.drandrologyaustralia.org

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Infertility

Common problems and causes of infertility

Historically, infertility has largely been attributed to the female.  In reality though, the causes are almost equally divided between men and women:

·       1/3 of infertility is due to a female factor – eg tubal, ovulatory or age related problems

·       1/3 of infertility is due to a male factor – sperm problems

·       1/3 of infertility is due to a combined male / female factor

·       up to 10% of infertility remains unexplained.

It is therefore important that investigations are done on both partners from the start.

Female problems include:

·       ovulatory disorders

·       tubal blockages

·       endometriosis

·       age related problems

·       lifestyle factors – eg smoking, large alcohol intake,

being under or overweight.

Male problems include:

·       semen factors

·       ejaculatory problems.

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Simple Steps to Improve Your Chances of Conception

1. ASK YOUR DOCTOR FOR ADVICE

2. LIFESTYLE FACTORS

Improving Nutrition

Both partners should eat a variety of foods choosing from the main food groups ie:

ü     Breads, cereals, rice, pasta and noodles

ü     Vegetables and legumes

ü     Fruit

ü     Milk, yoghurt, cheese

ü     Lean meat, fish, poultry , eggs

Both partners should limit the amount of fat in their diet.

It is recommended that women take a 0.5 mg folic acid tablet every day for at least one month before
getting pregnant and for the first three months of pregnancy. This reduces the chance of the baby having neural tube defects.

Achieving a Healthy Weight

Being chronically underweight or overweight can affect a woman’s fertility.

Overweight  women who lose weight through exercise and a healthy diet (average weight loss 5 to 10 kg) have improved pregnancy rates.

Exercising

Commencing and continuing a low intensity exercise program such as walking or swimming.

This helps to achieve a healthy weight and improve overall fitness.

Reducing Caffeine, Alcohol and Drugs

Too much caffeine can increase chances of miscarriage and complications of pregnancy.  It should be taken in moderation e.g. no more than three cups of tea or coffee daily. Caffeine is also present in Cola, chocolate and some foods.

It is not clear how much alcohol if any is safe to drink during pregnancy. No alcohol is the safest choice.  It is recommended that a woman who is pregnant or trying to conceive should not consume more than two standard drinks per week.

The use of street or recreational drugs such as marijuana, ecstasy cocaine or heroin should be avoided at all costs.

Prescribed drugs should not be ceased without consultation with a doctor.

Natural/ Alternative therapies should be discussed with a doctor.

It’s best to avoid contact with lead-based paints, pesticides, aerosols, oven cleaners and solvents.

Managing Stress

Maintaining a positive state of mind improves health and well being and chances of a successful pregnancy.  A degree of stress is inevitable, but how you deal with it is important. Counsellors who deal specifically with infertility are available, as are Support Groups. Others may choose to use family and friends as supports.

Stress management techniques such as meditation and relaxation may be useful.

3. HAVING INTERCOURSE AT FERTILE TIMES

The normal fertility rate is achieved with alternate day intercourse at across the fertile times. The normal fertile time is 12- 14 days before the next expected period in a woman with regular monthly periods.

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Age and Fertility- Protecting your fertility

Australian families are smaller and often come later in life than in earlier generations.  As women become older they become less fertile, yet the age at which women now choose to start a family is later.  In the past two decades, the number of women having their first baby over 35years of age has increased dramatically.  Society has encouraged women to delay marriage and childbearing in order to pursue their studies, career and travel.  Both men and women have followed this trend so that the average age of starting a family has shifted in the last decade from mid 20’s to around 30 years of age.

This has had an enormous effect on people needing to access reproductive medicine services, and infertility clinics have seen a 10 fold increase in numbers of older women (over 35 years) seeking treatment.  The average age of women starting IVF treatment in SA has risen to 37 years.  Women who wait until their early 40s to start a family have only a 13% chance of falling pregnant and a 50% chance of miscarriage. 

The main reason for the decline in fertility over the age of 35 years is due to the egg quality and the increase in chromosome abnormalities of the egg.

In South Australia , The Reproductive Technology Act of South Australia prohibits women accessing reproductive technology treatment if they have reached normal menopause.  Menopause is defined as: the permanent cessation of menstruation following the loss of ovarian function.  Currently this is aged greater that 46 years and the average is approximately 51 years of age.

Age and Eligibility Report

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Treatments for Infertility

In recent years there have been many advances in the treatment of infertility including:

• Hormonal therapy
• Surgery
• Intrauterine Insemination (IUI)
• Invitro Fertilization (IVF)
• Intracytoplasmic Sperm Injection (ICSI)
• Preimplantation Genetic Diagnosis (PGD)
• Donor Conception

Hormonal Therapy – Ovulation Induction

If a woman is not ovulating, this can be induced by giving medications to stimulate the ovaries. 

Surgical Procedures 

Conditions such as endometriosis, tubal blockages, fibroids or past pelvic infections can often be corrected surgically to improve fertility.  The procedures may be all that is needed to restore fertility or may be part of more comprehensive treatment.

Intrauterine Insemination (IUI)

If infertility is due to unexplained infertility, a decreased sperm count & motility or in situations where normal intercourse is not possible intrauterine insemination may be used.  IUI is usually combined with low dose injections to stimulate the ovaries and mature several eggs.   The semen goes through a process called “washing” to get the healthy sperm into a small concentrated form.  The sperm is then placed into the uterus by means of a fine plastic catheter.

In Vitro Fertilization (IVF)

Medication is used over approximately 12 days to stimulate the ovaries to produce and mature multiple eggs.  When the eggs are mature they are aspirated from the ovaries and taken to the IVF laboratory where each egg and sperm are placed together in a special medium to allow fertilization to occur.   If fertilization has occurred an embryo has formed and either one or two embryos are then transferred to the uterus, approximately 2 to 3 days later.  A blood test can be done 2 weeks later to see if an embryo has successfully implanted and a pregnancy has taken place.

Intra Cytoplasmic Sperm Injection (ICSI)

This is a laboratory technique used during IVF when there are severe semen problems and fertilization of the egg would not occur.  The treatment process is the same as for IVF, but once the eggs are collected and taken to the laboratory a single sperm is injected directly into the egg.

Preimplantation Genetic Diagnosis (PGD)

Some couples are known to be at high risk of conceiving a baby with a specific genetic condition, such as cystic fibrosis or muscular dystrophy.  If the underlying gene error causing this risk is known, then it may allow screening of embryos conceived by IVF for this gene error.  A single cell is removed from the embryo and tested for the presence of the particular gene.   Only those embryos identified not to have the gene error are chosen for transfer to establish a pregnancy.  This reduces the risk of a baby being affected by the condition, and is an alternative to prenatal testing of an already established pregnancy.

Freezing of Embryos, Sperm or Eggs

Embryos

Following an IVF cycle there may be enough good quality embryos produced to freeze for use at a later date. This allows another pregnancy attempt and maximizes the chance of pregnancy from each IVF cycle.

Sperm or eggs

For many years sperm has easily been able to be frozen for use at a later date and in recent years laboratory technology has allowed eggs to be successfully frozen and thawed.  Reasons for this include:

• Medical conditions requiring chemotherapy or radiation that could destroy sperm or egg production
• Freezing of sperm prior to vasectomy.
• Freezing of eggs where no sperm was able to be recovered on the day of egg collection during an IVF cycle

Donor Conception

Reproductive technology using donated eggs, sperm or embryos may be the only way some people can have a baby. These children are very much wanted and many happy families have been formed in this way. It does however raise a number of legal, ethical and social questions.  

Donor Conception Pamphlet

Donor Issues Discussion Paper

Donor Conception Support Group: http://members.optushome.com.au/dcsg/

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Adoption

There are many ways to form a family, for example:

·       people who are fortunate to be able to conceive naturally

·       through assisted reproductive technologies

·       through adoption

In the area of adoption Australia operates under a legislative framework of child’s best interest. However, adoption has a prescriptive Act to ensure best interest.

Criteria are set down in the South Australian Adoption Act 1988 and the Regulations pertaining to this Act.  Also each overseas country has its own criteria relating to prospective adoptive parents.

Forming a family through Inter-country Adoption is a very positive, rewarding and enriching experience.

Adoption and Family Information Service of South Australia - www.adoptions.sa.gov.au

Australians Aiding Children Adoption Agency Inc. www.adoptionagency.com.au

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Social and Ethical Issues

For a comprehensive examination of the social and ethical issues in assisted reproduction, see

Sozos J. Fasouliotis and Joseph G. Schenker ‘Social aspects in assisted reproduction’ in Human Reproduction Update 1999, Volume 5, Number 1, pages 26-39.  

Further Reading

Church of Scotland Board of Social Responsibility Pre-Conceived Ideas: A Christian Perspective on IVF and Embryology (1996).

Norman M Ford The Prenatal Person (2002)

Ted Peters For the Love of Children (1996)

SACRT Library

The SA Council on reproductive Technology has a number of books and brochures available in its library.
See the listing in the Resources page of this site.

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Reproductive Services in South Australia

Flinders Reproductive Medicine was established in 1977.  It is a wholly owned, non profit making company of Flinders University and is administratively integrated with the Department of Obstetrics, Gynaecology and Reproductive Medicine.  It is located at Flinders Medical Centre.

The Unit combines technologically advanced methods of fertility assessment and treatment with personal care and support during the treatment process.  To this end it employs a team of doctors, nurses, scientists, administrative and counselling staff who have experience and training in the area of infertility.

Flinders Reproductive Medicine Link: http://www.flindersivf.com.au/

Repromed is a University of Adelaide Reproductive Medicine Unit that is a world-renowned research centre providing services to advance the understanding of infertility and to improve infertility treatments.  It operates clinical programs in Adelaide at 180 Fullarton Road, Dulwich and in Darwin at the Darwin Private Hospital .

Repromed is not just an IVF unit but one that offers both high and low technology medicine involving reproductive epidemiology, endocrinology, menopause and adolescent gynaecology.  Any profits generated from Repromed's infertility treatments are directed back into research programs to expand international knowledge on human reproduction and the causes of infertility.

Outcomes of research programs are applied to clinical practice with improved embryo transfer techniques and quality controls resulting in increased pregnancy results.  For more detailed information see the Repromed website on www.repromed.com.au

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Frequently Asked Questions

There is a Frequently Asked Questions page on this web site.

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