Understanding fertility treatment: A Q&A with Dr Justin Chu

Fertility treatment can be complex, and your journey may feel overwhelming at times. So, completely normal to have questions about the process.

Justin Chu, the Medical Director of TFP Oxford Fertility, answers your questions related to fertility treatment, covering topics from ultrasound scans to male fertility.

Q. What is an antral follicle count (AFC) scan?

“The antral follicle count is the number of small follicles that we can see on a pelvic ultrasound scan. These small follicles are yet to be recruited into any future menstrual cycles. When women are on their period, the next cohort of follicles is ready to grow. When the anterior pituitary gland, which is at the bottom of your brain, produces two hormones, FSH (follicle-stimulating hormone) and LH (luteinizing hormone), they encourage the next cohort of follicles to grow.

If we have a high number of follicles in the AFC scan and stimulate the ovaries during the menstrual cycle, this should encourage a decent number of follicles to grow. This is then followed by a trigger injection, egg collection and fertilisation to create embryos. So, the antral follicle count is a surrogate marker for ovarian reserve and gives an indication of how many eggs we might be able to collect from a patient.”

Q. When is the best time to have an AFC scan?

“In the early follicular phase, usually between days two and six, would be a decent time to perform an AFC scan. The other test used to assess ovarian reserve is the anti-müllerian hormone (AMH) blood test. AMH is a hormone that's secreted by small follicles before they're ready for recruitment. A high AMH level generally indicates a normal ovarian response if we were to do an IVF-stimulated cycle.

During a first-time consultation, the assessment of ovarian reserve includes both the AMH blood test and AFC count. We use both variables to discuss what we think your egg reserve may be and what to expect during a potential IVF treatment cycle.”

Q. What is the best cycle protocol for a frozen embryo transfer (FET) if you have a large unrepaired C-section scar defect (isthmocele) that causes spotting of old blood until ovulation? I have heard a natural cycle might be better because it avoids fluid buildup in the lining – is that true?

“If a C-section scar niche (caesarean scar defect) is causing symptoms, we need to think about whether this niche will impact implantation. It might not necessarily matter whether we opt for a natural frozen embryo transfer protocol or a medicated one.

If a patient is having bleeding midcycle and we know on pelvic imaging that there is a caesarean section scar niche, go and see a gynaecologist who has the expertise in the management of a caesarean scar niche before proceeding with an embryo transfer.  I would worry if there's a large defect in the womb wall, particularly at the front where the lower segment of the womb may have been opened to deliver a baby. Trying to implant an embryo in that womb may not take or be successful.

Lastly, caesarean scar niches are not all the same. Management depends on the size and the symptoms that you're experiencing. Ultrasound scans on women who've had previous caesarean sections often reveal a thinner area on the front of the lower part of the womb. However, if a woman is not experiencing any symptoms, then surgical management may not be necessary. If there is a big defect and there are symptoms, it may be necessary to consider further imaging, such as an MRI or surgical management, to try to fix it.”

Q. I had an embryo transfer yesterday, but later I experienced diarrhoea, excessive sweating, and cramps that lasted about five minutes. Is this a normal reaction? I'm worried it may have affected my chance of implantation.

“It’s not normal to have these symptoms. It sounds like you might have been quite anxious at the time; doctors refer to this as vagal overdrive. When you feel a little nervous, you can feel clammy, sweaty and have some loose stool. So, the manifestation of those symptoms is probably due to anxiety.

I don't think these symptoms will impact implantation, so they shouldn't change the outcome of the embryo transfer procedure. However, if any patient having fertility treatment experiences severe symptoms after an embryo transfer, I always encourage them to contact their TFP unit to seek advice from the nursing or medical team.”

Q. Do you think we should be focusing on male fertility treatment?

“I strongly believe we need to focus more on the male fertility side of investigations. That’s mainly because around 40% of couples who struggle to conceive may be affected by male infertility. At the moment, we do tend to focus on female fertility. There are not a lot of tests available for men apart from sperm testing and sperm DNA fragmentation testing to identify why sperm counts, morphology, and sperm quality may be low.

In general, lifestyle factors are important for the male partner. It’s essential to maintain a whole-food diet, avoid ultra-processed foods, get a good night's sleep, and reduce your exposure to toxins, such as cigarette smoke, alcohol and excessive caffeine.

We also need to consider whether scrotal temperature is raised too high. During winter, many men may have been sitting on heated seats in their cars or spending a lot of time cycling. Increased scrotal temperatures can cause problems in terms of the quantity and quality of the sperm produced from the testicles.

Testing sperm parameters is a good first step in understanding sperm health. If you are worried about infertility and suspect that male factor infertility may be involved, seek out a sperm test at one of your TFP clinics around the UK.

We need to encourage more awareness and focus on both the male and the female partner and treat patients as a couple.”