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Assisted Reproduction
Assisted reproduction is conception that takes place outside the body or by insemination. This has become a common way to help involuntarily childless people become parents.
Unit for assisted reproduction offers treatment to couples with a child desire. One of ten couples of childbearing age are involuntarily childless.
The causes of infertility can be many. Roughly speaking, it is seen that the causes of infertility are distributed with one third each in the woman (e.g. anovulation, clogged fallopian tubes) and the man (e.g. reduced sperm quality), and one third where no clear cause is found.
Take a folic acid supplement – it is recommended that all women who are attempting to get pregnant should take 0.4 mg of folic acid a day. You should continue to take folic acid in the first three months of pregnancy.
Avoid using tobacco – Smoking impairs fertility in women and can lower the semen quality in men.
During treatment, your alcohol intake should be as low as possible. Women should refrain from drinking alcohol altogether after embryo transfer.
You should limit your caffeine intake. More than five cups of caffeinated drinks a day is considered a high intake and can reduce your chances of achieving pregnancy.
Keep your weight stable. Both overweight and underweight can affect the chance of getting pregnant by causing an imbalance in the hormonal system. This can affect the menstrual cycle, the natural development of eggs and ovulation. The body mass index (BMI) must be between 19 and 30 before one can start hormone therapy.
Child care certificate
Everyone who applies for assisted reproduction must, from 1 July 2020, submit a childcare certificate (police certificate of conduct). For couples applying, both must apply for a certificate. The application will be rejected unless a child care certificate can be presented.
A child care certificate is a police certificate for persons who are to care for minors. The certificate provides information on whether the person has been charged, prosecuted, has imposed a fine or has been convicted of a violation of several criminal decisions. (for example sexual crimes, murder, drug offenses and serious violence and robbery).
Any remarks on the certificate must be included as part of the overall suitability assessment of the couple. An individual assessment must be made by the treating doctor in each single case.
You can apply for a police certificate electronically or by letter. The certificate is valid for 3 months and must be attached to the application form.
Criteria and priorities for being accepted for treatment
The Biotechnology Act requires that an assessment be made of the couple with regard to whether they are medically and psychosocially appropriate.
The couple must be married or cohabiting in a marriage-like relationship.
The woman should not be older than 38 years of age at the time of application, and the man should not be older than 55 years. According to the Norwegian Directorate of Health's priority guidelines for gynecological diseases, one does not have the right to health care in the specialist health service after 40 years.
The couple must be psychosocially suitable to have children and a childcare certificate must be submitted
Women with chronic diseases that may get worse during a pregnancy, or where pregnancy can lead to serious complications, will be given special consideration.
The woman should have a Body Mass Index (BMI) <32 at the time of application. At the start of treatment, the woman should have a BMI <30.
The couple must be a compulsory member of the Norwegian National Insurance Scheme (Folketrygden).
In couples where the man has been sterilized, we first recommend that you try recanalization / reversal of the procedure. If the couple does not achieve pregnancy, they can be referred for treatment.
In the event of a chromosomal defect or hereditary conditions in one of the parties, treatment shall only be accepted after genetic guidance and an insignificant increase of the chance that offspring will have malformations on a genetic basis.
If one of the parties does not have children (regardless of how many children the partner has).
If the couple already has a child together.
Sibling trials in couples who have previously had a child through assisted reproduction. The woman should be <40 years old and have FSH and AMH in the normal range.
Pre consultation
Once the referral has been approved, you will get an appointment for a pre-consultation at the department. We know that people who come to us are in need of information, and we want you to feel well looked after, safe and heard through the entire treatment process. We hope that this information will be able to answer some of the questions that you may have. If you have further questions, please write them down and bring them along to your next appointment and we will do our best to answer them.
Please read through ALL information before meeting in the department. Requested blood samples must be taken in good time so that the sample results are available upon attendance.
At the pre-consultation you will both be seen by a doctor and a nurse and it is important that you let us know of any medication you are taking or if you have any allergies. In addition to this, the woman will have to undergo a gynaecological examination, and the man will have to submit a semen sample.
A nurse will explain the routines at the department and talk you through the normal treatment process for assisted reproduction. During the meeting with the nurse you will have to sign the assisted reproduction agreement (Agreement on assisted reprodction at pre-consultation) that you should print out from our website. You will find the agreement under “pasientskjema - forsamtale” on our website. Remember to bring ID as you will have to show it in connection with signing the agreement. You will also be taught how to use the syringes for self-injection to be used in treatment. If everything is in order, we will then agree on a method and a schedule for further treatment.
The man may choose whether to produce the semen sample at home and bring it to the unit, or produce it in a private room at the unit. If the semen sample is produced at home, it should be submitted to the unit no more than an hour later and should be kept at body temperature. When producing the sample, no more than two or three days should have passed since the most recent previous ejaculation.
The pre-consultation takes about two hours in total. If all test results are available and all criteria are met, a plan for starting treatment will be drawn up. The time for starting treatment will, among other things, depend on the capacity of the unit and the woman's menstrual cycle.
When you want to report that you have had a period, you can contact us at helsenorge.no or by telephone 55 97 42 00 . The unit for assisted reproduction uses messages on helsenorge.no as a form of communication with patients.
You log in to helsenorge.no and select «Health contacts»/”Helsekontakter”. There you will find "Ass. Befruktning" and can select "Write message"/”Skriv melding” to enter your questions and send directly to the unit.
Treatment
Consent to treatment
You will need to sign a consent form prior to treatment. You should therefore always bring your ID when you visit the unit. There are various treatment protocols in connection with assisted reproduction. We distinguish between long and short protocol. The treatment is adapted to each woman and couple.
1. Short protocol
Stimulation of the ovaries is given in the form of syringes that are injected daily in the stomach for about 10 days. You do this yourself. The stimulation usually starts on the second day of the menstruation cycle.
2. Long protocol
This protocol involves pre-treatment with nasal spray before starting hormone stimulation, as with short protocol. Nasal spray is used daily throughout the treatment.
Treatment plan
You will receive your individual treatment plan when the starting week of your treatment is set. You can find the plan as a nursing note in your patient record at helsenorge.no.
Prescriptions
The prescriptions are issued electronically, and the medications can be obtained from any pharmacy in Norway. The prescriptions are activated when you go to a pharmacy in person, and you will have to present ID. The pharmacy at the hospital, Haukeland Sjukehusapotek, has the various medications used in the treatment in stock. At other pharmacys the medication must be ordered at least one week prior to the treatment start. If you wish to check whether you have been sent an e-prescription, or what type of medication the doctor has prescribed, log onto helsenorge.no. Do not hesitate to contact us if you are unsure about anything.
We follow the development and growth of the follicles / egg sacs using ultrasound examinations. Based on these examinations, the doctor assesses how long the hormone treatment should last.
Ovulation injection
The ultrasound will allow the doctor to see when the follicles have reached the desired size. Once this has been confirmed, you will be notified of when to inject the ovulation stimulant. It is very important that you take your ovulation injection at the right time, in the evening 1.5 days before egg retrieval.
In vitro means outside of the body. This treatment involves the retrieval of eggs from the ovaries and fertilisation of these using sperm from the partner. Fertilisation takes place at our laboratory. This method is most often used when the man has a normal semen sample.
This method is used for patients with reduced semen quality, or where IVF attempts have failed. Just like IVF, this method involves retrieving eggs from the ovaries. However, this technique involves the direct insemination of sperm into the egg using a thin glass syringe. One is not guaranteed fertilization using this method, even if one has injected a sperm into the egg.
Insemination is a simple method of assisted reproduction where fertilization takes place inside the woman's body in a natural way. The sperm is inserted directly into the uterus with a thin catheter. In this way, the sperm cells get some help on the way to the egg cell at the time of ovulation.
Insemination with the use of own semen may be suitable in couples where the cause of infertility can not be explained after examination, where the man has slightly reduced sperm quality or whether it is difficult or not possible to have intercourse. Before insemination, the sperm sample is purified and concentrated, so that you get an increased number of good, motile sperm.
Lesbian couples are currently unable to receive treatment from us. The Department of Reproductive Medicine at Oslo University Hospital offers sperm donation to lesbian couples, and is currently the only operational public sperm bank in Norway. (Lenke til OUS, reproduksjonsmedisinsk avdeling: https://oslo-universitetssykehus.no/avdelinger/kvinneklinikken/reproduksjonsmedisinsk-avdeling)
If egg retrieval results in a surplus of embryos of a good quality, these can be frozen and stored for use at a later time. You will then receive a message on helsenorge.no after egg retrieval stating the number of embryos that have been frozen and a brief explanation of how to proceed in order to make use of these for future treatment. Embryos can be stored at the unit until the woman turns 46.
Thawed embryos can be transferred during a natural or hormone-regulated cycle, depending on whether or not the woman is experiencing regular menstruation with ovulation. Any stored embryos will normally be used before retrieving any new eggs from the woman.
This technique is applied in cases where no motile sperm are found in the semen. The doctor will retrieve sperm directly from the testicle under local anaesthetic. This method is used both for diagnosis and in connection with the actual assisted reproduction. ICSI will be used as the method of fertilisation in connection with assisted reproduction treatment.
Egg retrieval
On the day of egg retrieval, you must show up at the Section for Assisted Reproduction in the morning at the agreed time. Here, both of you must sign an agreement on treatment and present an ID card. You will receive brief information from the nurse, and the woman is assigned a bed. If you both want, the man can be present during the procedure.
Woman
Eat a light breakfast without coffee
Take painkillers 1 hour before the appointment. These are handed out at the ultrasound check where the egg retrieval day is determined. If you have had an ultrasound out of town, the medicine can be picked up at the unit the day before the egg retrieval, or taken here at the unit upon arrival. You can not drive a car this day!
Man
Deliver a semen sample, either which you take home or which you take when you arrive at the unit.
We do not recommend having intercourse in the last days before egg retrieval.
The woman is followed to the toilet just before the procedure
You will receive local anesthesia in the vagina which is given by the doctor just before the egg retrieval starts.
The actual egg retrieval takes 15-20 min.
The degree of pain at the egg retrieval varies from woman to woman, but most people describe the pain as menstrual-like pain that radiates to the lower back.
If you both want, the man can be present during the procedure.
You must stay in the unit for observation for ½-1 hour before you can go home from the hospital after the egg retrieval.
Some people experience pain in the abdomen the same afternoon / evening, but there is usually enough relief in Paracet and a hot water bottle. You should not use Ibux or Voltaren due to the increased risk of bleeding.
We can give you sick leave for three to four days after egg retrieval.
The woman must be followed home after she has been through the procedure. In addition, she should not be left alone for the first few hours after you return home, since she has been given various painkillers.
The day after egg retrieval, the laboratory will call you approx. at 13.00 (Saturdays approx. 10.00) to inform about how many eggs have been fertilized. At the same time, you will be given an appointment for when we will insert the fertilized egg.
We do not recommend having intercourse in the last days before, and for two weeks after egg retrieval. The woman should also not use a tampon or swim in a pool, bathtub or sea for the first two weeks after egg retrieval. Due to the enlarged ovaries, reduced physical activity during the same period is recommended.
We will administer progesterone treatment after egg retrieval. Progesterone is a hormone that helps rebuild the mucus membrane in the uterus and prepare it for receiving an embryo. It is common with increased discharge and that residues of the medicine come out again.
On day 2-5 following egg retrieval, we will transfer a fertilised embryo. This process will involve the following:
The woman is lying on a regular gynecological examination bench.
We insert a thin catheter through the vagina and into the uterus, where the egg is placed.
This will normally take about 15 min.
As the procedure is not painful, you will not be given any painkillers in connection with the embryo transfer.
Twin pregnancies are associated with an increased risk of fetal death, premature birth and low birth weight. Many serious complications occur more frequently in twin pregnancies than in normal pregnancies, such as preeclampsia and diabetes.
Our goal is to give childless couples a healthy child to term. We started our "single embryo transfer" policy in 2005.
This means that we preferably put in one embryo per treatment. Our pregnancy rate has remained stable, but the twin rate has fallen below 5 percent.
Follow-up
Pregnancy test
We want you to take a blood test 14 days following embryo transfer, even if you have experienced vaginal bleeding. Some women experience period-type pains and spotting in the space of these two weeks but may still be pregnant.
If you have this blood test taken at the laboratory at the Women's Clinic before 08:00 you will get the result the same day. If you have the test done at your GP’s clinic or anywhere else, you will have to wait until at least the following day. One of our nurses will call you to let you know the result of the test. If the pregnancy test is positive, you will be given an appointment for a vaginal ultrasound about five weeks after the embryo transfer took place.
If you live outside of Bergen, you can have the vaginal ultrasound performed by a gynaecologist where you live. If you do so, it is important that you and/or the gynaecologist notifies us of the result of the ultrasound.
All further follow-up will be handled by your GP.
If the pregnancy test is negative, you must decide whether or not you want further treatment with us.
You must have 2-3 menstruations before we can start a new treatment depending on what type of treatment you have just undergone, what type of treatment you are now going into and the capacity of the unit.
If you have had a long protocol and are going into a new long protocol, we can use your 2nd cycle. If you go from long or short protocol to short protocol, we can use your 3rd cycle. If you have eggs in the freezer, the time of transfer varies depending on whether you are going to use your natural cycle (3rd bleeding), or control your cycle with estrogen tablets (2nd bleeding). What type of treatment we decide on, depends on whether you have a regular cycle with ovulation or not.
There is no problem with taking a longer break between treatments unless age or hormone tests indicate otherwise. It is important for the result that you are motivated and mentally ready for a new treatment.
Many people have questions about how much it costs to go through treatment with assisted reproduction in a public hospital.
The preliminary examination is counted as a normal specialist outpatient rate, and you will have to pay a deductible. This applies to you both.
Ultrasound examinations, extra syringe training and controls during the course of treatment are counted as normal specialist outpatient rates. This usually only applies to the woman.
In the case of freezing attempts, you must pay a deductible, both for the ultrasound examination and the embryo transfer. The insertion of thawed embryos is part of the treatment from which the egg originates and is therefore not counted as a separate treatment.
You will receive an invoice after the consultations. If you have a deductible exemption card, you must bring this and show it before the appointment.
The Norwegian government will partially reimburse the cost of up to three attempts at assisted reproduction per child.
The couple will have to pay a deductible of NOK 1,500 to the Women’s Clinic for each completed treatment. A complete treatment must involve egg insertion.
This amount cannot be entered on the deductible card.
Expenses for medicines that exceed the amount limit set by HELFO are covered by the National Insurance Scheme.
For updated information on coverage of expenses, see the website of helsenorge.no
Remember to take care of all receipts. They must be sent to HELFO within six months after you have reached the amount limit. You must also submit a confirmation of the treatment (doctor's statement). You usually get this from us the same day as the egg insertion takes place.
For most people, undergoing assisted reproduction is very stressful psychologically, so it is best to be prepared for this. Our experience is that a positive attitude is important in order to be able to manage the treatment process. However, it is also important to be realistic and aware that, unfortunately, not all treatments have a successful outcome. It is important that you are understanding of each other’s potential reactions. You should try to carry on with your day-to-day life as usual, even though the treatment should and will be at the forefront of your minds.
We will be happy to help should you have any questions over the course of the treatment. We will also invite you to attend a summarising meeting with the doctor after your final attempt if you wish. Please know that you are always welcome to contact us.
Although rare, abdominal cavity bleeding is a potential side effect of egg retrieval, which is why we want to keep you under observation at the unit for ½-1 hour following egg retrieval.
Infection is a rare but possible side effect of egg retrieval. Infection symptoms will generally appear within three days of egg retrieval and can include persistent and increasingly severe abdominal pains, in addition to fever. You should see a doctor as soon as possible if you experience any such symptoms.
Allergic reactions as a side effect of the treatment medication are rare. Contact the unit if you experience symptoms of allergic reaction.
Possible side effects of medication are listed in the patient information leaflets accompanying each medication. Medication used in connection with assisted reproduction treatment causes a controlled over-stimulation of the ovaries, overriding your own menstrual cycle. The most common side-effects are:
Synarela nasal spray: Head aches, hot flashes, night sweats and mood swings.
Hormone stimulation: Pain, nausea, abdominal bloating, a heavy or prickly sensation in the lower abdominal/genital area, slight weight gain and increased vaginal discharge.
Some women react strongly to hormone stimulation treatment, resulting in the formation of an excessive number of follicles. Treatment may have to be discontinued in this event. This means that we will either cancel egg retrieval or freeze all the fertilised eggs and perform embryo transfer in a later cycle.
Hyperstimulation can occur from the point that you inject the ovulation stimulant to up to one week following embryo transfer. Contact us if you experience any of the following symptoms: bloating and pain in the lower abdominal/genital area, nausea, vomiting, diarrhoea or breathing difficulties. This may, in extreme cases, require admission to hospital.
If you are experiencing symptoms of hyperstimulation, call the Womans Clinic at (+47) 55 97 42 00 or contact your nearest hospital.
