At Tilly, we’re passionate about helping anyone who is struggling to have children. Together with Linn Heed from Coupleness, we’ve put together the guide "Doing anything to have a child; how do you take care of your relationship?" which contains a number of concrete tips for couples facing infertility.

2. Elin - what do you like most about Mario?

His humor. We laugh a lot together and that's really important, especially when you go through something difficult.

3. Mario - what do you like most about Elin?

Boring perhaps, but the answer is the same for me. Not a day goes by without us making each other laugh and that's absolutely magical! 

4. When did you realize that having children was not going to be easy? Did you react the same way? 

After about nine months, Elin began to suspect that something was wrong. She started reading up on how how we could optimise our fertility on our own while we waited to get help from the health system. Each cycle and round of PMS became worse than the last because they all meant that we hadn't become pregnant - again. After a year and a half (it took a little longer due to the outbreak of the pandemic) we finally got to do a fertility investigation at the Reproductive Medicine Center in Malmö. They told us that Mario didn't have any sperm in the semen, so-called azoospermia. It was a huge shock for both of us. Mario felt that life was drained of all meaning and both of us just felt it would never work out for us. We would never have children. It took a while to get past that shock and eventually we began to look into which help was available.

5. Fighting for a child can mean a lot of stress and grief. What are your best tips for supporting each other? 

It's been really special to struggle with infertility while there is also a pandemic going on in the world. Infertility is one prison and the pandemic yet another. Still, we tried to stay activated and to continue to make fun memories. Of course, that's easy to say and harder to do - we were also very sad and talked to a lot to each other about that.

We went to the summer cottage and renovated, we started a sauce club and cooked us through all the classic sauces, and we went on a road trip. Our best tip is really to try to create great memories. If, for example, a day is filled with anxiety - accept it but try to do one little thing like driving to the ocean for a dip or have a cup of coffee in a park. Then you can remember that one little happy thing instead of the anxiety even though you actually cried on the sofa most of the day.

Another tip is to make time for walks that you dedicate to talk about the fertility process, your feelings around it and your relationship.

"It's easy to assume you understand how the other one is feeling because you know each other so well, and therefore forget to ask. But a question can open so many thoughts and bring you closer together."

6. Is there anything you've felt completely different about along the journey and how have you handled that?

More than feeling differently, many times we have been at different phases of our process. When something felt ok for Elin, Mario struggled and vice versa. 

It can be both positive and negative not to be synched. Positive in the sense that you can support the one who is feeling down, negative because it's easy to come off as you don't understand. You simply have to try to really listen and understand each other, let each other feel anything.

Did you know that couples who go through multiple fertility treatments are up to three times more likely to separate? Scheduled sex, feelings of inadequacy and shame, and different ways of dealing with with the challenge are some of the problems that many face. Elin and Mario tell us about their journey and share their tips for how to nurture love and a healthy relationship when you're forced to fight infertility and IVF.

Elin & Mario - How to take care of the relationship when you struggle with infertility

Almost 3 years. And we've been doing IVF for half of that time. 

2. Amanda: What do you like most about Magnus?

Magnus is an incredibly warm and kind person, and he's truly great to talk to. He's a really good listener, never judges and gets along with just about anyone. He's also very funny and make people around him feel at ease. One thing that's been important throughout our IVF process, is also his ability to focus on the way forward and what he's grateful for, regardless of the situation. He makes me feel seen, valued, and loved every day.

3. Magnus: What do you like most about Amanda?

There are  many things I like about Amanda, one being her ability understand other's perspective and situation.  That's not only very attractive, but also reassures me that we can always sort things out between us. I also love is her social skills. She can have fun with anyone, but also love deep conversations where she's equally curious about others as open with her own experiences. Also, Amanda's mischievous side should not be forgotten. I love her sarcastic humor as well as fiery outbursts. The contrast between her serious and integrity side and her humorous and mischievous side is absolutely amazing!

4. When did you realize that having children was not going to be easy? Did you react the same way?

We knew from the beginning that children would come easy for us. I (Amanda) have known since I was about 20 years that I would need help if I ever wanted to become a mother. 

I didn't have a period and when I go tested, they found a sky-high FSH value (100 in several measurements). They first suspected POI (premature menopause), but then they saw that I had tons of follicles on my ovaries so that wasn't it. Over a year, I did a large number of examinations, from brain CTs to lots of blood tests, but they couldn't find an explanation for my absent period and high FSH values. 

I met Magnus when I was 31 and it was the first time I felt that I met someone I wanted to start a family with. Already on the second date, the question came up and I told him about my challenges. At that point, Magnus was mostly happy that I shared this with him and I don't think any of us really understood the width of my issues and what an IVF journey would mean at that point. 

We continued to date, and partially because we knew we needed help, we started planning for real quite quickly into the relationship. After about 8 months I (Amanda) contacted my diabetes clinic to understand if there was something I had to consider since I have type 1 diabetes. And a couple of months after that, I went off the pill (which I was on due to low estrogen levels). 

For the first 3 months, we both had some kind of naive hope that it might work without any help. But then I read my journal and started to understand what my diagnosis means for real, and only then did I understand that we should seek help as soon as possible. After three more months we got an appointment at a fertility clinic and go to start IVF immediately. 

At that first meeting with the clinic, when the doctor told us about our odds and that we may not succeed with my eggs, is when it hit us both for real. I (Amanda) felt afraid and sad, I gelt guilty and I guess some kind of suffered from fear, sadness, guilt, and a kind of existential anxiety. There were many questions about what life would look like without children and I very much felt like less of a woman and that Magnus deserves better. I started to educate myself and became very focused at "fixing" the problem as soon as possible. I ended up in a mild depression for a short period of time, and I was very jealous of my pregnant friends making me feel isolated. 

Magnus did not react as strongly, partially because the issue was not his in the same way. For him, the focus was to support me (Amanda), and he tried to stay strong in front of me not t make me feel more guilty. 

After a few months, we got out of the worst crisis and grief and I started to feel better. We found our way of handling the whole thing and some kind of acceptance. Now we share both joy and sorrow, and Magnus dares to show all his feelings which is so much better. 

It may sound obvious, but we think the most important thing is to talk to each other, and share all thoughts and emotions. Don't ever take for granted that you understand what the other person feels, it's always better to ask. 

"When you're not feeling great, it's important to feel that your feelings are ok, to feel seen. For me (Amanda), it's been very important that Magnus has always tried to understand even when he hasn't felt the same way." 

And remember to share positive emotions too - like when you feel joy or hope. It's been really important for us to actively verbalise what we are grateful form and to continue to do things we like and that gives us energy. Like arranging romantic dinners, working out together and travelling. To touch each other, sit close to each other on the couch, and continue to have sex has also been important to make us feel like a team. 

Lastly, we've felt it's been incredibly valuable to talk to people around us about what we're going through. One person can never give you everything you need, and it's important to have other people to talk to as well. 

6. Have you introduced any new routines that have helped you?

We've made sure to ask each other how we feel - a lot. And we've made a habit out of booking a small trip close to the test date - to give us time to be together and either celebrate or mourn together. 

Another thing is that Amanda always calls Magnus immediately after each visit at the fertility clinic to debrief Magnus about how it went. In this way, Magnus has felt a little more involved even though he wasn't allowed to come along due to covid. 

7. Is there anything you've felt completely different about along the journey and how have you handled that?

“We have very different experiences of guilt. I (Amanda) have felt very guilty because I'm the reason we need to go through this - a feeling that Magnus hasn't experienced. We have handled this by talking openly about it and simply allowing and accepting the guilt. Magnus has listened, confirmed that he understands and that it’s ok to feel this way. And only after that, he's said that I don't have to worry because I'm the one he wants to live with, and that he knows that our issues are beyond my control so he doesn't see it as being my fault at all. Much better than just saying “Don’t feel that way”.”

There is a lot of talk that having children can pose challenges for relationships. But strangely enough, there is almost no discussion at all about what a challenge it can be to try to have children, and what that can mean for the relationship. This is despite the fact that there is a lot of research on the high stress levels infertility causes and the pressure it puts on the relationship. In this article, Amanda and Magnus tell us about their journey and how they take of each other throughout all their challenges. 

Amanda & Magnus - IVF and relationship challenges 

2. Mayo Clinic: What ovulation signs can I look out for if I'm trying to conceive

4. Ovulation: What is it, and how do I know when I'm ovulating?

Ovulation should happen in a healthy menstrual cycle and if you're trying to have a baby, it's a crucial part. In fast, ovulation issues is the most common problem for women struggling to conceive. 

You can get pregnant if you have sex on about six days in each cycle - five days before ovulation (because sperm can "wait" for an egg in your fallopian tubes) and the day you ovulate. After ovulation the egg only survives around 24 hours. 

Understanding your cycle and ovulation can therefore help you if you want to get pregnant, but also if you want to avoid it. For example, getting pregnant ten days before or four days after ovulation is completely impossible. 

But how do you know when you ovulate then? If you have a regular menstrual cycle, you will most likely ovulate 11-15 days before your next period. Some women may feel a slight pain in the lower abdomen during ovulation, but most of us feel nothing and need other tools to identify it - we will go through some of the in this article. 

Remember - all bodies are different and the best way to get to know your body's unique signals is to track them over several cycles.

Your period is usually sign that you've ovulated, especially if you have a regular cycle. With a functioning cycle ovulation issues are rare. Still, menstruating is not a 100% proof of ovulation because you could build up a uterine lining even through an egg was never released. If you have an irregular cycle, it could be a sign that something is not working as it should and it it is then particularly important to start tracking your ovulation to understand it better.   

Your body temperature is affected by various factors, including which phase of your menstrual cycle you're in.  It's the hormonal changes that occur throughout the menstrual cycle that cause it to change. 

After ovulation the ruptured egg follicle produces progesterone, and this hormone affects the heat generation in the body causing your body temperature to rise. If you become pregnant, the progesterone level and your temperature will remain elevated. If you don't get pregnant, the progesterone level will drop and so will your temperature. Your temperature is at its lowest when you're menstruating and the day before ovulation and then increases immediately after ovulation. To confirm that ovulation has taken place, the temperature rise must last for three days. 

You measure what is called basal body temperature, which is the temperature you have when you are completely rested (after at least 5 hours of sleep) and you measure it in the morning before you've had time to get out of bed. You need to use a specific basal thermometer that shows two decimals as these changes are small (0.2-0.5C). And - this method requires that you measure temperature at least 5 days a week throughout the menstrual cycle to be able to follow the changes.

As we mentioned above, ovulation leaves a ruptured follicle that produces the hormone progesterone (and a bit of estrogen). Your ovaries are filled with these follicles that store your egg cells until ovulation releases them. If you hear about the "corpus luteum", this is another word for this ruptured follicle.

So basically - a high progesterone level is a proof that ovulation has taken place. It can give a clearer answer than measuring temperature (the effect of the rising progesterone levels), but it's more complicated to measure as a blood test has to be used. Some home tests which could make it easier have also started to appear on the market though,

It's important ot measure progesterone on the right day; 7 days after ovulation. Often, women are told to test on day 21 of the menstrual cycle, but this is based on that all women have a 28 days long cycle and ovulate on day 14 which isn't true for many of us.  You need to track your cycle to understand when you ovulate. 

LH stands for luteinizing hormone, which is secreted by the pituitary gland in the brain just before ovulation; about 24-48 hours before). The ovulation tests (urine tests) that are found in most pharmacies and grocery stores look for this change in LH. 

When a test shows a peak in LH, you can assume ovulation will happen within 24-48 hours, but it's not a 100% proof it actually will happen.

Some ovulation tests will not only show the LH peak, the day of peak fertility, but also a few fertile days leading up to this. That's because these tests also measure estrogen which start to rise earlier than LH. And since your'e fertile a few days before ovulation too (read the intro above if you've forgotten why), these are considered fertile days as well. 

Throughout your menstrual cycle, your cervical mucus changes appearance and texture. Again, due to the hormonal changes that happen in your body. So if you learn to interpret the changes, it can be a useful way to determine when ovulation is about to happen and when you're fertile.

It's really quite logical when you learn because different types of mucus are more or less "sperm friendly".

Just before your period and after your ovulation - when you're not supposed to become pregnant, your mucus is creamy (like body lotion) or thick and sticky. Makes sense it's difficult for sperm to get through this, right? 

In contrast, as ovulation approaches, the rising estrogen levels makes mucus thinner and watery, which is called fertile mucus. And then, just before ovulation, you often get mucus that looks like a raw egg white and is elastic/stretchable; it creates strings between your fingers if you hold it up (you can google pictures on this if it sounds weird). This is the most sperm friendly and thus fertile mucus! 

Another way to understand if your ovulation is on its way is to monitor the development of your ovaries via ultrasound. 

By doing a number of ultrasounds, one can identify that a follicle is growing Usualy sevreal to start with, and then one dominant) and , later, that it has collapsed. But this is of course complicated and time consuming, and is normally only done if you undergo a fertility investigation or treatment.

Ovulation - how do I know if it's on its way (or that I've had it)? Ovulation is a prerequisite for you to be able to get pregnant, but understanding when ovulation is underway or has happened is not always so easy. Learn to interpret the signs.

Ovulation - How do I know when I'm ovulating?

We often hear that miscarriages are common, and that’s true, unfortunately. That doesn’t make them any less stressful though. A miscarriage is often tough and understanding what has happened, as well as when it’s time to seek help, is important to feel a little more in control.

Although they all mean the same thing - that unfortunately the pregnancy doesn’t lead to a baby - there are different types of miscarriages and therefore also different reasons. Having one miscarriage is very different from having several - not only emotionally but medically too. So, let’s go through the different types of miscarriages...

An early miscarriage happens in the first trimester, during the first 12 weeks of pregnancy. It’s estimated that 10-20% of all pregnancies end in a miscarriage and this is by far the most common type. After 12 weeks, the risk for a miscarriage drops significantly.

An early miscarriage can either be spontaneous, meaning you start bleeding, or a so-called missed abortion (MA) where the bleeding doesn’t start by itself (at least not for a few weeks) after the fetus has died. Instead, the miscarriage is discovered via an ultrasound.

Is bleeding always a sign of miscarriage? No, bleeding is not uncommon during pregnancy for a range of reasons - most women who experience vaginal spotting or bleeding in the first trimester go on to have successful pregnancies. However, if you experience continuous bleeding and/or cramping in your abdomen or lower back you should visit a doctor.

A late miscarriage happens after the first trimester. It’s much less common than early miscarriages, estimated to happen in 1-2% of pregnancies. When you have a late miscarriage, it entails more than bleeding - since the fetus is much bigger (depending, of course, on which week it stopped growing) you will need to go through labor and giving birth, which can be very distressing. Sometimes labor starts spontaneously, or it needs to be induced when the miscarriage has been discovered via ultrasound.

If you’ve experienced more than 3 consecutive miscarriages, you’re one of the unlucky ones diagnosed with “recurrent miscarriages”. The exact definition varies from country to country. In some countries two consecutive miscarriages are considered recurrent, in some they don’t have to be consecutive.

In any definition, it’s an uncommon diagnosis, affecting around 1% of women, but when you’re a part of it, statistics don’t matter much. Please keep close to your heart that a clear majority of those suffering from recurrent miscarriages go on to successfully carry a pregnancy to term. However, the road there can be difficult because we don’t know that much about the cause of this condition and many are left with no explanation.

A chemical pregnancy is an early pregnancy loss that occurs shortly after implantation. It happens before an ultrasound can detect a fetus, but not too early for a pregnancy test to detect levels of hCG.

Often, the woman doesn’t even know that she’s pregnant this early on and the bleeding is thought to be an ordinary menstruation. However, if you go through IVF or if you're just trying to actively conceive you probably test early; a chemical pregnancy is then when you start to bleed just a few days or a week after the positive test.

Since early, late and recurrent miscarriages are such different things, the potential causes also have to be looked at separately.

The most common reason for early miscarriages is that the fetus has abnormal chromosomes, it’s basically not healthy. Since early miscarriages are the most common type of miscarriages, it is the most common reason for miscarriages in general.

“Abnormal chromosomes” may sound serious, but basically not all eggs or sperms have normal chromosomes. This is one of the reasons you don’t become pregnant every time you have sex when you ovulate even if there’s no issue out of the ordinary; unhealthy eggs and sperms most often don’t fertilize or implant at all. If they do, a miscarriage will happen. (Of course, there’s also chromosomal abnormalities that are not serious enough to always cause a miscarriage too, e.g., Trisomi21 also called Down’s Syndrome.)

When doctors say a miscarriage is “bad luck” (not very comforting, we know…) this is what they mean… you were unlucky enough to become pregnant with one of those eggs and/or sperm that didn’t have normal chromosomes. In other words, there is no indication that there’s any issue which would cause you to miscarry again.

There are, however, several factors that increase your risk of having a miscarriage due to chromosomal issues:

Maternal age. With age, the number of eggs with normal chromosomes becomes smaller which makes it both more difficult to become pregnant and increases risk for Miscarriage. Read more about egg quality here.

Smoking. Eggs and sperms are cells, and their quality is harmed by everything that causes so called oxidative stress, such as seen in smoking. Smoking, in other words, causes more abnormal eggs and sperms.

There can of course be other reasons for an early miscarriage than abnormal chromosomes; thyroid imbalances, hormonal issues, and blood clotting problems to mention some. But since the absolute majority are caused by chromosomal issues, other reasons are normally not investigated until you have suffered several miscarriages in a row (the risk of chromosomal issues being at play decreases the more miscarriages you go through) unless you already know you have an underlying health condition. You can read more about miscarriage investigations that are done after several consecutive miscarriages here.

Late miscarriages can be due to chromosomal and genetic factors just like early miscarriages. But compared to early miscarriages, late miscarriages more often have another reason. Potential reasons are:

You can read more about each of these potential causes as well as recurrent miscarriages in our app. There's also a checklist to bring to your doctor's appointment to make sure you get a correct investigation in case of recurrent miscarriages. 

We often hear that miscarriages are common, and that’s true, unfortunately. That doesn’t make them any less stressful though. A miscarriage is often tough and understanding what has happened

IVF add-ons such as PGT-A, ERA and immunological treatments could be a great option for you, helping you to improve chances. And sometimes your problem may be that your doctor doesn't  recommend add-ons at all; perhaps the clinic doesn’t offer them due to tradition or regulation. But it also happens that (profit-driven) clinics recommend add-ons even though research doesn’t support that it will improve your chances. Most add-ons are recommended for certain patient groups, not as a standard treatment. 

When all you want is a solution, you want to try it ALL. But costs (financial and physical) may not always outweigh the potential - at least at every stage of the treatment. No matter how frustrating it is, treating infertility often is a “trial and error” process where you have to try a few things and learn along the way. 

Having said that, there’s no right or wrong decision; only you and your doctor can agree on what the next step should be. But no matter the outcome it always feels better if you’ve asked the right questions to be able to make an informed decision. So here’s a few tips on questions you can ask to have a better discussion with your doctor. Bring this check-list to your appointment...

1. Why do I need this add-on? Do you recommend it to all patients or are there certain things that make it suitable for me?

2. What will happen if I don’t add this to my treatment or if I wait a while?

3. Are there any alternatives I should know about?

4. Are there any risks or side effects involved? How likely are they to occur?

6. In your opinion - do the potential benefits outweigh the risks and costs for me?

This checklist and many other are found in Tilly's app - bring them to your doctor's appointment and tick the questions you've asked. Feeling in control can make a big difference 💪

Checklist: Questions to ask when your doctor suggests an IVF add-on

An individual miscarriage is unfortunately quite common and is most often due to the embryo having abnormal chromosomes - something you can't do anything about. But when several miscarriages occur in a row, you may need treatment and identifying the underlying cause is therefore crucial.

Dr Hassan Shehata runs two clinics in UK that specialise in helping women who suffer from recurrent miscarriages or repeated (IVF) implantation failures - Center for reproductive immunology and pregnancy. He is a Consultant Obstetrician and Gynaecologist and a subspecialist in Maternal Medicine, and has managed and treated over 5,000 patients at the CRP Clinic with 80% success rate.

Most individual miscarriages are due to the fact that the embryo was not healthy; it didn’t have normal chromosomes. No one has only healthy eggs and sperm, so when the doctor says your miscarriage was "bad luck", he/she basically means that you were unlucky enough to get pregnant with an egg and/or a sperm that was not chromosomally normal.

If you have several miscarriages in a row, the probability that it's "bad luck" decreases, and in the event of more than three miscarriages in a row, you are diagnosed with what is called "recurrent miscarriages". I that case a miscarriage investigation should be done to try to identify the reason, and if tests show anything, treatment is available. But the fact is that classic miscarriage investigations quite seldom identify an issue. In other words, the cause of most cases of recurrent miscarriages remain undiagnosed.

Through his research, Dr. Shehata has established that the factors tested in a classic investigation only cause a minority of cases. So there are basically gaps in our knowledge and research; we just don't know that much about recurrent miscarriages yet.

Why is the immune system relevant to consider?

That the immune system plays a role during pregnancy is well established. If you receive a donated  kidney or heart, you must take immunosuppressant drugs for the body not to repel these genetically foreign body parts. But even though an embryo always consists of 50% genetically foreign material from the man (and sometimes 100% when donated eggs are used), the generally body doesn’t reject it. The immune system thus adapts in one way or another to support a pregnancy. 

So a logical theory is that if a woman's immune system somehow doesn't work as it should, her body could repel embryos causing miscarriages. The immune system could be overactive, there could be an abnormal presence of different antibodies and/or the woman could have an autoimmune disease.

The view on to what extent the immune system and miscarriages are related and what we can do about it, varies from country to country. In som countries (e.g. Sweden) doctors don't think we know enough to do immunological testing or treatment while it's common in many other countries. Dr Shehata is an example of a doctor who does research on the topic and also treats women with immunological issues at his clinic.

1. What immunological investigations and treatments do you do in case of repeated miscarriages?

In the event of repeated miscarriages, I do six different investigations that can lead to different treatment strategies.

Some types of NK cells are found naturally in the uterus, but another group of NK cells (CD16 +, CD56 +, CD69) can cause miscarriage when they attack the uterus. NK cells can also prevent embryos from attaching during an IVF treatment. This can be treated by calming these cells with immunosuppressant, reducing their effect. 

Elevated levels of TH1 / TH2 cytokines can lead to a miscarriage. Cytokines are small proteins that are crucial in controlling the growth and activity of other immune system cells and blood cells, and affect the growth of all blood cells and other cells that help the body's immune and inflammation responses. The activity of cytokine cells can be TH1 (pro-inflammatory) or TH2 (anti-inflammatory). The pro-inflammatory cells are needed when the blastocyst is to attach in the uterus and blood vessels are formed between the embryo and the woman, but if they become too many or remain for too long, they can instead become harmful. The treatment to inhibit this is different types of immunosuppressive drugs.

People who have the autoimmune disease SLE have ANA, and may have an increased risk of miscarriage. However, people who do not have SLE can also have an immune system that behaves in a similar way. Therefore, we investigate whether women have these antibodies, and if it's the case, treat them with Prednisolone (cortisone).

In case of thyroid disfunction, you're often considered treated if you have antibodies against the thyroid gland (TPO-ak, Tg-ak or TRAK) and the right dose of a medicine (e.g. Levaxin). In my opinion, the risk of miscarriage is greater if antibodies remain, so I give further treatment with Prednisolone (cortisone).

These antibodies are found in those who have celiac disease (gluten allergy). Even if you don't show symptoms of gluten intolerance, these antibodies can occur and be the cause of repeated miscarriages. It's treated with a lifestyle change that involves a gluten-free diet.

Anticardiolipid antibodies (APS) - "Sticky blood"

Anticardiolipid antibodies make the blood thicker and thus increase the risk of blood clots, especially in pregnant women, which can cause miscarriage both late and early. However, it is not a common cause of miscarriage (only 0.83% according to one of my  studies). The treatment entails blood thinners - a low dose of acetylsalicylic acid, which you start taking before pregnancy, and then injections of heparin.

2. Why are immunological causes of miscarriage still so debated?

Immunology is very complex if we talk clinical evidence. Even for general autoimmune diseases, tests very often don't deliver clear answers. For example, for a well-known autoimmune disease like rheumatism, tests only show positive in less than 20% of patients who carry the disease. Therefore, doctors have to look at symptoms like e.g. a swollen joint rather than just blood tests. And this makes it complicated when it comes to miscarriages and failed IVF attempts.

The lack of clear clinical evidence, is what complicates the debate. There is undeniably a strong correlation between pregnancy and the immune system, and although it has historically been seen as controversial to believe that the immune system can cause miscarriage, nowadays most people are convinced that there is a connection. The main debate regards how we test and treat, rather than why we test and treat. It's a discussion that will continue and the most important thing is that continued research is done within the area.

3. Is there an increased risk of miscarriages if you have rheumatism or another autoimmune illness? 

In general, yes, if you have an autoimmune issue then there is an increased risk of miscarriages and it’s important to be tested for the cells related to your particular illness. There are certain immune disorders that are particularly associated with a much higher risk of miscarriage such as Lupus Disease.

Briefly explained, an autoimmune disease means that the body attacks itself. Antibodies are present in the body to protect us from viruses and bacteria. They are formed by different types of immune cells. For people who have an autoimmune disease, the body's immune system instead begins to break down cells that we need. The immune system mistakenly believes that these cells are invaders in the body. 

About 5-7% of the population in the western world is affected by some type of autoimmune disease, and women are affected much more often than men. Examples of autoimmune diseases are type 1 diabetes, Hashimoto's (hypothyroidism / underactive thyroid), SLE (Lupus), rheumatoid arthritis (rheumatoid arthritis), celiac disease (gluten intolerance), Crohn's disease, Sjögren's disease and Addison's disease.

5. Can immunological disorders cause repeated implantation failure? 

Yes, implantation failure could be considered a very early miscarriage and if the issue is not the embryo or anatomical abnormalities it is worth looking into. 

6. Could a donated egg cause immune reactions from the body?

Recurrent miscarriages & Immunology - Q&A with Dr Shehata

When you step into the world of infertility and IVF, the amount of new things and terms you have to learn may make your head spin. So let’s go through some of the major acronyms that tend to come up when you meet your doctor or turn to Dr Google. 

IUI, or intrauterine insemination, is a fertility treatment in which your partner’s or donated sperm is being directly placed inside your uterus to facilitate fertilization. Sperms are “washed” to find the strongest ones and then injected through a catheter up through the cervix directly into the uterus,This is a cheaper and less invasive procedure in comparison to IVF. Sometimes ovulation is induced by medications such as Clomid or Letrozole, sometimes its done in a natural cycle. 

Invitro fertilization, commonly abbreviated as IVF, is a widely known technique to help people with infertility problems. At the simplest level it entails an egg being combined with sperm ‘in vitro’, i.e. ‘in glass’ (or today more accurately in a ‘plastic Petri dish’) outside of the body. For this to happen you take hormonal medications to stimulate follicle growth so that several eggs can be retrieved to be fertilised. 

A frozen embryo transfer, often abbreviated as FET, is a part of an IVF treatment referring to when a frozen embryo is transferred into your uterus. The embryo can come from a previous IVF cycle or donor egg cycle when it was frozen and to be thawed and transferred in a future cycle. (The alternative is a fresh transfer when an embryo is transferred in the same cycle as the egg retrieval.)

ICSI is an abbreviation for intracytoplasmic sperm injection, which is one of the IVF techniques used to improve chances in case of male infertility issues. A live single sperm, chosen by your embryologist, is directly injected into the center of your egg to be fertilized and then hopefully grown into an embryo that can be transferred to your uterus. (The alternative is to just place several sperm with the egg and let one find its way just like when fertilisation happens inside a woman’s body.)   

Physiological intracytoplasmic sperm injection (PICSI) is essentially ICSI with an extra step. It involves adding a special enzyme to the sperm to enhance insemination chances during an IVF treatment where there are  male infertility issues. The enzyme is called hyaluronan and is a natural compound in the body that attracts healthy strong sperm. The sperm binds with hyaluronan and then isolated to be used for ICSI.

TTC stands for trying to conceive is an abbreviation used on social media and fertility forums basically referring to people who are trying to get pregnant. 

Pregnant Until Proven Otherwise or PUPO is a common slang used on social media and fertility forums that describes your status after undergoing IVF and an embryo has been transferred to your uterus. Technically you are considered pregnant but this is not confirmed until the implantation has successfully happened. 

The two-week-wait (2WW) is the time (approx 14 days) between your ovulation and your next expected period.The term is very common between women who are trying to get pregnant (trying to conceive, TTC), especially those undergoing IVF, so it actually rather refers to the time between your ovulation and when you can take a pregnancy test.

Deciphering infertility acronyms: IUI, IFV, ICSI, PICSI, TTC… what do they all mean?

IVF or ‘In Vitro Fertilisation’ is one of the techniques that can help people who have fertility issues. In this Q&A our expert Dr Evangelia Elenis has responded to your questions about this treatment. Dr Elenis is an MD and PhD specialised in Reproductive Medicine. She is an affiliated researcher at Uppsala University with postdoctoral studies at Harvard Medical School. She is also a mother who has gone through IVF herself and has a strong passion for improving the patient experience. 

What is considered a normal fertilisation rate? And if it’s lower, is low sperm quality always the reason?

Average fertilisation rate, that is the proportion of mature oocytes that end up becoming fertilised by sperm, lies around 70% after regular IVF (conventional insemination). But rates down to 50% can be considered normal. It is when rates fall below 40% that most clinics use ICSI in order to improve pregnancy chances.  

A lower fertilisation rate can be the result of lower sperm concentration, quality or the origin of the sperm (that is depending if it is ejaculated sperm or after surgically extracting sperm from the testicles or the epididymis). But also issues with the eggs such as lower egg quality or a hardened, difficult to penetrate surrounding membrane called zona pellucida. Whether eggs are fresh or frozen can also play a role. So although sperm seems to account for most of the cases of lower fertilisation, it doesn’t seem to be the only factor that plays a role.

Will I lose eggs faster if I take fertility drugs that result in multiple eggs ovulating and releasing each month?

Although that sounds reasonable it doesn’t seem to be the case. IVF doesn’t lead to running out of eggs earlier and doesn’t bring on premature menopause.  Even in a normal cycle you lose more than the one egg you ovulate. What happens with IVF, is that by taking high doses of fertility drugs, such as FSH injections, all follicles that have started to grow during that cycle but would otherwise be wasted during a natural cycle can continue to grow and fully mature.  We can in this way make use of them with IVF. The remaining egg reserve is not affected negatively by fertility treatment.

More eggs is not always better! Large studies performed after thousands of IVF cycles show that pregnancy chances and live birth increase as the number of eggs retrieved rises. That is easy to understand since more eggs retrieved translates to higher chances for more fertilised eggs and more genetically normal embryos to transfer. However, that improvement reaches its peak when we collect around 15 eggs. When retrieving 15-20 eggs or more the pregnancy chances remain stable or somewhat decrease. The reason is not clear but one of the hypotheses is that more eggs produce higher estrogen levels; high estrogen in turn affects the uterine lining in a negative way and therefore the likelihood that the embryo will implant. Another hypothesis is that the large number of eggs might lead to immature eggs or eggs of lower quality but that has been largely debated and not confirmed by newer studies.

Is there any advice you would give a couple before starting IVF?

An IVF treatment is a process that is both physically and emotionally demanding, not only for the woman undergoing the stimulation and egg retrieval but also for her partner. Regarding the physical part I would recommend to the woman to start taking prenatal vitamins, and to the couple to quit smoking and cut back on alcohol. Also - make sure to establish a good dialogue with your doctors so that you feel you get the information you need to feel in control. 

Also, the couple’s psychological well-being  is equally important as the physical one! My advice would  be to try to manage the stress and anxiety, using tools that YOU like. It could be meditation, yoga or journaling. Both partners are going through a demanding phase in life so it’s important to always have an open dialogue with each other. Don’t be afraid to ask for help from your friends and relatives or a professional (such as the fertility clinic’s psychologist! Being also part of a fertility forum, communicating with women that go through similar difficulties, and sharing, can also help. Remember - you are not alone in this!

I’ve done many failed IVFs, never retrieved eggs that developed into embryos. Now moving on to donor eggs. Is the IVF-process different for the donor or same as I did? Does my husband have to leave a sperm sample on the day of her retrieval?

An embryo donation cycle is carried out in a similar way as a regular IVF. The egg donor will go through the same steps of egg stimulation with fertility drugs and egg retrieval that you did. On the scheduled day of egg retrieval the male partner leaves a sperm sample and depending on the quality of the sperm, the lab personnel fertilise the eggs either through regular IVF or through ICSI. The fertilised eggs will then hopefully grow in the incubator for 2-5 days and the best embryos will afterwards be selected for transfer or to be frozen. Usually, during the stimulation period of the donor, the recipient, that is you, receives fertility medications, such as estrogen and progesterone, in order to tune her uterus lining with the embryo and therefore maximize the chances that the embryo(s) will implant after they are transferred. Sometimes, the embryos are frozen / thawed and transferred in a natural unstimulated cycle, happening at a later phase. 

In which cases is transferring an embryo on day 2 or 3 better than waiting for a blastocyst?

Nowadays most fertility clinics choose to transfer embryos at the blastocyst stage compared to cleavage stage embryos (day 2 or 3). That is because embryos that manage to survive until day 5 have generally a superior quality compared to the ones that didn’t make it. A transfer of a blastocyst has therefore a higher chance to lead to a pregnancy (around 40-50%) compared to that of a cleavage stage embryo (25-35%). However if the number of eggs after a retrieval is relatively low (for example 1- 4 eggs) or if embryos from prior IVF-treatments didn’t reach the blastocyst stage despite adequate number of eggs collected, we might opt for a day 2-3 embryo instead. From our experience, a small number of embryos that would not qualify as blastocysts according to our strict lab criteria, could nevertheless thrive in the uterus and lead to a pregnancy. The human body can sometimes be a better “incubator” than that of the lab.

How are embryos graded? Heard it can be a bit subjective?

In order to increase pregnancy chances after IVF we have to choose wisely which embryo(s) to transfer. That is done by using embryo grading as a tool. Embryo grading is mainly based on the embryo's number of cells, their appearance in a high-power microscope as well as their growth rate. The scoring varies depending if the embryo is on day 2-3 (a cleavage stage) or on day 5-6 (a blastocyst).  In addition to these universal criteria, some fertility clinics have even developed their own systems to select how many and which embryos to transfer. 

So yes, individual judgement is important and the assessment is thus, at least partly, subjective.

My AMH is 0,2. Which type of stimulation protocol would you try? Know there are no guarantees.

This is a hard question to answer. No treatment protocol has been shown to be better than the rest for women with low egg reserve - it might therefore be necessary to test some of the “regular” IVF protocols to see what would suit you, such as the long agonist, the short antagonist or the short flare-up agonist protocol. Lately several fertility clinics have started testing mild IVF or natural modified IVF for women with low egg reserve, that is using low dose fertility injections in addition to ovulation pills during an IVF. The rest of the IVF steps are similar. The data thus far show similar success rates compared to regular IVF but lower medication cost, fewer side effects reported and potentially better quality of the embryos obtained.  

Who would you recommend an ERA-test to? 

ERA stands for Endometrial Receptivity Analysis (or Array) and  is a genetic test carried out during IVF in order to check whether your endometrium and your embryos are synchronized or your “wind of receptivity”. The test is done by taking cells from the endometrium through a biopsy on a specific day of the menstrual cycle and performing genetic analyses of over 200 genes. By evaluating the endometrium on the time it’s supposed to be receptive, you confirm whether that is the case or whether the endometrium is at an earlier or later stage than expected. In that case the timing of the embryo transfer should be pushed forward or back. The ERA test is relatively new, costly and hasn’t proven to be effective for all women that undergo IVF. However it may hold promise for women that have repeated failed IVF attempts, 3 or more failed embryo transfers that is. Especially if the embryos have been tested and proven to be genetically healthy (have normal chromosomes), meaning you’ve excluded the possibility that low embryo quality is the reason for your failed transfers.

How important is it to assess the correct day 1 of the period? It sounded very important that menstruation started properly with red bleeding. And depending on whether it came before or after 12 o'clock, it was decided what was day 1. Then start some with the simulation meds on day 2 and others on day 3? Why is that?

During IVF treatment, especially when using the short antagonist protocol, which is the most commonly used treatment, women start using stimulation meds at the beginning of their menstrual cycle. This has two main reasons. Firstly because we’re trying to take advantage of the natural FSH produced by a woman’s pituitary when it is at its highest. We can in this way increase the response from the ovaries. Furthermore, timing is essential! We synchronise the artificial stimulation period to the one otherwise happening naturally. That  ensures that the other involved organs are correctly tuned, the uterus for example. Women with shorter cycles would therefore need to start one day earlier in order to lower the risk of something being out of phase.

After 4 failed transfers with high quality embryos, what would you suggest? I've not done an ERA or a hysteroscopy.

When 3 or more IVF attempts with good quality embryos have been made and failed, we usually talk about repeated implantation failure (RIF). Several studies have been done on RIF but the results on the efficacy of treatments and the necessity of the evaluation are still conflicting. Before presenting what we know on the matter, I would therefore urge you to make an informed decision after talking with your fertility specialist on whether such tests and/or treatments might positively affect YOUR chances of success. Unfortunately, despite doing various tests, which can be both costly and sometimes painful, we don’t always find a reason. 

Possible reasons behind RIF include uterine pathology (that is anatomical problems), presence of endometrial polyps or fibroids, abnormal growth of the endometrium (endometrial hyperplasia), chronic inflammation (i.e. endometritis) et.c A hysteroscopy can therefore be needed in order to confirm or exclude such a diagnosis, especially if the gynecological ultrasound exam indicates it. Furthermore, it has been discussed whether the failed implantation for women with RIF, is due to an asynchrony between the embryo and the endometrium, that is if the uterus and the embryo are not ready at the same time. So an ERA test (I’ve explained more closely in another response how that works) could potentially give an indication. All of the above however presume that the “high quality embryos”  transferred were actually chromosomally normal and thus had the potential to lead to a normal pregnancy. You can therefore also discuss with your doctor if PGT-A (i.e. a genetic test of the embryo) could be indicated in your next treatments, especially if you are above 35 years of age. There is lastly an ongoing debate on whether an overactive immune and/or coagulation system could hamper a pregnancy and if treatment adjusting these systems could positively affect the pregnancy chances.  

What can be said, in general, about how egg quality is affected by PCOS? I’ve understood there’s different types of PCOS. I’m not overweight, but I have other symptoms. 

PCOS  is a condition characterised by high levels of male hormones (such as testosterone), irregular menses and/or polycystic ovaries seen on the ultrasound. Having two of the three indicators is enough to receive the PCOS diagnosis. That means that some women might have all three features and some different combinations of those three, which is what characterises the different PCOS types. So the “picture of PCOS” can therefore look different for different women. 

Although the eggs of women with PCOS don't seem to have a worse egg quality (they actually have a similar proportion of genetically healthy eggs), we have observed a higher rate of early miscarriages in this group. One potential explanation is that the miscarriages could be the result of high androgens and/or high insulin/ insulin resistance which is common among PCOS women and not the PCOS condition itself.

IVF - Dr Elenis responds to your questions

Dr. Fatin Willendrup is a Medical Doctor with key skills in communication of medicine and problem-solving. Fatin's passion is preventive work within fertility and helping people to live healthier lives and improve fertility potential. Fatin has two children that were conceived through IVF and a third child via natural conception, so her own journey inspires her work.

Fertility is complex - both female and male fertility. But what is clear when it comes to male fertility is that good sperm quality improves chances for pregnancy. So how do you find out how good your sperm quality is? And can it be improved? We turn to Dr. Fatin Willendrup to sort out common questions and misunderstandings when it comes to male fertility.

Is it common for men to have fertility issues?

In 40% of infertility cases worldwide, male infertility is the main reason for couples not being able to conceive. 

In the Western world average sperm quality has dropped by 50% in the last 40 years and 1/3 of young men have a sperm quality so low they are likely to experience problems with fertility.

Male fertility issues could be caused by:

Blockages that prevent the delivery of sperm to the female tract

Abnormal sperm function (lack of movement, inability to fertilize the egg)

And these causes can in turn have several reasons like injuries and infections as well as lifestyle factors. 

What can I do to identify issues, do I need to go to a clinic?

I advise you to see a doctor if you have been unable to conceive a child after a year of regular, unprotected intercourse. If you have any of the below symptoms and conditions, you need to consult your doctor sooner:

Semen analysis revealing low semen quality

Erection or ejaculation problems, low sex drive, or other problems with sexual function

Pain, discomfort, a lump, or swelling in the testicle area

A history of testicle, prostate, or sexual problems

A groin, testicle, penis, or scrotum surgery

And if you want to be proactive before starting to try for a baby - to exclude risk factors and/or be able to optimize sperm health - there is no reason not to take a test earlier. You can't know how good your sperm quality is just by looking at your ejaculation. A sperm analysis like Tilly's sperm test is the only way you can evaluate sperm quality and get a real idea of your fertility status.


How can I improve my sperm health and optimize fertility? 

It’s important to focus on scientifically proven lifestyle changes that increases sperm quality. Weight management, exercise, nutrition, antioxidants intake and excluding toxins like smoking are top priorities both for men and women when trying for a baby. For men we have identified the following 10 things you can do:

When taking a sperm test with Tilly you get access to an app with personalized lifestyle programs helping you to improve sperm quality if needed.


For men who need emotional support on the road to fatherhood, it can sometimes feel incredibly lonely. But there are some organisations trying to change that. The support is out there – you just need to know where to look for it. Here are just a few of the ways you can findsupport you need – in a way that feels comfortable for you.

Via Tilly's app: Tilly: Fertility & IVF support

How to improve male fertility and sperm health. Dr Fatin answers common questions about male fertility.

Fertility Facts