IVF journey in the East
By Dr. Roland Chieng
Obstetrician and Gynaecologist
MBBS (S'pore), MRCOG (UK), GDip (Acu)
What is an IVF treatment?
IVF treatment is the very first treatment tried when an egg donor is being used, there are severe cases of male infertility, or a woman’s fallopian tubes are blocked. Still, this comes after years of trying to get pregnant, followed by a slew of fertility tests. According to the World Health Organisation, incidence is about 10 percent worldwide. Another 10% to 12% of all other couples have only one child and would like to have more. The incidence of infertility is gradually increasing all over the world. For many people going through infertility treatment, the level of distress and tension can be very high. Mutual trust and faith in the doctor can help couples enquire about different types of treatment for both the male and female partner and make informed decisions about their reproductive status.
How is fertility assessment done?
Assessment of female fertility traditionally includes the assessment of ovulation and the physical condition of the fallopian tubes. Various methods are available for ovulation. The direct assessment using ultrasound to track how the egg develops in the ovaries is still the most reliable method.
Serial ultrasound visualization of the ovaries will be done to follow the development of eggs from about Day 10 of the cycle till the day of ovulation. Actual ovulation can be confirmed, and timed intercourse advice will then be more precise for a possible natural conception. “The gold standard for assessment of tubal conditions is still by laparoscopy or keyhole operation,” says Dr Roland Chieng. However, in the absence of other indications, x-ray or ultrasound assessment of the fallopian tubes is usually adequate. These can be done in a clinic setting.
1. Blood test for follicle-stimulating hormones (FSH) level at the time of menses
It dictates the amount of medication required for successful stimulation of the ovaries for egg development.
2. Antral follicular count (AFC)
This is done by a 3-D ultrasound examination of the ovaries. It has to be done on Day 2 of menstruation and measures the number of new egg follicles before stimulation is started.
3. Trail cannulation
This is a process whereby a trial run embryo transfer is done before the actual procedure.
Assessment of the male is of equal importance before IVF. Full assessment goes beyond just semen analysis or sperm quality assessment. There are numerous conditions in men that are amenable to treatment, which will increase the chances of spontaneous pregnancy.
01 Semen analysis and culture
A detailed semen analysis is necessary to determine the method of obtaining sperm at the time of IVF, whether obtaining sperm normally through masturbation or surgery.
02 Sperm function test
Sperm function tests include DNA fragmentation tests, hyaluronon binding assays (HBA), egg penetration tests, and others. Infertility can be explained by these tests, and they can also show if intracytoplasmic sperm injection (ICSI) or microinjection of the sperm into the egg for fertilization in IVF is needed.
What is involved in an IVF treatment?
There are basically four steps in the IVF treatment and embryo transfer process, which include:
Step 1: Ovarian stimulation
Injections are used during ovarian stimulation to stimulate multiple eggs to grow in the ovaries instead of having a single egg that is normally produced each month. Some eggs will not fertilise or develop normally after fertilization. With multiple eggs, the chances of successful treatment become higher. With the help of an ultrasound, the follicles can be found and evaluated one by one until the right time for egg retrieval.
Step 2: Egg retrieval
Egg retrieval is a minor surgical procedure that is performed via the vaginal route. During this time, both ovaries will be enlarged with egg follicles and they will be right next to the vaginal wall. A small injection using an aspiration needle is made through the wall under ultrasound guidance. The needle is connected to a suction device.
Eggs will then be aspirated from all the follicles. Multiple eggs can be aspirated in less than 15 minutes.
Step 3: Fertilisation
Once the retrieval of eggs is completed, they are observed in the laboratory for maturity and quality. Fertilisation is achieved either through insemination, where the motile sperm are placed together with the eggs incubated overnight, or through ICSI, where a single sperm if directly injected into each mature egg. Successful fertilisation can be assessed the following day.
Step 4: Embryo transfer
Embryos are fertilised eggs. Embryo transfer is the last step in the IVF process.
One or more embryos that are floating in culture medium are drawn into a transfer catheter with a syringe on one end. The tip of the transfer catheter is guided through the cervix and into the uterine cavity, where embryos are placed.
The most important thing that leads to multiple pregnancies is the number of embryos that are transferred. Commonly, Dr Roland Chieng advises only two embryos to be transferred at any one time.
How effective is an IVF treatment?
IVF treatment is often successful, though it may take more than one try. Studies show that the potential for success with IVF treatment is the same for up to four cycles. In general, the live birth rate for each IVF cycle is 30 to 35 percent for women under the age of 35, 25 percent for women aged 35 to 37, 15 to 20 percent for women aged 38 to 40, and 6 to 10 percent for women over the age of 40.
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