We would encourage you to come with your partner at the initial consultation. We also would want you to bring along copies of all your previous test results. Our objective is to demystify and simplify the entire treatment process.
During the consultation, we will review your history ask additional relevant questions, carry out a physical examination and offer a preliminary opinion. Clinical and laboratory testing might be recommended to confirm the actual cause of the infertility.
For couples who would require IVF or ICSI treatment, preliminary investigations include a hormonal analysis. This is best carried out during menstruation: either the second or third day of menses. Pre-IVF counseling is carried out at this time.
A wide range of fertility treatment is available at Gynescope. A treatment plan is chosen to meet your needs after due explanation. The following options are available.
Timed Intercourse (T.I.)
This involves tracking the follicles with ultrasound scan to determine the appropriate time for ovulation and possible intercourse. We either use your natural cycle or induce ovulation with drugs. Generally, ovulation occurs about 14 days before the onset of the next menses. For a woman with a 28 day cycle this means day 14 of her cycle. For a woman with a 35 day cycle however, this might possibly mean day 21. Within 12-24 hours, the egg or eggs are lost if no sperm cells are encountered as they journey through the fallopian tubes.
Intrauterine Insemination (IUI)
The difference between this and timed intercourse is that, once the follicles are matured enough for ovulation, following ultrasound scan monitored growth, rather than direct intercourse, the semen sample is specially prepared and injected directly inside the womb bypassing the neck of the womb (cervix). It is mainly indicated when the cervical mucous is hostile.
In Vitro fertilization (IVF)
The first baby conceived via IVF was delivered on July 25th, 1978. The initial indication was in women with blocked tubes as it effectively bypassed the tubes. There presently exist a whole range of indications for IVF. These include: blocked fallopian tubes; low sperm count; retrograde ejaculation; polycystic ovaries and even when all other forms of treatment fail. Because naturally one egg is released out of 1000 that initially begin the journey, we aim to give fertility drugs to recruit more eggs from the remaining 999 to join the one dominant egg. For this reason IVF is not associated with depletion of the eggs and therefore menopause will not set in earlier than expected.
If the numerous follicles (eggs) are allowed to grow without control, it is possible for one follicle to grow much faster than the others. The effect is that the follicle might reach maturation much earlier leading to the release of the hormone by the brain responsible for ovulation. This effectively leads to poor quality of all the other developing follicles as they had not attained full maturity before the release of this “ovulation” hormone. To prevent this, we usually would first suppress your ability to ovulate on your own by giving you other fertility drugs prior to the ones that stimulate egg production. We usually recommend that the drugs, which are in injection form, be taken at about the same time every day. The IVF nurses would usually administer the first shot. Because the needles and syringes are the same as those used by diabetics, the injections are associated with minimal discomfort. We also recommend that the drugs, whether injections or tablets, should be kept in the refrigerator.
The roundish follicles are measured repeatedly until they attain an average of about 17mm. Another hormonal injection responsible for final egg maturation and ovulation is administered. After 35 hours we usually would aspirate the fluid from the follicle and pass this on to the embryologist who confirms the presence of the eggs under the microscope. The process of egg collection lasts about 10-15 minutes. Local anesthetic is commonly used and the egg collection process involves the use of a Trans-vaginal ultrasound scan. The process usually does not require admission and you usually can go home after about 30 minutes to one hour.
The embryologist would inseminate the eggs with specially prepared sperms. We expect fertilization to have taken place within 16 hours. Division takes place thereafter, showing signs of life. The product now called an embryo is transferred 48-72 hours after the eggs were first collected into the womb. The embryo transfer process should be painless. We encourage you to go home thereafter and carry on with your normal activities while avoiding over exertion. You will usually continue with your medications until you perform a pregnancy test after 2 weeks.
Intracytoplasmic Sperm Injection (ICSI)
The process of ICSI revolutionized the treatment of male infertility. For a single sperm to penetrate an egg you require about 200,000 active and normal sperms surrounding that single egg. This means if you have 10 eggs then you will require about 2 million of such sperms or there would likely be no fertilization. Men with severely low sperm count therefore had to depend on donor sperms. With ICSI you only need a few sperms. Each sperm is isolated and injected into each matured egg.
The first ICSI pregnancy and delivery was in 1992, compared with 1978 for IVF. Therefore, since the children conceived via ICSI are still under intense observation and monitoring until enough evidence for its safety exists, it is recommended that the technology should not be applied indiscriminately. This is more so as all available studies suggest the same pregnancy rates for IVF and ICSI. It is equally important to note that patients for ICSI, still undergo the same clinical process as those for IVF.
Ovum (Egg) Donation
For some women, because of age, disease or onset of ovarian failure, they are unable to produce fertilizable eggs thus reducing their chances of achieving pregnancy using their own genetic material. This group of women would usually have a healthy uterus, which might be ‘quiet’ as they might no longer be menstruating. Egg donation from a much younger woman offers a realistic chance of achieving conception. The process involves preparing the uterus of the recipient with hormonal drugs while stimulating the donor to produce eggs that are subsequently fertilized with sperms from the recipient’s husband. The resultant embryos are transferred to the uterus of the recipient.
Candidates for egg donation should meet one or more of the following criteria:
Semen and Embryo freezing
We usually aim to transfer a maximum of three embryos at a time. If excess high grade embryos are present we aim to freeze (cryopreserve) them for future use. Because there is only about 60 – 70% chance of such embryos surviving freezing, we aim to freeze only if two or more high-grade embryos are available. While the pregnancy rates following the transfer of frozen embryos are lower than that following fresh embryo transfer, the quality of babies born are the same with no increased risk of abnormality.
Some men might decide to freeze their semen because they would likely be away when the semen sample would be needed (such as men who work offshore). Others might have had difficulty with producing semen during a previous cycle while a few others might freeze their semen as a result of the effect, on sperms of the treatment they are about to undergo (such as cancer treatment). Not all sperms survive freezing, therefore treatment plan might have to be changed to ICSI from IVF if need be.
Surgical Sperm Retrieval
There are various ways in which sperms can be retrieved surgically. Sperms can be retrieved from the epididymis, from the vas deference or directly from the testes. Commonly, this is done when there are no sperm cells in the ejaculate. Occasionally it can also be done when there is unexpected ejaculation failure on the day of egg retrieval. The procedure is carried out under local anaesthesia and after a few minutes rest, the man can usually go home.
This involves the passage of a flexible or rigid telescope-like instrument through the vagina to inspect the cervix and inside of the uterus for defects. Surgery designed to correct such defects or remove any unwanted tissues can be carried out. At Gynescope, we make use of a rigid hysteroscope and have been able to treat abnormal defects within the uterus, remove fibroids, adhesions and sometimes even fetal bones from a previous late abortion, which can prevent conception. Major open surgeries are prevented with the use of the hysteoscope.
This involves assessing the tubes, outside of the uterus and other pelvic and abdominal organs with a rigid telescope-like instrument passed usually through the umbilicus (navel). Major surgeries can also be carried out through this pin hole with minimal scar and quick recovery and discharge.