Health & Fertility Centre for Women
Tel (65) 6235 5066
Infertility is generally defined as the inability to conceive after 1 year of actively trying i.e. having sexual intercourse 2-3 times a week.
When to seek help
After 1 year of trying, 80-90% of couples would have been successful in conceiving. It is therefore advisable to seek help at this point.
Fertility does decline with age. Studies have found that the probability of conception over a month falls from 25% in women in their early twenties to 8% in their late thirties. Similarly, the probability of conception within a year falls from 97% in women in their early twenties to 65% in their late thirties.
It is therefore important to start planning for a pregnancy as early as possible and to seek help as soon as there seems to be difficulty. It would also be advisable to seek help early if you are over 30 years, or if there are any indicators of infertility factors such as irregular or painful menstruation.
Causes of Infertility
Infertility may be due to male or female factors.
Causes of female infertility include:
Often, there is a mixture of both male and female factors. In some cases, there appears to be no obvious reason and this is termed ‘unexplained infertility’.
Basic investigations include a semen analysis and, for the female partner, hormone tests and an ultrasound scan of the pelvis. Depending on the medical history and basic investigation results, advise will be given on the method of testing for patency of the Fallopian tubes.
Options for testing tubal patency include:
Some women may be recommended a test to assess the cavity of the womb called ‘saline sonography’. This test involves infusion of normal saline into the cavity of the womb to ensure that that the cavity of the womb is healthy without the presence of polyps.
Based on the investigation results, appropriate treatment will be recommended.
Intra- uterine insemination (IUI)
With IUI, the semen sample is prepared and sperms are placed directly into the uterus. This may be combined with superovulation (SO IUI) to improve the chances of conception.
In SO- IUI, medicines are given to stimulate the ovaries to produce several eggs. Ultrasound scans are performed to determine the size and number of eggs growing within the ovary. Insemination is performed around the time of ovulation. On the day of insemination, the couple has to bring the husband’s semen sample to the hospital. The semen undergoes special preparation so that the quality of the sperm to be inseminated is enhanced. This sample is then placed into the womb using a fine catheter. Pregnancy support is given to improve the chances of pregnancy. You should return to the Centre 17 days after the insemination for a pregnancy test.
Assisted Reproductive Techniques
ART is a complex and stressful process. It is usually recommended only if simpler treatment procedures have not worked unless there is severe male factor infertility with abnormal sperm count or quality, or if you are close to 40 years. Before starting the programme, the steps involved will be explained and you will need to sign a consent form.
ART Treatment Stages
Most women produce only one egg each month. To increase the number of eggs produced, and hence the number of embryos that can be formed and transferred into the uterus, hormonal injections are given. There are many regimes possible. One regime which provides most convenience to the patient involves the use of a Follicle Stimulating hormone (FSH) from the 2nd day of the menstrual cycle. The injections are given daily. Once the eggs are of a certain size, a second injection is introduced to prevent the eggs from being released on their own.
Women may come to the Centre every day for their injections, but as the needles used are very small, most find it easier to learn how to give self- injections, or get their husbands to do it.
Ovarian Follicle Monitoring
Scans and blood tests are performed once every few days in order to assess the growth of the developing eggs. The scans are done trans- vaginally using a long and slim probe. The blood tests that are done to check for levels of certain hormones (oestradiol and LH) produced by the ovary and the brain. These tests give us a good idea of the health of the developing eggs.
The dose of the hormones injected may have to be adjusted so as to allow optimum growth of the eggs. When the blood tests and ultrasound scans indicate that the follicles and eggs are ready for collection, a special injection called hCG is given to trigger the process of final egg maturation. Egg recovery is performed 36 hours after the hCG injection.
Oocyte / Egg retrieval
This procedure is done under sedation or a general anaesthetic. The procedure is generally pain free and the eggs are retrieved from the follicles through a fine needle attached to a vaginal ultrasound probe. Generally, most patients go home a few hours after the procedure with some antibiotics to minimise any chance of infection.
On the same morning that the woman goes for the egg collection, the husband has to produce a semen sample. To ensure that the specimens are of the best quality he should have abstained from sexual intercourse for 3 to 5 days before the day of collection. A course of antibiotics would also be prescribed to him to lessen the chance of any bacterial contamination for 2 weeks prior to this. Sterile specimen bottles for the semen should be collected before the egg collection. It is important that the specimen be kept warm at all times and to reach the clinic as soon as possible. Some husbands may have difficulties producing the sperm specimens without their wives' help and special arrangements can be made to collect and freeze the sperm before hand.
In the laboratory, the sperm sample is prepared and inspected. The most active and motile sperm is then chosen to inseminate the egg. This can be done either by mixing the egg with a known amount of sperm or by intra- cytoplasmic sperm injection (ICSI). ICSI involves injecting a single sperm into each egg via a microneedle to facilitate fertilization. ICSI is recommended for cases in which there is very poor sperm quality. It can also be offered in addition to IVF to increase the success rate of fertilization. The cells in the fertilised eggs divide everyday and are inspected daily by the Embryologist, who will ensure the best conditions to help them grow.
Once the embryos are ready for transfer into the womb you will be notified by the nurse. The exact time will depend on the quality of the embryos. The embryologist who has been nurturing the embryos will determine the most suitable day for transfer of the embryos back into the womb. The embryologist is also able to select the best quality embryos for transfer.
Embryo transfer is generally a painless procedure and usually no anaesthetic required. A full bladder however is needed during the procedure in order to ensure a smooth transfer. The embryos are placed back into the womb through the cervix using a very thin, soft plastic tube. This procedure is similar to having a Pap smear.
Usually, between 2 and 4 embryos are replaced. The limits are determined by the Ministry of Health, Singapore. The chances of pregnancy increase with the number of embryos transferred but so does the incidence of multiple births, hence the need for the control.
After the procedure, you should not do anything strenuous for the following few days. Hormonal medication will be given to you to support the anticipated pregnancy. Blood tests are performed 17 days after the embryo transfer to confirm pregnancy. Some bleeding from the vagina can occur even though you are pregnant, so it is important to do this test even if you think you are having your period.
It is important to realise that not every cycle results in a successful pregnancy. Failure in one cycle does not mean that you have a reduced chance of success in the next.
The thaw cycle may be ‘natural’ or ‘artificial’. For natural thaw cycles, you will be monitored to see when you ovulate. The egg in that cycle will not be collected but based on the time of ovulation, the embryos will be thawed for replacement. The embryo replacement is a simple procedure, similar to that in the fresh cycle.
If there is difficulty in having a good ovulation, an ‘artificial’ cycle may be advised. Here, hormonal medication will be given and the embryos will then be timed for transfer when the womb lining is of sufficient thickness. If you are pregnant you will need to continue on the hormone medication until the pregnancy is at least 10-12 weeks.