In-Vitro Fertilisation (IVF)

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In-Vitro Fertilisation (IVF) Fertility Treatment Singapore

In-Vitro Fertilisation or IVF refers to the use of laboratory techniques to bring the egg and sperm together outside of the woman's body. It is the most effective form of assisted reproductive technology (ART) treatment with a success rate of up to 50% to 60% for couples under the age of 35. IVF in Singapore is usually recommended to couples who have undergone 3-6 failed intrauterine insemination (IUI) cycles. The IVF treatment cycle generally involves several stages.

Most women produce only one egg each month. To increase the number of eggs produced for IVF, and hence the number of embryos that can be formed through IVF, hormonal injections are given. There are many IVF regimes possible. One IVF 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 throughout the IVF ovarian stimulation stage which should last normally between 10 to 12 days. 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.

To decide when the eggs are going to be ready for IVF, scans and blood tests are performed once every few days during the IVF ovarian follicle monitoring stage in order to assess the growth of the developing eggs. The scans are usually done trans-vaginally using a long and slim probe. Blood tests are also 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 and help confirm the best timing for the next IVF treatment stage which is retrieval of the eggs for IVF.

The dose of the hormones injected may have to be adjusted so as to allow optimum growth of the eggs for IVF. 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 34 to 36 hours after the hCG injection.

Once the oocytes or eggs have reached a minimum size of 17 to 18mm, they should be ready for fertilisation with the sperm. Oocyte or egg retrieval for IVF is done under sedation or a general anaesthetic. The procedure is generally pain free and the eggs are retrieved from all the follicles seen 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 (traditional IVF) or by intra-cytoplasmic sperm injection (IVF-ICSI). ICSI involves injecting a single sperm into each egg via a microneedle to facilitate fertilization. IVF-ICSI is recommended for cases in which there is very poor sperm quality. IVF-ICSI can also be offered in addition to traditional 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 formed from IVF are ready for transfer into the womb you will be notified. The exact day and 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, 1 to 2 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 IVF cycle results in a successful pregnancy. Failure in one IVF cycle does not mean that you have a reduced chance of success in the next IVF cycle.

Thaw IVF Cycles

Any extra embryos that are not transferred from the initial 'fresh' IVF cycle and are of sufficiently good quality may be frozen for future use. For patients who have embryos frozen after the fresh IVF cycle, they can call upon them if their fresh IVF cycle fails, or after they deliver and want to get pregnant again. The embryo storage needs to be renewed annually, up to a maximum of 5 years. Further storage requires approval from the Ministry of Health.

The thaw IVF cycle may be 'natural' or 'artificial'. For 'natural' thaw IVF 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' thaw IVF 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 through IVF cycles, you will need to continue on the hormone medication until the pregnancy is at least 10-12 weeks.

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What is the success rate of IVF?

The success rate for IVF is age-dependent. Generally, the pregnancy rate for IVF is up to over 60% for the younger age group, but falls to 15% once the woman reaches 40 years and down to 3% to 7% after 40. Live birth rates after IVF are around 30% for the younger age group and 5-10% for the older patients.

What can be done to increase the success rate of IVF?

In order to increase IVF success rates, a thorough gynaecological evaluation is important before commencing on an IVF cycle. Laparoscopic or minimally invasive key-hole surgery may sometimes be recommended before IVF for the treatment of swollen fallopian tubes, fibroids, ovarian cysts and endometriosis.

A hysteroscopy involving the use of a camera device to assess the uterine cavity may also be needed before IVF to ensure a healthy environment for the implantation and growth of the embryos transferred.

To maximise the success rate of IVF as with IUI, couples should enhance their health as much as possible. Any chronic medical conditions e.g. diabetes, should be brought under control before IVF treatment. A healthy diet and lifestyle should be observed. Couples should not smoke and should reduce their intake of alcohol and caffeine. A regular exercise regime can help to control their weight and provide stress reduction benefits for IVF as recommended by our IVF Clinician.

Men should avoid hot baths, saunas and jacuzzis as sperm quality is badly affected by high temperatures. Men should also avoid medications that can adversely affect their sperm function. Antioxidant supplements with vitamins A, C and E should be taken to improve the sperm quality as much as possible as both healthy sperm and egg are important for IVF success.

Women should ensure they are immune to rubella before undergoing IVF treatment because infection during pregnancy can lead to congenital birth defects. They should also take folic acid to prevent birth defects such as spina bifida.

FAQ on IVF

While IVF is an increasingly common treatment among couples who are experiencing infertility, the procedure itself is not suitable for everyone. Your fertility doctor will first screen you and your spouse to determine whether you’re eligible for IVF.

Generally, IVF in Singapore may be recommended for the following:

Women who have cut, damaged, blocked or missing fallopian tubes
Women diagnosed with endometriosis or uterine fibroids
Women with ovulation disorders or reduced ovarian reserve
Women over 40 years old with reduced fertility potential
Men with low sperm production or poor sperm function and motility
Couples with unexplained infertility
Couples with a genetic disorder that may be passed down to the child

As IVF involves several steps, which include ovarian stimulation, egg and sperm retrieval, fertilisation and embryo transfer, one cycle of IVF can take around four to seven weeks to complete. A pregnancy test may be taken two weeks after the embryo transfer to determine whether the IVF procedure was successful.

As with natural conception, the most important factor that will determine the success of IVF is the woman’s age. A woman in her 20s and 30s have around 50% to 60% chance of getting pregnant via IVF, while a woman in her 40s will only have a 3% to 7% chance. This is because the quantity and quality of a woman’s eggs decline with age. Similarly, the risk of a miscarriage and chromosomal disorders increase with age.

How many rounds of IVF a couple needs to do before getting pregnant will depend on a number of factors, which include age of the couple, age of the egg and/or sperm, and quality of the egg, sperm and embryo. While many couples can succeed in conceiving after one round of IVF, it is also not uncommon for couples to undergo more rounds to achieve success.

One of the initial procedures done during IVF is ovarian stimulation, in which hormone medications are injected into the lower abdomen or thigh. These medicines stimulate the ovaries to produce multiple mature eggs for fertilisation. Injections are not usually painful, but it will depend on the pain tolerance of the patient. Bruising on the injection is also common and normal.

During the egg retrieval process, an ultrasound probe with a needle at the tip will be inserted into the vagina and through the ovary to harvest the egg follicles. This procedure is usually done under anaesthesia so the patient won’t feel any pain. Cramping and spotting may occur but these should subside within 5 to 7 days.

The embryo transfer step is not done under anaesthesia, but it is also not painful. Many patients agree that the feeling is similar to having a vaginal ultrasound or a Pap smear.

Over the course of an IVF cycle, the patient may experience side effects that include cramping, abdominal bloating, bruising and soreness on the injection site during ovarian stimulation, headaches, nausea, fatigue, moodiness, hot flashes, breast tenderness, and a clear or bloody vaginal discharge. In some cases, IVF can cause ovarian hyperstimulation syndrome and multiple births.

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In-Vitro Fertilisation (IVF)

IVF Treatment Stage 1: Ovarian Stimulation

IVF Treatment Stage 2: Ovarian Follicle Monitoring

IVF Treatment Stage 3: Oocyte / Egg retrieval

IVF Treatment Stage 4: Fertilisation of eggs with sperm

IVF Treatment Stage 5: Embryo Transfer

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