Question: My husband and I had gone through 3 IVFs without success, does it mean that our chance of pregnancy is very slim? Is it due to my body condition?
Dr Helena’s Answer: To achieve a successful pregnancy through IVF, there are some basic pre-requisite factors:
(1) The age of the couple, especially the female partner
(2) The duration of Subfertility
(3) good quality and quantity of eggs and sperms to make good quality embryos
(4) a conducive uterus environment for implantation
Studies had also shown that there is a increasing cumulative pregnancy rate for women who went through a few cycles of IVF.
However, after going through three IVF without success, one may wonder whether there is light at the end of the tunnel.
Being a fertility doctor, I can understand how frustrating it would be. However, these IVF cycles which did not work out, may contain valuable information about your fertility. As we know, apart from being a treatment in its own right, IVF also serve as a diagnostic tool in its own right, by telling us how you respond to the medications, how your eggs and sperms qualities are, and how your embryos qualities are.
There a a few aspects we may consider to improve on for your next IVF treatment:
The IVF treatment protocol
Here are some consideration for you:
(1) The IVF Treatment protocol.
While the IVF treatment protocol is pretty standard, every patient responds differently to the types and dosage of IVF medication. Each cycle teaches us how your body responds to the injections to help your follicles grow. It takes a good IVF doctor to be able to decide on the right dose and right type of medications, to get you to produce an optimal number of high quality eggs. Some young patients with normal ovarian reserve grow well in response to a standard protocol, patients with poor ovarian reserve and those with PCOS need a lot of extra attention and closer monitoring.
However, at the end of the day, some of this is trial and error. A good previous record can help us to learn from each cycle , until we can customize the perfect protocol for you
(2) The IVF clinic/centre.
It is important to note most IVF clinic/ centre are pretty standard, there are variations in terms of their operations and quality controls, and hence their success rates. In Malaysia, there is still no regulatory body that mandates each IVF clinic/ centre to report their success rates. However, it is important to look for credible centres with proper accreditation to ensure the quality of your IVF treatment.
(3) The sperm.
Poor sperm quantity & quality may be associated with failed fertilization of an egg during an IVF but with the advent of ICSI, these problems are easily over-come. However, if the sperms are have high DNA fragmentation, the resulting embryos may still have poor quality. Simple lifestyle changes such as stop smoking & alcohol, weight loose, exercise and consumption of good quality food which are rich in anti-oxidants are some of the key elements in improving sperm quality and IVF outcome
(4) The eggs.
Human egg is a thousand times bigger than the sperm, and that the energy for cell division during embryo cleavage comes from the mitochondria in the egg’s cytoplasm, therefore, egg quality is another important factor for IVF success. Poor egg quality leads to poor embryos and hence failed IVF. The problem is that it’s very hard to make this diagnosis, as there is no blood tests or medical technology to identify poor eggs prior to an IVF cycle. In fact, IVF is a diagnostic tool in it own right, as egg quality can be assess during an IVF. To improve egg quality involves making lifestyle changes, improving diets, and sometimes some alternative medications such as DHEA.
(5) The uterus.
It is probably a very Oriental or ‘Chinese’ believe that failure to get pregnant/ implantation is always the fault of the uterus. It is not unusually to hear the terminology of ‘cold uterus’ being cited for the reason for not getting pregnant. Hence, the idea of surrogacy has become very popular recently because of the disproportionate amount of media attention it attracts, and especially so when cross borders IVF had become extremely popular with the ease of medical access overseas. This had lead to the idea that the best medical solution for them after many failed IVF cycles is surrogacy. After all, the fact that the embryos are not implanting means the uterus must be ” defective” , so doesn’t it make sense to use a fertile woman’s uterus as an incubator for 9 months ? However, the truth is that surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus. It is also important to stress that Surrogacy is ILLEGAL in Malaysia. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality sperms or eggs), rather than a uterine problem. However, in about 20-30% of women, failure in implantation maybe due to some small correctable issues in the uterus such as polyps or fibroids. These issues can be dealt with easily without having to resort to surrogacy
Question: I am a person who is fearful of pain. I gathered that going through IVF will required multiple injections, surgery and other procedures which are painful. Is it true?
Dr Helena’s answer:
IVF sounds daunting to many people. A lot of us have perceptions that it is extremely expensive. Some of us thinks that it would bring us a lot of inconvenience, such as having to go to hospital everyday, lay in bed for a few months, quit our job and etc
One of the greatest fear many had was the perception of pain associated with IVF procedures. The thought of having daily injections made most of us wanting to run away and hide from the doctors. Some people are scared thinking about the egg retrieval procedures. Some are dreading the embryo transfer procedure, thinking that it would bring great pain and discomfort. Some dread the injections which are taken after the procedure, which are the progestogen injections, aimed to support the lining of the uterus whilst the embryos are implanting.
However, with the new development and breakthroughs in the world of reproductive medicine, IVF procedures had become more and more comfortable and easy to management, with minimal disruption to daily life.
First and foremost, the durations of injections had been shortened significantly with the use of antagonist injections in IVF. This method of doing IVF is called the antagonist cycle or the short protocol. So, instead of having 3 weeks of injections in the agonist cycle or long protocol, the advent of antagonist injections had lead to a shortened period of 10-12 days of injections. This had greatly reduce the discomfort one needs to go through with injections.
The use of self-administered FSH injection pens with extremely fine needles, had significantly cut down the pain one experienced during injections. This self- administered injections pens are given to patients to take home, and the injections are administered by patients themselves, so patients do not need to come to the clinic or hospital to have their daily injections. The needles used are similar to the ones used in the insulin injection pens, which is extremely fine and almost painless.
There is also another long acting FSH injection which given at the beginning of an IVF cycle and can last for 7 days. After the initial injection, the patient need not take FSH injection for the next 7 days, which significantly cuts down the number of injections required.
The egg retrieval procedure which usually happened after 10-12 days of injections involved having a light sedation in an operating theatre. In the past, the use of certain sedations such as Valium, Dormicum or pethidine administered by the IVF doctors whilst performing the egg retrieval procedure had appeared to be increasingly unsafe. In many IVF units, a proper IVF operating theatre with a trained Anaesthetist giving sedation during the egg retrieval procedure is becoming a norm and deemed acceptable in terms of safety. One of the advantage of the involvement of an Anaesthetist is that egg retrieval procedure is becoming almost painless, and hence optimizing patient experience in IVF.
Embryo transfer procedure is usually carried out 3-5 days after the egg retrieval. During the procedure, the embryos which were created following fertilization of the retrieved eggs with sperms are replaced into the uterus. This procedure is performed without anaesthesia or sedation, is relatively pain free. The experience is almost the same as having a cervical smear. Therefore, women should not feel fearful about having an embryo transfer.
After the embryo transfer, to support the uterus lining and to ease implantation, a
Progestogen is prescribed. In the past, progestogen is administered by injections. These injections are usually painful and cause local irritations, which is uncomfortable and unacceptable to many. With the advent of effective oral and vaginal suppository preparations, studies had shown that these forms of progestogen are equally effective in delivering progestogen to uterus, injectable progestogen had slowly becoming a thing of the past in many IVF centres. This has also greatly cut down the pain experience in IVF
In conclusion, with rapid modernization in reproductive medicine & technology, IVF had become relatively painless. It is importantly to find out more information on IVF before you embark on this journey.
What you should know about AMH
When you seek medical advice for infertility issues, one of the hormone tests that you be advice to take is the Anti-Mullerian Hormone or AMH test. This test measures the AMH levels in your blood, which helps doctors determine your ovarian or egg reserve.
In this post, I’ll explain what egg reserves and AMH tests are, as well as what you can do if your AMH levels are low:
About egg reserves
Humans are born with a limited amount of eggs. To be precise, a girl is born with between one to two million immature eggs or follicles in her ovaries. But not all these follicles will survive into adulthood. In fact, throughout a woman’s life, the majority of her immature eggs will die in a natural process called atresia.
Did you know that by the time a girl has her first period, only about 400,000 follicles are left? And with each subsequent period, she loses about a thousand follicles, while just one matures into an ovum or egg. This means, throughout her reproductive life, a woman will develop only about 400 ovum. The number of developing follicles a woman has left, is called her “ovarian or egg reserve.”
Egg reserves and the quality of those eggs vary from one woman to another, due to factors such as age and infertility. Over time, both the quantity and quality of a woman’s eggs gradually decreases. Therefore, when seeking treatment for infertility, it is important for a woman to gain insight into the remaining quantity of her egg reserve and fertile years.
What is AMH?
When follicles develop in a woman’s egg reserve, her body release the Anti-Müllerian Hormone (AMH). AMH levels, therefore, can give us a good idea of the state of a woman’s ovarian reserve. Since AMH levels are determined by the number of developing follicles in a woman’s ovaries, low AMH levels are an indication that the ovarian reserve is depleted.
Fewer developing follicles mean slimmer chances for a mature and healthy egg to be released and fertilised. As such, when a woman knows the state of her egg reserve, she can determine how urgently she requires treatment.
While egg reserves generally decline in the mid to late 30s, leading to low AMH, age is not the only factor. Environmental factors can also cause low AMH, such as cancer treatment and inherited genetic causes. AMH levels can be easily assessed with a blood test, but like most diagnostic tests, it has its limitations. For example, it cannot indicate the quality of the eggs that are left, which requires a separate test. However, as AMH levels remain fairly constant in a woman’s cycle, she can have the test at any time.
What Can’t AMH tells you
As much as we would like to believe that AMH is ‘the ultimate test’ for ovarian reserves, however, it only tells us some aspect of your fertility performances but not all. AMH does not tell you the quality of your eggs. Therefore, some women who have plenty of eggs and high AMH level may not perform well in an IVF treatment cycle because of poor egg quality.
For women who take oral contraceptive pills, AMH level may not be a true reflection of their ovarian reserves. Those who were taking the pill had 19 percent lower levels of AMH and 16 percent fewer early-stage follicles.
Recently, there has been clinical studies which reported that there is a significant variation in serum AMH levels across the menstrual cycle regardless of ovulatory status. This variability, although statistically significant, is not large enough to warrant a change in current clinical practice to time AMH measurements to cycle day/phase.
What you can do
If you should take an AMH test and find that your level is low, do not lose heart! Your AMH level is just one piece in a complex jigsaw puzzle. Your best course of action is to discuss matters with your infertility specialist. Ask your doctor how you can protect your egg count and health, as well as discuss the best possible solution to your problem. For example, DHEA supplementation and well-managed IVF protocols have been shown to be effective in improving IVF pregnancy rates in women with low AMH. Maintain a positive outlook and don’t give up on your dreams of having a baby!
Can IVF bring on early menopause?
One of the most common question patients like to ask about IVF is that whether the treatment itself will bring on Menopause earlier. This is probably by far one of the greatest myths about IVF which we would like to clarify.
A woman’s ovaries contain immature eggs sacs known as follicles, which have the potential of developing into mature eggs. However, most of these follicles will be lost without having fulfilled their purpose.
Women are born with millions of eggs in their ovaries. These eggs are quiescent in the ovaries until the women reach the age of menarche (when they get their first menses). At that time, the eggs in the ovaries started to come up after hibernating for 10-16 years. This is due to a pulsatile release of hormones from the organs below our brain called hypothalamus and pituitary. So, at the start of our menses, our ovaries will recruit around 10-20 eggs at one go. However, after the menses, our body will only choose one egg to grow. The rest of the eggs will regress and die off. With the help of our hormones, the particular ‘chosen’ egg with grow to a certain size and maturity, and then ovulation will occur. Hence, we only release one mature egg every menstrual cycle.
But of these many follicles, only one of them will become dominant and mature. The others that do not get a chance to mature and release an egg, will simply disintegrate and be lost in a natural process called atresia. The loss of these follicles during each menstrual cycle means that several undeveloped eggs are also lost.
Therefore, throughout a woman’s reproductive life, her ovaries will release only around 400 eggs, despite being born with millions of eggs. So basically, we ‘wasted’ around 12-20 each menstrual cycle, until the day when we reach menopause, whereby there is NO eggs in our ovaries
So if a woman can naturally produce only one egg per menstrual cycle? How do IVF specialists harvest several eggs at once?
For a woman who is undergoing an IVF treatment, the use of injectable fertility drugs (hormonal drugs) will stimulate her ovaries to overcome the natural tendency of choosing one dominant egg and ‘wasting’ other eggs produced during this particular cycle. In this scenario, the hormonal injections will stimulate all the eggs recruited during this particular cycle to grow simultaneously. Once these eggs reached a certain size and maturity, they are being harvested during an egg retrieval procedure
When a woman undergoes IVF, she will be prescribed with injections containing FSH. The amount given will be several times higher than what her body would naturally produce. This high amount of FSH will stimulate a lot more follicles than usual and help more of them to mature into eggs. An important thing to understand is that FSH will only act on the follicles that a woman’s body will naturally produce each month. Therefore, there is no depletion of the overall egg supply. And when those eggs are harvested during an IVF treatment, they have actually been spared from atresia that would have occurred during that menstrual cycle.
It is also important to note, that whether or not they undergo IVF, women who struggle with infertility are usually already at risk of having poor ovarian reserve and reaching early menopause. One of the tests that can be used to detect low ovarian reserve is the Anti-Mullerian Hormone (AMH) blood test. Egg reserves and AMH levels usually decline with age and can be affected by environmental factors such as cancer treatment or ovarian surgery, as well as inherited genetic causes, endometriosis, tumors, immunological conditions and high body mass index.
With that in mind, studies conducted by research teams around the world, including the British Fertility Society, Queensland University, Australia, and Cornell University, US have confirmed that IVF, even with multiple cycles, does not lead to egg depletion nor early menopause.
Having studied hundreds of IVF patients through the years, these researchers have concluded that IVF does not affect the timing or severity of menopause symptoms. In fact, many IVF patients reach menopause at the average age of just over 50, which is comparable to most national averages and closely resemble that of their own mothers’. The studies also found that most respondents had given birth to at least one child as a result of IVF.