Double Joy, Double Trouble?

 

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The occurrence of identical twins after a single embryo transfer

Even after many years of being a doctor, it still brings me immense joy to announce to my patient that she is indeed pregnant following a successful infertility treatment. And sometimes, the happiness is multiplied, as there isn’t one, but two buns in the oven!

 

In general, it is widely known that the occurrence of multiple births is much higher following assisted reproductive technologies (ART) as compared to incidences of twins in natural or spontaneous pregnancies. This is directly related to the number of embryos transferred back to the uterus. In general, if 2 embryos are transferred back into the uterus, the chance of having twin pregnancies is around 20-30%. As we all know, twin pregnancies carries more risks to the expecting mother as well as the babies. The risks of miscarriage, bleeding in pregnancy, high blood pressure, diabetes in pregnancy, Placenta Praevias, Caesarean Sections are some of the significant obstetric risks. The babies are also at risk of preterm births, stillbirths and complications associated with preterm deliveries such as cerebral palsies.

 

Therefore, in many countries especially in the west, it is mandatory that the patients are informed of these risks before an embryo transfer. Some countries had restricted the number of embryos transferred to one. This move had significantly reduce the incidence of twins following an IVF and had reduced the economic burden associated with medical care of pregnancies associated with twins

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However, in recent years, it had been reported that there is a higher incidence of identical twins following single embryo transfer.

 

While the incidence of fraternal twins following the transfer of two embryos is an easily understandable consequence of IVF, the causes for identical twins after ART remain speculative at best. However, there is some evidence that attributes the phenomenon to the micromanipulation techniques, length of culture and culture medium used during treatment, as well as the genetics of the parents.

Identical twins, also known as monozygotic twinning or MZT, occur when an egg and a sperm unite to form a single zygote that divides into two embryos or separate individuals. It is a rare phenomenon, which occurs in only about 1% of natural conceptions. However, in assisted conceptions, the occurrence of monozygotic twinning almost doubles.

 

The splitting of the zygote into separate embryos can occur at any time during the first 2 weeks after fertilisation. However, the timing of the split will influence the type of identical twin. For example, in around 1/3 of MZT cases where the split occurs within 72 hours of fertilisation, the result is two placentas and two amniotic sacs. In the remaining 2/3 of MZT cases, the splitting occurs 4-8 days after fertilisation, resulting in one placenta and two amniotic sacs. And in about 5% of MZT cases, where splitting occurs 8-13 days after fertilisation, the outcome is one placenta and one amniotic sac. In very rare cases, the outcome is conjoined twins.

 

Although the prospect of having twins is certainly exciting, couples must also understand that twin pregnancies are considered high risk. They can lead to various pregnancy complications with long-lasting and even permanent effects for the children. These include caesarean section, premature birth, low birth weight, Twin-Twin Transfusion Syndrome (TTTS), pre-eclampsia, gestational diabetes, fetal abnormalities and congenital abnomalies. In view of the complications that can arise from a twin pregnancy, do speak to your infertility consultant about the risks involved should you have any worries.

 

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PCOS – What you should know

 

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PCOS – What you should know

As a fertility doctor, I see women who are troubled by Polycystic ovary syndrome (PCOS) on a daily basis. Most of them come to see me because they have difficulty in trying to conceive and some of them have irregular menses, but many of them are unaware of their condition. Polycystic ovary syndrome (PCOS) is a relatively common health problem, affecting an estimated 1 out of 10 women of childbearing age. However, many women who come to see me are either unaware or misinformed about PCOS. To help dispel some of the misconceptions about PCOS, in today’s blog I’ll be explaining what PCOS is, what causes it and how it can be treated.

 

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What is PCOS?

PCOS is a condition whereby small ‘cysts’ develop on a woman’s ovaries. In actual fact, these ‘cysts’ are not actually cysts per se, but are ovarian follicles which contain eggs. A healthy young woman will usually have about 5-10 follicles in each ovary, however, in the case of PCOS, each of the ovaries contain more than 10-12 follicles. Although these follicles are a sign of abundance in egg numbers, they cause the body to have hormone imbalances. Because hormones are chemical messengers, responsible for triggering various different processes in our bodies, when a hormone imbalance occurs it causes detrimental chain reactions.

For example, PCOS can cause the ovaries to produce more androgens (male sex hormones), which disrupts ovulation, causes irregular periods, as well as causes acne and extra body or facial hair. PCOS can also cause insulin resistance, which increases blood sugar levels and can cause diabetes over time.

Other health issues caused by PCOS are metabolism problems, heart disease and infertility. If you have a family history of PCOS, on either your mother or father’s side, your chance of getting it is much higher.

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PCOS Symptoms

Most women with PCOS share a number of common symptoms such as weight gain or trouble losing weight; extra facial or body hair (especially on the face, chest, belly and back); hair thinning on the scalp; irregular, few or no periods; heavy periods; fertility problems and depression. You may have many or just a few of these symptoms.

Diagnosis

In order to diagnose PCOS, your doctor will begin by asking you a series of questions about your health, symptoms and menstrual cycles. This will be followed by a physical exam, which will look for excessive body hair and high blood pressure, as well as take note of your body mass index (BMI). Next, some of your blood will be drawn to test your blood sugar, insulin and other hormone levels. Finally, you may have a pelvic ultrasound to look for cysts on your ovaries. Early diagnosis and treatment is crucial, as it can help you to control the unpleasant symptoms of PCOS, as well as prevent long-term health problems.

Treatment
Positive lifestyle changes can have a profound effect in treating PCOS. They not only reduce the unpleasant symptoms that you may experience, but also help prevent long-term health issues.  To kick start your PCOS treatment, fit in moderate to vigorous exercises to your daily routine, such as walking, swimming, aerobic dancing and bicycling.

You should also eat a healthier diet, comprising of lots of vegetables, fruits, nuts, beans and whole grains. You should also reduce your intake of high calorie food which are high in saturated fat and carbohydrate. These life style changes will improve your weight and reduces insulin resistance. If you are a smoker, quite smoking as it causes you to have higher androgen levels. Most polycystic women will also benefit from weight loss, which can help balance out your hormones and regulate your ovulation and menstrual cycle.

In addition to lifestyle changes, your doctor may prescribe you with medication to help reduce any symptoms you might be suffering, as well as to help you get pregnant. The common medications are ovulation inductions drugs, such as Clomiphene Citrate (Clomid) or FSH hormones injections. This will help you to ovulate naturally and increase your chance of pregnancy. Your doctor may also prescribe Metformin, which is a medication to reduce insulin resistance. This in turn will help to reduce weight, increase natural ovulations and reduces the androgenic effects of PCOS.

Laparoscopic ovarian drilling was once a popular surgery in reducing the effect of high androgens in PCOS patients. However, recent studies revealed that the effect of laparoscopic ovarian drilling is short-lived, i.e. the menstrual irregularity returns after a few months. On top of that, laparoscopic ovarian drillings has other adverse effects on women’s fertility, such as premature ovarian failure, adhesion formations causing tubal obstructions etc. Laparoscopic ovarian drilling is invasive and expensive especially in private settings.  Therefore, it has become difficult to justify its cost against its effectiveness.

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In some women, whereby there are other associated problems such as tubal obstructions or husbands’ sperms are weak or low in numbers, an IVF (In-vitro Fertilisation) treatment may be necessary and cost effective to achieve a pregnancy

Should you have any questions or concerns about PCOS and how it is affecting your health and chances of conceiving, as always, don’t hesitate to speak to your fertility consultant.

 

Insulin resistance and miscarriage

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The loss of a pregnancy or miscarriage is something that most couples rather not think of. However, it’s important for couples to understand why miscarriages can happen, especially as it can be caused by various factors and steps can be taken to lower the risks. The common causes of miscarriage are anatomical causes (like uterine abnormality), genetic causes, immunological disorders and hormonal imbalance. In this article, I will address one of the most common types of hormonal imbalance known today – insulin resistance.

Insulin resistance is a condition whereby levels of sugar, estrogen and testosterone in the blood are raised, while progesterone levels are lowered. The result is an excess of glucose in the bloodstream, which leads to prediabetes, diabetes and other serious health disorders. In pregnancy, insulin resistance causes a variety of concerns, such as delayed fetal growth and gestational diabetes.

Several scientific studies have also found that insulin resistance can lead to miscarriage. One such study was carried out by a team of researchers at the Reproductive Medical Centre, Peking University, People’s Hospital, Beijing, China. After examining 107 patients that achieved their first pregnancy after infertility treatment, they came to the conclusion the risk of miscarriage can be directly linked to insulin resistance.

A team from the Obstruction & Gynecology Department, Babol University of Medical Science, Babol, Iran offered similar findings, when they proved that women with elevated insulin levels are at a higher miscarriage risk.  As worrying as this is, it must be noted that insulin resistance doesn’t just heighten the risk of miscarriage; in fact, it has been shown to increase the risk of multiple miscarriages.

Several published studies have confirmed this, such as one by a team from the Department of Obstetrics and Gynecology at Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou. After investigating the differences in insulin resistance between women with recurrent miscarriage and those with normal pregnancy, they concluded that insulin resistance increases the risk for recurrent miscarriage during the first trimester of pregnancy.

The crucial link between insulin resistance and recurrent miscarriage was echoed in a prospective clinical study by a team of researchers from the Department of OB & GYN, Shiraz Medical University, Iran. Their study found that 39% of women with recurrent miscarriage have abnormal oral glucose tolerance test (OGTT) results. The OCTT, which measures the body’s ability to use glucose, is often used to check for insulin resistance and gestational diabetes.

Meanwhile, a team from the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, USA concluded that 27% of women with repeat miscarriage have high fasting insulin, despite normal glucose levels.

Insulin resistance is also associated with Polycystic Ovarian Syndrome or PCOS, which is why women with PCOS struggle with infertility. The condition raises levels of estrogen and testosterone in the body, while lowering progesterone levels. This interferes with the normal development of follicles in the ovaries, causing problems with ovulation.

However, if you have PCOS or insulin resistance and wish to undergo infertility treatment, hope is not lost. There are steps you can take to improve your insulin resistance sensitivity through lifestyle changes or medical intervention, before you undergo infertility treatment. Please don’t hesitate to speak to your infertility consultant should you have any concerns about insulin resistance. Your doctor can advise you on ways to reduce your risks and increase your chances for a safe pregnancy.

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TV2 你怎么说 What Say You – 兹卡病毒入侵大马,怎么预防? – 林韵璇医生 Dr Helena Lim

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目前医学界对兹卡病毒束手无策,大众尽能防范,避免被病毒传染。待孕或受孕的妇女更得额外当心,避免祸害胎儿。全民关注环境卫生,联手打击兹卡病毒。

 

BFM:DOCTOR IN THE HOUSE – PERIOD TRACKING APP

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Dr George Lee returns to discuss the latest medical news. Expect deep insights delivered with generous humour. Dr Helena Lim joins him this week to discuss period-tracking apps and whether it makes her work as a Consultant Obstetrician and Gynaecologist easier, or more difficult.

Dr George Lee is a renowned Urologist who dealt with male issues, whereas Dr Helena Lim is a Fertility Specialist

Find out more about what they have to say:

http://www.bfm.my/george-lee-helena-lim-period-tracking-apps.html

 

 

 

 

 

 

 

What you should know about PGD & PGS

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What you should know about PGD & PGS

If you and your partner have been struggling with fertility issues and are seriously considering In-Vitro Fertilisation or IVF, the consideration of whether you should be undergoing PGD and PGS on top of an IVF can be quite daunting. This is because, in normal IVF procedures, the best embryos are selected based on their appearance and morphology only. Therefore, the genetic content of those embryos or any chromosomal abnormality cannot be detected. However, by undergoing PGD and PGS, you will be able to screen your embryos for any potential genetic and chromosomal issues.  However, before we jump into the band wagon of having PGS or PGD, there are a few things we need to consider.

 

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What is PGS?
PGS stands for Pre-implantation Genetic Screening. In PGS, a cell is taken from an embryo  which was created following an IVF procedure, so that it can be tested for chromosomal abnormalities before the embryo is transferred to the womb. This test will be able to tell us whether the embryo has normal sets of chromosomes. However, it will not be able to tell us whether this embryo has a genetic problem or not.

It is important to note that not all the patients going through an IVF required a PGS. You may want to consider it if:

  • You are of advanced maternal age, whereby embryos may show greater levels of chromosomal abnormalities.
  • You have had recurrent miscarriages.
  • You have had repeated IVF failure.
  • Either of you has a chromosome rearrangement.

The PGS procedure involves:
1. You will undergo a normal IVF treatment and your eggs will be collected and fertilised.
2. An embryo is grown in the laboratory for a few days.
3. An embryologist will perform a biopsy and remove a few cells, usually on day 3 or 5.
4. All 24 chromosomes are analysed (22 non-sex chromosomes and two sex chromosomes X & Y).
5. If the embryo is normal, it will be transferred into your womb.
6. Any remaining unaffected embryos can be frozen for later use.
7. Affected embryos will be allowed to perish.

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What is PGD?
PGD is an abbreviation for Preimplantation Genetic Diagnosis. In PGD, a cell is taken from an IVF embryo so that it can be tested for a specific genetic condition before the embryo is transferred to the womb. It can be used to test for any genetic condition that is known to be caused by a specific gene.

At present, PGD is used to screen for more than 250 genetic conditions, such as Huntington’s disease, Cystic fibrosis, Thalassaemia, Duchenne muscular dystrophy and Fragile-XPDG to name but a few. Therefore, PGD enables individuals with an inheritable genetic condition to avoid passing it on to their children. The PGD process is more tidious and challenging compared to PGS. It is used to test for a specific genetic disease which is known to your family, i.e. you or your partner is confirmed a carrier of a specific gene at a certain point of the chromosome. You need to bear in mind that by performing a PGD, it does not mean that screening of ALL genetic diseases are performed at the same time. This is because human beings have millions of gene and it is impossible to screen ALL of the genes in one go.

However, not all IVF patients need to undergo PGD. You may want to consider it, or your specialist may recommend it to you if:

• You or your partner (or both) are carriers of single gene mutations.
• You ended a previous pregnancy due to a serious genetic condition.
• You have a child with a serious genetic condition.
• Either of you has a family history of a serious genetic condition or chromosome problems.

The PGD procedure involves

1. You will undergo a normal IVF treatment and your eggs will be collected and fertilised.
2. An embryo is grown in the laboratory for a few days, until it has divided into around 8 cells.
3. An embryologist will remove one or two of the cells from the embryo.
4. The cells are tested to see if the embryo has a gene that causes a genetic condition.
5. If the embryo is free of any genetic condition, it is transferred to the womb.
6. Any remaining unaffected embryos can be frozen for later use.
7. Affected embryos will be allowed to perish.

Since PGD and PGS help detect genetic conditions and chromosomal abnormalities, they help IVF patients to decide if they wish to continue with pregnancy.

The Pros and Cons of PGD and PGS
Before you decide on undergoing PGD or PGS, your fertility consultant will explain their pros and cons to you, which include:

Pros

  • They can detect an inherited chromosomal or genetic issues and help prevent passing chromosomal or genetic diseases to the next generations
  • They are a form of early detection of chromosomal or genetic problems before the embryo is transferred back into the uterus.
  • They help increase a couple’s chances of conceiving a healthy child.
  • It allows older women to still have viable children.

Cons

  • There is a risk that embryos may be traumatized or destroyed due to damage during the biopsy process.
  • There is always a possibility of an undetected disease, as no form of testing can guarantee 100% accuracy
  • The test is expensive
  • You may not have any embryos to transfer after the IVF & PGD/PGS , which is frustrating for patients because after investing time, money & effort, the result can be disappointing
  • There is no guarantee that an embryo which had been screened will definitely get implanted after being transferred into the uterus. Therefore, there is no guarantee that a PGS/PGD embryo will give you a life birth.

If you and your partner are interested in or have any concerns about PGD and PGS, be sure to speak to your fertility specialist to address concerns, inquiries and options.