Recently, a large study of 1.8 million Danish women found that hormone contraceptives cause a small but significant increase in the risk for breast cancer. We speak to consultant obstetrician & gynaecologist Dr Helena Lim to find out if women should be alarmed.
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When it comes to family planning, women bear a disproportionate amount of the responsibility. There are very few male methods for family planning that are both practical and effective. Consultant obstetrician and gynaecologist Dr Helena Lim explores what’s on the horizon for safer and better family planning methods.
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Question: My doctor told me that my husband’s sperm and my egg quality were poor. Does it mean that I have no chance of getting pregnant with IVF?
Dr Helena’s Answer:
To achieve a successful pregnancy, may it be naturally or through assisted reproduction techniques, requires some basic pre-requisite factors:
(1) good quality and quantity of eggs and sperms to make good quality embryos
(2) a conducive uterus environment for implantation
In some cases whereby the husband’s sperms were poor in quantity & quality, whereby natural conception is virtually impossible, a Intracytoplasmic sperm injection (ICSI) technique to fertilize eggs during an IVF cycle overcomes certain degree of difficulty to create an embryo. However, if the sperms are extremely poor in quality, there are good scientific evidence to suggest that Fertilization and cleavage rates, quality of embryos as well as blastocyst development rates were significantly reduced, as semen quality decreased.
An IVF cycle can also be unsuccessful if egg quality is poor even with good numbers of eggs (and embryos). Egg quality reflects about 95% of the final quality of an embryo. Poor egg quality, therefore, always leads to poor embryo quality. The quality of sperm, while not unimportant, is nowhere near as important as egg quality.
Embryos from low-quality eggs often fail to develop properly. In an IVF cycle, embryos are observed for 3 to 5 days as they grow, before they are transferred into the uterus. On the third day, good-quality embryos should reach 6- to 8-cell stage, and have a more or less regular shape. Embryos that don’t reach this stage within the first few days of development cannot be used for embryo transfer. In addition, some embryos that do reach this stage may be aneuploid (have chromosomal abnormalities). Aneuploid embryos, if they implant at all, are usually miscarried early in the pregnancy, thus also resulting in “failed” IVF.
Therefore, as many of our patients already know, it is not just the number of eggs that is important. The quality of eggs is also crucial for the success of IVF.
Although some people are born to have poor sperms or eggs, majority of poor sperms and eggs can be improved by various means. Change of lifestyles such as stop smoking, stop alcohol intake, exercise moderately, weight reductions, good quality sleep, good nutrition by taking balanced diet, taking food rich in anti-oxidants, acupuncture and etc are some of the strategies one can employ to improve sperms and eggs quality.
Numerous studies had shown that with these improvements in lifestyle, the success rates of IVF in these group of patients improve remarkably.
Therefore, if your doctor had commented that your sperms and eggs are not good in quality, it maybe a good idea to look into your lifestyle and food intake to improve your chances of pregnancy.
Question: I am current 40 years-old and would like to know what is my chance of getting pregnant with IVF. Can I choose the gender of my baby when I go through an IVF
Dr Helena’s Answer:
One of the biggest single determining factor for IVF success is the woman’s age. Before the age of 35, the IVF success rate is around 60-80%. After the age of 35, the success rate drops to 40-60%. The success rates of IVF drop drastically after the age of 40 to about 20-30% and then 1-2% after 45.
The reason for this is because as women aged, the number of follicles produce each menstrual cycle drop drastically. The quality of eggs also deteriorate as we age. As we aged, the division of chromosomes in our ovaries can become more imperfect, resulting production of eggs with faulty sets of chromosomes, leading to increase number of abnormal eggs and henceforth abnormal embryos.Therefore, women over the age of 40 has a lower rate of pregnancy with each individual IVF cycle, compare to their younger counterparts
This is a macroscopic view of the general population of women after the age of 40. However, an individual’s success rates is also dependent of her body condition, her ovarian reserves and her uterus receptivity. No two women at the age of 40 is exactly the same. A healthy 40 year-old woman with good ovarian reserves is more likely to produce good number of good quality embryos. Her counterpart who smokes and drinks, eats badly and have poor ovarian reserves is more likely to fail her IVF attempts.
Recently, advances in Pre-implantation Screening (PGS) tests allowed us to biopsy embryos at blastocyst stage to select embryos which is normal in chromosomal make-up before embryo transfer. This test is extremely useful in determining which embryo is more likely to get our patients pregnant. However, like all the tests in this world, it comes with its problems as well. First and foremost, PGS is still expensive, and this test can only be done on embryos created from IVF, which then increase the cost of the IVF cycle. If the embryos tested showed that all the embryos are abnormal, there is no way we can change or treat these embryos and make them chromosomally normal. And therefore, some patients may end up not having any embryos which is suitable for transfer after an IVF with PGS. However, if this is the scenario, the couple can then move on quickly to another cycle of IVF to collect more embryos for PGS, hence, shortening the time required to find the ‘right’ embryo to achieve pregnancy.
Although this technology is able to reveal the gender of the embryo, one must realize that the use of such technology to perform gender selection in STRICTLY Prohibited in this country and also most countries in this world. It is important to note that IVF and PGS are technologies to help couples to achieve a healthy pregnancy and must not be misuse for ones’ whims and fancies. Science and technology should be use sensibly to maintain and restore nature’s balances and any manipulation as such can potentially tip off the balance and create potential disasters to mankind.
Question: I have recently failed my IVF, when can I try IVF again?
Dr Helena’s Answer:
The world of IVF is a roller coaster for many patients. As much as IVF brings loads of joy with the success of pregnancies, at the flip side of the coin, IVF can also potentially fail, and left one wonders why it didn’t work.
There are many reasons why an IVF didn’t work out. It is sometimes impossible to find out the exact cause because most of the time, the existing science or technology may not be able to fully pin point the cause, for example, the endometrial receptivity. Science told us that almost 60-70% of the failure rates was caused by chromosomal abnormality of the embryos. This had been one of the reason why the uptake of Pre-implantation genetic screening tests had been rapidly increasing for the last couple of years. However, even in the presence of chromosomally normal embryos, the implantation rate is still ranging between 60-70%, leaving 30-40% of failure rate unanswered.
When your first IVF didn’t work out, one may need to ask what was the cause, find out the solution and then decide on the timing of your next IVF journey. Remember IVF failure sometimes gives the doctors valuable information and insight into your fertility problems. Rushing into another IVF immediately without realigning your strategies may not be the best solution for your problem.
If you have some embryos frozen during your first IVF cycle, you would not need to repeat another IVF cycle. All you need to do is to have the frozen embryos thawed and transfer during the next cycle. This can be done either with medicated cycle or under natural menstrual cycle. This can be done the following cycle after taking a break of a month.
However, if you have no embryos frozen and needed to start another IVF all over again, the earliest one could start the injections would be after a month of break. This is to let our body recover after the previous rounds of hormonal injections. This period of break also gives us plenty of opportunities to look back at the previous failed IVF, identify what are the possible causes and take measures to improve our body condition before the next IVF.
Question: We are thinking of having an IVF but we are not sure which IVF Centres we should choose. Are all IVF Centres the same? What are the factors we should take into consideration?
Dr Helena’s Answer:
The world of Assisted Reproductive Medicine had evolved rapidly and the demand for reproductive services had increase by leaps and bounce as fertility rate in many countries had dropped dramatically. In Malaysia, the demand for fertility services had led to the establishment of many fertility centres.
However, are all fertility centres and fertility the same? What are the factors and issues we need to consider when choosing a fertility unit or a particular Doctor?
Here are some useful tips on how you choose your doctor and the fertility centre
(1) Does the fertility centre has good reputation for its success rates and quality control?
Unlike in other countries such as Australia or UK, in Malaysia, there is no compulsory reporting system for a fertility unit’s success rates and live birth rates. Therefore, it is extremely hard to get information about a particular Centre’s success rates. Some centres do publish their rates on their website, but again these rates are not verified by authorizing bodies and the way of calculation of success rates differs from one centre to another, making it very difficult to compare apple to apple. Therefore, it maybe worthwhile to check with people you know who had been through IVF at these centres, to gather more information about a particular centre
Due to a recent incidence of mixing-up patient’s gametes in one particular centre in Singapore, many countries such as Singapore had now made it mandatory to have international accreditations for the fertility centres in order to have license to operate. Although this has not been the case in Malaysia, a small number of reputable IVF centres had been granted international accreditation after going through robust auditing process. One of the example of this accreditation is called RTAC Certification. The Reproductive Technology Accreditation Committee (RTAC) is a subcommittee of the Board of the Fertility Society of Australia and reports directly to that Board. It is charged with the responsibility of setting standards for the performance of ART through an audited Code of Practice and the granting of licences to practice ART within Australia. It further licences an International Version of the Code of Practice for the use by Certifying Bodies in countries outside Australia and New Zealand. These are some important markers to ensure good quality control and would serve as one of the key deciding factors for patients when they choose a particular IVF centre.
(2) Does the fertility centre has qualified doctors and lab scientists?
Fertility doctors are mainly Gynaecologist with special interest and training in Fertility. The lab scientists are called embryologists and their training involved reproductive lab sciences. It maybe worthwhile checking the doctors and embryologists qualifications to ensure they have the appropriate training to handle your IVF.
(3) Does the team at the Fertility Centre make you feel comfortable?
Fertility journey can be a daunting experience and hence a professional team who makes you at ease is important to support you through this journey. A team who is genuinely concerned about your wellbeing, sincere about helping you in every step of your fertility journey is the backbone to your fertility success
(4) Did the doctor spend enough time assessing your fertility issues and personalized your treatment plan?
Many people has a misconception that IVF is a standard cookbook and the doctor/ fertility centre just need to follow the recipe to achieve a pregnancy. Whilst this conception is true to some extent when it involves standard operating procedures in IVF, however, there are areas with subtle differences which can make a whole lot of difference to the outcome of an IVF. Variation such as choices in types of protocols used in patients, dosage and types of medications, clinical monitoring, protocols in the fertility lab and decisions on the timing of embryos transfers are some of the examples. A good IVF Doctor would be able to critically analyze a couple’s fertility problem and personalize the treatment plan for individual needs
(5) Does the fertility centre has new technology which has been proven useful clinically?
IVF world is always full of excitement with advent of new technology everyday. As much as we would like to embrace all the new technologies by investing on new machines and lab equipment, which in turn would increase the cost of IVF for patients, one need to ask whether these new technologies are proven useful clinically. Therefore, it is important to find out whether the added tests/ technology on the standard IVF is indicated for your condition. It is important to discuss with your doctor the risk and benefit of the extra tests/ technologies before going through your IVF.
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