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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BFM: STIGMA AND MEDICAL CONDITIONS

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What do mental health, HIV, and erectile dysfunction have in common? These are just some well-known medical conditions that are still highly stigmatised. Why are some medical conditions stigmatised and how did some of them manage to break the stigma? Upper GI and Bariatric Surgeon Dr Reynu Rajan shares her experience dealing with bariatric patients in the face of weight-bias and discrimination, while Fertility Specialist Dr Helena Lim shares what it’s like to help patients overcome the taboo of infertility.

http://www.bfm.my/reynu-rajan-helena-lim-medical-conditions-stigma.html