Endometrial scratching to improve IVF success rates

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Endometrial scratching to improve IVF success rates

Couples who are struggling with infertility often seek In-Vitro Fertilisation (IVF) treatment in order to improve their chances of starting a family. But what happens when you have gone through multiple unsuccessful IVF cycles? Is there something else you can try?

Many patients who’ve experienced this first hand, have asked me this question, eager to try out something new to enhance their chances in the next IVF cycle. Therefore, today, I’d like to tell you more about a procedure called endometrial scratching, which has become increasingly popular in recent years.

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What is it?

Endometrial scratching is a procedure that involves agitation of the endometrium, which is the mucus membrane that lines the uterus. For conception to occur, a fertilised egg has to successfully implant itself into the wall of the uterus. Sometimes, implantation fails, usually due to the quality of the embryo or the receptivity of the endometrium. In endometrial scratching, a fertility specialist passes a special thin catheter or pipille through a woman’s cervix. The pipille is then moved up and down to gently make tiny scratches or scrapes in the uterine lining.  The similar effect can also be achieved by introducing a hysteroscope through the cervix to visualised the lining of the uterus during polyps removal.

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Why is it done?

In theory, endometrial scratching is believed to trigger the uterus to repair itself and develop a new lining, which will be more receptive to an embryo implanting. While the effectiveness of the procedure needs further investigation, studies that have been done on endometrial scratching in recent years have shown encouraging results.

One such study was conducted by the University of Nottingham, UK, which involved 158 women who had undergone unsuccessful IVF procedures. The women were divided into two groups, with one group given the endometrial scratching procedure. As a result, they found the women who had undergone the scratching procedure achieved a 49% pregnancy rate, compared to 29% in the other group.

In another study involving 1000 women, presented at the annual meeting of European Society of Human Reproduction and Embryology (ESHRE), endometrial scratching is said to increase pregnancy success rates for couples trying to conceive naturally or with Intrauterine Insemination (IUI).

When is it done?

The endometrial scratching procedure is usually recommended for patients who’ve experienced multiple unsuccessful IVF cycles or Intracytoplasmic Sperm Injection (ICSI) treatment. The procedure is best performed prior to a woman’s period or right after the period. It is done before an IVF or frozen embryo transfer (FET) cycle begins.

Does it hurt?

While the endometrial scratching procedure has been described as generally painless, requiring no anaesthetic, some women do experience discomfort during and after the procedure. The pain is similar to period cramps and there may be slight bleeding afterwards. To help with possible discomfort, patients are advised to take over-the-counter pain medication about an hour before undergoing the scratching procedure.

If you’ve gone through several IVF attempts and are keen on learning more about endometrial scratching, take the next step and ask your fertility specialist if it is right for you.

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Anti Mullerian Hormone (AMH)- The Ultimate Ovarian Reserve Test?

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.

 

AMH testing
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?

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.

 

 

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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