Tag Archives: egg quality

What is the cause of my Failed IVFs?

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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
The clinic
The sperm
The eggs
The uterus

Here are some consideration for you:

(1) The IVF Treatment protocol.

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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.

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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-cell-womb

 

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.

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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

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

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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!

 

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Ethnicity can affect IVF success rates

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The Unknown Factor

Ethnicity can affect IVF success rates

For many couples who struggle with infertility, artificial reproductive techniques (ART) like In-Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI) are their only options in the hopes of conception and starting a family of their own. However, if you are considering IVF, it is important for you to learn about IVF success factors that can either boost or hinder your chances at pregnancy.

 

The main factors that may impact IVF success are age, especially of the mother; a history of previous pregnancies or miscarriage with the same or different partner; the type of fertility problem; lifestyle habits; the use of donor eggs and the fertility clinic chosen. However, several studies have contributed another factor for IVF success – a woman’s ethnicity.

 

In an observational cohort study conducted by the Nottingham University Research and Treatment Unit in Reproduction (NURTURE), UK, it was found that live birth rates following IVF treatment was significantly lower in Asian and Black women, as compared with white European women.

The study involved 1517 women, of which 1291 were white Europeans and 226 belonged to ethnic minorities. All these women underwent their first cycle of assisted reproductive technology between 2006 and 2011.

Despite sharing favourable chances of conceiving, such as the quality of their egg reserves, only 35% of Asian and Black women successfully conceived and gave birth after IVF, as compared with 44% of white women who were treated at the same clinic during that period.

The researchers at NURTURE are unsure why this is, but suggest that it could be down to genetics, as well as social and environmental factors. According to lead researcher, Dr Walid Maalouf, “Further research into genetic background as a potential determinant of IVF outcome, as well as the influencing effects of lifestyle and cultural factors on reproductive outcomes is needed.”

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NURTURE’s findings are supported by a research conducted at the University of Kansas-Wichita, USA. The researchers there state that while the average birth rate after IVF using fresh eggs is 25.7%, this figure conceals the wide variation in the success rates for different ethnic groups.

After studying the records of more than 80,000 IVF treatment cycles carried out between 1999 and 2000, they found that the birth rate for black women was 18.7%, 20.7% for Asian women, 26.3% for white women and 26.7% for Hispanic women. They also learnt that black women had the highest miscarriage rate of 22%, compared to 13.9% for white women, 16.4% for Hispanic and 16.2% for Asian women.

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Another US study, by researchers at the University of California, confirmed that Asian women had a lower pregnancy rate than non-Asians. The study looked at 1,200 IVF treatment cycles and found that the birth rate for Japanese, Indian and Chinese patients is about 60 per cent that of white women. However, the team stressed that the differences did not apply to natural conception.

Like the NURTURE team, the US teams are unsure of the reasons for these differences. According to Marion Damewoood, president of the American Society for Reproductive Medicine (ASRM), “The findings were preliminary but important, and we need to further explore these apparent racial differences to see if we can better understand and hopefully address their causes.”

While Asian couples may find these results worrying, it is crucial for all couples to be counselled on their realistic probabilities for IVF success. Based on these findings, Asian women are encouraged to seek treatment earlier to improve their chances of pregnancy.

 

A timely decision

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A timely decision

How age affects your chances of IVF success

Have you been seriously considering In vitro fertilisation or IVF treatment? If you have, it’s best that you understand how your age can affect your chances of success. This is so that you can make an informed decision on when to begin. But before we get into that, let’s take a brief look at IVF and what it entails.

For some couples facing fertility problems, IVF is a viable method that can help them to conceive. During IVF, a woman’s ovaries are stimulated and an egg is removed to be fertilised with sperm in a laboratory. Once fertilised, the egg becomes an embryo, and it is returned to the woman’s womb to develop.

Studies have shown that the success of IVF treatments can be affected by a woman’s age. This is because it’s an inescapable fact that a woman’s fertility declines as she grows older. So if you were to undergo IVF using your own eggs, your chances of conceiving would be higher if you were younger.

According to the Human Fertilisation and Embryology Authority (UK), in the most recent study conducted in 2010, on average, the percentages of live births resulting from women having IVF using their own fresh eggs are: 32.2% for women aged under 35, 27.7% for women aged between 35–37, 20.8% for women aged between 38–39, 13.6% for women aged between 40–42, 5.0% for women aged between 43–44 and 1.9% for women aged 45 and over.

As you can see from the statistics above, a woman’s fertility begins to decline at around age 30 and this exacerbates at about age 38. By the time she is 44, her chances of having babies via IVF with her own eggs is nearly nonexistent at less than 2%. This is why women above the age of 42 are generally discouraged from undergoing IVF, as the success rate is considered far too low.

Most IVF clinics also have an age limit for IVF treatments that use a woman’s own eggs. This is because the age of the eggs is crucial, not the age of the uterus. But, why is egg age so important? Two words – quality and quantity.

 

'It's my biological clock.'

‘It’s my biological clock.’

But what is egg quality? In fertility, an egg’s quality refers to its chromosomal status. As a woman’s age increases, the risk of chromosomal abnormalities in her eggs also rises. During IVF, we hope to obtain multiple healthy embryos, whereby the best ones will be selected for transfer into the mother’s uterus. But before embryos are transferred, we need to check their chromosomal status. Therefore, the embryos undergo Preimplantation Genetic Screening or PGS, which checks for chromosomal normalcy. On average, healthy embryos with normal chromosomes have a much higher potential for implantation and live birth.

Meanwhile, egg ‘quantity’ refers to how many eggs are left in a woman’s ovaries. As such, her egg quantity is often called her “ovarian reserve”. Although egg quantity doesn’t greatly impact the chances of a natural conception, in IVF, egg quantity may influence a woman’s response to ovarian- stimulating medications.

So if you’re considering IVF, don’t hesitate to ask questions and seek the advice of a fertility consultant. The information you receive can help you make a decision on when best to start your treatment.

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Unexplained Subfertility

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Like most Fertility Specialist, we faced patients with all kinds of fertility problems everyday. One of the most unique group of patients would be those who are categorised as unexplained subfertility.

 

It is the most frustrating & awful diagnosis for the patients. These patients are generally well but frustrated. The label of unexplained subfertility is a diagnosis of exclusion, which means that these patients had gone through most of the tests for subfertility and all the tests came back with normal results, but yet they are not able to get pregnant naturally.

 

In general, up to 10-25% of couples will not find any causes for their subfertility after going through fertility testing. This diagnosis can be frustrating as many of them would wonder: why is it they have not achieved a pregnancy given that all the test results had been normal?

 

The important thing to note is that even though all the tests are normal, it does not mean that there are no factors that prohibit them from having a baby naturally.

 

It is important to note that most of the fertility tests are mainly simple fertility tests. These tests do not necessarily assess function.

 

For example, despite showing both of your Fallopian tubes are patent through a dye test (hysterosalpingography, HSG) or a diagnostic laparoscopy, it does not necessary translate that the Fallopian tubes function are good and it does not necessarily ensure normal transport of eggs and sperm in the Fallopian tubes as there has not been a valid test for this. We know that Fallopian tubes were lined with multiple fine hairs (cilia) within the tubes, and the function of these fine hairs is to transport the eggs and sperms to meet at the most suitable place to encourage fertilisation. The cells in the Fallopian tubes also produce secretions to encourage the process of fertilization. Although the Fallopian tubes were patent, if these functions of the Fallopian tubes were poor, fertilization fails to occur. Unfortunately, there are still no tests for these conditions.

 

There are also conditions whereby there are poor quality of eggs or poor functionality of the sperms which attributes to this diagnosis. As Fertility Specialists, we can visualized the number of eggs you have and measure the hormones which governs egg productions. However, there is no valid test to check the quality of the eggs until the day one goes through an IVF (in-vitro Fertilization) where the doctors and the embryologists would be able to examine the eggs under microscope. Therefore, apart from being a treatment, IVF can be a diagnostic tool in its own right.

 

The same principle applies to the functionality of the sperms. During semen analysis, we can see the number, the activity, speed and shapes of the sperms. However, there is no test to check whether the sperms can fertilize eggs until the day we perform an IVF using these sperms. Again, IVF becomes a diagnostic test in this scenario.

 

If you had been diagnosed with unexplained subfertility, my advice to you would be not to leave it for ‘nature to take its course’. There maybe other underlying conditions whereby the current fertility tests available are unable to address the issues or to diagnosed the condition. It is important to put things into perspective and move on with Fertility Treatment.