Tag Archives: Fertility Treatment

Unexplained Subfertility

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Woman in tears

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.

 

 

 

 

Age and IVF success rate

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Pregnant Belly

Many couples went through IVF in hope to have a child. Many view this treatment as the last resort to having a child. Therefore, it is not unusual for me to encounter couples who had exhausted ALL forms of treatment and landed in my clinic after many frustrating years. Some had come a bit too late….

Part of my job as an IVF specialist includes constantly being asked by patients on their chances of pregnancy by IVF.

This is definitely a relevant question. IVF is an expensive treatment and certainly after spending XYZ amount money on this treatment, you would like to know what is your chance of pregnancy.

In general, the chance of pregnancy depend on 3 most important factors: The woman’s age, the number of years of subfertility & whether there had been any pregnancies in the past.

Out of these three factors, the most important and relevant factor would be a woman’s age.

Studies had shown that after the age of 35, the chance of women getting pregnant naturally as well as through Fertility Treatment declined gradually. There is a further sharp declined after the age of 40.

I do not mean to press the panic button for all the women over the age of 35. However, I strongly feel that this is an important message which many Fertility Specialists like us had not been shouting loud enough to educate the general public.

Studies from Australia & US had shown that the success rate of an IVF is around 50% before the age of 35. The success rate drops thereafter and hit the range of 20-30% by the time the woman turns 40. The chance of pregnancy after the age of 44-45 is close to 0%.

The reason for a lower success rate after the age of 35 is a combination of the fact that age is associated with decrease number of follicles and quality of the eggs. For women, we are born with millions of eggs and the process of recruitment and activation of eggs started as we reached puberty. The number of eggs in our ovaries go down as we aged. By the time we each menopause, the eggs were completely depleted in our ovaries. Therefore, at the age of 35, we are expected to be producing less number of eggs. As we age, the quality of eggs also decrease and there is higher likelihood to produce eggs with abnormal chromosomes. Therefore, there is a higher risk of miscarriage and fetal anomalies.

 

 

 

 

Doctor, twins please!!!!

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twins

As a mother of a pair of twins, my patients are usually quite curious how I managed to conceive with a pair of twins. Most of them thought that I have been through an IVF myself.

However, the reality is that I did not need to do so. I came from a family blessed with many pairs of twins and there were even triplets (conceived naturally) in my family. Multiple pregnancies gene runs in my father’s family: My 5th & 6th uncles are twins, my 5th uncle went on having a pair of twin girls himself. My first uncle had triplets (conceived naturally) in addition to 6 other children he had (with just one wife, blessed). Nobody suspected that my aunt carried triplets until the second baby was born and the doctor found another baby in the womb. Of course we can’t criticize the doctors then because those days were the days before the advent of ultrasound scans and the use of ultrasound scans for pregnancy only came on 10-15 years later. My first aunt (my father’s only sister) have a pair of twin grand-daughters. If you search long and hard enough, and look thoroughly at my family tree, you will notice that my grandfather’s brothers and sisters are all blessed with twins in their family. If you take all these pairs of twins into consideration, you are talking about probably at least 10-15 pairs of twins in the lineage of my great-grandfather.

How did it happened? We have no idea. We used to think that one would inherit the multiple pregnancy genes through maternal lineage. However, my father’s family had challenged the popular belief. My father used to think that it was the water or the soil around the area where they lived. However, I don’t live near the area where the family came from and I don’t believe that my brief stays of 1-2 weeks yearly as a child at my ancestor home would have contributed to the incidence. My aunt who delivered the triplets did not live around the ancestor home either.

My interesting family history has pre-determined my destiny to be blessed with a pair of twins. And as I am blessed with a job of my dream to help to create babies in the field of Assisted Reproductive Medicine, my profile as a mother of twins has gradually become a fascination for my patients.

I have had many e mails from patients directed to me asking whether I could help them to conceive with a pair of twins.

I felt very privileged by their request but yet find this request daunting because even with all the Fertility Treatment which are available, there is still no guarantee that one could be pregnant with twins.

The incidence of twins is 1:80 pregnancies if you let nature run its course. If a woman takes Fertility pills such as Clomid (Clomiphene citrate) to enhance their fertility, the chance of conceiving a pair of twins is estimated to be around 5-10% if she fall pregnant. If she undergo ovulation stimulation coupled with an intra-uterine insemination (IUI), the chance of her pregnant with a pair of twins is around 10-15%. If she undergo In-vitro Fertilization (IVF), her chance of getting a pair of twins is around 20% if she have had 2 embryos replaced into her womb.

What patient needs to understand is that all Fertility Treatments increase the chance of having multiple pregnancies in different proportions but none will be able to guarantee the outcome.

Having twins is not without its complications. I always like to warn patients but I am not sure whether this goes down well with them. These complications are real but yet we as clinicians find it hard to present it to patients simply because it is not so palatable.

First and foremost, multiple pregnancy poses risk for the expecting mother. There are increased risk of complications such as:
(1) high blood pressure in pregnancy (I was a typical example of such complications, having had fulminant high blood pressure with presence of protein in my urine and required high dependency care and emergency Caesarean section at 33 weeks)
(2) High blood sugar in pregnancy (I escaped narrowly as my test result was near borderline)
(3) Low lying placenta or Placenta Praevia in pregnancy (That too was a concern until 28 weeks and my obstetrician, who happened to be my boss ordered me to stop work at 26 weeks)
(4) preterm delivery (Statistically, 60% of twins are born before 37 weeks. Some of the pre-term deliveries were attributed by the medical conditions in pregnancies which required early delivery)

(5) Anaemia in pregnancy

The risks for the babies include:

(1) Higher risk of miscarriage & stillbirth

(2) Higher risk of early neonatal loss. The risk of death for premature babies around the week of birth is five times higher for twins and nine times higher for triplets than single babies.

(3) Higher risk of prematurity and long stay in Neonatal Intensive Care Unit, half of all twins are born prematurely (before 37 weeks) and have a low birthweight of under 2.5kg (5.5lb); triplets have a 90% chance of being born prematurely and of having a low birthweight. My babies was taken to Neonatal ICu at birth and stayed for 16 days. It was the worst 2 weeks of of my life, having to go through the emotional roller costers for 2 weeks

(4) Higher risk of babies having Cerebral Palsy. Twins are four times and triplets 18 times more likely to have cerebral palsy than single babies.

As for the family, the burden would be:

(1) $$$ (Diapers , Milk Powder, and everything else that requires 2 sets at the same time)

(2) Childcare. Looking after a pair of twins who cried simultaneously, need feeding and changing simultaneously would drive a sane woman insane.

(3) Lack of ZZZZ. A chronic problem as you need to wake up more often in the middle of the night for feeding and changing the diapers

(4) Bigger car required. A MPV is required to fit in 2 car seats and a spacious boot to fit in a double baby prem

So, before you ask me to help you to conceive with a pair of twins, would you consider reading this article beforehand?