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.

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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

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Does IVF has 100% of pregnancy rate ?

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Question: My husband & I had tried conceiving through IVF but did not succeed. If we try IVF again, would my chances of getting pregnant lower than others? How do I increase my chance of success?
Dr Helena’s answer: The advent of IVF had greatly revolutionize the world of reproductive medicine. Millions of babies had been born, as the result of IVF. Without IVF, the birth of these babies would not had been possible due to various infertility issues
 
However, is IVF a magic bullet with 100% of pregnancy success rates? 
 
The answer is no, as we know, IVF’s success rate is not 100%.  
 
A few important factors associated with success rates of IVF is women’s age, the duration of Subfertility and whether there is any previous history of pregnancies. Some other factors includes the quality and quantity of eggs, sperm quality & lifestyle and habits 
 
For couples who didn’t succeed in getting pregnant during their first round of IVF, it is logically to wonder, whether they will ever get pregnant in their subsequent cycles of IVF
Generally the overall success rates of ONE IVF for a woman who is under the age of 35 is around 60-70%. We also know for a fact that a frozen embryo transfer has a higher pregnancy rate compares to a fresh embryo transfer.  For most women under 35, there is a good chance that she produces more than 2 good quality embryos each IVF cycle. most of the time, these excessive embryos can be frozen and can be used in the future. Technically speaking, ONE IVF cycle can potentially resulting more than one pregnancy, if the woman has lots of embryos and keep coming back to get them transfer into her uterus.
 
Coming back to the question, we know for sure that if you have a good number of embryos from the result of ONE IVF, the chance of you getting pregnant with the subsequent Frozen embryo transfer is extremely likely, especially if you are under the age of 35

However, if you have no embryos frozen, what is your option?

This chart below showed a cumulative live IVF births from a study conducted.

 

Cumulative Birth Rates

This study looked at all the women under the age of 42, who are going through IVF.

The study revealed that the pregnancy rate is around 40% in this group of women after they completed their first cycle of IVF. For those women who did not get pregnant the first round and went on having the second round of IVF, there were another 20% who got pregnant after the second round. Therefore, by the 4th IVF cycle, around 80% of women would have achieved a live birth.

 

This statistic clearly shows that if you  persevere and keep moving on, chances of you getting pregnant by the end of the 4th IVF is around 80%.

Baby

Therefore, it is not unusual for Fertility doctors to encourage our patients to keep moving on because the statistics had clearly show us the evidence.

To improve your chance of pregnancy for the next IVF, it is important to improve the quality of your eggs and sperms by eating healthy and  improve lifestyle, quit habits which can potentially jeopardize your success rates such as smoking, alcohol and stress. Speak to your fertility doctor about what are the other options in your IVF treatment.

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Is IVF Painful?

 

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Question: I am a person who is fearful of pain. I gathered that going through IVF will required multiple injections, surgery and other procedures which are painful. Is it true?

Dr Helena’s answer:

IVF sounds daunting to many people. A lot of us have perceptions that it is extremely expensive. Some of us thinks that it would bring us a lot of inconvenience, such as having to go to hospital everyday, lay in bed for a few months, quit our job and etc

One of the greatest fear many had was the perception of pain associated with IVF procedures. The thought of having daily injections made most of us wanting to run away and hide from the doctors. Some people are scared thinking about the egg retrieval procedures. Some are dreading the embryo transfer procedure, thinking that it would bring great pain and discomfort. Some dread the injections which are taken after the procedure, which are the progestogen injections, aimed to support the lining of the uterus whilst the embryos are implanting.

However, with the new development and breakthroughs in the world of reproductive medicine, IVF procedures had become more and more comfortable and easy to management, with minimal disruption to daily life.

First and foremost, the durations of injections had been shortened significantly with the use of antagonist injections in IVF. This method of doing IVF is called the antagonist cycle or the short protocol. So, instead of having 3 weeks of injections in the agonist cycle or long protocol, the advent of antagonist injections had lead to a shortened period of 10-12 days of injections. This had greatly reduce the discomfort one needs to go through with injections.
Ovulation-Induction_ShortProtocol
The use of self-administered FSH injection pens with extremely fine needles, had significantly cut down the pain one experienced during injections. This self- administered injections pens are given to patients to take home, and the injections are administered by patients themselves, so patients do not need to come to the clinic or hospital to have their daily injections. The needles used are similar to the ones used in the insulin injection pens, which is extremely fine and almost painless.

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There is also another long acting FSH injection which given at the beginning of an IVF cycle and can last for 7 days. After the initial injection, the patient need not take FSH injection for the next 7 days, which significantly cuts down the number of injections required.

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The egg retrieval procedure which usually happened after 10-12 days of injections involved having a light sedation in an operating theatre. In the past, the use of certain sedations such as Valium, Dormicum or pethidine administered by the IVF doctors whilst performing the egg retrieval procedure had appeared to be increasingly unsafe. In many IVF units, a proper IVF operating theatre with a trained Anaesthetist giving sedation during the egg retrieval procedure is becoming a norm and deemed acceptable in terms of safety. One of the advantage of the involvement of an Anaesthetist is that egg retrieval procedure is becoming almost painless, and hence optimizing patient experience in IVF.

 

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Embryo transfer procedure is usually carried out 3-5 days after the egg retrieval. During the procedure, the embryos which were created following fertilization of the retrieved eggs with sperms are replaced into the uterus. This procedure is performed without anaesthesia or sedation, is relatively pain free. The experience is almost the same as having a cervical smear. Therefore, women should not feel fearful about having an embryo transfer.

embryo-transfer

After the embryo transfer, to support the uterus lining and to ease implantation, a
Progestogen is prescribed. In the past, progestogen is administered by injections. These injections are usually painful and cause local irritations, which is uncomfortable and unacceptable to many. With the advent of effective oral and vaginal suppository preparations, studies had shown that these forms of progestogen are equally effective in delivering progestogen to uterus, injectable progestogen had slowly becoming a thing of the past in many IVF centres. This has also greatly cut down the pain experience in IVF

In conclusion, with rapid modernization in reproductive medicine & technology, IVF had become relatively painless. It is importantly to find out more information on IVF before you embark on this journey.

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Is IVF Expensive?

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Question: My Husband & I had been married for 8 years, we have tried many different methods of getting pregnancy with no avail (except IVF). The reason I have not attempted IVF is because I heard that it is extremely expensive with low success rates, is this true?

 

Dr Helena’s Answer: Many people have a lot of myths and misunderstanding about IVF. In fact, IVF started in the 1970’s with many controversies. It used to be regarded as cultic practice in science, intertwined with many religious, social and ethical controversies

However, many years had gone by and IVF had progressed in leaps and bounds in its technology and approach, proving to the world its value and safety. At the turn of this century, reproductive doctors and scientists had achieved many new innovations and breakthroughs, to make IVF more accessible and safer. Hence, IVF had gradually become the mainstream in reproductive science, making the dreams of having children a reality for many couples

However, it is not unusual to find that people are still weary about IVF, and there are still myths and misconceptions surrounding IVF.

One of the myths about IVF is that it’s extremely costly. We hear stories that people had to ‘loose an arm or a leg’ to be able to afford IVF.

The truth is that IVF cost had reduced remarkably for the last 10-20 years, thanks to many creative innovations, especially in the advent of cost effective medications, culture mediums and lab equipments. The advent of a new freezing technique, called vitrification, allows IVF scientists to freeze embryos more effectively to allow storage of excessive embryos, to be used later, cutting down the need to repeat another IVF cycle, making IVF more cost effective.

The cost of IVF in Malaysia is generally ranging between RM12,000-RM20,000. The price range varies because of differences in clinical and laboratory settings, medications used and etc

The success rates are generally good depending on the age of the women. For women aged below 35, the success rate is about 60-80%. For women above the age of 35 but below the age of 40, the success rate is around 50%. The success rate fell dramatically after the women crossed 40 years of age.

There is recent study on Danish population about the cost effectiveness of IVF. The study followed almost 20,000 Danish women undergoing fertility treatments including IVF. Within three years, 65% of the women had given birth, with the figure rising to 71% within five years.

Therefore, it is important to find out more about IVF before deciding on or against it.

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A weighty issue

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A weighty issue
How a woman’s weight impacts the risk of miscarriage

A miscarriage is a devastating experience for couples, perhaps even more so for those who have struggled with infertility and gone through the initial joy of a successful fertility treatment. Statistics have shown that in both natural and IVF conception, about one in six pregnancies will end in a miscarriage before the 20th week, with the rate being higher in older couples.

Understandably, couples are frightened of miscarriages and would rather not think or talk about it. However, it is important for couples to understand why miscarriages happen, as well as what they can do to reduce their risks.

Although the exact reason for a miscarriage is often unexplainable, it can occur due to a number of reasons. These include chromosomal abnormality, improper implantation of the egg and maternal health problems or trauma. The mother’s age also plays a significant role, as does her lifestyle, which includes exposure to stress, smoking, drug use, malnutrition, excessive caffeine, radiation and toxins.

Another well-studied factor than increases a woman’s risk for miscarriage, is her weight. As these studies indicate, if the mother is obese or underweight, this increases her risk of not only infertility, but miscarriage as well, regardless of the method of conception.

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According to researchers at the Department of Obstetrics and Gynaecology, University of Adelaide, Australia, being overweight increase a woman’s risk of miscarriage by 29%, while being obese can increase the risk by 71% or more. However, for women undergoing assisted reproduction, researchers at the Assisted Fertilization Center, Brazil concluded that maternal obesity could increase the risk of miscarriage by up to 1330%.

Obesity also compounds miscarriage rates in women with PCOS. The Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Turkey found that the miscarriage rate in obese women with PCOS is about nine times higher than average.

And while miscarriage is often the result of an unhealthy fetus, researchers from the Department of Obstetrics and Gynecology, Stanford Hospital and Clinics, CA, USA found that the risk of miscarriage of a healthy fetus is significantly higher in obese women (with BMIs of 25 or more).

While obesity has been identified as a risk factor for spontaneous miscarriage, the mechanism for it remains unclear. But a study by The Academic Unit of Reproductive and Developmental Medicine, The University of Sheffield and Sheffield Teaching Hospitals, Sheffield, UK points to the endocrinological changes in obesity as possibily causing complex adverse effects including circulating adipokines, sex steroids and insulin resistance.

Women who are underweight, with a BMI of under 20, also face an increased miscarriage risk. A study by researchers at the German Cancer Research Centre found that pregnant women who were underweight faced a 70 % higher risk of having a miscarriage.

Therefore, it can be concluded that among intrauterine environmental factors, nutrition appears to play the most critical role in influencing placental and fetal growth. Since maternal undernutrition or overnutrition during pregnancy can impair fetal growth, women must adopt healthier diets and incorporate exercise to lower their risk of miscarriage.

If you have any concerns regarding miscarriage, especially after IVF, please do not hesitate to consult with your fertility consultant for advice.

Weight-Loss

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