|General Information & Services|
|Go directly to
• AN OVERVIEW OF IVF & ICSI TREATMENT • AN OVERVIEW OF TREATMENT WITH INTRA-UTERINE-INSEMINATION (IUI)
• AN UNEQUIVOCAL HCG RESULT • FISH AND OVARIAN RESERVE • TREATMENT WITH FROZEN EMBRYO REPLACEMENT
• POLYCISTIC OVARIAN SYNDROME (PSOC) & INFERTLITY
|The egg collection takes place in the procedure room and is done under light sedation. Patients are semi-asleep as a result of intravenous drugs administered at the time; however the level of sleep is light enough and allows for patients to still breathe on their own. The actual procedure takes no more than 20 minutes and involves a needle injection through the vagina into the adjacent ovary and the aspiration of the follicles into tubes. These tubes are then passed to the embryologist who at the time will search for the microscopic small eggs contained inside the fluid. All the follicles that are of a certain minimum size will be drained. Afterwards the patient is taken to the recovery area and allowed to leave for home within a couple of hours. Due to the administered drugs patients are not advised to drive or do potentially dangerous activities for the rest of the day, i.e. cooking on a hot stove, etc.
The same morning of the egg collection the male partner / husband hands in a sperm sample. This is washed and prepared by the embryologist and the eggs are then inseminated with the sperm. For those men who prefer specimen pot can be taken home and the sample produced at home, as long as the sample can be handed in within one hour from the time it is produced. The eggs together with the sperm are then placed in a special incubator where it is kept at a certain temperature. Every day an inspection is done and we would normally expect the following rate of development;
ICSI has been used in many centres over the world since it was pioneered in 1992. There is no increased risk to foetal abnormalities when compared to people conceiving naturally. In many centre’s almost half of all IVF cycles account for ICSI treatment.
|speculum in the vagina (same as when having a cervical smear done) and inserting a small catheter through the vagina and cervix into the uterine cavity. Patients barely feel this because of the fineness of the catheter. The sperm, which is drawn up in the catheter is then slowly released into the uterine cavity. Patients are asked to lie down for a few minutes after which they can get dressed and continue with a normal day’s activities, i.e. returning to work, etc. it is advisable to again have intercourse that same evening as this could maximize the overall chance.
After 14 days a pregnancy test is performed. During this time patients will be asked to take progesterone supplementation as this could also increase the chances of success. As with all women trying to conceive it is important to take Folic Acid in tablet form as this can reduce the risk of certain congenital defects. Should the pregnancy test be positive then it is advisable to continue with the progesterone and Folic Acid and a pregnancy scan will be performed after 2 – 3 weeks to determine the viability of the pregnancy.
In the event of a negative pregnancy test then in certain cases, and depending on the stimulation protocol that was used, patients can again try immediately the next month in which case patients must discuss this with the doctor so that arrangements for a scan on either day 2 or day 3 of the menses (period) can be done. Those patients who already had two cycles that were not successful need to instead consider having a follow-up consultation with the doctor to discuss other options of treatment.
LAPAROSCOPY AND TUBAL ASSESMENT
Alternatively an x/ray can be done at the radiology department whereby dye is inserted through the cervix into the uterine cavity and if the tubes are open then the dye will spill into the uterine cavity, confirming the tubes are open. This is called an HSG (hysterosalpingogram). Albeit it is an important and helpful investigation, nevertheless it is only a two-dimensional picture and cannot conclude on the relation of the tubes to the ovaries, etc.
QUALITY OF SPERM
|foetus, etc. When all of the components develop satisfactory then the production of the HCG hormone is adequate, as also reflected in the initial quantitative HCG level. Where some of the components did not develop correctly the cells producing the HCG hormone becomes sensitive to this and as a result less HCG hormone is being produced. This explains why some patients will have an initial HCG level of less than 25. Over time there will also be a decline in the rate at which HCG is being produced. The HCG production will however continue until finally the body realizes that not all of the components have developed correctly and eventually the production of the HCG hormone will seize and begin to drop.
There are however some cases, albeit very few, where the initial HCG level was less than 25 and yet patients gave birth to a healthy baby, which relates to slow development of the pregnancy in the beginning. For this reason every patient with an initial level of less than 25 will be monitored with follow-up HCG levels until finally, either the levels begin to drop or the scan confirms a clinical viable pregnancy. Unfortunately, and for most patients whose initial levels were well below 25, the prognosis is not always good. Apart from progesterone supplementation to assist hormonally, there is nothing else that doctors can do to avoid a disappointing outcome because in most cases the developing embryo was not programmed correctly. Although these remain disappointing and challenging times for patients, nevertheless one should remain hopeful for the future, as at least it is possible for the embryo to develop in utero and maybe next time another embryo could develop successfully.
|expect the level to be at its lowest. The interpretation of the level is then as follows: The younger the patient in general the better the chances to conceive. The higher the FSH levels the more difficult it becomes to conceive. For this reason a woman with a relatively high level of FSH will have a better chance to conceive than an older woman, merely because of her favorable age. This also explains why woman with a certain FSH level who is older has a lesser chance of success than a woman much younger with the same FSH level.
Further conclusions that can be drawn include the following: The higher the FSH level the less number of eggs we can expect in treatment with IVF (in vitro fertilization) and the poorer the quality of the eggs potentially. Fertilization in this group is sometimes also less and the overall quality of the embryos not that good, which results in less women getting pregnant. The opposite of all these points applies to women with low FSH levels.
Although there are certain medicine that will lower the level, it is important to remember that the level is now artificially being lowered due to the medicine and not because the ovary is suddenly better functioning. There is to date unfortunately nothing we can do to improve on the ovary so that it can restore its potential and reserve. This condition is also referred to as premature ovarian failure, although this term actually relates to those women where the ovary has stopped functioning all together.
It is also advised that patients who once had a raised FSH level should have the test repeated to obtain a better interpretation on whether the level next time is the same, lower (which will be more encouraging) or even higher. A better test for the interpretation of the ovarian status is the anti-Mullerian hormone, which give a more accurate reflection of the ovarian status seen over a longer time frame. Another important point is the FSH level and whether to start with fertility treatment during a certain month: If the level is in a particular cycle slightly lower, them potentially more eggs can be recruited but not significantly more and the overall quality of the eggs will remain unchanged.Finally, it is difficult to give a precise estimate of success when looking at various FSH levels for women in a certain age, but in general one could say that ideally the level should be below 8.0. If the level is between 8 and 10 then chances are reduced and, between 10 to 12 the chance to conceive is lessoned with at least a third compared to those women of the same age group with a level below 8. If the level is around 14 or more then in general the success to conceive becomes less than 10%.
|TREATMENT WITH FROZEN EMBRYO REPLACEMENT|
|Treatment for the replacement of frozen embryos can in many cases be quite rewarding with many babies born as a result. The treatment is also mush ‘easier’ than for so-called fresh IVF treatment, as there is no stimulation of the ovaries and therefore no daily injections are required.
Treatment can be offered in three ways namely:
In most cases we would opt for number ‘B’, which compromises of the following:
For treatment with option C the drug leuprorelin acetate (Lucrin®) is administered at the beginning of the treatment and usually around 7 – 14 days before treatment with oestrogen commences. This is applicable in some patients and the decision will depend on the patients underlying circumstances.
Treatment with option A, whereby no medicine is prescribed can be offered to those patients who have absolutely normal, regular menstrual cycles and who are known to ovulate with adequate endometrium development as a result of their own hormones. Some studies have suggested that this option should only be considered for women under a certain age whose oestrogen level are generally still better than older women. Once the developing follicle with an egg is ready to be released, ovulation induction is achieved by administering a single injection. Depending at what cell stage of development the embryos were frozen, a date and time is then given for the replacement of embryos. There should be enough progesterone within the body following ovulation to supplement this part of the treatment for which there is thus no need to add any more progesterone hormones.
|POLYCISTIC OVARIAN SYNDROME (PSOC) & INFERTLITY|
|PCOS is a fairly common condition associated with infertility and accounts for a portion of women seen at any fertility unit. The main problem is that patients have a hormone imbalance and as result their eggs do not always mature during the menstrual cycle. In most cases where eggs do reach some level of maturity the body does not have the ability to release the eggs from the ovary and as a result patients do not ovulate. Because no egg is released, the sperm therefore does not have an egg to fertilize inside the fallopian tube, which is where normal fertilization occurs.
PCO-syndrome patients normally have several associated clinical signs, which classify them as having the syndrome whereas with polycystic type ovaries only the ultrasound scan findings are typical. Albeit there is a distinct difference between having the syndrome and just having the PCO appearance on ultrasound scan, nevertheless the effect and treatment for infertility in both groups are mostly the same.
With PCO there is normally one or more of the following characteristics:
Offering stimulation can be done by either just giving clomiphene citrate tablets at the beginning of the cycle for 5 days, or by adding FSH injections on certain days. Which protocol to follow will depend on the severity of the patients’ symptoms and following on the response when only clomiphene tablets were given in the first instance? With all PCO patients there is also a risk that patient can easily over respond to the dosage prescribed, with too many eggs developing. This will directly place the patient at an unnecessary risk for a multiple pregnancy and therefore great care has to be taken to avoid too many eggs from developing but yet, ideally a few should develop and mature. The prognosis for treatment is very good and most patients do conceive but it can in some cases require a few attempts and often it is difficult to say exactly how an individual would react to the stimulation protocol from the onset. We have also seen that there is also an underlying sperm problem the eggs do not always fertilize favorable, as seen in the laboratory with patients undergoing IVF (in vitro fertilization) treatment. To overcome poor fertilization patients do better when the sperm is injected into the eggs so that better fertilization can occur, a technique also known as IVF with ICSI (intra-cytoplasmic sperm injection.) Not all patients would require this form of treatment but this option would be recommended for patients who;
By making small holes into the ovaries, many of the cysts are destroyed and as a result some patients can benefit from having more regular cycles and as a result they can also now ovulate spontaneously. This option should only be reserved for patients with extreme cases of PCOS. Following this procedure patients can then have a window of opportunity whereby they can conceive naturally, or embark on stimulated treatment and this is especially helpful for those who had difficulty in responding to the treatment protocol. Patients are often concerned that their ovaries are being ‘destroyed’ as a result of drilling fine holes, which is not the case when done correctly and for the right patients. The ovaries are often anyway larger than normal and by drilling fine holes very little of the ovary is being affected but just enough to ensure an improvement. There was a time however when this procedure was done quite too often and also on the wrong patients, but nowadays most fertility specialist would only advise on this in exceptional cases.