Frequently Asked Questions

IVF treatment is just one of the treatments available for fertility problems. It may be appropriate if the women have blocked tubes, polycystic ovaries, endometriosis or cervical mucus problems; if the sub-fertility is largely due to male factors e.g. low sperm count or poor quality sperm; or if the sub-fertility is unexplained after at least one year of regular intercourse without using contraception.

IVF using donated eggs may be necessary for women

• suffering from premature menopause
• having poor quality eggs
• whose ovaries have been damaged or removed

IVF using donated sperm may be necessary for men

• with very poor sperm quality
• suffering from testicular function failure
• who had previous vasectomy

Typically, most centres use two regimes depending on the history of treatment.

• Short Protocol (more commonly used)

Fertility hormone injections (Gonal-F, Puregon Menogon or Pergovaris) is used to stimulate the follicles to grow. Halfway through the stimulation, another medication, antagonist, is given to prevent premature ovulation. This allow most of the follicles to continue growing until ultrasound monitoring and blood tests indicate that most follicles have reached the appropriate size, HCG (Ovidrel) or agonist (Decapeptyl)  is then given to induce the final maturation of the eggs.

• Long Protocol

GnRH analogue drug namely Decapeptyl is used to control the hormones produced by the pituitary gland. Fertility hormone injections, FSH (Gonal-F and Puregon) and Purified HMG (Menopur and Pergovaris) are used to stimulate egg production. Once the egg-containing follicles reach the appropriate sizes, HCG (Ovidrel) is given to induce the final maturation of the eggs.

As with many medical procedures, ART carries some risk of complications. We will try to minimize these risks by identifying those women most likely to be at risk and by monitoring their treatment cycle closely. The most common complications are Ovarian Hyper Stimulation Syndrome (OHSS), Miscarriage, Ectopic Pregnancy and Multiple Pregnancy.

While receiving fertility hormone injections, some women may experience abdominal bloating, breast tenderness, increase in vaginal secretions and some abdominal discomfort and breathlessness. For most of these women, these symptoms are usually short-lived and cease when the treatment finishes.

In rare cases, some women’s ovaries will over-respond to the fertility hormone injections and produce too many follicles. If this happens and treatment continues, there is a risk of developing Ovarian Hyper Stimulation Syndrome (OHSS). Approximately 1-2% of women undergoing ART treatment will experience OHSS. OHSS is caused by the over-sensitivity of the ovaries to the fertility drugs, and is more frequently associated with women with polycystic ovarian disease.

Mild OHSS may pass unnoticed, but severe OHSS can cause breathing difficulties, temporary kidney “shut down”, and some arterial and venous thrombosis. In rare cases extensive thrombosis causes interference with blood supply to parts of the brain or to other organs. In addition, fluid from the blood stream leaks into the abdominal cavity causing it to swell noticeably and leaving the blood more concentrated and more viscous. Death due to OHSS whilst very rare, is possible.

Patients who suffer severe OHSS must be hospitalized and treated. This treatment would involve the infusion of intravenous fluids and the fluid in the abdomen may need draining off. In very severe cases, fluid may get into the lung cavity and may need to be drained.

Close monitoring of potential candidates using blood test and ultrasound scanning of the ovaries to ensure the ovaries do not over-respond to the drugs.

If OHSS occurs, the options are to cancel the cycle, or to collect and fertilize the oocytes and freeze the embryos. These options will be discussed should this situation arise.

The incidence of miscarriage in women who conceive naturally is approximately 25%. With assisted conception treatment, this figure is not significantly different although in women over 40, there is an increased risk.

An ectopic pregnancy is a pregnancy that occurs somewhere other than in the uterus; most commonly in the fallopian tubes. The incidence of ectopic pregnancy with assisted treatment is approximately 2.5%. It is a potentially serious condition, but can be detected very early in the pregnancy by an ultrasound scan.

One of the complications of assisted reproduction is the increased incidence of multiple pregnancy. Problems are most commonly seen in incidences of triplet or higher-order multiple pregnancies, but may also occur with twin pregnancies. Here, babies may be born before they are mature enough to survive because of the greater chance of pre-term labour and delivery.

In Singapore, the maximum number of embryos that can be transferred is two. Our statistics shows that women who had AR program in CARE, <10% of the pregnancies are multiples. This is in line with MOH and RTAC guidelines of keeping multiple pregnancies rates low for the welfare of the mother and child.

Suppression medications put you into a temporary state of menopause. Symptoms, such as hot flushes, insomnia, becoming easily irritable may be similar to what one experiences with menopause. Husband should be more understanding and supportive when the wife is undergoing treatment. However, these symptoms will not last long.

Treatment may be cancelled if :-

• Too few follicles developed
• Hormone levels too low
• Ovarian cysts developed during stimulation
• Missed ovulation
• No eggs at pick-up
• No fertilisation
• No good embryos for transfer

Blastocysts (implantation stage embryos) have to hatch out of the outer shell of the egg before they can implant into the womb lining. Some eggs have thick and/or tough shells and the blastocyst may have difficulty hatching. Assisted hatching is a laboratory technique that induces a hole or weakening in the egg shell and this should facilitate and assist the hatching process and implantation.

Assisted hatching is commonly used on eggs of older women, eggs with thick zona pellucida (egg shell), eggs with hardened outer surface or on frozen-thawed embryos as the freezing process may have hardened the egg shell. Assisted hatching can also be used on embryos thought to lack sufficient energy to complete the hatching process and also on women who have failed two or more IVF cycles.

Assisted hatching is done using Laser hatching performed using precision laser technology. The fertilised egg is placed in the laser path and the outer wall is thinned using laser energy. This technique is swift and is very accurate.

Implantation occurs between 6 to 10 days after egg retrieval, depending on the development of the embryos.

Women will probably not be able to feel the implantation process, but they may begin to experience some symptoms of pregnancy (such as nausea). However, a positive confirmation is only evident from a urine or blood test to detect the pregnancy hormone HCG, one week after implantation.

It can disrupt the hormone balance that is necessary for normal egg and sperm production

Please make an appointment (Tel: +65 6659 6638 or email us) to see our IVF Fertility Counsellor at CARE IVF.

Pre-IVF blood tests generally include VDRL, HIV, Hepatitis B and C, Rubella antibody status and Thalassemia Screening.

An elevated FSH level may indicate failing ovarian function or poor ovarian reserves. This has important prognostic value. There is a high possibility of having a poor response to the standard stimulation regimes and the quality of oocytes may also be poor. Therefore there will be a need to modify the stimulation regime so as to be able to get a better response with better quality oocytes.

Always try to store them in the refrigerator. If you are traveling, you can keep them in a cooler bag with an ice- pack in it. Tablets can be stored at room temperature.

If you have started suppression in the first half of the cycle then you will not have a period. However, if you have started the suppression on the second half of the cycle, you will experience a menstrual flow.

If estrogen level is still high after a period of suppression this may indicate that there are some ovarian activities or presence of a persistent cyst. Continuation of the suppression drugs for another week or aspiration of the cyst will suppress patients further and thus they will be able to start their treatment as planned.

If you have had a previous IVF cycle where the response to stimulation was poor, then your clinician should try to improve the response the second time around. This may include reducing the suppression dose or remove the suppression altogether.

The stimulation drugs cause a higher than normal number of oocytes to develop. These oocytes collectively produce higher than normal levels of the estrogen hormone. In ordinary circumstances, when the estrogen levels reach a certain concentration, it triggers ovulation through the LH surge. By continuing the suppression drugs we are able to bring the oocytes to maturity without losing them prematurely through the early release of LH.

If the stimulation is successful in producing the desired number of oocytes you may feel some bloatedness around the 7th day of stimulation onwards. If there are more oocytes than we expected then there will be symptoms of water retention, not only in the abdomen, but also in the dependent parts of the body e.g lower limbs and lungs.

In severe cases of Ovarian Hyperstimulation Syndrome, management and observation in hospital may be required. Fortunately, this happens infrequently.

Other symptoms include nausea, dizziness, drowsiness, abdominal pain and heartburn.

Hormone tests together with follicle measurements were used to indicate maturity of the oocytes.

Yes, timing is crucial. A little leeway is however permissible depending on the scheduled time for egg collection.

Yes. The bleeding comes from the needle puncture wounds in the vagina. Red vaginal spotting may last for 24 to 48 hours after the retrieval. If the spotting is more like bleeding (soaking a pad), call the Centre immediately.

Fertilisation and development of the fertilised eggs is influenced by the quality of the eggs and sperm.

The age of women and the source of the sperm affect the fertilisation rate. Higher fertilisation rate is obtained from freshly ejaculated sperm while surgically retrieved sperm results in lower fertilisation rates.

On the average 70% of eggs should fertilise when using ejaculated sperm and 80% of the fertilised eggs should divide.

Intracytoplasmic sperm injection (ICSI) is a process whereby a single sperm is injected into an egg. This technique of assisting fertilisation has revolutionised the management of severe male factor infertility. Previously, men with very poor sperm quality would have to resort to using donor sperm to impregnate the wife.

There is no standard set of symptoms for early pregnancy. The range of symptoms differs among different patients. Medication given during the treatment period can cause symptoms (i.e nausea), which could be mistaken for pregnancy symptoms.

There are several reasons for spotting during the two weeks of waiting. It could mean that:

• The embryo is implanting causing implantation bleeding
• The implanted embryo is detaching
• You are shedding your uterine lining i.e. your period is starting

Let your clinic advise you accordingly if spotting occurs. Go ahead with your clinic’s pregnancy test even if the spotting is heavy. There is really no way of telling what is happening until you obtain the blood pregnancy test result and confirm the outcome of the treatment.

It is very tempting to do a home pregnancy test before the one scheduled by your clinic but they may not be accurate and either raise hopes or cause unnecessary disappointment.

You could get a false positive result if you had an hCG injection close to your pregnancy test date as the injected hCG is still in your system.

You could also get a false negative result if the hCG level produced by the implanted embryo is not high enough to be detected or if there is a late implantation.

A natural cycle FET is for women who have regular menstrual cycles. The natural cycle would be most ideal as your cycle will be monitored to determine the correct timing to transfer the embryos, and this is synchronized to the age of the embryo. You do not have to take any medication.

A medicated FET is suitable for women who do not ovulate or ovulate irregularly. There are two treatment protocols.

1. You will be given medications (sometimes with suppression drugs), Estrogen and then some form of Progesterone to create an artificial cycle. This allows the clinic to have more control over when to transfer the embryos. This cycle is ideal for Ovum Recipients and those who do not ovulate regularly.
2. You will be given similar drugs as in an IVF cycle but only sufficient to stimulate a small number of follicles to enable the development of the endometrium to receive the thawed embryos.

It is difficult to determine whether all of your embryos will survive the freeze/thaw process. The result will only be known on the day of thawing. The survival rate greatly depends on the quality of the embryos at freezing.

Egg freezing is suitable for anyone who wants to preserve their egg for future use. This procedure may be ideal for people who:

• Need more time to complete their studies or build their career/finances
• Have not found a suitable partner yet
• Have an underlying condition that require heavy medication/treatment such as cancer
• Want to preserve their eggs, just in case
• Are not ready to have child but would like to in future

As a rule of thumb, the younger the better. Women in their twenties generally reach peak fertility, until age 30, after which it rapidly declines. If you want children but need more time to prepare, egg freezing gives you that very advantage, without reducing your chances for conception.

1. Hormone injections for ovary stimulation would be prescribed, which allows for the maturation of multiple eggs
2. Blood tests and ultrasounds performed to monitor your health and ovulation
3. Before ovulation happens, egg retrieval is done to extract eggs
4. Retrieved eggs would be scanned for possible birth defects using pre-genetic testing (PGT)
5. Eggs then undergo flash freezing, also known as vitrification, before it goes into storage

The entire procedure may take between 10 to 14 days.

With cryopreservation, eggs can be stored indefinitely. The flash freezing method ensures for marginal damage to eggs and effectively preserves its quality. However, most women use their eggs within ten years.

Depending on age, your healthcare provider may recommend preserving 10-15 eggs. Older women may need undergo more than one egg retrieval cycle to collect healthier eggs while women under 35 can expect to produce sufficient eggs in one cycle.

• Egg freezing: $10,000* to $12,000* (cost may differ according to treatment)
• Egg storage: $600* to $800* annually

* actual cost might differ due to the treatment prescribed and centre where procedures are performed

Egg freezing is known to be a low-risk procedure that generally leads to high rates of success. Research suggests that thawed eggs have a 90% survival rate.

The main difference lies in the cell structure. An egg is made up of a single cell enclosed in liquid while an embryo refers to an already fertilized egg with multiplied cells.

There are slight advantages to freezing embryos over freezing eggs. Due to its single cell nature, eggs are marginally more vulnerable to flash freezing than embryos. Studies show that frozen embryos have an approximate 95% survival rate, versus frozen eggs at 90%.

When you are ready to have children, consult your healthcare provider to decide on the subsequent steps. Your doctor will likely run tests to ensure you are in good health before taking your egg out from storage.

After you have undergone the necessary tests, your eggs will be thawed and prepared for fertilization. Once fertilization is complete, the embryo will be transferred back into your uterus, where it may possibly lead to a healthy, normal pregnancy.

Make an appointment with our fertility nurses from CARE IVF at +65 6659 6638 or WhatsApp +65 8028 9431

Extended culture to blastocyst allows the selection of more advanced embryo for transfer, increasing the chance of implantation. However, not all embryos will develop into blastocyst. Some embryos may stop developing at any stage before reaching blastocyst. Hence, there is a greater risk of transfer being abandoned.

Probable reasons for implantation failures:

• Pathological lesions in the uterine cavity that prevents implantation.
• Presence of hydrosalpinges where toxic substances and fluid may back flow into the uterine
• Presence of obstructive fibroids that distort the endometrial cavity.
• Endometriosis known to affect egg quality.
• Poor embryo quality.
• Poor or abnormal embryo-endometrium interaction.
• Other abnormalities of the uterine cavity.

It is accepted that implantation rate is lower in older patients and those with high FSH. These women have diminished ovarian reserve and have shown to have increased risk of Down Syndrome. This shows that ageing oocytes are at higher risk of chromosomal abnormalities and malfunctions within the egg environment.

Patients undergoing IVF/ICSI should attain approximately 30% chance of conception. Research has shown that this rate does not change over the initial three treatment cycles but decreases considerably after four or more failed attempts.

The cumulative pregnancy rate differs significantly between women less than 35 years of age and those over 35 years. Conception rate also decreases significantly in both age groups when the number of retrieved eggs is less than 5.

Patients are often concerned about the risks of premature depletion of their ovarian follicle pool and cancer.

There is no evidence that ovarian stimulation diminish ovarian reserve. It is found that the number of eggs is maintained with repeated treatment attempts. However, it is evident that ovarian response decreases with increasing female age. If the female’s age is a pressing issue, the couple should undergo repeated treatment cycle without undue delay.

As for the fear of breast cancer, Veen et al; 1999 showed that the overall incidence of breast, ovarian and uterine cancer was no greater than expected incidence in the normal population.