Frequently Asked Questions
We have compiled an extensive comprehensive FAQ for our patients to refer to at every stage of their treatment. We hope this will help clarify and answer some commonly asked questions which you may have.
Who is this FAQ for?
It is for couples experiencing fertility problems and trying to figure out the next step. It is not just for Centre for Assisted Reproduction Pte Ltd (CARE) patients, but anyone struggling to get answers to some of the issues surrounding fertility treatments.
When Is IVF advised?
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
What are the drugs used in infertility treatment?
Typically, most centres use two regimes depending on the history of treatment.
- Long Protocol
GnRH analogue drugs namely Buserelin or Lucrin are used to control the hormones produced by the pituitary gland. Fertility hormone injections e.g. FSH (Gonal-F and Puregon) and/or HMG (Menogon), Purified HMG (Menopur) are used to stimulate egg production. Once the egg-containing follicles reach the appropriate sizes, HCG (Pregnyl or Ovidrel) is given to induce the final maturation of the eggs.
- Short Protocol
GnRH analogues (Buserelin or Lucrin) are used together with the fertility hormone injections (Gonal-F, Puregon or Menogon) until ultrasound monitoring and blood tests indicate that all follicles have reached the appropriate size, HCG (Pregnyl or Ovidrel) is then given to induce the final maturation of the eggs.
What are the Possible Complications of Assisted Reproductive Technology (ART) treatment?
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.
What is Ovarian Hyper Stimulation Syndrome (OHSS)?
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.
How do you prevent OHSS?
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.
What is the risk of Miscarriage?
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.
What is an Ectopic Pregnancy?
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.
Could we have multiple pregnancy?
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.
What side effects can I expect from the suppression medication?
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.
Why would my treatment be cancelled?
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
What is assisted hatching?
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.
When does implantation occur?
Implantation occurs between 6 to 10 days after egg retrieval, depending on the development of the embryos.
How can you tell if and when implantation occurs?
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.
Does weight influence fertility?
If you are overweight, your fertility will be reduced. It is unclear whether it is the weight that is the independent factor or whether other factors such as polycystic ovarian syndrome (PCOS) result in both the infertility and excess weight.
At the other extreme, if you are under your ideal weight, you are more likely to have an ovulation problem. Being under or over the desired weight for both males and females can disrupt the normal balance that is necessary for normal egg and sperm production.
The Body Mass Index (BMI) is a ratio used to compare your weight with your height. The ideal BMI ratio before embarking on IVF treatment is between 20 to 24. A BMI of less than or greater than the desired weight can lead to fertility problems.
My question isn't answered here, so what should I do?
Please make an appointment (Tel: +65 6659 6638+65 6659 6638 or email us) to see our IVF Specialist or Chief Embryologist at CARE.
What tests do clinics routinely run before you are accepted into an IVF program?
Pre-IVF blood tests generally include VDRL, HIV, Hepatitis B and C and Rubella antibody status.
The husband should have a sperm test to assess his fertility status and have the semen culture for bacteria infection. Samples are produced after two to four days of abstinence.
A hormonal profile of the woman, in particular the FSH, LH and prolactin levels on Day 2 of your period. This helps us decide on the stimulation regime and dosage of medications used.
Optional tests may include: Thalassaemia screening, specialised sperm assays e.g. sperm survival tests, sperm fertilising capacity, etc.
What does an elevated FSH mean for my IVF cycle?
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.
How long will it take me to be suppressed?
Usually two weeks. A blood test will be done to confirm suppression.
Where should I store my medication?
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.
Can I get my period while on the suppression drugs?
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.
Why am I not getting suppressed?
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.
Can I ovulate while on suppression drugs?
If the suppression is given in an adequate dose you should not be ovulating.
Why do I have to continue to take the suppression drugs when I start my stimulation drugs?
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.
What side effects can I expect from the stimulation drugs?
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.
How does the clinic know when my eggs are ready to be retrieved?
Hormone tests together with follicle measurements were used to indicate maturity of the oocytes.
Do I have to take the hCG injection exactly when the clinic has told me to?
Yes, timing is crucial. A little leeway is however permissible depending on the scheduled time for egg collection.
What will the egg retrieval process be like?
Light sedation and pain relief will be given and the oocytes will be retrieved through ultrasound guided transvaginal aspiration. An anaesthetist will be in attendance to ensure that the egg collection procedure is as comfortable as possible. You will need to rest in the clinic for approximately 1 hour after the process.
Is spotting after the retrieval normal?
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.
Will my eggs fertilise and divide?
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.
What is ICSI?
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.
What will the transfer process be like?
The transfer stage is when the embryos are transferred to the uterus via a soft catheter. The transfer procedure is quite simple and usually takes about 10 minutes.
The transfer process is very similar to intra uterine insemination process. It is usually pain-free compared to the retrieval process. The embryos are loaded into a thin flexible catheter, which is inserted into your uterus via the cervix.
Once the embryos are placed into the uterus, the catheter is slowly removed. The catheter is then sent back to the lab to confirm that all the embryos are indeed transferred into the uterus.
You will be requested to rest in the clinic before you are allowed to go home.
Is bed rest recommended after the embryo transfer?
It has not been proven that bed rest will give you a better chance of getting pregnant, but most clinics recommend that you should take it easy for at least the first few days after embryo transfer to allow the best chance of implantation. Certainly, rigorous activity is not recommended.
You should follow the advice of your clinic and doctor for your particular situation.
The most difficult time of the IVF treatment is during this waiting period after embryo transfer. We advise patients to make plans to keep themselves occupied during this time.
What symptoms should I be experiencing if I am pregnant?
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.
I am experiencing spotting before my scheduled pregnancy test. Is this normal?
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.
When can I do a home pregnancy test?
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.
Frozen Embryo Transfer (FET)
Should I freeze my extra embryos?
If the clinic feels that your extra embryos are of good enough quality to be frozen for future use, then you should take their advice. It will not only save you money but also it is generally less stressful and less traumatic to go through a frozen-thawed embryo transfer than to begin a fresh IVF cycle.
What is the difference between a natural cycle and a medicated Frozen Embryo Transfer (FET)?
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.
- 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.
- 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.
Will all of my frozen embryos survive the freeze/thaw process?
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.
What is a Blastocyst?
A blastocyst is an embryo that consists of around 100 cells. It is at the blastocyst stage of development (5 -6 days after fertilization) that an embryo would normally move out of the fallopian tube and into the uterus. Once in the uterus, the blastocyst starts to attach to the uterine lining in a process known as implantation.
I have heard so much about blastocyst transfers giving high pregnancy rates. Should I have blastocyst transfer?
Extended culture to Blastocyst may be carried out for some patients for the purpose of selecting more advanced embryos for transfer.
Blastocyst transfer may not be suitable for all patients. Centre for Assisted Reproduction Pte Ltd (CARE) does not do blastocyst transfer unless it is considered to benefit the patient. Blastocyst transfer is usually offered to patients who have previous failed IVF attempts.
Blastocyst transfer will normally take place on day 5 or 6 after egg collection depending on blastocyst development. Not all embryos will develop into Blastocysts. Some embryos may stop developing at any stage before reaching the Blastocyst stage. Hence, there is a greater risk of transfer being abandoned.
Post Treatment Management
What is post-treatment management?
If the treatment is unsuccessful, all patients should be given an opportunity to meet up with specialists to discuss the potential causes of implantation failure, correctable causes and offer remedy if any.
Why did my embryos fail to implant?
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.
What are the chances of conception following multiple failed IVF/ICSI attempts?
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.
What are the risks associated with repeated assisted conception treatments?
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.
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