I have divided this segment into 2 :
a) Treatment Options To Make Me Pregnant
b) Which Infertility Treatment Will I Need ?
Treatment Options To Make Me Pregnant
A) Ovulation Induction (OI)
This method involves giving you medicine in the form of oral pills or injections to stimulate growth of eggs/oocytes in the ovary. The duration of the medication depends whether its a oral pill or injections. For example, oral pill such as Clomifene Citrate is taken from Day 2-6 of menses while injections such as Humog or Menopur is injected from day 2 till day 9/10. During this time, regular ultrasound scan will be performed to assess the growth of the follicles that contain the egg/oocyte. Once the follicles has grown to the desired , hCG injection (trigger injection) will be given to assist with ovulation.
B) Timed-Sexual -Intercourse (Timed SI)
This can be done with or without OI (refer above). If done without OI, it is known as natural cycle Timed SI. Regular ultrasound scans will be done to assess the growth of the follicle. Once desired size is achieved, trigger injection may/may not be given. Couples are generally will be asked to have sexual intercourse 24-48 hours after the trigger injection. If no trigger injection given, couple are normally advised to have sexual intercourse once the follicles has grown to appropriate size.
C) Intra-uterine Insemination (IUI)
IUI treatments starts with ovulation induction (refer above). For IUI to have a reasonable chance of pregnancy, a minimum concentration of post-wash sperm is needed (ie > 1 million sperms/ml). Once the follicles has grown to appropriate size, trigger injection will be given. 36 hours post-trigger injection, male partner’s sperm will be collected and washed. The washed sperm is then injected into the womb / uterus via a tiny catheter . This process is done without any sedation and generally pain-free.
D) In-Vitro fertilization (IVF) / Intracytoplasmic sperm injection (ICSI).
In IVF, generally, more eggs / oocytes are needed . To achieve this, ovarian function to produce egg/oocyte will be ‘taken-over’ by the fertility doctor. They are many ways of doing this, but more common methods are highlighted below.
Long down regulation protocol: In this method , a medicine called gonadotrophin-releasing hormone agonist(GnRH agonist) is injected from Day 21 of menses (down regulation phase). This medication will suppress the ovarian function. Once the woman’s next menstrual cycle starts, blood tests and ultrasound scan of the pelvis will generally be done. Once the woman is ‘down-regulated’, FSH (Follicle Stimulating Hormone) injections to grow the follicles will be started (stimulation phase). Stimulation phase may last for about 7-12 days, in average 9-10 days.
b ) Antagonist protocol : t is generally started on day 2 of menses. FSH (Follicle Stimulating Hormone) injections to grow the follicles will be started (stimulation phase). Once the leading follicle >14mm or after a pre-specified day, gonadotrophin-releasing hormone antagonist (GnRH antagonist) will be injected daily till the day of egg collection. Regular ultrasound scans are performed to assess follicular growth.
c) Mixed protocol: Your doctor may use a ‘mixed-protocol’ , where orl and injections are used to grow the egg/oocyte.
Once the follicles containing the eggs has grown to required size (ie > 17mm), you will proceed to ‘egg collection’ stage.
36 hours prior to ‘egg collection’, you will be given a ‘trigger injection’ . Egg collection is generally done under sedation. A transvaginal ultrasound probe is placed in your vagina,through which a tiny needle is introduced into the follicles. The fluid inside the follicles will be sucked out and handed over to the embryologist. The embryologist will look for the egg/oocyte in the follicular fluid under a microscope.
Fertilization / ICSI
The eggs are then prepared for fertilisation or ICSI. In conventional IVF, the washed sperms are mixed with the eggs in a dish. 1 (one) sperm will find its way into the egg and fertilisation occur.
In ICSI, 1 (one) sperm is chosen and it is then injected into the egg for fertilisation to take place. Not all eggs that are injected with sperm will fertilise. The successful fertilisation of each egg will be known the day after ICSI or conventional IVF. It is important to remember that not all eggs collected are suitable for IVF / ICSI and not all eggs that are injected with sperm will fertilise.
The fertilised eggs/oocytes are known as embryo (early form of human life). The embryo will
be grown in special culture media up to 3-5 days. The embryologist will check the growth of the embryo daily and its quality graded. Depending on the fertility centre, embryo can be transferred back into your womb on Day 3 or 5 after egg collection.
This is a simple procedure which is done without any sedation. It is done under sterile condition. You will be placed on a couch , just like when a pap smear is done, and a small fine plastic tube which contains the embryos will be introduced into your womb and the embryos will be injected into your womb. After that you will be given some medicines to support the pregnancy, it is called “luteal support”. Generally 1-2 embryos will be transferred.
You will see your fertility consultant in 2 weeks after embryo transfer to test your blood for pregnancy hormone called human chorionic gonadotrophin (Hcg). Hcg hormone will rise in your blood stream if you are pregnant.
Which Infertility Treatment Will I Need ?
Treatment options can be divided into treatment for male infertility and treatment for female infertility.
Reduced sperm quality.
According to world standard (World Health Organization) , sperm quality is taken as ‘normal’ when the sperm concentration is > 15 million/ml, motility is > 40% , normal form is > 4% , vitality > 58%.
When the semen analysis shows values less than this, it is considered ‘low’ in sperm quality. How to improve sperm quality? Please refer to our brochure : How To Improve My Chances Of Getting Pregnant.
Treatments that can be offered are lifestyle changes and oral medication called anti-oxidants.
Research had shown that high level of reactive oxygen spesis (ROS) and low level of antioxidant in the semen reduces sperm quality. Supplementing men with oral antioxidants improves sperm quality especially motility. There are many antioxidant such as vitamin C, vitamin E, L-carnitine, Co-enzyme Q, zink and selenium. Your doctor will give a combination of these antioxidants.
2. Azospermia ( no sperm)
When there is no sperm found, it could be due to obstruction in the channel that sperm passes through (vas deferans) or due to low or no sperm production in the testis. Your doctor will do some blood test on male partner and examine the testicles to arrive to a diagnosis.
Obstruction can be caused by infection or injury to testicles . Sometimes the men is born without vas deferens. It can also be due to previous vasectomy (male sterility procedure).
There are several options to retrieve the sperm:
For men with previous vasectomy, a vasectomy reversal surgery can be done. However, the success rate is low. If failed, PESA or TESE can be done (see below)
If obstruction diagnosed, PESA (percutaneous epididymal sperm aspiration) can be done. In this procedure, sperm is directly aspirated from epididymis (where sperm is stored in the testis) using a fine needle.
If obstruction or low sperm production is suspected, TESE ( testicular sperm extraction) can be done, where a biopsy or several biopsies taken directly from the testis after making a small incision in the scrotal skin.
Tubal factor infertility means that there is a problem for the egg / oocyte to pass through the Fallopian tube to meet the sperm. It includes a diseased or surgically removed) unilateral (one) / bilateral (both) Fallopian Tubes or absence of Fallopian tubes. If 1 (one) of the fallopian tubes are open/patent, much simpler treatments such as Timed-sexual intercourse or Intrauterine Insemination (IUI) can be done. If both the Fallopian tubes are not patent or absent, IVF is needed.
If the fallopian tubes are swollen, you may need a laparoscopic (keyhole) surgery to remove the diseased fallopian tube.
If the woman is not ovulating, such as in women with Polycystic Ovarian Syndrome (PCOS), fertility pills (ie Clomid) can help. It is normally taken for 5 days starting on Day 2 of menses. Together with fertility pills, Timed Sexual intercourse or IUI can be done. If these methods are not successful, IVF/ICSI is needed.
3. Uterine / Ovarian / factor
Sometimes there is a problem or pathology with uterus or ovary. Problems with uterus are presence of uterine fibroid , abnormal uterine shape (ie bicornuate uterus), presence of intrauterine adhesions (synaechia) or intrauterine septum. Problems with ovary could be presence of ovarian cyst or polycystic ovary (PCO). Many of these conditions are treatable with surgery, especially laparoscopic (keyhole) surgery. Depending on the problem and the success of surgical treatment, Timed Sexual Intercourse , IUI or IVF/ICSI can be tried.
4. Unexplained Infertility
This is a little bit more tricky to treat since there is no cause found. Generally treatment will depend on the female partner’s age, duration of infertility and the couple’s wishes. Generally, IUI or IVF/ICSI will be needed in this situation. More detailed discussion of the treatment options for couple in this category will be done by your fertility specialist.