Patient Guide

Female :

There are 2 periods during menstrual cycle which are most appropriate time for fertility investigation.

• Day 2 of period : this is the right time measure hormones that correlate to ovarian function.
• Day 12-14 of menstrual cycle : transvaginal ultrasound and pelvic examination will yield information about condition of cervix, cervical mucous ,uterine lining ,uterus and ovaries.

Male :

Semen analysis is the primary and essential part for male fertility investigation. You need to abstinence for 3-5 days before you come to Bangkok Infertility Center and give your semen sample. The computer assisted semen analyzer will provide semen analysis result in a very short period of time and whether other investigation is required will be discussed with infertility specialist.

Please arrange appointment by telephone call or e-mail in order to get efficient medical service.

Body mass index is an indicator to point out that each individual has normal weight distribution or not. The body mass index or BMI = body weight in kg. / (height in meter)2 Normal BMI = 18.5-25.0 kg. / m2 BMI over 25.0 kg. / m2 consider as overweight. There is a very high prevalence of obese women in the infertile population and many studies have highlighted the link between obesity and infertility. A large proportion of infertility women have polycystic ovary syndrome (PCOS) which is also linked with increased risk of obesity and other metabolic anomalies. The association between obesity and / or PCOS and hyperinsulinism, hyperandrogenism and abnormal secretion of other hormones, such as leptin, underlies many reproductive disorders observed in this population. It has been demonstrated that weight loss can improve the fertility of obese women through the recovery of spontaneous, where as other will have improved response to ovarian stimulation infertility treatment. Therefore, it is proposed that following the initial assessment of infertility and body mass index or other measurement of obesity, various weight management interventions, including diet, exercise or pharmacotherapeutic approaches, should be considered for overweight and obese infertile women.

Once IVF program had completed its stimulation part, oocyte retrieval will be performed. Eggs and sperms will be put together and cause fertilization, fertilized egg will develop and become embryo.

• Day 1 embryo will be at pronuclei stage
• Day 2 embryo will be at 4 cell stage
• Day 3 embryo will be at 8 cell stage Day 4 embryo will be at morula stage
• Day 5 embryos will be at blastocyst stage

In order to raise embryo up to day 5, you need a skillful embryologist and sophisticated laboratory. Once the embryo reaches blastocyst stage and the quality is good, then the chance of pregnancy after smooth embryo transfer may be as high as 40%. But if you have very good day 3 or 4 embryos for transfer, the chance of pregnancy is also as high as 35-40%. So the benefit of blastocyst transfer is to reduce number of embryos replaced and still maintain high chance of pregnancy. The appropriate number of embryo replacement for any women less than 38 years old should be 2 and for anyone older should be 3 embryos at a time.

Yes, there is. Right now, It seems that there is more correlation between obesity, PCOS and infertility. First line management for this problem is weight management and below is the summary, explanation and recommendation for the problem.

Summary and recommendation for weight management of infertile patients

There is well-established evidence for the detrimental effect of overweight and obesity on women’s reproductive function; this is further complicated by presence of PCOS in many infertile women. In addition, the distribution of body fat is also related to the reduction or even loss of fertility. So far, most research has indicated that overweight and obese conditions lower the concentration of SHBG and increase androgen, insulin and leptin secretion and insulin resistance, leading to hyperinsulinaemia and hyperandrogenemia. However, there is limited understanding of the details of how these changes affect human reproductive function. On the other hand, weight loss has been shown to improve metabolic function, hormonal profile and lead to marked recovery or improvement of reproductive function. Therefore the recommendation for overweight/obese patients with infertility is closely related to the ramification of this problem. They should have their height, weight and waist circumference recorded at their first consultation and at regular intervals thereafter. Once the patient has been classified as overweight or obese, then weight management should be offered as a first line treatment option. Dietary intervention and increased physical activity remain the optimal treatment strategy for overweight/obese women with PCOS. A relatively small weight loss (~ 5 kg.) can improve insulin resistance and hyperandrogenism, menstrual function and fertility, and large changes in weight may not be needed to restore reproductive function. Weight loss can also improve long-term metabolic health and realistic and achievable target weight loss goals can be set for women. Obesity and overweight can be treated by a variety of strategies including dietary management, physical activity, behavior modification, pharmacotherapeutic treatment and surgery. Dietary management with lifestyle modification as an objective should be adopted initially with pharmacological and other interventions reserved for use when weight-loss regimes have proved unsuccessful. Since the overall emphasis is to achieve and maintain a reduced weight, attempts should be made to establish sensible eating patterns and a healthy lifestyle. A number of alternative dietary approaches to the conventional low fat-high carbohydrate regime such as partly modified diets or moderately HP-lower carbohydrate diets which are consistent with a healthy eating plan may assist in maintaining an energy restricted diet. The other lifestyle factors, such as alcohol intake, smoking and psychosocial stressors, should also be addressed. A group environment can provide support for weight loss and maintenance of weight loss. At the same time, it is necessary to tailor intervention to an individual’s weight and current dietary and exercise patterns. The use of a dietician is warranted to aid in the evaluation of dietary intake and eating patterns and in individualizing an appropriate dietary approach.

From the beginning of each woman’s life, there were about 3 millions eggs in the ovaries. When this woman becomes a teenager, numbers of eggs reduce to about 300,000. There are totally about 350 eggs ovulated during the whole fertility period or about 30 years started from age 16 through 45. Eggs which stored in ovary will gradually lost their quality and increase abnormality throughout time. After 38 year of age, chance of pregnancy is declined and significantly declined after age of 40. This is the reason why infertility specialist try to give information to public that any woman would like to have a child must come and seek for advice before 38 years old, or else the chance will be slim.

Yes. The IVF procedure bypasses the fallopian tubes. Eggs are collected from the ovaries and embryos are replaced directly into the uterus. A pregnancy can therefore be achieved without having to reopen the tubes. However, depending on the method used when the tubes were tied, they may be reopened surgically (tubal reanastomosis). The success rate for pregnancy (non-IVF) following a tubal reanastomosis is somewhat decreased.

When taking fertility drugs, there is always a chance for multiple births. Dr.Viwat, however, can use ultrasound and blood tests to monitor egg production each cycle. Medication can be adjusted to increase or decrease egg production and minimize the risk of multiple birth.

A Reproductive Endocrinologist is a physician who has completed a medical degree (4 years), an Obstetrics and Gynecology residency (4 years), and an approved fellowship in Reproductive Endocrinology and Infertility (2-3 years). This subspecialty of Obstetrics and Gynecology deals with the diagnosis and treatment of infertility and its many associated conditions. These conditions vary from anatomical to hormonal. In order to treat the variety of conditions which his or her patients may present, a Reproductive Endocrinologist is trained in the most advanced conservative surgical techniques in both the endoscopic and microsurgical realm. This allows him or her to perform restorative procedures to treat the many patients who suffer with endometriosis or other anatomical conditions. He or she is also trained extensively in advanced reproductive techniques such as In Vitro Fertilization (IVF) and Embryo Transfer.

IVF procedure is composed of 4 sequential steps:

• Ovarian stimulation: IVF programs use superovulation to stimulate production of several eggs by hormonal therapy.

• Ovum pick up: Aspiration of the preovulatory follicles is performed by ultrasonography under local anesthesia.

• In vitro fertilization and embryo culture: to fertilize the mature eggs with capacitated sperms in the laboratory conditions.

• Embryo transfer: Replacement of fertilized egg into the uterus via small catheter.

 

Superovulation serves to stimulate production of several eggs and improves timing of egg aspiration. Both number of aspirated eggs and fertilized ova are increases like production of high quality embryo probability.

 

To stimulate production of multiple eggs several hormonal medications are used. GnRH anologs (Suprefact, Enantone, Lucrin ..) are drugs that have the same effect of GnRH. When they are used, at the beginning of therapy they increase the secretion of endogenous gonadotropins ( FSH and LH ), after a while hypophysis becomes unresponsive to these agents and suddenly gonadotropin levels cease at a lower levels. Medication with the GnRH analogs generally starts at the beginning or mid phase of menstrual period. They have many available forms like subcutaneous injections or nasal spray. After around 10 days of treatment, superovulation is carefully monitored with ultrasound scanning and serum estradiol determinations. If enough suppression is achieved then treatment with daily injections of FSH or hMG (Humegon, Menogon, Pergonal, Gonal-F, Puregon) will be commenced. At the same time, GnRH agonists are used altogether with gonadotropins. Serum estradiol levels are complementary to ultrasonography in evaluating the maturation of preovulatory follicles and timing of hCG (Pregnyl, Profazi) administration. we stop treatment with GnRH agonists and gonadotropins before giving hCG injection

Most accurate and reliable terms of evaluating development of follicles are serum estradiol measurements, follicle numbers / diameters and endometrial thickness under ultrasound investigation.

One mostly chosen method of ovum pick-up is done with transvaginal ultrasonography. In transvaginal aspiration a needle is passed through the posterior vaginal wall using a vaginal ultrasound probe and directed into the ovary. There might be some disturbing pain and this procedure may be done under local or general anesthesia according to patients’ view.

Ovum pick-up is usually trustful, non-complicated method under specialized hands. It is harmless and it may be repeated several times to capture follicles. But rarely puncture of an artery and rupture of vessels or bowel may be the reason of dangerous side effects of procedure.

Fertilization and culture of eggs are probably the most crucial stages of IVF. Eggs are incubated in various culture media with sperm (100,000 motile sperm per one oocyte).

At various intervals after the attempted fertilization, the eggs are examined in order to identify changes which confirm fertilization as well as blastomere which confirms cleavage.

2 - 5 days after aspiration, fertilized ova (embryo) are ready to transfer in uterus. Embryo can be transfer at several stages such as Day3 stage which has 4-8 cells or blastocyst stage on Day5 or Day6 which has around a hundred cells. The transfer is by special small catheter to replace embryo(s) in uterus. Transfer procedure is not painful event. Abdominal ultrasound with a full filled urinary bladder helps to manage procedure. Number of embryo to be transferred is depended on age and special condition of mother.

As about 10 minutes rest give a favorable outcome to increase pregnancy rates. In B.I.C. we take care patient to lay on bed about 1 hour after the procedure. The day after transfer, patient can do her own job and activity as usual. Heavy exercises are prohibited.

To give support developing pregnancy, patient may use drugs of progesterone vaginally for local effect.

10 days after embryo transfer, beta hCG levels are measured in blood and 2 weeks later on gestational sac can be seen under ultrasound.

By giving 2 months apart, IVF can be done as long as pregnancy occurs.

No.  2%-3% of all pregnancies have the risk of abnormal baby pattern. There have been no grossly increased abnormally risk attribute to IVF is present.

After transfer of enough embryos, there may be excess embryos that can be frozen for later use by using special media.

This is a procedure whereby a single sperm is injected into an egg using a micro-needle under the microscope instrument. First of all, numerous cells named cumulus oophorus must be cleaned around mature eggs by using special enzymes. The successs rate of ICSI is nearly 80-90 %.

If infertility is due to male factor then ICSI is used effectively. There may be less sperm concentration or low quality in some conditions and ICSI is used perfectly in these circumstances. By the helping of TESE or PESA technique available sperms are captured and used for ICSI procedure.

If a male patient who has no sperm in his semen is carefully examined in operating room by special technique named MESA, there is a chance to find enough amounts of sperms and get a child by using these sperms for the procedure ICSI.

Micro-dissection via a single larger incision and sampling of testicular tissue under local anesthesia allows sperm extraction and availability for ICSI performance. This procedure has no harmful effect on male sexual health.

Microscopic TESE: It is the same procedure like TESE but this is done under microscope and it allows to find sperm in worst quality in some patients.

If woman gets older and older, the area surrounding mature ova named zona pellucida becomes thicker.

This thick zona pellucida may inhibit implantation of embryo and decreases successs. We can deal with this problem by opening a gap on zona pellucida and it has no adverse effect. This method can be used over 38 years of age ideally.

One of the most important steps in pregnancy is implantation of embryo to endometrium. Before implantation, zona pellucida surrounding blastocyst is resorbed. To help this step to occur we can make a gap in zona pellucida. This is done by mechanically, by using acidic media or harmless laser. Also we can take cells out of embryo and have sample for genetic analysis from this gap.

No. Age is not the only one parameter for this method. Zonal thickness is the most important factor and repeated failed ICSI is another indication mostly seen. Laser is also used to clean toxic materials around embryo and increases quality.

Blastocyst is the later stage of embryo on Day 5 after fertilization developing embryos divide into over 100 cells and differentiate to 2 groups of cell: trophectoderm and inner cell mass (ICM). Trophectoderm will become a baby while ICM wll become placenta of the baby. Scientists develop the technique to grow or culture embryos longer to this stage call “blastocyst culture” in order to identify the potential embryos which can better implant to the endometrium. Blastocyst transfer has been done and offer better success rates. In the sequential transfer program, on the 6’th day after OPU, blastocyst transfer is done additional to embryo transfer on day 2.

In some conditions there may be excess embryos that can be frozen for later use. Freezing protocols vary with stage of embryo development. Cellular water is gradually replaced by cryo-protectants. Embryo may be frozen at any stage and remain viable for at least several years. Embryo freezing does not harm the embryo. Also sperm of patients can be frozen for later use in some conditions.

In women whom ovaries are in danger due to radiotherapy or chemotherapy, ovum freezing is chosen. It is more difficult to freeze ovum than sperm or embryo but success rates are higher too.

Right now we can freeze ova (egg cells) for women who are not ready for getting pregnant now and to preserve her eggs at age provides good quality of eggs.