Frequently Asked Questions on IVF treatment answered by Dr. Charles MPL.
If you have any questions or concerns about various aspects of IVF treatment, you may like to look at the following questions and answers. Please scroll down to see all the questions.
IVF treatment with Dr. Charles MPL
What are the causes of infertility?
Approximately 40% is of male origin, 40% of female origin and in 20 % there is no obvious identifiable cause. Many couples have combined male and female causes.
The male causes result in a reduction in quality and quantity of sperms.
The female causes can include one or more of the following:
Ovulation defects including polycystic ovarian disease (PCO).
Fallopian tube blockage or disease.
One form of fertility counseling occurs when you have a private discussion with a sympathetic nurse counselor. You share with her your feelings and concerns about your fertility status, the treatment program and your chances for pregnancy. She will listen patiently to you and answer your questions as best she can. She will assist you in resolving your concerns and enable you to decide on the next course of action.
What is the available range of fertility treatment?
The treatment of choice is to treat the underlying cause.
For example, if your problem is infrequent ovulation, ovulation induction is the appropriate choice. If you have PCO, Metformin will be helpful. However in many instances, this may not result in pregnancy even though several cycles of ovulation induction have been attempted. It is at this time that IVF may be appropriate.
If you have endometriosis, then the preferred treatment is to clear the pelvis of the disease by first suppressing ovulation with Depot Lucrin followed by laparoscopic removal of cysts and destruction of endometriotic deposits. If conception does not occur after six months of trying, it would be logical to try additional treatments. One is to employ ovulation induction in the hope of increasing the chance for pregnancy. The other is to resort to IVF.
If you have fallopian tube disease, this can sometimes be corrected by laparoscopic surgery. However in instances when the tubal disease is severe, it may be more effective to achieve pregnancy with IVF. Nevertheless, laparoscopic removal of dilated hydrosalpinges prior to IVF would optimize the outcome.
If your husband has a low sperm count, a sperm enhancing regimen can be tried. Intra-uterine insemination (IUI) is an option as well. However, if there are only very few sperms, the only remaining avenue would be to resort to IVF with intra-cytoplasmic sperm injection (ICSI). Even when there is absence of sperms in the semen (azoospermia), but some live sperms retrievable from the testis, pregnancy can still be achieved by ICSI.
When there are no eggs left in the ovaries or if there is no sperm production in the testes, the last resort is to consider use of eggs or sperm from donors.
In-vitro fertilization (IVF) is a process in which your eggs collected from your ovaries are mixed with your husbandís sperms in a test tube or plastic dish with the objective of one sperm entering one egg and combining to produce one embryo. One to three embryos are then placed in your uterus for implantation and development into one or more babies.
IVF is recommended if you are unable to conceive in the normal way or when other treatments have not succeeded in producing the baby that you so earnestly desire.
(See Simplified IVF ICSI protocol)
(See ICSI, fertilized egg and embryo)
(See IVF babies and children)
What tests must I take before I can receive IVF treatment in Singapore?
Tests for human immune deficiency virus (HIV), syphilis, hepatitis B virus, Hepatitis C virus and Rubella virus (German Measles) are required for you and your husband and should be done in a laboratory in Singapore within the six months preceding the IVF attempt. Protective immunization would be offered to you if you are not immune to Rubella.
Optional but preferred tests are hemoglobin, hemoglobin electrophoresis, blood group, Toxoplasma IgM, AMH, Thin-prep cervical smear and swab form your cervix for Chlamydia. Your husband should have his semen cultured for bacteria and Mycoplasma.
On your first or second menstrual day, your Follicle stimulating hormone (FSH) level is measured and your antral follicle count is made by vaginal probe ultrasound scan to determine the appropriate starting dose of ovarian stimulation medicine.
A raised basal FSH level means that the number of eggs remaining in the ovary is reduced. A higher dose of ovarian stimulation medicine would be required to produce ripe eggs. Even so, some of the eggs may be sub-optimal in quality.
If the level is very high and in the menopausal range, this indicates that there are no eggs left in the ovary which are capable of ripening. Using eggs from an egg donor may be a more effective approach.
is the significance of a low Anti Mullerian
An AMH level below 0.5ng/ml is associated with poor ovarian response and fewer eggs to harvest. A higher dose of Gonal F is required to stimulate egg development.
An AMH level above 3.5ng/ml is associated with a higher probability of Ovarian Hyperstimulation.
AMH levels can also be used as a guide when deciding on the dose of fertility drugs for ovarian stimulation.
This is a fluid filled structure which houses the developing egg (oocyte). The covering of the follicle contains cells which produce the female hormone (estrogen) called Estradiol 17beta. After release of the egg (ovulation), these hormone producing cells switch to producing the implantation supporting hormone called Progesterone. This structure is yellow in color and is called the Corpus Luteum.
What is the Antral
This is the total number of small fluid-filled structures seen in both ovaries which are about 2-8mm in diameter detected by vaginal probe ultrasound scan on the second day of the menstrual cycle. Each follicle contains one oocyte (egg). The higher the count, the more the number of eggs which can be harvested after stimulation. A low count is one with less than 10 antral follicles. This indicates a poorer response to ovarian stimulation. A high count is one with 30 or more follicles. This indicates a condition called Polycystic Ovaries. There is a higher chance of hyperstimulation in such patients.
Microgynon. This is an oral contraceptive tablet used in the preparation cyle to help adjust the timing of the start of the stimulation cycle.
Lucrin. This is an LH Agonist which initially stimulates LH production from the brain and then later suppresses it so as to prevent your own LH from triggering ovulation before your eggs can be harvested. It is given in the form of a subcutaneous injection.
Cetrotide. This is an LH Antagonist which suppresses LH prduction from the brain so as to prevent your own LH from triggering ovulation before your eggs can be harvested. It is given as a subcutaneous injection.
Gonal F. This is Follicle Stimulating Hormone which stimulates your ovarian follicles to grow. It is given in the form of a subcutaneous injection.
Pregnyl. This is Human Chorionic Gonadotrophin which acts like LH to trigger ovulation 36 hours after administration. It is also given to support the luteal phase. It is given as a subcutaneous injection or an intra-muscular injection.
Crinone. This is progesterone. It permeates the uterus and supports the endometrium to allow implantation of the embryo. It is given in the form of a gel inserted into the vagina with an applicator.
Cyclogest. This is progesterone. It increases the receptivity of the internal lining (endometrium) of the uterus to allow implantation of the embryo.It is given in the form of a pessary to be insterted either into the vagina or into the rectum.
Utrogestan. This is progesterone in the form of a round capsule. It can be used as a pessary to be insterted into the vagina or taken orally. It increases the receptivity of the internal lining (endometrium) of the uterus to allow implantation of the embryo
Duphaston. This is a progestogen in the form of a tablet. It increases the receptivity of the internal lining (endometrium) of the uterus to allow implantation of the embryo. The tablets are taken orally.
Progynova. This is estradiol valerate. an estrogen given together with progesterone to support the endometrium during the luteal phase. It is in the form of tablets taken orally. It is also used for maturing the uteine lining in thaw embryo transfer cycles. Other estrogen preparations include Oestrogel cream and Vagifem pessary.
Saizen. This is Human Growth Hormone given to improve egg quality. It is given in the form of a subcutaneous injection.
Atosiban. This is an oxytocin antagonist which reduces uterine contractions to reduce the chance expulsion of the embryo after embryo transfer. It is diluted in a saline intravenous infusion.
These medicines have been specially selected because of a favorable record of giving consistent and optimal response for IVF.
What are some of the complications of treatment by IVF?
A complication is an undesirable effect associated with treatment.
The main complication of IVF is ovarian hyperstimulation syndrome (OHSS).
The second complication is multiple pregnancy with more than twins. Eg triplets, quadruplets etc.
The third is ectopic pregnancy. The other rare complications include bleeding and infection from the needle puncture at egg collection.
What are some side effects of ovarian stimulation medicines?
The most important is ovarian hyperstimulation syndrome (OHSS).
The second is multiple pregnancy.
The other complications result from an enlarged ovary. It may twist upon itself and result in torsion, or it may bleed or rupture, requiring operation. Sometimes a functional cyst persists after the cycle is over.
What is Ovarian Hyperstimulation Syndrome (OHSS)?
This is a condition in which many follicles are produced and cause accumulation of fluid in the abdomen and sometimes in the chest. The abdominal fluid causes bloating. The fluid in the chest causes breathlessness.
This condition is usually temporary. However women with poly cystic ovaries and those with high AMH have an increased sensitivity to FSH and are more susceptible to severe hyperstimulation. Sometimes, admission to hospital is required and drainage of the accumulated fluid from the abdomen and occasionally from the chest may be done. Treatment with concentrated albumin infusion is effective in reducing the severity of this condition. Dostinex 0.5mg daily for 10 days may also be tried.
The preferred approach is to avoid this complication.
If LH Antagonist cycle is employed, the HCG trigger can be replaced by LH Agonist Lucrin 0.5ml (2.5mg) given subcutaneously. Lucrin initially stimulates the production of LH by the brain. The additional luteal phase support required is oral Progynova together with Progesterone in oil by intramuscular injection.
If hyperstimulation is anticipated, the dose of Gonal F can be gradually reduced or even stopped for up to 3 days before the HCG trigger.
Another way is to proceed with the HCG trigger (5,000 units), harvest all the follicles and freeze store the embryos for future transfer. This avoids further aggravation of OHSS if pregnancy occurs.
Cancellation of the cycle by omitting the HCG trigger would almost completely eliminate the risk of hyperstimulation. For these cases, the Lucrin or Cetrotide would be continued for three extra days to further reduce the chance of spontaneous LH surge. A fresh cycle can be started with a lower dose of FSH.
When do I know that my eggs are ripe?
When two or more of your leading follicles are 20mm or more in average diameter and if your Estradiol level is about 1,000 pmol per Lit for each large follicle, your eggs are mature enough to have the HCG trigger injection. Usually there will be clear mucus from your vagina and the ultrasound scan would show an endometrial thickness in excess of 8mm.
You will not have food nor drink for six hours before the procedure. You will empty your bladder and be placed under a short general anesthesia for usually less than fifteen minutes. A 17 gauge needle will be inserted under vaginal probe ultrasound scanning. The follicles will be emptied systematically and the aspirated fluid will be examined under a dissecting microscope for the cumulus- oocyte complex. Antibiotics will be given and after a three hour rest, you can go home. You may experience a little lower abdominal discomfort for a short while and some pain-relief medicine will be given to you to bring home. There may be some bleeding from the vagina after egg collection. This is usually minimal and would stop within a day.
What is ICSI?
Intra Cytoplasmic Sperm Injection (ICSI) is a modification of IVF.
ICSI is a procedure in which one immobilized sperm is sucked into a very narrow pipette and then injected inside the egg, allowing fertilization to take place.
It is usually employed when sperms are unable to enter eggs by their own power.
Most forms of male infertility can be solved by use of ICSI. Sperm donation is now less required.
ICSI can also be used to maximize the yield of embryos.
(See ICSI, fertilized egg and embryo)
Some women have egg shells (zona pellucida) which are hard and which may prevent the developing embryo from hatching and implanting in the uterus. In order to assist in hatching, an opening is made in the shell of the egg. This can be done either mechanically, optically (laser) or chemically (acid).
In ICSI cases, the egg shell has already been weakened by the insertion of the sperm injecting pipette. In theory, this would allow hatching to occur more easily.
Can my eggs be fertilized?
Fertilization depends on the quality of the eggs and sperm. With ICSI, the main variable is egg quality. Egg quality depends on your age, AMH and basal FSH level. Fertilization is increased with ICSI.
This is the process in which fertilized eggs are placed inside your uterus using a flexible catheter (Wallace 1816N 23cm). This procedure is painless. Insertion of the catheter is done slowly. The use of trans-abdominal ultrasound scanning allows for guidance of the catheter tip to the upper cavity of the uterus. If entry into the uterine cavity is not successful, a bulb-tipped cannula is used (Cook K-JETS 7019-SIVF). Removal of the catheter is also done slowly. After the catheter is removed, it is checked under the microscope to ensure that all the embryos have been placed inside the uterus.
Usually two day-3 embryos are placed inside your uterus at a time. With three embryos transferred, there is a possibility of a triplet pregnancy . Triplet pregnancies carry a much higher chance of premature delivery and should be avoided. If day-5 embryos (blastocysts) are used, one embryo is sufficient in younger women.
There does not appear to be any difference in the chance of pregnancy whether there is bed rest or not. However, it is preferred that you do not to engage in strenuous activities.
Can I have Sex with my husband during the two weeks after embryo transfer?
It has not been proven that avoiding coitus during the two weeks after embryo transfer makes any difference to the chance of pregnancy. However most couples prefer to abstain from coitus.
This is the process by which the hatched embryo attaches itself to the internal lining of your uterus and starts to take nutrition and oxygen from you. This takes place a few days after embryo transfer. You will not be able to feel it.
Bleeding may be due to implantation of the embryo or detachment of the embryo or early menses. It is preferred that you do the urine test for pregnancy at the designated time (usually sixteen days after embryo transfer) in order to clarify the reason for the bleeding.
When is the earliest time I can test for pregnancy?
For the urine pregnancy test, you should use your first morning urine sixteen days after the day3 embryo transfer or fourteen days after day5 (blastocyst) transfer. Doing it earlier may produce a negative result even if you are actually pregnant because the level of HCG from the very early pregnancy may not be sufficient to show up in the urine test. On the other hand, if you are given implantation (Luteal) phase support in the form of injections of HCG (Pregnyl), you may get a positive result even if you are actually not pregnant. Hence, it can be misleading to do the urine pregnancy test too early. If you want your blood tested for HCG, you can do it two days earlier than the urine test.
Freezing has been replaced by Vitrification (make into 'glass'). This involves immersing the embryo in a dehydrating and cryo-protecting solution containing hydroxipropyl cellulose and trehalose and plunging the embryo into liquid nitrogen for vitrification and storage at -196 degrees Centigrade. The embryos can survive indefinitely. In practice, they are thawed and used for transfer within five years. Survival is better after vitrification as compared to slow freezing.
Can my frozen embryos survive storage?
The quality of your embryos is the main determinant for survival and implantation. Expected survival is about eighty percent. Quality of embryos is determined largely by the quality of your eggs (oocytes).
a natural cycle?
If you have a regular ovulatory cycle. One way is to test your urine twice daily from day 12 to day 16 for the Luteinizing hormone surge. This would show as a definite double line in a plastic cassette. You will be given an injection of HCG 10,000 units (Pregnyl) under your skin of your tummy .
If your embryos have been frozen at the 6 or 8 cell stage, transfer will take place five days after the injection.
On the day of transfer, you will have a trans abdominal ultrasound scan to determine the position of your uterus and the length of the cavity.
The number of embryos to be transferred will be decided upon and they will be thawed and cryo preservative washed away. The thawed embryos would be inspected for viability before transfer.
Three days before embryo transfer, luteal phase support is started. Vaginal progesterone 90mg (Crinone) is inserted two times a day for 20 days.
On the day of embryo transfer, the implantation (luteal) phase support is also augmented with HCG (Pregnyl) 2,500 units under the skin. This is repeated every three days for a total of 3 times.
Sixteen days after embryo transfer, the urine will be tested for pregnancy. If you are pregnant, Crinone will be continued for the next 10 weeks. You will also be given folic acid 5 mg daily and salbutamol (Ventolin) 1 mg twice daily.
How do I undergo Thawed embryo trnasfer in an Ovulation Induction cycle?
1 You will take one tablet (50mg) of clomiphene citrate (Duinum) from day 3 to day 7 of your menstrual cycle.
2 On day 8 of your menstrual cycle, you will be given one ampoule of Gonal F (75 units), under the skin of your tummy (abdomen) through a 27 gauge very fine needle. This is repeated on day 10.
3 You would be seen on day 12 of your menstrual cycle to check the growth of your follicles with a trans-vaginal probe ultrasound scan.
4 If there are more than three follicles greater than 14 mm in diameter, the third dose of Gonal F is omitted. This would reduce the chance of ovarian hyper stimulation syndrome (OHSS).
5 Your urine is tested twice daily from day 12 to day 16 for the Luteinizing hormone surge. This would show as a definite double line in a plastic cassette. You will be given an injection of HCG 10,000 units (Pregnyl) under your skin of your tummy .
6 If your embryos have been frozen at the 6 or 8 cell stage, transfer will take place five days after the injection.
7 On the day of transfer, you will have a trans abdominal ultrasound scan to determine the position of your uterus and the length of the cavity.
8 The number of embryos to be transferred will be decided upon and they will be thawed and cryo preservative washed away. The thawed embryos would be inspected for viability before transfer.
9 Three days before embryo transfer, luteal phase support is started. Vaginal progesterone 90mg (Crinone) is inserted two times a day for 20 days.
10 On the day of embryo transfer, the implantation (luteal) phase support is also augmented with HCG (Pregnyl) 2,500 units under the skin. This is repeated every three days for a total of 3 times.
11 Sixteen days after embryo transfer, the urine will be tested for pregnancy. If you are pregnant, Crinone will be continued for the next 10 weeks. You will also be given folic acid 5 mg daily and salbutamol (Ventolin) 1 mg twice daily.
How do I undergo a Thawed embryo transfer in a hormone replacement cycle?
This applies if you do not have a regular menstrual cycle or are receiving donated oocytes.
When required, withdrawal bleeding is induced with one 5mg tablet of Norethisterone twice daily for five days.
In order to simulate the proliferative phase of the menstrual cycle, Estradiol valerate (Progynova) 2mg, three tablets twice a day are given from day 3 of your menstrual cycle for 12 to 20 days until the endometrium is more than 8mm in thickness and there is clear cervical mucus.
To simulate the secretory phase of the menstrual cycle, vaginal progesterone 90mg (Crinone) is inserted two times a day for 20 days
Embryo replacement takes place 3 days after starting progesterone. On the day of transfer, you will have a trans-abdominal ultrasound scan to determine the position of your uterus and the length of the cavity.
The number of embryos to be transferred will be decided upon and they will be thawed and cryo-preservative washed away. The thawed embryos would be inspected for viability before transfer.
Urine is tested for pregnancy 16 days after embryo transfer. If pregnancy occurs, Progynova and Crinone will be continued for another 10 weeks. You will also be given folic acid 5 mg daily, salbutamol (Ventolin) 1 mg twice daily and Duphaston 10 mg three times daily.
What are the Factors which influence outcome?
The chance of pregnancy is influenced by your age, your AMH level and your basal FSH level. In general, the younger you are, the better the outcome.
The chance of pregnancy is also dependent on the number of embryos transferred. Although more embryos transferred increases the chance of pregnancy, it also results in a higher chance of multiple pregnancy with its associated problem of premature births. In practice, two or three embryos are transferred..
It is preferred that you bring along all available previous tests that you and your husband have undergone to show the fertility specialist. Dr. Charles MPL will review your menstrual history, past tests and treatments and then examine you and your husband. You will be given a provisional diagnosis as to the likely cause for your inability to conceive. Based on the findings obtained, a series of additional tests would be ordered and a provisional plan of treatment outlined.
If the treatment is IVF, the plan would include blood tests, counseling, ovarian stimulation, egg collection, embryo transfer, luteal phase support and test for pregnancy.
An appointment is given at a later date to review the results of tests ordered and modify the treatment plan where appropriate.
These requirements only apply to IVF performed in the Republic of Singapore.
Valid marriage license.
Below 45 years of age.
Both tested negative for human immune deficiency virus (HIV) in a Singapore laboratory within the last 6 months.
Tested for syphilis, hepatitis B and Hepatitis C in a Singapore laboratory within the last 6 months.
Tested for German Measles (Rubella).
It would be useful if you can arrange for your blood to be tested for FSH level on day 2 of your menses in your home country. You and your husband should arrive in Singapore just after your next menses has stopped. This would allow you time for preliminary consultation, counseling and tests. These will take approximately three days, after which you and your husband may return to your home country with a supply of medicine.
You will return to Singapore just prior to your menses and stay for approximately three weeks. Your husband will come to Singapore once the egg retrieval day has been decided upon. He will stay for only two days. If he has elected to freeze and store his sperms at the first visit, it may not be necessary for him to make the second trip.
For thaw replacement, you will require to be in Singapore for about seven days. Your husband is not required to be present.
Please click the following Singapore Immigration Hyperlink to find out whether you require a visa to enter Singapore.
Please contact Dr. Charles MPL if you require further information.
Dr. Charles MPL ?
The fastest method is to telephone Dr. Charles MPL at Tel: (65) 6737 3666 or Fax: (65) 6738 3803
If you prefer e-mail, you can click on this address: firstname.lastname@example.org provided your Microsoft Outlook Express has been properly configured to send e-mail. Otherwise, you can copy down this address, minimize this web page, select your usual web courier and then send your e-mail.
Dr. Charles MPL's clinic?
3 Mount Elizabeth,
#13-02, level 13,
Mount Elizabeth Medical Center,
Republic of Singapore.
(click here for map)
Dr. Charles MPL's clinic
The following are the hyperlinks to some of the nearby hotels which are within walking distance.
York Hotel tel +65 6737 0511
Elizabeth Hotel tel +65 6738 1188
The Quincy tel +65 6496 7699
Grand Park Orchard tel +65 6603 8888
Mandarin Orchard tel +65 6737 2200
Marriott Hotel tel +65 6735 5800
Grand Hyatt Hotel tel +65 6738 1234
It is preferred that every husband be advised to attempt to improve the quantity and the quality of his sperms in order to enhance the likelihood of fertilization and conception. The main idea is to keep the scrotum and testes cool. Sperm production is improved when the testes are exposed to a lower temperature. The following advice would be given to your husband.
Wear loose, boxer style, cotton or satin underwear. Wear satin pajama pants.
Wear only loose pants and avoid jeans.
Use a cool seat cover for his vehicle and avoid sitting on hot surfaces.
Keep his legs apart when seated and do not cross them.
Shower with cool water and avoid hot baths and sauna.
Spray cold tap water on his private parts for one minute at each bath.
Take one capsule of vitamin E (400 units). daily
If his sperm count is below 10 million per ml, a supplement containing co-enzyme Q10 can be tried.
If his scrotal skin is thickened and itchy, he has fungal disease and requires anti-fungal cream and powder.
If he has a varicocele, he can have his enlarged veins surgically tied by a Urologist.
If he has no sperm in his semen and his testes is normal in size, the absence of sperms is probably due to obstruction. He is referred to a Urologist to explore the testes and epididymis and to obtain sperms for freeze storage for future intra-cytoplasmic sperm injection (ICSI).
1. Raw semen is brought to the laboratory within one hour of production.
2. Culture medium is layered on top. The specimen is left in the incubator at 37 degrees Celsius for one to two hours. The highly motile sperms will swim up into the culture medium.
3. The enriched upper layer is then removed and sent to the clinic where it is flushed into the uterus using a flexible catheter.
4. It is important to load the catheter correctly so that air is not introduced into the uterine cavity and block the fallopian tubes.
5. This procedure is performed during the time of ovulation in order to increase the chance of conception.
6. IUI is more effective when combined with ovulation induction.
(See IUI etc babies and children)
If you have at least one fallopian tube which is not blocked, and if your husbandís sperm concentration is at least 5 million per ml, and if you have not already tried this treatment method, three cycles of ovulation induction may be tried.
1. You will take one tablet (50mg) of clomiphene citrate (Duinum) from day 3 to day 7 of your menstrual cycle.
2. On day 8 of your menstrual cycle, you will inject one ampoule of Gonal F (75 units), under the skin of your tummy through a fine needle in the area 4cm below the belly button.
3. This is repeated on day 10 and day 12 of your menstrual cycle. You can do the injection yourself or get a nurse or family doctor to do it. Do not get a get a gynecologist to do it as he may prefer to use his own style of treatment.
4. Use your second morning urine to test for Luteinizing hormone (LH). This would be performed from day 12 to 16 of your cycle. The LH test kit is a cassette into which a few drops of urine is placed. You can read the result in fifteen minutes. The appearance of two lines indicates the LH surge which means imminent ovulation. This is expected to occur around day 15 of your menstrual cycle if you have a normal 28-30 day cycle.
5. Have sexual intercourse on the night of the LH surge and two nights later. Place three pieces of tissue paper at your vulva and close your legs and turn to the side to prevent leakage of the semen. Do not get up for an hour. This is to allow time for the moving sperms to swim into your cervical mucus. After one hour, you can pass urine and wash your vulva. You will notice some semen coming out. Do not worry. This contains mainly the non-moving sperms.
6. (When you have sexual intercourse at other times of your menstrual cycle, you are free to get up to pass urine and wash immediately after the intercourse.)
7. If your menses is delayed for one week, test your urine or pregnancy. If it is positive, see me or your local gynecologist one week later for an ultrasound scan to look for the gestational sac.
8. If your menses comes, you would like to proceed to super-ovulation and intra-uterine insemination. Write the date of the first day of your menstrual cycle on the time-table provided and fax it to +65 6738 3808. Take one tablet of Duinum 50mg daily from the second day of your menses for 5 days.
9. Come to Singapore on seventh day of your menstrual cycle and see me for ovarian stimulation with Gonal F. You will stay in Singapore for about one week.
10. Once your urine is tested positive for the LH surge, your husband will come to Singapore that night.
11. The next morning, your husband will produce a semen specimen at 8am in the hotel and bring it to MEFC laboratory before 9 am. If he prefers, he can produce his semen in the Mount Elizabeth Fertility Center at 8.30 am. MEFC lab will extract the live sperms within two hours. You will collect the washed sperms at 11 am and bring it to Dr Limís clinic for insemination.
12. Do not pass urine. A full bladder will allow ultrasound scanning of your uterus to help in guiding the Wallace catheter into your uterus. Intra-Uterine Insemination (IUI) is usually completed by 12 noon.
13. Both you and your husband can return to your home country at 3pm on the day of insemination.
What is PCO (poly cystic ovary)?
Poly cystic ovary is a benign condition in which there are many small follicles in the ovaries usually arranged as a ring like a pearl necklace around a central solid core. This condition is associated with impaired insulin metabolism. It is manifested by irregular and infrequent menstrual cycles, sub-fertility, and a higher rate of miscarriage. Women who are given ovulation inducing medication often over-respond sometimes resulting in ovarian hyperstimulation syndrome.
There are three degrees of severity. The mildest is polycystic ovarian morphology (PCOM). PCOM patients have a normal body mass index (BMI). The intermediate form is poly cystic ovarian syndrome (PCOS). PCOS patients are also overweight (BMI > 25) and have more hair over the lower abdomen and legs. The severe form is polycystic ovarian disease (PCOD). PCOD patients also suffer from diabetes and hypertension.
Metformin is the treatment of PCO. Metformin partially corrects the metabolic effects of PCO. It is also used to treat diabetes. It's side effects include nausea, dyspepsia, gastic pain and weight loss. It should be started in gradually increasing doses of 500mg after meals up to three times a day. Continuation of 500 mg Metformin during pregnancy up to 12 weeks may reduce the chance of miscarriage.
Your fallopian tubes will be checked for blockage.
The initial preference is to perform an X-ray examination called Hysterosalpingogram (HSG). This involves coming on day 7 or day 8 of your menstrual cycle. You will be brought to the X-ray department. A radio-opaque liquid will be flushed into your uterus and fallopian tubes. An X-ray is taken to show the liquid spilling out from your tubes. There will be some discomfort when you undergo this examination.
Since ovulation induction treatment can help some couples get pregnant with minimal discomfort, and since the majority of X-ray examinations of fallopian tubes show no blockage, the initial preference is to try one cycle of ovulation induction before proceeding to HSG.
Another way to assess whether your fallopian tubes are blocked is to perform an operation called video-laparoscopy and hydrotubation. This is an invasive procedure involving the insertion of instruments through the abdominal wall to see your uterus, ovaries and fallopian tubes. It will be performed painlessly under general anesthesia.
Methylene blue is added to sterile water and flushed into the uterus and out through the tubes to test for blockage. A major advantage of this procedure is that various problems which may be the cause of your failure to conceive can also be corrected at the same time. These are Endometriosis, ovarian cyst and pelvic adhesions. Even some blocked fallopian tubes can be opened. The laparoscopic procedure can be used for diagnosis as well as for treatment.
Since ovulation induction treatment can help some couples get pregnant with minimal discomfort, and since the majority of laparoscopic examinations of fallopian tubes show no blockage, the initial preference is to try at least one cycle of ovulation induction before proceeding to the operation.
What are the Tests for ovulation?
Ovulation status is assessed by noting menstrual cycle length and regularity. If you have a cycle length shorter than twenty six days, it is useful to do a basal Follicle stimulating hormone (FSH) test on the second day of your menstrual cycle to see your egg reserve.
If you have intervals between menses of longer than 34 days, poly cystic ovary (PCO) is suspected. This is confirmed be finding a ring of small follicles in your ovaries on ultrasound scanning. In PCO, the basal Luteinizing hormone (LH) is usually raised and can be more than double the level of your Follicle stimulating hormone (FSH) on the second day of your menstrual cycle.
If you have an irregular menstrual cycle and problem with ovulation is suspected, you will be given an appointment to return on day 2 of your next menses for your blood to be taken for testing of hormones: Follicle stimulating hormone, Luteinizing hormone, Estradiol, Testosterone, Thyroid stimulating hormone and Prolactin.
The egg develops within a fluid filled structure called a follicle. Usually some fourteen days after the first day of the menses, this follicle bursts open (ovulate) to release the egg (oocyte). The remaining follicle wall develops into a yellow body (corpus luteum) which produces a hormone called Progesterone. Progesterone prepares the internal lining (Endometrium) of the uterus for implantation of the fertilized egg (embryo). A raised progesterone level some seven days before the expected next menses indicates that ovulation has taken place.
Progesterone also raises the basal body temperature (BBT). BBT is your body temperature taken on first waking up in the morning. When charted over a menstrual cycle, a shift to a higher temperature is seen at about mid-cycle denoting ovulation.
The developing follicle can be seen by use of a vaginal probe ultrasound scan. In unstimulated cycles, only one of the many small follicles would grow and ovulate. This can be tracked by using the trans vaginal probe ultrasound scan. In unstimulated cycles, ovulation is imminent when the leading follicle is more than sixteen mm in average diameter. However, when you have received medicines to stimulate egg production, ovulation usually occurs after the leading follicle reaches twenty mm in average diameter.
The endometrium can show the influence of progesterone. A biopsy specimen of endometrium can be used to indicate that ovulation has occurred. However, the biopsy procedure can be uncomfortable.
Most of the tests show ovulation only after it has occurred and is not useful in predicting imminent ovulation for the purpose of timing coitus or insemination.
The urine Luteinizing hormone test can predict ovulation within 24 to 36 hours. This is a do-it-yourself urine test on the second morning urine specimen during the five days when ovulation is anticipated.
For tracking of ovulation and timing of coitus or intra uterine insemination, the preference is to use the vaginal probe ultrasound scan to assess follicle size. Since the follicle grows at about 2mm per day, the time it reaches 20mm can be predicted. The urine LH test is the used at around the predicted time to anticipate the day of ovulation more precisely.
This is a minimally invasive operation, performed under general anesthesia, where small incisions in the abdomen allow special instruments access to view the pelvic organs and to correct problems in the pelvis.
Laparoscopy is used for assessing the state of health of the fallopian tubes. The fallopian tubes are not blocked if there is spillage of methylene-blue dye tinted water flushed into the uterus from below.
Laparoscopic surgery can permit the removal of ovarian cysts and myoma, separation of adhesions and destruction of deposits of endometriosis. The objective is to restore the pelvis to a healthy state.
The best time to perform laparoscopy is after the menses. The day before the procedure, medicine is taken to clear the intestines.
At the umbilicus a 1 cm incision is made for the laparoscope. The pelvic organs are inspected and another two or three 0.5 cm incisions are made in the lower abdomen for specialized instruments to perform the required surgery. The duration of surgery varies according to the task at hand and varies between half an hour to two hours.
After the procedure, you will only feel minimal discomfort and should be able to go home the next day and be able to go back to work within a week.
If laparoscopy is done for fertility assessment, it is preferred to also have a hysteroscopic examination at the same time.
Hysteroscopy is a procedure of inspecting the inside of the uterus with an optical instrument (hysteroscope) inserted through the cervix from below. This allows abnormalities in the uterine cavity to be seen and dealt with. Hysteroscopy performed before IVF is useful because it permits polyps and other problems within the uterus to be seen and corrected. It also enlarges and smoothens the canal leading from the neck of the uterus (cervix) to the uterine cavity proper. This ensures ease of replacement of the embryo and improves the chance of pregnancy.
Hysteroscopy is usually done as a day surgery procedure. A tablet of Cytotec is placed in the vagina two hours before the procedure to cause the neck of the uterus to open. A short general anesthesia allows hysteroscopy to be performed painlessly. Saline or glycine is infused at 100mm Hg. to distend the uterine cavity in order to allow the inside of the uterus to be inspected.
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