IVF

There are many reasons why IVF treatment is recommended in Singapore. Some of these include:

• Tubal factor: fallopian tubes are blocked or damaged/swollen (hydrosalpinx). This eliminates the meeting place for the egg and sperm.  
• Male factor: sperm count, motility or morphology are poor on semen analysis.
• Endometriosis: usually for moderate/severe cases 
• Ovulation disorders: ovulating irregular or not ovulating at all (anovulation) resulting in infertility. The most common is polycystic ovary syndrome (PCOS).
• Genetic factors: IVF is needed to test embryos for certain genetic disorders before transferring into the uterus (pre-implantation diagnosis)
• Unexplained infertility: where no cause is found despite investigations
• Fertility preservation: for women who have been diagnosed with cancer and require egg freezing before starting cancer treatment e.g. chemo- or radiotherapy 
• Other assisted reproductive techniques have failed: e.g. ovulation induction or intrauterine insemination

Pre-IVF investigations
Fertility workup includes checking for communicable diseases (HIV/syphilis/hepatitis), ultrasound scan (for uterus and ovaries), testing for ovarian reserve and semen analysis.

Ovarian stimulation
This involves hormone injections (self administered at home) to stimulate the development of more than 1 egg at the same time. Further injections are required to prevent premature ovulation, and to help with maturation of the eggs. 

IVF monitoring
This involves regular ultrasound scans to monitor follicle growth and blood tests to measure your hormone levels – this allows your gynaecologist to adjust your injection doses according to your response. 

Egg collection (oocyte retrieval)
This is usually done as a day surgery under general anaesthesia. A fine needle is inserted through your vagina under ultrasound guidance to tap on your follicles for egg collection. This takes 15-30 minutes. These eggs will be checked for quality and maturity, placed in culture medium and incubated. 

Sperm collection
Your partner will provide a semen sample to the lab on the day of your egg collection – this will be processed and good quality sperm will be picked. If there is frozen sperm, that can be used as well.

Fertilisation 
This can be done by conventional (incubate healthy sperm and egg overnight) or intracystoplasmic sperm injection (ICSI), where 1 healthy sperm is injected into each good quality egg. A combination of both can also be done. ICSI is usually done if there is a limited number of eggs and/or sperm, or if previous IVF cycles have not been successful. 

Additional procedures (if needed)
This may include: 

• Timelapse embryo monitoring: using a special machine to allow continuous, non invasive embryo monitoring without needing to remove embryos from their optimal environment
• Assisted hatching: artificially helping the embryo “hatch” from its membrane to allow for easier implantation into the uterine lining
• Pre-implantation genetic testing: this is where a small sample is removed from the a 5- or 6-day embryo to test for either the correct number of chromosomes or certain genetic diseases that can be passed on. Only embryos that are not affected are transferred into the uterus. 
  
• Embryo transfer This does not usually require general anaesthesia. A thin tube containing the embryo is inserted into your uterus through the cervix and the embryo is placed inside your uterus. This takes 5-10 minutes. The recommended number to transfer is 1 for most cases to avoid the risk of multiple pregnancies, however for some women especially older/failed previous IVF cycles, this number can be increased to 2. Extra embryos are frozen for use at a later date.

Progesterone support 
Your gynaecologist will prescribe medications to prepare the lining of your uterus for embryo implantation after egg collection/embryo retrieval.

Pregnancy test
This is typically via blood test to measure your blood pregnancy hormone (hcg) levels, performed in approximately 2 weeks.

The success of IVF depends on several factors including:

• Maternal age: the older you are, the higher the likelihood of low ovarian reserve and poor egg quality
• The cause of infertility 
• Embryo quality: Day 5 embryos are better developed than Day 3 embryos; however, not all embryos can survive incubation until Day 5

The success rates for IVF vary across countries and centres. A rough estimate of live birth rates from IVF from the USA:

It is not uncommon for couples to undergo a few IVF cycles before getting pregnant. Depending on the reason why IVF was not successful, your gynaecologist may recommend alternative ways to increase your success rates e.g. donor eggs or sperm.

The cost can be quite high and depends on:

• Tests required
• Dose and duration of medications needed 
• Number of cycles before getting pregnant

You will need to discuss with your gynaecologist as each case is different.

• Multiple pregnancies e.g. twins 
• Having preterm labour/ birth and small baby: these risks are higher in older mothers  
• Ovarian hyperstimulation syndrome (OHSS): where there is excessive response to ovarian stimulation medications during IVF, 33% of women undergoing IVF may have mild OHSS
• Egg collection complications: this includes discomfort, infection, bleeding, and injury to surrounding organs
• Ectopic pregnancy: pregnancy outside of the uterus (1%)
• Heterotopic pregnancy: pregnancy inside the uterus and another pregnancy outside the uterus (1%)
• Stress on you and your partner: IVF can be taxing on your physical, emotional and financial health

Miscarriage rates are the same for natural pregnancies versus IVF pregnancies. Although birth defects are slightly higher in infertile patients, this is thought to be related to infertility rather than IVF itself.