By KKIVF Centre, KK Women's and Children's Hospital
What Is IVF?
In-Vitro Fertilisation (IVF) involves putting the eggs and sperms together. By natural selection, the egg will usually allow only one sperm to enter and this usually leads to the fertilisation process in the laboratory. After fertilisation, the embryos are allowed to grow for a short period of time before being placed into the uterus. A successful pregnancy can be confirmed about two weeks later.
Who Is Suitable For IVF?
IVF is the only fertility treatment for women with irreparably damaged or blocked fallopian tubes. IVF is also offered when infertile women cannot conceive with simpler methods of treatment for conditions such as endometriosis, ovulatory dysfunction, unexplained infertility, sperm disorders and immunological problems.
What Is ICSI?
Intra-Cytoplasmic Sperm Injection (ICSI) involves injecting a single sperm into each egg to allow fertilisation to occur in the laboratory.
Fig 1. Injecting single sperm into an egg
Who Is Suitable For ICSI?
ICSI is recommended if your husband has poor quality sperms or if you have had difficulties with fertilisation in the past. If this is your first ICSI cycle, it may also be combined with regular IVF.
Counselling & Consent
This is a session where the clinician will explain and discuss the procedure with you. Any questions that you have about the treatment can be raised at this time. This will enable you to fully understand the treatment you are about to embark on. You will also need to make some decisions regarding unfertilised eggs and abnormal/poor quality embryos.
A written consent for IVF/ICSI and cryopreservation/thawing of the embryos is also obtained.
You will also need a separate session by our IVF counsellor on the emotional and physical demands of undergoing the treatment programme and dealing with disappointments of failed attempts.
Blood tests have to be performed to exclude venereal diseases such as syphilis, HIV, Hep B and AIDS. A rubella antibody test will also be carried out. You will be advised to have a rubella vaccination before the IVF procedure if you have no immunity against it. Your husband will have a pre-IVF semen analysis to determine any need for the sperms to be frozen and stored. The wife should also start taking folate daily.
IVF ICSI Prgramme IVF programmes utilise Controlled Ovarian Hyperstimulation which results in more eggs and hence a better chance of pregnancy. Controlled Ovarian Hyperstimulation is carried out with GnRHa (e.g. Lucrin) and gonadotrophins (e.g. Gonal F or Puregon) injections. Various protocols are used. The protocol using GnRHa and gonadotrophins is described here:
1. Controlled Ovarian Hyperstimulation and Monitoring
a. GnRHa Injection
GnRHa treatment is given daily to prevent a spontaneous ovulation and to ensure that the ovarian follicles grow in synchronous fashion. It usually starts in the second half of your menstrual cycle and continues for about 14 to 20 days. Some patients may need to take this medication for longer periods.
Blood tests and ultrasound scans will be done to ensure that the optimum response is reached. Once this is achieved, you will proceed to the gonadotrophin injections.
b. Gonadotrophin Injection
Gonadotrophin is injected daily into the muscle/subcutaneous tissue of your thigh or buttock to stimulate the growth of the follicles in the ovaries. After several days of gonadotrophin injections, an ultrasound scan is performed to determine the number and size of the growing follicles. You will need additional injections if the follicles have not reached the desired size.
Fig 2. Transvaginal ultrasound scan showing follicles in the ovary after hormonal stimulation
When the follicles have reached the desired size, an injection of HCG is given and GnRHa and gonadotrophin are discontinued. The HCG is required for the final maturation of eggs before the egg collection. The egg collection is scheduled about 36 hours after the HCG injection.
2. Sperm Preparation
During the gonadotrophin injections, your husband need not abstain from sexual intercourse before the egg collection. On the day of the egg collection, your husband needs to produce a fresh masturbated semen sample.
3. Egg Collection (Oocyte Pick Up)
The egg collection is performed at KKIVF. The eggs are collected through a special needle attached to an ultrasound vaginal probe. A mild sedative will be given to you, as only minimal discomfort will be experienced during the procedure.
After the egg collection, you will be observed for a few hours before going home. It is important to understand that not all follicles will necessarily contain an egg and that some of the eggs may not be ripe enough for fertilisation. An overnight fast is required before oocyte pick-up procedures.
Fig 3. Egg Collection
Hormonal stimulation induces superovulation; eggs aspirated from the mature follicles transvaginally with ultrasound-guided needle
The sperm is added to the collected eggs in a dish to allow fertilisation to occur by natural selection in the laboratory. A check to confirm that fertilisation has occurred is carried out the following day.
Unfortunately, in about 10% of couples, there is no fertilisation at all.
4B. Intra-Cytoplasmic Sperm Injection
ICSI will be performed on the day of oocyte pick-up. During the procedure, a single sperm will be injected into each egg via a microneedle. On the following day, a check is made to confirm that fertilisation has occurred.
5. Embryo Transfer
A few days after the egg collection, you will need to return to KKIVF to have the embryos placed into your uterus. An overnight fast is recommended before the embryo transfer procedure.
Embryos are re-placed into the uterus using a fine catheter. This is usually painless and takes only a few minutes. Usually, two or three embryos are transferred. A smaller number may be transferred if there are insufficient embryos or in younger patients. We encourage your husband to sit in during the embryo transfer.
Fig 4. Embryo Transfer
Eggs fertilized in-vitro (IVF) with sperms. Embryo transferred directly into uterus, bypassing tubal occlusion.
You may go home shortly after the embryo transfer. You will be given daily hormonal support (progesterone or HCG) to support the lining of the uterus and to enhance the chances of the embryos implanting.
There is no restriction on activities including sexual intercourse.
6. Freezing of Extra Embryos
A proportion of patients may have excess good quality embryos. These may be frozen for future use. Patients do not need to undergo Controlled Ovarian Hyperstimulation and egg collection again for these future thaw cycles.
There is an annual storage fee for these frozen embryos.
You will need to come to KKIVF 17 days after the embryo transfer for a pregnancy test. You should call KKIVF if you are menstruating so that further instructions can be given.
If you are pregnant, subsequent ultrasound scans and blood tests will be arranged to ensure that the pregnancy is proceeding normally.
8. Useful Information
Success rates (KKIVF rates)
Our overall clinical pregnancy rate is about 40-44% per cycle and the take-home-baby rate is about 30%.
Generally, patients who are below 36 years old have a better pregnancy chance. However, your chances of success will depend very much on your own individual circumstances.
Disappointment & Risks
• Cancellation of the treatment cycle may occur due to various reasons, including poor follicular development. Our cancellation rate is approximately 5%.
• Ovarian Hyperstimulation Syndrome (OHSS) happens when too many ovarian follicles have developed in response to the usual dosage of medication. Although uncommon, it warrants medical attention until its complications have been treated. The severe form of OHSS will affect less than 1% of our patients.
• The miscarriage rate is about 10-15% while the ectopic pregnancy rate is about 5%.
• When 3 embryos are replaced, there is a risk of 10% of twins and 3% of triplets.
• The risks of oocyte collection (OPU) are very rare. As the procedure involves a needle entering the ovary, it may be complicated by bleeding from the ovaries, uterus or adjacent blood vessels and injury to the intestines. In such an instance, further treatment may be necessary.
With the increased risk of multiple pregnancies, babies born as a result of the Assisted Reproductive Programme (ARP) have a greater chance of being hospitalised in a neonatal ward or ICU. Hence, as required by the Ministry of Health, all patients undergoing ARP treatment in Singapore must subscribe to the neonatal insurance.
For enquiries, please call KKIVF Nurse Coordinators at tel: +65 6394 1694.
This featured article is contributed by the KKIVF Centre, KK Women's and Children's Hospital. To read more please visit www.kkh.com.sg/HealthPedia.