Intra-Uterine Insemination (IUI)

A simple fertility treatment, IUI is commonly the first line of treatment especially when no fertility problem is identified. It is meant to be easy and inexpensive but may need to be repeated multiple times as pregnancy rates are only 15-20% each time it is performed.

This is the simplest form of assisted conception treatment. It involves inserting the husband's sperm into the wife’s uterus at the time of ovulation. The sperm sample is first prepared to remove dead and weak sperm and the best sperm are then strengthened even further to improve their ability to make a baby. On the day of IUI, the husband has to produce his semen by masturbation. He is advised to comply with the following instructions: ·         3 to 5 days of abstinence prior to semen collection ·         inform the nurse if he was sick or on any medication for the past 2 months ·         collection by masturbation is preferred ·         wash hands with soap and clean with water before semen collection ·         do not use lubricant, soap or perfume during semen collection ·         avoid spillage when semen is collected

After the semen is produced, the laboratory technician or embryologist will process the semen by removing the seminal plasma, debris, residual cells, dead and sluggish sperm. This is done by a series of steps including adding sperm wash media and centrifuging. The final solution with live and motile sperm will be used for insemination.

The wife too is usually given hormonal medications (tablets and occasionally hormonal injections) so that she will produce more eggs from her ovaries. When the ovarian follicles reach 18mm in diameter, a human chorionic gonadotropin (hCG) injection is given to mature the eggs and trigger ovulation. The hCG injection is usually given 36 hours before IUI is performed.

The process of IUI requires no sedation or anaesthesia and it is similar to that of pap smear. A speculum is inserted into vagina to hold it open. Then the washed sperm is inserted into the wife's uterus using a long and thin catheter through the cervical canal. The whole procedure takes just 5 minutes to complete.

 

After IUI, the wife may require some luteal support to strengthen the uterus such as vaginal pessary or injection. She has to take extra care such as:

·         rest more and avoid excessive physical activities. Bed rest is not necessary.   ·         drink plenty of water ·         do not take any medication without doctor consultation

Urine or blood pregnancy test will be done two weeks after the procedure to confirm pregnancy.

This combination of good sperm, extra eggs and timing during ovulation is the key to success. IUI is useful for couples with unexplained infertility and where the husband’s sperm quality or quantity is slightly below normal. It cannot be used where the fallopian tubes are damaged or where the sperm is very poor.

Acronyms / Jargons

For a newbie in the world of TTC (Trying to Conceive), there are many acronyms or jargons you should familiarize yourself with. Especially if you’ve decided to join any of the online support groups and forums as these jargons are used extensively within the support groups or forums. Here are some of the acronyms/jargons most commonly used:

2WW - 2 week wait

AF - Aunt Flo = Period (menses)
BBT - Body Basal Temperature = to detect ovulation
BCP - Birth Control Pills
Beta - Blood test used to detect pregnancy
BFP - Big Fat Positive = Pregnant
BFN - Big Fat Negative = Not pregnant
BW - Blood work
CD - Cycle Day
CM - Cervical Mucus
DE - Donor Eggs
DH - Darling Husband
DPO - DaysPost Ovulation
DPR - Days Post Retrieval
DPT - Days Post Transfer
DS - Donor Sperm
DX - Diagnosis
ED - Egg Donor
ER - Egg Retrieval
ET - Embryo transfer
FET - Frozen Embryo Transfer
FSH - Follicle Stimulating Hormone
GS - Gestational Surrogate
HCG - Human Chorionic Gonadotropin
HPT - Home Pregnancy Test
ICSI - Intracytoplasmic Sperm Injection
IUI - Intra-uterine Insemination
IVF - In-vitro Fertilization
LH - Luteinizing Hormone
LP - Luteal Phase
MC - Miscarriage
MF - Male Factor
OHSS - Ovarian Hyperstimulation Syndrome
OPK - Ovulation Prediction Kit
OPU - Oocyte (egg) Pick Up
PCOS - Polycystic Ovarian Syndrome
POAS - Peeing on a Stick = Pregnancy test
POF - Premature Ovarian Failure
PGD- Pre-implantation Genetic Diagnosis
Prog or P4 - Progesterone
PUPO - Pregnant Until Proven Otherwise
RE - Reproductive Endocrinologist
SA - Semen Analysis
UPT - Urine Pregnancy Test
TTC - Trying to Conceive
US - Ultrasound
UTI - Urinary Tract Infection
TVS - Transvaginal Scan

 

Infertility Treatments

Now that the cause of your childlessness has been established, it is time to discuss what are the treatments available. Depending on the results of the tests, you may be directed towards one particular treatment or may be offered a range of appropriate options. Unfortunately, in human fertility, no one treatment is guaranteed to succeed and each one is associated with a particular chance of pregnancy. Many other factors also may play a part in the success rates such as lifestyle, the woman’s age, smoking etc. and these will all be addressed. The most important thing to remember is that with persistence, the majority of couples will be rewarded with a child, or more! :)

 

There are multiple treatments available to help a couple become pregnant. It all depends on the cause, and most times, the test results will indicate the problem that needs treatment.

The simplest treatments relate to couples who have difficulty deciding when the most fertile time of the month is. This is especially true for women who have irregular menstrual cycles due to either early or late ovulation. Ovulation problems account for about a quarter of the problems in childless couples and these are often the easiest to resolve without needing expensive treatments. There are medications which can regulate the ovulation, for example Clomiphene. This type of treatment is called Ovarian Induction.

If ovarian induction doesn’t work after a couple of months, or if there are other problems such as weak sperm, it may be wise to move on to intrauterine insemination (IUI) as the next step. If all else fails, or if it a severe problem such as blocked or damaged fallopian tubes or an extremely low sperm count, In-vitro Fertilization (IVF) or Intracytoplasmic Sperm Injection (ICSI) may be necessary. These last two treatments have very high success rates.

All of these treatments will be discussed further in upcoming posts.

The Causes of Infertility

Let's find out what are the things that's keeping you from being pregnant.

Causes of Female Infertility

1.       Hormonal Imbalance

The right hormonal balance is very important for conception. Hormonal imbalance can lead to the disturbance of the ripening process of the egg, a lack of ovulation or poor luteinisation (the process by which the ruptured follicle transforms into the corpus luteum). Somewhat suprisingly, women produce small amount of male hormones, androgens, in their bodies and sometimes increased amounts of this hormone can disturb the hormonal balance, often in combination with ovarian cyst (follicle like-structure).

Hormonal balance can also be disturbed by being very underweight or overweight, large weight changes in a short period of time, extreme physical exertion, disturbance in the working of thyroid gland or in the secretion of the hormone prolactin, certain types of medication and stress.

2. Tube-related Problems

In some childless women, the fallopian tubes are found to be partly or completely blocked. Most frequently, the fallopian tubes are damaged by infection which might have happened many years before. Other possible causes are an earlier pregnancy in which the embryo implanted in the fallopian tube instead of the uterus (ectopic pregnancy) or adhesions (scar tissues) following an operation or endometriosis.

3. Endometriosis

Endometriosis is the growth of endometrium (the lining of the uterus) outside the uterus itself. It is not known exactly how this occurs. It is probably due to very small amounts of the endometrium passing through the fallopian tubes to the abdominal cavity during menstruation. Here it may settle, causing adhesions between the abdominal organs and painful menstruation.

4. Antibodies Against Egg-cells.

This is an uncommon cause of infertility. In rare cases, the body does not recognize its own egg cells and the immune system forms antibodies against them. Antibodies against the man’s sperm in the cervical secretions are quite common. As a result, sperm cannot enter the womb and fertilization does not take place.

5.Uterus Abnormalities.

A bicornuate uterus (a womb with two 'horns') is the most common. Instead of the womb being pear-shaped, it is shaped like a heart, with a deep indentation at the top. This means that the baby has less space to grow than in a normally shaped womb.

A uterine fibroid is a non-cancerous tumour that originates from the smooth muscle layer and the accompanying connective tissue of the uterus. Fibroids are the most common benign tumours in females and typically found during the middle and later reproductive years. They can grow and cause heavy and painful menstruation.

Causes of Male Infertility

1.       Disturbance of Sperm Maturation.

The most frequent problem affecting the male fertility is insufficient production of normal, freely mobile sperm. Male semen (a mixture of sperms and nutrient fluids) is considered to be of normal quality if there are more than 20 million sperms per millilitre (ml), about half a teaspoon, of semen. Even in fertile men, most sperm are imperfect and many cannot swim properly, but at least 30% of them should be normally formed and 50% freely mobile. If these values are not reached, the man’s procreative capability can be reduced. However, even with normal sperm a functional problem may prevent sperm from penetrating the egg. The ability to produce healthy sperm may be reduced as are result of a mumps infection in childhood. Varicose veins in the testicles (varicocele) may also lead to poor sperm quality. Other causes are hormonal disturbances, stress, environmental factors such as smoking, undescended testes or hereditary factors such as genetic damage. Infections such as flu may reduce sperm quality, but this is usually temporary. Semen analysis is conducted to assess the condition of the sperm.

2.       Disturbance in Sperm Transportation.

In 4% of cases, sufficient semen is formed but cannot enter the woman’s body on ejaculation because the seminal duct is blocked. This situation is comparable with blockage of the fallopian tube in women. Possible causes are previous sterilization or sperm ducts which are underdeveloped or blocked by adhesions, usually as a result of a previous infection of the reproductive organs.

3. Other Causes

Other factors could be sexual difficulties such as erectile dysfunction or the inability to ejaculate.

So, has the cause of your or your husband's infertility been determined? What will you do next?

Ovulation, Fertilization and Implantation

Ovulation

 

For those who are still unsure of the process, here is a scientific explanation of how a baby is made. In a woman’s body, each month about 30 immature eggs will develop in small follicles. At about the 9th day of the menstrual cycle, one of the follicles will become the dominant follicle and it will suppress the growth of other follicles. The dominant follicle will mature on the 14th day, rupture and release the egg from the ovary. This process is called ovulation. The egg that is released is swept into the fallopian tube, where fertilisation will take place. The egg can be fertilised for 24 hours after ovulation. So sexual intercourse should be done with 24 hours after ovulation in order for the fertilisation to take place.

These are the signs and symptoms that may suggest ovulation is occuring:

·         Increase in cervical mucus which is thin and stretchable.

·         Pain due to rupturing of the mature follicle.

·         Rise and fall of oestrogen levels.

·         Breast tenderness due to progesterone stimulation.

·         Increase in basal body temperature due to rise of progesterone levels

 

 

Fertilization

 

The sperm will travel from the vagina through the cervical canal, up to the uterus and into the fallopian tubes. Fertilization usually occurs in the ampula (the swelling end) of the tubes. The egg is covered by zona pellucida (egg-shell) and on it are receptors for the sperm to attach and fertilise it. The sperm will penetrate the zona pellucida through these receptors , fertilise the egg and together form the zygote. After one sperm has entered the egg, the zona pellucida will be depolarized (the shell will harden) to prevent other sperm from entering. So, only 1 sperm can fertilize an egg. After fertilization, the zygote (fertilised egg) will travel along the tube towards the uterus, due to the wave movements of the fimbriae and cilia. During its travel to the uterus, zygote will undergo cell divisions and differentiation.

 

 

Implantation and Pregnancy

 

After 24-hours of fertilization, the zygote will divide into two cells, then four cells, then eight cells. On the fifth day, the embryo will become a blastocyst (70-100 cells) and reach the uterine cavity. Just before implantation the cells of the blastocyst have to hatch out of the zona pellucida (a hole in the zona pellucida for the cells to come out). The blastocyst will usually implant on the posterior uterine wall. There may be a spot of bleeding when the blastocyst penetrates then endometrium. The cells in the blastocyst will continue to divide and differentiate to form inner cell mass (future foetus), trophoblast (future placenta) and amnotic sac. The trophoblast will produce progesterone which is essential for the embryo to grow and develop at the implantational site. It also produces hCG which can be detected in the woman’s blood after 10 days of fertilisation or in the urine after 14 days of fertilsation. 3 weeks after fertilisation, the amniotic sac can be detected using ultrasound scan. So there it is, the precious baby you've sooo been longing for!

Here's a video of the ovulation-fertilization-implantation-menstruation process, except that we don't want the menstruation part. We want the embryo to stay embedded in the uterine lining and grow into a healthy foetus and come into the world some 9 months later :)

 

The Female Reproductive Anatomy

Before we delve further into the world of infertility, let's have a look at the female reproductive system. The female reproductive anatomy consists of two main parts, namely, the external female genital organs (vulva) and the internal female genital organs. The internal organs include the vagina, cervix, uterus, fallopian tubes and ovaries.

The vagina is a passage which allows the escape of the menstrual flow, received the penis and the ejected sperm during sexual intercourse and provides an exit for the baby during delivery. The cervix lies at its upper part.

The cervix is the base of the uterus. It the passage through which sperm travel to meet the egg, to allow bleeding when menstruation occurs and exit for the baby during delivery. The main function of the uterus is to act as a nurture room for the developing foetus during the whole course of pregnancy. It is also supports the bladder and the bowel. The bladder sits in front of the uterus, and the bowel sits behind it. The lining of the uterus, the endometrium, will shed each month as menstrual blood if no fertilisation occurs.

The fallopian tubes are two very fine tubes which are lined with tiny hair called cilia leading from the uterus to the ovaries. The ends of the tube lying next to the ovaries have a finger-like structure named fimbriae. At ovulation, the fimbrae will catch the egg into fallopian tube after it is released from the ovary. The beating wave of cilia in the fallopian tube will move the egg to the uterine cavity through the tube. They are a path in which an egg will travel through in order to reach the male sperm which was released from the male.
 

The ovary is the egg-producing organs in female, often found in pairs at the fimbriae ends. It is oval in shape. Usually each ovary takes turns to release eggs every month. However, if there was a case where one ovary was absent or dysfunctional then the other ovary would continue providing eggs to be released.

First Visit and Initial Investigation

Couples should seek help from a fertility specialist if they can’t conceive:

·         after 12 months of trying, if they are less than 30 years of age  

·         after 6 months of trying, if they are between 30-34 years of age

·         after 3 months of trying, if they are 35 years of age or more

When a couple with an infertility problem first visits a gynaecologist or a fertility specialist, the doctor will need to assess the situation and decide where the problem may lie. The doctor will initially go through with the history, checking relevant details such as regularity of menstrual cycles, previous pelvic infections or surgeries, frequency of intercourse, etc. A gynaecological examination is next to pick up any abnormality.

Subsequently both partners will be tested to check their respective fertility. Approximately 40% of problems will relate to the male partner, 40% to the female, 15% will be unexplained (no problem can be found) and the remaining 5% will be miscellaneous rare causes.

 

Basically, to get pregnant you need good sperm, good eggs, a healthy uterus and healthy fallopian tubes, at least one, so the tests are designed to check these. All these tests can be completed within one menstrual cycle, which is around one month.

Most fertility specialists start with an ultrasound scan of the pelvis to directly visualize the uterus and ovaries. Any abnormalities of these will easily be seen and if relevant, be acted upon. This scan is usually performed during the woman’s menstruation, along with a blood test, to assess hormonal imbalances that can contribute to infertility. The combination of these two tests gives the doctor a good idea of the ovarian reserve, a term used to describe her fertility potential.

Subsequently, another ultrasound scan around the time of ovulation may be performed to assess the receptivity of the endometrium (lining of the uterus) to an embryo and exclude any problems that may decrease this such as polyps or fibroids.

At any time, and after 2-5 days of abstinence from sexual intercourse, a check of the husband’s sperm count and quality can be performed.

These three simple tests would have checked the quality of sperm, egg and uterus and can all be completed within the first two weeks of the period.

Now all that is left is a check of the fallopian tubes. This is slightly less easy than the above tests, so it is usually left for last. One of two methods may be suggested, either a hysterosalpingogram (HSG) or a laparoscopy. A hysterosalpingogram is a test done in the radiology department and the patient is awake. It involves a procedure similar to the taking of a pap smear. A dye is injected into the uterus and over the next minute or so, it makes its way through the fallopian tubes and demonstrates whether these are open or blocked. The whole procedure takes less than five minutes and involves no surgery.

 

A laparoscopy is a surgical procedure done under a general anaesthetic. A telescope (laparoscope) is inserted into the patient’s abdomen through a small cut at the navel and the doctor can directly see the tubes, ovaries and pelvis. Any small problems encountered can be dealt with immediately such as ovarian cysts. There are advantages to directly visualising a woman’s reproductive organs, but the necessity for a general anaesthetic, surgery and the associated risks makes this the second choice for most doctors. A hysterosalpingogram (HSG) will often be enough.

 

There are advantages & disadvantages to each procedure and the doctor will recommend the one most suitable for each individual.

Only after the tests are complete can a treatment plan be formulated, but with a little planning, everything can be completed within a month and the couple is ready to commence on their road to a baby!

 

 

Fertility Specialists

So you and your husband finally decided to seek professional help for your inability to reproduce. Who should you see? Would a normal gynaecologist suffice or should you consult a real fertility expert? I say go for the latter. You'll sleep better at night knowing you have seen the best, if not, one of the best fertility doctors in the country.

 

There are about 40 fertility specialists scattered all over Malaysia. Here are some of the fertility specialists practising in the Klang Valley:

Dr. Colin Lee & Dr. Leong Wai Yew

Alpha Fertility Centre
Website: http://www.alphafertilitycentre.com

Dr. Haris Hamzah

Subang Fertility Centre, Sime Darby Medical Centre
Website: http://www.subangfertility.com

Dr. Paul Tay Yee Siang

Prince Court Medical Centre
Website: http://www.princecourt.com

Dato’ Dr. Prashant Nadkarni

KL Fertility & Gynaecology Centre
Website: http://www.klfertility.com

Dr. Surinder Singh

TMC Fertility Centre, Tropicana Medical Centre
Website: http://www.tropicanamedicalcentre.com

Dr. Tee Swi Peng

Metro IVF, Metro Maternity Hospital
Website: http://www.metro.com.my

Dr. Wong Pak Seng

Sunfert IVF, Sunway Medical Centre
Website: http://www.sunfert.com

Dr. Zamri Abd. Rahim

DEMC Specialist Hospital, Shah Alam
Website: http://www.demc.com.my

Professor Dr Zainul Rashid Mohd Razi
Professor Madya Dr Mohd Hashim Omar

Medically Assisted Conception Unit (MAC), UKM Medical Centre
Website: http://www.ppukm.ukm.my

So take your pick. Which one does your heart desire? The deciding factor would be cost and success rates. The links have been provided, it's now up to you to do the research on which doctor would be the best for you.

Infertility Rates in Malaysia

According to a survey conducted by the National Population and Family Development Board (LPPKN), the total fertility rate in Malaysia has declined from 2.8 in 2004 to 2.4 in 2010. (Total fertility rate is defined as the average number of babies born to women during their reproductive years.) The Health Ministry recently estimated there were about 350,000 couples in Malaysia aged between 20 and 40 who experienced some form of infertility, and the number seem to be increasing.  

So what is infertility? Infertility is defined as the inability of a couple to conceive a child after a year of regular unprotected intercourse or the inability to carry pregnancies to a live birth. Regular intercourse means an average frequency of two times per week. If the female partner is above 35 years old, they should consult a doctor after trying for 6 months because pregnancy rate declines for women over 35 years of age. Causes of infertility can be broadly divided to male factor only (35%), female factor only (35%) or combined (20%). In 10% of couples, no causes can be identified (unexplained).

As a woman gets older, her fertility reduces. This is more apparent once she crosses the age of 35. The risk of miscarriage also increases with age. For women below 25 years of age, the miscarriage rate is 7%. For those between the ages of 25 to 35, the miscarriage rate is between 10% to 15%. For ages 36 to 40, the miscarriage rate is between 20% to 25%. For women above 40 years of age, the risk rises sharply to between 30% and 50%.

In order to conceive, both partners should lead a healthy lifestyle, reduce stress levels, consume a healthy diet and avoid toxins such as smoking, excessive alcohol or caffeine. Stress and hectic urban lifestyle were reasons contributing to infertility.

It is important to seek help early if there is a suspicion of problems such trying without success for more than a year, history of surgery to the reproductive organs or women who are attempting a pregnancy at a more advanced age (more than 37 years). The couple would be advised to undergo thorough investigations such as semen analysis, pelvic ultrasound, hormonal blood tests or if necessary diagnostic keyhole surgery (laparoscopic surgery) to look at the internal female organs.

Here's a video of a normal female reproductive system...

I Wanna Be A Mommy...

You meet the man of your dreams. Fall in love. Get married. Naturally, the next step after getting married is to start a family. Some might want a baby immediately, others might want to wait for a while until their finances are stable as the cost of raising a child is not cheap, or for what ever reason. Some might be lucky & conceived on their first try, some might even conceive without even trying. Others might not be so lucky.
 

The ‘unlucky ones’ tries month after month after month and still fails to get pregnant. They tried each and every method and trick known to mankind. Buy ovulation prediction kits, consult sinseh, feng shui masters, ustaz, bomoh, pawang, bidan, shaman, medicine man, monk, priest, eat this, eat that, don’t eat this, don’t eat that, you name it, they’ve tried it all.

“Lie in bed for 30 minutes after you make love!”

“Prop your butt up on a pillow after you make love!”

“Put your legs up against the wall after you make love!”

These are some of the unsolicited advice/tips given by society in general to those who are trying to conceive. After about six months or so of trying without luck, it starts to get frustrating. Especially when others around you are getting knocked up left, right and centre. Boo-hoo. Don’t get me started on nosy relatives.

Trying without luck month after month after month is emotionally draining. By this time your heart aches and bleeds for a baby. It is also a very lonely journey especially if everyone else around you has no problem conceiving. Infertility is still not openly discussed in this country so you feel as though no one understands what you’re going through.  Sometimes there are no more tears left to cry. You desperately want to become a mommy, but luck is just not on your side. And your biological clock is ticking. Chances for a woman to conceive and produce good quality eggs declines as she gets older. Meaning, the older you become, the more difficult it is for you to get pregnant.

The best thing to do is seek professional help and opinion in finding out why it is so damn difficult for you to get pregnant.