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Having Problems Conceiving Naturally?

There is hope yet for couples who have trouble conceiving naturally. Read on for a glimpse of the main reproductive techniques available.

If you have been trying to conceive for a while now without success, you are not alone. About one in six couples in Singapore have trouble getting pregnant naturally, experts estimate. This could be due to many reasons, from poor egg quality due to advanced maternal age, reproductive hormonal imbalances, endometriosis, uterine growths, malfunctioning fallopian tubes and poor quality sperm. “Many couples who have been trying to fall pregnant for one to two years, with no success, seek to have problems in their reproductive systems corrected by hormonal treatment and keyhole surgery. Despite these measures, however, they still have trouble conceiving naturally,” says Professor Christopher Chen, obstetrician and gynaecologist at Gleneagles Hospital. In such cases, assisted reproductive techniques may be used to help them:


Intra-uterine Insemination (IUI)

If a couple has been diagnosed with unexplained infertility, “hostile” cervical mucus, minor sperm abnormalities or other male fertility issues, IUI is often used to help them fall pregnant, says Dr. Roland Chieng, medical director of Virtus Fertility Centre Singapore. This technique is also recommended in cases where the man’s semen has been frozen. IUI involves inserting the prepared sperm sample through the neck of the womb and into the uterus, close to the time of ovulation. The woman may need to first undergo ovulation induction or artificial hormone stimulation. “IUI is much simpler and less invasive than in-vitro fertilisation (IVF), and it has a good success rate,” adds Dr Chieng. “But if a couple has had three or more unsuccessful attempts with IUI, or if the woman is aged 35 or over, they are likely to have a higher chance of success with IVF.”


In-vitro Fertilisation (IVF)

Prof Chen says the aim of IVF is to first develop a good number of quality eggs via hormonal injections. The eggs are then harvested from the ovaries and fertilised in the laboratory using selected quality sperm from the husband. The resulting fertilised eggs, or embryos, are then placed into the uterus in the hopes that pregnancy occurs. “In vitro” means “in glass”, as fertilization happens in a glass or plastic dish, rather than in the fallopian tubes. Dr Chieng says that for many, IVF offers the best or only chance of conception. It can help overcome a wide range of fertility issues in both men and women.


Intra-cytoplasmic Sperm Injection (ICSI)

This procedure, which was introduced about a decade ago, has helped to increase fertilization rates. It involves injecting a single healthy sperm directly into an egg, resulting in more and better-quality embryos being obtained. ICSI treatment is typically part of a couple’s IVF cycle. “If a couple has been diagnosed with male fertility problems, such as low sperm count or low sperm motility, ICSI can help with conception when combined with IVF treatment. It is also recommended when there is no sperm in the semen, or if the man has had a vasectomy, and we need to obtain the sperm surgically from the testes,” Dr Chieng explains. So, what does ICSI entail? First, the ovaries are stimulated to produce eggs, which are collected at the same time as the sperm. ICSI is then performed microscopically on mature, normal-looking eggs. The eggs that fertilise and progress as normal-looking embryos are

selected for implantation on the third or fifth day, when they are more advanced. Embryos that grow normally in the laboratory can also be stored frozen at -196 deg C for later use, says Prof Chen. Then comes time for the embryo transfer. In most cases, two embryos are implanted within the cavity of the uterus through the vagina, with or without ultrasound control. The shell covering the embryos is nicked mechanically or by laser to increase the chances of implantation. Hormonal support of the uterine lining, in the form of oestrogen and progesterone medication, is mandatory after the embryo transfer, or pregnancy may not occur, stresses Prof Chen. A pregnancy test is done nine days after the transfer.


Intra-cytoplasmic Morphologically-selected Sperm Injection (IMSI)

This is an advanced fertility treatment whereby the quality of the sperm is assessed using a high-powered microscope with a magnifying power of around 6,000 times – compared to 400 times for microscopes used in ICSI. This allows doctors to pick only the best quality sperm and discard those with abnormalities prior to the microinjection. Dr Chieng says IMSI can produce high-quality embryos and therefore increase a couple’s chances of a successful pregnancy. However, the treatment is more expensive than ICSI and is usually recommended after attempts at IVF conducted with ICSI have failed. For couples who are at risk of passing on inherited genetic disorders, Dr Chieng says there is the option of undertaking genetic testing as part of their fertility treatment to enable the selection of an unaffected embryo for transfer. ”Pre-implantation Genetic Diagnosis (PGD) is a highly sophisticated technique that tests embryos for specific genetic or chromosomal abnormalities… such as cystic fibrosis or Down‘s syndrome,” he explains.

Dr Chieng adds that Virtus Fertility Centre Singapore, as well as other Singapore centres, are able to undertake the biopsy of an embryo for medical reasons and send the cells to the PGD unit at the National University Hospital, which is the only hospital approved by the Ministry of Health to undertake the diagnosis.


By Sasha Gonzales, Simply Her, April 2015

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