How to prepare yourself for examination at BIC?
There are 2 periods during menstrual cycle
which are most appropriate time for fertility investigation.
2 of period : this is the right time
measure hormones that correlate to
12-14 of menstrual cycle :
transvaginal ultrasound and pelvic
examination will yield information about
condition of cervix, cervical mucous
,uterine lining ,uterus and ovaries.
Semen analysis is the primary and essential
part for male fertility investigation. You
need to abstinence for 3-5 days before you
come to Bangkok Infertility Center and give
your semen sample. The computer assisted
semen analyzer will provide semen analysis
result in a very short period of time and
whether other investigation is required will
be discussed with infertility specialist.
Please arrange appointment by telephone call
or e-mail in order to get efficient medical
is body mass index and its significance?
Body mass index is an indicator to point out that
each individual has normal weight distribution or not. The body mass index or
BMI = body weight in kg. / (height in meter)2 Normal BMI = 18.5-25.0 kg. / m2
BMI over 25.0 kg. / m2 consider as overweight. There is a very high prevalence
of obese women in the infertile population and many studies have highlighted the
link between obesity and infertility. A large proportion of infertility women
have polycystic ovary syndrome (PCOS) which is also linked with increased risk
of obesity and other metabolic anomalies. The association between obesity and /
or PCOS and hyperinsulinism, hyperandrogenism and abnormal secretion of other
hormones, such as leptin, underlies many reproductive disorders observed in this
population. It has been demonstrated that weight loss can improve the fertility
of obese women through the recovery of spontaneous, where as other will have
improved response to ovarian stimulation infertility treatment. Therefore, it is
proposed that following the initial assessment of infertility and body mass
index or other measurement of obesity, various weight management interventions,
including diet, exercise or pharmacotherapeutic approaches, should be considered
for overweight and obese infertile women.
What is the benefit of
embryo culture and transfer at blastocyst
Once IVF program had completed its
stimulation part, oocyte retrieval will be
performed. Eggs and sperms will be put
together and cause fertilization, fertilized
egg will develop and become embryo.
- Day 1 embryo will be at pronuclei
- Day 2 embryo will be at 4 cell stage
- Day 3 embryo will be at 8 cell stage
Day 4 embryo will be at morula stage
- Day 5 embryos will be at blastocyst
In order to raise embryo
up to day 5, you need a skillful
embryologist and sophisticated laboratory.
Once the embryo reaches blastocyst stage and
the quality is good, then the chance of
pregnancy after smooth embryo transfer may
be as high as 40%. But if you have very good
day 3 or 4 embryos for transfer, the chance
of pregnancy is also as high as 35-40%. So
the benefit of blastocyst transfer is to
reduce number of embryos replaced and still
maintain high chance of pregnancy. The
appropriate number of embryo replacement for
any women less than 38 years old should be 2
and for anyone older should be 3 embryos at
Is there any relationship between obesity, PCOS and infertility?
Yes, there is. Right now,
It seems that there is more correlation
between obesity, PCOS and infertility. First
line management for this problem is weight
management and below is the summary,
explanation and recommendation for the
Summary and recommendation for
weight management of infertile patients
There is well-established evidence for the
detrimental effect of overweight and obesity
on women’s reproductive function; this is
further complicated by presence of PCOS in
many infertile women. In addition, the
distribution of body fat is also related to
the reduction or even loss of fertility. So
far, most research has indicated that
overweight and obese conditions lower the
concentration of SHBG and increase androgen,
insulin and leptin secretion and insulin
resistance, leading to hyperinsulinaemia and
hyperandrogenemia. However, there is limited
understanding of the details of how these
changes affect human reproductive function.
On the other hand, weight loss has been
shown to improve metabolic function,
hormonal profile and lead to marked recovery
or improvement of reproductive function.
Therefore the recommendation for
overweight/obese patients with infertility
is closely related to the ramification of
this problem. They should have their height,
weight and waist circumference recorded at
their first consultation and at regular
intervals thereafter. Once the patient has
been classified as overweight or obese, then
weight management should be offered as a
first line treatment option. Dietary
intervention and increased physical activity
remain the optimal treatment strategy for
overweight/obese women with PCOS. A
relatively small weight loss (~ 5 kg.) can
improve insulin resistance and
hyperandrogenism, menstrual function and
fertility, and large changes in weight may
not be needed to restore reproductive
function. Weight loss can also improve
long-term metabolic health and realistic and
achievable target weight loss goals can be
set for women. Obesity and overweight can be
treated by a variety of strategies including
dietary management, physical activity,
behavior modification, pharmacotherapeutic
treatment and surgery. Dietary management
with lifestyle modification as an objective
should be adopted initially with
pharmacological and other interventions
reserved for use when weight-loss regimes
have proved unsuccessful. Since the overall
emphasis is to achieve and maintain a
reduced weight, attempts should be made to
establish sensible eating patterns and a
healthy lifestyle. A number of alternative
dietary approaches to the conventional low
fat-high carbohydrate regime such as partly
modified diets or moderately HP-lower
carbohydrate diets which are consistent with
a healthy eating plan may assist in
maintaining an energy restricted diet. The
other lifestyle factors, such as alcohol
intake, smoking and psychosocial stressors,
should also be addressed. A group
environment can provide support for weight
loss and maintenance of weight loss. At the
same time, it is necessary to tailor
intervention to an individual’s weight and
current dietary and exercise patterns. The
use of a dietician is warranted to aid in
the evaluation of dietary intake and eating
patterns and in individualizing an
appropriate dietary approach.
How Important is the age of female, when we talk about the chance of pregnancy?
From the beginning of each woman’s life, there were about 3 millions eggs in the ovaries. When this woman becomes a teenager, numbers of eggs reduce to about 300,000. There are totally about 350 eggs ovulated during the whole fertility period or about 30 years started from age 16 through 45. Eggs which stored in ovary will gradually lost their quality and increase abnormality throughout time. After 38 year of age, chance of pregnancy is declined and significantly declined after age of 40. This is the reason why infertility specialist try to give information to public that any woman would like to have a child must come and seek for advice before 38 years old, or else the chance will be slim.
My tubes are tied and I have now remarried. Is there a chance I can become pregnant?
Yes. The IVF procedure bypasses the fallopian tubes. Eggs are collected from the ovaries and embryos are replaced directly into the uterus. A pregnancy can therefore be achieved without having to reopen the tubes. However, depending on the method used when the tubes were tied, they may be reopened surgically (tubal reanastomosis). The success rate for pregnancy (non-IVF) following a tubal reanastomosis is somewhat decreased.
Will I have twins or triplets if I take fertility drugs?
When taking fertility drugs, there is always a chance for multiple births. Dr.Viwat, however, can use ultrasound and blood tests to monitor egg production each cycle. Medication can be adjusted to increase or decrease egg production and minimize the risk of multiple birth.
Who is a Reproductive Endocrinologist?
A Reproductive Endocrinologist is a physician who has completed a medical degree (4 years), an Obstetrics and Gynecology residency (4 years), and an approved fellowship in Reproductive Endocrinology and Infertility (2-3 years). This subspecialty of Obstetrics and Gynecology deals with the diagnosis and treatment of infertility and its many associated conditions. These conditions vary from anatomical to hormonal. In order to treat the variety of conditions which his or her patients may present, a Reproductive Endocrinologist is trained in the most advanced conservative surgical techniques in both the endoscopic and microsurgical realm. This allows him or her to perform restorative procedures to treat the many patients who suffer with endometriosis or other anatomical conditions. He or she is also trained extensively in advanced reproductive techniques such as In Vitro Fertilization (IVF) and Embryo Transfer.
What is the technical procedure of IVF?
IVF procedure is
composed of 4 sequential steps:
IVF programs use superovulation to stimulate production of several eggs by
Ovum pick up:
Aspiration of the preovulatory follicles is performed by ultrasonography
under local anesthesia.
In vitro fertilization and embryo
culture: to fertilize the mature eggs with
capacitated sperms in the laboratory conditions.
Replacement of fertilized egg into the uterus via small catheter.
What are the benefits of superovulation by hormonal therapy?
Superovulation serves to
stimulate production of several eggs and improves timing of egg aspiration. Both
number of aspirated eggs and fertilized ova are increases like production of
high quality embryo probability.
What are the types of ovulation induction therapy?
To stimulate production of multiple eggs several
hormonal medications are used. GnRH anologs (Suprefact, Enantone, Lucrin ..) are
drugs that have the same effect of GnRH. When they are used, at the beginning of
therapy they increase the secretion of endogenous gonadotropins ( FSH and LH ),
after a while hypophysis becomes unresponsive to these agents and suddenly
gonadotropin levels cease at a lower levels. Medication with the GnRH analogs
generally starts at the beginning or mid phase of menstrual period. They have
many available forms like subcutaneous injections or nasal spray. After around
10 days of treatment, superovulation is carefully monitored with ultrasound
scanning and serum estradiol determinations. If enough suppression is achieved
then treatment with daily injections of FSH or hMG (Humegon, Menogon, Pergonal,
Gonal-F, Puregon) will be commenced. At the same time, GnRH agonists are used
altogether with gonadotropins. Serum estradiol levels are complementary to
ultrasonography in evaluating the maturation of preovulatory follicles and
timing of hCG (Pregnyl, Profazi) administration. we stop treatment with GnRH
agonists and gonadotropins before giving hCG injection
How to evaluate follicular development?
Most accurate and reliable terms of evaluating
development of follicles are serum estradiol measurements, follicle numbers /
diameters and endometrial thickness under ultrasound investigation.
How do we pick-up developed ova?
One mostly chosen method of ovum pick-up is done
with transvaginal ultrasonography. In transvaginal aspiration a needle is passed
through the posterior vaginal wall using a vaginal ultrasound probe and directed
into the ovary. There might be some disturbing pain and this procedure may be
done under local or general anesthesia according to patients’ view.
Does ovum pick-up have harmful effect on my ova?
Ovum pick-up is usually trustful, non-complicated
method under specialized hands. It is harmless and it may be repeated several
times to capture follicles. But rarely puncture of an artery and rupture of
vessels or bowel may be the reason of dangerous side effects of procedure.
How to fertilization occurs?
Fertilization and culture of
eggs are probably the most crucial stages of IVF. Eggs are incubated in various
culture media with sperm (100,000 motile sperm per one oocyte).
At various intervals after the
attempted fertilization, the eggs are examined in order to identify changes
which confirm fertilization as well as blastomere which confirms cleavage.
How and when the embryo transfer occur?
2 - 5 days after aspiration, fertilized ova
(embryo) are ready to transfer in uterus. Embryo can be transfer at several
stages such as Day3 stage which has 4-8 cells or blastocyst stage on Day5 or
Day6 which has around a hundred cells. The transfer is by special small catheter
to replace embryo(s) in uterus. Transfer procedure is not painful event.
Abdominal ultrasound with a full filled urinary bladder helps to manage
procedure. Number of embryo to be transferred is depended on age and special
condition of mother.
How long does it take to have rest?
As about 10 minutes rest give a favorable outcome
to increase pregnancy rates. In B.I.C. we take care patient to lay on bed about
1 hour after the procedure. The day after transfer, patient can do her own job
and activity as usual. Heavy exercises are prohibited.
Do I have to use medicine after transfer?
To give support developing pregnancy, patient may
use drugs of progesterone vaginally for local effect.
When will I do pregnancy testing?
10 days after embryo transfer, beta hCG levels are
measured in blood and 2 weeks later on gestational sac can be seen under
How many time can we try IVF?
By giving 2 months apart, IVF can be done as long
as pregnancy occurs.
Does abnormal baby birth rate increases with IVF treatment?
No. 2%-3% of all pregnancies have the risk of
abnormal baby pattern. There have been no grossly increased abnormally risk
attribute to IVF is present.
What is embryo freezing?
After transfer of enough embryos, there may be
excess embryos that can be frozen for later use by using special media.
What is the procedure of ICSI?
This is a procedure whereby a single sperm is
injected into an egg using a micro-needle under the microscope instrument. First
of all, numerous cells named cumulus oophorus must be cleaned around mature eggs
by using special enzymes. The successs rate of ICSI is nearly 80-90 %.
In which condition couples are able to use ICSI?
If infertility is due to male factor then ICSI is
used effectively. There may be less sperm concentration or low quality in some
conditions and ICSI is used perfectly in these circumstances. By the helping of
TESE or PESA technique available sperms are captured and used for ICSI
Can patient who have no sperm in semen get a child?
If a male patient who has no sperm in his semen is
carefully examined in operating room by special technique named MESA, there is a
chance to find enough amounts of sperms and get a child by using these sperms
for the procedure ICSI.
How is TESE procedure performed?
Micro-dissection via a single
larger incision and sampling of testicular tissue under local anesthesia allows
sperm extraction and availability for ICSI performance. This procedure has no
harmful effect on male sexual health.
It is the same procedure like TESE but this is done under microscope and it
allows to find sperm in worst quality in some patients.
Are there some additional modalities if age of patients over?
If woman gets older and older,
the area surrounding mature ova named zona pellucida becomes thicker.
This thick zona pellucida may
inhibit implantation of embryo and decreases successs. We can deal with this
problem by opening a gap on zona pellucida and it has no adverse effect. This
method can be used over 38 years of age ideally.
What is Assisted Hatching?
One of the most important steps in pregnancy is
implantation of embryo to endometrium. Before implantation, zona pellucida
surrounding blastocyst is resorbed. To help this step to occur we can make a gap
in zona pellucida. This is done by mechanically, by using acidic media or
harmless laser. Also we can take cells out of embryo and have sample for genetic
analysis from this gap.
Does laser procedure is applied to older women only?
No. Age is not the only one parameter for this
method. Zonal thickness is the most important factor and repeated failed ICSI is
another indication mostly seen. Laser is also used to clean toxic materials
around embryo and increases quality.
What is blastocyst transfer?
Blastocyst is the later stage of embryo on Day 5
after fertilization developing embryos divide into over 100 cells and
differentiate to 2 groups of cell: trophectoderm and inner cell mass (ICM).
Trophectoderm will become a baby while ICM wll become placenta of the baby.
Scientists develop the technique to grow or culture embryos longer to this stage
call “blastocyst culture” in order to identify the potential embryos which can
better implant to the endometrium. Blastocyst transfer has been done and offer
better success rates. In the sequential transfer program, on the 6’th day after
OPU, blastocyst transfer is done additional to embryo transfer on day 2.
In some conditions there may be excess embryos that
can be frozen for later use. Freezing protocols vary with stage of embryo
development. Cellular water is gradually replaced by cryo-protectants. Embryo
may be frozen at any stage and remain viable for at least several years. Embryo
freezing does not harm the embryo. Also sperm of patients can be frozen for
later use in some conditions.
In women whom ovaries are in
danger due to radiotherapy or chemotherapy, ovum freezing is chosen. It is more
difficult to freeze ovum than sperm or embryo but success rates are higher too.
Right now we can freeze ova
(egg cells) for women who are not ready for getting pregnant now and to preserve
her eggs at age provides good
quality of eggs.