It's for couples experiencing fertility problems and trying to figure out the next step. It's not just for Centre for Assisted Reproduction Pte Ltd (CAREPL) patients, but anyone struggling to get answers to some of the issues surrounding fertility treatments.

IVF treatments can be stressful and physically demanding and so couples need to be sure it's something they both want to do. To help them understand what's involved and the choices available, they should visit different centres, speak to staff, enquire about the facilities and services, and ideally speak to patients who have undergone treatment.

• A comprehensive range of fertility treatments and relevant expertise
• An experienced team of doctors, nurses, embryologists and technicians
• A feeling of genuine care, warmth and support for couples
• Flexibility of appointments especially if both couples are working
• Information, understanding and emotional support for couples

It is useful to decide which factors are the most important to you so that you can then make a decision to choose the centre for treatment. It is important to know your cause of infertility and why and how the treatment will be given.

• Cost of treatment and payment mode and schedule
• Location and accessibility of clinic
• Opening hours
• Restriction on treatment (Age and number of attempts)
• Waiting Time (by appointment or walk-in)
• Flexibility of appointment time (Especially for working women)
• Special expertise
• Availability, amount and cost of counselling
• Availabilty of gametes and embryo storage
• Success rates

Decide which factors are the most important to you so that you can then make your decision. To do this it is important to know the cause of sub-fertility, and why and how the treatment will be given.

Our services range from simple fertility investigations to highly sophisticated treatments.

• Ovulation induction and cycle monitoring
• Intra-Uterine Insemination (IUI), including donor insemination
• In-Vitro Fertilisation (IVF)
• Gamete Intra-Fallopian Transfer (GIFT) and tubal Embryo Transfer (TET)
• Treatment of Male Infertility / Assisted Fertilisation (ICSI)
• Surgical Sperm Retrieval
• Assisted Hatching
• Gametes and Embryo Donation
• Embryo Freezing and Replacement of Frozen Embryos
• Egg/Sperm and Embryo Banking

IVF treatment is just one of the treatments available for fertility problems. It may be appropriate if the women have blocked tubes, polycystic ovaries, endometriosis or cervical mucus problems. If the sub-fertility is largely due to male factors e.g. low sperm count or poor quality sperm; or if the sub-fertility is unexplained after at least one year of regular intercourse without using contraceptions.

IVF using donated eggs may be offered to women

• suffering premature menopause
• those whose eggs will not fertilise
• those having poor quality eggs
• those whose ovaries have been damaged or removed
• older women

IVF using donated sperm may be offered to men

• with very poor sperm quality
• suffering from testicular function failure
• those whose sperm do not have the capability or very poor capabilty of fertilising eggs
• those who had previous vasectomy
• older men

Typically, most centres use two regimes depending on the history of treatment.

• Long Protocol

  GnRH analogue drugs namely Buserelin or Lucrin are used to control the hormones produced by the pituitary gland, and then fertility hormones e.g. FSH (Gonal-F and Puregon) and/or HMG (Menogon) are used to stimulate egg production using fertility injections. Once the egg-containing follicles reach the appropriate sizes, HCG is given to induce the final maturation of the eggs.

• Short Protocol

  GnRH analogues (Buserelin or Lucrin) are used together with the fertility injections (Gonal-F, Puregon or Menogon) until ultrasound monitoring and blood tests indicate that all follicles have reached the appropriate size, HCG is given to induce the final maturation of the eggs.

  Fertility injections (Gonal-F, Puregon or Menogon) are used to stimulate the ovaries to produce eggs. Ultrasound monitoring is used to assess the appropriate size where GnRH antagonist injections(?) (Cetrotide) can be used to control ovulation. Ultrasound and blood tests monitoring the follicles indicate the appropriate time for the maturation injection (HCG) to be given.

As with many medical procedures, ART carries some risk of complications. We will try to minimize these risks by identifying those women most likely to be at risk and by monitoring their treatment cycle closely. The most common complication are Ovarian Hyper Stimulation Syndrome (OHSS), Miscarriage, Ectopic Pregnancy and Multiple Pregnancy.

While receiving fertility injections, some women may experience abdominal bloating, breast tenderness, increase in vaginal secretions and some abdominal discomfort and breathlessness. For the majority of such women, these symptoms are usually short-lived and cease when the treatment finishes.

In rare cases, some women's ovaries will over-respond to the fertility injections and produce too many follicles. If this happens and treatment continues, there is a risk of developing Ovarian Hyper Stimulation Syndrome (OHSS). Approximately 1-2% of women undergoing ART treatment will experience OHSS. OHSS is caused by the over-sensitivity of the ovaries to the fertility drugs, and is more frequently associated with women with polycystic ovarian disease.

Mild OHSS may pass unnoticed, but severe OHSS can cause breathing difficulties, temporary kidney "shut down", and some arterial and venous thrombosis. In rare cases extensive thrombosis causes interference with blood supply to parts of the brain or to other organs. Essentially, fluid from blood stream leaks into the abdominal cavity causing it to swell noticeably and leaving the blood more concentrated and more viscous. Death due to OHSS whilst very rare, is possible.

Patients who suffer severe OHSS must be hospitalized and treated. This treatment would involve the infusion of intravenous fluids and the fluid in the abdomen may need draining off. In very severe cases, fluid may get into the lung cavity and may need to be drained.

Close monitoring of potential candidates using blood test and ultrasound scanning of the ovaries to ensure the ovaries do not over-respond to the drugs.

If OHSS occurs, the options are to cancel the cycle, or to collect and fertilize the oocytes and freeze the embryos. These options will be discussed should this situation arise.

The incidence of miscarriage in women who conceive naturally is approximately 25%. With assisted conception treatment, this figure is not significantly different although in women over 40, there is an increased risk.

An ectopic pregnancy is a pregnancy that occurs somewhere other than in the uterus; most commonly in the fallopian tubes. The incidence of ectopic pregnancy with assisted treatment is approximately 2.5%. It is a potentially serious condition, but can be detected very early in the pregnancy by an ultrasound scan.

One of the complications of assisted reproduction is the increased incidence of multiple pregnancy. Problems are most commonly seen in incidences of triplet or higher-order multiple pregnancies, but may also occur with twin pregnancies. Here, babies may be born before they are mature enough to survive because of the greater chance of pre-term labour and delivery.

In Singapore, the maximum number of eggs or embryos that can be transferred is three. Our research data shows that in women of 35 years or younger, 22% of the pregnancies are twins.

At CAREPL Fertility Centre, we assess each individual patient's condition and determine the optimal number of embryos to be transferred to enable the best chance of success.

Suppression puts you into a temporary state of menopause. The symptoms, such as hot flushes, insomnia, becoming easily irritable may be similar to what one experiences with the menopause. Husbands should be more understanding and supportive when the wife is undergoing treatment. However, this won't last long.

The treatment may be cancelled if the chances of obtaining healthy eggs are low.

Reasons for this would be:

• Too few follicles
• Hormone levels too low
• Ovarian cysts
• Missed ovulation
• No eggs at pick-up
• No fertilisation or embryo transfer

Blastocysts (implantation stage embryos) have to hatch out of the outer shell of the egg before they can implant. Some eggs have thick and/or tough shells and the blastocyst cannot come out of the shell to implant into the womb lining. Assisted hatching induces a hole or weakening in the egg shell and this should facilitate and assist the hatching process and implantation.

Assisted hatching is commonly used with the eggs of older women, whose shells may have a hardened outer surface or with frozen-thawed eggs and embryos where the cryoprotectant used and the freezing process may have hardened the egg shell.

Assisted hatching can be done using the following microscopic techniques:

A. Mechanical hatching

This process involves holding and manipulating the fertilised egg with very fine glass needles and making a slit in the outer shell of the egg. It can be laborious and difficult especially if the egg wall is tough and difficult to break and damage to the cells can occur.

B. Enzyme hatching

Enzyme or acid is used to thin the outer layer of the egg. Exposure to such chemicals could be harmful to the fertilised egg.

C. Laser hatching

Performed using precision laser technology. The fertilised egg is placed in the laser path and without mechanically holding the fertilised egg, the outer wall is thinned using laser energy. This technique is swift and is very accurate.

Implantation occurs between 6 to 10 days after egg retrieval, depending on the development of the embryos.

Women will probably not be able to feel the implantation process, but they may begin to experience some symptoms of pregnancy (such as nausea). However, a positive confirmation is only evident from a pregnancy hormone (HCG) urine or blood test one week after implantation.

If you are overweight, your fertility will be reduced. It is unclear whether it is the weight that is the independent factor or whether other factors such as polycystic ovarian syndrome (PCOS) result in both the infertility and excess weight.

At the other extreme, if you are under your ideal weight, you are more likely to have an ovulation problem. Being under or over the desired weight for both males and females can disrupt the normal balance that is necessary for normal egg and sperm production.

The Body Mass Index (BMI) is a ratio used to compare your weight with your height. The ideal BMI ratio before embarking on IVF treatment is between 20 to 24. A BMI of less than or greater than the desired weight can lead to fertility problems.

The cost of treatment greatly depends on nature of the fertility problems and the treatments required. The age of the woman is a factor. Older patients may require more drugs for stimulation and thus there is a higher cost.

Cost of IVF treatment in Singapore varies between S$9,000 to S$14,000 depending on the amount of drugs required to stimulate the ovaries. The cost maybe higher if there are excess embryos to be frozen or other procedures to be performed e.g. assisted hatching.

In Singapore, CPF contributors can use their Medisave account to offset part of their treatment cost for three attempts. S$6,000 for the first attempt. $5,000 second and S$4,000 for third attempt. You can find out more information at www.moh.gov.sg (NB. search using "ACP" or "IVF").

As one of our missions is to make available our services to all patients, we have started a CAREPL Financial Help Fund to help patients in need of financial assistance. Please call us for details on how to apply for the funds.

Please contact our clinic for detail costing and further discussion on mode and schedule of payment.

Couples need to be aware of certain factors affecting the success of infertility treatment namely:

• A. Age of the woman

  The main factor influencing the chance of success in IVF treatment is age of the woman. Whether a woman conceives naturally or by assisted conception, her chances of achieving a pregnancy decreases with age. The age of the eggs is the determining factor in achieving pregnancy. It is shown that a forty-five year old woman using the eggs of a twenty-five year old donor, has the same chance of conceiving as that of a twenty-five year old woman. It is also recognised that the chances of miscarriage and foetal abnormalities increases with the woman's age.

• B. Quality and number of eggs retrieved / embryos transferred

  The chances of success are dependent on the quality of the eggs the woman produces for fertilization, and this is directly effected by the number of embryos transferred. Not every embryo transferred to the uterus will result in a baby. Therefore, the more embryos transferred, the better the chance of becoming pregnant. However, the risk of multiple pregnancy also increases.

  Each couple's individual infertility circumstances will be reviewed when deciding on how many embryos to transfer. Ministry of Health Guidelines in Singapore allow a maximum of three embryos to be transferred unless the woman has repeated failed previous attempts at our Centre. Special permission will be sought from the Ministry of Health to allow a four embryo transfer.

• C. Length of infertility period

  This refers to the time the couple has been trying to have a baby. The longer the time period, the more difficult it may be to achieve a pregnancy.

• D. Previous pregnancies

  Women who have been pregnant before, or who have had a previous IVF birth, have a higher chance of conceiving with IVF treatment. The time lapsed from the last pregnancy also influences the chance of success as the uterine receptivity may change and this can decrease the chance of success.

• E. Previous IVF attempts

  It is the policy of our Centre to offer a maximum of three attempts as it has been shown that the live birth rate decreases with the number of failed attempts, especially from those whose repeated treatment did not show improvement in egg, sperm and embryo quality. A woman's first cycle of IVF carries an average 17.4% success rate, but this dips to 14.4% by the fifth attempt (figures taken from HFEA(IVF Watchbody in UK). We offer couples post-treatment counseling to discuss the outcome of each cycle before embarking on repeated treatments.

Please make an appointment (Tel: +65 6659 6638 or email us) to see our IVF Specialist or Chief Embryologist at CAREPL.