Fact Sheet Quick guide to infertility and treatment options www.ptafertility.co.za info@ptafertility.co.za +27 12 998 8854
Ovarian Hyper stimulation syndrome OHSS is a potentially life threatening complication of ovulation induction. High levels of estrogen somehow interfere with the way that the fluid in the body is balanced between intra- and extracellular spaces. This can lead to fluid collections in the abdomen (ascites) as well as in the chest. This syndrome may also lead to lower urine output, weight gain and alterations in the salt levels in the body. Mild OHSS is fairly common and may develop in up to 5 10 % of all IVF cycles. Patients need to know that hospitalization may be required. High risk patients can often be identified before starting an IVF cycle and their protocol can be tailored to help reduce the risk. Risk Factors 1. Age: younger women are more at risk. 2. Women with PCOS or high AMH level. 3. Women who had had OHSS in a previous cycle. 4. High estrogen levels and number of follicles developing in response to the fertility medication. When does it develop? It usually starts about a week after the HCG injection (about 5 days after egg retrieval). Symptoms may include excessive bloating, weight gain, coughing or shortness of breath, reduced urine output, upper abdominal discomfort, nausea and vomiting. If any of these symptoms develop, the patient should contact the clinic. It usually intensifies during pregnancy and then treatment is required. Ways in which to prevent the syndrome. 1. Identify persons at risk 2. Use the antagonist protocol and trigger with an agonist like Lucrin. 3. Use a lower dose of the HCG trigger. 4. Use Dostinex (usually one tablet a day for 4 days). 5. Increase fluid intake. Intravenous fluids may be required in some instances. 6. Increase protein intake either with an infusion or via diet. 7. Cancel the cycle and freeze the embryos.
When to contact the clinic? 1. Difficulty in breathing 2. Vomiting and nausea 3. Abdominal pain and extension 4. Decreased urination 5. Weight gain Treatment of OHSS 1. Fluid balance is crucial and patients may be asked to visit the clinic on an outpatient basis. 2. Daily ultrasounds, intravenous fluids. 3. Draining of the fluid accumulating in the abdomen. A small needle to drain fluid is inserted with ultrasound guidance. The repetition of this procedure might be necessary every 2-3 days. 4. In severe situations hospitalization is required. 5. Avoiding pregnancy by freezing the embryos. This could be disappointing but will not necessarily decrease chances of pregnancy. The advantages of avoiding OHSS outweigh a fresh transfer. PFC uses vitrification (Cryotec) with a much higher success rate than the old technique of slow freeze. Severe OHSS has become rare due to a better understanding of the condition and newer stimulation protocols.
Egg donation Egg donation is a fertility treatment through which a couple utilizes an anonymous or sometimes a known donor to achieve pregnancy. Reasons for egg donation? 1. Women whose ovaries are unable to produce eggs (ovarian failure). Reasons for ovarian failure include genetic, cancer or premature menopause. 2. Eggs of a lesser quality. 3. Women who carry genetic disorders. Who could be an egg donor? Egg donors are ideally aged between 21 30, healthy and willing to donate eggs to a recipient couple. Anonymous donors are recruited through egg donor agencies. Some couples consider a known donor (family member or friend). Those considering recruiting their own donor are advised to consider seeking legal advice. How does egg donation work? 1. A donor is selected from an agency. Each agency has its own database of donors. 2. Once a donor has been selected her initial screening will be booked. This will involve a medical examination, blood tests and consultation. Egg donors are tested for infectious disease like HIV, Hepatitis B & C, gonorrhea, chlamydia and syphilis. Other genetic testing should be performed based on the donor s history and ethnic background. Some genetic tests could also be performed according to the recipient s history or their genetic makeup. A psychological assessment is also part of the mental health screening. Once all results have been obtained, the cycle could move forward. 3. The cycle coordinator will contact the patient to initialize the planning of the cycle. This usually involves an oral contraceptive to synchronize the cycles of the donor and the patient. Preparation of the recipient involves administering estrogen. The donor then starts with the IVF stimulation to form the eggs. Once the follicles have reached certain size egg retrieval will be booked. The
patient s male partner or the desired sperm must be available. 4. Embryo transfer is usually undertaken on either day 3 or 5 of embryo culture. The embryologist will contact the patient on day 2 of embryo culture regarding the development of the embryos. The patient must report at the clinic at the given time with a full bladder. 5. A pregnancy test is done 8 10 days later with a HCG blood test. In South Africa egg donation is conducted anonymously and no information may be exchanged. Egg donation is managed according to guidelines and protocols contained by SASREG (Southern African Society of Reproductive Medicine and Gynecological Endoscopy) http://www.fertilitysa.org.za/eggdonation/
Acupuncture A combination of western medicine and acupuncture could be a very effective form of infertility treatment. The process of acupuncture is believed to adjust and alter the body s energy flow into healthier patterns. According to a study in the medical journal Fertility & Sterility (Fertility and Sterility, Volume 97, Issue 3) an increase in pregnancy rates in women who received acupuncture at the time of embryo transfer was indicated. Subsequent studies did not show the same benefit. Possible benefits from acupuncture: 1. Improves blood flow to the ovaries and uterus. 2. Calms the uterus to help prepare for implantation. 3. Reduces stress. 4. Improves response to hormonal stimulation. Acupuncture is widely used in some units but good scientific evidence of benefit is lacking.
Co enzyme Q 10 Co enzyme Q10 is a vitamin-like substance also required as an essential ingredient or co-factor for the completion of essential biological cell activities. The human body has various cells that require energy, usually supplied by the blood stream. All living cells have a unique system and function. Oocytes contain a crucial component called mitochondria. This component uses Co enzyme Q 10 for energy production. The egg is the largest and probably the most sophisticated cell in the human body. Upon ovulation the egg requires a substantial quantity of energy and Co enzyme Q10 assists in providing that. Co enzyme Q 10 could improve egg quality although no-one really knows what the optimum dosage is. Any dosage between 300 and 600 mg/day is helpful seeing that taking more than necessary is not harmful. A common side effects is upset stomach. Patients may stop taking the supplement as soon as pregnancy has been confirmed. Robust scientific evidence about the efficacy is lacking at this point. DHEA DHEA is used to improve the outcome of women with low ovarian reserve. DHEA is produced by the adrenal gland and is converted to various other hormones including male hormones (androgens).there is some evidence that DHEA and other forms of male hormone may hold benefits for poor responders. The hormones are taken several weeks before the onset of IVF treatment.
Pregnancy after sterilization When sterilization was performed and a women wants to conceive two possible options can be considered: IVF or the reversal of sterilization. Sterilization is commonly performed and there are different ways in which to perform the surgery. One of the more frequently used techniques is a laparoscopy using Filshie clips. The clips are small peg-like structures that are clipped on to the tube right near where it meets the uterus. The clip causes a crushing injury to a small segment of the fallopian tube which then dies. An alternative technique is where a part of the fallopian tube is cut out and the ends are tied off with suture material. The result of this technique is that a part of the tubes are missing. Surgical tubal reversal There are surgeons that specialize in microsurgical techniques. If a tubal reversal is considered the important issue is to identify which method was used to perform the sterilization. Filshie clips tend to cause the least amount of tubal destruction. This leaves a maximum length of tube left for the surgeon to work with in order to repair it. Success rates of this procedure are partially dependent on the original technique used to occlude the tubes, the surgical expertise of the surgeon, and the patient s age. Age has a significant effect on fertility for women under the age of 35. If the procedure goes smoothly the chances of conceiving may be as high as 75 % over a two year period. Because of the age effects on fertility the success rate is lower in older women. Before reverting to a tubal reversal it is essential to perform a semen analysis as sperm quality can seriously affect fertility. After tubal reversal there is always a risk of an ectopic pregnancy. The risk of an ectopic pregnancy is usually around 10-15 %. An ectopic pregnancy can be potentially dangerous. A patient who has had a tubal reversal and successfully becomes pregnant must keep in mind the critical importance of seeing her doctor very early in the pregnancy in order to confirm the pregnancy is in the uterus.
IVF The other option is in vitro fertilization. In vitro fertilization is a process whereby fertility drugs are administered to stimulate the ovaries to produce a number of eggs. The eggs grow inside little capsules called follicles. Once the follicles have matured the eggs are retrieved under ultrasound guidance. The eggs are fertilized with the preferred sperm in the laboratory. A fertilized egg is called an embryo. The embryos are then cultured in the laboratory for 3 5 days and the premium embryos will be transferred. The success rates of IVF are directly proportional to age. In patients under the age of 35 who have two embryos placed back the chances for a successful pregnancy are in the region of 55 % As a patient ages the success rate starts to decline and by the age of 40 the success rate is closer to 20 %. Factors determining the decision to have a tubal reversal or IVF: 1. Age: Maternal age does have a significant effect on fertility. Fertility starts declining quite significantly after the age of 35 and even more so after the age of 40. When it comes to expectations for pregnancy this has to be taken into consideration. 2. Male factor: Performing a semen analysis before considering any fertility treatment is essential. If the semen analysis indicates poor sperm quality or morphology, IVF is by far the better option. 3. Social circumstances: In some situations couples do not want to wait a couple of years to conceive. Contributing factors include the age of other children or professional commitments. Under these circumstances IVF would be the preferred option. 4. Cost: The cost of IVF should be compared to that of the reversal. 5. Desire to have more children: Despite having had sterilization a couple could decide to have more children and the reversal could allow them that choice. 6. The female partner needs to use a contraceptive when a baby was born after a reversal. There is no hard and fast rule but keeping in mind the ongoing chance of pregnancy after a successful reversal is crucial.
Vasectomy Are there options to have children after having undergone a vasectomy? First option: Vasectomy reversal. This procedure is usually done under general anesthetic using microscopic techniques to reconnect the vas, a very thin tube connecting the sperm producing testes via the epididymis to the genital outflow tract. Second option: IVF using sperm surgically retrieved from the testes (TESA) This procedure is done under local anesthetic or conscious sedation. Sperm obtained via TESA can only be used with IVF and not with artificial insemination. Once the eggs have been retrieved from the female partner a technique called ICSI is used to inject a single sperm into each egg to assist with fertilization. The optimal embryos are then transferred. Should there be good quality embryos remaining they could be frozen for future use. Important investigation/tests: Male: Blood tests determining hormone levels to ensure whether the testes are still producing normal quantities of hormones. A physical examination could be required to establish that the testes are healthy. Female: Full fertility evaluation to determine whether the patient is appropriately fertile for her age. Ultrasound of the uterus/antral follicle count and blood tests to confirm her ovarian reserve. Contributing factors to the success of a vasectomy reversal. 1. In the case of a vasectomy performed more than 10 years before there is a high incidence of anti-sperm antibodies developing. The male immune system is normally protected from sperm proteins. However, after a vasectomy sperm proteins enter the male s systemic circulation and trigger the immune system to produce antibodies. The immune system does not recognize these proteins and start defending the male against them. These antibodies will then attack the sperm.
2. The anti-sperm antibody production can occur at any time after a vasectomy or an injury. Although a vasectomy reversal may be surgically successful and the semen analysis show plenty viable sperm, the anti-sperm antibodies bind to the sperm and may impair its function, reducing its ability to fertilize the egg. 3. The age and ovarian reserve of the female partner. Unlike men women are born with a finite number of eggs and as they age so do their ovaries. The female s fertility therefore declines significantly with age. When is a vasectomy reversal the best option? 1. When the interval from the original vasectomy is less than 10 years. 2. When the female is younger than 35 and has a healthy and normal reproductive diagnosis. Pros 1. It allows opportunity for natural conception. Vasectomy reversal Cons 1. If there are anti-sperm antibodies binding to the sperm the chances for conception may be affected. However, despite the presence of antibodies natural pregnancy may still be possible. 2. If successful, the process is financially less taxing than IVF. 3. It allows a continuous chance of pregnancy with every ovulation. 4. It spares the female partner undergoing IVF. 5. If pregnancy is not achieved after a year or two there is still the possibility of IVF. 2. After a period of time obstruction may develop where the reversal was done. 3. A few years need to be allowed before the success of the process can be determined.
Pros 1. The male partner is spared a surgical procedure, 2. The procedure can start immediately. 3. More than one embryo may be created, allowing freezing. IVF Cons 1. It is more costly if pregnancy is not achieved with the first cycle. 2. The female partner needs to be subjected to the IVF- injections and retrieval of eggs. 3. The chance of a pregnancy exists only during the cycle. Vaginal bleeding post pregnancy test. Bleeding after a positive pregnancy test is a very common complaint. In most cases, this is a very light bleeding (pink or red) or spotting. One could refer to this as implantation bleeding our recommendation will be to continue with all of the medication and take it easy. To perform an ultrasound is not helpful because the pregnancy is still too small to be visible and will not make a difference towards the managing of the bleeding. Again, in most cases this bleeding is inconsequential but it could also indicate problems such as inadequate hormone support, thereby causing the endometrial lining to start to slough. It could also indicate that the period is starting or that an abnormal pregnancy exists or is being miscarried. When the bleeding is light, no intervention is required. For one, there is no intervention that can be done, other than checking the HCG levels and increasing the progesterone if required. Secondly, this could be normal, if in fact it is implantation bleeding. Thirdly, if vaginal progesterone is used, the progesterone may be causing the cervix to be more delicate or friable and therefore cause cervical bleeding. This is the most common reason though this is unproven or based on studies. One cause of light bleeding that does need medical attention is when it occurs after the pregnancy has already been diagnosed. This bleeding may be a sign of an ectopic pregnancy (pregnancy in the tubes) your doctor needs to be made aware of this if you have already been diagnosed with a positive pregnancy test or ultrasound. At our clinic we make use of vaginal progesterone on most patients, and 90+% of them complain of some light bleeding.
The only worrisome bleeding is if the bleeding is heavy like a period or more. This could mean that the period is starting, because no implantation occurred or could be an early miscarriage if it did. It can also occur in a multiple pregnancy, such as a twin, if one of the foetuses is lost. So if bleeding occurs, it is not necessarily indicating the end of the pregnancy. There are other medical causes of bleeding once the pregnancy is established, but that would be a totally different topic and is more pregnancy related than IVF related.