In-Vitro Fertilisation- Embryo Transfer (IVF-ET)

Complications

In general, the complication rate of assisted reproduction is low. These may include:

Ovarian hyperstimulation syndrome (4%)

Signs and symptoms include abdominal distension, vomiting, ovarian cysts, fluid in the abdomen and the lungs. The worst complications are renal failure and blood coagulation problems. This might result in death. With new treatment protocols, this is rare nowadays.
Prevention
- OI/IUI cycle: use low gonadotrophin dosage to stimulate ovulation
- IVF cycle: Before stimulation, if a lot of antral follicles are seen, we use the antagonist protocol, use GnRH agonist for ovulation trigger and freeze all embryos, to be put back into the uterus during subsequent cycles.

Multiple pregnancies (20%)

Ovarian stimulation medicine used in assisted reproduction to produce more ovarian follicles formation will result in an increase in multiple pregnancies, which is associated with high rate of preterm labour and is undesirable for long term childhood outcome.
Prevention
- OI/IUI cycle: use low dose gonadotrophin to stimulate ovulation. The aim is 1-3 follicles.
- IVF-ET cycle: Put back one embryo in each cycle. Wait till day 5 and choose one better developing embryo and do blastocyst transfer. This will improve the success rate while minimizing multiple pregnancy rates, although there is still a small chance of splitting of the blastocyst and results in monozygotic twins. The rest of the embryos would be frozen for use in subsequent cycles.
Treatment
- In case triplets occur, the patient may have to decide on fetal reduction to minimise the complications of triplet pregnancies. However, there is a 10% chance of losing all the fetuses because of the procedure.

Surgical complications (1%)

The chance of surgical complications is low. This includes bleeding, pelvic infection and injury to the surrounding organs.

Congenital birth defects (3-4%)

Birth defects may be a result of fertility treatment or infertility itself.
For natural conception, the prevalence of birth detect is about 3%. Recent studies showed that the increased risk of birth defects associated with IVF was no longer significant after adjustment for parental factors. The risk of birth defects associated with ICSI remained increased after multivariate adjustment. The increase can be due to the procedure or the transmission of male genetic abnormalities to the offspring (see ICSI section). However, even if there is an increase rise of 30-40% in birth defects with ICSI fetus, given a baseline of 3% of birth defects, the increase is by 1%, that is 4%. Counselling is required before treatment.
Females over 35 years of age have higher chance of chromosomally abnormal fetuses.

Pregnancy outcome

Miscarriage (20%)
The miscarriage rate is slightly higher than the general population given the background risk of miscarriage is higher in the subfertile population.
Ectopic pregnancy(5%)
Ectopic pregnancy, i.e. pregnancy located outside the womb. Usually the ectopic pregnancy is located in the fallopian tube. This may be due to increased incidence of abnormal fallopian tubes in patients requiring IVF treatment.
Treatment can be conservative, medically with methotrexate or surgically with salpingectomy.

Ovarian Cancer

There is No Evidence that infertility treatment will increase the incidence of ovarian cancer.

Q&A

Q: How do I know whether I ovulate?

If your menstrual cycle is between 28-35days, most often ovulation do occur.
You can have ovulation assessed in 3 ways

Blood LH surge tests at around ovulation time
Follicle tracking by ultrasound at around ovulation time
Blood progesterone test 7 days after ovulation

Q: If I have regular menstrual cycles, will oral ovulation induction medicine improve
my pregnancy rate?

Probably not. Regular monthly cycles indicate that you most probably ovulate regularly. Oral ovulation induction medicine like clomid may decrease the thickness of the inside lining of the uterus, making implantation of the embryo difficult.

Q: Is there medicine that can improve semen parameters?

Poor semen parameters is usually genetic in origin. Taking medicine like clomid, testosterone or steroid will not improve semen parameters. Male infertility usually necessitates in vitro fertilization treatment, with or without intracytoplasmic sperm injection (ICSI).

Q: If a couple has been diagnosed as being suffered from infertility, is the chance of
getting pregnant very slim?

No, on the contrary, if you get appropriate management of your infertility problem early, the chance of pregnancy is still pretty high. Although simple advice and measures can help for the initial stage, aggressive treatment may have to be employed at a later stage. According to Nice guideline (Feb2013), in vitro fertilization (IVF) will be offered to women with unexplained infertility, mild endometriosis and mild male infertility who have not conceived after 2 years.

Q: Will I have premature menopause after a few cycles of IVF, since many eggs have been
used up during each treatment cycle?

No. Each woman have 400,000 eggs at puberty and one egg will reach maturity to ovulate every menstrual cycle. There is a total of 400-500 menstrual cycles for the whole reproductive life span. The rest of the eggs will become atretic. Infertility treatment recruits some of the eggs that will regress anyway. Menopause is a stage when all the eggs have naturally regressed and therefore you do not have to worry about premature menopause.

Q: I have tried intrauterine insemination (IUI) for 3 times, why am I still not pregnant?

Usually, IUI is considered a milder form of treatment for infertility if the fallopian tubes are normal. The success rate is around 10 percent per cycle even if gonadotropins injection is employed. You do not have to be discouraged even if you have failed to get pregnant after 3 cycles of IUI. We can employ in vitro fertilization for treatment as the success rate is 3-4times higher than IUI. Some cases do require IVF for success.

Q: Will ovarian stimulation medicine cause ovarian cancer?

Up to date, literature has shown that ovarian stimulation will not increase the chance of ovarian cancer.

Q: What is considered completion of one cycle of in vitro fertilization?

One cycle of ovarian stimulation for in vitro fertilization may result in producing many embryos. For every subsequent cycle, we put back 1-2 embryos into the uterus, if pregnancy has not been achieved. It is not until we have put back all the frozen embryos that it is considered we have completed one full cycle of IVF.

Q: Is the pregnancy rate employing frozen thaw embryos less than fresh embryos?

No. Nowadays, we employ ultra rapid method (vitrification) for freezing embryos, which will not lead to crystal formation that is damaging to the embryos. Moreover, we usually employ natural non stimulated cycle which involves a lower estradiol levels, when we put back frozen thaw embryos and this result in a better pregnancy rate.

Q: Usually how many IVF cycles should I undergo?IVF

Usually we will advise at least 3 cycles of IVF before giving up as the cumulative pregnancy rate increases. Of course, it depends on assessment after each cycle.