Battling Infertility with ART

Despite the increase in citizen marriages, Singapore is on the verge of a fertility crisis, with the total fertility rate down to lowest in history. The reason behind this: More and more Singaporeans are choosing to stay single and marry way past their reproductive prime. This, along with an observed decline in sperm count among Singaporean men, plus other factors, contributed to couples facing difficulties getting pregnant.

All is not lost, however. Thanks to significant advances in medicine, various techniques for assisted reproductive technology (ART) are available to help increase a couple’s chances of achieving a successful and healthy pregnancy. The most popular ART options among Singaporean couples include:

In Vitro Fertilization (IVF)

(Source: MediGence)

In Vitro Fertilization (IVF) is a process wherein the fertilization of egg and sperm is done outside the body. One cycle of IVF takes about 4 to 6 weeks, and consists of the following steps:

1. Ovulation induction or hyperstimulation – Fertility drugs such as follicle-stimulating hormones (FSH), luteinizing hormones (LH) and human chorionic gonadotropin (HCG) are administered at the start of every IVF cycle to stimulate the ovaries to produce several mature eggs.
2. Egg retrieval – Using transvaginal ultrasound aspiration, an ultrasound-guided needle is inserted through the vagina and into the ovaries to retrieve the eggs. This process is usually done 34 to 36 hours after ovulation induction and takes about 15 to 20 minutes to complete.
3. Sperm retrieval – Semen is collected via masturbation on the same day as the egg retrieval. Sperm are then extracted from the seminal fluid. Harvesting viable sperm may also be done via testicular aspiration. Donor sperm may be used as well.
4. Fertilization – Sperm is introduced to the egg in a petri dish to facilitate fertilization. In some cases, a single sperm is injected directly into the egg in a technique called intracytoplasmic sperm injection (ICSI).
5. Embryo Transfer – The fertilized egg (embryo) is transferred into the uterus using a thin catheter. Embryo transfer is usually done 2 to 5 days after egg and sperm retrieval.

After about 2 weeks after egg and sperm retrieval, blood tests are conducted to check and confirm pregnancy. The success rate of IVF varies, but it usually depends on the woman’s age. For instance, the IVF success rate for a woman under 35 is around 40%, while a woman over 40 has a success rate of only 4%.

Intrauterine Insemination (IUI)

(Source: American Pregnancy Association)

Intrauterine insemination (IUI), or artificial insemination, refers to the process of injecting sperm directly into the uterus during peak ovulation times. This puts viable sperm closer to the mature eggs, increasing the chances of natural fertilization inside the body.

Similar to IVF, in IUI, sperm is first extracted from the seminal fluid before being placed in the uterus through a thin and flexible catheter. For women with irregular periods, IUI is performed in combination with ovulation induction, where the ovaries are stimulated to produce several eggs. Sperm are injected into the uterus once ovulation is confirmed.

Similar to IVF, the success rate of IUI depends largely on age. A woman under 35 has a success rate of about 10 to 20%, while a woman over 40 has only 2 to 5% success rate.

In Vitro Maturation (IVM)

(Source: VARTA)

In an IVF cycle, the ovaries are stimulated to produce several mature eggs using medications and hormone injections. With in vitro maturation (IVM), immature eggs (oocytes) are harvested from the ovarian follicles and matured outside the body. The process usually takes 48 hours. Once matured, the eggs are fertilized, either by sperm introduction (IVF) or ICSI, and the resulting embryo implanted into the uterus.

The harvested eggs, whether mature, immature or fertilized, may also be frozen to be used later. IVM is recommended for women with polycystic ovary syndrome (PCOS) or empty follicle syndrome (EFS).

Gamete Intrafallopian Transfer (GIFT) & Zygote Intrafallopian Transfer (ZIFT)

(Source: Hayat Fertility & Women’s Health Centre)

Similar to IVF, gamete intrafallopian transfer (GIFT) starts by taking medication to stimulate the ovary to produce several mature eggs. These eggs are then retrieved and mixed with sperm in a test tube. The contents are then immediately placed back into the fallopian tube for natural fertilization. 

(Source: Hayat Fertility & Women’s Health Centre)

The same processes of egg maturation and egg and sperm retrieval apply in zygote intrafallopian transfer (ZIFT). The difference is that with ZIFT, fertilization of the sperm and egg is done outside the body. Once fertilized, the resulting zygote is placed back into the fallopian tube. Both GIFT and ZIFT are done laparoscopically.

Alternative Infertility Treatments

ART procedures may seem like an instant solution to all couples, but the reality is that they are not for everyone. For instance, aside from the obvious financial constraints, IVF is only available to married couples in Singapore. Those interested to undergo ART treatments are also required to meet certain qualifications to be considered an eligible candidate. This may include being diagnosed with conditions that can affect the success of treatments, which include ovarian dysfunction, uterine fibroids and congenital cervical and uterine abnormalities.

Whatever the case, alternative infertility treatments for ART are available, and sometimes recommended. These include:

• Lifestyle changes – Adopting a healthier diet and fit lifestyle not only helps create a viable environment for both conception and pregnancy, but also affects the quality of both egg and sperm. Maintaining a healthy weight is ideal as well, as studies show that 30% of infertility cases are caused by obesity or being severely underweight. Practical steps to improve fertility include regular exercise, smoking and drinking abstinence, getting enough sleep, and avoiding stress.
• Acupuncture – A form of traditional Chinese medicine, acupuncture involves inserting needles in specific points of the body to treat certain health conditions. in terms of treating infertility, acupuncture is said to help stimulate blood flow to the sex organs, regulate hormones and alleviate stress, thereby increasing fertility.
• Donor eggs and sperm – Infertile couples who are unable to produce healthy eggs or sperm can choose to use donor specimen to achieve pregnancy. In terms of effectiveness, it is found that using donor eggs and sperm have the highest success rate in all fertility treatments.