Conception Problem, Difficulty Conceiving

Have you been trying to conceive without success? Please do not feel alone. Approximately one in six couples will have difficulty conceiving and may need medical help to identify the possible causes.

The good news is that there are many treatments available and getting started is the first step. Couples are generally advised to seek medical care through their obstetricians or a reproductive specialist.

Your obstetricians can offer some initial testing or initial treatments and hopefully this will work. However, after three months of unsuccessful treatment, it is recommended that you seek consultation with a reproductive specialist.

When should I see a Specialist?

There are a number of ways for you to receive the treatment you need. One option is to start by speaking with your obstetrician/gynaecologist first; another is to go directly to a reproductive specialist. Both physicians will start by performing initial tests to assist in identifying potential causes of your infertility. Obstetrician/Gynaecologist can complete the initial testing, do surgery to correct identified problems, or prescribe a medication to help with ovulation.

However a reproductive specialist generally does further exploration of potential causes and provides more advanced treatments.

As a woman’s fertility naturally decreases with age, starting in her late 20s and dropping more rapidly after 35 and fertility success follows the same pattern, you should not go too long without an evaluation by a specialist

Treatment Options

  • IUI: Intra Uterine Insemination. Learn more here.
  • IVF: In-Vitro Fertilisation. Learn more here.
  • Male Infertlity Treatment. Learn more here.
  • Laboratory Procedure. Learn more here.

This is an alternative for couples who have not found success with some treatment option.

What is Intrauterine insemination (IUI)?

Intrauterine insemination or IUI is a fertility treatment whereby best quality sperms that have been prepared and selected in the laboratory are placed inside the uterus around the time that the egg is being released.

  • There are two types of intrauterine insemination. The first type is the natural cycle IUI, where the woman is able to ovulate on her own. The second type is the Stimulated IUI, where women who are unable to ovulate are given drugs such as clomiphene to stimulate ovulation.

Who is suitable for intrauterine insemination?

  • It is useful when the patient’s spouse hasmild or moderate sperm problems.

What does the process involve?

  • In the woman, it involves doing serial ultrasound scan to monitor the growth of the follicle (which contains the egg) in order to detect ovulation. Once the size of the ovarian follicle reaches 18mm, she will then be given a subcutaneous injection, hCG, to mature the follicle.
  • The intrauterine insemination will then be performed 36 hours after the injection.
  • The husband will have to produce semen sample on the morning of the IUI. The sample will then be prepared in the laboratory so that the best quality sperm are selected.
  • The procedure itself is quick and painless. A speculum will be placed in the vagina to visualize the cervix. The sperms are then placed in the uterus using a thin catheter.

What if the husband is not around during the IUI?

  • It is possible for the husband to provide semen sample in advance and for the specimen to be frozen. On the day of the IUI, the sample will be thawed and prepared in the usual way. This avoids the problem of the husband being absent on the day of the IUI.
  • However, it is usually advisable to provide fresh semen sample.
  • The other option will be to cancel the cycle and try again when the husband would be around.

What are the risks of Intrauterine insemination?

  • Natural cycle IUI does not pose much risk at all.
  • Stimulated IUI can lead to multiple follicular growth, which increases the chance of a multiple pregnancy.

What is the success rate of IUI?

  • Doctors might try three cycles of IUI, and if these are unsuccessful, they might recommend more advanced methods such as in vitro fertilization (IVF).
  • Unlike IVF, IUI does not involve egg collection or IV sedation.

7. How many times can a couple try IUI?

  • IUI can be attempted as many times as the couple wishes.
  • However, the likelihood of success decreases with increasing numbers of failed IUI.
  • Couple must remember that increasing woman’s age reduces fertility.
  • The current recommendation is to try 3 cycles of IUI, and proceed to in vitro fertilization (IVF) if unsuccessful.
IUI: Intrauterine Insemination

Intrauterine insemination (IUI) is a fertility procedure in which sperm are washed, concentrated, and injected directly into a woman’s uterus. The most common indications for IUI are cervical mucus abnormalities, low sperm count, low sperm motility, increased sperm viscosity or antisperm antibodies, unexplained infertility, and the need to use frozen donor sperm. In natural intercourse, only a fraction of the sperm make it past the woman’s cervical mucus into the uterus. IUI increases the number of sperm in the fallopian tubes, where fertilization takes place.

Studies show that IUI is most successful when it is coupled with fertility drugs that recruit multiple follicles. This technique often is called controlled ovarian stimulation and IUI.

IUI sometimes is recommended for couples with unspecified infertility who have been trying to have a baby for six to 12 months. You should have a thorough infertility evaluation before trying IUI.

Male Partner Requirements for IUI

IUI relies on the natural ability of sperm to fertilize an egg in the fallopian tubes. Studies show that IUI will not be effective in cases where the male has low sperm counts or poor sperm shape (also known as sperm morphology). Sperm tests are required, therefore, in order to indicate:

  • Sperm count (number of sperm per cc)
  • Sperm motility (percentage of sperm moving)
  • Sperm morphology (shape)

In addition, our centre requires that the male (or female) partner must have blood test done to rule out certain infectious diseases.

Female Patient Requirements for IUI

The patient should have normal day 3 blood test results, open fallopian tubes, and a normal uterine cavity.

  • Women with ovulatory disorders can be candidates for IUI if they respond adequately to fertility drugs. In these cases, hormone treatments stimulate follicle growth and the IUI is timed to take place after ovulation is induced. Hormone treatments are usually used even for women without ovulatory disorder. 
  • Women with mild endometriosis may benefit from IUI if they do not have a distortion of the pelvic structures. 
  • Women with severely damaged or blocked fallopian tubes are not candidates for IUI.
Intrauterine Insemination Procedures

IUI is timed as closely to ovulation as possible, therefore you will be monitoring your cycle with an timing ovulation scan and/or we will control the time of ovulation with hCG. The insemination is accomplished by placing a speculum in the vagina to visualize the cervix in a procedure position similar to a Pap smear. A small, sterile catheter containing the sperm will be inserted through the cervical opening into the uterine cavity next to the tubal openings.

Depending on which type of treatment you are doing, a second sample of sperm is placed in the cervix. Some women may experience mild cramping. You may experience some spotting or light bleeding after the insemination, which is normal; however, we do ask that you avoid any strenuous exercise on the day of your insemination.

Success Rates of IUI

Doctors might try three cycles of IUI, and if these are not successful, recommend more advanced methods such as in vitro fertilization (IVF). Unlike IVF, IUI does not involve egg collection or IV sedation.

IVF : In-Vitro Fertilisation

In vitro fertilization (IVF) is a technology that introduces the female egg (oocyte) and male sperm together in a specialized culture medium where the chances of successful fertilization are greatly enhanced. The embryos are observed and grown in our IVF laboratory, where they are graded for quality and reintroduced to the recipient’s uterus at a multicell embryo stage or later at the blastocyst embryo stage. All procedures required during an IVF cycle, including ovarian stimulation and monitoring, egg retrieval, and embryo transfer, are performed on-site in our facilities.

Example of IVF Calendar

IVF Pre-Treatment steps

Part 1: Egg Retrieval

Part 2: ICSI

Part 3: IVF and Embryo Transfer

Finances Option

Male Infertility Treatment

The importance of a thorough evaluation of both partners in the relationship cannot be overestimated. Male factors account for at least 30 to 50 percent of all fertility issues in patients.

Semen Analysis

The semen analysis is done on an ejaculated sample collected after masturbation. It is best to do this test after a patient has abstained from sexual activity for two to five days. The test can be inaccurate if there has been recent ejaculation (counts too low) or if ejaculation has not occurred in a long time (many dead sperm). Once the sample has been taken to the laboratory, it is analyzed for many different parameters, including fluid volume, sperm numbers, sperm motility (the percentage of moving sperm), and sperm morphology (the shape and appearance of the sperm). Variations can occur from test to test, even in the same man, and sometimes the test needs to be repeated.

Sperm Retrieval

When a man has little to no sperm in his ejaculate, it may be possible to retrieve sperm from his testicles or epididymis. This is a procedure performed by a urologist. The sperm retrieved can either be frozen for future use or used immediately for an IVF cycle.

Laboratory Procedure

The Clinic For Human Reproduction, NUH Women’s Centre, provides comprehensive services for the diagnosis and treatment of infertility. Our nationally certified embryology lab operates year-round and employs three full-time embryologists and additional support personnel. Our andrology lab technologists have extensive experience to assist you with all your andrology and endocrine lab service needs. The Clinic for Human Repoduction’s IVF laboratory programme includes services in all aspects of Assisted Reproductive Technology (ART).

  • ICSI: Intracytoplasmic Sperm Injection
  • PGD: Preimplantation Genetic Diagnosis
  • Assited Hatching
  • Embryo Grading
  • Fertility Preservation
ICSI: Intracytoplasmic Sperm Injection

Within IVF, there are two different insemination techniques: standard insemination and ICSI insemination. Standard insemination is a procedure in which the eggs retrieved are maintained within their cumulus complex and are combined with sperm in the same culture dish. As their cumulus complex is maintained, egg quality and maturity cannot be evaluated.

In order to perform ICSI insemination, the cumulus complex of the egg is removed and the egg maturity and quality are evaluated. Maturity of the oocyte is important because only mature eggs have the opportunity to fertilize. ICSI involves the insertion of a single sperm directly into the cytoplasm of a mature egg. ICSI is typically recommended if a patient in our centre.

PGD: Preimplantation Genetic Diagnosis

Preimplantation genetic diagnosis (PGD) is a technique that can be used in conjunction with IVF to test embryos for genetic disorders prior to their transfer to the uterus. PGD makes it possible for couples with serious inherited disorders to decrease the risk of having an affected child. PGD can also be considered for couples experiencing repeat pregnancy loss due to genetic disorders, couples that already have one child with a genetic disorder and are at high risk of having another, and couples interested in family balancing.

PGD is performed using a high-powered microscope. A single cell is removed from each embryo on day three of development and tested for the genetic trait of interest. The unaffected embryos are identified, separated from the affected embryos, and transferred into the uterus.

Assisted hatching

Assisted hatching is a technique where a small opening is created in the outer shell of the embryo (zona pellucida), which weakens the shell and improves the likelihood of successful hatching and embryo implantation. Indications for assisted hatching include advanced age, thick or pigmented zona, and previous IVF failures. This technique is typically performed with fresh multicell-stage embryos and all frozen embryos.

Embryo Grading

During IVF, the embryos are cultured for up to six days and receive quality grades each day.

Egg Retrieval and Insemination Day 0

Egg maturity is important because a mature egg has the best chance of being fertilized. There are three different stages of egg maturation:

  • Germinal vesicle (GV): The egg has not begun meiosis yet, so it is considered immature.
  • Metaphase I (MI): The egg is in the first phase of meiosis; however, it is still not completely mature because it has not entered the second phase of meiosis. This kind of immature egg may mature after a couple of hours of temperature-controlled incubation.
  • Metaphase II (MII): The egg is in the second phase of meiosis and is mature. Eggs at this stage of maturity are ready for fertilization.

Egg quality is graded on a good-fair-poor scale

  • Good
    • Clear cytoplasm/normal shape
    • Single distinct polar body
    • Clear/thin zona pellucida
  • Fair
    • Slightly grainy cytoplasm/misshapen
    • Fragmented/abnormal polar body
    • Slightly pigmented/amorphous zona
    • Cytoplasmic bodies
    • PV debris
  • Poor
    • Dark/grainy cytoplasm/misshapen
    • >1 polar body structure
    • Pigmented/thickened zona
    • Vacuoles
    • PV debris
Fertilization Check Day One

Fertilization can be seen 16 to 22 hours post insemination. Normal fertilization is identified by exactly two pronuclei in the centre of the single cell zygote. Fertilization is considered abnormal when there is only one pronucleus or when there are more than two pronuclei.

Multicell Grading Day Two/Three

On day two the single cell zygote should divide into an embryo (approx. two to four cells). On day three the embryo should continue to divide (four to eight cells).

Embryo Quality:

  • Good: cells are symmetrical with clear cytoplasm
  • Fair: cells are slightly asymmetrical and/or have slight cytoplasmic irregularities
  • Poor: cells are significantly asymmetrical and/or have dark, grainy cytoplasm

Fragmentation: little bits of cytoplasm that escape during cellular division and stay within the embryo. The ranges of fragmentation are listed below from least to most heavy. Fragmentation ranging from A to B is most preferred.

  • A = No fragmentation
  • B =
  • C = 10-35% fragmentation
  • D = >35% fragmentation
Day Four

On day four, embryos begin their transition from a multicell embryo to a more advanced developmental stage. Embryos should begin compacting and forming morulae. Cells of a morula-stage embryo are not as distinct as in previous days; therefore, these embryos do not receive quality grades.

Day Five/Six Blastocyst Stage

A blastocyst is a highly developed embryo that is composed of two different cell types: one group of cells, called the inner cell mass, leads to fetal tissue and another group of cells, called the trophoectoderm, forms the placenta. Blastocysts are graded on their expansion (early, expanding, expanded, and hatching) as well as the quality of the two different cell types (graded on a good-fair-poor scale). Blastocysts that are good to fair quality meet freeze criteria.

Fertility Preservation.

Oocyte cryopreservation, or egg freezing, is a relatively new procedure in the field of assisted reproductive technologies. Overall, this technology increases a woman’s potential to have children later in life. Since the first successful pregnancy using egg freezing was reported in 1986, approximately 600 babies have been born. Currently, pregnancy rates are between 30 and 40 percent.

  • Egg Freezing
  • Embryo Freezing
Egg Freezing

Egg freezing allows a woman to preserve her fertility until she is ready to start her family. During an egg-freezing cycle, a patient will go through many of the same steps that are involved in a typical IVF cycle: ovulation stimulation, ultrasound monitoring, and egg retrieval. After egg retrieval, the eggs will be cultured for a few hours and then frozen the same day for future use.

Embryo Freezing

Embryo freezing is a technique that is recommended when high-quality embryos remain after embryo transfer. These embryos remain frozen until the patient is ready to use them. If patients have completed their families, they have the option to donate these frozen embryos to research, another couple, or training; the embryos can also be discarded.

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