Miscarriage

The loss of a baby through miscarriage is more common than many people realize. Most miscarriages occur within the first two months of pregnancy.

The warning signs are vaginal bleeding, cramps and backache similar to those experienced during your menstrual period, and absence signs such as tender breasts and morning sickness. Once a miscarriage starts, little can be done to halt it.

What are the causes? Most couples who lose a pregnancy do so for no clear reason and go on to have a healthy baby later. While a miscarriage, particularly in the early months, does not mean an increased risk of another, some women do have repeated miscarriages. If you have repeated miscarriages, consult your obstetrician. You may be referred for an investigation, which may include a genetic counselor who will determine the level of risk and the best way forward.

Rubella, Chlamydia are known common causes of miscarriage, as is a major abnormality in the foetus or abnormalities of the uterus, such as fibroids or polyps. An incompetent cervix can also causes as a miscarriage.

Placenta Disorders. Severe vaginal bleeding in the third trimester is the symptom most indicative of placenta previa and placenta abruption. These are disorders that need urgent attention. An emergency Caesarean is performed to prevent extensive blood loss in the mother and oxygen deprivation in the foetus.
Dealing with Infertility

Difficulty Conceiving

Have you and your partner 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 generally are advised to seek medical care through their ob-gyns or a reproductive endocrinologist.

Your ob-gyn can offer some initial testing or initial treatments and hopefully this will work: however, after three months of unsuccessful treatment it is recommend you seek consultation with a reproductive endocrinologist.

• When should I see a specialist?
• Various treatment options

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 ob-gyn first; another is to go directly to a reproductive endocrinologist. Both physicians will start by performing initial tests to assist in identifying potential causes of your infertility. Ob-gyns can complete the initial testing, do surgery to correct identified problems, or prescribe Clomid, a medication to help with ovulation: however a reproductive endocrinologist generally does further exploration of potential causes and provides more advanced treatments.

Because 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

Various treatment options

A reproductive endocrinologist specializes in treating reproductive disorders. Reproductive endocrinologists have completed the same education and medical requirements as ob-gyns. In addition, they also have finished a two to three-year fellowship in reproductive endocrinology, passed specialized examinations (if board certified), and completed a two-year practice in reproductive endocrinology.

The reproductive endocrinologists at San Diego Fertility Center will assist you in creating your own effective fertility treatment strategy.

Fertility Treatment

Core values of integrity, intelligence and innovation serve as our center’s foundation. Regardless of your circumstance, our infertility specialists work closely with you to develop a personalized treatment plan including: In-Vitro Fertilization (IVF), Egg Donation, Pre-Genetic Implantation Diagnosis (PGD) and other protocol options.

• IUI: Intra Uterine Insemination
• IVF: In-Vitro Fertilisation
• Egg Donation & IVF
• Male Infertlity Treatment
• Laboratory Procedure

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 Requirement for IUI
• Female Patient Requirement for IUI
• IUI Procedure
• Success Rate of 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 & Embryo Transfer
• Finances Option

Egg Donation & IVF

This is key to conception when a woman cannot produce her own eggs.

The Clinic For Human Reproduction, NUH Women’s Centre, provides an egg donor program and IVF treatment which meet the criteria set forth by the Ministry of Health.

For donor egg IVF, an egg donor recipient may select an egg donor who is her a sister, close friend, or relative of the recipient’s. Donor egg IVF successfully treats women who are carriers of genetic diseases, women who have had multiple failed cycles of IVF, women with impaired ovarian function or healthy older women. This IVF treatment also heightens the chance of pregnancy for women whose attempts at IVF have revealed a poor response to fertility medications or whose eggs did not fertilize well or form viable embryos.

As part of the IVF egg donation programme protocol, an egg donor injects fertility medication to stimulate her ovaries to produce multiple eggs. Hormone replacement is used to synchronise the recipient to the egg donor cycle. Just prior to ovulation, using standard IVF techniques, the eggs are retrieved from the egg donor’s ovaries and fertilized with sperm from the recipient couple.

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
• Assisted 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 can 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 = <10% fragmentation
• 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.