Options for those trying to conceive


By BRIGITTE ROZARIO

Conceiving a child does not happen as easily for everyone. Some couples find that after months and months of trying, taking the wife's temperature, timing their attempts during her ovulation period and waiting anxiously, they are disappointed every month when her menstruation begins.

Not only is it upsetting and stressful for the couple; it also means they need to start all over again.

To make matters worse, everywhere you look there are advertisements for baby products, photos of pregnant women, all your friends seem to be pregnant and worst of all, your parents keep asking you when you're going to start giving them grandchildren.


Today, couples have many more options than there were in their parents' time. There is fostering, adoption and even fertility treatment.

Malaysia now has several fertility centres around the country catering to the needs of such couples who desperately want to have children but just can't seem to conceive. While fertility treatments offer hope they do not guarantee success.

Treatment is available

Obstetrician-gynaecologist Dr Fong Chee Kin, with the Subang Fertility Centre at the Sime Darby Healthcare in Subang Jaya, says that married couples who have a strong desire to have children and who have been trying to conceive for a certain period of time should go for fertility treatment.

“Generally, if the couple is young, we ask them to try for six months of regular intercourse. Regular means trying two to three times a week and not just when the wife is ovulating. We normally discourage the couple from timing their sexual exposure because it puts unnecessary psychological pressure on both the man and the woman.

“We find that if you do that and you don't get pregnant then after some time you might have erectile dysfunction and that compounds your problem.

“If you are 30 and above, we ask you to try regular intercourse for three months. We normally don't like you to cross 35 years old because that's when the statistics for your success rate starts to decline. And if you don't succeed in three months you should be seen first by a doctor and not plunge straight into test tube baby treatment but to see whether you need some simple tests,” he says.

The doctor would first assess the couple and advise them how to proceed.

They would be checked with simple tests first and then work towards more complicated and invasive procedures. According to Dr Fong, the Centre avoids invasive procedures unless it's warranted.

Dr Fong Chee Kin.
He says that the physical examination will tell you if you have all your reproductive organs, and your history would show if your reproductive organs are functioning.

“So, if you are menstruating regularly, the chances are your reproductive organs are intact and working pretty normally. As far as the man is concerned, getting a sperm count test is sufficient.

“If the man has normal sperm count and the woman is normal and sexual intercourse is normal, there are no problems, then we start looking for other factors – whether there are any barriers to the sperm reaching the egg. So usually a mucous test will tell us whether the patient's cervix is having a satisfactory amount of mucous and an X-ray of the fallopian tubes will tell us whether the tubes are blocked or not.

“The ultrasound will tell us the ovarian reserve, whether you have got enough eggs or you have some eggs or whether you have too many eggs. And the blood test will also tell us your hormone statistics because if you're going towards ovarian failure – that means even if you have eggs but the quality is bad – your blood test will show it,” says Dr Fong.

Among the common causes for infertility are the inability to ovulate (produce eggs), blocked fallopian tubes which prevent the sperm from reaching the egg, poor sperm quality, endometriosis and polycystic ovaries.

However, Dr Fong says that for most couples it is a mixture of problems that prevents them from conceiving.

“The chances of a man being responsible for infertility is nearly 50%. So it's pretty high and some of them are unexplained,” he says.

Fertility options

* Timed intercourse

This is the least disturbing and least invasive of the treatment options. It is also the cheapest.

Who is it for?

If the woman's fallopian tubes are normal and the man's sperm count is normal and you want to make sure you're trying to make a baby at the right time and there's no cervical hostility then timed intercourse is probably all you need.

* Intrauterine Insemination (IUI)

After ovarian stimulation to help the wife produce eggs, the prepared sperms are introduced into the uterus.

Who is it for?

IUI is for those who are healthy (the woman has healthy fallopian tubes and the man has satisfactory sperm quality) but are still unable to conceive.

* In Vitro Fertilisation (IVF)

This treatment involves the removal of the woman's eggs after ovarian stimulation for fertilisation with the man's sperm outside the body.

The fertilised eggs are nurtured in an incubator until they go through a process called cell division, which is when they become embryos. The embryos are then transferred into the uterus.

Who is it for?

It is for women who have blocked fallopian tubes or men who have poor sperm quality, or those who have failed to conceive via the IUI method.

* Intracytoplasmic sperm injection (ICSI)

In this option, the sperm is injected directly into the egg. It is only used when IVF fails or is expected to fail in fertilising the egg and developing good quality embryos.

Who is it for?

If the man has very low or poor quality sperm count or even no sperm count then he should go for ICSI. According to Dr Fong, men who have no sperm count may not be sterile. They may have sperm in the testicles which are unable to come out because of some blockage. Using surgical sperm retrieval methods, these sperm can be harvested from the testicles and then using ICSI they can be injected directly into the egg.

Additional treatments

* Ovulation induction and monitoring of cycles

The woman is given a series of injections and/ or oral medications to stimulate her ovaries to produce eggs. She is monitored and later given another injection to release the eggs.

* Surgical sperm retrieval

A minor surgical technique is performed on the man to retrieve his sperm if he has very low sperm production or if there is some blockage which prevents his sperm from entering the semen.

* Cryopreservation

When IVF and ICSI are conducted there is usually an excess of embryos. The fertility centre usually freezes the embryos and stores them in liquid nitrogen for as long as the couple wants them kept. There is a cost factor, of course.

The embryos can at a later date be transferred into the woman's womb.

For couples with fertility problems, this option means they don't have to go through the IVF or ICSI process all over again. The embryos cannot be transferred or given to other couples.

The risks

The fertility centre normally puts in two embryos into the woman's uterus if the couple goes for IVF or ICSI.

Explains Dr Fong: “We are quite responsible. If you're young and we think you are fertile we will put back two embryos for you. If the person is older we put in more because the chances of conception are lower.

“So, there is a chance of multiple pregnancies (getting twins) because we put in two or more embryos. Multiple pregnancies is one of the side effects of an ART (assisted reproductive technologies) programme and since it's expensive, most people try to hedge their bets by putting back more embryos. The drawback is if they all succeed then you also have a set of 'problems'.”

Premature menopause has also been said to be one of the side effects because of the number of eggs the woman uses up. However, Dr Fong says it shouldn't affect the patient too much if they only undergo treatment for one or two cycles.

If you undergo too many cycles, theoretically you might have problems and you may menopause a lot earlier. However, because of the high cost involved, most patients drop out of the programme after one or two cycles.

One of the biggest risks of assisted reproduction is that the woman could die from Ovarian Hyperstimulation Syndrome.

“You don't die from ovarian hyperstimulation itself but if you go into full-blown Ovarian Hyperstimulation Syndrome where not only are you hyperstimulated but you also attract a lot of other medical complications as a result of that whereby your kidneys, lungs, blood are involved, then you're in deep trouble. You may die,” says Dr Fong.

However he adds that there are not many deaths worldwide annually due to this syndrome.

Donated eggs and sperm

This is a bit of a tricky area as it involves getting contracts signed.

Dr Fong says the Subang Fertility Centre does work with married couples who intend to obtain donated eggs and sperm.

“There are certain medical legal implications so we normally ask them to see a lawyer, get a contract drawn up so that the couple and the donor don't have claims on each other if they get pregnant.

“We normally ask them to choose their own relatives for egg donation and for sperm donation, to choose people they know to avoid the problem of HIV.

“We are only worried about the Muslim law which is a little bit more conservative.

“We do tell them which lawyers do these kinds of contracts and the lawyers will see them separately. After the contract is signed, they show it to us. Once we know that there's a contract then we can proceed,” he says.

Success rate

Similar to natural pregnancies, the chances of people who go for fertility treatments conceiving per month is about 30%.

“The results are actually very similar to what happens in nature. It's not 100% or even 80%. If you take 100 women who are having regular intercourse for one month, only 30% will conceive. So all our results are actually about that, too,” he says.

Cost

Couples are charged per cycle and according to the treatments used.

At the Subang Fertility Centre, if you are on oral medication for IUI, it can cost from RM800 to RM1,000. If you are on injectibles for IUI, it can cost from RM1,500 to RM2,000+.

IVF treatment can cost up to RM16,000+.

ICSI treatment can cost up to RM18,000+.

(Note: Prices relevant as of March 2009.)

The fertility centre advises couples to set aside an additional RM2,000-RM3,000 just in case you need more medication.

Conclusion

Dr Fong says about 10% of the population has fertility problems. The Subang Fertility Centre conducts about 100 cycles a year for couples.

Most patients go for timed intercourse, IUI, IVF and ICSI treatments as well as the frozen embryo transfer.

He adds that currently there is a trend for people to check their ovarian reserve to see whether their biological clock has still got many more miles to go.

“I don't think there is any proof to show that it is accurate because you can check to see how many eggs you have left but you don't know the quality of the eggs. And it is well known that the quality of the eggs decreases as you grow older. No doubt about that because your eggs are as old as you are.

“My advice to couples is try to get pregnant while they're young. That's the most important message. We don't like them to come to us for treatment. We would prefer it if they can get pregnant on their own and the most important thing is age, age and age. Don't delay the pregnancy till they are 35 and above,” he says.

* The Subang Fertility Centre has a website at

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