Infertility can affect both men and women. It is defined as “the inability of a couple to achieve conception after 12 months of regular, unprotected sexual intercourse”.

Types of Infertility:

Primary

- Difficulty in conceiving for the first time (i.e. first pregnancy)
  Secondary

Secondary

- Difficulty in conceiving the second or subsequent pregnancies
 

A diagnosis of infertility does not mean that a couple is incapable of achieving a pregnancy. Some couples (about 50%) will eventually achieve a pregnancy spontaneously or with appropriate treatment.

Infertility may be attributed to female factors (such as tubal disease, ovulatory disorder, endometriosis) in approximately 40% of cases, to male factors in about 40% of cases and to unexplained factors in about 20% of cases. In about a third of couples with infertility, there may be multiple problems present.

The following are the main factors that will affect a couple’s chances of conceiving:

• Oocyte (egg) quality declines as early as the age of 31. The earlier the problem is investigated, the better the chances are for a successful pregnancy.
• Non conception within 3 years of unprotected intercourse. Pregnancy is unlikely to occur without treatment.
• Failure to establish the actual cause of infertility in the couple.
  

Causes

1. Blockage of fallopian tubes due to:

- previous infections such as sexually transmitted disease,   the use of intrauterine device or a ruptured appendix. - previous tubal sterilisation. - endometriosis. - scarring of fallopian tubes due to previous pelvic surgery.

2. Problems with ovulation  

- endocrine(hormonal) disorders - general medical problems - serious illness, emotional    stress, obesity, low weight or excessive   exercise.

3. Problems with the uterus and/or cervix

- previous surgical procedures (cervical cone biopsy or dilation and curettage) - hostile cervical mucus affecting sperm motility.

4. Factors contributing to male infertility affecting the quality and/ or the quantity of sperm

5. Unexplained infertility

Assisted Reproductive Techniques (ART)

These are different types of assisted conception treatments. What treatment an individual will require will depend on the cause of infertility. 

In-Vitro Fertilisation (IVF)

IVF involves the following steps: 

Step 1 : Ovulation induction The ovaries are stimulated to produce multiple eggs (superovulation) with fertility drugs given either orally or in the form of injections. In the IVF procedure injections are almost always used to get as many eggs as possible. The doctor then does an ultrasound examination of the ovaries to see if the eggs are growing satisfactorily and a final injection is subsequently given to complete the maturation process.

	Step 2 : Retrieval of eggs The eggs are collected 34-36 hours later vaginally under ultrasound guidance and less commonly by laparoscopy. This procedure is done under sedation or general anaesthesia.
	Step 3 : Sperm collection and preparation Semen is obtained from the male partner through masturbation. In men who do not have sperms in their ejaculate, sperms are taken through a small incision on the scrotum by specific sperm retrieval techniques or testicular biopsy. The sperms are prepared using culture medium under controlled laboratory conditions. Note : Sperms from the above techniques can only be used in the ICSI procedure.
	Step 4 : Fertilisation and transfer  Eggs and sperms are incubated under appropriate conditions in an incubator for 2-3 days for fertilisation to occur & division to take place. The resulting embryos are placed into the uterus through the cervix under ultrasound guidance.
	Step 5 : Freezing of Embryos  Cryopreservation (Freezing) of human embryos maximises the potential for pregnancies in patients undergoing IVF and ICSI procedures. Excess good quality embryos can be stored thus preventing wastage. Satisfactory pregnancy rates are obtained with cryopreserved-thawed embryos.
	Step 6 : After the embryo transfer The patient remains rested with a slight head down tilt on her bed for 2 hours before being allowed home. Oral and vaginal medications are given for two weeks after which the patient has blood tests to ascertain a pregnancy.
	Step 7 : Pregnancy and birth     Embryos implanted in the uterus may result in either single or multiple pregnancy. While most pregnancies reach full term successfully, there is a small risk of miscarriage and premature delivery.

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Intracytoplasmic sperm injection (ICSI)

The ICSI procedure is performed when the male partner has poor sperm parameters to the extent where natural sperm penetration of the egg is highly unlikely. It is sometimes also performed where eggs are noted to have a thick covering (Zona Pellucida).

In the ICSI procedure, the eggs are obtained as in IVF and the sperms are prepared in a similar manner. A microneedle is used to inject a single sperm into the egg. The microinjection is carried out under very high magnification using an operating microscope. 

After injection of the sperm, the eggs are incubated for 16-18 hours. After which they are examined for evidence of fertilisation and possible damage. They are then transferred back into the uterus using the standard IVF procedure. Excess good quality embryos can be frozen for transfer at a later date. 

Gamete Intra Fallopian Transfer (GIFT)

GIFT is a procedure that involves the laparoscopic placement of eggs obtained from the female partner and sperms from the male partner into the fallopian tubes of the woman where normal fertilisation takes place.  

GIFT can be used as an effective treatment for infertility of all causes except for women with tubal disease and in men with poor sperm parameters. In many centres with good IVF/ICSI success rates, the GIFT procedure has been replaced. The disadvantages of the GIFT procedure is that it requires an abdominal surgical procedure and in cases of failures, one would never know if fertilisation ever took place. 

Ovulation induction is performed as in IVF. When the eggs are matured, they are collected using the laparoscope. Sperms are obtained as in IVF. The eggs and sperms are placed together in the fallopian tubes, allowing for natural fertilisation. 

Success Rates 

Our overall IVF/ICSI pregnancy rates have ranged from 30 to 42% per embryo transfer between the years 2004 to 2006. Pregnancies in women over 40 years is less than 10%. These results are comparable with other well established  fertility centres, locally and abroad.

We do not set an age limit for patients seeking assisted reproduction. However, women more than 40 years of age will be counselled and informed of the lower success rates before embarking on the programme.

Cancellation 

Patients going in for ART may have their treatment cancelled either due to poor response or ovarian
hyperstimulation (see Ovarian Hyperstimulation Syndrome) 

Side effects and risks

1. Local side effects 

2. Ovarian Hyperstimulaiton Syndrome (OHSS)

3. Multiple births    

4. Health risks for children born following infertility treatment

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Artificial Insemination 

Artificial Insemination is a technique where unprepared or prepared sperm is inserted into the vagina or uterus at the time of ovulation. It can be divided into intravaginal insemination and intrauterine insemination (IUI). Intravaginal insemination is performed in patients who have sexual problems like vaginismus or impotence. Intrauterine insemination using prepared sperm (as in IVF) is an effective and minimally invasive treatment where sperms are introduced into the uterine cavity using a thin flexible tube (catheter). It is mainly used in patients who have cervical factor infertility and men with moderately low sperm counts.

In IUI oral medication or low dose gonadotrophin injections are usually used for ovulation induction.

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Egg and sperm donation

In females where there is poor response to ovarian stimulation or when the eggs are not available and in males with no sperm production, donation of eggs and/or sperms offers an option to still have a child. However, as there are no rules regulating the above in Malaysia the recipient couple and the donor concerned will be required to undergo extensive counselling and have a legal agreement drawn up with their appointed lawyers. Syariah law however will apply to Muslim patients.

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When to Seek Treatment

You may want to contact us if:

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Cost

The average cost per cycle of IVF/ICSI treatment is between RM 12,000 to RM 15,000. It is dependant on the following factors: