Couples may find it difficult to conceive naturally due to different reasons. .

ART, an acronym used for “assisted reproductive technology” consists of a comprehensive programme that is offered to couples who are unable to conceive naturally.

ART encompasses both Invitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI). The initial part of both IVF and ICSI is the same. The difference is only in the laboratory, and this is covered in the Assisted Conception section of the website.

ART is a very safe treatment programme. There are now over five million babies born in the world from ART. When assessing the risk of ART, there is only an increase of 0.2% from the background risk.

Stimulation Protocols

Every treatment protocol is customized according to your needs and your doctor will be able to advise you as to which protocol is suitable for you. There is no standard protocol for ALL patients, as every patient is different.

Your doctor will choose a protocol that best suits you, that gives the least discomfort and has the shortest duration, yet accords you the highest chance of success.

The Long Down Regulation Protocol (LDR)

This is one of the most common protocols that is employed in Sunfert. The suppressive effects of the initial injections (busereline) seem to be beneficial for women with endometriosis which sometimes can be undiagnosed. Studies have shown that success rates with LDR protocol are marginally better than other protocols.

First visit to the clinic is roughly about a week before the onset of your menses (usually Day 21 of your menstrual cycle). During this visit, you will undergo a scan to confirm that you have ovulated. Sometimes, your doctor may have given you some oral contraceptive pills (OCPs) from the beginning of your menstrual cycle (usually Day 2 or Day 3) and you commence injections on your own a few days before the last pill. The first type of injection is called busereline (Suprefact) and is given as a daily dose in the morning before you go about your usual daily activities.

These injections are well tolerated, though sometimes the patient may have hot flushes. You will still have a menstrual period though it may be lighter or prolonged.

After about 2 weeks of injections, you will be seen in the clinic for a repeat scan to confirm down regulation (ovaries that are quiet). The dose of busereline is subsequently reduced and approximately a week later, you will commence stimulation of the ovaries. This involves the use of a daily hormonal injection called FSH (Gonal F,Puregon or Menopur) for about 10 to 12 days.

The LDR protocol takes about 4 weeks plus in total.

The 'Short' GnRH Antagonist Protocol

This protocol is gaining prominence due to its shorter duration and is commonly employed in Sunfert. It is particularly useful in women with polycystic ovaries, as there is a lower risk of ovarian hyperstimulation syndrome. Your doctor may sometimes give you several days (up to 3 weeks) of OCPs from the onset of your menses. Then on the second or third day of your withdrawal menses after the pill, you commence the daily FSH injections immediately. A scan would be repeated on Day 5 of injections after which another injection called GnRH antagonist (Cetrotide or Orgalutran) is commenced. This injection which is also done daily prevents premature release of the eggs. In total you will do about 10 to 12 days of injections.

The Microflare Protocol

This protocol is reserved for older women, women with low ovarian reserve or who have responded poorly with previous protocols. This protocol involves a pre-treatment with OCPs and subsequently a low dose busereline injection from Day 2 of menses, which acts to flare up the ovaries. You will subsequently be commenced on daily FSH injections from Day 3 onwards. The entire treatment protocol takes about 10 to 12 days.

The Natural Cycle IVF

Women with regular cycles but low ovarian reserve can opt for natural cycle IVF. These women will also very likely produce one or two eggs on their own or with a low dose of FSH stimulation. These eggs are easier to harvest and more likely to be better in quality and subsequently develop into an embryo. The advantage of this cycle is a reduction in cost and improved patient tolerability.

During the period of stimulation, you are expected to visit the clinic about 3 times. You are advised to carry on with your usual routine of work or house duties to minimize your stress levels. All injections are self-administered for your convenience, and our fertility nurse will teach you how to perform the injections. It is important to keep the injections in the refrigerator to preserve their effectiveness.

The Egg Collection Procedure

You will subsequently undergo egg collection, which involves retrieving or aspirating the eggs from the ovary, fertilizing them in the laboratory, and transferring the embryos back into the uterus a few days later. It is a minor procedure performed under sedation or general anaesthesia depending on the patient’s condition. The egg collection is performed in our specialized IVF Operating Theatre (OT) via transvaginal ultrasound (similar to the ultrasound used for monitoring of follicles during stimulation). Once the ovary is visualized by ultrasound, a very fine needle is passed through the

vaginal wall into the ovary to harvest the eggs. The eggs which are now in a test tube are handed over to the embryologist for processing. The embryologist examines the follicular fluid, identifies the egg, and then transfers each egg to a special culture media. In order to ensure minimal exposure to the external environment our laboratory is located next to the IVF OT. The procedure takes about 15 minutes to complete and refreshments will be served once you are fully awake. You will be discharge about an hour later.

The Embryo Transfer

The eggs are fertilized and are now called embryos. The embryos are cultured for between 2 to 5 days, depending on the number of fertilized eggs available. Embryo transfer is a minor procedure where the fertilised eggs are transferred into the womb via a very fine flexible catheter. An embryologist will meet with you to discuss your embryos and the number of embryos planned for your transfer. The number of embryos to be transferred depends on several factors such as the age of the woman, the quality of the embryos and the wishes of the patient. Sunfert endeavours to transfer the optimum number of embryos to achieve the best results with the least risk of multiple pregnancies.

Good embryos that are not transferred will be frozen for use in the future.

Once you, the embryologist and doctor have confirmed the plan for the embryo transfer, the doctor will insert a speculum. A vaginal ultrasound will be used to visualize the uterine cavity. The embryologist will obtain the embryos and load them into the catheter. A small catheter is gently passed to the top of the uterus, through the cervical opening, where the embryos are placed. The catheter is then carefully removed. Following the Embryo Transfer you will remain lying down for about an hour before discharged.

Most women would take about a week of rest from work or strenuous house duties to maximize the chance of success, though strict bed rest is unnecessary. You may get up to go to the bathroom, shower, and eat. You may also use stairs but avoid strenuous physical activity or heavy lifting. If you wish, your doctor will be able to provide a medical leave for this purpose. During this period of time, you are required to insert progesterone pessaries (Cyclogest or Crinone) as well as progesterone injections to support the womb and the resulting pregnancy.

Pregnancy Test

A blood pregnancy test is carried out approximately 2 weeks after the transfer. Progesterone supplementation will be continued for two weeks following the Embryo Transfer, and continue thereafter if your pregnancy test is positive for another month or so. If your pregnancy test is negative, you will discontinue all medications. Your menstrual cycle may take several days to start and may be slightly heavier than normal as Progesterone may delay your period, even if you are not pregnant. The doctor will review your entire treatment with you and discuss your options again if you would like to try again. You are also entitled to another session with the life coach, if you require, to help you cope with it.

Frozen Embryo Transfer (FET)

Healthy embryos resulting from an IVF cycle but not transferred to the patient at the end of the cycle can be cryopreserved and stored. If the initial treatment was unsuccessful and you have excess embryos frozen, you may undergo a FET about 2 months later. There is also a trend to “freeze all” the embryos in the fresh cycle and then transferring the frozen embryos later when the womb lining is more receptive.

There are a few protocols for the FET. The focus of the FET cycle is to build an optimal uterine lining and to identify the appropriate point in the patient’s cycle to transfer the embryos. In natural cycle FET, the doctor scans the patient frequently to identify ovulation and the embryos are transferred after the patient is given some progesterone. Some FET patients may also take hormone medications to prepare for the transfer. The medication prescribed is to keep your ovaries from ovulating during your cycle as ovulation causes the uterine environment to change, preventing accurate synchronization of your uterus with your embryos. The embryo transfer procedure is the same as the IVF procedure.

Side effects of ART

ART is a very safe treatment programme. There are now over five million babies born in the world from ART. When assessing the risk of ART, one must understand that in terms of fetal anomalies, there is only an increase of 0.2% from the background risk.

Other risks are like the risk of pelvic infection after egg collection (<0.5%), which is rare due to use the antibiotics. Ovarian Hyperstimulation Syndrome (OHSS) is not commonly seen nowadays due to the use the antagonist protocol and a drug called GnRH agonist to trigger egg maturity.

Fortunately, the most common outcome of ART in Sunfert is a pregnancy. Be assured that we will try our very best to ensure that you have a favourable outcome. We wish you every success!

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