01  Fertility Screening

Fertility is a summation of several factors present in a couple. As woman’s chance of conceiving and delivering a healthy baby declines rapidly with age, a married couple who are ready to start a family should do so quickly. In general, a young and healthy couple may try naturally for 1-2 years before consulting a fertility specialist for review. However, the older woman (above 37 years) or those with symptoms suggestive of disorders of the reproductive system, should seek help earlier.

Significant symptoms include irregular menstrual cycles, painful menstruation, painful intercourse, painful defecation or chronic pelvic pain. Likewise, women with any pre-existing gynecological conditions or hormonal disorders should also check with their gynecologist regarding their ability to conceive naturally.

Fertility assessment should include the following areas:

1. Sperm count
2. Assessment of the woman’s egg reserve and ability to ovulate
3. Integrity of the womb and its lining
4. Patency of the fallopian tubes
5. Status of the woman’s pelvis

For selected couples, a detailed examination of the female pelvis with laparoscopy (keyhole surgery) may be recommended, especially if bedside examination reveals possible conditions that can be treated during laparoscopy.

02  Endometriosis

Endometriosis is estimated to affect about 10% of girls after puberty and women in the reproductive age group. This figure is likely to be grossly under-estimated as many women who have endometriosis may not have significant symptoms hence they do not present themselves for assessment or the disease may have escaped the untrained eye. As such, we see the majority of our patients who come for fertility assessment actually having endometriosis usually undetected for months or years. After we diagnose the condition and joined the dots for them, they then begin to realise that the “normal” menstrual cramps, “backache” during period, “discomfort” at sexual intercourse, painful urgency to pass urine or pass motion during menstruation were actual symptoms of endometriosis which were written off as being “normal” for years.

There is a wide spectrum of symptoms for endometriosis ranging from the truly silent mild variant to the excessively scarring and debilitating state of the severe disease. Most of our fertility patients have mild to moderate variants as those who have more severe symptoms would have already presented themselves to our endometriosis clinic. The mild disease is particularly challenging to diagnose as the symptoms are often not pronounced and diagnosis requires high degree of experience and suspicion as well as appreciation of subtle signs during bedside pelvic assessment. Unfortunately, “mild” / “moderate” only refers to the extent of spread of the disease. It does not necessarily correspond to the impact on fertility. In fact, many women with mild disease may be subfertile. Amongst women who are labelled as having unexplained infertility, it is not surprising to find many with undiagnosed mild endometriosis.

03  Reproductive Surgery

Laparoscopy, also commonly referred to as keyhole surgery, is integral to the state-of-the-art gynecology and fertility services provided at STO+G. This minimally invasive route of surgery allows the fertility specialist to assess the woman’s pelvis to confirm the presence of gynecological conditions as well as to determine the cause of infertility. Most surgical procedures required to treat these conditions can be accomplished via laparoscopy itself making it a truly one-stop, see-and-treat procedure for infertility.

The benefits of laparoscopy (over conventional open surgery) includes shorter hospitalization, faster recovery, less blood loss, less pain and less internal scarring. More precise dissection allows for less damage to surrounding tissue during surgery (this is specially important for fertility cases). Furthermore, the cosmetic effect of the “keyhole” wounds are far better than that of conventional open surgery. Our fertility specialists are all Level-3 laparoscopists who have undergone rigorous training to be well-versed in treating all common gynecological diseases of the pelvis especially those with impact on fertility. Common laparoscopic procedures performed by our fertility specialists include:

1. Removal of fibroids
2. Removal of ovarian cysts
3. Removal of endometrial polyps
4. Pelvic clearance of endometriosis (targeted resection)
5. Reconstruction or re-joining of damaged fallopian tubes

The cornerstone of reconstructive / corrective reproductive surgery is meticulous dissection and conservation of important tissue such as ovarian cortex where the eggs are stored. Besides infertility, laparoscopy is commonly used to treat other gynecological diseases such as removal of diseased ovaries, fallopian tubes, or even the entire womb. For selected cases, these procedures may even be performed with a single keyhole buried in the belly button resulting in an essentially scarless surgery for the best cosmetic outcome.

04  Assisted Reproduction

Ovulation Induction (Ol)

Not being able to ovulate naturally is a challenge faced by many infertile women especially those without regular menstrual cycles. Ovulation induction (Ol) is a simple treatment with the aim of releasing 1-3 matured eggs each month while the couple commits to having regular intercourse during the fertile window.

Super-Ovulation IntraUterine Insemination (SOIUI) Super-Ovulation Intra-Uterine Insemination (SOIUI) is a fertility treatment commonly used to help couples with milder fertility issues. It starts with the stimulation of eggs to maturity leading to eventual release from the ovary (ovulation). This is followed by the processing of the partner’s semen and depositing it directly into the womb. Fertilisation and pregnancy will take place naturally. Once pregnancy is confirmed on urine or blood test, a scan will be performed to determine the site and number of pregnancy sacs.

Super-Ovulation IntraUterine Insemination (SOIUI)

SOIUI is a fertility treatment commonly used to help couples with milder fertility issues. It starts with the stimulation of eggs to maturity leading to eventual release from the ovary (ovulation). This is followed by the processing of the partner’s semen and depositing it directly into the womb. Fertilisation and pregnancy will take place naturally. Once pregnancy is confirmed on urine or blood test, a scan will be performed to determine the site and number of pregnancy sacs.

In-Vitro Fertilisation (IVF)

Assisted reproduction, also known as In-Vitro Fertilisation (IVF) or Intra-Cytoplasmic Sperm Injection (ICSI) has evolved over the past few decades with increasing success rates. It involves the following essential steps:

1. Controlled stimulation of the ovaries to recruit and mature eggs
2. Harvesting of matured eggs
3. Fertilisation of eggs with sperm
4. Culturing and grading of the resulting embryos
5. Transfer of embryos
6. Supporting the pregnancy
7. Freezing of excess embryos not transferred

As the eggs present within the ovaries are immature, they have to be stimulated before harvesting. Variable degrees of stimulation are practiced depending on the profile of the individual woman. During stimulation it is crucial to monitor the eggs with regular ultrasound scans. When matured, the eggs are harvested under ultrasound guidance and processed in the laboratory. The partner’s semen is processed simultaneously to select suitable sperm for fertilisation. The fertilised eggs become embryos and will be transferred into the womb for implantation. After the transfer, the womb lining needs to be supported with hormones. A pregnancy test will be performed 2 to 3 weeks after transfer. If unsuccessful, extra embryos frozen during the treatment cycle may be thawed in future for transfer without the need for stimulation of eggs and harvesting.

05  Social / Elective Egg Freezing (EEF)

Social /elective egg freezing is a medical treatment for well women who wish to harvest some of her existing eggs to be frozen (in liquid nitrogen) as a form of fertility preservation. This utilises current knowledge and technology of assisted reproduction techniques (used in IVF) to stimulate, mature and harvest eggs for freezing. In time to come when the woman is ready to conceive, these eggs may be used in IVF to create embryos for transfer into her womb. These frozen eggs may never be utilised if the women is able to conceive naturally when they try or they may be a lifeline for women whose egg reserves become severely affected by diseases or medical therapies (for example, cancer and chemotherapy), or just by advanced age alone.

Read more about Social Egg Freezing here.

06  Surgical Sperm Retrieval

Occasionally, obstruction of the male reproductive tract results in the ejaculated semen containing no sperm at all. In such scenario, attempts can be made to retrieve live sperm from the testes surgically. If successful, the sperm obtained can be used for ICSI to create embryos for transfer into the wife’s womb. The alternative to this procedure is to use donor’s sperm for IVF.

07  Oncofertility

In recent years, major advances have been made in the treatment of cancer in children and adults. Hence many cancer survivors go on to lead a normal life with long term favourable quality of life(QOL). One major focus of QOL includes the effects of treatment-related infertility, which is of great concern to young patients. This group of patients may experience regret and distress if not given the opportunity to discuss their fertility preservation options prior to cancer treatment. Fertility preservation is the process of saving or protecting eggs, sperm or reproductive tissue so that a person can use them to have a biological offspring in the future.

Fertility preservation for females

• Egg / embryo freezing – requires stimulation of ovaries(similar to IVF)
• Ovarian Tissue Cryopreservation(OTC) – storing part of the ovarian tissue
• Suppression of ovarian function with medications during chemotherapy
• Shielding the ovaries or uterus during radiation treatment
• Transposition of the ovaries (temporary surgical transposition of the ovaries to move them away from the site of radiation treatment)

Fertility preservation for males

• Sperm freezing