TREATMENT

IVF procedure

1. Women will meet with the doctor within the first three days of their menstrual period to receive an ultrasound and hormone checkup. The doctor will prescribe egg-stimulating medication that is suitable for each patient.
2. Women will meet with the doctor after receiving egg stimulant 2 – 3 times in order to do an ultrasound. It depends on the development of eggs. After the egg is in a good size (bigger than 17 – 18 millimeters), the doctor will order ovulation induction medication. At the same time, men will be recommended to ejaculate 2 – 3 days before the day for egg collecting.  
3. On the appointment for egg collecting, both partners should come together. Men will be asked to collect their sperm while women’s eggs will be collected by using local anesthesia. 
4. The process of fertilizing egg and sperm together is called ICSI. Once it becomes an embryo and continues to culture is called the blastocyst.
5. During egg transferring in the stimulant process, the patient will have the embryo transferred to the uterine cavity 3 – 5 days after collecting the eggs. However, if the doctor recommends the patient to do embryo freezing and transfer during the following period, she will meet with the doctor within the first two days of the menstrual period to do an ultrasound and receive medication to prepare the uterine cavity. Then there will be a hormone checkup for pregnancy within 7 – 10 days after embryo transfer.

Ovum Pick Up: OPU or Egg Retrieval

Ovum Pick Up (OPU) is a technique used in conjunction with In – Vitro Fertilization (IVF) process. It is normally established within 34 – 36 hours after triggering ovulation. OPU technology is to remove eggs from ovaries by an ultrasound-guided procedure performed under intravenous sedation. This process is approximately no longer than 30 minutes. Embryologists then carefully examine and select these removal eggs. After that, all good-quality eggs proceeded to the Intracytoplasmic sperm injection (ICSI) process.

Patient Instructions Before Ovum Pick Up (OPU)

1. Please review your appointed date and time for an ovulation induction trigger shot as instructed by your doctor.
2. Please do not eat or drink for at least 8 hours prior to the egg retrieval.
3. Please arrive at N.I.C IVF Clinic 1 hour before the egg retrieval.
4. Please take a shower and clean your genital area before coming for egg retrieval.
5. The husband must prepare for semen collection around the same time as egg retrieval.
6. Please avoid sexual intercourse prior to egg retrieval. Since it could cause damage to the ovary.
7. Please avoid using any fragrance, perfume, spray, or cosmetic products including powder on the day of egg retrieval.
8. Please remove any nail polish or any nail chemical at least 1 day before the egg retrieval.
9. Please do not wear any jewelry or accessory on the egg retrieval date.
10. Please get enough rest and sleep.  Relax and avoid stress.

Patient Instructions After Ovum Pick Up (OPU)

1. After recovering from anesthesia, you may experience nausea, abdominal pain, or a small amount of vaginal bleeding.
2. All patients must take rest for at least 1 to 2 hours in the recovery room before being discharged.
3. You may use prescribed pain medicine when the symptom occurs.
4. Please take the injectable/oral/suppository medications as instructed by your doctor.
5. Please relax and take rest as much as possible.
6. Please do not drive a car by yourself after the procedure.
7. If following symptoms such as abdominal distension, severe bloating, severe abdominal pain, difficulty breathing, or vaginal bleeding occur, please call and/or come to the clinic immediately.

By Assoc.Prof. Matchuporn Sukprasert

Nowadays, people in Thai society tend to get married at older ages. According to the figure in picture 1, we can see that age plays as an important role in the quality of eggs. The best time for reproductive systems is between 25 – 29 years old and then will continue to decrease especially when women are more than 35 years old. This is why there is a recommendation for women to do egg freezing before turning 35 years old in order to stop egg aging. 

Picture 1 demonstrates the relationship between ages and reproductive percentile.

Additionally, the eggs in women who are more than 35 years old tend to have embryos with abnormal chromosomes when fertilize with sperm.  This fact is shown in Picture 2.

Picture 2 demonstrates the relationship between the age of women and the percentile 
of having Down syndrome babies.

Due to egg production stops since being in the mother’s womb and has the most amount during the 7 months of pregnancy. Then the amount will gradually decrease that is why women should consider egg freezing when they are still young according to Picture 3.

The process of egg freezing begins by stimulating the ovaries in order to produce multiple eggs as same as doing IVF / ICSI procedure.  It is to make sure that we have enough eggs. After eggs are in an appropriate size, they will be retrieved and stored separately from sperm by the method of egg freezing which is the same as the embryo. The only differences are the chemicals being used. However, after being frozen, the endurance of eggs is less than embryos.  After eggs are dissolved to prepare for fertility, the remaining eggs are only 80% overall.

Egg Freezing Indications

1. Egg freezing is done to fertilize with sperm that belongs to a legal husband in the future.
2. Egg freezing is done after being diagnosed with certain cancer which is the plan of treatment: for example, chemotherapy can affect egg production.  In addition, treatments for other diseases can cause lower quality in egg production as well. 

By Assoc.Prof. Matchuporn Sukprasert

A surgical procedure to extract sperm from epididymis can be done when men have the following abnormalities:

1. Sperm cannot be found in the fluid due to blockages in the vas deferens, or there is no vas deferens since birth.
2. Not being able to store sperm with natural methods.
3. Not being able to ejaculate sperm normally, or having a problem doing so because of other health problems. All the sperm that come out are not alive.
4. Those who have been done a vasectomy and do not want to have a reversal.

In the past, men who had been diagnosed with infertility were unable to have children unless they received donated sperm. However, with advanced technology, now doctors can perform a procedure that retrieves healthy sperm directly from the source which is the epididymis or testis. The doctor will examine an appropriate method of surgery according to the condition of each patient.  

These are the steps of the procedure:

PESA (Percutaneous Epididymal Sperm Aspiration)

PESA is a surgical procedure that requires a small needle with a radius of 2 millimeters to extract sperm from the epididymis. The epididymis is on the top part of the testicles which is where sperm is. After retrieving the fluid, the doctor will examine, look for sperm, evaluate the quality, and use it for ICSI procedures. PESA usually takes about 10 – 20 minutes, and the patient will be given local anesthesia before the procedure. The patient should rest for an hour after the procedure is done then he can go home.

TESE (Testicular Sperm Extraction)

This method is used after trying to retrieve sperm but cannot find sperm in the epididymis. The doctor will use a small blade to trim the skin that covers the testicles. The cut is not more than 1 – 2 millimeters. The doctor will bring the tissue that produces sperm in order to examine for sperm. Local anesthesia will be given, and it will be a bit painful. Therefore, painkiller medicine might be given, and all the pain will be gone within 3 days.

Guidelines before the procedure

The doctor will require a blood test to evaluate overall health and to prepare for the surgery. The patient must refrain from eating and drinking 6 – 8 hours before the procedure.

Guidelines after the procedure

1. Keep the wound dry and avoid swimming or being in a bathtub until the wound is completely dry and healed.
2. After using the toilet, make sure to wipe the wound dry and always keep it clean and dry. 
3. Take painkiller medication and antibiotics according to the doctor’s prescription to reduce swollen and avoid inflammation.
4. Avoid doing exercises for 2 weeks to avoid pain and inflammation.
5. Refrain from having sexual intercourse until the wound is completely dry and healed. 

Risks and side effects of the procedure

We only found less than 2% that has an infection, blood clot in the testicles, and pain after the surgery. However, these can be treated and go back to normal.

The Success of this treatment

TESE procedure is very successful, especially in patients with blockage in vas deferens. However, the success rate also depends on the causes of each individual.

Is PESA/TESE safe procedures?
In general, they are very safe procedures, and they offer better options for patients with infertility. From a current study, the rates of having abnormalities and disabilities in babies from doing the procedures are not different from normal cases.

By Assoc.Prof. Matchuporn Sukprasert

Picture 2 demonstrates endometrial polyp inside the uterine cavity.

Submucous myoma is a fibroid that usually can be found in reproductive-age women. The one that develops in the uterine cavity can interfere with pregnancy. As shown in Picture 3, this can create no symptoms at all or can cause excessive heavy menstrual bleeding, and it will lead to anemia.  This kind of fibroid mostly will not be cancerous but need to be removed before pregnancy.

Picture 3 demonstrates fibroid that grows inside the uterine cavity.

Septate uterus is a deformity that happens before birth. The inner portion of the uterine cavity was divided by a wall of tissue, and the embryo cannot be implanted, or there is a high risk of having a miscarriage later.  This could be treated with surgery to remove the wall of tissue inside the uterine cavity as shown in Picture 4.

Picture 4 demonstrates the surgery to remove a wall of tissue inside the uterine cavity.

Uterine synechiae is a condition that usually happens after dilatation and curettage or after having a severe infection in the uterine cavity that can cause adhesion. Therefore, surgery needs to be done to remove the adhesion before pregnancy. 

Picture 5 demonstrates adhesion band inside the uterine cavity.

2. Hysteroscopic surgery 

The procedure is done in the surgery room. Usually, the size of the hysteroscope will be bigger than the one used during diagnosis, and the cervix needs to be enlarged before inserting the camera.  These are additional tools such as electric loops, small scissors, and morcellator to help remove polyps, fibroids, adhesions, or a wall of tissue inside the uterine cavity. So, the patient may be given medication to help her relax and to block the pain during the surgery. 

The appropriate time to schedule for diagnostic hysteroscopy and surgery is after the menstrual period until before ovulation. During this time, the uterine cavity is not thick and not swollen from ovulation’s discharge, so we can clearly see the pathology. 

Preparation for uterine cavity hysteroscopy

1. Diagnostic Hysteroscopy

This procedure can be done an outpatient department (OPD), and anesthesia is not required. So, the patient does not have to prepare many things in particular. However, the procedure should not be performed right after having a meal to avoid vomiting during the hysteroscopy. So, the patient should avoid having food 2 – 3 hours before the procedure.  Make sure to use the toilet and may also take some painkiller medicines an hour before the procedure. 

Hysteroscopic surgery 

• Refrain from eating and drinking 6-8 hours before the surgery.
• Medicine will be inserted into the vagina 6-8 hours before the surgery. This is necessary because it will open the cervix and help the process to be smoother. However, there might be some side effects such as having a low-grade fever, stomach pain, or having blood show from the vagina due to the medicine that causes contraction. These symptoms will be gone after the surgery.

Post-surgery Instructions

1. Complete the course of antibiotics.
2. Avoid having sexual intercourse, swimming, and heavy exercise for the first 2 weeks after the surgery.
3. Eat healthy meals. There is no specific restriction. 
4. There might be some blood from the vagina within the first week after the surgery but it should not have any smell.  Stomach cramps that are similar to menstrual cramps might occur, but they are not harmful.  Should there be any serious symptoms, please contact your doctor. 

By Doctor Warawun Lupthalug

These techniques are as of followings.

1. Next Generation Sequencing (NGS)

This is a testing technique that screens all 24 chromosomes or whole-genome human sequencing in the least amount of time. This particular method, when applied to the pre-implantation process, allows a doctor or scientist to select only embryos with a normal chromosome profile to transfer. This could yield a higher chance of an effective pregnancy rate compared to Fluorescence in situ hybridization (FISH) technique which is able to screen only 5 pairs of chromosomes.

2. Macs® Art Annexin V system

This is a technology that optimizes sperm separation in assisted reproduction. It helps separate sperm with activated apoptosis signaling (dead cell) before entering the fertilization process. This results in an enhanced clinical pregnancy rate compared to an old technique that cannot distinguish the sperm.

3. Halosperm® G2

This technique allows the visualization of sperm that contains highly degraded DNA compared to other sperm. It is a fast, simple, and cost-effective method that provides an IVF doctor 
to examine sperm DNA fragmentation easily. Therefore good quality sperm selection could be obtained for a fertilization process. This could increase the fertilization rate and embryo implantation rate accordingly.

4. Endometrial Receptivity Test (ERA® Test)

ERA is a genetic test that evaluates the state of endometrial receptivity, which is the optimal time for embryo transfer.  It diagnoses the time that a uterus is ready to receive the embryo. Since the implantation period for each woman is different. The ERA test enables us to personalize embryo transferring time for each couple accurately. This greatly increases the chance of a successful embryo transfer rate and pregnancy rate.

5. Oosight® Spindle view

This computerized high-power microscope technology enables a doctor or an embryologist to see spindles of retrieved eggs when performing Intracytoplasmic sperm injection (ICSI). This is to avoid corrupting the egg spindles when injecting sperm cell into the egg. Therefore, a successful chance of fertilization becomes higher compared to one without the Oosight technique which the doctor or embryologist can perform the ICSI procedure merely from an educated guess.

6. Preimplantation Genetic Testing for Monogenic Disease (PGT-M)

The PGT-M are created uniquely for each family or each fertile couple who has a risk of transmitting a genetic disorder to their offspring. The genetic disorder includes, for example, Thalassemia, Huntington's disease, Duchenne Muscular Dystrophy, Hemophilia and etc. This exceptional technique must be solely performed by a doctor who is a specialist and graduated in Reproductive Genetic. One of our clinic team, Assistant Professor Dr. Matchuporn Sukprasert is the first doctor in Thailand who graduated in this particular field. She was a fellow from Weill Cornell Medical College, Cornell University, New York, United States. She and our scientists are ready to consult willingly with any couple who is possibly related to monogenetic diseases.