Welcome to Bumrungrad Q&A on family planning. Answering frequently asked questions on family planning and related fertility issues are our OB/GYN specialists, Assoc. Prof. Dr. Chartchai Srisombut and Dr. Nahathai Paktinum.
When to see a fertility doctor?
One of the most common problems shared by couples who plan to have a family – and then struggle to conceive a baby - is the question of timing. When is it the right time to start seeing a fertility specialist?
Most couples try by themselves for about one year to have a child, explains Dr. Chartchai. If their attempts to naturally conceive are still unsuccessful, it is recommended to see a specialist doctor.
The doctor’s first step is to establish the conditions of the patients. The first task always is to identify the problem causing the fertility issue, which will then determine the treatment option. Initial ultrasound and hormone tests can indicate the chance of fertility. The patient will learn whether the possibility to get pregnant is low or still intact.
Depending on the condition, the doctor will pursue different treatment methods that each vary in complexity and time requirements. Bumrungrad specialist doctors aim to find the most promising solution for each and every patient individually. Chances are, that after initial treatment, a patient is able to conceive and might not need IVF.
The mother’s age
The age of the woman trying to conceive has a fundamental impact on her ability to conceive. As a rule, pregnancy before the age of 35 years is recommended. “If a woman is of advanced age, especially if older than 38 years, the chance of getting pregnant is lower,” explains Dr. Chartchai.
The main reason for this is because the aging woman carries less and less eggs. It’s a one-way process, explains Dr. Nahathai, and the count of eggs cannot be increased by medical means: “Once we are getting older, we have to be aware of the limited number of eggs, especially after the age of 38.” Although women with a good ovarian reserve still have a good chance to get pregnant even above the age of 38.
It is recommended that an aging woman should measure her fertility before attempting to become pregnant. If the egg reserve becomes too low, there is no time to lose. This process of egg decreasing, Dr. Nahathai explains, can be very fast.
But how can a woman know that her egg count is already low? A hint to this might be if the period is not regular or if the period is short-cycled. These are clear signs for a woman, if she is trying to conceive, to come and see a doctor.
Advanced age implies other risk factors as well. The chance of chromosome abnormality becomes higher, which in turn increases the risk of miscarriage.
Any women over 35 years, or any woman who wants to make sure to have a baby as quickly as possible, should consult with a fertility specialist.
Are IVF-babies different from naturally conceived babies?
An important question that many prospective parents, with difficulties to conceive, have, is the question whether babies conceived through in-vitro fertilization (IVF) are different from babies conceived naturally. When they do something not natural, could it affect the baby?
The clear answer is: no. Every child has the chance of abnormality, Dr. Chartchai explains. The IVF process does not increase or decrease this chance, but with IVF doctors can also do chromosome checking and thereby decrease the chance of abnormalities.
The first IVF-baby was born more than 30 years ago. Ever since, IVF-conceived children have no higher abnormalities detected. The artificial insemination technique does not lead to a higher number of children born with defects. On the contrary, IVF might decrease the chance of abnormality. It’s common standard nowadays to test the chromosomes before the embryo is transferred back to the mother. This allows to test for Down syndrome as well as trisomy 13 and 18.
Furthermore, one of the main reasons for miscarriage is chromosome abnormality. The chance of miscarriage can be minimized by ensuring the health of the chromosomes.
Besides IVF, are there other fertility treatments?
Fertility issues can be treated in different ways. Treatment might start with medication only to induce ovulation. A next step could be medication alongside intrauterine insemination (IUI), which is a type of artificial insemination and another procedure for treating infertility. IUI is usually applied for five to six cycles.
If IUI artificial insemination combined with medication and timing do not work, doctors may proceed to IVF, which is the last method available. Yet, the quality of the embryo and the quality uterus determine the chance of pregnancy as well. If the embryo quality is low or abnormal, then it cannot be transferred to the mother’s womb.
Success rates of each procedure vary. An IUI success rate of 10 to 20 percent is common. Conceiving with this method, however, depends on many factors, such as the quality of the sperm. It is also important to know that this process takes up to half a year. Some patients do not want to wait for that long. They try IUI for three months or so and then proceed to IVF with offers a success rate of more than half of all cases. Between 50 to 60 percent of IVF attempts lead to pregnancy.
Patients older than 42 are not recommended to try IUI in the first place. Dr. Nahathai remembers a patient who became pregnant with IUI with the first cycle at 43, but this is a rare exception, she says.
IUI is the treatment of choice if the patient is free of certain cervix issues and if sperm and egg are of good quality. IVF is the solution for more demanding cases. Some patients, for instance, have a very low sperm count or no sperm at all. But even if there is no sperm ejaculation, hormones and testicular function can be checked. If the condition is not too severe, testicular tissue can be regrown. Be it by surgery or medication, there is a chance to produce sperm again.
How does IVF work?
IVF consists of two processes. First there is the ovarian stimulation with daily injections for 10-12 days, followed by the egg collection at a certain size and, on the same day, the collection of the man’s sperm. This first phase takes two to three weeks until the harvesting of the egg and the fertilization in laboratory environment. During this process, cells of the embryo can be retrieved to test the chromosomes.
Second step about two weeks after insemination is the embryo transfer. The success rate does not depend on the cycle. Studies suggest that a frozen embryo implantation is more successful than transferring the embryo straight after the biopsy in a fresh IVF cycle. Nevertheless, the Bumrungrad specialist doctors emphasize that their patients also have a lot of pregnancies during the so-called fresh cycle.
This process of the embryo transfer takes about two weeks, with the transfer itself being held in the third week. Eight to nine days later a first pregnancy test is done.
Specific male issues
Bumrungrad specialists deal with many difficult fertility cases from all over the world, says Dr. Nahathai. “In most cases we can help.” Some countries, adds Dr. Chartchai, have more specific male factor problems, such as patients from Africa and the Arabian world. “A lot of people from these countries come to our hospital. We have a lot of experience treating these cases.”
Do smoking and drinking have an impact on fertility?
Alcohol consumed moderately should not affect the chance of pregnancy. While alcohol does not directly affect fertility, it can affect the libido. Patients who drink a lot of alcohol may not have a normal sex life.
Smoking, on the other hand, can cause bigger problems. Men who smoke have reduced overall fertilization capacity, due to, decreased motility (how sperm swim), fewer normally shaped sperm and increased sperm DNA damage.
Can vasectomy be reversed?
An often-asked question is whether there is a way to become a father after vasectomy. If the patient does not have any additional health issues and if the hormone function and levels are still good, then there is a process called reverse vasectomy that can help.
Even with vasectomy, the sperm can still be good – until about seven years after the intervention. A patient still has a good chance if a vasectomy is reversed within this timeframe. In some cases, however, it is a better choice to retrieve sperm directly from the testicles.
How can couples improve their fertility?
The easiest and most simple way is eating healthy food with good nutrition. Our doctors recommend a Mediterranean diet with vegetables and berries, food that is said to improve the egg and sperm quality. Women should try to avoid sweet and sugary food and not eat a lot of carbohydrates because they decrease the quality of the egg.
As for vitamins and supplements, women are advised to take folic acid. Again, this does not lead to a higher number of eggs. It also does not make getting pregnant easier, but folic acid improves the egg quality and decreases the risk of having a baby with neurological issues. Vitamin B and C are recommended as well, as are supplements with antioxidants, such as coenzyme CoQ10 and zinc or multivitamins.
Coffee, too, is recommended, just not too much, maybe one or two cups a day. The correct amount of coffee might increase the capacity of the sperm, says Dr. Chatchai.
Exercise can also be beneficial to fertility. Exercising is said to be good for ovulation while the sperm quality of exercising men is said to become better since physical activities produce growth hormones and improve the body’s metabolism.
However, avoid too strenuous exercise such as running marathons, heavy bicycling or too much sauna which are said to damage the sperm and also the eggs. High temperature increases the mortality of the sperm. A few sessions of reasonable exercising a week is good enough. And by all means avoid steroids to build muscles, as infertility is a known problem for athletes who use steroids. Testosterone to increase libido is as well not good for the quality of sperm.
Should a woman freeze her eggs?
There is the possibility of fertility preservation by freezing the eggs. This is an option if a woman is not married and is getting older, or if she does not have plans to get pregnant in the near future.
The collected eggs are frozen for future use and can be thawed at any time. This is a recommended procedure if a woman is older than 30 years of age and still unsure about starting a family. If a woman is approaching 40 and still unsure, then she is advised to consider this method right away, says Dr. Nahathai, instead of wasting any more precious time.
Knowing all this, how many times is it reasonable to try naturally?
Some couples try one cycle only before seeking medical help. If you feel healthy and everything looks okay, three or four cycles should be tried, especially if the woman still has a good ovarian reserve.
It is important that patients and doctor understand each other very well, says Dr. Nahathai. Patients need a clear understanding whether they can accept the chances and the risks. It is the doctors’ duty to provide the information patients need to make a sound decision.
Dr. Nahathai Paktinun
OB/GYN (Women), Reproductive Medicine
+66 2011 2361
Location: Bumrungrad International Hospital (BIH) Building, 2nd